Every finding on record at Hudson Park Rehabilitation and Nursing Center

Based on observation, record review, and staff interview during a Recertification Survey, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen and 4 of 4 kitchenettes. Specifically, the automatic dishwashing machine was not functioning properly, and areas of the main kitchen and unit kitchenettes were not clean. This is evidenced by: During observations of the main kitchen on 6/04/2024 at 9:06 AM, the following were observed: Food contact equipment was being washed in the automatic dishwashing machine and the final rinse temperature was 150 degrees Fahrenheit; the information plate on the dishwashing machine stated that the final rinse is to be 180 degrees Fahrenheit. The can opener holders, knife rack, kitchen floor in corners and along the wall, dry storage area wall behind the air handler and floor, locker room floor, and mop buckets were soiled with food particles, dirt, or grime. During observations on 6/04/2024 at 9:52 AM, the following were observed: The refrigerator, microwave oven, and cabinets in the second-floor kitchenette were soiled with food spills or food particles. The refrigerator, microwave oven, and drawers in the third-floor kitchenette were soiled with food spills or food particles. The refrigerator, drawers, and sink in the fourth-floor kitchenette were soiled with food particles or a black build-up. The drawers, freezer door gasket, and waste receptacle in the fifth-floor kitchenette were soiled with food particles or grime. The undated document titled Dishwasher Procedure documented that dietary staff were trained to monitor the automatic dishwashing machine final rinse temperature for 180 degrees Fahrenheit. During an interview on 6/04/2024 at 10:05 AM, Interim Food Service Director #1 stated that they would contact the maintenance department to have the dishwashing machine checked, and the can opener holders, knife rack, floors, and items found in the kitchenettes would be cleaned. During an interview on 6/07/2024 at 12:54 PM, Regional Food Service Director #1 stated that the booster heater servicing the dishwashing machine required a minor repair and was now functioning properly. During an interview on 6/07/2024 at 12:56 PM, Administrator #1 stated that a log would be created to ensure the main kitchen and kitchenettes were kept clean, and kitchen staff would receive education on how to check the dishwashing machine for proper functioning and sanitizing. 10 New York Codes, Rules, and Regulations 415.14(h) Chapter 1 State Sanitary Code Subpart 14

Based on observations, record review, and interviews during a Recertification Survey, the facility did not maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the possible development and transmission of communicable infections for 2 of 4 care units. Specifically, the facility did not ensure staff appropriately used and discarded personal protective equipment. This is evidenced by: The Policy and Procedure titled, Infection Prevention and Control Policy last reviewed 5/2024, documented, An Infection Control Program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. Important facets of infection prevention include educating staff and ensuring they adhere to proper technique and procedures. The Policy and Procedure titled, Personal Protective Equipment last revised 3/15/2023, documented, Training in the proper donning, use, and disposal od personal protective equipment is provided upon orientation and at regular intervals. According to the Centers for Disease Control and Prevention's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, last reviewed found online at https://www.cdc.gov/infectioncontrol/guidelines/core-practices/index.html, core practices should include development of processes to ensure that all healthcare personnel understood and were competent to adhere to infection prevention requirements as they performed their roles and responsibilities. Healthcare personnel were required to perform hand hygiene in accordance with Centers for Disease Control and Prevention recommendations. Staff should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient, before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces and immediately after glove removal. Personal protective equipment should be removed and discarded upon completing a task before leaving the patient's room or care area. Healthcare personnel should not use the same gown or pair of gloves for care of more than one patient and disposable gloves should be removed and discarded upon completion of a task or when soiled during the process of care. Healthcare facility was to ensure that healthcare personnel have immediate access to and were trained and able to select, put on, remove, and dispose of personal protective in a manner that protects themselves, the patient, and others. During an observation on 6/04/2024 at 11:35 AM, a Resident Assistant walked out of a resident's room on Unit 2 (Resident ' s room was identified by signage as being under Enhanced Barrier Precautions) wearing blue gloves, touched a clean linen cart in the hallway, walked down the hall and into two other resident rooms, went to another clean linen cart at the other end of the hallway, and back into the original resident ' s room with the gloves still on. During an observation on 6/04/2024 at 11:43 AM, a Resident Assistant walked up from a resident's room to the nursing station on Unit 2 and removed blue gloves but did not wash hands or use hand sanitizer. During an observation on 6/04/2024 at 1:00 PM, in a resident's room on Unit 2 (identified by signage as being under Enhanced Barrier Precautions), there were three used surgical gloves balled up on a small dresser in the room. During an observation and interview on 6/06/2024 10:27 AM, soiled gloves and a plastic bag were on the floor in a resident ' s room on Unit 5. Certified Nurse Aide #3 stated they left bag and gloves on floor because there are no bins for waste. Certified Nurse Aide #3 was later observed exiting the room with the plastic bags filled with soiled contents, brought them to dirty room, and did not wash or sanitize hands after handling the soiled bags. During an observation and interview on 6/06/2024 10:37 AM, Certified Nurse Aide #4 exited a resident ' s room on Unit 5 with two plastic bags of soiled contents, entered and exited dirty utility room without washing or sanitizing hands, then entered another resident's room that was identified by signage as being under Contact Precautions). Certified Nurse's Aide #4 did not don (put on) protective gown or gloves prior to entering the room. Certified Nurse Aide #4 stated the room was under contact precautions, and that they went into the room to assist, and should have gowned up. 10 New York Codes, Rules, and Regulations 415.19 (a) (1-3)

Based on observation and interviews during a Recertification Survey, handrails were not maintained on 2 of 4 resident units. Specifically, handrails were not firmly secured and affixed to the corridor walls. This is evidenced by: During observations on 6/11/2024 from 9:33 AM through 10:33 AM, handrails were loose and not securely attached to the wall on the second-floor east corridor, fourth floor east corridor, and outside room [ROOM NUMBER]; additionally, the handrail end turn piece was missing from the handrail by room [ROOM NUMBER]. During an interview on 6/11/2024 at 10:30 AM, Director of Maintenance #1 stated that they would assign a maintenance worker to check and secure all handrails and install the turn piece. During an interview on 6/11/2024 at 2:44 PM, Administrator #1 stated the facility would audit the entire building and securely attach any loose handrails. 10 New York Codes, Rules, and Regulations 713-1.8(a)

Based on observations, record review, and interviews during a recertification survey, the facility did not ensure that each resident was treated with respect and dignity and cared for in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, dining meals were served with disposable utensils in 1 (fourth floor) of 4 dining rooms; and for 1 (Resident #150) out of 3 residents reviewed, the facility did not ensure the resident was treated in a dignified manner by ensuring resident was fully clothed in common areas. This is evidenced by: Fourth Floor Dining Room During an observation on 6/07/2024 at 12:15 PM, seven residents were given plastic utensils for their meal. During a record review, no comprehensive care plans included the usage of plastic utensils at meals. During an interview on 6/10/2024 at 3:05 PM, Licensed Practical Nurse #4 stated that plastic utensils may be used for safety reasons and should be in the comprehensive care plan. During an interview on 6/10/2024 at 3:35 PM, Registered Nurse #5 stated the use of plastic utensils should be in the comprehensive care plan for each resident that uses plastic utensils. Resident #150 Resident #150 was admitted to the facility with the diagnoses of multiple sclerosis (a condition that causes damage to our nerves), gastroesophageal reflux disease, and herpes viral infection. The Minimum Data Set (an assessment tool) dated 4/11/2024 documented Resident #150 was cognitively intact, usually understood and could usually understand others. During multiple observations on 6/04/2024 in the morning, Resident #150 was walking in the hallway with their pants falling down, exposing the incontinence brief. During observations, facility staff did not intervene. The Comprehensive Care Plan titled Activities of Daily Living Functional Status/Rehabilitation Potential dated 10/24/2023, Resident #150 was care planned for moderate/partial assistance for upper body and lower body dressing assistance. During an interview on 6/10/2024 at 11:25 AM, Certified Nurse Aide #6 stated if a resident was found to be clothed inappropriately, they would grab a hospital gown from the linen cart and place it on the resident. They would bring the resident back to their room to get appropriately dressed. During an interview on 6/10/2024 at 3:05 PM, Licensed Practical Nurse #4 stated the resident should not have been wearing those pants as they did not fit the resident appropriately. They stated residents should not have clothes on that did not fit appropriately. 10 New York Codes, Rules, and Regulations 415.5 (a)

Based on observations, record review, and interviews during a recertification survey, the facility did not ensure that it provided an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 2 of 4 resident units reviewed for activities. Specifically, residents on 2 of 4 resident units were not provided with activities that met the residents' preferences and cognitive abilities. This is evidenced by: The Policy and Procedure titled Activities dated 2/14/2024 stated the facility would provide activities, social events, and schedules that were compatible with the resident's interests, physical and mental assessment, and overall plan of care. The Policy and Procedure stated activities were offered 7 days a week. Resident #15 Resident #15 was admitted to the facility with the diagnoses of vascular dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life caused by decreased blood flow to the brain), schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), and major depressive disorder. The Minimum Data Set (an assessment tool) dated 4/15/2024 documented the resident has severe cognitive impairment, was usually understood and could usually understand others. The resident resided on a primarily dementia care unit. During an observation on 6/05/2024 at 11:56 AM, no activities were observed for the unit. Comprehensive Care Plan titled, Activities and dated 12/02/2019, documented Resident #15 enjoyed reading and viewing pictures in a magazine, enjoyed music, and needed encouragement and assistance as needed. As documented in the Comprehensive Care Plan, the resident was to be offered one on one visits at least three times a week, assistance to activities was to be offered as well as in room activities of interest when the resident did not prefer group activities. A document titled Daily Activity Tracking Form dated 4/15/2024 documented the resident received a coloring activity. During an interview on 6/07/2024 at 12:51 PM, Activities Director #1 stated they assessed the residents for likes and dislikes and would reach out to family to see what the preferences were if the resident was unable to state. Most dementia residents would receive one on one visits and sensory activities like coloring. They stated they would do the one-on-one visits themselves. During an interview on 6/10/2024 at 10:43 AM, Resident Aide #1 stated they had been employed at the facility for 3 weeks. They stated they had only seen anyone from the activities department on the floor once or twice since they started at the facility. During an interview on 6/10/2024 at 11:25 AM, Certified Nurse Aide #6 stated there were not a lot of activities for the residents and the residents were given 'toddler' games if they were becoming agitated. They stated they had not seen anyone from the activities department on the floor often but recently had been coming up occasionally with activities such as coloring, balloons, and things like that. During an interview on 6/10/2024 at 3:05 PM, Licensed Practical Nurse #4 stated they would try to do activities with the residents but was not able to too often due to nursing and care duties. During an interview on 6/10/2024 at 3:35 PM, Registered Nurse #5 stated recreation individuals would sometimes come up and sit with residents but would not stay very long or try to interact with them. They believed more activities would be helpful with cognition on the unit as that unit was primarily a dementia unit. 48615 Resident #91 Resident #91 was admitted to the facility with diagnoses of sepsis due to methicillin resistant staphylococcus aureus, anxiety disorder, and type 2 diabetes. The Minimum Data Set, dated dated dated [DATE] documented the resident was cognitively intact, could understand, and be understood by others. A document titled Daily Activity Tracking Form dated 5/01/2024 documented the resident received a new monthly calendar. During an interview on 6/07/2024 at 11:11 AM, Resident #91 stated they did not attend activities because they were not interested. They stated they were unaware of a recent ice cream social and would have attended it if they had known about it. During an interview 6/10/2024 at 3:05 PM, Licensed Practical Nurse #6 stated the activities department would occasionally come to the floor and provide activities but usually the residents would go down to activity room for the events. During an interview on 6/07/2024 at 12:51 PM, Activities Director #1 stated activities should be documented in the Activity Tracking in the electronic medical record. They stated the residents had to let the activities department know if they want to attend an activity. They were unable to state how residents who required assistance with transfers or mobility would attend activities. They stated that at this time, only Catholic religious services were available to residents. 10 New York Codes, Rules and Regulations 415.5(f)(1)h

Based on observation, record review, and interviews conducted during the recertification and abbreviated (Case # NY00323716) survey, the facility did not provide effective housekeeping and maintenance services on 4 of 4 resident units, the basement, and the facility grounds. Specifically, floors, window blinds, tables, ceiling light covers, room signs, and facility grounds were not clean or maintained. This is evidenced by: During observations on 6/04/2024 from 10:19 AM through 11:00 AM, 6/05/2024 at 11:45 AM, 6/07/2024 from 10:01 AM through 3:07 PM, and 6/11/2024 from 9:33 AM through 10:33 AM: Finding #1 Floors 1) On the fourth floor, the corridor floor and door thresholds were soiled with dirt and were sticky, the walls and doors were soiled with scrape, scuff, and smudge marks, and dead flies were found in the corridor ceiling lights. 2) The basement floor and the floors in the mechanical rooms on the second floor, third floor, fourth floor, and fifth floor were heavily soiled with dust and dirt. Finding #2 Window Blinds, Light Covers, Room Number Signs 3) Window blinds were soiled with a buildup of oily dust in room #s 213, 221, 226, 301, 317, 326, 510, and 518. 4) The corridor call bell light covers were missing for resident room #s 402, 411, and 413. 5) Resident room #s 400, 401, 402, 403, and 405 were hand-written on the corridor wall; these rooms did not have room number signs as was typical for the other rooms on the unit. Finding #3 Tables and Facility Grounds 6) The underside of dining room tables was soiled with food particles and grime on the second floor, third floor, fourth floor, and fifth floor. 7) The grounds between the road and building were littered with paper waste, and the grounds behind the building were littered with paper waste, used surgical gloves, and plastic wrapping. The undated document titled, Enhanced Environmental Rounds, documented staff were to clean windows (including blinds), ensure all components of the call bell system (including call bell light covers) were functioning, and that trash was picked up around the facility grounds. There was no documented evidence that the facility routinely checked the underside of the dining room tables for cleanliness and the basement and mechanical room floors for cleanliness. Interviews During an interview on 6/11/2024 at 11:49 AM, Regional Director of Environmental Services #1 stated that the floors, walls, and window blinds would be cleaned and checked for good repair; and a new audit would be developed for checking the underside of the dining room tables. During an interview on 6/11/2024 at 11:49 AM, Administrator #1 stated cleaning the basement floor and mechanical rooms would be added to the weekly rounding, the missing call bell light covers would be repaired, the facility had purchased and would install the new room number signs, and the housekeeping department would be assigned to keep the grounds free from litter. 10 New York Codes, Rules, and Regulations 415.5(h)(4)

Based on observation, record review, and interviews during a Recertification survey, the facility did not ensure residents were assessed by an interdisciplinary team to determine their ability to safely self-administer medication when clinically appropriate for 1 (Resident #91) of 1 resident reviewed for medication administration. Specifically, Resident #91 was observed self-administering medications in their room without being evaluated as to whether they could safely do so. This is evidenced by: The facility policy titled, Medication Administration and last revised 6/01/2024, documented medications should be administered in a safe and timely manner, and as prescribed. Medications would not be left at the resident's bedside. Residents may self-administer their own medications only if the Physician, in conjunction with the Interdisciplinary Care Planning Team, had determined that they have the capacity to do so safely. Resident #91 was admitted to the facility with diagnoses of sepsis due to methicillin resistant staphylococcus aureus (a type of staph infection that can be resistant to several antibiotics known also as MRSA), diabetes, and psoriasis (patches of abnormal skin). The Minimum Data Set (an assessment tool) dated 4/06/2024, documented the resident was cognitively intact, could be understood, and could understand others. During an observation on 6/06/2024 at 12:21 PM, Resident #91 was observed in their room applying betamethasone cream to their right lower extremity. Additionally, generic lubricant eye drops were observed in the resident's room. A Physician's Order dated 4/17/2024, documented the resident was to be administered betamethasone cream 0.05%, apply to psoriasis plaques/lesions twice a day. The order documented an end date of 5/17/2024. A Physician's Order dated 4/18/2024, documented the resident was to be administered Systane (lubricant eye drops) 0.4-0.3%, 1 drop each eye four times a day. The Medication Administration Record for May 2024 documented the betamethasone was administered twice daily from May 1, 2024, through May 17, 2024. There was no documentation of the medication being administered after May 17, 2024. The Medication Administration Record for June 2024 documented the Systane was administered as ordered from June 1, 2024, through June 12, 2024. Upon review of Resident #91's electronic medical record, there was no documented evidence that the resident was assessed to safely self-administer medications; there was no physician order or care plan in place for the resident to self-administer medications. During an interview on 6/06/2024 1:09 PM, Registered Nurse #4 stated there were no residents on their Unit who self-medicated. If a resident wished to self-medicate, the Physician would be notified and an assessment completed in the electronic medical record. 10 New York Codes, Rules, and Regulations 415.3 (e)(1)(vi)

Based on interviews and record review during the recertification survey, the facility did not thoroughly investigate or prevent further accidents for 1 (Resident #15) of 1 resident reviewed for accidents. Specifically, Resident #15 was found on the floor in their room on 6/01/2024 with a significant injury to their head. The facility did not thoroughly investigate the root cause to rule out abuse or neglect. This is evidenced by: Resident #15 was admitted to the facility with diagnoses of unspecified severity vascular dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life caused by decreased blood flow to the brain) without behavioral disturbance, chronic obstructive pulmonary disease (narrowing of airways in the lungs making it difficult to breathe), and Type 2 diabetes mellitus. The Minimum Data Set (an assessment tool) dated 4/15/2024 documented that the resident usually could be understood and could understand others. A Brief Interview of Mental Status indicated the resident had severe impairment in cognition for daily living decisions. The Policy and Procedures titled, Abuse Prevention and dated 9/2023, documented that all residents have the right to be free from verbal, sexual, physical, or mental abuse. The policy further documented that policy was to investigate all reported incidents, accidents, and resident complaints for potential abuse and crime. The Policy and Procedures titled, Incident Report and dated 3/2024, documented the facility was to document and investigate any accident or incident involving a resident. Comprehensive Care Plans for falls dated 7/01/2021 documented that the resident had been identified as a fall risk related to a decline in activities of daily living, acute illness, and medication use. Nursing progress notes dated 6/01/2024 documented resident was found on the floor in their room at approximately 6:30 AM. Resident #15 had a large hematoma on the left side of the head/eye area with swelling. The nursing supervisor notified the doctor and sent the resident out to the hospital for further evaluation at 7:43 AM. The incident and accident report dated 6/01/2024 at 7:00 AM documented the resident fell out of their wheelchair in the hallway. During an interview on 6/10/2024 at 3:05 PM, Licensed Practical Nurse #4 stated that the resident had a fall on 6/01/2024 in their room and was found on the floor. The nursing supervisor was called, resident was evaluated and sent to the hospital for further evaluation. They stated resident had no other issues since the fall. They stated that they did not know what the root cause of the incident was as they were unsure if an investigation was conducted. During an interview on 6/10/2024 at 3:35 PM, Registered Nurse #5 stated that any unwitnessed fall resulting in significant injuries should be investigated and a root cause analysis done. They stated they were unsure if an investigation was done on this incident. During an interview on 6/12/2024 at 9:45 AM, Director of Nursing #1 stated investigations of incidents should be started right away. They stated that every major incident along with injuries of unknown origin should be investigated. During an interview on 6/12/2024 at 10:00 AM, Administrator #1 stated that all incidents were to have a root cause investigation completed. They stated that all allegations of abuse, neglect, and injuries of unknown origin should be investigated. The facility investigation documentation was requested for record review, however, none was provided at the time of survey. New York Codes, Rules and Regulations 483.12(c)(2 - 4)

Based on observations, record review, and interviews conducted during a recertification survey, the facility did not ensure Comprehensive Care Plans were reviewed and revised based on changing goals, preferences, and needs for 3 (Residents #15, 20, and 524) of 36 residents reviewed for care plans. Specifically, the comprehensive care plan was not revised (a) for Resident #15 after they had a fall with significant injuries on 6/04/2024; (b) for Resident #20 to address the resident's oxygen administration requirements, and (c) for Resident #524 after the resident sustained a wound. This is evidenced by: A review of policy and procedure titled, Comprehensive Person-Centered Care Plans and last revised in February 2024, documented an Interdisciplinary Team, which included the resident or representative, develop and implement a Comprehensive Care Plan for each resident. Each resident's Comprehensive Care Plan would be consistent with the resident's right to participate in developing and implementing their personalized Comprehensive Care Plan. The facility would inform the resident of their right to participate, or an explanation placed in their medical records determining that the resident or representative was not practicable. The care planning process would facilitate the involvement of the resident or representative. Resident #15 Resident #15 was admitted to the facility with diagnoses of unspecified severity vascular dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life caused by decreased blood flow to the brain) without behavioral disturbance, chronic obstructive pulmonary disease (narrowing of airways in the lungs making it difficult to breathe), and type 2 diabetes mellitus. The Minimum Data Set (an assessment tool) dated 4/15/2024 documented resident had severe cognitive impairment, usually could be understood, and could understand others. Comprehensive Care Plan for Falls was initiated on 11/2019 related to a decline in Activities of Daily Living, acute illnesses, and medications. Residents' short-term goal was to have no injuries related to falls through review dates. During a record review of nursing progress notes, it was documented that Resident #15 had several falls within the past several months, including on 4/06/2024, 4/10/2024, 4/11/2024, 6/04/2024, and 6/05/2024. Record review of the resident's care plan revealed the care plan was revised after a fall on 1/31/2024 to include a fall mat positioned to the left side of the bed when the resident was in their bed. There was no documented evidence that the care plan was revised after Resident #15 experienced a significant fall on 6/04/2024. During an interview on 6/10/2024 at 3:05 PM, Licensed Practical Nurse #4 stated Resident #15 had a significant fall on 6/01/2024 in their room and was found on the floor. The nursing supervisor was called, and the resident was evaluated and sent to the hospital for further evaluation. They stated resident had no other issues since the fall. They stated that they did not know the incident's root cause as they were unsure if an investigation was conducted. They stated that for any significant issue or changes in residents' condition, a care plan revision should have been completed with the interdisciplinary team. During an interview on 6/10/2024 at 3:35 PM, Registered Nurse #5 stated for any significant change, a care plan revision should be done-especially for a resident who has [NAME] frequent falls. They stated the resident would hardly fall during the day, withmost of the falls happening at night. They stated that they believed the resident fell because they were getting up to go the bathroom without assistance. They stated that the resident was care planned for falls by being monitored every two hours. When asked to locate the care plan modification for recent significant falls by being monitored every 2 hours, Registered Nurse #5 was not able to locate one, and identified a care plan intervention for monitoring every 2 hours for behavioral issues of the resident sleeping on the floor. 48615 Resident #20 Resident # 20 was admitted with diagnoses of Parkinson's Disease (a disorder that affects the nervous system and the parts of the body controlled by the nerves); diabetes mellitus, chronic obstructive pulmonary disease (a lung disease causing restricted airflow and breathing problems). The Minimum Data Set, dated dated dated [DATE] documented the resident was cognitively intact, could be understood, and coulde understand others. During an observation and interview on 6/04/2024 at 11:28 AM, Resident #20 was noted to have oxygen via nasal cannula set at 3 liters per minute. The resident stated they recently had an episode of pneumonia and asked for oxygen. They were given oxygen and since then self-applied oxygen as needed. Comprehensive Care Plan for Alteration in Respiratory Status dated 7/17/2023 and last revised 1/23/2024 documented the resident required oxygen, with interventions obtaining and documenting the resident's oxygen saturation as per physician orders. A Nursing Progress Note dated 4/16/2024 documented chest x-ray result that was taken on 4/15/2024 noted a left basilar pneumonia or effusion, which was relayed to Nurse Practitioner #1. The Medication and Treatment Administration Reports dated 03/20/2023 - 05/23/2024 had no orders for oxygen therapy. 47140 Resident #524 Resident #524 was admitted to the facility with diagnoses that included insomnia (difficulty sleeping), depression, and acute respiratory failure. The Minimum Data Set (an assessment tool) dated 5/14/2024 documented resident had severe cognitive impairment, could sometimes be understood, and could sometimes understand others. A Nursing Progress Note dated 5/22/2024 documented Resident #524 had been found on the ground near the nurse's station. Upon assessment, the resident had a lacerated wound noted on the right leg shin area with a measurement of 1.4 centimeters by 0.6 centimeters. A steri strip (thin adhesive bandages that help close shallow cuts or wounds) was applied to the affected area and covered with an opti foam patch (wound dressing). The resident's family and physician were documented to have been notified. During an observation on 6/05/2024 at 11:22 AM, Resident #524 was seated in a wheelchair by the second-floor nurse's station with an uncovered wound on their right shin, which was approximately 3 inches long and half an inch wide. The wound had reddened edges and was without weeping or active bleeding. A review of Resident #524's Care Plan revealed the care plan was updated on 6/05/2024 (14 days after the injury was first observed) to include the resident had an actual impairment of skin integrity as evidenced by a skin tear to their right shin; interventions included that nursing staff should follow the facility's skin tear protocol, treatment was to be done as per physician orders and the resident was to be seen on weekly rounds by the Wound Nurse and measurements obtained. An Occupational Therapy/Physical Therapy assessment was to be completed per the physician's order to evaluate positioning devices and/or therapy needs to promote wound healing. During an interview on 6/05/2024 at 11:35 AM, Registered Nurse #1 stated that Resident #524 had a recent fall, during which they obtained the injury to their right shin. They stated the wound should be cleansed and covered, and the dressing changed every three days. During an interview on 6/11/2024 at 3:10 PM, Wound Nurse #1 stated that typically when they would initially assess a new wound was when they would update the resident's care plan with interventions. They stated they were first notified of Resident #524's wound to their right shin on 5/29/2024 (7 days after it was first observed/documented). During an interview on 6/12/2024 at 10:01 AM, Director of Nursing #1 stated that when a wound/laceration was identified, the physician should be notified, the wound should be evaluated by the wound nurse, treatment orders obtained, and the resident's care plan should be updated with treatment orders/any new interventions. They stated after the wound was identified, it should be monitored and tracked to determine if it is healing/worsening. 10 New York Codes of Rules and Regulations 415.11(c)(2)(ii)

Based on observations, record review, and interviews during a Recertification Survey, the facility did not provide needed care and services that were resident centered and in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for 1 (Resident #524) of 34 residents reviewed. Specifically, Resident #524 fell on [DATE] and sustained a wound; the wound was not tracked, monitored or treated as the resident's wound was observed to be uncovered and larger than it was initially assessed to be at the time of the fall. This is evidenced by: Cross referenced to F657: Care Plan Timing and Revision The Policy and Procedure titled, Incident Report, Residents and last revised 03/05/2024, documented any bruises, cuts, lacerations, etc. sustained during a fall must have a size and description documented by the nurse and nursing staff should continue to monitor for any changes, injury, or effects of the incident. Resident #524 Resident #524 admitted to facility with diagnosis which included insomnia, depression and acute respiratory failure. The Minimum Data Set (as assessment tool) dated 5/14/2024 documented the resident could sometimes be understood and could sometimes understand others with cognitive impairment for decisions of daily living. During an observation on 6/05/2024 at 11:22 AM, Resident #524 was seated in a wheelchair by second floor nurse's station with an uncovered wound on their right shin, which appeared to be approximately 7.62 centimeters long and 1.27 centimeters wide. The wound had thickened, reddened edges without weeping or bleeding. A Nursing Progress Note dated 5/22/2024, written by Registered Nurse #2, documented Resident #584 had been found on the ground near the nurse's station. Upon assessment, the resident had a lacerated wound noted on their right leg shin area with a measurement of 1.4 centimeters by 0.6 centimeters. A steri strip (thin adhesive bandages that help close shallow cuts or wounds) was applied on the affected area and covered with an optifoam patch (wound dressing). The resident's family and physician were documented to have been notified. Review of the Treatment Administration Record revealed that Resident #524 had a standing (on-going) physician order with a start date of 4/25/2024 to treat any skin tears as needed by cleansing the wound, covering with an optifoam wound dressing and changing the dressing every three days. Review of the record revealed nursing staff did not sign off that wound care and dressing changes were completed from 5/22/2024 to 6/05/2024. During an interview on 06/05/2024 at 11:35 AM, Registered Nurse #1 stated that Resident #524 had a recent fall, during which they obtained the injury to their right shin. They stated that the wounds should be cleansed, covered, and dressing changed every three days. They stated Resident #524 had a behavior of picking at their skin and removing wound dressings. A Registered Nurse assessment dated [DATE] at 12:50 PM, written by Registered Nurse #1, documented Resident #524's continued to be unchanged in size and that the resident continued to pull off the dressing and picks at the wound. The wound edges were thickened, rolled under and appear irritated by the frequent picking. The wound was dry with no drainage or odor. Treatment was updated to have wound dressing changed every 3 days, with kerlix (wound dressing) added to deter the resident from removing their dressing and picking the wound. A Treatment Order was entered for Resident #524 on 06/05/2024 (14 days after the injury was first observed) for the wound to be cleansed and optifoam wound dressing to be applied and secured with kerlix (wound dressing) every three days and as needed. A Wound assessment dated [DATE] at 2:40 PM, completed by Wound Nurse #1, documented the resident was seen for assessment of a skin tear to the resident's right shin. The wound was documented to be 4 centimeters long by 0.9 centimeters wide. The wound was documented with partial thickness. The measurement revealed that the wound had more than doubled in length from when it was first assessed to be 1.4 centimeters long at the time of the fall. The wound was photographed during the assessment. Review of Resident #524's Care Plan, revealed the care plan was updated on 6/05/2024 (14 days after the injury was first observed) to include that the resident had an actual impairment of skin integrity as evidenced by a skin tear to their right shin. Interventions included nursing staff should follow the facility's skin tear protocol, treatment were to be completed per physician orders and the resident was to be seen on weekly rounds by the Wound Nurse and measurements obtained. An Occupational Therapy/Physical Therapy assessment was to be completed per physician order to evaluate positioning devices and/or therapy needs to promote wound healing. During an observation on 6/07/2024 at 9:40 AM, Registered Nurse #1 took measurements for Resident #524's wound and reported that the wound was 3.8 centimeters long by 0.8 centimeters wide with a depth of 0.1 centimeters. The wound appeared to be improved from when it was initially observed on 6/05/2024. A Wound assessment dated [DATE] at 8:13 AM completed by Wound Nurse #1, documented the wound was identified on 6/05/2024, however, a note added to the bottom the assessment documented that the assessment was a late entry and was actually completed on 5/29/2024 (12 days prior). The assessment documented the wound was 3 centimeters long by 0.5 centimeters wide. The wound was not photographed during the assessment, and it was documented that this was due to the resident being restless at the time. During an interview on 6/11/2024 12:50 PM, Registered Nurse #2 stated they were working on another unit when they were called to come assess Resident #524 on 5/22/2024. They stated the resident was on the floor near the nurse's station and upon assessment, had sustained a wound to their right shin. They stated when they first observed the wound, it appeared to be a laceration (a deep cut or tear of the flesh). They stated they used the side of a piece of gauze to measure the size of the wound and relayed the measurements to the on-call physician. They stated they had not been trained in obtaining wound measurements. During an interview on 6/11/2024 at 3:10 PM, Wound Nurse #1 stated Resident #524's wound had worsened since they had initially assessed the wound. They stated they were initially informed of the wound on 5/29/2024 but that they did not enter the assessment in the system until 6/11/2024. They stated the had seen the resident again on 6/05/2024 for follow-up and the wound was larger. They stated the resident would pick at their skin/wound. They stated typically when they would initially assess a new wound was when they would update the resident's care plan with interventions. They stated it was important to track and monitor wounds for changes and signs of infection. During an interview on 6/12/2024 at 10:01 AM, Director of Nursing #1 stated wounds should be documented timely, accurately and tracked for any changes. They stated they believed Wound Nurse #1 was first notified of Resident #524's wound and completed an assessment on 5/29/2024, however, they did not enter their assessment into the system until 6/11/2024. They stated sometimes nursing staff would forget to chart their assessments right away. They stated the facility would enter standing orders for treatment of skin tears. They stated when a new wound was identified, treatment orders should be obtained, the Wound Nurse should be notified, and the resident's care plan should be updated. They stated the Wound Nurse should obtain initial measurements in order to track the wound. 10 New York Codes, Rules, and Regulations 415.12

