Every finding on record at Livingston County Center for Nursing and Rehabilit

Based on observations, interviews, and record review, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for four (4) of nine (9) resident's reviewed (Residents #166, #176, #185, and #225). Specifically, Resident #166 was observed on multiple occasions with overgrown facial hair. Resident #176 had long facial hair on the upper lip. Resident #185 had long chin hair and facial hair at the corners of their upper lip. Resident #225 had long facial hair. Additionally, the facility lacked documented evidence staff consistently offered, provided, or documented grooming services or refusals in accordance with the residents assessed needs and preferences.The findings include, but are not limited to:The undated facility policy titled Shaving the Resident indicated it was the policy of the center to follow established techniques when shaving residents' facial hair. Persons with basic responsibility for implementing this policy included Licensed Nurses and Nursing Assistants, with the purpose being to remove facial hair and improve the resident's appearance and morale.The facility policy titled Bathing a Resident (Shower) dated 06/23/2009 included the procedure for giving a shower to a resident included washing, drying and combing the resident's hair, shaving male residents daily and women as needed.Resident #166 had diagnoses including Alzheimer's disease, dementia, and depression. The Minimum Data Set (a resident assessment tool) dated 12/18/2025 indicated the resident had severe cognitive impairment and required maximum assistance with personal hygiene.Review of the current comprehensive care plan on 01/23/2026 included Resident #166 needed the assistance of a staff member to perform personal hygiene and grooming. Review of the current Kardex (a care plan used by certified nursing assistants to perform daily care) on 01/23/2026 included the resident required staff assistance with shaving.Review of Resident #166's electronic medical record from 11/01/2025 to 01/26/2026 did not include documented evidence staff offered, provided, or documented refusals of assistance with grooming or shaving.During an observation on 01/21/2026 at 9:53 AM, Resident #166 had long, patchy facial stubble and an overgrown mustache with hair curling into the mouth.During an observation on 01/23/2026 at 9:32 AM, Resident #166 continued to have long, patchy facial stubble and an overgrown mustache curling into the mouth.During an interview on 01/23/2026 at 9:34 AM, Resident #166's family member stated staff were expected to assist with shaving and the resident did not like having facial hair.During an interview on 01/27/2026 at 03:40 PM, Certified Nursing Assistant #4 stated residents were shaved on shower days and Resident #166 required staff assistance with shaving. The Certified Nursing Assistant stated the resident could be resistive to care at times.During an interview on 01/27/2026 at 03:50 PM, Registered Nurse Manager #2 stated residents were expected to be shaved on shower days and was not aware of documented refusals for Resident #166.During an interview on 01/28/2026 at 11:56 AM, the Director of Nursing stated facial hair was expected to be groomed at least on shower days. The Director of Nursing further stated there was no designated area for staff to document grooming assistance, and refusals of personal care were expected to be documented in a progress note.Resident # 185 had diagnoses including cerebral infarction (stroke), diabetes, and hypertensive heart disease. The Minimum Data Set, dated [DATE], included the resident was cognitively intact, did not reject care, and required substantial assistance with personal hygiene, including hair combing and shaving.Review of Resident #185's current Comprehensive Care Plan on 01/23/2026, revealed the resident required assistance with grooming. Review of the Kardex included the resident had visual impairment and staff were to assist with hair combing and shaving.Review of Resident #185's Activities of Daily Living sheet for December 2025 and January 2026, grooming was to be completed after set-up assistance and did not include documented refusals of care. Staff were to reapproach the resident for care if applicable.During an observation and interview on 01/21/2026 at 11:08 AM, Resident #185 had long chin hair and stated they disliked having facial hair but did not want to bother staff.During an observation and interview on 01/23/2026 at 8:15 AM, Resident #185 had long chin hair and visible facial hair along both sides of the upper lip. Resident #185 stated staff had not offered assistance with facial hair removal and, due to impaired vision, could not safely remove the hair independently. The resident stated they did not refuse grooming care.During an interview on 01/23/2026 at 9:50 AM, stated Resident #185 did not refuse care and staff were expected to offer facial hair removal even when residents did not request it.During an interview on 01/23/2026 at 12:51 PM, Registered Nurse Manager #1 stated staff were expected to offer grooming assistance and Resident #185 had no history of refusing care.During an observation on 01/27/2026 at 10:09 AM, Resident #185 continued to have long chin hair and facial hair on the upper lip.During an interview on 01/27/2026 at 11:05 AM, the Director of Nursing stated staff were expected to remove facial hair based on resident preference and assessed needs.Resident #225 had diagnoses including Parkinson's disease, diabetes, and anxiety. The Minimum Data Set, dated [DATE] included Resident #225 was cognitively intact and required moderate assistance with personal hygiene.Review of the current Comprehensive Care Plan on 01/23/2026 revealed Resident #225 required staff assistance with grooming. Review of the current Kardex on 01/23/2026 revealed staff were to assist with shaving and trimming facial hair.Review of Skin Observation documentation (including bathing related information) from 11/01/2025 through 01/23/2026 did not include documented evidence staff offered, provided, or documented refusals of grooming assistance.During an observation and interview on 01/21/2026 at 1:08 PM, Resident #225 had a beard several inches long and a mustache curling into the mouth. An electric razor was observed