Based on observation, interview, and record review conducted during a Recertification survey, the facility did not ensure that residents received proper treatment and assistive device to maintain hearing abilities for 1 (Resident #58) of 4 residents reviewed. Specifically, Resident #58 did not receive assistance with replacement of broken hearing aids and did not receive follow up Audiologist (a healthcare professional that manages hearing loss and balance disorders) visits for maintenance of hearing aids as recommended. This is evidenced by: Resident #58 was admitted with diagnosis of Unspecified osteoarthritis (degeneration of bone causing pain and stiffness), Impacted cerumen (ear wax), bilateral; Chronic obstructive pulmonary disease, unspecified (a condition involving constriction of the airways and difficulty or discomfort in breathing). The Minimum Data Set of 3/28/2024, documented resident was cognitively intact, could be understood, and understand others. During an observation and interview on 6/04/2024 at 1:50 PM, Resident #58 was noted to be very hard of hearing. Resident #58 requested writer stand within 1 inch of their ear to hold conversation. Resident stated they were hard of hearing, and they do not have a hearing aid. No other hearing adaptive devices were observed for this resident. Comprehensive Care Plan Titled Alteration in Sensory Perception dated 12/11/2023 documented resident had a hearing deficit. Both ears, considered deaf. Long Term Goal: Resident would maintain adequate communication daily through next review of 7/28/2024. Intervention include Speak slightly louder and towards left ear. Resident lost hearing aide. Schedule hearing consultant and see if it could be replaced. During an interview on 6/11/2024 at 12:17 PM, Unit Manager, Registered Nurse #4 sated Resident #58's hearing aid had been broken several times as Resident likes to disassemble their hearing aid. Resident had not had a functioning hearing aid since 12/11/2023. An in-house audiology exam was scheduled for 5/13/2024, although, the visit or consultation was not documented. Unit Manager, Registered Nurse #4 stated they would follow up on audiology consult and obtaining a new hearing aid. During an interview on 06/11/2024 at 12:15 PM, Certified Nurse Aide #5 stated Resident #58 was extremely hard of hearing. They stated they do not attempt to assist Resident #58 because Resident #58 refuses care and yelled at staff a lot. During an interview on 06/11/2024 at 12:55 PM, Director of Nursing #1 stated residents were followed up every six months for audiology maintenance and as needed. Review of Treatment Administration Record dated 12/11/2023, documented appointment for audiology hearing aids as needed. There was no documented audiology or hearing consults for Resident #58 after order date. 10 New York Codes, Rules, and Regulations: 415.12(3)(b)

Based on observations, record review, and interviews during the Recertification Survey, the facility did not ensure that residents who required respiratory care were provided such care in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident goals and preferences for 2 (Resident #20 and 98) of 3 residents reviewed. Specifically, Resident #s 20 and 98 oxygen therapy were not administered as ordered by the physician. This is evidenced by: The Policy and Procedure titled Oxygen Administration, last revised on 4/09/2024, documented the purpose of the procedure was to provide guidelines for safe oxygen administration. The procedure included that nursing staff should first verify the physician order for oxygen and then adjust the flow of oxygen as prescribed. Resident #20 Resident # 20 was admitted with diagnoses of Parkinson ' s Disease (disorder that affects the nervous system and the parts of the body controlled by the nerves); diabetes mellitus (a disease in which the body does not control the amount of glucose (a type of sugar) in the blood). chronic obstructive pulmonary disease (a lung disease causing restricted airflow and breathing problems). The Minimum Data Set (an assessment tool) dated 3/29/2024, documented resident was cognitively intact, could be understood and could understand others. During an observation and interview on 6/04/24 at 11:28 AM, Resident #20 was noted to have oxygen via nasal canula set at 3 liters per minute. Resident #20 stated they recently had pneumonia and asked for oxygen. They were given oxygen and since then applied oxygen as needed. Nursing Progress Note dated 4/16/2024, documented Chest X-ray result taken on 4/15/2024, showed left basilar pneumonia or effusion, was relayed to Nurse Practitioner #1. Ordered to start Azithromycin 500milligram tablet today, then 250 milligram tablets tomorrow until 4/21/24. Comprehensive Care Plan Titled Alteration in Respiratory status requiring oxygen, dated 7/17/2023, last revised 1/23/2024, Intervention include obtain and document oxygen saturation as per physician orders. The Medication and Treatment Administration Reports dated 3/20/2023 - 5/23/2024 had no orders for oxygen therapy. 48615 Resident #98 Resident #98 was admitted to facility with diagnoses which included chronic obstructive pulmonary disease, acute pulmonary edema and glaucoma. The Minimum Data Set, dated dated dated [DATE] documented the resident was cognitively intact, could be understood and could understand others. Comprehensive Care Plan, Titled at Risk for Compromised Respiratory status dated 4/04/2024, documented the resident was at risk for compromised respiratory status related to diagnoses of chronic obstructive pulmonary disease, pulmonary edema and recent intubation. Interventions included resident to receive oxygen therapy as ordered at a flow rate of 4 liter per minute. A Physician Order dated 4/02/2024 documented 4 liters per minute of continuous oxygen flow. During an observation on 6/04/24 at 12:29 PM, Resident #98 was seated in the dining room on the second floor. The resident had oxygen via nasal cannula with a portable oxygen contractor which was set to a liter flow of 2 liters per minute. During an observation and interview on 6/05/24 at 9:13 AM Resident #98 was lying in their bed receiving oxygen therapy via nasal cannula with the concentrator set to a liter flow of 3 liters per minute. During an interview on 6/07/2024 at 11:52 AM, Licensed Practical Nurse #2 stated only nurses could adjust the liter flow on oxygen concentrators. They stated that all residents who required oxygen therapy should have a physician order which indicated how much oxygen the resident should be administered, how it should be delivered (nasal cannula versus face mask) and how often (continuously or as needed). They stated that oxygen therapy was considered to be the same as administering a medication and should always be administered as indicated by the physician order. They stated that if a resident did not receive enough oxygen, they could potentially have increased confusion or become lightheaded. During an interview on 6/11/2024 at approximately 2:00 PM, Registered Nurse #1 stated that the adjustment of liter flow on an oxygen concentrator needed to be completed by a nurse. They stated that each resident that required supplemental oxygen should have a physician order which indicated a prescribed liter flow per minute. They stated that some risks existed for residents who received too much or too little oxygen. During an interview on 6/12/2024 at 10:01 AM, Director of Nursing #1 stated that all residents who required oxygen therapy should have physician order which indicated the amount of oxygen the resident required to maintain oxygen levels. They stated that nurses should check the physician order to ensure that oxygen was administered correctly. They stated that some residents had physician orders to titrate (determine and adjust the needed concentration) of oxygen when within certain parameters of oxygen saturation. Director of Nursing #1 reviewed Resident #98 ' s physician orders and noted that Resident #98 did not have an order to titrate oxygen. 10 New York Codes, Rules, and Regulations 415.12 (k)(6)

Based on observation, record review, and interviews during an Abbreviated survey (Case # NY00323479), the facility did not ensure residents were free from misappropriation of residents' property and free of exploitation for 3 (Resident #s 1, 2, and 3) of 3 residents reviewed. Specifically, for Resident #1 and #3, the facility failed to prevent forgery of the stolen checks which lead to the theft of the residents' personal funds. Specifically, for Resident #2, the facility did not ensure the resident had a secure location for their personal check book to prevent forgery of the resident's checks. Subsequently, leading to theft of the resident's personal funds, requiring Resident #2 to close their account to prevent further attempts of their funds being stolen from their checking account. This is evidenced by: The facility's policy and procedure titled, Misappropriation of Resident Property, last revised on 02/16/2024, was reviewed and indicated all reports of theft, unauthorized use or removal, embezzlement, or intentional destruction of resident's personal property regardless of monetary value would be investigated by the facility. The policy indicated the policy purpose was to facilitate the investigation of missing property and maintain respect for the resident's property rights. The facility's policy and procedure titled, Abuse Prevention, reviewed on 08/2023 and last reviewed on 07/09/2023, indicated it was the facility's policy that all residents would be protected from abuse, neglect, mistreatment, or misappropriation of property in accordance with State and Federal regulations. The policy indicated Misappropriation of resident's property meant the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Resident #1: Resident #1 was admitted to the facility with diagnoses of peripheral vascular disease (narrowing of the peripheral blood vessels), morbid obesity, and atrial fibrillation (irregular heart rhythm). The Minimum Data Set (an assessment tool) dated 07/29/2023 documented the resident was understood and could understand others with a Brief Interview for Mental Status indicated intact cognition for daily decision making. The facilities Investigation Report, dated 09/07/2023, was reviewed and documented the following: On 09/07/2023 at 9:30 AM, Resident #1 reported to the social workers that their bank had contacted them about suspicious activity on their checking account. Resident #1 reported that two checks had been presented to the bank and cashed, Resident #1 checked their bank book and found three checks missing. The investigation indicated Resident #1 had not signed the two checks and was unsure when the checks had been taken. The investigation noted one check out of the 3 stolen checks had not been presented to the bank. The investigation indicated that with the assistance of the Social Worker the police were notified. The investigation indicated: Staffing schedules were checked to see if the signature on the checks matched any of the staff's signatures. Certified Nurse Aide #1 who was hired on 08/14/2023 signature was a match on the forged checks. The investigation of Certified Nurse Aide #1's personnel file demonstrated a background check was completed upon hire. The investigation indicated the facility made several attempts to contact Certified Nurse Aide #1 without any success. Summary of the investigation determined there was sufficient evidence to determine misappropriation had occurred and Certified Nurse Aide #1 was culpable and was terminated. The summary indicated Certified Nurse Aide #1 was reported to the Office of the Professions on 09/08/2023. Resident #2: Resident #2 was admitted to the facility with diagnoses of End Stage Renal Disease requiring dialysis, heart failure, and depression. The Minimum Data Set, dated dated dated [DATE] documented the resident was understood and could understand others with a Brief Interview for Mental Status indicating intact cognition for daily decision making. The investigation further revealed that later that day, 09/07/2023 at 1:30 PM, Resident #2 reported to the social workers that they had received a call from their bank, regarding suspicious activity with their checks. The investigation indicated that a bank staff member reported to Resident #2 a woman had attempted to cash a check from the resident's starter account. The investigation indicated the check was made out to a person identified by the facility as Certified Nurse Aide #1. The investigation indicated the bank staff refused to cash the check without speaking to the account holder so the person told the bank that Resident #2 was in their car and they would go get them. The investigation indicated the woman took the check and identification and left without returning into the bank. The investigation indicated the social worker assisted Resident #2 with filing a police report. A facility investigation begun on 09/07/2023 was reviewed and indicated the following: Resident #1 reported misappropriation first on 09/07/2023 at 9:30 AM to Social Work. Resident #2 reported misappropriation on the same day 09/07/2023 at 1:30 PM to Social Work. Investigation concluded on 09/08/2023. Summary of Investigation by the Administrator of Record determined misappropriation had occurred. Resident #3 Resident #3 was admitted to the facility with diagnoses of bipolar disorder (A mental health disorder), diabetes mellitus, and depression. The Minimum Data Set, dated dated dated [DATE] documented the resident was understood and could understand others with a Brief Interview for Mental Status indicated intact cognition for daily decision making. Facility Investigation conducted on 10/13/2023 at 12:00 PM was reviewed and indicated the following: On 10/13/2023 at 12:00 PM, Resident #3 reported to the social worker suspicious activity on their checking account. Two checks were cashed at their bank on 8/25/2023 for a total of $1750.00 without authorization of the account holder. The final summary dated 10/13/2023 after staff and resident interviews and after review of previous misappropriation on 09/07/2023 during the investigation on 10/13/2023, no correlation was found that could conclusively associate the incidents with Certified Nurse Aide #1's misappropriation of resident's funds. The Interdisciplinary Teams Meetings determination was that Resident #3 was likely complicit in the transaction. The incident and investigation were added to the file folder for the Facility reported complaint #NY00323479. A Police Report #23155441 dated 10/13/2023 documented the following: Resident #3 reported on August 25th, 2023, two checks #984 and #985 were removed from their room. The suspect (Certified Nurse Aide #1) forged Resident #3 signature on both Checks #984 for $ 800.00 dollars and #985 for $ 950.00 dollars and cashed said checks valued at $1750.00. Furthermore, the representative for the nursing home stated there had been previous similar incidents (Cross Reference Incident #23-134513 and #23134411) where the suspects name was written on those checks. During an interview on 02/16/2024 at 1:45 PM, Family Member #1 stated they were waiting for the bank to reimburse the money totaling $1750.00 for the two checks that were cashed at the bank by Certified Nurse Aide #1 on 08/25/2023. The Power of Attorney stated that they took over the financial duties for the resident after this occurred in late October 2023. The police report indicated that during an interview on 02/21/2023 at 10:06 AM, Resident #3 stated they were anxious to go forward with their life. The report indicated the resident stated their family were helping them with their finances and they did not know the outcome of the missing money. The report indicated Resident #3 indicated someone took their money, and they were not sure how this occurred or when. The report indicated the resident stated they had a locked drawer but did not have it when they first came to the facility in August 2023. Interview: During an interview on 02/15/2024 at 1:58 PM, Director of Nursing #1 stated a full investigation was done after both incidents of misappropriation were reported to social work. Police were notified and Certified Nurse Aide #1 was terminated. No further misappropriation occurred. All staff were reeducated on abuse, neglect, and misappropriation. During an interview on 02/15/2024 at 2:34 PM, Administrator #1 stated there was an investigation and summary of the misappropriation which involved Resident #1 and #2 done on 09/07/2023. Administrator #1 indicated another investigative summary was found for the reported misappropriation that involved Resident #3 on 10/13/2023. The residents name, police report, and details of the incident and investigation were added to the file under the facility reported incident #NY00323479 from 09/07/2023. During an interview on 02/16/2024 at 4:10 PM, Assistant Administrator #1 stated they were familiar with the events that took place with the misappropriation. The Assistant Administrator #1 indicated the facility had discovered Certified Nurse Aide #1 was the person identified by the bank as the person who had cashed the checks. It was determined that the Certified Nurse Aide #1 had access to both residents. Residents #1 and #2 were assessed for psychosocial harm, the physician and families were notified on 09/07/2023, concerning the misappropriation. Maintenance did an audit to identify any residents that needed a locked drawer, installed them and gave a key to residents that needed them. Reeducation on Abuse, Neglect, and Misappropriation was started on 9/07/2023 and completed on 09/10/2023. On 10/13/2023 Resident #3 reported to the Director of Social Work that they had just become aware that checks totaling $1,750.00 dollars were cashed on 8/25/3023 by Certified Nurse Aide #1. The Police were notified and filed a police report for stolen funds. Resident #3 was added to the investigation complaint file completed on the 09/08/2023 on 10/13/2023 for misappropriation of funds as it was determined the same information and dates were consistent with the incidents reported by Residents #1 and #2. During an interview on 2/16/2024 at 4:34 PM, Director of Social Work #1 stated they were notified on 9/07/2023 that Resident #1 had a problem with missing checks. The police were called, and a police report was filed. Later in the day on 9/07/2023 Resident #2 reported their bank had notified them a person had attempted to cash a check from their account that was just opened. The Director of Nursing and Administrator were notified, and all policies and procedures were followed to investigate the incident and to protect the residents. Interdisciplinary team meeting was done to review cause, effect, and prevention of future misappropriation to the residents. Follow up was done with Resident #1 and #2 to assess any psychosocial concerns. Comprehensive Care Plans to prevent abuse and misappropriation were placed in both residents' charts. On 10/13/2023 Resident #3 presented to the Social Work office reporting they had checks stolen from them at some point during their admission. The Police were notified, and a police report was made on 10/13/2023. Last report from the police department on the criminal investigation determined no arrest had been made but the charges were still pending. The residents involved were monitored and no psychosocial concerns had been found at the time of the investigation. Past Non-compliance- F602 Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement at the time of this survey: On 09/07/2023, the facility identified Resident #1 and #2 had a concern with misappropriation, and the following corrective actions were taken immediately: -- Residents #1 and 2 were assisted by social work to contact the police and report the fraudulent activity on their private checking accounts -- A facility-wide audit was completed on personal property to assess for any residents who had been a victim of misappropriation of funds or personal property. -- All reports of missing items reported were investigated -- An investigation was started immediately with an audit done to determine days, shifts and units that Certified Nurse Aide #1 worked on from 8/14 to 9/07/2023. The Police were notified. -- Certified Nurse Aide #1 was contacted by phone and suspended pending the outcome of the investigation. The staff member never returned any attempts at contact and never returned to the facility. Access to the building was blocked for the protection of the residents. -- The physician and families were notified of concerns with misappropriation of funds. -- The Social Worker followed up on Resident #1 and 2 with no negative findings. Socio emotional care was provided to both residents. Social Worker to provide ongoing support when needed. -- All resident were provided with a locked drawer with a key to store personal property. -- The interdisciplinary team met to discuss the incident and directed all nurses to begin education for abuse and neglect which include special focus on misappropriation. No additional non-compliance was noted. -- Quality Assurance and Performance Improvement was summoned by the Administrator, including the Medical Director to review the incident and directed a facility-wide audit reported for misappropriation. No additional non-compliance was noted. -- Summary of Investigation for 09/07/2023 by previous Administrator was updated on 10/13/2023. -- The Staff Educator were directed and completed education for all staff on all shifts on the proper policy and procedure for abuse, neglect, and misappropriation. - On 10/13/2024, the following corrective actions were taken: -- Resident #s 3 was assisted from social work to contact police and report the fraudulent activity on their private checking accounts -- Facility-wide audit was completed on personal property to assess any residents who had been a victim of misappropriation of funds or personal property. -- All reports of missing items reported were investigated -- A cross reference was completed of Days and Shifts Certified Nursing Assistant #1 worked and on what units. -- An investigation was started, and staff and residents were interviewed to determine if there were any witnesses or residents that could identify any further misappropriation. -- A house wide reeducation on abuse, neglect and misappropriation had begun. -- Certified Nurse Aide #1 had already been removed from resident care and terminated. -- The Social Worker followed up on Resident #s 1, 2 and 3 with no negative findings. Socioemotional care was provided to both residents. Social Worker would provide ongoing support when needed. -- Audit was done to ensure all resident were provided with a locked drawer with a key to store personal property. -- Follow up with the Police determined no arrest had been made but charges from 2 complaints of misappropriation committed by Certified Nurse Aide #1 were pending. --Resident #1 had been reimbursed by the financial institution for funds that were misappropriated and had a new bank account and was utilizing their locked drawer with no further issues, --Resident #2 had changed their bank account and issued new checks and a debit card. Resident #1 was utilizing their locked drawer with no further issues of misappropriation. --Resident #3 had a family member who was appointed Power of Attorney in handling their financial matters and checking account. Attempting to recover funds had been supported by the facility. - At the time of survey, there were no additional reportable misappropriation concerns identified. A random sample in-house audit was reviewed during the survey; there were no findings identified with misappropriation. It was determined that the facility had not notified the New York State Department of Health that Resident #3 had also been involved in the misappropriation that had occurred between 8/16/2023 through 9/07/2023. The facility would have been cited under F- tag 609 but the facility was in an open enforcement cycle for plan of correction associated with Survey Event ID 7UJF11 dated 09/01/2023. 10 New York Codes, Rules, and Regulations 415.4(b)

Based on observation, interviews, and record review conducted during the abbreviated survey (NY00337430), the facility did not provide effective housekeeping and maintenance services on five (5) of 5 resident units. Specifically, the facility did not ensure that resident room, resident bathroom, common areas, and closets were clean; and furniture and walls were in good repair. This is evidenced by: The following observations were noted on 01/10/2024 from 9:50 AM through 3:30 PM and again on 04/03/2024 from 11:35 AM through 12:06 PM: Finding #1: Soiled Floors Floors were soiled in corners and next to walls in resident room #s 201, 203, 213, 217, 221, 227 bathroom, 304, 316, 317, 317 bathroom, 401, 402, 427, 523, and 525 (behind loose coving baseboard). Floors were soiled around wardrobes in resident room #s 407, 408, 409, 412, 418, 420, 421, and 422. The bathroom shower floor drains were soiled with a black buildup in resident room #s 505, 513, and 522. The bathroom floor in resident room [ROOM NUMBER] was soiled with a black mold-like substance. The door tracks for elevator #1 and elevator #2 were soiled with black particles. Finding #2: Heater/air conditioning units The heater/air conditioning units were soiled with dust, grime, beverage drips, or smudge marks in resident room #s 203, 304, 316, 317, 401, 402, 407, 412, 421, 427, 503, 505, 511, 512, 513, and 525, and the 5th floor dining room. Finding #3: Windows Windows were soiled with in resident room #s 206, 207, 211, 212, 213, 214, 215, 219, 304, 307, 308, 309, 312, 313, 314, 315, 316, 317, 401, 402, 405, 409, 410, 418, 420, 421, 422, 427, 503, 504, 511, 512, 513, 523, and 525; and in the corridors on the 2nd, 3rd, 4th, and 5th floors. Finding #4: Other environmental concerns The wall paneling was dusty in resident room #s 227, 403, and 500. The mop buckets and mop wringers in use on the 4th and 5th floors were heavily soiled with a black buildup. Record Review There is no documented evidence that facility staff are trained or expected to clean resident room floors in corners or next to walls, the heating/air conditioning units, wall paneling, around wardrobes, or windows. There is no documented evidence that facility staff are trained or expected to clean the floor drains in resident room showers that have a buildup of debris. There is no documented evidence that the facility requires elevator door tracks and mop buckets and wringers are to be kept clean. Interviews During an interview on 04/03/2024 at 1:46 PM, Interim Director of Housekeeping #1 stated that the facility had developed a schedule to deep clean all resident rooms, the maintenance department would be asked to move the wardrobes, cleaning the heating/air conditioning units and wall paneling would be added to the cleaning schedule, and a new housekeeping director had been hired starting work next week. Interim Director of Housekeeping #1 stated that the mop buckets and wringers would be cleaned by the end of the day today. During an interview on 04/03/2024 at 2:10 PM, Administrator #1 stated issues with environmental cleanliness including floors and windows have been identified; interdisciplinary rounding audits with housekeeping, maintenance, and someone from another department have begun; and though much improvement with the environment has been accomplished more needs to be done. 483.10(i)(2) 10 New York Codes, Rules, and Regulations 415.5(h)(4)

Based on record review and interviews during an abbreviated survey (NY00336807), the facility did not ensure each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used without adequate indications for its use for 1 (Resident #3) of 5 residents reviewed for unnecessary drugs. Specifically, Resident #3 was administered Resident #9's medication in error when the nurse became distracted. This is evidenced by: The Policy and Procedure titled, Medication Administration, revised 3/8/2024, documented medications shall be administered in a safe and timely manner, and in a way that ensured the resident's safety. Medications must be administered in accordance with the orders. Resident #3 The resident was admitted to the facility with diagnoses of diabetes, peripheral vascular disease (narrowed blood vessels reduce blood flow to the legs), and heart disease with heart failure. The Minimum Data Set (an assessment tool) dated 2/15/2024, documented the resident was cognitively intact, could be understood, and could understand others. The Medication Order Report dated 3/4/2024 - 4/4/2024 did not document any Medical Doctor orders for Xeljanz (used to treat rheumatoid arthritis, a disorder that causes warm, swollen, painful joints), Baclofen (a muscle relaxant), or Celexa (a medication to treat depression). A Nurse's Progress Note dated 3/21/2024 at 10:35 AM, documented the resident received another resident's (Resident #9) medications by mistake. The medications administered were Baclofen 5 milligrams, Celexa 40 milligrams, and Xeljanz 5 milligrams. Vital signs were within normal limits. An untimed Nurse Practitioner Encounter Note dated 3/21/2024, documented they were notified by Registered Nurse Unit Manager #3 that Resident #3 received Resident #9's medications in error. Resident #3 stated they felt fatigued but denied other symptoms. Registered Nurse Unit Manager #3 reviewed the medications with Resident #3 and explained the medications could make them feel fatigued. During an interview on 4/09/2024 at 11:12 AM, Registered Nurse Unit Manager #3 stated on 3/21/2024 Resident #3 was administered another resident's medications by Licensed Practical Nurse #8. The Nurse Practitioner was notified and Resident #3 was monitored. During an interview on 4/15/2024 at 2:10 PM, Licensed Practical Nurse #8 stated they had prepared Resident #9's medication and was getting ready to administer it to them when Resident #3 who was getting ready to leave the unit - approached them and asked if they could take their medication before they left. Licensed Practical Nurse #8 stated they started having a conversation with Resident #3 as they were dispensing their medication into the cup and then gave them to Resident #3. They stated when they went to give Resident #9 their medication, all that was on the medication cart was the cup of water they were going to give them with their medication; the medicine cup was gone. That was when Licensed Practical Nurse #8 realized what had happened. They stated they told the unit manager immediately and the Medical Provider was notified. Licensed Practical Nurse #8 took Resident #3's vital signs, which were within normal limits. Licensed Practical Nurse #8 stated the resident became sleepy and the Nurse Practitioner told Resident #3 and Licensed Practical Nurse #8 that it was an expected medication reaction. Licensed Practical Nurse #8 stated when Resident #3 returned to the unit, they rechecked their vital signs, and they were still within normal limits. They stated they gave report to the next shift regarding the incident. During an interview on 4/16/2024 at 10:25 AM, Director of Nursing #1 stated Licensed Practical Nurse #8 had Resident #9's medications ready to administer to them when Resident #3 approached the nurse and asked them to administer their medications because there were leaving the unit. Director of Nursing #1 stated that in being distracted, Licensed Practical Nurse #8 put Resident #3's medication in the same cup with Resident #9's and gave it to them. Director of Nursing #1 stated the Nurse Practitioner was notified, the resident was seen and monitored. There were no ill effects to Resident #3. 10 New York Codes, Rules, and Regulations 415.12(l)(1)

Based on record review and interviews during an abbreviated survey (NY00336807), the facility did not ensure its residents were free of any significant medication errors for 1 resident (Resident #2) of 5 residents reviewed for significant medication errors. Specifically, Licensed Practical Nurse #6 applied a 50 microgram Fentanyl transdermal patch (a strong narcotic pain medication that could be absorbed through the skin by applying a patch on the skin) on the resident's arm. The resident was prescribed a Fentanyl 12.5 microgram transdermal patch. This is evidenced by: The Policy and Procedure titled, Medication Administration, revised 3/08/2024, documented medications should be administered in a safe and timely manner, and in a way that ensured the resident's safety. Medications must be administered in accordance with the orders. The individual administering the medication must check the label 3 times to verify the right medication, right dosage, right time, and right route of administration before giving the medication. Resident #2 Resident #2 was admitted to the facility with diagnoses of lupus (an illness that occurs when the immune system attacks healthy tissues and organs), psoriatic arthritis (an inflammatory autoimmune condition that can affect both the joints and skin), and mild asthma. The Minimum Data Set (an assessment tool) dated 2/21/2024, documented the resident was cognitively intact, could be understood, and could understand others. Physician's Orders dated 3/22/2024, documented Fentanyl patch 12.5 micrograms, 1 patch transdermal every 72 hours. The Medication Administration Record dated March 2024 documented a Fentanyl patch was applied on 3/25/2024 by Licensed Practical Nurse #6. There was one removed and destroyed on 3/26/2024 by Licensed Practical Nurse #7. A Nurse's Progress Note dated 3/26/2024 at 2:05 AM, documented the resident seemed sleepy. The resident's blood pressure was 158/98, heart rate 98 and regular, respirations 20, and temperature 97.1 degrees Fahrenheit. The resident denied pain and discomfort. Lung sounds were clear. A Nurse's Progress Note dated 3/26/2024 at 12:22 PM, documented the resident received a 50-microgram patch accidentally for a short period of time. The patch was removed, and 12.5 microgram was applied as ordered. The Medical Doctor was aware. There were no adverse effects noted. During an interview on 4/03/2024 at 11:32 AM, Resident #2 stated on 3/25/2024, they had been given the wrong dose of Fentanyl. They stated Licensed Practical Nurse #6 applied a 50-microgram transdermal patch when they were prescribed a 12.5 microgram patch. They stated they started feeling a little funny, so they told the floor nurse (they did not know their name). The floor nurse confirmed to them that they received the wrong dose of Fentanyl, and called Registered Nurse Supervisor #2. Resident #2 stated Registered Nurse Supervisor #2 made a phone call and the correct dose of Fentanyl was then applied. During an interview on 4/09/2024 at 11:14 AM, Licensed Practical Nurse #6 stated they were floated to Resident #2's unit 3/25/2024 between 8:45 AM and 9:00 AM . They stated they had taken a Fentanyl patch from the medication room to lock in the locked box in their medication cart, and did not realize there were two residents on the unit using Fentanyl patches. When they took the patch out of the box, they did not notice a label. They stated there were 2 boxes of Fentanyl, 1 was already open and one was fully closed. Licensed Practical Nurse #6 stated it did not occur to them that the Fentanyl patches were for two different residents. They stated Resident #2 was leaving the unit for a time period and asked if they could wait to have their Fentanyl patch applied until after they returned. Licensed Practical Nurse #6 stated when the resident returned, they asked for their Fentanyl patch, and they applied it. Licensed Practical Nurse #6 stated they were re-educated to double check everything and always check the boxes of Fentanyl patches for labels. During an interview on 4/09/2024 at 11:12 AM, Registered Nurse Unit Manager #3 stated when they came in to work on 3/26/2024, they heard Resident #2 had a 50-microgram Fentanyl patch applied (was Resident #4's Fentanyl). They stated the patch was removed prior to their shift on 3/26/2024 and the correct dose applied (12.5 micrograms). During an interview on 4/15/2024 at 10:48 AM, Registered Nurse Supervisor #2 stated Resident #2 reported to them they had the wrong dose of Fentanyl applied. They stated Resident #2 had a 50-microgram patch applied to their arm instead of the 12.5 microgram patch that was ordered for them. They stated the 50-microgram Fentanyl patch was removed and they immediately called the Medical Doctor, who ordered to put the 12.5 microgram patch on the resident which was done. During an interview on 4/16/2024 at 10:25 AM, Director of Nursing #1 stated Licensed Practical Nurse #6 was sent to Resident #2's unit from another unit. The Licensed Practical Nurse grabbed Resident #4's fentanyl patch in error and applied it to Resident #2. It was the wrong dose. The resident was administered 50 micrograms, and the resident was prescribed 12.5 micrograms. 10 New York Codes, Rules, and Regulations 415.12(m)(2)

Based on interviews and facility record review during an abbreviated survey (Case #NY00277162), the facility did not ensure that 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 to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (Resident #2) of 3 residents reviewed for injuries of unknown origin. Specifically, for Resident #2, the facility staff did not ensure to report a serious bodily injury of unknown origin within 2 hours of an allegation when on 5/14/2023 at 2:17 PM, facility staff observed bruising to the resident's contracted right arm with vocalized pain in the arm. On 5/14/2021 at 10:30 PM, x-ray results confirmed the resident had an acute midshaft humeral (upper arm bone) fracture of their right arm. This is evidenced by: The facility policy titled Abuse Prevention stated All alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property, must be reported immediately, but no later than 2 hours after the allegation is made, if the events that caused 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 Department of Health. Resident #2 Resident #2 was admitted to the facility with diagnoses of hemiplegia, dementia, osteoporosis, and congestive heart failure. The Minimum Data Set (MDS-an assessment tool) dated 4/4/2021, documented the resident could be understood and could usually understand others and had severe cognitive deficiency for decisions of daily living. The Comprehensive Care Plan (CCP) titled ADL (activities of daily living) Functional status/ Rehab potential documented Resident #2 had impaired physical mobility related to limited range of motion secondary to contracture of right upper extremity. The interventions included hand posies to bilateral hands, off with care, administer medications as ordered by the physician, monitor for changes and report to physician, OT/PT evaluation on admission and PRN, and provide emotional support with all care. The Nursing Progress Note dated 5/14/2021 at 2:17 PM, documented during weekly rounds, Resident #2 was observed lying in bed. The resident had a bruise to their right arm and discomfort was vocalized during the assessment. The Unit Manager was made aware, and the appropriate individual was notified. The Nursing Progress Note dated 5/14/2021 at 2:54 PM, documented Resident #2 had bruising to the right arm that was contracted. The arm was assessed and had bruising to the upper and inner arm but was not measurable due to the contracture. The resident was seen by Occupational Therapy (OT) recently for evaluation for a splinting device. The physician was called and made aware. There were new orders for x-ray. The Nursing Progress Note dated 5/14/2021 at 10:30 PM, documented the results from the x-ray to the right arm confirmed an acute midshaft humeral fracture. The Administrator was made aware. The facility investigation dated 5/14/2021, documented the resident has spastic hemiplegia and osteoarthritis and documented at the time the bruises were discovered, the wound nurse went to assess the resident's right arm contracture status and found the resident with bruising and pain. RN (Registered Nurse) #1 assessed the resident, and they were unable to measure the bruising due to the residents severely contracted baseline. The resident had signs of pain where the arm was touched so a complete skin check was not completed. The investigation concluded the statements obtained during the investigation provided a timeline showing the injury happened the afternoon of 5/12/2021. During that time Resident #2 was assessed for range of motion (ROM) by an Occupational Therapist (OT). The OT did not see bruising or signs of injury prior to treatment. The report documented that the OT did not feel the injury occurred during ROM, the injury was consistent with an accidental fracture. It was possible the injury occurred during routine care with staff manipulating the resident's arm during dressing, but all staff interviewed denied manipulating the resident's arm. As it occurred accidentally, during a therapeutic treatment, it was not reportable per the NYS DOH reporting manual. There is no evidence of abuse or neglect. During an interview on 7/27/2023 at 2:30 PM, the Nursing Home Administrator (NHA) stated they were responsible for reporting to the Department of Health. At the time of the injury of unknown origin, they were following New York State Department of Health reporting guide. The NHA stated they now follow Centers for Medicare and Medicaid Services (CMS) guidelines. 10 NYCRR415.4(4)

Based on observation, record review, and interviews during abbreviated survey (NY00308571)dated 08/08/23 through 08/31/23 the facility did not maintain a pest-free environment and an effective pest control program one (1) of 6 resident units and the main kitchen. Specifically, the floors in the main kitchen electrical closets were heavily soiled with dirt and food particles, and dead cockroaches were found in the insect glue traps found therein. Additionally, the pest control vendor report dated 08/08/23 documented that insect traps were placed in resident room #s 510, 511, 513, and #515, however insect traps were not found in resident room #s 510, 511, 513, and #515 on survey. This is evidenced as follows: The document titled [NAME] Valley Pest Control, Inc. Service Report documented that the facility had been treated for cockroach activity approximately every one to 2 weeks from 10/04/22 through 08/08/23. The document titled Pest Sighting Log dated 12/02/21 through 08/06/23, documented that within the past 9 months, cockroaches were found in resident room [ROOM NUMBER] on 01/21/23 and again on 07/05/23; in room [ROOM NUMBER] on 11/05/22, 12/05/22, 12/29/22, and again on 01/07/23; in room [ROOM NUMBER] on 01/24/23; in room [ROOM NUMBER] on 06/27/23; in room [ROOM NUMBER] on 01/24/23 and again on 02/02/23; in the 3rd floor corridor on 02/21/23; on the 4th floor kitchen door on 04/14/23; in room [ROOM NUMBER] on 12/05/22 and again on 05/02/23; in room [ROOM NUMBER] on 11/11/22 and again on 04/25/23; in room #s 512 and 514 on 05/22/23, in room [ROOM NUMBER] on 07/19/23; and in the cold foods area of the basement on 08/06/23. The document titled Personal Laundry and Labeling and revised 09/01/22, is the facility policy on receiving resident personal clothing; this document did not speak to preventing insects from being brought into the facility. The document titled Culinary Services F-Tag Compliance Tool, the document titled Cooks Sanitation List, and the document titled Food Service Operating Checklist (documents were not dated) are cleanliness audit tools for the main kitchen. These documents did not include checking the electrical closets for cleanliness, and these documents did not include checking the insect traps for activity. The document titled [NAME] Valley Pest Control, Inc. Service Report dated 08/08/23 documented that insect baits were placed in resident room #s 510, 511, 513, and 515 at 9:00 AM on 08/08/23. During observations on 08/08/23 at 11:05 AM, the floors in the main kitchen electrical closets were heavily soiled with dirt and food particles, and the insect glue traps found therein had dead cockroaches. Insect traps were not found in resident room #s 510, 511, 513, and 515 but were noted to have been placed in these rooms at 9:00 AM on the pest control vendor report dated 08/08/23. During an interview on 08/08/23 at 11:39 AM, the Administrator stated that the problem with insect infestation has been intermittent. The Administrator stated it was not known that insect traps had been removed from resident rooms and that it is a possibility that the insect traps were removed in resident room #s 510, 511, 512, 513, and 515 when the floors were stripped and waxed. The Administrator stated that the Dietary Director is responsible for checking the electrical closets for cleanliness. During an interview on 08/08/23 at 11:25 AM, the Director of Maintenance stated that maintenance does not check or clean above the drop ceilings in resident rooms (a potential harborage area for insects) and housekeeping likely removed the insect traps from the resident rooms when the floors were stripped and wax yesterday. During an interview on 08/08/23 at 11:49 AM, the Director of Housekeeping stated that staff picked up the insect traps from the rooms as a reaction to the surveyor entering the facility but does not know exactly why. 10 NYCRR 415.29(j)(5)

Based on observations and interviews during a focused infection control survey, the facility did not ensure to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of Covid-19 on 3 out of 4 care units. Specifically, the facility failed to ensure that staff appropriately wore personal protective equipment (PPE), performed hand hygiene when indicated and followed infection control practices and protocol to prevent cross-contamination. The facility was in an active outbreak at the time of survey with 11 active cases of Covid-19 among residents on the 3rd, 4th and 5th floor care units. The findings include: The Policy and Procedure (P&P) titled Covid-19 Action Plan, revised on 8/3/22, documented; All health care providers and other facility staff shall wear a face mask while in the facility. The face mask must completely cover both the nose and mouth. Extended wear of facemasks is allowed; facemasks should be changed when soiled or wet and when the health care provider goes on breaks'. Health care providers who enter the room of suspected or confirmed SARS-CoV-2 infection should use a NIOSH-approved particulate respirator with N95 filters and eye protection (i.e., goggles or face shield that covers the front and sides of face). The P&P titled Standard Precautions, revised 11/18/21, documented standard precautions apply to the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Personnel are trained in the various aspects of standard precautions to ensure appropriate decision making in various clinical situations. Standard precautions include hand hygiene practices. Hand hygiene is performed with alcohol-based hand rub (ABHR) before and after contact with a resident, before performing an aseptic task, after contact with items in the resident's room and after removing PPE. During an observation on 3/21/23 at 12:36 PM, Certified Nursing Assistant (CNA) #4 was observed passing lunch trays on the fifth-floor care unit. They picked up a tray from the meal cart in the hallway and walked into room [ROOM NUMBER], placed the tray down and walked out of the room without performing hand hygiene. They then walked back to the hallway, opened the door to the meal cart and retrieved another tray. They then brought the tray into room [ROOM NUMBER]. While in room [ROOM NUMBER], they adjusted a side table in the room and then started to open the resident's meal items for them. They exited the room and did not perform hand hygiene. They went to the hallway and retrieved another tray which they brought to room [ROOM NUMBER] and set on a side table in the room and exited without performing hand hygiene. They retrieved another tray from the meal cart and opened the room to door number 523 and dropped off the meal tray and closed the door behind them when they exited and did not perform hand hygiene. CNA #4 proceeded to deliver meal trays without performing hand hygiene in between residents or after touching surfaces in the resident environment. During an observation on 3/21/23 at 12:45 PM, Temporary Nurse Aide (TNA) #2 pushed a meal cart full of trays on the fifth-floor care unit. They pulled food trays from the cart and when doing so, dropped five single serve coffee creamers on the floor. They picked up the coffee creamers without donning gloves and placed the coffee creamers on the resident meal trays. They did not perform hand hygiene afterwards. During an observation on 3/21/23 at 12:55 PM, Licensed Practical Nurse (LPN) #7 was observed in the hallway of the fourth-floor care unit wearing a surgical mask that was pulled down below their nose. During an observation on 3/21/23 at 1:00 PM, CNA #7 was seated at the fourth-floor nurse's station desk wearing a surgical mask that was pulled down below their nose and chin and they were watching a video on their cell phone. They stated there were residents on isolation/ droplet precautions on the unit. They said if they were going into a room that was on isolation/droplet precautions, they would put on a gown, N95 mask, face-shield and gloves. During an observation on 3/21/23 at 1:20 PM, the door to Resident #1's room was observed to open, there was no signage on the door indicating that the resident was on isolation precautions. During an observation on 3/21/23 at 1:23 PM, a bariatric wheelchair was observed in the hallway of the third-floor care unit. The wheelchair had a garbage bin without a lid with debris, plastic food wrap, and used PPE in it. A used N95 respirator mask hanging from the arm rest. During an observation on 3/22/23 at 10:15 AM, CNA #2 was observed standing in the doorway of a resident room on the second-floor care unit wearing a surgical mask that was pulled down below their nose. CNA #2 was observed to wipe their nose with their fingers and then pick up an open box of surgical gloves with the same hand and did not perform hand hygiene. Review of Resident #1's record revealed a Nursing Progress Note dated 3/13/23, documented the resident tested positive today for Covid-19 via rapid swab conducted for outbreak testing. The resident denied any current shortness of breath (SOB), cough, fever, headache, fatigue, loss appetite, smell or taste. They were started on Covid-19 precautions and will continue to monitor until the end of their quarantine period. Review of the facility's Covid-19 line-listing (Covid-19 infection tracking) spread sheet revealed Resident #1 tested positive on 3/13/23 and was scheduled to come off from droplet/isolation precautions on 3/24/23. Interviews During an interview on 3/21/23 at 9:40 AM, the Director of Nursing (DON) stated the facility was in an active outbreak of Covid-19. They had eighty-two residents and twenty-six had tested positive since the start of the current outbreak. They stated there were residents on isolation/droplet precautions from testing positive or due to having exposure, however, many residents had been taken off droplet/isolation precautions after their period of quarantine. The staff and visitors should don N95 respirator masks and face-shields upon entering the care units which were available on PPE stations setup at the entrance of each unit. During an interview on 3/21/23 at 10:56 AM, LPN #2 said several residents tested positive for Covid-19. They stated the facility's policy required staff to follow infection control guidelines. They said staff are expected to wash or sanitize hands before and after resident contact. During an interview on 3/22/23 at 10:21 AM, TNA #2 said they had completed infection control training at the facility. They said they knew the facility had active cases of Covid-19. They said they should wash or sanitize hands before and after entering and exiting a resident room. They said any food product that has been dropped on the floor cannot be placed back on the residents' food tray. They said they should not have picked the coffee creamer off the floor and placed it on the resident tray, however, they had been informed there was a shortage of single serve coffee creamers. They said during lunch meal service on 3/21/23, they forgot to sanitize and wash hands between residents, and they were trying get things done quickly. During an interview on 3/22/23 at 12:58 PM, the Assistant Director of Nursing (ADON) stated the facility had enacted their outbreak protocols and were testing all staff and residents twice per week as indicated. The said they utilized a tracking tool to determine when an individual was exposed or tested positive to determine when droplet/isolation precautions were to be lifted. They said hand hygiene should be performed frequently and specifically between care for residents or after touching items or surfaces in a resident environment. They said when staff were passing out meal trays, there were many opportunities that staff should be performing hand hygiene. They said all staff or visitors entering a floor where cases of Covid-19 were present should wear an N95 respirator mask and a face-shield. They said additional PPE should be worn when entering a resident room including a gown and gloves which should be doffed inside the resident room near the door before exiting. They said nurse managers were responsible for updating signage on resident rooms as residents either tested positive for Covid-19 or completed their isolation period after testing positive. They said the facility updated and reviewed their Covid-19 line listing daily to update as needed while the facility was in an active outbreak. During an interview on 3/22/23 at 1:42 PM, the DON stated they acted as the Infection Preventionist (IP) for the facility. They said all facility staff had received education on use PPE and hand hygiene practices. They said all masks must be worn in a way that properly to covers the nose and mouth. They said staff were required to wear masks throughout the building and should wear N95 masks and face shields while on care units with active cases of Covid-19. They said gowns and gloves should be donned before entering a room on isolation/droplet precautions and should be doffed prior to exiting the room and face shield should then be disinfected. They said there should be signage on the door of resident rooms that were under droplet/isolation precautions. They stated each day a report was print out of rooms coming off from isolation/droplet precautions was provided to nurse managers on the units who would then ensure signage on the door was updated. They said some residents had removed signage from their doors. The DON stated hand hygiene, should be performed frequently during meal service; in between each resident meal tray that was served, before and after entering a resident room and after touching or handling anything in the resident environment. They said if any items from a meal cart dropped on the floor, hand hygiene should be performed by the staff member picking them up and the items should not be served to the resident in order to prevent infection/cross contamination. 10NYCRR 415.19(b)(4) 10NYCRR 415.19(a)(1-3)

Based on interview and record review during an abbreviated survey (Case #NY00305405), the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 3 residents reviewed. Specifically, the facility failed to reconcile Resident #1's hospital medical record on admission. Subsequently, Resident #1 did not receive a BiPAP machine treatment (a form of non-invasive ventilation) from 10/24/2022 to 10/29/2022 and did not receive 7 physician-ordered medications for up to 4 days. Additionally, the facility failed to ensure the physician was notified when the medications and BiPAP were not available. This resulted in harm that is Immediate Jeopardy and Substandard Quality of Care to resident health and safety with the likelihood to affect all residents in the facility. The Immediate Jeopardy was lifted on 11/19/2022. This is evidenced by: Resident #1: Resident #1 was admitted with the diagnoses of respiratory failure, sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts), and schizoaffective disorder. The Admission Observation dated 10/24/2022 at 3:40 PM, documented the resident was alert and oriented to person, place, time, and situation. The Admission Observation documented respiratory equipment used was a CPAP (continuous positive airway pressure therapy- a common treatment for obstructive sleep apnea), oxygen with activity and oxygen while at rest. The Policy and Procedure titled Admission/Readmission Medication Orders dated 9/21/2021, documented upon review and approval of the hospital discharge medication list and discharge summary by the Physician or Nurse Practitioner, the admitting nurse will put the orders into electronic medical record system (EMR). If the next scheduled pharmacy delivery time is after the first scheduled dose of medication for the resident, the Admitting Nurse will check the automatic medication dispensing unit to ensure that the medications are available to administer the first dose. This will be reviewed with the physician and placed as an order. Many times, medications can be started the next day. This will be reviewed with the provider when orders are obtained. A corresponding note will be placed in the EMR. If a medication is not available for the next dose the physician needs to be made aware for new orders at their discretion. A corresponding note will be placed in the EMR. A Hospitalist Progress Note dated 10/23/2022 at 11:15 AM, documented the resident had a significant history for chronic obstructive pulmonary disease (COPD), diabetes (DM), cerebrovascular accident (CVA), and deep vein thrombosis (DVT) on Eliquis (used to prevent serious blood clots from forming due to a certain irregular heartbeat) who presented to the hospital on 9/19 with increased shortness of breath (SOB) and weakness for the past few days, patient admitted to stepdown unit for acute on chronic hypoxic hypercapnic respiratory failure (a condition when there is too much carbon dioxide in the blood) with component of COPD exacerbation transferred to ICU for worsening acidosis (develops when there is too much carbon dioxide (an acid) in the body) and hypercarbia (an increase in carbon dioxide in the bloodstream). The patient had not been wearing BiPAP (a form of non-invasive ventilation) at night for the last 3 weeks prior to hospitalization due to not having a working machine. The progress note documented to continue 3L [of oxygen] at baseline and to continue BiPAP at night. A hospital document with a subtitle Nursing Activity Orders dated 10/23 at 10:48 PM and 10/24 at 4:50 AM, documented: BiPAP set rate (breaths/min) 16, inspiratory positive airway pressure (IPAP) 18, expiratory positive airway pressure (EPAP) 10 and FiO2 (the concentration of oxygen in the gas mixture) 30%. This document was printed by facility staff on 10/24/2022 at 12:10 PM, prior to the resident's admission to the facility. The Hospital Discharge Summary dated 10/24/2022, documented the reason for admission was acute on chronic respiratory failure with hypercapnia. The resident had a significant history for COPD, DM, CVA, and DVT on Eliquis, chronic respiratory failure with hypercapnia and probable OSA (obstructive sleep apnea) on nightly BiPAP. The resident was compliant with the BiPAP at the hospital. The Discharge Summary documented the following medical conditions were resolved: sepsis due to pneumonia (PNA), COPD exacerbation, acute on chronic resp failure with hypercapnia, and PNA due to infectious organism. A review of the Admission Physician Orders and the Medication Administration Record (MAR),documented the following medications were ordered to begin on 10/24/2022 in the evening: -Acetazolamide (a medication used to treat glaucoma, epilepsy, altitude sickness, periodic paralysis, idiopathic intracranial hypertension (raised brain pressure of unclear cause), urine alkalinization, and heart failure) 250 MG (milligram) 2 tabs three times a day at 9 AM, 2 PM, 9 PM. This medication was documented as administered on 10/25/22 at 9 PM. This resulted in 3 missed doses. -Asmanex Twisthaler (used to control and prevent symptoms, such as wheezing and shortness of breath, caused by asthma) 1 puff twice a day at 9 AM and 9 PM. This medication was documented as administered on 10/25/22 at 9 AM. Two doses were documented as not administered on 10/24/22 at 9 PM and 10/25/22 at 9 PM. -Buspirone (used to treat symptoms of anxiety, such as fear, tension, irritability, dizziness, pounding heartbeat, and other physical symptoms) 10 MG 3 times a day at 9 AM, 2 PM, 9 PM. This Medication was documented as not administered on 10/24 at 9 PM. This resulted in 1 missed dose. -Clozaril (used to treat certain mental/mood disorders, including schizophrenia and schizoaffective disorders) 50 MG 4.5 tablets at 8 PM. This medication was documented as not administered until 10/28/22 at 8 PM. This resulted in 4 missed doses. The documentation was as follows: 10/24 at 8 PM- not administered pending delivery from pharm; 10/25 at 8 PM not administered pending review of labs; 10/26 at 8 PM not administered pending review of labs by pharm, MD aware, no new orders; 10/27 at 8 PM not administered: pending review of labs. -Eliquis (used to prevent serious blood clots) 5 MG 2 times a day at 9 AM and 9 PM. This medication was documented as not administered on 10/24 at 9 PM: new admission pending med arrival from pharmacy. This resulted in 1 missed dose. -Metformin (used to control high blood sugar) 500mg BID 9 AM and 9 PM. This medication was documented as not administered on 10/24 at 9 PM: new admission pending med arrival from pharmacy. This resulted in 1 missed dose. A review of the Physician Orders and the Medication Administration Record (MAR), the following medication was ordered to begin on 10/25/2022 in the morning: -Ezetimibe 10mg at 9 AM. This medication was not documented as administered on 10/25 at 9AM: pending delivery from pharm. This resulted in 1 missed dose. A review of the medical record did not include documentation the physician was notified that 7 physician-ordered medications were not available to administer to the resident in accordance with the physician orders and did not include documentation the physician was notified that the resident did not have a BiPAP or BiPAP settings upon admission. Progress notes documented the following: -10/26/2022 at 1:15 PM, by the Nurse Practitioner (NP), the patient was seemingly noncompliant with BiPAP due to machine not working 3 weeks prior to hospitalization , which likely precipitated her current illness. Ensure the residents gets their BiPAP, monitor and follow-up with the resident. The note documented Schizophrenia: continue Clozaril. -10/26/2022 at 2:38 PM, the RN (registered nurse) spoke with resident regarding their BiPAP. The resident did not know their settings for the BiPAP but gave the RN the name and number for their pulmonologist. -10/26/2022 at 4:16 PM, the RN received call back from Pulmonologist office who stated they have gone as far back in their records as possible, and the resident was on the BiPAP prior to coming a patient at their practice. The office did not have evidence of a sleep study and the settings that the resident was on were not in their records. -10/29/2022 at 2:47 PM, the family provided BiPAP settings. The BiPAP company was called, and a message left for BiPAP to be delivered to facility. -10/29/2022 at 9:19 PM, the BiPAP company delivered a BiPAP machine; settings were put in and the resident was fitted with mask. -10/30/2022 at 9:31 AM, the resident was observed out of bed, complaints of nausea related to covid booster received. The resident stated they wore BiPAP all night and felt better. Lungs were diminished bilaterally. The resident denied SOB or dyspnea on exertion (DOE). -10/30/2022 at 2:37 PM, per family request they felt the resident was not themselves; upon assessment the resident could not use their phone and was having difficulty remembering events they would normally be clear on. The note documented ? CO2 retention due to history of hypercarbic respiratory failure. Physician (MD) notified, and family was notified of pending transfer to the hospital. The Hospitalist History and Physical (H&P) dated 10/30/2022 at 11:43 PM, documented today on evaluation in the emergency room , the patient was found to have carbon dioxide (CO2) narcosis (a condition that develops when excessive CO2 is present in the bloodstream, leading to a depressed level of consciousness) and acute on chronic respiratory acidosis with pH of 7.2 (acidosis occurs when the blood is too acidic, with a pH below 7.35), PCO2 of 93 (critical high) on venous blood gas. Also, Ativan (antianxiety medication) 1 MG intravenous for anxiety (patient is having a significant psychiatric history including schizoaffective disorder and PTSD). The H&P Review of Systems documented the resident was positive for shortness of breath, weakness, and confusion. The plan and assessment included the following: -CO2 narcosis with acute confusion/acute respiratory acidosis: currently on BiPAP, continue BiPAP overnight. Patient is significantly improved as far as confusion; suspect etiology was noncompliance with BiPAP for several days. -Schizoaffective disorder/PTSD (post-traumatic stress disorder)/Anxiety: due to break in therapy greater than 2 days, 4 in total, the patient's Clozaril cannot be safely started at the previous dose of 225 MG daily, per discussion with clinical pharmacist and review of prescription recommendations for manufacture, the medication will have to restart at 12.5 MG twice daily with titration toward therapeutic dose of 225 MG daily. During an interview on 11/16/2022 at 12:07 PM, RN #1 stated for new admissions, the nurses used the discharge summary from the hospital, and verified the orders with their physician. RN #1 did not recall there being discrepancies with Resident #1's medications. If a medication was not available, the physician would be notified and the Director of Nursing (DON). There should be documentation the doctor was notified. The nurses should just not give a medication because it was not in the facility. RN #1 stated they saw the resident the day after their admission and the resident told them they were supposed to have a BiPAP. Resident #1 did not mention that the medications were not available. Resident #1 only mentioned that they did not have the BiPAP. RN #1 stated no one knew the settings for the BiPAP. The interdisciplinary team had discussed in a meeting how to order a BiPAP without settings. RN #1 stated they thought another nurse had called the hospital to ask about the BiPAP and the BiPAP settings. During an interview on 11/16/2022 at 12:26 PM, Licensed Practical Nurse (LPN) #1 stated they helped with new admissions and prepped the room with the supplies the resident would need upon their arrival to the facility. LPN #1 stated they received report (nurse to nurse communication) from the hospital for Resident #1's admission and the hospital stated the resident was on a BiPAP and the resident's family would be providing a BiPAP. LPN #1 stated they usually verbally discussed the report from the hospital with the other nurses. The family was supposed to bring in a BiPAP but never did. LPN #1 had not known until later that there had been an issue with obtaining the BiPAP. LPN #1 stated when the nurses were doing an admission, they would go off the discharge summary for the resident's medications and treatments and then would forward it to their physician who would agree with the discharge summary or make changes accordingly. If a medication was not available to administer, the nurses would get an order from the MD to hold the medication, receive another direction, or the physician would order something else. As a nurse, you would have to do something if a med was not available, and the nurse would have 2 hours to do something. LPN #1 stated a nurse would document that they notified the physician when a medication was not available. During an interview on 11/16/2022 at 12:50 PM, LPN #2 stated they recalled that the resident's medications were not available to give on the evening of 10/24/2022. LPN #2 stated working on the Rehab Unit could get hectic and although they tried to notify the physician and document that the physician was notified, that did not always happen. LPN #2 stated they did not administer the resident medications that were pending delivery from pharmacy and did not recall notifying the physician or writing a note. LPN #2 stated they put the resident on the BiPAP the night it came and the next day the resident went to the hospital. During an interview on 11/16/2022 at 2:06 PM, the DON stated the staff were to notify the physician if medications were not available and ask for a new order or to hold until arrival from pharmacy. The DON did not recall if they were notified that Resident #1's medications were not available to be administered. The DON stated the BiPAP and the BiPAP settings were not documented on the discharge summary and none of the hospital paperwork included BiPAP settings. The DON stated staff called the resident's previous facility, they did not have BiPAP settings, the resident's pulmonologist was called, they did not have settings, and the hospital was called, and they did not have BiPAP settings. The DON stated they were aware the resident was to have a BiPAP but could not verify settings and their physician would not order the BiPAP without a setting. The DON stated the NP was made aware on 10/26/2022 by Resident #1 that they did not have a BiPAP, the same day the pulmonologist was called. The DON stated the family was able to obtain settings from a respiratory therapist on 10/29/2022, who treated the resident in the past. At that time, a BiPAP was ordered and received for Resident #1 on 10/29/2022. The DON stated Resident #1 was transferred to the hospital on 10/30/2022 at the request of the family for altered mental status. The DON stated they had been assessing the resident all weekend, the weekend Resident #1 was transferred to the hospital. The DON stated clinically, they did not think the resident needed to go out and thought another night with the BiPAP would help. A review of the medical record did include documentation that the hospital or previous facility were called for BiPAP settings. During an interview on 11/17/2022 at 11:56 AM, RN #2 stated they were asked to find out if the resident had a pulmonologist or if the resident knew the settings for their BiPAP. RN #2 spoke with the resident, who did not know the settings, but knew the name of their pulmonologist. RN #2 called the pulmonologist on 10/26/2022, the same day the resident was seen by the NP. The pulmonologist office did not have settings for the BiPAP. RN #2 stated the hospital had said the resident was on a BiPAP in the hospital and RN #2 saw in the hospital notes that the resident was on a BiPAP but stated the discharge summary did not document the resident was on a BiPAP. The Hospital Discharge Summary did not document settings or orders for a BiPAP. RN #2 stated the discharge summary also said the resident's acute respiratory failure was resolved. RN #2 stated usually, if a resident was coming to the facility on a BiPAP, the discharge summary would document the settings and would document to continue with the BiPAP. RN #2 stated, the DON had mentioned about talking to the family to obtain settings, but that was the end of their involvement with the BiPAP after with speaking with the resident. RN #2 stated when there was a new admission, the nurses entered medications from the discharge summary and the orders were sent to the pharmacy. Most of the time, the nurses had the medications in house stock, or it the medication would be ordered to start the next morning. RN #2 stated if a medication was ordered and the nurses did not have the medication to administer, they would contact the doctor and ask for a substitution or ask for an OK not to give the medication. The nurses would then document in the nurses notes that they spoke to the physician. Sometimes the nurse who reviewed the discharge summary and the discharge medications with the physician, would write in a note that it was OK to give the medication when they arrived from pharmacy. RN #2 stated they did not see that note in Resident #1's chart. During an interview on 11/17/2022 at 3:03 PM, the Admissions Coordinator (AC) stated they did the clinical review for new potential admissions prior to them being admitted . They looked through the hospital portal and hospital documentation to see why the resident was admitted to the hospital and to see if their needs could be accommodated in the facility. The AC stated they did not have Resident #1's paperwork in front of them but what they recalled was that Resident #1 had a BiPAP at their previous facility that was broken. The AC stated they did not believe Resident #1 had a BiPAP at the hospital and the resident did not say that they were currently on a BiPAP. The AC met with Resident #1 and the case manager in the hospital and neither one said the resident was on a BiPAP. The AC stated the discharge summary would document what the resident should be receiving in the facility for their care. The BiPAP would have to have been ordered on the discharge summary and the AC did not recall being told that the resident needed a BiPAP. During an interview on 11/18/2022 at 12:30 PM, the medications with doses that were not documented as administered were reviewed with Physician #1. Physician #1 stated acetazolamide was a diuretic, and it would probably not be significant to miss 3 doses. An indication of a problem would also be excessive weight gain, or the resident being hypertensive (high BP). If the BP was ok, then it would be ok that a couple doses were missed. Physician #1 would not think missing 3 doses of this medication would impact a hospitalization days later. Physician #1 stated missing doses of Asmanex would depend on the resident and their symptoms. It would be ok to miss the inhaler up to 5 days, unless the resident was having severe symptomatic COPD, otherwise it might not have much significance if doses were missed. Physician #1 stated missing 1 dose of Buspar, Eliquis, metformin, and ezetimibe were not significant. Physician #1 stated Clozaril dosing depended on labs and some pharmacies would not dispense the medication until they reviewed labs. Clozaril was a significant medication, and it should not have taken that long (dates reviewed with the physician, 10/24/22 to 10/28/2022) to obtain the medication from pharmacy. Physician #1 stated the staff should have followed up with the pharmacy and when a medication was not available the staff should notify the physician and the physician could order something in the interim. Physician #1 stated most times they received communication from staff when medications were not available from pharmacy. Physician #1 stated if a resident did not take the medication for 48 or 72 hours, there would not be much effect, but more than that, the resident would probably experience withdrawal symptoms, such as agitation, sleeping difficulty, and/or anxiousness. The missed doses of Clozaril probably would not have led to a hospitalization if it was a medical reason as to why the resident was hospitalized . Physician #1 stated if the resident was on oxygen that would have given them a little bit of a buffer before the BiPAP was needed. If the resident did not have O2, then it would be quite significant that the resident did not have the BiPAP. In the absence of the BiPAP, indicators to look for would be oxygen saturations, respiratory rate, and how the resident was breathing, for example, was the resident short of breath, did the resident have difficulty breathing, and was the resident able to complete a sentence. A couple of days without a BiPAP would be ok and it would depend on what the resident was hospitalized for whether the BiPAP played a role. If the resident was admitted to the hospital with difficulty breathing, Physician #1 would have to think it was related to the resident's respiratory status and a BiPAP might be one of the culprits. Physician #1 was aware the resident was sent to the hospital but was not aware why the resident was readmitted . During an interview on 11/21/2022 at 2:05 PM, NP #1 stated they did not recall being made aware that medications were not available from pharmacy to administer to Resident #1. NP #1 stated if the resident had been on Clozaril for a long time, they may go into withdrawal symptoms, symptoms of schizophrenia worsen or behavioral issues. It was not brought to the NP's attention in this case that there was a delay in getting the medication. The nurses should let a facility medical provider know and then the provider would do a risk benefit analysis to determine whether to continue to wait for the medication. NP #1 stated notifying the providers to let them know medications were not available to administer was a standard of practice/care. NP #1 stated the resident did not come into the facility with a BiPAP. A BiPAP was supposed to be brought in from home. NP #1 found out the resident did not have BiPAP through discussion with the resident on 10/26/2022. NP #1 stated they raised concern that the resident did not have a BiPAP and could run into serious problems or might have to be sent back to the hospital. NP #1 stated they discussed the BiPAP with nursing staff and discussed how they could get the resident a BiPAP. Nursing was trying to get the BiPAP setting. NP #1 stated the settings needed to be confirmed with pulmonology and the NP told nursing staff to coordinate with the family. NP #1 stated they were concerned the resident did not have a BiPAP because of the resident's comorbidities and from their discussion with the resident, they used one before they came into the facility. NP #1 stated, they told the resident if they were previously on a BiPAP, the facility had to make sure the resident got one because the resident could go into cardiac arrest and even die. NP #1 stated the resident gave them the impression they would be compliant if the facility got the information to get a BiPAP. NP #1 stated the resident had risk factors that put them at a higher risk to worsen their sleep apnea without a BiPAP. The NP stated the BiPAP was something they wanted the resident to have to decrease the resident's risk of hospitalization . If a resident came to the nursing home with BiPAP settings the settings would need to be reviewed because the hospital settings might be set higher than what they would have in a nursing home; however, it was very likely that those settings from the hospital would be continued after they were reviewed. NP #1 stated they were not sure how the BiPAP played out as they had been off for 2 weeks. During a subsequent interview on 11/22/2022 at 11:48 AM, the AC stated prior to the resident's admission, they reviewed the hospital paperwork and then sent the paperwork via email to the rest of the team at the facility. The email contained the information the AC reviewed from the hospital. The email was sent to a lot of different people, including the nursing department, therapy, social work, and administration. The AC stated they did not recall seeing the BiPAP setting in the hospital paperwork or in the physician orders. The AC stated they spoke with case managers in the hospital for additional information that was needed for a resident's admission, but the case managers did not tend to give a lot of information. The nurses in the facility would get report from the hospital nurses and might get more detailed information that was not provided to AC by the case manager. The nurses would follow up on whatever information they received in the nurse-to-nurse report at that point. During an interview on 11/23/2022 at 10:24 AM, the Administrator stated the AC sent an email to the facility before the admission came that included the hospital paperwork. The Administrator received the emails but was not involved clinically for new admissions. The Administrator was not exactly sure of what everyone did for a new admission. The AC reviewed the paperwork initially, and the first person to clinically review the paperwork was DON or Unit Manager. The Administrator stated the resident was in the hospital for a month and the facility staff would not review all the paperwork; they would review the discharge summary and the facility went by the orders given to them from the hospital. The Administrator stated a BiPAP was not ordered in the discharge summary, and it was not listed on the discharge summary that the resident would need a BiPAP. The Administrator stated there were a lot of modalities in the hospital that were not carried over to the nursing home so that was not unusual. The Administrator stated the facility physician would have to provide orders for the BiPAP and they did not upon the resident's admission. The Administrator stated the resident's medications should have been ordered to start the next day with physician approval. The Administrator stated the physician should have been called when the medications were not available to administer. For the Clozaril, the Administrator recalled the DON stating they needed to get labs for the pharmacy to dispense the medication. The Administrator did not know if the physician was made aware at that point that the Clozaril was not available to be administered. During a subsequent interview on 11/23/2022 at 10:49 AM, the DON stated the AC sent the hospital information for new admissions to the team at the facility via email and it was reviewed by the different departments. The DON was sure who looks at what for their discipline. The DON stated they did not know there were BiPAP settings in the hospital paperwork or else they would have used them. For new admissions, the nurses reviewed the discharge summary with the discharge orders and the PRI (Patient Review Instrument- a medical evaluation tool). The DON stated the discharge summary documented the resident was compliant in the hospital with the BiPAP but did not list an order below that for the BiPAP and the BiPAP was not documented on the PRI. The family was called to bring in the BiPAP, but they were not necessarily called for a BiPAP settings that was why on Saturday (10/29) when they said they could get a setting, the DON said for them to go ahead. The DON stated best practice was for the physician to be notified at the time a medication was not available and each time that medication was not available. The DON stated they send the hospital labs to pharmacy for the Clozaril. Pharmacy requested the labs and the DON told them they already sent the labs. Then the facility was told they needed to obtain new lab work. Once the new lab work was obtained and sent to the pharmacy, the pharmacy dispensed the medication. The DON stated it was difficult to get Clozaril because of the nuances to it and the specific lab values. Typically, the facility would get the labs from the hospital and send them to the pharmacy, and pharmacy would dispense the medication. 10 NYCRR415.12