in the resident's bathroom. Resident #225 stated they wanted assistance with trimming their beard and mustache and it had been months since grooming was last completed.During an observation and interview on 01/23/2026 at 10:08 AM, Resident #225's facial hair remained unchanged, and the resident stated grooming assistance had not occurred.During an interview on 01/27/2026 at 2:18 PM, Certified Nursing Assistant #5 stated they assist residents with facial grooming, which is usually done on shower days and reported to the licensed practical nurse for documentation. Certified Nursing Assistant #5 stated Resident #225 had not asked for any help trimming their facial hair.During an interview on 01/27/2026 at 4:08 PM, Licensed Practical Nurse #8 stated facial hair grooming would not be documented because it was a part of (bathing) care, and they would document if the resident refused a shower. Licensed Practical Nurse #8 stated Resident #225 had not asked for grooming assistance and would often refuse care.During an interview on 01/28/2026 at 9:31 AM, Registered Nurse Manager #4 stated staff were expected to assist residents with grooming and facial hair care but was unaware of recent requests from Resident #225.During an interview on 01/28/2026 at 12:12 PM, the Director of Nursing stated nursing staff were expected to assist residents with grooming based on resident preference and assessed needs.10 NYCRR 415.12(a)(3)

Based on observations, interviews, and record review, the facility did not ensure residents were treated with respect, dignity, and care in a manner and in an environment that promoted maintenance or enhancement of quality of life for two (2) of five (5) residents reviewed (Residents #13 and #166). Specifically, Resident #13 waited more than 45 minutes for their lunch meal after all other residents had been served resulting in emotional distress, and Resident #166 was repeatedly visible from the hallway while unclothed. This findings include: The facility policy titled Meal Service, revised September 2001, included the responsibility of the Licensed Nurse and Certified Nursing Assistant was to distribute food trays to residents in resident rooms, dining rooms, and ancillary dining rooms in a timely manner. A tray sequence may be used in dining rooms, so all residents seated at a table were served at the same time. Resident #13 had diagnoses including diabetes, cerebral palsy, and anxiety disorder. The Minimum Data Set (a resident assessment tool) included the resident was cognitively intact and required set-up assistance with meals. During a dining observation on 01/20/2026 at 12:44 PM, the first meal tray was passed to a resident in the dining room, followed shortly by several other residents. Resident #13 was observed watching a resident seated across from them eat while Licensed Practical Nurse #1 informed Resident #13 their meal would arrive shortly. During a dining observation on 01/20/2026 at 12:59 PM, Resident #13 remained the only resident in the dining room without a meal. Resident #13 was observed resting their right hand on the side of their face while staring at the meals of other residents seated nearby. At 1:18 PM, Licensed Practical Nurse #1 stated aloud they did not want to call the kitchen again due to the negative response received during a prior call. During an observation and interview on 01/20/2026 at 1:22 PM, Resident #13 had still not received their meal and left the dining room to return to their room. When interviewed at that time, Licensed Practical Nurse #1 stated the resident may have gotten tired of waiting and then contacted the kitchen to inquire about the meal. Licensed Practical Nurse #1 stated they did not know why the resident's meal was delayed and acknowledged the meal should have arrived with the other residents' meals. During an observation on 01/20/2026 at 1:30 PM, Resident #13 was lying in bed when their meal arrived on the unit. Licensed Practical Nurse #1 delivered the meal to the resident's room and stated awareness the resident had completed their meal ticket that morning. During an interview on 01/20/2026 at 1:32 PM, Resident #13 stated other residents routinely received their meals while they waited, with delays sometimes lasting 30 minutes to one hour after others were served. Resident #13 stated sitting across from residents eating while they waited made them feel bad and contributed to frustration, which led them to leave the dining room. During an interview on 01/23/2026 at 9:39 AM, Certified Nursing Assistant #1 stated they frequently contacted the kitchen regarding Resident #13's meal and were often told it would take additional time, even though other residents had already been served. During an interview on 01/23/2026 at 1:10 PM, Registered Nurse Manager #1 stated it was problematic Resident #13 did not receive their meal for more than 45 minutes after others. Registered Nurse Manager #1 stated meal tickets were completed in the morning, and Supervisor of Dining Services #1 had reviewed the resident's ticket but could not explain why the meal was not placed on the cart. During an interview on 01/27/2026 at 10:04 AM, Supervisor of Dining Services #1 stated meals were passed based on meal tickets and seating arrangements. Supervisor of Dining Services #1 acknowledged residents seated together were not always served together and attributed this to lack of attentiveness to seating sheets. During an interview on 01/27/2026 at 11:46 AM, the Director of Nursing stated awareness of dining concerns and confirmed other residents had reported long wait times. The Director of Nursing stated staff should have recognized the emotional impact on Resident #13 and ensured timely follow-up with the kitchen. Resident #126 had diagnoses including paraplegia (paralysis of both arms and legs), traumatic brain injury, and presence of a feeding tube (used to deliver essential nutrition, fluids, and medication directly into the stomach). The Minimum Data Set, dated [DATE] included the resident had severe cognitive impairment. Resident #126's comprehensive care plan and Kardex (a care plan used by certified nursing assistants to provide care), reviewed 01/23/2026, included the resident preferred not to wear clothing while in bed and required the privacy curtain to remain drawn at