Based on record review and staff interview during a partial extended abbreviated survey (NY# 704 and NY# 927), the facility did not immediately investigate or prevent further potential abuse after the report of witnessed resident abuse for two (Resident #1 and #2) of three residents reviewed. Additionally, the facility did not screen employees in accordance with established policies and procedures. Specifically, for Resident #1 a Certified Nurse's Assistant (CNA) reported witnessed potential abuse by another CNA to two Licensed Practical Nurses (LPNs) and a Registered Nurse Supervisor (RNS). The resident verbalized that her arm was broken and the alleged abuser remained assigned to the resident for more than 5 hours after the report. The resident was not assessed, was sent to the hospital and diagnosed with [REDACTED]. The facility failed to report the incident to law enforcement immediately. Resident #2 was the victim of misappropriation of resident funds on 7/17/13. The facility did not report the incident to the Department of Health, did not investigate the incident thoroughly and did not assess or care plan to protect the resident from further victimization. On 8/31/13 Resident #2 reported to an LPN that she was victimized again. The LPN failed to report the allegation to supervisory staff . When the resident continued to verbalize that she was robbed again, the facility initiated an investigation. This has the potential to affect all residents in the facility. This resulted in no actual harm but has the potential for more than serious harm that is Immediate Jeopardy to the health and safety of the residents and Substandard Quality of Care. This is evidenced by: Resident #1 was admitted to the facility on [DATE] diagnosed with [REDACTED]. Incident and Accident Report dated 8/17/13 at 4:00 pm documented that Resident #1 struck CNA #1 on the right side of the face with a closed fist, when CNA #1 and CNA #2 were changing the resident and she again became combative with them. Nurses Note dated 8/17/13 at 4:57 pm signed by RNS #1 documented that "the CNA assigned to this resident 1:1 informed me that this resident struck her on the right side of her face and that she is going home. She was persuaded to stay until RN was able to come to the unit to assess and evaluate the situation. The resident was agitated and restless and was difficult to follow instruction and to redirect. She remains alert and very confused and seated in her wheelchair. She is also speaking incoherently to herself. She also "stated that her left arm is broken" upon inspection and examination there exists range of motion (ROM), no swelling present, no change in color." Nurse's Note dated 8/18/13 at 12:31 am signed by LPN #3 documented that the resident complains of left arm pain, states it is broken. RN Supervisor to assess, will continue to monitor. Nurse's note dated 8/18/13 at 8:55 am signed by LPN #4 documented that the resident was given Tylenol for left arm pain and that the resident's left arm and wrist are swollen and red upon examination, supervisor notified. X-ray report dated 8/18/13 documented an oblique [MEDICAL CONDITION] arm. Nurse's note dated 8/18/13 at 1:01 pm signed by RNS #2 documented that the resident's physician was notified of the x-ray results and an order was obtained to transfer the resident to the hospital. In a facility statement dated 8/17/13, CNA #1 documented that she was giving care to Resident #1 when Resident #1 struck her in the face with her right closed fist. CNA #1 further documented that she and CNA #2 took the resident to her room. CNA #1 documented that the resident continued to be combative during incontinence care, was swinging at her while and she was able to snatch the incontinence brief from between the residents legs. CNA #1 documented that the resident continued to be combative by swinging at her and she grabbed her arm to keep her from hitting her again. CNA #1 documented that at no time did she abuse Resident #1. In a statement dated 8/17/13, CNA #2 documented that she and CNA #1 transferred the resident onto the commode when Resident #1 starting hitting CNA #1. CNA #2 documented that CNA #1 grabbed the resident's arm and twisted it behind her back then ripped off her incontinence brief and slapped the resident's face with it, grabbed the resident's arm and persisted on making the resident hit herself with her own hand. CNA #2 documented that upon removing the resident from the bedroom, the resident stated that her arm was broken. CNA #2 documented that she reported to two nurses on the floor at the time who reported it to the RNS. CNA #1's Time Card documented that on 8/17/13, CNA #1 punched out at 9:30 pm. Two days later, in a follow-up statement conducted by the Corporate RN and signed by CNA #2, CNA #2 documented that she and CNA #1 were assisting the resident to her wheelchair when the resident struck CNA #1. CNA #2 documented that she transported the resident to her room and CNA #1 came to assist with toileting. CNA #2 documented that once on the commode, the resident became combative and CNA #1 grabbed the resident's left wrist, twisted her arm up and behind her head. CNA #2 stated that CNA #1 then grabbed the soaked incontinence brief and hit the resident in the face with it. CNA #2 documented that she witnessed CNA #1 taking the resident's left arm, above her wrist and struck the resident on the left side of her face with the resident's hand. CNA #2 documented that she removed the resident from her room and the resident stated to her "my arm is broken" and that she continued to repeat the statement all night. CNA #2 documented that she reported the incident to LPN #1 who went to RNS #1 and reported back stating he "handled it." CNA #2 stated she then reported the incident to LPN #2 who didn't say much but appeared shocked. CNA #2 stated she then went to the RNS and reported the incident to her and then RNS directed her to write a statement and stated that she would call the on-call RN to figure out what to do. CNA #2 documented at about 7:00 pm, CNA #1, who was the resident's 1:1(always remained with the resident) CNA, asked for assistance in putting the resident to bed. CNA #2 stated that she remained on duty for the 11pm - 7am shift and was assigned to Resident #1. CNA #2 documented that she approached the resident at 11:30 pm and the resident stated her arm hurt and was hiding her arm under the blanket. CNA #2 documented that she observed the residents arm, noted a bruise to her forearm and swelling in the same area and reported it to LPN #3. CNA #2 documented that LPN #3 looked at the resident's arm and stated that she would notify the supervisor to assess her and would chart it. CNA #2 stated she observed the resident at 3:00 am and again at 6:00 am and the resident continued to complain of pain in her arm and each time CNA #2 reported the resident's complaint to LPN#3 who told her that it had been charted. In a facility statement dated 8/20/13, LPN #1 documented on 8/17/13 he was assigned to the 3:00 pm - 11:00 pm shift and shortly after his shift began, he overheard two CNAs talking and approached them to find out what was wrong. LPN #1 documented that CNA #2 stated that Resident #1 was stating that her arm was broken, and she didn't want to cause problems but didn't know what to do. LPN #1 documented that he approached the resident and asked her what was wrong and the resident responded "they broke my arm" and was guarding her left forearm. LPN #1 documented that he asked the resident who and the resident responded "that [***] broke my arm." LPN #1 documented that he observed the resident's arm near her wrist, identified discoloration and immediately reported to RNS #1. LPN #1 documented that RNS stated that she would get to it but she was busy. LPN #1 documented that he approached LPN #2 to determine if she was aware of an incident, and when she didn't appear to be aware of it, LPN #1 stated that he went back to RNS #1 and reiterated that the resident needed to be assessed. LPN #1 documented that RNS #1 asked him how the resident's arm looked and he told her that he could not make an assessment but that the arm looked "off" and told her that she needed to look at it because the resident may have been involved in an incident and was complaining of pain. LPN #1 documented that he recommended an x-ray and that she further investigate the incident. LPN #1 documented that RNS #1 accompanied him into the dining room, briefly looked at the residents arm, moved it a bit and stated "she has range of motion, she is fine". LPN #1 documented that he was unfamiliar with the resident and was not sure if her range of motion was within normal limits for her but "it didn't appear so." LPN #1 documented that RNS #1 stated she would take care of everything and make the notes. LPN #1 documented that the next day (8/18/13), the day supervisor, RNS #3, asked if he knew anything about Resident #1's arm and told her that he didn't know about the incident or who was involved but knew that Resident #1's arm looked off. In an undated facility statement, LPN #2 documented that between 5:00 pm and 5:30 pm, Resident #1 became agitated in the dining room and was being wheeled from behind in her wheelchair when Resident #1 raised her hand and punched CNA #1 on the left side of her face and CNA #1 and CNA #2 then brought the resident to her room. LPN #2 documented that she called the RNS #1 to the floor, and called a second time to report that the resident was agitated, had hit a CNA and that the resident was stating that her arm was broken. LPN #2 documented that she asked the RNS #1 how to obtain an x-ray and the RNS #1 questioned her about her assessment and the resident's range of motion. LPN #2 documented that she informed RNS #1 that she could not make that decision and suggested an x-ray to be safe. LPN #2 documented that CNA #2 had approached her and reported that she had witnessed CNA #1 physically abuse the resident and LPN #2 documented that she was "shocked and stunned". LPN #2 documented that she agreed with CNA #2 that the incident needed to be reported and she paged the RNS #1. LPN #2 documented that after CNA #2 reported the incident to her, she approached CNA #1 and told her that CNA #2 was reporting the incident and that she would be reporting the incident too. After noting that CNA #1 was being sent home, she asked CNA #2 if she had reported the incident and CNA #2 said yes. LPN #2 documented she had called to RNS #1 several times but RNS #1 did not get to the floor and she did not have the opportunity to report the incident. In a facility statement dated 8/20/13 at 3:15 pm, LPN #3 documented she checked Resident #1 at midnight and her arm was swollen and red and she notified her supervisor, RNS #3. LPN #3 documented that RNS #3 did not come to see the resident. LPN #3 documented that later in the shift, RNS #3 came to the unit, they had a conversation and she reported that the resident was stating that her arm was broken, complained of pain and RNS#3 stated "I am tired of cleaning up after RNS #1's messes." LPN #3 documented that RNS #3 did not see the resident. LPN #3 documented that at the end of her shift, she requested the day supervisor, RNS #2, to contact the resident's physician. Review of Attendance Record dated 7/19/13 for Abuse, Mistreatment and Misappropriation inservice documented 32 staff signatures. Review of Attendance Record dated 8/20/13 for Abuse, Neglect, Mistreatment Travel Board inservice documented 51 staff signatures. Review of staff Responsibility to review Resident Profile inservice dated 8/28/13-8/30/13 documented 64 staff signatures. Review of facility staffing listed dated 9/19/13 documented 273 employees. During an interview with the Administrator and the Assistant Director of Nursing (ADON) on 8/26/13 at 11:30 am, the Administrator stated that CNA #2 reported an allegation of physical abuse to two LPNs and the RNS. The Administrator stated that he learned of the incident on 8/19/13 and began an investigation. The Administrator stated that it did not appear that while there is documentation that the RNS #1 observed Resident #1, it does not appear that it addressed the concern of the alleged physical abuse. The Administrator further stated that when the resident continued to complain of pain, she was not assessed by the RNS #3. The Administrator stated that RNS #1 should have immediately suspended the accused pending the investigation, and did not do so. The Administrator stated that the accused remained on duty for several hours after the incident. The Administrator stated that he was not notified of the alleged incident until the morning of 8/19/13, and he should have been called immediately. The Administrator stated that RNS #1 resigned and the other nursing staff were inserviced on Abuse, Neglect and Mistreatment reporting. The ADON stated that she was acting for the Director of Nursing (DON)and she was advised of the allegation on 8/18/13, she did not direct anyone to contact the local law enforcement authorities but was familiar with the Elder Justice Act and reporting requirements. The ADON further stated that she should have contacted the Administrator when she became aware of the incident. During an interview on 9/19/13 at 11:30 am, the RN Educator stated that she is responsible for conducting the education within the facility including Abuse, Neglect and Mistreatment. The RN educator stated that on or about 7/19/13 there was an incident in which a resident's credit card was used by a CNA and the RN educator was asked by administration to conduct abuse, neglect and misappropriation of resident fund training. The RN educator stated that she started the training and got who she could to go. The RN educator stated she was told again to complete abuse, neglect and mistreatment training with staff after the facility determined that Resident #1's arm had been broken allegedly by a CNA. The RN educator stated that she began the training and once again, got as many staff as she could but because the training was not put forward as mandatory, where all staff would be required to report to the facility for the training, she did not educate all facility staff on abuse, neglect and mistreatment. The RN Educator stated that another incident occurred on 8/22/13 in which a CNA failed to follow the care plan and another resident was injured. The RN Educator stated that she again initiated another abuse, neglect and mistreatment training, this time emphasizing the need to follow the care plan and profile card, but again, was unable to educate all facility staff. The RN educator stated that she was not directed to conduct training for the licensed nursing staff on assessments. The RN Educator stated, "I have an issue with being re-active, I would bring up issues during morning report and suggest reeducation and accountability of the RNs and was met with an "I know" response from administration, but since we are constantly trying to put fires out, we haven't been able to do it. During an interview on 9/19/13 at 4:00 pm, the Chief of Operations stated that he oversees the facility operations and provides support services to the facility upon request, however, expects that the facility administrator and staff will follow regulaory requirements and the incident reporting procedures. The Chief of Operations stated that investigations were a concern, however, he does not recall reviewing any incident in detail but that a webinar was held recently. In review of the incident involving Resident #1, the Chief of Operations stated that the goal of an immediate investigation is for protection of residents and the alleged abuser should go home and the resident's should be assessed. The Chief of Operations stated he was unaware that CNA accused of breaking resident #1's arm remained on duty for 4 to 5 hours as the resident's 1:1 aide and stated "on a weekend, at that facility, I'd say 4 hours to get that person out is progress." Resident #2 was admitted to the facility on [DATE] diagnosed with [REDACTED]. The MDS dated [DATE] assessed the resident as cognitively intact. Policy and Procedure titled Abuse, Neglect, Mistreatment and Misappropriation of Resident's Property last revised on 8/19/11 documented that "Misappropriation of Resident Property" means deliberate misplacement, exploitation or wrongful, temporary, or permanent use of resident's belongings or money without the resident's consent." The Policy and Procedure also documented that all perspective employees will be screened prior to employment to rule out any history of prior abuse or mistreatment to residents. This will include contacting the state nurse aide registry. Policy and Procedure titled Abuse, Neglect, Mistreatment and Misappropriation of Resident's Property last revised on 8/19/13 documented that "Misappropriation of Resident Property" means deliberate misplacement, exploitation or wrongful, temporary, or permanent use of resident's belongings or money with/without the resident's consent." Investigation Summary dated 7/17/13 signed by the DON documented that Resident #2 had given her credit card and personal identification number to CNA #3 to purchase and exchange some clothing from a local retailer. The summary documented that with the assistance of the DON, the resident contacted the credit card company to cancel the credit card and was informed of two unauthorized transactions by CNA #3. The DON and the Administrator attempted to reach CNA #3 to direct that she return the residents credit card and to meet with them, however, the calls went unanswered. The police were notified. The investigative summary documented that the plan was to follow up with the police report, have social services and psychology provide support and reassurance, continue with suspension and terminate aide if appropriate, to assist the resident with filing a claim with the credit card company and to provide the resident with the funds available to the facility to attain proper fitting clothing. Incident/Accident (I&A) Report signed 9/1/13 by RNS #3, documented that she responded to the resident's floor after Resident #2 complained about being robbed. The I&A documented that the resident reported to LPN #5 on 8/31/13 at 8:00 pm and re-reported to several staff on 9/1/13 at the nursing station. During an interview on 8/26/13 at 11:30 am the Administrator and ADON , Department of Health (DOH) surveyor reported the allegations of case #NY 7 and the Administrator stated that it was an investigation that the DON was doing and that he was aware there was an allegation of misappropriation of resident funds. The Administrator was advised that the allegation was not reported to the DOH and the Administrator stated that he was not aware that it was not reported, however, it should have been and the reporting to DOH would have been the responsibility of the DON. The Administrator stated that he would attempt to locate the investigation as the DON was on vacation and unable to be reached. During an interview on 9/4/13 at 8:45 am with the Administrator and the DON, the DON stated that she did not report the misappropriation of resident funds to the DOH because it was not required as stated in the facility's policy and procedures. The DON stated that the policy was updated and she now understands that she was required to report the resident's allegation of 7/17/13. During an interview on 9/4/13 at 12:45 pm, the Administrator stated he was unaware the resident was requesting to access funds from an outside source. The Administrator stated that he was aware that the resident had given a CNA her card and that after the unauthorized transactions, he knew that the DON was working with the resident to get a new card and that the resident was told not to give her card to anyone. The Administrator stated that he had never heard of a resident requesting assistance with accessing funds from an outside source but if he had, "I would have had the social worker go out with the resident." The Administrator stated, "had the resident come to my office, we would have done it, it is reasonable that the facility would facilitate this for her." The Administrator stated that after the first incident, he would expect that the facility would make sure that the resident had a locked box in her room, that the social worker would work with the resident to insure that she was not psychologically affected by the incident. The Administrator was advised that the social worker stated to the DOH that she was unaware of the incident on 8/31/13 and the Administrator stated, "that would surprise me, everyone knows." The Administrator stated that Resident #2 had left him a voice mail message stating she was robbed again, however he had not had any communication with the Director of Social Services about the second incident and had not asked anyone to assess the resident for psychological impact to the resident. The Administrator stated that the social work staff did not bring to his attention that she needed assistance in accessing funds, but given the past, "I would have addressed it." During an interview on 9/19/13 at 9:30 am, the Human Resource (HR) Director stated that she is newly appointed to her position and received one and half days of training in her new role which includes all Human Resource functions and payroll. The HR Director stated that she is responsible for the screening of all new non-licensed staff members in the facility. The HR Director was asked to locate the nurse aide registry check for a housekeeper, and the HR Director stated that she was unable to locate the nurse aide registry check. When asked about a licensed staff member's nurse aide registry check, the HR Director stated that the Administrative Assistant completes the checks for licensed staff. When asked about the staff in the Physical Therapy Department, the HR Director stated that the facility does not keep files on the Physical Therapy Department staff because they are contracted staff. During an interview on 9/19/13 at 10:00 am, the Administrative Assistant stated that she does not complete nurse aide registry checks on licensed staff. During an interview on 9/19/13 at 11:00 am, the Administrator stated that he was unaware that there was not a nurse aide registry check on the housekeeper and that the Administrative Assistant completes the screening of licensed staff members. The Administrator stated that the Administrative Assistant does not complete nurse aide registry checks for licensed staff members, was asked to read the screening portion of the Abuse Policy and read that the screening should be conducted on all perspective employees and stated "I don't think that should be in there." I don't think we have ever done that." A short time later, the Administrator stated that he was mistaken and thinking about another screening procedure and that yes, the facility should be screening all employees through the nurse aide registry check, and he was unaware that it was not being done. The Administrator stated that he reports directly to the Chief of Operations and had advised him of the on-going incidents. The Administrator stated that typically he will forward via emial the investigations to the Chief of Operations but does not recall any specific direction with regard to Resident #1's investigation other than to insure that all all staff were inserviced on abuse prevention and reporting. During an interview on 9/19/13 at 4:00 pm, the Chief of Operations stated he was aware that the facility was late or did not report at all to the DOH regarding the misappropriation of Resident #2's funds, and that is should have been reported according to the incident reporting manual. The Chief of Operations stated that he was aware of the second incident of misappropriation of Resident #2's funds and he believed that was reported. 10NYCRR 415.4(b)(1)(ii)

Based on medical record review and staff interview during a partial extended abbreviated survey (NY 704), the facility did not provide the necessary care and services to attain or maintain the highest practicable physical and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, for 2 (Resident #1 and 2 ) of 5 residents reviewed, upon report by a Certified Nurses Assistant (CNA) of a witnessed physical abuse of Resident #1 and Resident #1's verbal complaint that her arm was broken to two Licensed Practical Nurses (LPNs) and the Registered Nurse Supervisor (RNS), the facility did not thoroughly assess the resident at the time the incident was reported, did not immediately investigate the allegation of abuse, did not remove the alleged abuser from resident care, did not assess the resident after the resident continued to verbalize that her arm was broken, and did not immediately report the incident to local law enforcement authorities. Resident #2 was the victim of misappropriation of resident funds and reported to staff money was missing. The facility did not report the incident to the Department of Health (DOH), did not investigate the incident thoroughly and did not assess the resident or care plan to protect the resident from further victimization. This has the potential to affect all residents in the facility. This resulted in actual harm for Resident #1 and no actual harm for Resident #2 and has the potential for more than serious harm that is Immediate Jeopardy to the health and safety of the residents and Substandard Quality of Care. This was evidenced by the following: Resident #1 was admitted to the facility on [DATE] diagnosed with [REDACTED]. Incident and Accident Report dated 8/17/13 at 4:00 pm documented that Resident #1 struck CNA #1 on the right side of the face with a closed fist, when CNA #1 and CNA #2 were changing the resident and she again became combative with them. Nurses Noted dated 8/17/13 at 4:57 pm signed by RNS #1 documented that "the CNA assigned to this resident 1:1 observed when she called and informed me that this resident struck her on the right side of her face and that she is going home. She was persuaded to stay until RN was able to come to the unit to assess and evaluate the situation. The resident was agitated and restless and was difficult to follow instruction and to redirect. She remains alert and very confused and seated in her wheelchair. She is also speaking incoherently to herself. She also "stated that her left arm is broken" upon inspection and examination there exists range of motion (ROM), no swelling present, no change in color." Nurse's Note dated 8/18/13 at 12:31 am signed by LPN #3 documented that the resident complains of left arm pain, states it is broken. RN supervisor to assess, will continue to monitor. Nurses Note dated 8/18/13 at 3:43 am, signed by LPN #3, documented that she was called to the resident's room to look at her left wrist, her left wrist appears to have a bruise and is slightly swollen. resident still complains of pain but refuses medication, will continue to monitor and supervisor is aware. Nurses Note dated 8/18/13 at 8:55 am signed by LPN #4 documented that the resident was given Tylenol for left arm pain and that the resident's left arm and wrist are swollen and red upon examination, supervisor notified. X-ray report dated 8/18/13 documented a oblique [MEDICAL CONDITION] arm. Nurse's note dated 8/18/13 at 1:01 pm signed by RNS #2 documented that the resident's physician was notified of the x-ray results and ordered to transfer the resident to the hospital. In a facility statement dated 8/17/13 , CNA #1 documented that she was giving care to Resident #1 when Resident #1 struck her in the face with her right closed fist. CNA #1 further documented that she and CNA #2 took the resident to her room. CNA #1 documented that the resident continued to be combative during incontinence care, was swinging at her while and she was able to snatch the incontinence brief from between the residents legs. CNA #1 documented that the resident continued to be combative by swinging at her and she grabbed her arm to keep her from hitting her again. CNA #1 documented that at no time did she abuse Resident #1. In a facility statement dated 8/17/13, CNA #2 documented that she and CNA #1 transferred the resident onto the commode when Resident #1 starting hitting CNA #1. CNA #2 documented that CNA #1 grabbed the resident's arm and twisted it behind her back then ripped off her incontinence brief and slapped the resident's face with it, grabbed the resident's arm and persisted on making the resident hit herself with her own hand. CNA #2 documented that upon removing the resident from the bedroom, the resident stated that her arm was broken. CNA #2 documented that she reported to two nurses on the floor at the time who reported it to the RNS. CNA #1's Time Card documented that on 8/17/13, CNA #1 punched out at 9:30 pm. Two days later, in a follow-up facility statement conducted by the Corporate RN and signed by CNA #2 on 8/19/13, CNA #2 documented that she and CNA #1 were assisting the resident to her wheelchair when the resident struck CNA #1. CNA #2 documented that she transported the resident to her room and CNA #1 came to assist with toileting. CNA #2 documented that once on the commode, the resident became combative and CNA #1 grabbed the resident's left wrist, twisted her arm up and behind her head. CNA #2 stated that CNA #1 then grabbed the soaked incontinence brief and hit the resident in the face with it. CNA #2 documented that she witnessed CNA #1 taking the resident's left arm, above her wrist and stuck the resident on the left side of her face with the resident's hand. CNA #2 documented that she removed the resident from her room and the resident stated to her "my arm is broken" and that she continued to repeat the statement all night. CNA #2 documented that she reported the incident to LPN #1 who went to RNS #1 and reported back stating he "handled it." CNA #2 stated she then reported the incident to LPN #2 who didn't say much but appeared shocked. CNA #2 stated she then went to the RNS #1 and reported the incident to her and then RNS #1 directed her to write a statement and stated that she would call the on-call RN to figure out what to do. CNA #2 documented at about 7:00 pm, CNA #1, who was the resident's 1:1 CNA, asked for assistance in putting the resident to bed. CNA #2 stated that she remained on duty for the 11:00 pm - 7:00 am shift and was assigned to Resident #1. CNA #2 documented that she approached the resident at 11:30 pm and the resident stated her arm hurt and was hiding her arm under the blanket. CNA #2 documented that she observed the residents arm, noted a bruise to her forearm and swelling in the same area and reported it to LPN #3. CNA #2 documented that LPN #3 looked at the resident's arm and stated that she would notify the supervisor to assess her and would chart it. CNA #2 stated she observed the resident at 3:00 am and again at 6:00 am and the resident continued to complain of pain in her arm and each time CNA #2 reported the resident's complaint to LPN#3 who told her that it had been charted. In a facility statement dated 8/20/13, LPN #1 documented on 8/17/13 he was assigned to the 3:00 pm - 11:00 pm shift and shortly after his shift began, he overheard two CNAs talking and approached them to find out what was wrong. LPN #1 documented that CNA #2 stated that Resident #1 was stating that her arm was broken, and CNA #2 didn't want to cause problems but didn't know what to do. LPN #1 documented that he approached the resident and asked her what was wrong and the resident responded "they broke my arm" and was guarding her left forearm. LPN #1 documented that he asked the resident who and the resident responded "that [***] broke my arm." LPN #1 documented that he observed the resident's arm near her wrist, identified discoloration and immediately reported to RNS #1. LPN #1 documented that RNS stated that she would get to it but she was busy. LPN #1 documented that he approached LPN #2 to determine if she was aware of an incident, and when it didn't appear that she was aware, LPN #1 stated that he went back to RNS #1 and reiterated that the resident needed to be assessed. LPN #1 documented that RNS #1 asked him how the resident's arm looked and he told her that he could not make an assessment but that the arm looked "off" and told her that she needed to look at it because the resident may have been involved in an incident and was complaining of pain. LPN #1 documented that he recommended an x-ray and that the RNS #1 further investigate the incident. LPN #1 documented that RNS #1 accompanied him into the dining room, briefly looked at the residents arm, moved it a bit and stated "she has range of motion, she is fine" LPN #1 documented that he was unfamiliar with the resident and was not sure if her range of motion was within normal limits for her but "it didn't appear so." LPN #1 documented that RNS #1 stated she would take care of everything and make the notes. LPN #1 documented that the next day (8/18/13), the dayshift supervisor, RNS #2, asked if he knew anything about Resident #1's arm and told her that he didn't know about the incident or who was involved but knew that Resident #1's arm looked off. In an undated facility statement, LPN #2 documented that between 5:00 pm and 5:45 pm, Resident #1 became agitated in the dining room and was being wheeled from behind in her wheelchair when Resident #1 raised her hand and punched CNA #1 on the left side of her face, and CNA #1 and CNA #2 then brought the resident to her room. LPN #2 documented that she called the RNS to the floor, and called a second time to report that the resident was agitated, had hit the CNA #1and that the resident was saying that her arm was broken. LPN #2 documented that she asked the RNS #1 how to obtain an x-ray and the RNS #1 questioned her about her assessment and range of motion in the resident's arm. LPN #2 documented that she informed the RNS #1 that she could not make that decision and suggested an x-ray to be safe. LPN #2 documented that CNA #2 had approached her and reported that she witnessed CNA #1 physically abuse the resident and she was "shocked and stunned". LPN #2 documented that she agreed with CNA #2 that the incident needed to be reported and she paged the RNS #1. LPN #2 documented that after CNA #2 reported the incident to her, she approached CNA #1 and told her that CNA #2 was reporting the incident and that she would too. LPN #2 documented that after CNA #1 was sent home, she asked CNA #2 if she had reported the incident and the CNA said yes. LPN #2 documented that she would have reported the incident also but was being told by the RNS #1 that she would be up shortly but she never got the chance to talk to her. In a facility statement dated 8/20/13 at 3:15 pm, LPN #3 documented she checked Resident #1 at midnight and her arm was swollen and red and she notified her supervisor, RNS#3. LPN #3 documented that RNS #3 did not come to see the resident. LPN #3 documented that she is not sure of the time, but she did have a conversation with RNS #3 that the resident stated her arm was broken, complained of pain and was refusing Tylenol and the RNS #3 stated "I'm tired of cleaning up RNS #1's messes" and that RNS #3 came onto the unit but did not see the resident. LPN #3 stated that at the end of her shift, she asked that RNS #2 contact the resident's physician. During an interview with the Administrator and the Assistant Director of Nursing (ADON) on 8/26/13 at 11:30 am, the Administrator stated that CNA #2 reported an allegation of physical abuse to two LPNS and the RNS. The Administrator stated that he learned of the incident on 8/19/13 and began an investigation. The Administrator stated as a result of the investigation he initiated on 8/19/13, he was concerned with several aspects of the handling of the allegation of abuse. The Administrator stated that it did not appear that while there is documentation that the RNS #1 observed Resident #1, it does not appear that it addressed the concern of the alleged physical abuse. The Administrator further stated that when the resident continued to complain of pain, she was not assessed by the RNS #3. The Administrator stated that RNS #1 should have immediately suspended the accused pending the investigation, and did not do so. The Administrator stated that the accused remained on duty for several hours after the incident. The Administrator stated that he was not notified of the alleged incident until the morning of 8/19/13, and he should have been called immediately. The Administrator stated that RNS #1 resigned and the other nursing staff were inserviced on Abuse, Neglect and Mistreatment reporting. The ADON stated that she was acting for the Director of Nursing (DON) and she was advised of the allegation on 8/18/13, she did not direct anyone to contact the local law enforcement authorities but was familiar with the Elder Justice Act and reporting requirements. The ADON further stated that she should have contacted the Administrator when she became aware of the incident. Resident #2 was admitted to the facility on [DATE] diagnosed with [REDACTED]. The MDS dated [DATE] assessed the resident as cognitively intact. Policy and Procedure titled Abuse, Neglect, Mistreatment and Misappropriation of Resident's Property last revised on 8/19/11 documented that "Misappropriation of Resident Property" means deliberate misplacement, exploitation or wrongful, temporary, or permanent use of resident's belongings or money without the resident's consent." Policy and Procedure titled Abuse, Neglect, Mistreatment and Misappropriation of Resident's Property last revised on 8/19/13 documented that "Misappropriation of Resident Property" means deliberate misplacement, exploitation or wrongful, temporary, or permanent use of resident's belongings or money with/without the resident's consent." Investigation Summary dated 7/17/13 signed by the Director of Nursing (DON) documented that Resident #2 had given her credit card and personal identification number to CNA #3 to purchase and exchange some clothing from a local retailer. The summary documented that with the assistance of the DON, the resident contacted the credit card company to cancel the credit card and was informed of two unauthorized transactions by CNA #3. The DON and the Administrator attempted to reach CNA #3 to direct that she return the residents credit card and to meet with them, however, the calls went unanswered. The police were notified. The investigative summary documented that the plan was to follow up with the police report, have social services and psychology provide support and reassurance, continue with suspension and terminate aide if appropriate, to assist the resident with filing a claim with the credit card company and to provide the resident with the funds available to the facility to attain proper fitting clothing. In a statement dated 8/27/13, Resident #2 documented that on 7/17/13 she gave her credit card to a CNA to purchase clothing for her. In her statement, Resident #2 documented that "CNA told me that since she was running this errand for me, could she have money for gas" and the resident told her she could take $10. In a statement signed and dated 8/30/13, the Licensed Master Social Worker (LMSW) documented that she was advised by nursing on 7/17/13 that Resident #2 had given her credit card to a CNA and that the CNA had taken money from the card. In a memo undated, the Business Office Manager documented that on 7/19/13 she met with Resident #2, the Nurse Practitioner and a member of the activities department, to discuss how the facility could assist the resident in purchasing some items she needed. The Business Officer Manager documented that the resident reported that she did not have any funds because her money had been stolen when she asked a Certified Nurses Assistant to buy her some things. The Business Office Manager documented that the resident was told not to ever give her credit card or cash to anyone and that if she needed something she should come to her office or to her social worker and they would help her obtain the needed items. The Business Office Manager documented that the resident understood that staff were not allowed to shop for her. Progress Notes for the period of 7/17/13 through 8/5/13 did not contain any notes from Social Work. Nursing Service 24-hour Report dated 8/31/13 documented "nothing" for the 7 am - 3 pm shift and "no issues" for the 3 pm - 11 pm shift. Nursing Service 24-hour Report dated 9/1/13 documented "complaint of stolen money" for the 7 am - 3 pm shift. Nurses note dated 9/1/13 at 1:15 pm signed by LPN #6 documented that upon arrival, Resident #2 stated that someone stole $190 out of her dresser and it went missing at approximately 6 - 7 pm last night (8/31/13). LPN #6 documented that the supervisor was notified and a statement of everything the resident reported was completed. Progress Notes for the period of 8/31/13 through 9/4/13 were reviewed and one note from Social Work documented on 9/4/13 at 2:56 documented that the Social Worker assisted the resident in transferring phone number to a new phone. Incident/Accident Report signed 9/1/13 by RNS #3, documented that she responded to the resident's floor after Resident #2 complained about being robbed. The Incident/Accident documented that the resident reported to LPN #5 on 8/31/13 at 8:00 pm and re-reported to several staff on 9/1/13 at the nursing station. Resident #2's statement documented by RNS #3 documented that "resident began with complaint of not being able to go out to take care of business for her apartment and that she needed $300 for a deposit." It is further documented that the Resident has asked a housekeeper to go to the ATM with her debit/credit card to withdrawal the funds, which the housekeeper did. The resident's statement documented that on 8/31/13 the same housekeeper was asked by the resident to pick up the newspaper and a milkshake and one for herself, and was given $15.00. The statement documented that the resident reported that she was in the bathroom when the housekeeper returned with the items and that the resident believes that the housekeeper took her envelope with $150 in it. Investigative Summary Form signed by the DON documented that the resident is alert and oriented and that the investigation was initiated on 9/1/13. In an undated statement prepared by RNS #3 and signed by Licensed Practical Nurse (LPN) #5, LPN #5 documented that the resident's story did not make sense, that the resident stated the money was for rent but that the resident had told her that the apartment fell through, that the resident makes up stories, thought that no one could have that kind of cash on them and that everything went through the Unit Manager. LPN #5 further documented that she knew Resident #2 was an elopement risk and felt it could not be true. Disciplinary Report dated 9/1/13 prepared by RNS #4 and signed by Housekeeper #1, documented that last week, housekeeper accepted credit/debit card from the resident to go to the ATM and withdraw $300 from the residents account and when she returned the resident gave the housekeeper $10-$15 to buy herself lunch. On 8/31/13 the resident gave the housekeeper $15.00 to buy the newspaper and a shake and one for herself and that the housekeeper returned and have the purchase to the resident sitting in the chair at the window. In a statement dated 9/1/13, the Director of Maintenance documented that it had come to his attention that the resident had been requesting a key for her nightstand and after checking the maintenance log for the past two months, no request was found, however, he now had the lock replaced and provide the resident with a key. Comprehensive Care Plan for Behavioral Symptoms initiated on 9/3/13, more than one and a half months after the first misappropriation of resident funds and two days after the second incident of misappropriation of resident funds, documented that the resident attempts to elicit sympathy from staff, and offers financial rewards to persuade them to do personal tasks (ie. banking, shopping). Approaches documented included, to encourage the resident to keep only small quantities of cash on her person, encourage resident to request Social Work assistance with managing personal tasks, encourage resident to keep debit/credit card in a locked drawer and to provide resident with a locked drawer for valuables. Comprehensive Care Plan Return to Community Referral initiated on 9/3/13 documented that the resident expresses desire to be discharged to the community. During an interview on 8/26/13 at 11:30 am with the Administrator and Assistant Director of Nursing (ADON) Department of Health (DOH) surveyor reported the allegations of case #NY 7 and the Administrator stated that it was an investigation that the DON was doing and that he was aware there was an allegation of misappropriation of resident funds. The Administrator was advised that the allegation was not reported to the DOH and the Administrator stated that he was not aware that it was not reported, however, it should have been and the reporting to DOH would have been the responsibility of the DON. The Administrator stated that he would attempt to locate the investigation as the DON was on vacation and unable to be reached. During an interview on 9/4/13 at 8:45 am with the Administrator and the DON, the DON stated that she did not report the misappropriation of resident funds to the DOH because it was not required as stated in the facility's policy and procedures. The DON stated that the policy was updated and she now understands that she was required to report the resident's allegation of 7/17/13. During an interview on 9/4/13 at 10:30 am, Resident #2 stated "I was robbed again." Resident #2 stated that she has asked a CNA to return some things for her and to buy her a few new things but would not return her calls so she reported it to the facility. Resident #2 stated that there were two unauthorized transactions on her account but the police were working on the case. Resident #2 stated that she was robbed again when she asked a housekeeper to go withdrawal $300 from the ATM for her. Resident #2 stated that she gave the housekeeper her credit/debit card and her PIN number and she brought her back $300. Resident #2 stated on 8/31/13, she asked the housekeeper to go to the store for her, which she did, and after she returned, later that night an envelope with her cash in it was gone. Resident #2 stated that she believes that the housekeeper took her money because "she saw that the money was in my dresser." Resident #2 was asked if she had a secure place in her room where she can lock up valuables, and the resident stated "now I do, I had been asking for a lock and after I got robbed the second time, they put in a new lock and gave me the key." Resident #2 stated that she asked the social worker if she could assist her in getting cash just a few days before the 8/31/13 incident, but was told that it was against policy for staff to get resident's money. Resident #2 stated that she just wanted to leave the facility, she wanted to get an apartment because she didn't need to be at the facility, and she keeps getting robbed. Resident #2 stated that she thought she had an apartment lined up but she needs money for a security deposit and rent before social security will help, but she got robbed again. Resident #2 stated that she does not have access to the community and that facility staff won't help her with trying to get an apartment. Resident #2 stated that she feels like she has to hide everything and she just wants to get out of the facility. During an interview on 9/4/13 at 12:00 pm, the Social Worker stated that she has been assigned to Resident #2 since admission and the Resident's plan was to return to the community. The Social Worker stated that she contacted Assisted Living programs on behalf of the resident, however, it appears as though the resident is not appropriate for assisted living. The Social Worker stated that the resident wanted her own apartment, however, the progress has been stalled because the resident does not have access to the community. The Social Worker stated that she has assisted in contacting apartments for the resident, however, when asked specific questions about when and the results of her efforts, the Social worker was unable to recall specifics, reviewed her progress notes and was unable to locate any notation of her efforts. The Social Worker stated that since the resident would require a staff member with her to tour potential apartments, the resident's apartment search depended on the availability of staff and she was unsure if and when staff would be available to go with her and didn't know if she had approval from administration to utilize staff. The Social Worker was asked if she was aware that Resident #2 was the victim of misappropriate of resident funds and the Social Worker stated that she knew that a CNA had taken the resident's credit card and had made unauthorized transactions. The Social Worker stated that she learned of the incident about a week or so after the incident and at that time, she went to talk to the resident. The Social Worker reviewed her progress notes and stated there was no notations related to her visit to the resident. The Social Worker was asked if she was aware of the second incident of theft of Resident #2's funds on 8/31/13 and the Social Worker stated "no". The Social Worker stated that the resident did ask her on Wednesday or Thursday (8/28 or 8/29/13) of last week to assist her in getting to the ATM to withdrawal money. The Social Worker stated that she informed the resident that she could not assist her and thought that the facility policy was to have resident's go through the business office to access funds. The Social Worker stated that she did tell the Director of Social Services about the resident's request and was told that they couldn't do it and did not offer another alternative. During an interview on 9/4/13 at 12:45 pm, the Administrator stated he was unaware the resident was requesting to access funds from an outside source. The Administrator stated that he was aware that the resident had given a CNA her card and that after the unauthorized transactions, he knew that the DON was working with the resident to get a new card and that the resident was told not to give her card to anyone. The Administrator stated that he had never heard of a resident requesting assistance with accessing funds from an outside source but if he had, "I would have had the social worker go out with the resident." The Administrator stated, "had the resident come to my office, we would have done it, it is reasonable that the facility would facilitate this for her." The Administrator stated that after the first incident, he would expect that the facility would make sure that the resident had a locked box in her room, that the social worker would work with the resident to insure that she was not psychologically affected by the incident. The Administrator was advised that the social worker stated to the DOH that she was unaware of the incident on 8/31/13 and the Administrator stated, "that would surprise me, everyone knows." The Administrator stated that Resident #2 had left him a voice mail message stating she was robbed again, however he had not had any communication with the Director of Social Services about the second incident and had not asked anyone to assess the resident for psychological impact to the resident. The Administrator stated that the social work staff did not bring to his attention that she needed assistance in accessing funds, but given the past, "I would have addressed it." The Administrator stated that Resident #2 told him today that she needed assistance in looking at apartments and seemed upset today which is unusual for her. The Administrator stated that the resident does not need facility level care, that there is no facility policy that would prevent staff from accompanying her to tour apartments, and yes, they could utilize staff to do that. If they indicated that they could not help her with her funds or the apartment, "that was not appropriate." The Administrator stated that three weeks ago a staff member transported the resident to go look at an apartment but could not recall any details and was unaware that there was no documentation of the activity in the resident's medical record and was unaware that the resident stated that the facility had not assisted her in touring apartments. During an interview on 9/4/13 at 1:15 pm, the Director of Social Services stated that she was familiar with Resident #2, stated that she was not appropriate for the facility and although she thought that the resident would do well in an assisted living setting, she was aware that placement in assisted living was not successful. The DSS stated that she had assisted in working with the resident on a community placement with a friend that fell through and then the resident was changed to the SW's caseload. The DSS stated that resident did not have community access and she did not recall the resident requesting assistance in touring potential apartments. The DSS stated that when the resident requested to go on-line and look for apartments, the facility would assist in getting her on-line but she did not recall being asked to arrange for the resident to tour apartments. The DSS also stated she did not recall the SW asking for assistance so that the resident could tour apartments. The DSS stated that there is no policy in place that would prevent a staff member from accompanying a resident to tour an apartment and she did not recall asking the Administrator for assistance in utilizing staff to assist the resident. At short time later, the DSS stated "oh, now I recall, 1 - 2 weeks ago, the Administrator said it was okay to use staff and told me to work with the staffing coordinator to arrange for staff to go with the resident." The DSS was asked about her knowledge of the misappropriation of Resident #2's funds. The DSS stated that she heard that a CNA had taken the resident's credit card and used it. The DSS stated that after that incident, she would expect that the SW would work with the resident to make sure she was okay and to talk about how to access the activities department to get the resident the items she needed. The DSS was asked how the facility would assist the resident in getting funds from the bank if needed and the DSS stated "we have never run into that" and stated that the SW told her about the resident's request for funds today. The DSS was asked if the resident could be accompanied to obtain funds from an ATM and the DSS stated, "no, its against our policy." When asked how the facility would facilitate a resident obtaining funds, the DSS stated, "that's a good question, I don't know how to answer that." The DSS stated I think everyone is so new here and no one had ever asked us to go with them to the ATM. When asked if she was aware that the resident had given her ATM card to the housekeeper to obtain funds and that the resident had reported that she was robbed again, the DSS stated, "no, I was not aware of that, I have a problem with that, I am the Director of Social Services." The DSS stated based on the events, "I agree, she has not been accommodated, and I will talk with the Administrator about a new policy. Every one here is so new, we need reeducation on how the process works." During an interview on 9/4/13 at 1:55 pm, the DON stated that the Interdisciplinary team discussed the misappropriation of resident funds in morning meeting on 9/3/13. The DON stated that Social Services team attends these meetings and she would expect that someone would follow up with the resident. The DON was advised that according to the Social Worker and the Director of Social Services, they were not aware of the incident until interviewed by the DOH and stated, "it would surprise me

Based on medical record review and interviews during a partial extended abbreviated survey (Case #NY 704) it was determined that the Administrator failed to ensure that the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, for 2 ( #1 and 2) of 5 residents reviewed the Administration failed to ensure that mental or physical abuse and misappropriation of resident funds were not occurring. The Administration failed to produce evidence that all allegations of abuse were thoroughly investigated and reported to the New York State health department (DOH). Additionally, the Administration failed to protect the residents from exposure to the alleged perpetrator. This resulted in actual harm for Resident #1 and no actual harm for Resident #2 and has the potential for more than serious harm that is Immediate Jeopardy to the health and safety of the residents and Substandard Quality of Care. This is evidenced by the following: Refer to F 225- Abuse- scope and severity -L Refer to F-309- Quality of Care - scope and severity-L During an interview with the Administrator and the Assistant Director of Nursing (ADON) on 8/26/13 at 11:30 am, the Administrator stated that certified nurses aide (CNA) #2 reported an allegation of physical abuse to two licensed practical nurses (LPNs) and the registered nurse supervisor (RNS). The Administrator stated that he learned of the incident on 8/19/13 and began an investigation. The Administrator stated as a result of the investigation he initiated on 8/18/13, he was concerned with several aspects of the handling of the allegation of abuse. The Administrator stated that it did not appear that while there is documentation that the RNS observed Resident #1, it does not appear that it addressed the concern of the alleged physical abuse. The Administrator further stated that when the resident continued to complain of pain, she was not assessed by RNS #3. The Administrator stated that RNS #1 should have immediately suspended the accused pending the investigation, and did not do so. The Administrator stated that the accused remained on duty for several hours after the incident. The Administrator stated that he was not notified of the alleged incident until the morning of 8/19/13, and he should have been called immediately. The Administrator stated that RNS #1 resigned and the other nursing staff were inserviced on Abuse, Neglect and Mistreatment reporting. The ADON stated that she was acting for the Director of Nursing (DON)and she was advised of the allegation on 8/18/13, she did not direct anyone to contact the local law enforcement authorities but was familiar with the Elder Justice Act and reporting requirements. The ADON further stated that she should have contacted the Administrator when she became aware of the incident. During an interview on 8/26/13 at 11:30 am the Administrator and ADON , DOH surveyor reported the allegations of case #NY 927 and the Administrator stated that it was an investigation that the Director of Nursing was doing and that he was aware there was an allegation of misappropriation of resident funds. The Administrator was advised that the allegation was not reported to the DOH and the Administrator stated that he was not aware that it was not reported, however, it should have been and the reporting to DOH would have been the responsibility of the DON. The Administrator stated that he would attempt to locate the investigation as the DON was on vacation and unable to be reached. During an interview on 9/4/13 at 8:45 am with the Administrator and the DON, the DON stated that she did not report the misappropriation of resident funds to the DOH because it was not required as stated in the facility's policy and procedures. The DON stated that the policy was updated and she now understands that she was required to report the resident's allegation of 7/17/13. During an interview on 9/4/13 at 12:45 pm, the Administrator stated he was unaware the resident was requesting to access funds from an outside source. The Administrator stated that he was aware that the resident had given a CNA her card and that after the unauthorized transactions, he knew that the DON was working with the resident to get a new card and that the resident was told not to give her card to anyone. The Administrator stated that he had never heard of a resident requesting assistance with accessing funds from an outside source but if he had, "I would have had the social worker go out with the resident." The Administrator stated, "had the resident come to my office, we would have done it, it is reasonable that the facility would facilitate this for her." The Administrator stated that after the first incident, he would expect that the facility would make sure that the resident had a locked box in her room, that the social worker would work with the resident to insure that she was not psychologically affected by the incident. The Administrator was advised that the social worker stated to the DOH that she was unaware of the incident on 8/31/13 and the Administrator stated, "that would surprise me, everyone knows." The Administrator stated that Resident #2 had left him a voice mail message stating she was robbed again, however he had not had any communication with the Director of Social Services about the second incident and had not asked anyone to assess the resident for psychological impact to the resident. The Administrator stated that the social work staff did not bring to his attention that she needed assistance in accessing funds, but given the past, "I would have addressed it." The Administrator stated that Resident #2 told him today that she needed assistance in looking at apartments and seemed upset today which is unusual for her. The Administrator stated that the resident does not need facility level care, that there is no facility policy that would prevent staff from accompanying her to tour apartments, and yes, they could utilize staff to do that. If they indicated that they could not help her with her funds or the apartment, "that was not appropriate." The Administrator stated that three weeks ago a staff member transported the resident to go look at an apartment but could not recall any details and was unaware that there was no documentation of the activity in the resident's medical record and was unaware that the resident stated that the facility had not assisted her in touring apartments. During an interview on 9/4/13 at 1:15 pm, the Director of Social Services (DSS) stated that she was familiar with Resident #2, stated that she was not appropriate for the facility and although she thought that the resident would do well in an assisted living setting, she was aware that placement in assisted living was not successful. The DSS stated that she had assisted in working with the resident on a community placement with a friend that fell through and then the resident was changed to the SW's caseload. The DSS stated that resident did not have community access and she did not recall the resident requesting assistance in touring potential apartments. The DSS stated that when the resident requested to go on-line and look for apartments, the facility would assist in getting her on-line but she did not recall being asked to arrange for the resident to tour apartments. The DSS also stated she did not recall the SW asking for assistance so that the resident could tour apartments. The DSS stated that there is not a policy in place that would prevent a staff member from accompanying a resident to tour an apartment and she did not recall asking the Administrator for assistance in utilizing staff to assist the resident. At short time later, the DSS stated "oh, now I recall, 1 - 2 weeks ago, the Administrator said it was okay to use staff and told me to work with the staffing coordinator to arrange for staff to go with the resident." The DSS was asked about her knowledge of the misappropriation of Resident #2's funds. The DSS stated that she heard that a CNA had taken the resident's credit card and used it. The DSS stated that after that incident, she would expect that the SW would work with the resident to make sure she was okay and to talk about how to access the activities department to get the resident the items she needed. The DSS was asked how the facility would assist the resident in getting funds from the bank if needed and the DSS stated "we have never run into that" and stated that the SW told her about the resident's request for funds today. The DSS was asked if the resident could be accompanied to obtain funds from an ATM and the DSS stated, "no, its against our policy." When asked how the facility would facilitate a resident obtaining funds, the DSS stated, "that's a good question, I don't know how to answer that." The DSS stated I think everyone is so new here and no one had ever asked us to go with them to the ATM. When asked if she was aware that the resident had given her ATM card to the housekeeper to obtain funds and that the resident had reported that she was robbed again, the DSS stated, "no, I was not aware of that, I have a problem with that, I am the Director of Social Services." The DSS stated based on the events, "I agree, she has not been accommodated, and I will talk with the Administrator about a new policy. Every one here is so new, we need reeducation on how the process works." During an interview on 9/4/13 at 1:55 pm, the DON stated that the Interdisciplinary team discussed the misappropriation of resident funds in morning meeting on 9/3/13. The DON stated that Social Services team attends these meetings and she would expect that someone would follow up with the resident. The DON was advised that according to the Social Worker and the Director of Social Services, they were not aware of the incident until interviewed by the DOH and stated, "it would surprise me that they were not aware, how could they not?" The DON stated that she was unaware if the resident had been assessed. The DON stated that the Comprehensive Care Plan for Behavioral Symptoms which had been initiated on 9/3/13, should have been initiated after the first incident of misappropriation of funds. During an interview on 9/4/13 at 3:15 pm, the Administrator stated that he spoke with Resident #2 and Resident #2 requested assistance in obtaining her funds from the ATM and requested assistance in looking for an apartment. The Administrator stated that he would follow-up to see that the resident was assisted with obtaining funds from the ATM. During an interview on 9/5/13 at 11:00 am, the Administrator and DON called the surveyor to report an incident with Resident #2 and stated that there was a problem with the resident calling a cab company to get money. When the surveyor asked the Administrator what arrangements the facility had made to assist the resident based on the 9/4/13 at 3:15 pm interview with the Administrator, the Administrator stated that he was busy and had not communicated with the resident yet, nor had he arranged for the facility to assist the resident in obtaining funds. 10NYCRR 415.26

Based on observation, record review and staff interview during complaint investigation (NY# 686), the facility did not insure that 1 (Resident #1) of 3 residents had care planned safety devices implemented to prevent accidents. Specifically, Resident #1 was assessed as a high fall risk and was care planned for a chair and bed alarm. The resident fell on [DATE] at 7:00 PM from a straight back chair and fell again at 11:00 PM after being assisted to bed and sustained a fractured hip. This resulted in actual harm that is not immediate jeopardy. Resident #1 was admitted to the facility on [DATE] diagnosed with [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident had moderate cognitive impairment. Observation on 4/8/13 at 2:00 PM, the resident was alone in her room in her bed without a bed alarm. The resident was attempting to get out of bed. A Fall Risk assessment dated [DATE] documented the resident was at high risk for falls. The Comprehensive Care Plan for Falls, initiated on 10/9/12, documented that the resident was at high risk of falls due to impulsive behaviors/dementia. On 10/9/12, a bed alarm, chair alarm, toileting schedule and close supervision were implemented. On 10/23/12, an additional approach was documented to provide the resident with bed/chair alarm and to check placement every shift. A Fall Risk assessment dated [DATE] documented that the resident was at medium risk for falls, had no challenging behavior in the last 30 days and had a normal gait/balance. A Fall Risk assessment dated [DATE] documented that the resident was at high risk for falls due to a change in wandering and/or aggressive impulsive behaviors, and required the use of an assistive device. The Resident Profile( used by the certified nurses aide (CNA) to provide care to the resident) documented use of a Bed/Chair alarm, check function and placement every shift starting on 10/9/12. The Treatment Record for the period of 3/1/13 through 3/30/13 was absent an entry for Bed/Chair alarm check each shift. Incident/Accident Report dated 3/29/13 at 7:00 PM documented that Resident #1 was in the dining room, attempted to move from her armchair to her walker and fell . Care Plan interventions currently in place were documented as proper lighting, proper footwear and a toileting program. Changes made to the care plan to prevent reoccurrence were documented as a medication review and a toileting program. Nurses Note dated 3/29/13 at 10:31 PM documented that the Registered Nurse Supervisor (RNS) was called to the dining room to assess Resident #1 who was observed in a sitting position next to her chair and walker. The note further documented that the resident had no injuries and was assisted to the chair and then to her bed. Incident/Accident Report dated 3/29/13 at 11:00 PM documented that the resident was observed lying in her room on her right side with blood from the right side of her face/head. Clinical findings documented that the resident was transferred to the hospital for treatment. Care Plan interventions currently in place were documented as proper lighting and a toileting program. Changes made to the care plan to prevent reoccurrence were documented as a medication review, low bed and a toileting program. Nurse ' s note dated 3/29/13 at 11:42 PM documented that the RNS was called again at 11:00 PM to assess the resident who was observed lying on the floor in her room on her right side and there was blood oozing from the right side of her head. Nurse ' s note dated 3/30/13 at 6:02 am documented that the resident was admitted to the hospital with [REDACTED]. Transfer Summary dated 4/8/13 documented that the resident was admitted to the hospital after a fall, found to have a right subcapital femoral fracture and underwent open reduction and internal fixation. During an interview on 4/8/13 at 2:05 PM, CNA #1 stated that she was floated to the unit and assigned to the resident. CNA #1 stated that the resident had just returned from the hospital at around 12:30pm. CNA #1 stated that there was no bed alarm in the resident ' s bed. During an interview on 4/18/13 at 2:10 PM, Registered Nurse Manager (RNM) stated that the resident did not have a bed alarm placed and asked CNA #1 if she was in the room with the resident prior to the DOH observation, to which CNA #1 responded " no " . During an interview on 4/8/13 at 2:25 PM, CNA #2 stated that the resident was not using any alarms prior to the fall. During a followup interview on 4/18/13 at 2:30 PM, the RNM stated that the resident returned from the hospital and needed to be cleaned up and he thought the CNA would stay with the resident. The RNM stated that the resident was assessed by the Admissions Nurse while he was trying to obtain a bed alarm. The RNM stated " I don't know why she was left alone " and was without a bed alarm. The RNM stated the resident had just returned from the hospital at 1:30 PM and while he was trying to obtain a bed alarm, the admissions nurse was assessing the resident. During an interview on 4/8/13 at 2:40 PM, CNA #3 stated that resident was not using a bed or chair alarm prior to her falls on 3/29/13. During an interview on 4/8/13 at 2:45, LPN #1 stated that if the resident had an alarm that needs to be checked and documented, an entry is placed on the Treatment Record. LPN #1 stated that there was no entry on the treatment record for Resident #1 prior to the resident ' s fall on 3/29/13. During an interview on 4/8/13 at 2:50 PM, RN MDS Coordinator stated that she was formerly a RNM and Resident #1 was assigned to her unit. RN MDS Coordinator stated that when Resident #1 was transferred to her current unit, she was not using a chair or bed alarm. MDS Coordinator reviewed the Fall Assessments dated 11/16/12 and 1/10/13 which documented that the resident ' s fall risk had increased from medium to high on 1/10/13 and stated that the social workers were in charge of the care conferences at that time and maybe they missed the fact that the resident was care planned for a chair and bed alarm but was not utilizing them. When asked if the discrepancy was identified in the care conference of 11/16/13 in which the MDS Coordinator would have been the RNM, the MDS Coordinator stated " I have no answer for that. " During an interview on 4/8/13 at 4:30 PM, the Director of Nursing (DON) stated that the CNA assigned to the resident on 3/29/13 had been terminated for failure to follow the care plan because the resident was suppose to have a chair and bed alarm. The DON stated that the RN Supervisor on 3/29/13 did not identify the care plan violation and when she placed the resident in bed to assess her after the first fall, the RNS did not identify that the bed alarm was not in place. The DON stated that during her investigation into the incident, she learned that the chair and bed alarms were not being utilized by any of the staff. The DON stated that resident ' s profile card documented that the alarms should be checked every shift for placement and functionality, however, that was not being done either. The DON stated that checks are done and documented in the computer, but the problem is that some checks are done on the treatment record and some are done on the profile card. The DON was advised of the DOH recorded observation of the resident at 2:00 PM and the DON stated " the alarm should have been placed on her bed before she got back from the hospital. " During an interview on 4/8/13 at 8:15 PM, the Assistant Director of Operations for the ambulance company stated that Resident #1 was transported from the hospital to the facility and arrived at 12:34 PM and the ambulance was placed back in service at 12:50 PM. The Assistant Director of Operations stated that the ambulance crew will transfer the resident from the stretcher to the resident ' s bed before leaving. 10NYCRR 415.12(h)(1)(2)