least halfway. During an observation on 01/20/2026 at 9:56 AM, Resident #126 was lying in bed unclothed with the room door open, genitals exposed and could be seen from the hallway. During an observation on 01/22/2026 at 09:12AM, Resident #126's room door was open, they were lying in bed unclothed, wearing only an incontinence brief, with stool present between the resident's legs. The resident could be seen from the hallwayDuring an interview on 01/27/2026 at 2:32 PM, Certified Nursing Assistant #3 stated Resident #126 preferred to be unclothed and acknowledged the room lacked a privacy curtain. Certified Nursing Assistant #3 stated staff sometimes left the bathroom door open to conceal the resident from view. During an interview on 01/27/2026 at 2:52 PM, Licensed Practical Nurse #5 stated staff covered the resident with a top sheet and left the bathroom door open to partially conceal the resident due to their preference not to wear clothing. During an interview on 01/27/2026 at 3:13 PM, Registered Nurse Manager #3 stated staff attempted to preserve the resident's dignity by covering them but was unaware the resident was frequently visible from the hallway. During an interview on 01/22/2026 at 4:01 PM, the Director of Nursing stated it was staff responsibility to preserve resident dignity and acknowledged it was not dignified for Resident #126 to be visible from the hallway while unclothed. 10 NYCRR 415.3(d)(1)(i)

Based on interviews and record reviews conducted during an Abbreviated Survey (Incident #2610304) completed from 09/29/2025 to 10/10/2025, the facility did not ensure residents are free of significant medication errors for two (2) of five (5) residents (Resident #2 and #3) reviewed. Specifically, Licensed Practical Nurse #1 prepared medications for Residents #2 and #3 at the same time, left the medications intended for Resident #3 at Resident #2's bedside, and Resident #2 mistakenly took the medications. This resulted in actual harm to Resident #2 that is not Immediate Jeopardy. The findings are:The facility policy Medication Administration, dated 02/12/2025, included medications may not be prepared in advance and may not be left for resident self-administration outside of the licensed nurse's view. Resident #2 had diagnoses including hypertension (high blood pressure), atrial fibrillation (rapid heart rate), and heart failure. The Minimum Data Set (a resident assessment tool) dated 06/26/2025 documented the resident was cognitively intact and taking anticoagulant (blood thinner) medication. Review of Resident #2's Comprehensive Care Plan, last reviewed on 06/30/2025, revealed the resident was at risk for injury related to Eliquis (a blood thinner and a medication used to prevent blood clots) use and had hypertension. Interventions included, but were not limited to, administer medications as ordered. There is no documented evidence Resident #2 had a medical order or was assessed for their ability to safely and competently self-administer medications.Review of a Medication Discrepancy/Error Report dated 09/06/2025, revealed Licensed Practical Nurse #1 set a medication cup on Resident #2's overbed table containing Resident #3's bedtime medications, including anticoagulants and cardiovascular (heart) medications. Licensed Practical Nurse #1 left the bedside and Resident #2 self-administered the medications intended for Resident #3. Review of Resident #2's September 2025 Medication Administration Record revealed on 09/06/2025, Resident #2 received prescribed medications including, but not limited to, Eliquis 2.5 milligrams for atrial fibrillation at 8:00 AM and 8:00 PM, furosemide (a diuretic medication) 20 milligrams at 8:00 AM for heart failure, and triamterene-hydrochlorothiazide (a combination medications of two diuretics used to treat high blood pressure and swelling) 37.5-25 milligrams at 8:00 AM for heart disease with heart failure.Review of Resident #3's September 2025 Medication Administration Record revealed medications prescribed and signed as administered on 09/06/2025 at 8:00 PM, included tamsulosin hydrochloride (a medication used to treat urinary symptoms or an enlarged prostate) 0.4 milligram capsule, Eliquis 5 milligrams tablet, metoprolol tartrate (a medication used to treat high blood pressure) 50 milligram tablet, and lisinopril (a medication used to treat high blood pressure and heart failure) 20 milligram tablet. In progress notes dated 09/06/2025, Registered Nurse #1 documented Resident #2 reportedly grabbed and ingested Resident #3's cup of bedtime medications including Eliquis, metoprolol tartrate, and tamsulosin. The incident was reviewed with Physician Assistant #1 who ordered blood pressure monitoring until the next afternoon. A manual blood pressure documented at 11:57 PM was 92/50. There was no documentation indicating the Physician Assistant was made aware of the low blood pressure.In a progress note dated 09/07/2025 at 5:43 AM, Licensed Practical Nurse #5 documented Resident #2 had a manual blood pressure reading at 4:00 AM of 90/52, the resident voiced feelings of nausea and shakiness, had two (2) episodes of vomiting, and the nursing supervisor was aware. There was no documentation indicating the Physician Assistant was made aware of the continued low blood pressure or change in status.In a progress note dated 09/07/2025 at 6:44 AM, Licensed Practical Nurse #6 documented Resident #2 had a manual blood pressure reading of 62/36, the resident was lethargic (sluggish), and had episodes of diarrhea and vomiting. The charge nurse was notified. In a progress note dated 09/07/2025 at 7:44 AM, Registered Nurse #2 documented the on-call provider was notified and directed to hold all of Resident #2's medications, except levothyroxine (a medication used to treat low thyroid hormone levels) and Eliquis. The nursing staff were to continue to push fluids, monitor blood pressures, and notify the on-call if Resident #2 became unresponsive or had a change in their status. In a progress note dated 09/07/2025 at 11:05 AM, Registered Nurse #3 documented Resident #2 was experiencing weakness, vomiting, and hypotension (low blood pressure) with a manual blood pressure reading of 68/40. Resident #2's responsible party was notified, Physician Assistant #1 was consulted, and Resident #2 was transported to the hospital via ambulance. In a hospital Discharge summary dated [DATE], Physician #1 documented Resident #2 arrived at the emergency room on [DATE] with nausea, vomiting, and hypotension after an accidental intake of their roommate's medication and was admitted to the Intensive Care Unit for monitoring until 09/10/2025. Resident #2 took metoprolol and lisinopril on top of their prescribed blood pressure medication (hydrochlorothiazide) resulting in severe bradycardia (an abnormally low heart rate) into the 30's and 40's and significant hypotension requiring continuous monitoring, frequent reassessments, and medical treatment. Resident #2 developed a significant kidney injury due to hypotension and Acute Tubular Necrosis (ATN; a condition that causes sudden damage to the small tubes in the kidneys, leading to impaired kidney function) likely due to medication overdose.During an interview on 09/29/2025 at 11:55 AM, Resident #2 stated Licensed Practical Nurse #1 gave them their bedtime medications on 09/06/2025 and asked Resident #2 what to do with Resident #3's medications because the resident was in the bathroom at that time. Resident #2 told the nurse to leave the medications on the bedside table and they would tell Resident #3 to take them. Resident #2 stated when they looked over and saw the pills, they thought they were their own medications and took them. During an interview on 09/29/2025 at 12:40 PM, Licensed Practical Nurse #2 stated medications should not be left with a resident, instead the nurse had to watch the resident take their medications. During an interview on 09/29/2025 at 2:10 PM, the Assistant Director of Nursing stated the facility policy instructs, and nurses are educated not to leave medications in a resident's room unattended. During an interview on 10/01/2025 at 9:15 AM, the Administrator stated nurses are repeatedly educated not to leave medications in resident rooms, but it still happens. During an interview on 10/01/2025 at 10:45 AM, the Director of Nursing stated leaving medications unsupervised in a resident's room is a safety concern and residents with cognitive impairment could unintentionally take another resident's medications or take medications by the wrong route, such as eating a topical (a medication applied to the skin for local treatment) medication. During a telephone interview on 10/0l/2025 at 12:26 PM, Licensed Practical Nurse #1 stated they were passing evening medications and poured medications for Residents #2 and #3 at the same time, labeling both medication cups with the resident's names. They became distracted during the medication pass when Resident #3 dropped their walker in the bathroom and left Resident #3's medications on Resident #2's bedside table to check on Resident #3. Upon returning, Licensed Practical Nurse #1 stated they discovered Resident #2 had taken Resident #3's medications and reported the error immediately. During a telephone interview on 10/10/2025 at 9:53 AM, the Medical Director stated Resident #2 ingesting Resident #3's medications led to a low blood pressure and heart rate, became an emergent situation, and is considered a significant medication error. The Medical Director stated nurses should observe residents take their medications and medications should not be left at the bedside. The Medical Director stated pre-pouring medications for two residents and attempting to administer medications for both residents at the same time is not acceptable, medications should be given to one patient at a time. 10 NYCRR 415.12(m)(2)

Based on observations, interviews, and record review conducted during an Abbreviated Survey (Intake ID: 02610304) from 09/29/2025 to 10/10/2025, the facility did not ensure the residents' environment remained as free of accident hazards as possible for two (2) (Residents #2 and #4) of three residents reviewed. Specifically, medications were left unsupervised at the bedsides of Resident #2 and Resident #4, and there was no evidence the residents had medical orders or were assessed for their ability to safely and competently self-administer medications. Additionally, an unlocked medication cart was left unattended in a common hallway.The findings are:The facility policy Medication Administration last reviewed 02/12/2025 included, but was not limited to, medications may not be left for resident self-administration outside of the licensed nurse's view. During administration of medications, the licensed nurse must maintain line of sight of the medication cart and when not physically at the medication cart, it must be kept closed and locked. The facility policy Self-Administration of Drugs at the Bedside last reviewed 07/20/2016 included, but was not limited to, the care planning team will assess each resident to determine if the resident is capable of safe self-administration. Residents will not be permitted to self-administer or retain medications in their rooms unless the attending physician and the interdisciplinary team agree the resident is safe and competent to do so. 1. Resident #2 had diagnoses including hypertension (high blood pressure), atrial fibrillation (rapid heart rate), and heart failure. The Minimum Data Set (a resident assessment tool) dated 06/26/2025 documented the resident was cognitively intact.Resident #2's Comprehensive Care Plan, last reviewed on 06/30/2025, did not include measurable goals or interventions related to the self-administration of medications.Additional review of the health record did not include documented evidence Resident #2 had a medical order or was assessed for their ability to safely and competently self-administer medications.Review of a Medication Discrepancy/Error Report dated 09/06/2025, revealed Licensed Practical Nurse #1 set a medication cup on Resident #2's overbed table containing Resident #3's bedtime medications, including anticoagulants and cardiovascular (heart) medications. Licensed Practical Nurse #1 left the bedside and Resident #2 self-administered the medications intended for Resident #3. During an interview on 09/29/2025 at 11:55 AM, Resident #2 confirmed the nurse left the pills behind and they accidentally took them.2. Resident #4 had diagnoses including osteoarthritis (degeneration of joint cartilage and bone that causes pain and stiffness), rheumatoid arthritis (a chronic autoimmune disease causing inflammation of the joints resulting in swelling and stiffness), and chronic pain. The Minimum Data Set, dated [DATE] documented the resident was cognitively intact.Resident #4's current Comprehensive Care Plan, reviewed on 09/29/2025, did not include measurable goals or interventions related to the self-administration of medications.Additional review of the health record did not include documented evidence Resident #4 had a medical order or was assessed for their ability to safely and competently self-administer medications.During an observation and interview on 09/29/2025 at 12:45 PM, there was an unmarked medication cup sitting unattended on Resident #4's tray table with approximately one-half inch of a white topical cream. When interviewed at that time, Licensed Practical Nurse #2 stated the cream was Voltaren (an arthritis medication) and Resident #4 did apply the cream independently but had not been care planned or assessed for the self-administration of medications.During an interview on 9/29/2025 at 2:10 PM, the Assistant Director of Nursing stated licensed nursing staff are educated on the facility policy and procedure for medications which includes medications cannot be left in a resident's room unattended by a nurse.During an interview on 09/30/2025 at 1:45 PM, Resident #4 stated the nurse left the Voltaren cream on the tray table for the resident to apply themselves.3. During an observation on 09/29/2025 at 12:25 PM, a medication cart was unlocked and unattended in the hallway near Room #B238. During an observation and interview on 09/29/2025 at 12:28 PM, Licensed Practical Nurse #4 opened and exited the door of Room #B229. When interviewed at that time, Licensed Practical Nurse #4 stated they were trying to get things done but should not have left the medication cart unlocked and out of their view. During an interview on 10/01/2025 at 9:15 AM, the Administrator stated nurses are repeatedly educated not to leave medications in resident rooms, but it still happens. During an interview on 10/01/2025 at 10:45 AM, the Director of Nursing stated leaving medications unsupervised in a resident's room is a safety concern and residents with cognitive impairment could unintentionally take another resident's medications or take medications by the wrong route, such as eating a topical (a medication applied to the skin for local treatment) medication. The Director of Nursing stated there are residents with mild dementia on Residential Unit B (where Resident #2 resides, and the unlocked and unattended medication cart was observed).10 NYCRR 412.12 (h)(1)

Based on observations, interviews, and record review conducted during the Recertification Survey 11/2/23 to 11/8/23 it was determined that for one (Resident #194) of two residents reviewed for pain management the facility did not manage the resident's pain to the extent possible in accordance with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. Specifically, there was a lack of consistent pain assessments, monitoring of the effectiveness of the pain management plan of care, and the lack of medical provider notification after continued verbalization of pain and refusals of pain medications. This is evidenced by the following: The facility policy Pain Management, dated 1/24/19, directed the staff to look for nonverbal signs of pain including facial expression, agitation, crying, combative, anxious, moaning, screaming, and calling out. The policy included pain not meeting the resident comfort goal by using pharmacologic or non-pharmacologic interventions will be reported to the physician for further treatment consideration. Resident #194 had diagnoses that included dementia, diabetes, and right shoulder pain. The Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment, was on scheduled pain medication, did not receive PRN (as needed) pain medication, and did not receive non-medication interventions for pain. The MDS Assessment also included that when asked, Resident #194 denied having any pain at the time of assessment. The Comprehensive Care Plan, dated 7/13/23, revealed the resident was at risk for pain with a goal that the resident's pain level will lessen within one hour of intervention. Interventions included administer pain relief as physician indicates, assess characteristics of pain and pain location, observe for nonverbal signs of pain, medications as ordered, therapy referral as needed for comfort/pain control, and to provide non-medication interventions for pain as indicated. A Care Plan Change Form included the resident went on comfort care on 10/4/23. In a medical progress note dated 10/27/23, the Nurse Practitioner (NP) #1 documented that Resident #194 was refusing care and medications, the resident was screaming and calling out during care and activities of daily living. Hydromorphone (a pain medication) was ordered PRN for pain every eight hours and lorazepam was ordered daily at 8:00 AM and PRN one time daily and to continue with every shift pain assessment. During an observation on 11/2/23 at 11:11 AM Resident #194 was moaning, crying out, and in tears. The resident's family was at the bedside and stated they changed medications last week. During an observation on 11/6/23 at 3:23 PM a family member present at the time stated the resident was in pain and had been yelling out. During an observation on 11/7/23 at 9:57 AM Resident #194 was up in their chair in their room crying out. At 10:30 AM the resident was still crying out repeatedly. During an observation on 11/7/23 at 4:01 PM resident #194 was in bed crying out Help me lord. Two staff members were attempting to provide care and the resident screamed out. The resident stated they were in pain but were unable to say where. Review of November 2023 Medication Administration Record (MAR) 11/1/23 through 11/7/23 revealed that ongoing pain assessments were checked off as completed for each shift. The MARs also included that the daily ordered lorazepam (per the NP note) was checked off as not administered on 11/4/23 through 11/6/23, no PRN lorazepam was documented as administered and no hydromorphone was documented as administered. Review of the nursing progress notes, 11/2/23 through 11/7/23, revealed five nursing progress notes documenting that Resident #194 was