Based on medical record review and staff interview, the facility failed to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment, plan of care and current standards of practice for 20 ( #s 1, 2,3, 4, 5, 6, 7, 9, 10,11, 12,13,14,15,16,17,19,20, 21) of 22 residents reviewed, during a partially extended abbreviated survey (Case #s NY 367, NY 595, NY 539 and NY 816). Specifically, the facility failed to ensure: that admission/readmission orders [REDACTED]. This had the potential to effect all of the residents receiving medication in the facility. This resulted in no actual harm, with the potential for serious harm that is Immediate Jeopardy to residents' health and safety and Substandard Quality of Care for the residents. The facility was able to remove the immediacy prior to exit by implementing the following: 1. Revision of the Policy and Procedures. 2. Reviewing and auditing all new admissions and readmissions for completion and accuracy of physician's orders [REDACTED]. 3. All licensed staff was educated on all areas of concern noted in the deficiencies, including electronic physician order [REDACTED]. 4. Medication pass audits were completed on all units and all shifts. This is evidenced by: The Policy and Procedure (P&P) for Utilization of Matrix (the electronic medical record (EMR) system) dated 04/11/2012, documented that all orders and documents were to be entered into the Matrix EMR upon admission and through discharge. All medication and treatment administration were to be completed and documented timely and accurately in Matrix. The facility was to audit, run and maintain all Matrix Compliance Reports at the discretion of the Vice President of Clinical Services. The P&P for Transcription of physician's orders [REDACTED]. A licensed nurse was to enter physician's orders [REDACTED]. The medication/treatment order was automatically sent to the pharmacy after the order is verified by a second nurse through a direct computer interface with the pharmacy. The pharmacy then dispensed the appropriate ordered medications to the facility and delivered the medications to the facility supervisor. The General P&P for Medication Administration with a revision date of 01/2013 documented that medications were to be administered by a Licensed Practical Nurse (LPN) or a Registered Nurse (RN). All medications were to be administered and documented using the EMR. The purpose of the P&P was to ensure that medications were administered in a way that ensured the resident's safety and satisfied medical and legal concerns. Nurses were to document all medication and treatment administration in the EMR and review the electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. If the medication was not available on the nursing unit, the RN Supervisor (RNS) was to be notified. RNS was to contact the pharmacy and notify the physician as necessary. A note at end of the P&P documented in bold letters, "Ask the pharmacy to deliver the medication STAT (term used for immediately) and if you have any problems with this, report to the RNS; RNS will call the pharmacy to request STAT medications; if she/he has any problems will notify the Director of Nursing (DON) or Administrator to ensure prompt delivery." The P&P for Medication Error, Monitoring and Follow-up revised in 01/2013, documented that all medication/treatment errors were to be reported and reviewed immediately upon discovery, and followed up with the appropriate person/persons as necessary to assure the quality of care was maintained for all residents. The nurse discovering error was to complete the Medication/Treatment Error Discovery forms and notify the Nurse Manager (NM)/RNS. The NM/RNS was to assess the resident for possible side effects if any, and notify the physician (MD). The Medication/Treatment Error form was to be submitted to the DON who was to complete a full investigation. The DON reserved the right to institute immediate discipline. During an interview on 1/30/13 at 2:00 pm, the Director of Nursing (DON) stated that the facility did not have a P&P for new admissions/readmissions. The Pharmacy Information form (posted on each nursing unit) listed the cut off times for physician orders [REDACTED]. The cut off times included: Morning cut off time 9:00 am for departure time of 11:00 am. Evening cut off time 4:00 pm for departure time of 6:00 pm. Night cut off time 10:00 pm for departure time of 12:00 am. The weekends cut off time was 9:00 am for departure time of 11:00 am. The weekends cut off time 2:30 pm for departure time of 6:00 pm. The Back-up Box (a box that is provided by the pharmacy and contained those medications that the facility deemed most likely to have an emergency need for) documented the contents which included [MEDICATION NAME] and [MEDICATION NAME]. Resident # 1: The facility failed to ensure the physician was notified when the resident was admitted to the facility, and failed to obtain physician orders [REDACTED]. The facility resumed the pre-hospital orders and the resident received three doses of Aspirin. The resident was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident was moderately cognitively impaired. The Comprehensive Care Plan (CCP) dated 05/03/2012 documented the resident was at risk for bleeding due to use of Aspirin therapy. The goal documented the resident will receive prompt attention for signs and symptoms (s/s) of bleeding. Approach documented administer medications as ordered by the physician (MD). There was no CCP for the resident's subarachnoid hemorrhage. The hospital physician's Discharge Order sheet dated 01/18/2013, documented the resident's discharge [DIAGNOSES REDACTED]. Special instructions for the resident included: no Aspirin for two weeks per Neurosurgery, and follow up with MD at facility by 11:00 am the day after discharge from hospital. The hospital report of the CT scan (computed tomography (CT) scan uses X-rays to make detailed pictures of structures inside the body) of the head dated 01/25/2013 documented findings were compared to CT scan of 01/16/2013. CT documented findings compatible with evolving, decreasing hemorrhagic contusions. Review of the physician's orders [REDACTED]. Review of the Resident Progress Notes (used by nurses to document information) revealed that there was no documentation of this resident's readmission on 1/18/13, or that the physician was notified of the resident's readmission. physician's orders [REDACTED]. The physician's orders [REDACTED]. [MEDICATION NAME] (an asthma inhaler approved for the maintenance treatment of [REDACTED]. Calcium [MEDICATION NAME] (Calcium [MEDICATION NAME] is a dietary supplement used when the amount of calcium taken in the diet is not enough) 500 mg twice a day. ICaps (vitamin a-vitamin c-vitamin e) once a day. [MEDICATION NAME] (used to treat anxiety and major [MEDICAL CONDITION]) 10 mg once a day. [MEDICATION NAME] (used to treat hypertension, [MEDICAL CONDITION] and to improve survival after a [MEDICAL CONDITION]) 2.5 mg once a day. Multivitamin (preparation intended to be a dietary supplement with vitamins, dietary minerals, and other nutritional elements) with minerals once a day. [MEDICATION NAME] (used to treat dementia associated with [MEDICAL CONDITION]) 10 mg once a day. [MEDICATION NAME] (used to treat [MEDICAL CONDITION] reflux disease (GERD) and other conditions caused by excess stomach acid) 20 mg twice a day. [MEDICATION NAME] (used to lower cholesterol and triglycerides in the blood) 20 mg once a day. [MEDICATION NAME] (an antidepressant used to treat major [MEDICAL CONDITION]) 15 mg at bedtime. [MEDICATION NAME] (used to treat [MEDICAL CONDITION] and symptoms of [MEDICAL CONDITION] disorder) 0.5 mg twice a day. Vitamin D3 (a group of fat-soluble secosteroids responsible for intestinal absorption of calcium and [MEDICATION NAME]) 1,000 unit once a day. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview on 01/29/2013 at 2:30 pm, Registered Nurse Supervisor (RNS) # 4 stated she always checks on the readmissions and admissions to make sure everything was completed. RNS stated that I do not know what happened, I lost this one (Resident # 1's admission) and I take the responsibility. RNS found out on Monday (three days after readmission) that the readmission had not been completed and the physician not notified for new orders and stated that Resident # 1 did receive three days of Aspirin because of this. RNS stated the LPN should have completed the orders and called the physician. The RNS further stated that RNS should have been notified by the LPN that it was not done. This RNS begins the shift by checking with admissions department to see who was admitted and yet to be admitted , then calls the staffing numbers to the units. RNS does the assessment portion of the admission/readmission and the LPN does the transcription and make the phone calls to the physician and pharmacy. The LPNs should contact the pharmacy and physician when a medication is not available to administer. During an interview on 01/30/2013 at 11:15 LPN # 2 stated the supervisor was responsible for the admission process on Resident # 1. LPN # 2 was the only nurse on the unit for the 3:00 pm to 11:00 pm (evening) shift. LPN #2 stated it was settled at the beginning of the shift that the supervisor would take care of the entire admission because there was only one nurse on the unit that evening. LPN#2 further stated that the fourth floor computers do not work properly and to admit a new resident the nurse has to go to another unit to use their computers. LPN#2 stated it would be impossible for one nurse to take care of the unit alone and to do an admission or readmission. During an interview on 01/28/2013 at 3:00 pm the DON stated that a two day hospital stay would require the readmission process to be done. Resident # 1's orders should have been discontinued and new orders should have been started. The DON was not aware that Resident # 1 was not readmitted properly and orders obtained. The DON stated that an investigation should have been done in regards to Resident # 1's readmission. During an interview on 01/29/2013 at 9:45 am, via telephone, Physician # 1 stated she went to the facility on Sunday evening, 01/20/2013 and noticed Resident # 1 was in the facility. When the staff were questioned why the Physician had not been notified the Resident had been readmitted , no one could answer. The physician requested the discharge summary at that time and the staff could not find it. The Physician requested the facility obtain the discharge summary and fax it to the office. The Physician did not receive the discharge summary until Monday afternoon, at which time she discontinued the Aspirin due to the [DIAGNOSES REDACTED]. The Physician stated that it is not very often that she receives phone calls in regards to medications not available or given. The Physician made it well known to staff that they are to call at any time when there is an issue with any of the Physicians' residents. During an interview on 01/29/2013 at 2:00 pm, the Medical Director (MD) stated he was not aware of a problem with readmissions or admissions receiving their medications on the evening of the admission. Review with the MD of the Resident charts in the computer system, he stated "we have a problem here". MD stated that the physicians should be notified any time there are medications that are unavailable. The MD further stated that the readmissions and admissions should have more priority in getting completed. Resident #2 The facility failed to ensure the resident, who was a new admission, received evening medications. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Nursing Observation Report dated 01/18/2013 documented the Resident was alert and oriented to person only. The hospital Transfer Summary dated 1/18/13, documented that the resident was discharged from the hospital on the following medications: [REDACTED] Atorvastatin (lowers cholesterol) 20 mg by mouth (PO) every night (QHS) [MEDICATION NAME] chloride (used for [MEDICAL CONDITION]) 12.5 mg po three times a day(TID) [MEDICATION NAME] (used for respiratory diseases) 0.5 mg inhaled every 12 hrs [MEDICATION NAME] (stool softener) 100 mg po twice a day (BID) Memantine ([MEDICATION NAME]) (used for [MEDICAL CONDITION]) 10 mg po BID [MEDICATION NAME] 50 mg po BID Pramipexole (used for [MEDICAL CONDITION]) 0.125 mg po QHS Tamsulosin (used for [MEDICAL CONDITION]) 0.4 mg po QHS The Resident Progress notes dated 1/18/13 at 8:41 pm, documented the resident was a new admission. The nurse spoke with the physician (MD) and all medication orders were obtained. The Physician order [REDACTED]. Atorvastatin 20 mg po QHS at 8:00 pm [MEDICATION NAME] chloride 12.5 mg po TID at 8:30 am, 12:30 pm and 4:30 pm [MEDICATION NAME] 50 mg po BID at 8:00 am and 8:00 pm Memantine ([MEDICATION NAME]) 10 mg po BID at 8:00 am and 8:00 pm The Physician order [REDACTED]. [MEDICATION NAME] 0.5 mg inhaled every 12 hrs 8:00 am and 8:00 pm [MEDICATION NAME] 100 mg po BID at 8:00 am and 8:00 pm Pramipexole 0.125 mg po QHS at 8:00 pm Tamsulosin 0.4 mg po QHS at 8:00 pm The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Atorvastatin, [MEDICATION NAME] chloride, [MEDICATION NAME], Memantine ([MEDICATION NAME]) [MEDICATION NAME], Pramipexole, and Tamsulosin all of which were ordered 1/18/13 . During interview on 01/28/2013 at 4:40 pm, LPN # 4 stated that none of the paperwork had been done with the new admission at 3:00 pm, when the evening shift started, and this is often the case. LPN #4 stated when the medication orders are sent late and would not arrive until late, the residents just don't get them. LPN further stated that in the case that the medications are ordered late, the LPN would just put them in the computer to start the next day. LPN stated when the call was made to the physician for Resident # 2, it was not mentioned that the medications would be late. The LPN stated there is an emergency kit (E-kit) for antibiotics and narcotics only. LPN#4 was not aware of other types of medications that were available for back-up medications. During an interview on 01/28/2013 at 4:20 pm, RNS # 1 stated that the pharmacy deliveries come from Binghamton, and the delivery times are between 9:00 pm and 11:00 pm. RNS stated that the nurse should know to call the RNS for medications not available to see if they are in the E-kit. RNS stated the 3:00 pm to 11:00 pm (evening) shift RNS is responsible to complete the observation and assessment part, of the admission and the LPNs are responsible to complete the orders for the admission and readmissions. The RNS should do periodic spot checks to see if things are being done properly. The RNS further stated that the LPNs just don't call the supervisor when there is a problem. During an interview on 01/28/2013 at 3:00 pm, the DON was not aware of a problem with admissions or readmission's receiving their evening medications. DON stated that a medication error report should be completed for medication omissions. During an interview on 01/28/2013 at 12:30 pm the RNM # 1 had started employment with the facility less than two weeks ago. RNM#1 would expect that the orders for admissions and readmissions would be done immediately to allow time for delivery. RNM #1 stated that the physician should be notified if an ordered medication was not available. RNM#1 stated he had not completed an admission yet. Resident #7 The facility failed to obtain physician's orders [REDACTED].#7 had been receiving in the hospital as follows: [MEDICATION NAME] (medication that is used to treat fluid retention and [MEDICAL CONDITION]); Levimer (a long acting insulin used to treat diabetes) and [MEDICATION NAME] (used to treat [MEDICAL CONDITION]-chest pain and hypertension) [MEDICATION NAME] (used to prevent blood clots after a recent [MEDICAL CONDITION] or stroke),[MEDICATION NAME](used to prevent [MEDICAL CONDITION] attacks) and Potassium Chloride (Supplement). Physician orders [REDACTED]. The resident was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident had cognitively intact skills for daily decision making. The Comprehensive Care Plan (CCP) for Functional Activities of Daily Living (ADL) dated 12/7/12, documented that the resident was at risk for bleeding due to the use of daily [MEDICATION NAME] and [MEDICATION NAME]. Medications were to be administered as ordered by the physician. The Transfer Summary from the resident's hospital admission (1/8/13-1/16/13), dated 1/16/13 documented the resident's [MEDICATION NAME] was decreased to 12.5 mg twice a day which improved her blood pressure, the resident should continue on [MEDICATION NAME] 35 units sq at bedtime (lower dose) and the resident had been receiving [MEDICATION NAME] (used for fluid retention) and [MEDICATION NAME] while in the hospital. The Resident Admission Record documented the resident was admitted to the facility on [DATE] at 5:30 pm. The Physician order [REDACTED]. Potassium Chloride Extended Release (supplement) 20 meq give 1 tab by mouth everyday at 5:00 pm Imdur (treats heart conditions) extended release 30 mg give 2 tabs by mouth once a day at 5:00 pm [MEDICATION NAME] (Insulin-lowers blood sugar) 100 units/ml give 35 units sq at bedtime everyday (lowered dose from prior to the resident's hospital admission) [MEDICATION NAME] 25 mg tab give 1/2 tab by mouth twice a day [MEDICATION NAME] 75 mg (blood thinner) give 1 tab by mouth once a day at 5:00 pm [MEDICATION NAME] (treats fluid retention) 2 mg tab give 1 tab by mouth twice a day 10:00 am and 8:30 pm The physician did not reorder the [MEDICATION NAME]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 1) The resident did not receive the Potassium Chloride, [MEDICATION NAME] 1/16/13 at 5:00 pm 2) The resident received 50 units of [MEDICATION NAME] Insulin on 1/16/13 at bedtime (as opposed to the 35 units the resident had been receiving in the hospital) 3) The resident received [MEDICATION NAME] 50 mg tab 1/2 tab on 1/16/13 at 8:30 pm (as opposed to the 12.5 mg the resident was receiving in the hospital) 4) The resident did not receive [MEDICATION NAME] until after the physician's orders [REDACTED]. During an interview on 01/29/13 at 2:00 pm, the DON stated that she was not the DON at the facility on 1/16/13, but was the Registered Nurse Manager (RNM) on this resident's unit at that time. She stated that she was not aware that the resident had not received physician ordered medications and that there were no orders for this resident until the following day (1/17/13). She stated that the nurse should have obtained orders from the physician and sent the orders to the pharmacy. The resident should have received the medications on 1/16/13 and that if there was a delay in receiving the medications from the pharmacy, the physician should have been notified. The DON stated that there was no documentation in the resident's record that the physician was notified that the resident had returned to the facility until 1/17/13. She also stated that the omissions on 1/16/13 constituted a medication error and that a medication error report should have been completed. During an interview on 1/29/13 at 9:58 am, Physician #3 stated that he could not recall specifics concerning this resident's re-admission to the facility on [DATE], but that he expected to be immediately notified when a resident returned or was admitted to the facility. He stated that the resident should have received his evening medications on 1/16/13 as ordered, and that if there was a problem getting the medications, he should have been immediately notified so he could make decisions on what to do. Additional Interviews: During an interview on 1/28/13 at 5:00 pm, LPN # 5 stated that the LPN's job is to do the admissions and notify the supervisor if they do not get done. admission orders [REDACTED]. Evening meds are not given if they do not come in from pharmacy, the physician should be notified, and a stat order should be made to the pharmacy. Emergency medications include antibiotics and narcotics, not aware of other medications. She also stated that there was no list of available emergency medications on the units. During an interview on 1/29/13 at 7:30 am, RNS # 2 stated that she was responsible for residents who were admitted or readmitted during the evening shift. Supervisors were supposed to do observations period, and an assessment note. The LPNs were supposed to do the orders and transcription. It should be a coordinated effort if someone cannot finish. There is very poor communication at the facility, admissions should be passed on in report but are not always. It does happen that admissions are not always communicated to the evening supervisor. When asked if medication error reports are completed for the admission/readmission medication omissions, RNS state I doubt it, I have not seen any. An error report should be completed for an omission. Medication passes are very heavy, these people are on way too many drugs. When short staffed on the evening shift a nurse will pass medications on the entire unit and a second nurse will be sent to the unit to complete treatments. The Supervisor often gets involved in other things and many times can not help out. During an interview on 01/28/2013 at 12:15 pm, LPN # 6 stated when the discharge summary from the hospital arrives, any nurse can review the orders and call the doctor for approval. The orders then get entered into the computer and a second nurse needs to review the orders before they are sent to the pharmacy. This should be done right away, but sometimes the second nurse is busy and it can take a while. The LPNs are supposed to have the second nurse on their unit do the second verification. During an interview on 01/28/2013 at 12:25 pm, LPN # 7 stated that for an admission or readmission the LPN calls the physician with the medication list and receives the order, then sends the orders to pharmacy. The physician should be called for an order to be given when the medications are going to arrive late. The NM does the assessments, care plans and care cards. There are emergency kits downstairs, not sure what medications are in them. During an interview on 01/28/2013 at 2:00 pm, LPN # 8 stated the LPN reviews the discharge summary and calls the physician with the orders. If a medication is not given the physician should be notified for an order and the pharmacy should be called. LPN works day shift, does not run into problems with admission orders [REDACTED] During an interview on 01/28/2013 at 3:00 pm, LPN # 9 stated LPNs review the orders for admissions and readmissions and calls the physician for orders. Day shift works as a team, usually the second team nurse verifies the orders right away and they are then sent to the pharmacy. If a medication is not delivered on time for a scheduled dose the physician should be called to find out what to do and the pharmacy has to be called. During an interview on 01/28/2013 at 2:15 pm, RNM # 2 stated I have only been working here for a week and a half. I started on the second floor and came in today and was told I was going to the fifth floor. I have done admissions, a second nurse needs to verify the orders before they are sent to the pharmacy. Not aware of any problems yet. If medications are not available for administration the nurse should check the med cart, then med room for the medication. The NM or supervisor should be notified as well as the physician. If there is an omission of a medication, that is a med error and a report should be completed. During an interview on 01/28/2013 at 2:35 pm, RNM # 3 stated I have only been working at the facility for two months. The discharge summary is reviewed by the LPN who calls the physician for the orders. The NM does the assessments. The orders should be verified by a second nurse and it should be soon after they are ready. If it is getting late the pharmacy can be called for an emergency run. If medications are not given the NM needs to complete a medication error report and counsel the nurse responsible. During an interview on 01/28/2013 at 4:20 pm, RNS # 1 stated nurses know to call the Supervisor for medications from the emergency kit. The medication delivery times are between 9:00 pm and 11:00 pm, pharmacy comes from Binghamton. Evening Supervisor checks on admits and readmits to make sure the orders were done by the LPNs, the Supervisors do the observations and assessments. Supervisors are to cover and complete an admission if the LPNs cannot. Supervisors should do spot checks to make sure things are getting done because the nurses just don't call and let you know. The policy and procedure books for ordering medications are on the units and in the nursing office. During an interview on 01/29/2013 at 10:30 pm, RNS # 3 stated only works one or two days per week on the night shift, does not do admissions. RNS starts at 11:00 pm, gets the supervisors report from the evening supervisor and then goes to the unit and compares it to the unit report and it usually does not match. As supervisor on the night shift I usually like to look at the chart of a new admission. Medication delivery times are approximately 11:30 pm, 12:30 am and sometimes 2:00 am. Night nurse have gotten no reports of medications missing that she is aware of. If a medication is not available the nurse should call the physician and let them know. All orders and transcriptions are checked on the night shift, no problems. An omission of a medication is a medication error, and a report should be completed. During an interview on 01/28/2013 at 11:30 pm, LPN # 11 stated if medications do not come in from pharmacy they use the emergency kit medications. LPN was not sure what was in the emergency kit, but if a needed medication was not in the emergency kit the pharmacy should be called. Pharmacy can have medications delivered from a local back up pharmacy. If they don't call the pharmacy " there out of luck ", and the residents don't get their medications . During an interview on 01/30/2013 at 2:30 pm LPN # 12 stated LPNs do the orders and the supervisors do the assessments (for admissions/readmissions). It is very difficult sometimes to get help, some will help and some will not, supervisors and nurses. Med passes are heavy, I don't bother asking for help anymore. Lot of medications are charted late because of the computer, the Internet is a problem there. 10NYCRR 415.12

Based on observation, medical record review and staff interview during a partially extended abbreviated survey (#NY 539, NY 595, NY 367 and NY 816) the facility failed to ensure that residents were free of significant medication errors. Specifically, for 11 (1, 2, 3, 4, 5, 6, 7, 9, 10, 11) of 22 residents reviewed, the facility failed to ensure residents received their physician ordered significant medications, on the evening of admission/readmission and failed to prevent avoidable significant medication errors/omissions. This had the potential to affect all residents receiving medication. This resulted is no actual harm with potential for serious harm that is Immediate Jeopardy and Substandard Quality of Care. The facility was able to remove the immediacy prior to exit by implementing the following: 1. Revision of the Policy and Procedures. 2. Reviewing and auditing all new admissions and readmissions for completion and accuracy of physician's orders [REDACTED]. 3. All licensed staff was educated on all areas of concern noted in the deficiencies, including electronic physician order [REDACTED]. 4. Medication pass audits were completed on all units and all shifts. This is evidenced by the following: . The Policy and Procedure (P&P) for Utilization of Matrix dated 04/11/2012 documented it is the policy of the facility to utilize Matrix as the preferred Electronic Medical Record (EMR) for the facility. The procedures included: all orders and documents are entered into the Matrix EMR upon admission through discharge; all medication and treatment administration will be completed and documented timely and accurately in Matrix; and the facility will audit, run and maintain all Matrix Compliance Reports at the discretion of Clinical Services. The P&P for Transcription of physician's orders [REDACTED]. A licensed nurse was to enter physician's orders [REDACTED]. The medication/treatment order was automatically sent to the pharmacy after the order is verified by a second nurse through a direct computer interface with the pharmacy. The pharmacy then dispensed the appropriate ordered medications to the facility and delivered the medications to the facility supervisor. The General P&P for Medication Administration General dated as revised 01/2013 documented: medications will be administered by a licensed practical nurse (LPN) or a registered nurse (RN). All medications will be administered and documented using the EMR. The purpose documented: to administer medications in a way that ensures the resident's safety and satisfies medical and legal concerns. Procedures included: Keep the basic rules of safe administration in mind; right drug, right resident, right time, right dose, right route; Document all medication and treatment administration in the EMR; Medications are to be administered no more than one-hour before or one hour after the ordered time, (document late medication per Matrix protocol) and if you believe you will be outside the expected time frame notify RN Nurse Manager/Supervisor immediately; Review electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] If the medication is not available on the nursing unit, notify the RN Supervisor (RNS). RNS will contact the pharmacy and notify the physician as necessary. Note at end of policy documented in bold letters, documented: ask the pharmacy to deliver the medication STAT (term used for immediately) and if you have any problems with this, report to the RNS; RNS will call the pharmacy to request STAT medications; if she/he has any problems will notify the Director of Nursing (DON) or Administrator to ensure prompt delivery. The P&P for medication error, monitoring and follow-up dated as revised 01/2013 documented: all medication/treatment errors will be reported and reviewed immediately upon discovery, and followed up with the appropriate person/persons as necessary. The purpose is documented: to assure the quality of care is maintained for all residents. Procedures documented: RN/LPN discovering error should; complete the medication/treatment error discovery forms; Notifies Nurse Manager (NM)/RNS; NM/RNS assesses resident for possible side effects if any, and notifies physician (MD); The medication/treatment error form is submitted to the DON. The DON must complete a full investigation; the DON reserves the right to institute immediate discipline. The P&P for medication administration times and dated as revised 01/2012 documented: Medication times may be altered to meet residents needs and timely administration. All medications must be administered within one hour of scheduled times. Resident # 17: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Nursing Observation Report dated 01/28/2013, documented that the resident was alert and oriented, to person and place. Physician orders [REDACTED]. During an observation on 1/30/13 at 11:25 am, the computer used by LPN#11 showed a red notice that there were medications that were past due. LPN#11 showed the surveyor that the resident's [MEDICATION NAME] Insulin was due to be given at 8:00 am before breakfast, and stated that he had not yet given this resident the morning insulin. LPN#11 also stated that the resident had already eaten his breakfast and that on a couple occasions that morning he had started to look for the resident but he kept getting interrupted by staff. He stated that this was not late documentation but that he had a busy morning with frequent interruptions and that he had not been able to give all the residents their morning medications yet. He stated that this was not unusual and that management knew that the nursing staff could not always get the medication passes done on time. During an interview on 1/30/13 at 11:28 am, the DON stated that she had spoken to the resident and he told her that he had refused his morning insulin. During an interview on 1/30/13 at 11:52 am, the resident stated that he had refused something earlier in the morning but could not remember what it was. He stated it was possible that he had refused the insulin. A Nurses Note dated 1/30/13 at 11:03 am, and signed by the DON, documented that the resident had refused to have lab draws taken that morning ([MEDICATION NAME] Time and INR). During an interview on 1/30/13 at 11:55 am, LPN#11 stated that the resident did not refuse his morning insulin, he had just not had time yet to give it to the resident due to being very busy and being interrupted. He stated that he charted in the EMAR at 11:54 am that he had documented late as opposed to administering the medication late. He stated that was the way he had been taught to document a late medication. Resident #2 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Nursing Observation Report dated 01/18/2013 documented the Resident was alert and oriented to person only. The hospital Transfer Summary dated 1/18/13, documented that the resident was discharged from the hospital on the following medications: [REDACTED] Atorvastatin (lowers cholesterol) 20 mg by mouth (PO) every night (QHS) [MEDICATION NAME] chloride (used for [MEDICAL CONDITION]) 12.5 mg po three times a day(TID) [MEDICATION NAME] (used for respiratory diseases) 0.5 mg inhaled every 12 hrs [MEDICATION NAME] (stool softener) 100 mg po twice a day (BID) Memantine ([MEDICATION NAME]) (used for [MEDICAL CONDITION]) 10 mg po BID [MEDICATION NAME] 50 mg po BID Pramipexole (used for [MEDICAL CONDITION]) 0.125 mg po QHS Tamsulosin (used for [MEDICAL CONDITION]) 0.4 mg po QHS The Resident Progress notes dated 1/18/13 at 8:41 pm documented the resident was a new admission. The nurse spoke with the physician (MD) and all medication orders were obtained. The Physician order [REDACTED]. Atorvastatin 20 mg po QHS at 8:00 pm [MEDICATION NAME] chloride 12.5 mg po TID at 8:30 am, 12:30 pm and 4:30 pm [MEDICATION NAME] 50 mg po BID at 8:00 am and 8:00 pm Memantine ([MEDICATION NAME]) 10 mg po BID at 8:00 am and 8:00 pm The Physician order [REDACTED]. [MEDICATION NAME] 0.5 mg inhaled every 12 hrs 8:00 am and 8:00 pm [MEDICATION NAME] 100 mg po BID at 8:00 am and 8:00 pm Pramipexole 0.125 mg po QHS at 8:00 pm Tamsulosin 0.4 mg po QHS at 8:00 pm The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Atorvastatin, [MEDICATION NAME] chloride, [MEDICATION NAME], Memantine ([MEDICATION NAME]) [MEDICATION NAME], Pramipexole, and Tamsulosin all of which were ordered 1/18/13 . During interview on 01/28/2013 at 4:40 pm, LPN # 4 stated that none of the paperwork had been done with the new admission at 3:00 pm when the evening shift started, and this is often the case. LPN #4 stated when the medication orders are sent late and would not arrive until late, the residents just don't get them. LPN further stated that in the case that the medications are ordered late, the LPN would just put them in the computer to start the next day. LPN stated when the call was made to the physician for Resident # 2, it was not mentioned that the medications would be late. The LPN stated there is an emergency kit (E-kit) for antibiotics and narcotics only. LPN#4 was not aware of other types of medications that were available for back-up medications. During an interview on 01/28/2013 at 4:20 pm, RNS # 1 stated that the pharmacy deliveries come from Binghamton, and the delivery times are between 9:00 pm and 11:00 pm. RNS stated that the nurse should know to call the RNS for medications not available to see if they are in the E-kit. RNS stated the 3:00 pm to 11:00 pm (evening) shift RNS is responsible to complete the observation and assessment part, of the admission and the LPNs are responsible to complete the orders for the admission and readmissions. The RNS should do periodic spot checks to see if things are being done properly. The RNS further stated that the LPNs just don't call the supervisor when there is a problem. During an interview on 01/28/2013 at 3:00 pm the DON was not aware of a problem with resident admissions or readmissions receiving their evening medications. DON stated that a medication error report should be completed for medication omissions. During an interview on 01/28/2013 at 12:30 pm the RNM # 1 had started employment with the facility less than two weeks ago. RNM#1 would expect that the orders for resident admissions and readmissions would be done immediately to allow time for delivery. The RNM stated that the physician should be notified if an ordered medication was not available. RNM#1 stated he had not completed an admission yet. Resident # 10 The resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident had long and short memory problems with severely impaired decision making according to the Minimum Data Set ((MDS) dated [DATE]. Physician orders [REDACTED]. Pulmocort suspension for nebulization (a controller medication for asthma); 0.5 milligram (mg)/2 milliliter (ml), 1 vial; inhalation. Twice a day at 8:30 am and 8:30 pm. [MEDICATION NAME] tablet extended release, 180 mg, once a day at 8:30 am. [MEDICATION NAME] (Used to help control certain types of [MEDICAL CONDITION] caused by [MEDICAL CONDITION]), 500 mg, twice a day at 8:30 am and 9:00 pm. Physician orders [REDACTED]. [MEDICATION NAME] (used to treat dementia associated with [MEDICAL CONDITION]), 5 mg tablet, once per day at 8:30 am. [MEDICATION NAME] (used to treat mild to moderate dementia), 10 mg at bedtime (hs), 8:30 pm. [MEDICATION NAME] 25 mg, 1.5 tablets, once a day at 8:00 am. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] [MEDICATION NAME], 500 mg twice a day at 8:30 am and 8:30 pm was dated to start 01/14/2013. Medication was documented as given late at 9:53 am on 1/22/2013. Documented as given late at 10:03 pm on 01/27/2013. [MEDICATION NAME], 500 mg twice a day, at 8:30 am and 9:00 pm was dated to start 01/29/2013. Medication was documented as given late at 10:14 pm on 01/29/2013. [MEDICATION NAME], 5 mg once a day at 8:30 am was dated to start on 01/30/2013. Medication was documented as given late at 10:40 am on 01/30/2013. [MEDICATION NAME] suspension for nebulization, 0.5 mg/2 ml, inhalation twice a day at 8:30 am and 8:30 pm, dated to start on 01/29/2013. Medication was documented as given late at 10:14 pm on 01/29/2013. Given late at 10:40 am on 01/30/2013. [MEDICATION NAME] 25 mg once a day at 8:00 am was dated to start on 01/30/2013. Medication was documented as given late at 10:40 am on 01/30/2013. [MEDICATION NAME] tablet extended release 180 mg at 8:30 am dated to start on 01/29/2013. Medication was documented as given late at 10:40 am on 01/30/2013. [MEDICATION NAME] 10 mg, at hs at 8:30 pm was dated to start on 01/14/2013. Medication was documented as drug unavailable at 10:41 pm on 01/14/2013. Medication was documented as given late at 10:03 pm on 01/27/2013. Progress notes dated 01/01/2013 through 01/30/13 revealed no documentation that the physician or supervisor was notified of the above listed medications being administered late or not administered. During an interview on 01/30/2013 at 10:30am, LPN# 1 stated the medication pass was late because the nurses are frequently pulled away for alarms and other resident needs. The LPN stated she does not ask for help when behind on medication pass because you will not get help. Many times the computer is slow and this can make a medication pass late because the nurse has to go back to residents to document the medications they had already given. Todays medication pass is slow because the unit is a little short staffed. During an interview on 01/29/2013 at 7:30 am RNS # 2 stated the medication passes are very heavy, the residents receive a good deal of medications. RNS stated it would not be possible to pass medications on time and complete an admission. RNS stated there should be a medication error report completed for late medications and omissions. RNS stated there have been times when the evening shift RNS is not made aware of an admission or readmission and it would not be on the 24 hour report. During an interview on 01/30/2013 at 10:45am, RNM # 1 stated the medication nurse should report to the RNM when medications are going to be administered late. The RNM stated that even though he is a new employee at the facility, he would expect the physician to be notified when a medication is late. RNM did state that the unit was working with one less Certified Nurse Aide (CNA) than usual due to three residents requiring 1:1 supervision with a CNA. RNM stated he was not aware that the medication nurse was so late passing medications. During an interview on 01/30/2013 at 1:00 pm, the Administrator stated he was not aware of medications being passed late. He stated he was only aware of late medications on occasion. Staff should be notifying the supervisors when the medication pass is late. The DON is responsible to monitor the medication pass via the computer reports, but unfortunately the DON was no longer employed at the facility. Resident # 19: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], assessed the resident was cognitively intact. Physician order [REDACTED]. The EMAR for 1/201,3 documented that the resident was to receive [MEDICATION NAME] at 8:30 am, 12:30 pm and 4:30 pm every day, and [MEDICATION NAME] at 8:30 am and 8:30 pm every day. During an observation on 1/30/13 at 11:50 am, the computer used by LPN#11 showed a red notice that there were medications that were past due. LPN#11 showed the surveyor that the resident's [MEDICATION NAME] and [MEDICATION NAME] were due to be given at 8:30 am and stated that the medications had not yet been given. He stated that this was not late documentation, but that he had a busy morning with frequent interruptions and that he had not been able to give all the residents their morning medications yet. He stated that this was not unusual and that management knew that the nursing staff could not always get the medication passes done on time. Review of the EMAR on 1/30/13 at 1:30 pm, revealed that it was documented that the 8:30 am doses of [MEDICATION NAME] and [MEDICATION NAME] had been documented late at 12:24 pm (as opposed to being administered late). During an interview on 1/30/13 at 1:34 pm, LPN#11 stated that he gave this resident's 8:30 am doses of [MEDICATION NAME] and [MEDICATION NAME] a little after 12:00 pm. He stated that he charted in the EMAR that he had documented late as opposed to administering the medication late. He stated that was the way he had been taught to document a late medication. LPN#11 again stated that the medications were given a little after 12:00 pm, and that he had not notified the RNM that he was late with medications and he had not contacted the physician. During an interview on 1/30/13 at 1:44 pm, RNM#3 stated that she had been the RNM on the unit for two months. She was not aware that this resident's medications were late, and that she normally checks the Matrix program to monitor the timeliness of the medication passes. She stated that medications were occasionally late on the unit because the medication nurses were frequently interrupted to assist with care, including attending to emergencies, helping transfer residents and answering questions of staff, residents and family members. She stated that these interruptions sometimes caused the nurses to be late in administering medications. RNM#3 also stated that she had not had to do or review Medication Error Reports in the two months that she has worked at the facility. Additional Interviews: During an interview on 01/29/2013 at 07:30 am, RNS # 2 stated that I am responsible for residents who come in on my shift and I start at 3:00 pm. The RNS stated Supervisors are supposed to do the observations period and an assessment note for admissions/readmissions and the LPNs are supposed to do the orders and transcription. It should be a coordinated effort if someone cannot finish, but it is not always. There is very poor communication here, it does happen that admissions are not always communicated to the evening supervisor. The RNS stated an error report should be completed for an omission. Medication passes are very heavy, these residents are on way too many drugs. When short staffed on the evening shift a nurse will pass medications on the entire unit and a second nurse will be sent to the unit to complete treatments. The Supervisor often gets involved in other things and many times can not help out. During an interview on 01/28/2013 at 4:20 pm, RNS # 1 stated that supervisors should do spot checks to make sure things are getting done because the nurses just don't call and let you know. The policy and procedure books for ordering medications are on the units and in the nursing office. During an interview on 01/30/2013 at 2:30 pm, LPN # 12 stated the LPNs do the orders and the supervisors do the assessments. It is very difficult sometimes to get help, some will help and some will not; supervisors and nurses. Med passes are heavy, I don't bother asking for help anymore. Lot of medications are charted late because of the computer, the Internet is a problem there. 10NYCRR 415.12(m)(2)