crying/screaming out, refusing medications, and was combative with care. None of the five notes included that the provider had been notified of the ongoing pain or the refusals of the oral pain medication or non-medication interventions. During an interview on 11/7/23 at 9:59 AM Licensed Practical Nurse (LPN) #10 stated Resident #194 was medicated with lorazepam, hydromorphone, and a lidocaine pain patch on her right shoulder at 8:00 AM but had to be moved out of the dining room due to moaning and did not eat much. During an interview on 11/7/23 at 2:22 PM Certified Nursing Assistant (CNA) #2 stated that when Resident #194 cries out they try to comfort the resident and see what might be wrong. CNA #2 stated that Resident #194 sometimes cries out with care. During an interview on 11/8/23 at 1:28 PM Nurse Manager #4, stated that an interdisciplinary team meeting was held on 11/7/23 (after surveyor intervention) for Resident #194 and a hospice referral was completed and pain medications were reviewed, and routes changed (due to refusals of oral medications). 10 NYCRR 415.12

Based on observations, interviews and record reviews conducted during the Recertification Survey from 11/2/23 to 11/8/23, it was determined that for one (Resident #61) of three residents reviewed for activities of daily living (ADLs), the facility did not ensure the resident received the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #61 was observed on multiple occasions with sharp, jagged fingernails. This is evidenced by the following: The facility policy Nails, Care of (Finger and Toe), dated 3/13/15, included that the facility would provide residents with fingernail and toenail care in order to promote health and good hygiene. Certified Nursing Assistants (CNAs) could perform the procedure if the resident was not at risk for complications, and a licensed nurse would perform if the resident was high-risk. Additionally, a Podiatrist could perform the procedure on residents if nails were thick or if unable to be managed by nursing staff. Resident #61 was admitted to the facility with diagnoses that included a stroke and adult failure to thrive. The Minimum Data Set assessment dated [DATE], included that Resident #61 was severely impaired cognitively and required the extensive assistance of staff with personal hygiene. Review of the Comprehensive Care Plan included that Resident #61 required the assistance of one staff member with grooming. Review of Resident #61's Kardex (a paper copy of a care plan used by the CNAs on the resident unit) documented the resident's shower day was Wednesdays. During an observation on 11/3/23 (two days after the scheduled shower) at 10:09 AM, Resident #61 had several sharp fingernails on both hands. During an observation on 11/8/23 at 10:17 AM, Resident #61 continued to have sharp and jagged fingernails to several fingers on both hands. Review of Resident #61's Interdisciplinary Progress Notes in the electronic health record (EHR) from 10/1/23 to 11/7/23, revealed no documentation related to nail care or refusals of nail care. Review of a Registered Nurse Progress Note dated 10/16/23 at 11:32 AM included that Resident #61 was noted to have sharp and jagged nails, possibly causing a small abrasion on the left hand in addition to combativeness and agitation with care. Review of a Charge Nurse Progress Note dated 10/17/23 at 11:16 AM, included that Resident #61 had a contracture and sharp nails that could cause an abrasion when combative. Review of the ADL sheet in the resident's unit binder included that Resident #61 received a bed bath (versus a shower) on 11/1/23. It did not include any mention of nail care. During an interview on 11/8/23 at 10:22 AM, CNA #1 said that nail care should be done on the resident's scheduled shower day and on shifts with extra staff. CNA #1 stated if nail care was done, they would write it on a piece of paper and either tell the resident's nurse or the unit nurse manager. CNA #1 said that Resident #61 had a bed bath and had their washed first thing this morning and that the resident had a fungus on both thumbnails that they were being treated for. During an interview on 11/8/23 at 10:40 AM, Licensed Practical Nurse (LPN) #1 said that usually the CNAs do nail care on residents' shower days and document it or document if the resident refused or has behaviors (impacting ability to provide nail care). LPN #1 said there were no antifungal treatments ordered for Resident #61. During an interview on 11/8/23 at 10:53 AM, LPN #2/Charge Nurse said nail care should be done on residents' shower days and nails cut and filed as best as possible. LPN #2/Charge Nurse stated there is no place for staff to document nail care, and since it is expected to be done during shower/bath, it is part of the shower documentation, and that staff should document any refusals. LPN #2/Charge Nurse said Resident #61 had received anti-fungal nail polish for almost a year which was discontinued about two months ago. LPN #2/Charge Nurse (with the Registered Nurse Manager) observed Resident #61's fingernails at this time and stated that the left thumbnail was jagged and sharp. 10 NYCRR 415.12(a)(3)

Based on observations, interviews and record review conducted during the Recertification Survey from 11/2/23-11/8/23 the facility did not ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being for one (Resident #128) of four residents reviewed for dementia care. Specifically, the facility did not ensure the development and implementation of a person-centered care plan that included interventions specific to Resident #128 dementia, did not address the resident's behaviors, goals, or interventions required and did not address the use of multiple psychotropic medications or the monitoring of. The is evidenced by the following: Resident #128 had diagnosis including non-Alzheimer's dementia, depression, mental disorder, and repeated falls. The Minimum Data Set (MDS) Assessment, dated 10/10/23, documented that Resident #128 had severe impairment of cognitive function, had difficulty focusing attention, trouble concentrating, verbalized feeling down, depressed or hopeless, and was tired or having little energy on multiple days in the seven-day look back period. The MDS Assessment also included that Resident #128 was on multiple psychotropic medications (medications used to treat mental illness that require close monitoring due to possible severe side effects). The question regarding if a gradual dose reduction of the psychotropic medications was attempted was blank. Review of Resident #128's Comprehensive Care Plan did not include any mention of the resident's behaviors with goals or interventions for staff to utilize and did not include use of multiple psychotropic medications and monitoring for side effects, goals or attempting a gradual dose reduction if indicated for the care of a resident with dementia. The resident's Kardex (care plan used by the Certified Nursing Assistants (CNAs) for daily care) under behaviors/triggers/behavior plan was blank. During multiple observations on 11/7/23 and 11/8/23 morning and afternoon, Resident #128 was in bed asleep. During an interview on 11/7/23 at 1:00 PM Licensed Practical Nurse (LPN) #7 (working on Resident #128's unit) stated that they did not normally work on that unit and did not know Resident #128 very well but that the resident does refuse their medications at times. During an interview on 11/7/23 at 1:18 PM CNA #3 (Resident #128's CNA) stated that the resident does have behaviors and will not let the staff provide care unless a family member is present. CNA #3 said the resident did not have a sunflower on their Kardex (indicative of a behavior plan that staff should refer to for interventions) or a behavior plan which would offer different ways to approach the resident when they refuse care and that they are not sure what to do for the resident when this occurs. CNA #3 said that the preference sheet for Resident #128 in the CNA binder was no longer applicable to Resident #128. CNA #3 stated the resident's behaviors were not daily but were often enough and added that the resident also sleeps a lot. During an interview on 11/7/23 at 1:40 PM Registered Nurse Manager #2 stated that the resident's CCP start as standard and are then become more specific to the resident. RNM #2 stated that Resident #128 should have a care plan for dementia care to guide the staff and for the psychotropic medications they are on to monitor for side effects. 10 NYCRR 415.12

Based on interviews and record reviews conducted during the Recertification Survey from 11/2/23 to 11/8/23, it was determined that for one (Resident #132) of five residents reviewed for immunizations, the facility was unable to provide documentation that Resident #132 (who was eligible) had been offered, declined, and/or educated on the Pneumococcal immunization or had received it prior to admission. This is evidenced by the following: The facility policy Infection Control, Pneumococcal Vaccine (Pneumovax 23, Prevnar 13), dated 10/25/22 documented, it shall be the policy of the [NAME] County Center for Nursing and Rehabilitation that all residents will be offered the pneumococcal vaccine (Pneumovax 23, Prevnar 13) to aid in preventing infections and pneumonia. Prior to or upon admission, residents will be assessed for eligibility to receive the Pneumococcal vaccine, and when indicated, provided the vaccination within 30 days of admission to the facility unless medically contraindicated or the resident refuses the vaccine for personal or religious reasons. Resident #132 had diagnoses including heart failure, dementia, and chronic kidney disease. The Minimum Data Set assessment dated [DATE], documented the resident was over [AGE] years of age, was cognitively intact, that their Pneumococcal vaccine was not up to date and that they had not been offered the Pneumococcal vaccine. Review of the hospital discharge summary dated 11/7/23 revealed Resident #132 was recently discharged from the hospital with multiple admitting diagnoses that included but not limited to chronic respiratory failure with hypoxia (low oxygen levels). During an interview on 11/03/23 at 1:06 PM, LPN #5 said Resident #132 required oxygen, but that they continuously took their oxygen off, resulting in a decrease in their oxygenation. During an Infection Control record review and interview on 11/08/23 at 9:23 AM, the Infection Control Nurse (ICN) stated they could not find proof that Resident #132 had received the Pneumococcal vaccine or had been offered it. The ICN said there was a note in the electronic medical record (EMR) that documented the resident was offered the influenza vaccine, but that they declined, so the ICN said they assumed the resident had declined the Pneumococcal vaccine as well. The ICN said that the resident's representative had stated the resident had not received the Pneumococcal vaccine. During an interview on 11/08/23 at 1:53 PM, the Director of Nursing (DON) said they were aware that staff could not find evidence that Resident #132 had received the Pneumococcal vaccine upon admission. The DON said the admitting nurse should check with the provider to see if the resident had received the Pneumococcal vaccine and if not, they should confirm with the provider if the resident is eligible and should receive it. The DON said they could not find evidence that the provider was called or if the resident had received the vaccine. Additionally, the DON said Resident #132 had recently been sent to the hospital for respiratory related issues, but they were unaware if the hospital had a record of the resident's immunizations. Review of Resident #132's EMR revealed no evidence the resident had received the Pneumococcal vaccine, educated on it or had declined the vaccine. Review of the primary care physician's note on 11/8/23, documented per their records, Resident #132 had never received the Pneumococcal vaccine. Verbal consent was given, and the resident accepted the vaccine. 10 NYCRR 415.19(a)(3)