Based on interview, the facility did not ensure the quality assessment and assurance committee (QA) developed and implemented appropriate plans of action to correct identified quality deficiencies. Specifically, residents who were newly admitted or readmitted did not receive their physician ordered medications on the evening shift of their admission/readmission, due to orders not being transcribed in a timely manner, resulting in the medications being unavailable. Interviews revealed staff were not completing the admissions in a timely manner to ensure medications were available and there was a lack of communication between the unit nurses and nursing supervisors. Interviews revealed that staff were frequently out of compliance in administering medications in a timely manner. The QA Committee failed to complete investigations when medications were omitted, when significant medication errors occurred and when standards of practice were not followed for the timely administration of medications. This resulted in no actual harm but had the potential for serious harm that is IMMEDIATE JEOPARDY to resident health and safety and had the potential to affect all residents in the facility. The facility was able to remove the immediacy prior to exit. This was evidenced by: Refer to F309 scope and severity - K - Quality of Care Refer to F 333 scope and severity- K- Medication Errors During an interview on 01/28/2013 at 3:00 pm, the Director of Nurses (DON) who had become the Acting DON that day, stated that the problem was looked into on 01/28/2013 and discovered there was a problem with delay in the second nurse verification of orders. Nurses were not using the back-up box for medications and not notifying the physician. During an interview on 01/29/2013 at 10:00 am, the Administrator stated that the facility had become aware of medication ordering issues with a previous deficiency a couple of weeks ago. The Administrator stated he was not aware of these specific issues in regards to the readmissions and admissions delay in transcribing medications until 01/28/2013. During an interview on 1/29/13 at 1:32 pm, the Administrator stated that QA met monthly and that medication errors was one of the topics that was monitored by QA. He stated that there had only been two Medication Error Report forms submitted since 11/2012 and that this was not reasonable. He stated that the week prior, he had instructed the DON to investigate the lack of Medication Error Reports, but she had resigned from the facility effective 1/25/13. The Administrator stated that the DON did not report the progress of her investigation prior to leaving. During an interview on 01/30/2013 at 2:00 pm, the DON was not aware of the volume of medications being administered late. The supervisors and nurse managers have the ability to run reports from the computer system to monitor the timeliness of the medication administration. The DON stated the omission of and late administration of medications would be a medication error and a medication error report should have been completed. During an interview on 01/30/2013 at 1:00 pm, the Administrator stated the DON was responsible to monitor the computer system for medication administration, and unfortunately the DON's employment ceased as of the past weekend. QA was not addressing the medication timeliness, but had identified a lack of education to staff and was working on this. The Administrator stated the lack of a steady DON and the shortage of nurse managers could be a contributing factor in the timeliness of medication administration. 10NYCRR 415.27(a-c)

Based on record review, and staff interviews, the Administration failed to ensure that the facility operated in a manner that enabled it to effectively use its resources to maintain the highest practicable well-being and safety of each resident. (#NY 539, NY 595, NY 367 and NY 816) Specifically, 11 (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11) of 22 residents reviewed, who were newly admitted or readmitted , did not receive their physician ordered medications on the evening shift of their admission/readmission, due to unavailability of the medication. The administration failed to ensure that medication omissions were investigated and action was taken to prevent recurrence and failed to take action to prevent recurrence of significant medication errors. The administration failed to ensure that physician ordered medications were transcribed timely to prevent avoidable medication omissions. Additionally, the administration failed to follow the standard of practice in administering medications in a timely manner. Specifically, 20 (1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 12, 13, 14, 15, 16, 17, 19, 20, 21, 22) of 22 residents reviewed, did not receive their physician ordered medications within the time frame they were ordered to be given. Interviews revealed staff failed to complete the admission or readmission process for newly admitted and readmitted residents in a timely manner, resulting in residents not receiving medications as ordered by the physician. Investigation further revealed that the staff were not following the facility policy by notifying the physician, pharmacy and supervisor when medications were not available for administration. Investigation further revealed that the omission of medications were not investigated to determine the root cause of the medication omissions and to prevent further incidence. Additionally, staff failed to administer physician ordered medications at the time they were ordered to be given. This resulted in no actual harm but had the potential for serious harm that is IMMEDIATE JEOPARDY to resident health and safety. The facility was able to remove the immediacy prior to exit. This was evidenced by: Refer to F309 scope and severity - J - Quality of Care Refer to F 333 scope and severity- K- Medication Errors During an interview on 01/28/2013 at 3:00 pm, the Director of Nurses (DON) who had become the Acting DON that day, stated that the problem was looked into on 1/28/13 and discovered there was a problem with delay in the second nurse verification of orders. Nurses were not using the back-up box for medications and not notifying the physician. During an interview on 1/30/13 at 2:00 pm, the DON stated she was not aware of the volume of medications being administered late. The supervisors and nurse managers have the ability to run reports from the computer system to monitor the timeliness of the medication administration. The DON stated the omission of and late administration of medications would be a medication error and a medication error report should have been completed. During an interview on 01/29/2013 at 10:00 am, the Administrator stated that the facility had become aware of medication ordering issues with a previous deficiency a couple of weeks ago. He stated that he was not aware of these specific issues in regards to the readmissions and admissions delay in transcribing medications, until 01/28/2013. During an interview on 1/30/13 at 1:00 pm, the Administrator stated that he was only aware of late medication administration on occasion, but was not aware of an issue to this point. The Administrator stated the DON was responsible to monitor the computer system for medication administration and unfortunately the DON's employment ceased as of the past weekend. QA was not addressing the medication timeliness, but had identified a lack of education to staff and was working on this. He stated the lack of a steady DON and the shortage of nurse managers could be a contributing factor in the timeliness of medication administration. 10NYCRR 415.26

Based on medical record review and staff interviews during a follow-up survey for a complaint (NY 839), the facility failed to ensure that necessary care and services were provided to maintain 1 (Resident # 1) of 4 residents reviewed at their highest practicable physical, mental and psychosocial well-being, in accordance with their comprehensive assessment and plan of care. Specifically, when Resident# 1 ' s physician (MD#1) ordered an increase of the resident ' s [MEDICATION NAME] ( used to prevent [MEDICAL CONDITION]) at 10:00am on 1/8/13, the resident did not receive the increased dose until 8:30pm on 1/9/13. This resulted in no actual harm but had the potential for more than minimal harm that is not immediate jeopardy. This is evidenced by the following: Resident # 1 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician ' s progress note dated 1/8/13 at 10:00am, documented the resident ' s [MEDICATION NAME] was being increased from 500mg twice a day to 750mg twice a day. The prescription order for [MEDICATION NAME] for Resident #1 documented in the history of the order that MD #1 wrote an order on 1/8/13 increasing the resident ' s dose of [MEDICATION NAME] from 500 mg twice a day, to 750 mg twice a day. This order was not entered into the computer until 1/9/13 at 5:13pm. The order was not faxed to the pharmacy until 1/9/13 at 6:18pm [MEDICATION NAME]. The prescription order also documented that the first dose of the new order was not scheduled to be administered until 8:30pm. The medication record for January 2013, revealed the resident received [MEDICATION NAME] 500mg instead of 750mg for the doses scheduled for 1/8/13 at 8:00pm and 1/9/13 at 9:00am. The first dose of [MEDICATION NAME] 750mg, administered to Resident # 1 was on 1/9/13 at 8:30pm. During an interview on 1/17/13 at 11:00am the Registered Nurse Unit Manager (RNUM) stated she did not know why there had been such a delay but there could be any number of reasons, such as a crisis on the unit. The RNUM stated that MD#1 did not enter her own orders into the computer. The procedure for orders was that MD#1 wrote new orders on the resident ' s progress note and then later in the day a nurse would copy the orders into the electronic medical record. During an interview on 1/17/13 at approximately 11:00am the Director of Nursing (DON) stated t it would be her expectation that a medication order written by a physician on 1/8/13 would have been entered into the computer as an order on that day. The DON stated that it was not acceptable practice to enter a medication order written by the physician in the morning on 1/8/13, into the computer as an order on 1/9/13 on the evening shift. 10NYCRR 415.12

Based on medical record review and staff interviews during a complaint investigation (NY 9), the facility failed to ensure that necessary care and services were provided to maintain 1 (Resident #10) of 4 residents reviewed at their highest practicable physical, mental and psychosocial well-being, in accordance with their comprehensive assessment and plan of care. Specifically, the facility failed to ensure that a resident (Resident #1) who was receiving [MEDICATION NAME] for a long standing [MEDICAL CONDITION] disorder, was adequately monitored to ensure the resident's serum drug level was maintained in a therapeutic range to prevent [MEDICAL CONDITION]. As a result, the resident while on [MEDICATION NAME] had two [MEDICAL CONDITION] followed by a hospitalization for [MEDICATION NAME] toxicity and then an emergency department (ED) admission for a third [MEDICAL CONDITION]. This resulted in actual harm that was not Immediate Jeopardy. This was evidenced by: Resident #10: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessed the resident was severely cognitvely impaired. A laboratory form in the residents medical record dated 3/7/12, revealed a [MEDICATION NAME] level of 8.0 mcg/ml. The resident's MD#1 initialed the form indicating she had seen the results and noted, "No [MEDICAL CONDITION] in more than one year". The next attempt at a [MEDICATION NAME] level drawn at the nursing home was on 9/7/12 when someone (unknown author) enters a note on the laboratory form that the blood was not drawn because the resident refuses venipuncture. There is no indication that there was another attempt to draw that [MEDICATION NAME] level or that MD#1 was notified that the blood was not drawn. The next [MEDICATION NAME] level drawn is dated 9/25/12 with a result of 10.9 mcg/ml. physician's order [REDACTED]. dose of [MEDICATION NAME] each to 400 mg a day. When the resident was readmitted to the nursing home after hospitalized from [DATE] to 9/21/12 for [MEDICATION NAME] toxicity, the resident's [MEDICATION NAME] was not reordered but a [MEDICATION NAME] level was ordered to be drawn on 9/24/12. A nurse's note dated Friday, 5/18/12 at 6:59pm, revealed the resident had a 60 second [MEDICAL CONDITION] and an MD (no indication of which MD) was made aware and will see the resident on Monday (5/21/12). There are no physician or nurses notes to indicate that the resident was seen on 5/21/12 by a physician. A nurse's note dated 6/22/12 at 6:05pm revealed that a therapist reported that the resident had [MEDICAL CONDITION] activity and that MD#1 was made aware and informed that the resident's last [MEDICATION NAME] level drawn in March 2012 was 8.0mcg/ml. The note documented that MD#1's response was to monitor the resident and that no new orders were given at that time. On 9/17/12 at 5:56 pm the nurse documented that the resident was confused with garbled speech and an order was obtained to send the resident to the ED. In a follow-up note written that evening, at 10:39pm, the nurse documented that the resident was admitted to the hospital with [REDACTED]. In the discharge summary after the resident ' s hospital stay from 9/17/12 to 9/21/12, the Hospitalist dictated that the resident was admitted for UTI and management of [MEDICATION NAME] toxicity; the [MEDICATION NAME] was held during the hospitalization ; [MEDICATION NAME] levels were monitored and were trending down and the [MEDICATION NAME] should continue to be on hold and the resident should follow-up with the primary physician for adjustment of the [MEDICATION NAME] dose. A nurse's note dated 9/24/12 at 4:25pm documented that staff were unable to obtain a [MEDICATION NAME] level on 9/24/12 at 7:00am. In a subsequent note dated 9/27/12 at 8:58am a nurse documented that the resident had experienced clonic [MEDICAL CONDITION] activity [MEDICATION NAME] 2 minutes and this was followed by a second "short [MEDICAL CONDITION]" with arched neck and disorientation. The resident was transferred to the ED. The resident returned to the facility on [DATE] at 1540 hours and a telephone order was obtained for [MEDICATION NAME] 500mg twice a day. In the discharge summary from the resident's ED stay on 9/27/12 the ED physician dictated, "the resident was recently admitted to an outside hospital for [MEDICATION NAME] toxicity, with no restarting of her antiepileptic, She comes through, not surprisingly, with a breakthrough [MEDICAL CONDITION] today. She has been seen by neurology in the past year. We will start the patient on [MEDICATION NAME] 1000mg IV load and then plan for discharge on 500mg twice a day with follow-up with neurology." During an interview on 11/29/12 at approximately 8:30am, MD #1 stated that after reviewing the residents medical record she could surmise that at some point she was aware that the resident's [MEDICATION NAME] level was sub therapeutic at 8.0mcg/ml because the resident had not experienced any [MEDICAL CONDITION] activity in more than one year and she had not increased the dose of [MEDICATION NAME] until after the resident ' s second [MEDICAL CONDITION] on 6/26/12. MD# 1 did not recall being contacted on 5/18/12 after the resident had a [MEDICAL CONDITION]. She was confident she would not have told the nurse she would see the resident on Monday because she did not make rounds on Monday. She stated she depended on nursing staff to inform her when residents were on medications that needed to be monitored and expected that she would be made aware by nursing staff of lab results or if a resident refused a blood draw or to take medication. She did not recall being notified that the resident had refused the 9/7/12 blood draw for a [MEDICATION NAME] level and if she had been made aware she would have instructed the nursing staff to attempt to draw the specimen again or the next day. She did not recall being notified of the results of the 9/25/12 [MEDICATION NAME] level (10.9) but noted that she had initialed the form on 9/27/12. MD #1 stated that typically if she had seen a [MEDICATION NAME] level of 10.9 and knew that the resident's [MEDICATION NAME] was "on hold" for toxicity, she would have restarted the [MEDICATION NAME] knowing that the resident had [MEDICAL CONDITION] activity when she was subtherapeutic in the past. She stated that she usually came to the facility and started rounds around 8:30 in the morning on Tuesdays and Thursdays. During an interview on 11/29/12 at approximately 11:00am, a licensed practical nurse (LPN#1) stated he was working on 9/7/12 and would have been caring for Resident # 1. He did not recall the resident refusing to have blood drawn that morning but stated that generally in a situation like that he would ask the lab technician to re-approach the resident and make another attempt at drawing the blood and if they were still unable to get the specimen he would make the physician aware and ask for further orders. He could not explain why he had not written a note describing what he had done on 9/7/12. He stated typically he would have written a nurse's note describing what he had done and could not explain why he had not. He did not recall notifying MD#1 of the resident's refusal to have blood drawn. During an interview on 11/29/12 at approximately 11:30 am, the registered nurse unit manager (RNUM) on Resident #1's unit stated that she recalled discussing the resident's [MEDICAL CONDITION] activity with MD #1 at some time during the summer but could not recall specifics and did not recall if she made MD#1 aware of [MEDICATION NAME] levels or [MEDICATION NAME] dosing or if it was time to draw blood to monitor. 10NYCRR 415.12

Based on medical record review and staff interviews during an abbreviated survey (Case #NY 452) it was determined for one (Resident #1) of two residents reviewed that the facility did not ensure the physician reviewed the resident's total program of care, including medications, laboratory values and treatments. Specifically, the resident was admitted to the facility from the hospital on a medication for anticoagulation (increases blood clotting time) of blood, which was documented on the hospital records. The facility physician ordered the medications listed on the hospital discharge summary, dated 2/13/12, twenty-five days before the resident's actual discharge date of [DATE]. Laboratory values on the 2/13/12 indicated a International Ratio (INR which indicates clotting time) of 2.2 (anticipated range 2.5 to 3.5). The hospital progress notes written on 3/7/12, one day prior to the actual discharge date , documented an INR of 5.2. The resident continued to receive [MEDICATION NAME] until 3/13/12, when the resident was noted to have old brown rectal bleeding, blood pressure (BP) of 84/50 (normal 120/70) INR 6.5, hemoglobin 6.3 (normal 13.4-17.0) and a hematocrit of 18.9 (normal 39.1-49.5). The resident was transferred to the hospital. This resulted in actual harm that is not immediate jeopardy. This is evidenced by the following: Resident 1: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was assessed to have no cognitive impairment, and was able to make his needs known. The hospital form titled discharge summary dated 2/13/12 and titled as a "preliminary result", documented that the resident's INR was 2.2, sub therapeutic for the desired range of 2.5-3.5 . Additional hospital forms titled "Progress Notes" dated 3/7/12 documented an INR of 5.1. Further notes dated 3/8/12 documented that a goal of the INR was a therapeutic range of 2.5-3.5 and the resident was being discharged . The facility form titled "History & Physical" dated 3/8/12 and written by the physician documented that the resident was on [MEDICATION NAME]. The INR goal range was to be 2.5 to 3.5 The physician documented that the resident's current hemoglobin was 8.7 and the INR was 2.2. The physician orders [REDACTED]. Nurse's notes dated 3/9/12 at 2:53 pm documented a BP of 122/62. Nurse's notes dated 3/10/12 at 2:40 pm documented that the resident's visitor reported to a CNA (Certified Nursing Assistant) that the resident had a bloody nose and had vomited. There was no documentation that a Registered Nurse (RN) or physician had been notified. Nurse's notes dated 3/11/12 at 12:43 pm documented that the INR results of 4.6 were reported to the physician. The physician gave a new order to hold the [MEDICATION NAME] on 3/11/12, and start [MEDICATION NAME] 2 mg. on 3/12/12, and repeat the INR on 3/14/12. Nurse's notes dated 3/13/12 at 6:03 am documented that the resident experienced a moderate amount of old brown blood coming from the rectum. The nurse's note documented the resident's BP was 99/46 and the resident would be monitored. There was no documentation that the physician was made aware. Nurse's notes dated 3/13/12 at 5:52 pm documented that the resident reported he was having a large amount of rectal bleeding which had started last night, an the nurses were aware. The resident also reported he had vomiting and stomach pain. His BP was 92/50 and 84/50. The physician was notified and ordered the resident be transported to the hospital for evaluation. A nurse's note dated 3/13/12 at 10:43 pm documented that the resident was admitted to the intensive care unit. During an interview on 3/19/12 at 1:00 pm the facility medical records staff member stated the facility did not have an updated discharge summary. She stated that the hospital had been called, and they stated they initiated a new computer system around 3/8/12, and there must have been a glitch. The hospital then sent an updated discharge summary to the facility with updated lab values. During an interview on 3/2912 at 2:50 pm the physician stated she usually reads the discharge summary to elicit information regarding the resident's condition and medications. She stated she does not usually read progress notes from the hospital unless she needs clarification. She stated the hospital is supposed to send addendum's if the discharge summary is written before the resident is actually discharged . She stated she was not informed of the resident's nose bleed, vomiting nor the old brown rectal bleeding that the resident experienced. The physician stated she usually checks the date of the discharge summary, but may not have in this case. She said the hospitals send outdated discharge summaries more than you would think. She said in this situation there is not a good outcome with a system failure, and the facility need a system. 10 NYCRR 415.15(b)(2)(iii)

Based on medical record review and staff interviews during a complaint investigation (Case # NY 750), it was determined that the facility did not ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.. Specifically, the facility did not ensure for one ( #1) of two residents reviewed, that measures were put in place to prevent the further breakdown of the resident's left heel after it was assessed by the registered nurse unit manager (RNUM) on 2/18/11 upon readmission to the facility, to be "boggy." Although the resident had been assessed to be at "high risk" for developing pressure ulcers upon readmission, there were no orders obtained or treatment initiated to prevent further breakdown of the resident's left heel. On 2/20/11, the resident's left heel was noted to be blistered and draining "bloody drainage." Further observation revealed the residents heels were on the floor with out preventative devices. The resident subsequently developed a Stage II area on the left heel. This resulted in actual harnm that is not immediate jeopardy. This is evidenced by the following: A facility policy titled, "Pressure Sore Assessment and Monitoring," dated 12/13/99, with a revision date of 04/21/10, documented on page 2, under the section listing pressure ulcer prevention precautions, in item 10, "Obtain protective devices as recommended by the team: heel booties, low air loss mattress, etc." The " C " section documented, " Any new area will be assessed by an RN and treatment initiated based on wound care protocol, data will be documented in the Interdisciplinary Progress Notes. The responsible party and Physician will be notified of change." 1. Resident #1 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having moderately impaired cognitive skills. A facility form titled, "Admission and Orientation to Unit" dated 02/18/11, documented under the "Integumentary System" section that the resident's skin was "intact." The RNUM also documented in this section that the resident's left heel was "boggy"(spongy) and the skin intact." A facility form titled "pressure ulcer risk assessment form" documented the resident was assessed by the RNUM on 2/18/11, (the day the resident was readmitted to the facility from the hospital), as a number "6" for pressure ulcer risk. The key on this form documented that a score of 12 or below places the resident at "high risk" for developing pressure ulcers. The nurse's notes from 2/18/11 to 2/20/11 included no documentation addressing the resident's heels until 2/20/11 at 5:11 pm when the RN supervisor (RNS) documented that he was called to the floor at 2:30 pm and the resident was noted to have an area on her left heel that was dark red in color, boggy on palpation and measured 4 cm in diameter. The RNS documented that the area was noted to be draining bloody fluid and the physician (MD) was notified. The area was cultured and the resident was started on antibiotics. A physician's orders [REDACTED]." An order dated 2/20/11 at 7:00 pm documented "float both heels, foam booties." The History & Physical form completed by the facility MD on 2/20/11 (untimed), after the resident was readmitted to the facility, documented a left heel decubitus and that the blister was "ruptured." The "Interdisciplinary Care Plan" titled skin integrity dated 2/25/11, documented interventions of "off-loading and heel protectors", five days after the resident was noted to have a draining blister on the left heel. A facility document titled, "Weekly Pressure Sore Record" completed for Resident # 1, dated 2/22/11, documented a pressure sore to the left heel and noted it to be a Stage II with sero-sanguineous drainage (bloody and serous) and 3 centimeters (cm) by 2 cm in size. A follow-up report dated 3/2/11, described the area to be 4 cm X 4.5 cm with an inside open area that measures 2 cm X 1 cm. Documents titled, "ADL Reference" (a CNA care card used to instruct the CNA's on how to care for each specific resident) that were current at the time the resident was readmitted to the facility on [DATE] until the most recent was printed on 3/1/11, did not identify the resident to be at risk under the section for "pressure sore risk" and did not instruct the CNA to provide any specific care to the resident's heels, did not instruct the CNA to protect the residents heels from developing pressure ulcers and did not instruct the CNA to off-load heels or use foam booties as the MD ordered on [DATE]. During an interview on 3/1/11 at 2:30pm, the Registered Nurse Unit Manager (RNUM) stated that on 2/18/11 when the resident returned to the facility from the hospital, she completed the resident's assessment and noted that her left heel was "boggy" (soft, spongy and an early sign of potential for skin breakdown on heels). She entered that information on the nursing admission form, under the skin assessment section. The RNUM stated that she elevated the resident's heels up on pillows at that time, and asked one of the LPN's to call the MD and get an order to apply "skin prep" to the resident's heels. She stated she did not instruct the CNA caring for the resident at the time to keep the resident's heels up on pillows. The RNUM added that the order for skin prep was never received and the treatment was never initiated. She thought maybe the LPN did not hear her instructions to call the MD. The RNUM agreed that a doctor's order was not necessary for skin prep or elevation of the feet and these measures could be performed per nursing judgement. The RNUM could not explain why she had not initiated these measures on 2/18/11 when she assessed the resident's left heel and described it as "boggy." The RNUM stated the CNA's caring for the resident would know to elevate Resident # 1's heels off of the bed, or to apply foam booties to both feet to protect the heels from breakdown, because that information would be on the ADL (CNA care card) Sheet. When asked if she had added that information to the ADL sheet she stated that she had not. The RNUM stated that on Tuesday, 2/22/11 when she returned from a three day weekend off, she was made aware that the resident's left heel had blistered and was noted on 2/20/11 to have opened and was draining. She realized at that time that a wound culture had been obtained and the resident had been started on antibiotics but there was still no order for a dressing or any specific treatment to the resident's heel. In a follow-up interview on 3/4/11 at 2:00pm, the RNUM was asked to clarify her documentation on the "weekly pressure sore record" dated 3/2/11. She stated that the pressure ulcer was still assessed as a Stage II and measured 4 cm X 4.5 cm, with an area in the center of the wound where the skin had pulled away. This area measured 2 cm X 1 cm. During an interview on 2/25/11 at approximately 2:30pm, a CNA (CNA #1) stated that she really was not sure what to do with the resident's foam booties. She did not know the resident was supposed to wear both booties. CNA # 1 stated that when she got the resident out of bed that day she did not want the resident's foot to drag on the ground and so she put one bootie on the resident's right foot and left the left foot bootie off because the left foot had a bandage. The CNA apologized for making a mistake and said she tried to do what was right. She stated that she had looked at the ADL card to see if there was any instruction for using the booties but there was not. During an interview on 3/1/11 at approximately 3:30pm the RNS stated that he was on Resident # 1's unit on Sunday 2/20/11 sometime in the afternoon and was asked by one of the staff to look at Resident # 1's foot because the family was extremely upset when they found that the resident's heel had blistered and was draining. The RNS stated he assessed the resident's heel, instructed the LPN to call the MD and get orders for treatment and he came back later in the shift and documented his assessment in the medical record. Resident #1 was observed on 2/25/11 at approximately 11:20 am sitting in a chair in the dining room with both feet on the floor and one foam bootie on the right heel and no bootie on the left heel. The resident's left foot was resting on the floor on the heel portion of the foot with a dressing wrapped around the heel. The ADL reference sheet printed on 2/25/11 did not instruct the CNA to use foam booties or to float the resident's heels as ordered by the physician. On 3/1/11 at approximately 2:20 pm the resident was once again observed sitting in a chair in the dining room with both feet on the floor and one foam bootie on her left heel and no bootie on the right heel. The resident's right foot was resting on the floor on the heel portion of the foot. The ADL reference sheet printed on 3/1/11 still did not instruct the CNA to use foam booties or to float the resident's heels. The RNUM stated she did know why the resident did not have foam booties on her feet and she responded that she would find the CNA caring for the resident and inquire. 10 NYCRR 415.12(c) (1)(2)

Based on observation, record review, and staff interview the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of disease and infection for 10 ( #'s- 131, 142, 144, 181, 182, 188, 189, 193, 194 and 214) of 17 residents reviewed during the extended recertification survey and a complaint investigation (Case #NY 814). Specifically, for residents #s 181, 182, 188, 189, and 194, on the third floor unit, the facility failed to develop, implement and educate staff on infection control practices. Staff used one electric razor to shave multiple residents without cleansing and disinfecting the razor between residents. On more than one occasion staff noted blood on the razor and proceeded to wipe it off without disinfecting the razor. One resident was noted to have Methicillin Resistant Staphylococcus Aureus (MRSA, a bacteria that causes infections) in his nostrils. In addition the facility failed to ensure that glucose meters (used to check blood sugar levels) were cleaned between each resident's use for Residents #s 131,142,144,193 and 214 by three nurses on 3 of 4 units. This had the potential to effect all residents that required shaving on the third floor unit and all residents that required glucose testing on the second, third and fourth floor units. This resulted in no actual harm but had the potential for more than minimal harm which is Immediate Jeopardy to the health and safety of the residents. This is evidenced by: Resident #194: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having severe cognitive impairment. The Policy and Procedure for Use of Electric Razor, Safety Razor, with a revision date of 9/20/06, documented that residents receiving anticoagulant medications were required to use an electric razor. A facility-owned electric razor was to be cleaned prior to use by rinsing the razor head in cold water or a new razor head could be obtained. The undated Certified Nurses Aide (CNA) Assignment Sheet, which the CNA's used to know what care each resident required, documented that this resident was on bleeding precautions and required assistance with personal hygiene. The physician's orders [REDACTED]. A Laboratory Report dated 12/30/10 documented that the resident was found to have MRSA in his nostrils. A Nurses Note dated 1/2/11 at 10:59 am, documented that the resident was positive for MRSA in his nostrils. The physician was notified and ordered an antibiotic ointment to be applied to the residents nostrils. Review of the Infection Control Current Infection List for 1/11 documented that this resident was on contact precautions due to being found positive for MRSA in the nostrils on 12/28/10. Review of the medical record on 1/27/11 revealed that there had been no follow-up culture of the resident's nostrils. During an interview CNA#1 on 1/27/11 at 10:00 am, stated that she purchased an electric razor for the residents. She kept the razor in her personal locker at the facility and used it to shave the five male residents that she was assigned to. She stated that some of the other CNA's also had brought in electric razors and that these razors were shared among various residents. CNA#1 stated that she cleaned the razor between residents by shaking the whiskers out then used a brush to finish cleaning the razor. CNA #1 stated she would use an alcohol wipe to remove blood when it was seen on the razor. During an interview CNA#2 on 1/27/11 at 12:12 pm, stated that CNA#1 had an electric razor that she had brought in from home for use with residents on the floor. She said that if a resident's razor was missing or not working, she occasionally used the "community razor" for her residents. She stated that she could not recall which day it was, but earlier in the week she shaved this resident and somehow the resident received some nicks on his face. She stated that there was blood on the razor but she wiped the blood off with a paper tissue prior to using it on another resident. During an interview CNA#3 on 1/27/11 at 12:15 pm, stated that she occasionally used CNA#1's electric razor on her residents. She stated that she always cleaned the razor by shaking out the whiskers and using a brush to finish cleaning it. CNA#3 said that the facility did provide electric razors to the residents, but that they did not shave closely. If a resident's razor was not working or was missing, she would use the CNA#1's razor. During an interview with the Infection Control Registered Nurse (RNIC) on 1/27/11 at 1:45 pm, she stated that she was not aware that the CNA's were sharing an electric razor between residents. She stated that it was inappropriate to share a razor between residents because it needed to be disinfected between residents and not just cleaned. She said that using an electric razor with this resident, who had tested positive for MRSA, and then using it on other residents without disinfecting the razor put the other residents at risk for getting MRSA. This resident was due for a follow-up culture after being treated for [REDACTED]. During an interview with the Medical Director on 1/27/11 at 2:35 pm, he stated that an electric razor should not have been shared between residents as this could spread infection. He stated that if a resident had MRSA a shared razor could spread the infection to other residents. During an interview with the Director of Nursing (DON) on 1/27/11 at 2:42 pm, she stated that she was not aware that the CNA's were sharing an electric razor between residents. She said this practice was unacceptable and posed an infection control risk to the residents because there was no method for disinfecting the razor between residents. During an interview with the Registered Nurse Manager (RNM) on 1/27/11 at 3:07 pm, she stated that she was not aware that the CNA's were sharing an electric razor between residents and that this posed an infection risk to the residents. During an interview with the Administrator on 1/27/11 at 3:12 pm, he stated that he was not aware that the CNA's were sharing an electric razor between residents. He stated that this was not good practice and that it could spread infection. Resident #193 The facility's Policy and Procedure titled Measuring Blood Glucose after Fingerstick with a revision date of 6/22/10 and 1/27/11 documented that to ensure all glucose meters are not contaminated with blood, each monitor is to be cleaned with an alcohol pad after use between each resident's use. To clean the outside of your blood glucose meter, use a lint -free cloth dampened with soapy water or alcohol ( 70%- 85 % ). The resident was admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed the resident as having severely impaired cognition. During observation of medication pass on Unit 3 on 1/24/11 at 12:00 pm, licensed practical nurse (LPN) #3 was observed to perform a glucose finger stick with the facility's glucose meter on resident # 193. The LPN did not clean the glucose meter prior to placing it back in the drawer of the medication cart. During an interview on 1/24/2011 at 12:15 pm , LPN # 3 stated she should have cleaned the glucose meter with alcohol prior to placing it in the drawer of the medication cart . During an interview on 1/25/11 at 4:45 pm , the DON stated that the glucose meters should be cleaned and disinfected between each resident's use and also should be cleaned after each use before placing the glucose meter on the medication cart and /or in the drawer of the medication cart. During an interview on 1/27/11 at 9:30 am, the RN IC stated that the glucose meter was to be cleaned between each resident's use and should not be placed on the the medication cart or in the drawer of the medication cart without being cleaned. Resident #144 The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. During observation of the medication pass on Unit 2 on 1/24 /11 at 4:40 pm, 4:50 pm and 5:00 pm, LPN # 4 was observed to have performed a glucose fingerstick on residents #s 144, 142, and 131 using the same glucose meter. The glucose meter was not cleaned after use or before it was used for each resident. During an interview on 1/24/11 at 5:10 pm , LPN #4 stated he did not clean the glucose meter after each resident's use and he was not aware of any policy or procedure for cleaning the glucose meter. During an interview on 1/25/11 at 4:45 pm , the DON stated that the glucose meters should be cleaned and disinfected between each resident's use and also should be cleaned after each use before placing the glucose meter on th medication cart and /or in the drawer of the medication cart. During an interview on 1/27/11 at 9:30 am, the RN IC stated that the glucose meter was to be cleaned and disinfected between each resident's use and should not be placed on the the medication cart or in the drawer of the medication cart without being cleaned . Resident # 142 The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed the resident had moderately impaired cognitive skills for daily decision making. During observation of the medication pass on Unit 2 on 1/24 /11 at 4:40 pm, 4:50 pm and 5:00 pm, LPN #4 was observed to have performed a glucose fingerstick on residents #s 144, 142, and 131 using the same glucose meter. The glucose meter was not cleaned after use or before it was used for each resident. During an interview on 1/24/11 at 5:10 pm , LPN # 4 stated he did not clean the glucose meter after each resident's use and he was not aware of any policy or procedure for cleaning the glucose meter. During an interview on 1/25/11 at 4:45 pm , the DON stated that the glucose meters should be cleaned and disinfected between each resident's use and also should be cleaned after each use before placing the glucose meter on th medication cart and /or in the drawer of the medication cart. During an interview on 1/27/11 at 9:30 am, the RNIC stated that the glucose meter was to be cleaned and disinfected between each resident's use and should not be placed on the the medication cart or in the drawer of the medication cart without being cleaned . Resident # 214 The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed the resident as being cognitively intact. During an interview on 1/24/11 at 5:15 pm , LPN #5 stated that she did not clean the glucose meter after testing resident's #214 fingerstick blood glucose and placed the glucose meter on top of the medication cart. In addition, the LPN stated she did not clean it because she had no other blood glucose fingersticks scheduled until 8:30 pm and she would use it again on resident #214 and then would clean the glucose meter before using it on another resident. During an interview on 1/27/11 at 9:30 am, the Infection Control Registered Nurse (RNIC) stated that the glucose meter was to be cleaned and disinfected between each resident's use and should not be placed on the the medication cart or in the drawer of the medication cart without being cleaned. During an interview on 1/25/11 at 4:45 pm , the Director of Nursing (DON) stated that the glucose meters should be cleaned and disinfected between each resident's use and also should be cleaned after each use before placing the glucose meter on th medication cart and /or in the drawer of the medication cart. 10 NYCRR 415 .19 (a) (b)

Based on interviews and medical record review during an extended recertification survey and a complaint investigation (Case # NY 814), it was determined the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, the Administration failed to ensure that the facility develop, implement, and educate staff on infection control practices. The Administration failed to ensure that electric razors were not shared between residents on one of four units and that glucose meters ( used to check blood sugar levels) were cleansed and disinfected between resident use on two units of four units. This had the potential to effect all residents that required shaving on the third floor unit and 20 residents that required glucose monitoring on the second and fourth floor units. This resulted in no actual harm with the potential for more than minimal harm which was Immediate Jeopardy to resident health and safety. This was evidenced by: F-441 was found to be at a pattern which constituted immediate jeopardy for resident health and safety. During the survey of January 24- 28 2011 staff used one electric razor to shave multiple residents on the third floor unit. On more than one occasion staff noted blood on the razor and proceeded to wipe it off of the razor. One resident was noted to have [MEDICAL CONDITION] (MRSA, a bacteria that causes infections) in his nostrils. In addition the facility failed to ensure that glucose meters (used to check blood sugar levels) were cleaned and disinfected between each resident's use. During an interview CNA#1 on 1/27/11 at 10:00 am, stated that she purchased an electric razor for the residents. She kept the razor in her personal locker at the facility and used it to shave the five male residents that she was assigned to. She stated that some of the other CNA's also had brought in electric razors and that these razors were shared among various residents. CNA#1 stated that she cleaned the razor between residents by shaking the whiskers out then used a brush to finish cleaning the razor. CNA #1 stated she would use an alcohol wipe to remove blood on the razor. During an interview CNA#2 on 1/27/11 at 12:12 pm, stated that CNA#1 had an electric razor that she had brought in from home for use with residents on the floor. She said that if a resident's razor was missing or not working, she occasionally used the "community razor" for her residents. She stated that she could not recall which day it was, but earlier in the week she shaved this resident and somehow the resident received some nicks on his face. She stated that there was blood on the razor but she wiped the blood off with a paper tissue prior to using it on another resident. During an interview on 1/25/11 at 4:45 pm, the DON stated that the glucose meters should be cleaned and disinfected between each resident's use and also should be cleaned and disinfected after each use before placing the glucose meter on the medication cart and /or in the drawer of the medication cart. During an interview with the Administrator on 1/27/11 at 3:12 pm, he stated that he was not aware that the CNA's were sharing an electric razor between residents. He stated that this was not good practice and that it could spread infection. 10NYCRR415.26

Based on staff interview and medical record review the facility did not ensure that the resident received and that the facility provided 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 for 3 (#'s 134, 151 and 288 ) of 17 residents reviewed during the extended recertification survey and a complaint investigation (NY 005). Specifically, for Resident # 288, insulin and fingerstick blood sugars were not reordered on readmission to the facility. The blood sugar levels were not monitored and the resident was readmitted to the hospital with [REDACTED].#288 that was not immediate jeopardy. Resident #134 was to be seen by the dentist for a tooth extraction, and had a delay in treatment multiple times due to a medication not being held prior to the scheduled tooth extractions. Resident #151 did not receive pain medication as ordered. This resulted in no actual harm with the potential for more then minimal harm that is not immediate jeopardy for Resident 134 and 151. The findings are: Resident #288 The facility did not clarify an order on readmission for administration of insulin and monitoring of blood sugar; did not ensure a timely assessment of a resident with change of condition; and the physician did not follow up on the unclear order or verify that the resident's diabetes was adequately controlled. The resident was initially admitted to the facility 12/9/10 for rehabilitation following a prolonged hospitalization which included bowel resection with complications, diabetes, [MEDICAL CONDITION], and [MEDICAL CONDITION]. The resident was assessed on the Minimum Data Set ( MDS) of 12/15/10 and 12/28/10 with no impairment of memory or decision-making, no behavioral or mood alterations, and needing assistance for all activities of daily living. The initial Transfer Discharge summary from the hospital physician dated 12/9/10, listed medications including [MEDICATION NAME]sliding scale as needed based on fingersticks, and [MEDICATION NAME]35 units subcutaneously(sq) twice a day. The Nursing Home physician (MD) provided new admission medical orders dated 12/9/10, including blood sugar sliding scale, [MEDICATION NAME]coverage (no doses), [MEDICATION NAME]35 u sq BID. These were administered to the resident from 12/9/10 to 12/15/10. On 12/15/10, laboratory blood glucose of 260 (normal 70 to 110) and BUN of 145 (normal 7 to 23) was reported to the physician. The resident was sent to the Emergency Department for evaluation and admitted to the hospital. On 12/21/10, the resident was readmitted to the nursing facility at 5:05 PM. A Physical Therapy (PT) note dated 1/3/11, (not timed) documented the resident was shivering, coughing and expectorating thick sputum, fingers were purple, the resident was returned to the unit and the nurse was informed. After lunch PT revisited the resident. The resident continued to present with a change in status and the symptoms were again reported to the nurse. There was no documentation of a nursing assessment of the resident after the PT report until 10:35 PM. The Nursing Progress Notes dated 1/3/11 at 10:50 PM documented that a Certified Nursing Assistant (CNA) reported the resident was " not acting right." The nurse found the resident responding sluggishly to verbal stimuli; a fingerstick blood glucose read HI (per the operators' manual, a reading of HI means greater than 550). The MD was notified and ordered [MEDICATION NAME] 10 units. The resident was sent to the hospital via Emergency Medical Services at 10:35 PM. The history and physical exam from the hospital, dated 1/3/11, documented the presence of pneumonia, uncontrolled diabetes, dehydration, and acute-on-[MEDICAL CONDITION]. The Licensed Practical Nurse (LPN) who completed the admission paper work for the 12/21/10 readmission of the resident was interviewed 1/27/11 at 3:15 PM and stated that the MD visited the facility prior to the resident's arrival and provided a 3-page document entitled "Transfer Discharge" which the LPN identified in the resident's medical record. This document was easily identified because the MD had initialed and made notations on it. Listed on the discharge medications was " [MEDICATION NAME] sliding scale " as needed. There is a handwritten question mark after this entry, made by the physician. The LPN stated that she did not have a chance to review the admission documents until 10:30 PM on 12/21/10. The LPN stated that since the order for [MEDICATION NAME] was an incomplete order, and could not be carried out as written, she did not transcribe it onto the new order sheet, and communicated to the evening supervisor and the next shift nurse that the order needed clarification. She further stated that she wrote it on the 24-hour report. The MD orders from the residents readmission did not include insulin or monitoring of blood sugars. The 24-hour report was obtained, and the resident's readmission was documented on the report, but there was no documentation regarding the insulin or that an order needed clarification. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview with the MD and Medical Director on 1/27/11 at 1:00 PM, the course of events for this resident was reviewed. The discharge orders from hospital, dated 12/21/11, were reviewed with the MD including the order for [MEDICATION NAME] as needed. The MD was asked how nursing staff would know how much insulin to give if no fingersticks were ordered. The MD stated that they would not know. The MD stated that the LPN who read the orders from the discharge summary to her was supposed to clarify the order with the supervisor, and did not do so. When asked how often she had reviewed the fingerstick results after the resident was readmitted from the hospitalization , the physician stated that she usually only reviews the fingerstick blood sugars once a month. The MD added that she thought that fingersticks were being done and that she would have been notified if any were abnormal. The MD was shown a history and physical examination Patient not on insulin, watch for [MEDICAL CONDITION] and dehydration." The MD and Medical Director were asked whether the elevated blood sugar could have contributed to the development of dehydration. They stated that the resident's degree of pre-existing [MEDICAL CONDITION] may have contributed to a high glucose reading. They also stated that the hospital determination of the [DIAGNOSES REDACTED]. The facility provided a document entitled "Investigation of Medication Errors", showing the date of the error as 12/21/10 and the date of discovery as 1/3/11. This form identified the error as failure to transcribe the order for insulin onto the resident's readmission orders [REDACTED]. Resident #134 The resident had multiple delays in treatment due to a medication not being held prior to scheduled tooth extractions. The resident was admitted on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as moderately cognitively impaired. The physician's orders [REDACTED]. The order documented to please call to confirm the next dental visit, and discontinue ASA three days prior to that. On 10/19/10 there was an order to hold ASA 81 milligrams (mg) from 10/21/10- 10/26/10 for a tooth extraction on 10/26/10. On 11/6/10 there was an order to hold ASA 81 mg on 11/6, 11/7, 11/8, and 11/9 for tooth extraction. On 11/9/10 there was an order to discontinue ASA 3 days prior to the dental appointment. Again, on 12/7/10 and 12/14/10 there was an order to discontinue ASA three days prior to dental appointment. The dental consult sheets documented the following: On 9/21/10 the resident was interested in a follow up appointment, and needed an extraction of teeth # 2, 3,and 6. The note documented on the next visit there would be an extraction. On 10/12/10 the dentist documented that the resident must be off aspirin before an extraction. The plan was for an extraction on the next visit. On 10/19/10 the patient was rescheduled and again aspirin was not held. The note documented the aspirin should be held starting Thursday 10/21/10 through 10/26/10 for the dentist to extract the residents' teeth. The note documented the medication nurse was told and the plan was for an extraction to be done on the next visit. On 11/2/10 the dentist noted that the resident was still on aspirin and was again rescheduled. On 11/9/10 the note documented that an extraction occurred. A piece of the bone around the tooth chipped off with the tooth, making the wound of the extraction bigger than a normal extraction wound. The dentist noted it was decided not to extract #3 that day. On 11/16/10 the dentist noted that the resident was healing normally and during the next visit extraction of #3 would occur. On 12/7/10 the dentist attempted to extract #3, however the aspirin was not held. The resident was rescheduled and on 1/4/10 the extraction of #3 occurred. During interview on 1/26/11 at 12:50 pm, the Registered Nurse Manager (RNM) stated she was aware of some of the concerns, specifically 11/2/10 and the most recent 1/4/11 appointment. She stated she was not aware of all of the appointments when the resident's aspirin was not being held. The RNM stated she did not always receive the consults, sometimes the charge nurse did. She stated that the charge nurses had not notified her of concerns or need for follow up. She stated from this point on she will be reviewing all of the dental consults when they come up to the floor. During an interview on 1/26/11 at 8:45 am the unit secretary who is responsible for setting up the dental appointments, stated that she gives the dental consults to the RNMs the day the appointment occurs. If the RNM is not available she gives them to the charge nurse. She stated the dentist comes every Tuesday. On occasion he will cancel and she calls the floors to let them know. The unit clerk indicated that the nurses would be responsible for follow up or medication orders. During an interview the Director of Nursing (DON) on 1/26/11 at 9:15 am, stated that the secretary should be giving the dental consults to the the nurse, then the nurse and physcian should review it for any follow up needed. Resident 151 The facility did not ensure the resident received the prescribed extended release opiate narcotic [MEDICATION NAME] extended release (ER), 60 milligrams (mg) by mouth (po) every 12 hours (hrs) for a period of 11 days from 12/21/10 to 12/31/10 because the order was never transcribed and the pharmacy never received the order or the prescription. Also, the resident did not receive 5 doses of the prescribed [MEDICATION NAME] ER 60 mg every 12 hrs on 1/2/11, 1/3/11, and 1/4/11 because the facility did not have the medication available for the resident. Additionally, the facility did not adequately and consistently monitor the resident's level of pain. The resident was admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. In addition, the resident has a history of narcotic addiction related to chronic pain. The Minimum Data Set ((MDS) dated [DATE] assessed that the resident was cognitively intact. An interim attending physician (MD)order, hand written by the MD, on 12/21/10 documented the prescription number and an order for [REDACTED].[REDACTED] Prior to the 12/21/10 order, the resident was ordered to receive [MEDICATION NAME] ER 60 mg twice a day as needed (prn). This order was not discontinued on 12/21/10 on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] The MAR for the month of 12/10 documented [MEDICATION NAME] 60 mg twice a day as needed (prn) was administered on 12/28/10, on 12/30/10 and on 12/31/10 for a total of 3 doses. The 12/10 MAR indicated [REDACTED]. The MAR for 1/11 documented [MEDICATION NAME] ER 60 mg po every 12 hrs. This MAR also documented that 5 doses of the [MEDICATION NAME] ER 60 mg were not administered on 1/2/11, 1/3/11, and 1/4/11 because the facility did not have the medication available. The back of the MAR indicated [REDACTED]. A nurse's note (NN ) dated 12/28/10 at 12:00 pm ,documented that the resident stated he had pain all over and when the nurse had asked the resident if [MEDICATION NAME] was controlling his pain the resident stated " hardly"'. The nurse administered the prn dose of [MEDICATION NAME] ER . The resident stated that he thought he was to receive the [MEDICATION NAME] every 12 hrs . This same nurse documented that she reminded the resident that it was ordered prn. ( This was during the time that the [MEDICATION NAME] ER 60 mg every 12 hrs was not transcribed ). A NN dated 1/2/11 and untimed, written by LPN # 1, documented the [MEDICATION NAME] ER 60 mg was not available to be administered. The note documented the pharmacy will send the medication today. The note documented the script was written on 12/21/10. A later NN written by LPN #1 at 3:40 pm documented that the facility's pharmacy did not have the prescription written on 12/21/10 . LPN #1 also documented that the MD was notified and the MD will not call in any narcotics and told this LPN " to find the script". A NN written on 1/3/11 at 2:00 pm by LPN #2 documented that the MD refused to sign a new prescription for the [MEDICATION NAME] ER 60 mg every 12 hrs. This LPN also documented that the RN /Supervisor was notified. A Controlled Substance Order form dated 1/4/11 documented a MD prescription for [MEDICATION NAME] ER 60 mg every 12 hrs for one month. An Interim MD Renewal Note dated 1/4/11 and written by the MD documented that the prescription for [MEDICATION NAME] ER 60 mg every 12 hours written on 12/21/10 was lost. The medical record was reviewed and there was no pain assessment on the Daily Nurses Progress Note, which included a Pain Assessment Tool , that addressed the resident's level of pain on the evening shift on 1/2/11 and 1/3/11 and on the night shifts on 1/2/11 and 1/3/11. During an interview on 1/24/11 at 12:15 pm, the resident stated that, about 1 month ago, he did not receive his [MEDICATION NAME] 60 mg twice a day for about 5 days because the script ran out. The resident stated that he was in a lot of pain, was feeling "antsy," very fidgety, nervous, and could not sleep or eat. He stated "it made him upset and aggravated because he was feeling so lousy and in a lot of pain and needed the [MEDICATION NAME]". Additionally, the resident stated that he was concerned about having to take more doses of [MEDICATION NAME] because it causes him to have constipation and he has been hospitalized a few times in the past few months related to bowel obstruction. During an interview on 1/25/11 at 12:25 pm , the RN/ NM stated that the resident should never have had to go without receiving the [MEDICATION NAME] ER 60 mg from 1/2/11 to 1/4/11. She stated the Medical Director should have been notified when the facility did not have the [MEDICATION NAME] available and the MD would not call in an emergency script to the pharmacy. During a later interview on 1/26/11 at approximately 4:00 pm , the RN/ NM stated that she was not aware that the order for [MEDICATION NAME] ER 60 mg every 12 hrs written by the MD on 12/21/10 was never transcribed until 12/31/10. The RN/NM also stated that the order should have been discovered on the next shift by the night nurse who was to check all of the new interim orders and the nurse who transcribed the order on 12/31/10 should have notified her of the transcription error. During an interview on 1/25/11, the RN /Supervisor who worked the day and evening shift on 1/2/11 stated that she did not address the fact that the resident did not have any [MEDICATION NAME] ER 60 mg any further at that time because she had spoken to the nurses and they were monitoring the resident's pain and the [MEDICATION NAME] was effective. During an interview on 1/25/11 at approximately 5:00 pm , the Director of Nursing (DON) stated she did not recall hearing about this situation or seeing a medication error report. The DON also stated that the resident never should have missed 5 doses of [MEDICATION NAME] and she was surprised that she nor the Medical Director were not notified immediately to address this situation. . During an interview on 1/27/11 at 1:00 pm with the Medical Director present , the MD (attending physician) stated that the resident should not have missed 5 doses of the [MEDICATION NAME] ER 60 mg . The MD stated that the nurse never told her that the resident did not have any [MEDICATION NAME] 60 mg available and had the nurses told her she would have called in an emergency prescription. At this time the MD also stated that she knew that the resident had only 9 doses of the [MEDICATION NAME] ER 60 mg when she wrote the missing prescription for [MEDICATION NAME] ER 60 mg every 12 hrs on 12/21/10. During an interview on 1/27/11 at 1:00 pm, the Medical Director stated that he should have been called so that the resident would not have to go without receiving the 5 doses of [MEDICATION NAME] ER 60 mg. 10NYCRR 415.12

Based on medical record review and staff interview, the facility did not ensure that the resident received and was provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (Resident #2) of 3 residents reviewed during a complaint investigation (Case #NY 259). Specifically, the facility did not obtain or monitor laboratory values as indicated, while being treated with [MEDICATION NAME] (antibiotic which can lead to drug toxicity and/or [MEDICAL CONDITION]) and [MEDICATION NAME] (a diuretic used to decrease excess body fluid). Subsequently, the resident experienced a change in condition including, mental status changes, which included hallucinations, [MEDICAL CONDITION], and a 30 pound weight gain, which resulted in an acute hospital admission for treatment of [REDACTED]. This resulted in actual harm that was not immediate jeopardy. This was evidenced by the following: Resident #2 The resident was admitted to the facility on [DATE] with a readmitted 7/8/10, with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident to have intact long and short term memory and no impairment with daily decision making skills. The Hospital Discharge/Transfer Summary dated 7/7/10, documented that the resident had been hosptalized on [DATE] due to fever, abdominal pain and black tarry stools. During the hospital course the resident was treated with [MEDICATION NAME] (antibiotic), administered both intravenously (IV) and orally (po) [MEDICAL CONDITION] infection (an infection in her blood) and [MEDICAL CONDITION] (an infection in the bowel). The discharge summary documented that the antibiotic was to be continued for a total of 4 weeks, and that the resident had already received one week of medication. The document included a [DIAGNOSES REDACTED]. The nursing home admission orders [REDACTED]. Additionally, an order for [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Nursing Drug Handbook 2009, documented a side of effect of [MEDICATION NAME] to include nephrotoxicity (toxic to the kidneys). When used in the elderly dosing is based on body weight and kidney function (monitored by blood tests). The handbook documented that dosing should be adjusted based on the degree of renal impairment when used in patients with renal (kidney) insufficiency. The handbook documented that the medication levels, Peak and Trough, as well as [MEDICATION NAME] levels (measures kidneys function) should be monitored closely to alert for drug toxicity and [MEDICAL CONDITION]. The Comprehensive Care Plan (CCP) dated 7/8/10 titled, Acute Infectious Process related [MEDICAL CONDITION] and [MEDICAL CONDITION] listed interventions that included; to monitor for loose stool and obtain tests (unspecified) as ordered. An additional CCP titled, Alteration in Elimination (bowel and bladder) related to [DIAGNOSES REDACTED]. The interventions did not include specific laboratory tests. The MAR indicated [REDACTED]. The laboratory report dated 7/13/10, documented a blood urea nitrogen (BUN-used to monitor kidney function) of 11 (normal range 7-23), a [MEDICATION NAME] level of 1.8 (range 0.6-1.3), a [MEDICATION NAME] Peak level of 33.7 (range 25.0-40.0) and a Trough level of 19.6 (range 10-20). The report included a notation that the Trough levels between 15-20 maybe desirable, but must be weighed against the risks of toxicity. The report included that PCP #2 was notified of the results on 7/14/10 at 7:00 am and no new orders were received. The nurse's note dated 7/17/10 at 2:30 pm, documented the resident had [MEDICAL CONDITION] (swelling from fluid retention) on both feet and was alert and oriented. The nurse's note dated 7/19/10 at 2:00 pm, documented that the resident continued with firm [MEDICAL CONDITION] in the legs and had a weight increase of 30 pounds (lbs) since admission on 7/8/10. The resident complained of feeling full. The note documented that the PCP #2 was notified and did not want to order a diuretic at that time. PCP #2 instructed the nursing staff to follow-up with the nephrologist whom the resident was being treated by in the community. The note included that an appointment was scheduled and that laboratory results were faxed to the nephrologist's office. The note did not include what laboratory results were faxed. The nephrology consultation report dated 7/21/10, documented the reason for consultation was due to increased [MEDICAL CONDITION] and weight gain of 30 lbs in 2 weeks. The nephrologist documented that the resident presented with volume overload (excessive body fluid) and [MEDICAL CONDITION]. Laboratory tests were performed at this visit and the test results included; a blood urea nitrogen (BUN) of 11 (range 7-22) and a [MEDICATION NAME] of 1.9 (range 0.6-1.2). The nephrologist wrote recommendations for [MEDICATION NAME] 40 mg twice daily at 9:00 am and 6:00 pm, with the first dose to start at 6:00 pm on 7/21/10. The note included to obtain "a Basic Metabolic Panel (BMP) after 7 days of [MEDICATION NAME] treatment to ensure a stable kidney function." PCP #2 was notified by telephone on 7/21/10 at 5:30 pm of the nephology recommendations. PCP #2's telephone order dated 7/21/10 at 5:30 pm, included an order for [REDACTED]. The nephrology consultation report dated 7/21/10 was signed by PCP #2 on 7/23/10 (indicating that it was read) and PCP #2 wrote an order for [REDACTED]. The MAR indicated [REDACTED]. The laboratory report dated 7/27/10, included the results of the [MEDICATION NAME] Peak level at 43.1 (range 25.0-40.0) and the Trough level at 34.6 (range 10-20). The report included that these results were telephoned to the facility by the laboratory staff on 7/27/10 at 9:38 pm. A hard copy of this report was sent to the facility on [DATE] at 1:06 pm. A handwritten notation documented on the report dated 7/28/10, included that the PCP #2 was made aware of the results and a verbal order was received to "fax results to whoever ordered it." The next notation included that the results were faxed on 7/28/10 at 2:30 pm, to the vascular group. There was no documented evidence that the [MEDICATION NAME] was ordered by a vascular physician. During an interview on 10/5/10 at 2:25 pm with the Director of Nursing (DON), Registered Nurse Manager and PCP #2, the DON stated that the resident was started on the [MEDICATION NAME] while in the hospital. PCP #2 stated that it would be up to the physician who ordered the [MEDICATION NAME] to make dosage changes. PCP #2 stated that she did not make changes to the dosage and instructed the nurse to fax the results to the ordering physician. There was no evidence documented that PCP #2 was made aware of the telephone laboratory report received on 7/27/10. The facility could not produce a policy addressing the process for faxing resident information and test results to consulting physicians when asked for by the investigator. A nephrology consultation report dated 8/3/10, documented that the resident's [MEDICAL CONDITION] persisted and no recent laboratory results were available at this visit. The note included that laboratory tests were obtained during this follow-up visit. The recommendations of this visit included; to increase the [MEDICATION NAME] to 60 mg twice daily, add [MEDICATION NAME] 5 mg (a diuretic used in conjunction with [MEDICATION NAME] to reduce excessive body fluid) once daily and to obtain a BMP in 7 days to ensure stable kidney function and a [MEDICATION NAME] level around 2.7. The laboratory results from this visit dated 8/3/10 included a blood urea nitrogen (BUN) of 19 (range 7-22), and a creatinine of 2.9 (range 0.6-1.2). On 8/3/10 PCP #2 ordered [MEDICATION NAME] 40 mg in the am and 20 mg at 2:00 pm and to obtain a CMP in 14 days. There was no physician's progress note included to explain the rationale for [MEDICATION NAME] 40 mg and 20 mg, rather than [MEDICATION NAME] 60 mg twice daily. The nurse's note dated 8/10/10 at 1:20 am, documented that the resident stated she was being bitten by bugs and that there were bugs all over her bed and pillow. The bed was inspected by the nursing staff and no insects were found. The note documented that the resident was alert and coherent. The next nurse's note written 8/10/10 at 1:00 pm, documented that the resident stated that she saw sand on the floor and that fleas were in her bed. The resident complained of itching and stated she was being being bitten by the fleas. The note documented that the PCP #2 was notified of the need for the resident to be examined. The nurse's note written on 8/10/10 at 3:00 pm, documented by the RNM, included that the resident was confused and continued to complain of being bitten by bugs and that PCP #2 was reminded that the resident needed to be seen. There was no documented evidence that PCP #2 examined the resident. The nurse's note date 8/11/10 at 1:00 pm, documented that PCP #2 was notified that the resident continued to complain of seeing bugs and her blood pressure (B/P) was noted to be extremely high (per therapist both numbers running in the 100's, actual reading not documented), during a physical therapy session. The note included that PCP #2 stated to the nurse, "she is just being paranoid." PCP #2's ordered [MEDICATION NAME] (to reduce blood pressure) 10 mg and Chemistry Panel (blood test) was to be obtained on 8/12/10. The nurse's note dated 8/12/10 2:30 am, documented that the resident called, 911. The dispatcher notified the nursing home to validate the resident's complaint of "being locked up." The note further documented that the resident's call bell was in reach and the resident did not ring the bell for staff assistance. When questioned by the staff the resident stated, she called 911 for someone else. PCP #2 was notified and an order was written to discontinue (d/c) the as needed order for [MEDICATION NAME] (ordered on [DATE] for her itching) A nurse's note dated 8/12/10 at 8:00 am, documented that the blood specimen was unable to be obtained by way of peripheral intervenous central catheter (PICC) line or by venous puncture. There was no documentation that the PCP was notified at that time. On 8/12/10 at 3:30 pm the resident was evaluated by the Medical Director (MD) for mental status changes. The MD documented that the etiology of the mental status change was uncertain and that a reaction to medication was high on the list. The resident's medications were reviewed by the MD and orders were written to increase the [MEDICATION NAME] to 60 mg twice daily. The following medications were discontinued [MEDICATION NAME] ( to lower blood pressure), [MEDICATION NAME] ( an anti-depressant, [MEDICATION NAME] ( to treat gout) and [MEDICATION NAME] ( to improve urine flow). [MEDICATION NAME] (used for depression) dose was decreased and [MEDICATION NAME] (used for pain) added. The MD also ordered a urine culture and sensitivity (used to test for infection in the urine). The nurse's note dated 8/13/10 at 7:00 am (for the 11:00 pm-7:00 am shift), documented the resident continued to be confused, continued to hallucinate, and was not able to follow directions. The nurse's note dated 8/13/10 at 3:20 pm, documented the resident continued to be confused, was very sleepy, difficult to arouse and her appetite was poor. PCP #2 ordered a urine culture and sensitivity to be obtained. The note included that the urine specimen was obtained and the urine was dark yellow and appeared to be very concentrated. The laboratory report dated 8/13/10, documented a blood glucose level of 34 (range 70-110), BUN of 47 and a [MEDICATION NAME] of 5.8. A hand written notation on the report dated 8/13/10, included that a verbal order was received to discontinue insulin (medication used for diabetes). There was no documentation that the PCP#2 was made aware of the BUN and creatinine level. The laboratory report was signed by PCP #2 on 8/17/10. The nurse's note written by the RNM dated 8/17/10 at 10:30 am, documented that the resident continued to be quiet, lacked interest in activities of daily living and continued with visual hallucinations. The note included that the laboratory report dated 8/13/10 was reviewed and the RNM notified PCP #2 at 10:45 am. The note did not include what information was given to PCP #2, the note included that an order was received to transfer the resident to the emergency room . The laboratory report dated 8/17/10 at 1:17 pm, included a BUN of 62 and [MEDICATION NAME] level of 6.2. received after the resident was transferred to the hospital. This laboratory report was not reviewed until after the resident was transferred to the hospital. The resident was admitted to the hospital on [DATE] and required [MEDICAL TREATMENT] three times a week. During an interview on 9/29/10 at 3:05 pm, the RNM stated that she was not able to get a blood specimen on 8/12/10. She stated the PICC line flushed fine, but a blood return was not gotten. She stated she contacted the laboratory technician to attempt to obtain a specimen by way of the vein and this as well was unsuccessful. The RNM stated it was decided by them to wait until the next morning and retry to obtain the specimen. The RNM stated she did not inform the PCP #2 or any other physician, because the usual practice was to retry the next day and if still not able to obtain a specimen, then the physician would be notified. The RNM stated that the specimen was obtained on 8/13/10. The RNM stated that looking back, the laboratory values should have been monitored more frequently. The RNM stated that the resident had a history of [REDACTED]. The RNM stated that the resident's laboratory values should had been monitored more closely. After a review of the resident's medical record, the RNM was not able to state whether the Peak and Trough levels received on 7/27/10, were addressed by the physician or whom the results were faxed to. She stated she did not know where the results were faxed, as the only information available was that the laboratory report was faxed to a "vascular group." She could not state whether or not the results where reviewed by a physician or if her staff made any follow up calls to the vascular physician's office. When asked if the results should have been sent to a vascular physician, she stated they should have been faxed to the nephrologist's office. In an interview on 10/5/10 at 2:25 pm, PCP #2 stated that with the resident's known history of kidney disease, blood test and kidney function should had been monitored more closely. She stated that the Peak and Trough levels and kidney function levels should had been monitored by the nephrologist, but stated that as the PCP she should have monitored these levels as well. PCP #2 stated that she would not have made any changes in the dosage of [MEDICATION NAME] IV without first consulting the ordering physician, but stated that she should have looked at the kidney function levels and hydration status of the resident more closely. In an interview on 10/5/10 at 2:55 pm, PCP #2 stated she recalled receiving the call regarding the resident's low blood sugar results from the 8/13/10 laboratory report. PCP #2 stated that she gave orders to d/c the insulin. She stated she could not recall if she was made aware of the elevated BUN and creatinine levels. When asked if she reviewed the paper copy of the report she stated, "yes, I signed it." When PCP #2 was asked if she followed the recommendations of the nephrologist, PCP#2 stated she did. When asked about the elevated BUN and creatinine level PCP #2 stated, those numbers were not that alarming, the resident has kidney disease. On 10/7/10 at 1:30 pm, the DON provided a statement that documented information which verified the resident was not seen by a vascular physician, but rather a nephrologist and the report was sent to the wrong physician's office. The DON stated that the nurse was given the wrong physician's phone number. The DON stated that it appeared that the test results were never followed up on by her staff. The resident continued to receive [MEDICATION NAME] 1 gm IV. During an interview with PCP #1 on 11/8/10 at 1:20 pm, she stated that the resident was being treated with the [MEDICATION NAME] IV for a systemic infection and [MEDICATION NAME] by mouth, for an intestinal infection. She stated that [MEDICATION NAME] by mouth was needed to treat the intestinal infection, as the IV form would be ineffective. She stated that the kidney function and Peak/ Trough levels should have been checked frequently and monitored closely. She stated that it was a standard of practice to monitor kidney functions when prescribing [MEDICATION NAME] IV, because of the potency of this drug. The rationale being, that in the event the kidney function becomes impaired, the medication was not able to metabolize and clear from the blood stream, causing drug toxicity. 10NYCRR 415.12