Based on observations, interviews and record reviews conducted during the Recertification Survey 11/2/23 to 11/8/23, it was determined that for 6 (Residents #'s 23, 54, 98, 128, 140, and 674) of 37 residents reviewed for care planning, the facility did not develop a person-centered Comprehensive Care Plan (CCP) that included measurable objectives and timeframes to meet the residents medical, nursing, mental and psychosocial needs and included goals, desired outcomes and preferences. Specifically, there was no CCP to address refusals of care (Resident #54), an indwelling urinary catheter (Resident #98), pressure ulcers and non-pressure skin conditions (Residents #'s 23, 140 and 674) and the use of psychotropic medications (medications to treat mental illness that can have severe side effects) and anti-coagulant medications (medications to prevent blood clots that require close monitoring) (Resident #128). This is evidenced by but not limited to the following: The facility policy, Care Plan- Baseline & Comprehensive, dated 2/8/17 documented that the facility will develop and implement a comprehensive person- centered care plan for each resident that includes measurable objectives and timeframes to meet the resident's preferences, choices, and goals, and address medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. 1.Resident # 98 had diagnoses which included urinary retention, chronic kidney disease, and urinary tract infections. The Minimum Data Set (MDS) assessment dated [DATE], documented that the resident was moderately impaired cognitively and had an indwelling urinary catheter (catheter inserted directly into the bladder via the urethra to drain urine into a drainage bag). During an observation on 11/3/23 at 10:36 AM Resident #98 was in bed. The urinary catheter and bag were hanging free, not attached to the bed, and contained dark orange tinted urine and was not covered for privacy. Review of the current CCP, dated 9/21/23 did not include that Resident #98 had a urinary catheter with goals or interventions for appropriate care of. Review of the Certified Nursing Assistant (CNA) Kardex (care plan used by the CNAs to provide daily care), documented that Resident #98 had a urinary catheter but did not include any information on the care expectations for the catheter. During an interview on 11/6/23 at 12:00 PM, Licensed Practical Nurse (LPN) #3 stated that a resident should have a urinary catheter care plan so that staff would be aware that the resident had a catheter in place and how to provide care for it. During an interview on 11/7/23 at 10:00 AM, Registered Nurse Manager (RNM) #2 and LPN #4/Charge Nurse both stated that a urinary catheter should be in the CCP and on the Kardex and should include person-centered interventions. 2.Resident #674 had diagnoses which included diabetes, sacral stage III (full thickness tissue loss involving damage to or death of subcutaneous tissue) pressure injury, and right lower extremity injury requiring negative pressure wound therapy (NPWT). The MDS Assessment, dated 10/10/23 documented that the resident had moderate impairment of cognitive function and was admitted with one stage two (partial thickness skin injury) pressure ulcer. The Care Area Assessment (tool used to assist facilities in baseline areas requiring a comprehensive person-centered care plan with goals and interventions) included that pressure ulcers had been triggered (indicating that a new care plan or revision was necessary to address the issue) but the care plan decision box was blank and there was no documentation as to why there was no care plan initiated. Review of a medical progress note date 11/2/23 revealed that Resident #674 was admitted to the facility for assist with wound care requiring a wound vac (intensive treatment involving a vacuum-assisted closure of a wound using a pump to assist in healing) for a poor healing leg wound following an injury that would require plastic surgery follow-up and eventual surgical intervention. Review of the current CCP revealed no person-centered care plan, including goals and interventions related to any current pressure ulcers or large leg wound requiring a wound vac. During an interview on 11/8/23 at 9:35 AM, RNM #1 stated that when a resident is admitted to the facility, they are required to add five mandatory care plans which included the resident was at risk for falls, pain, and pressure ulcers, activities of daily living, resident preferences, and dental. RNM #1 said the LPNs do not have time to go into each care plan to see interventions because the care plan is not specific for each wound, but the treatments are more specific. 3.Resident #128 had diagnosis including non-Alzheimer dementia, a pulmonary embolism (blood clot to the lungs) and mental disorder. The MDS Assessment documented that the resident had severe impairment of cognitive function, was on anti-psychotic medications, anti-depressant medication and anti-coagulant (blood thinner) medication (all medications requiring increased monitoring due to at high risk for side effects). The question requesting a date for Gradual Dose Reduction (GDR) of the anti-psychotic medication (per regulations) or reason why not was blank. The Care Area Assessment included that psychotropic medications had been triggered but the care plan decision box was blank and no documentation as to why there was no care plan. Review of a pharmacy medication review dated 10/2/23 revealed Pharmacist comments that included, but not limited to, that Resident #128 was on 4 different psychotropic (a group of medications to treat various forms of mental illness), and for staff to monitor for sedation, confusion, falls, to monitor for risk versus benefit and required GDRs. Review of Resident #128's CCP included no information related to anti-psychotic medications, anti-depressant medications or anti-coagulant medications. During an interview on 11/7/23 at 12:55 PM the MDS Assessment staff member stated that if the GDR is not checked on the MDS Assessment it may not get care planned for and it should. During an interview on 11/7/23 at 1:32 PM the Assistant Director of Nursing stated the Nurse Managers are responsible for completing the care plans. During an interview on 11/7/23 at 1:40 PM RNM #2 stated that they start with standard care plans and then build on it from there (for person-centered issues). RNM #2 stated Resident #128 did not have a CCP for the anti-psychotic medications, the anti-depressant medication or the anti-coagulant medication and should have. 10 NYCRR 415.11 (c)(1)

Based on observations, interviews, and record review conducted during the Recertification Survey 11/2/23 - 11/8/23 it was determined that for two (Resident # 144 and Resident #727) of five residents observed during medication administration, the facility did not ensure it was free of a medication rate of 5 percent (%) or greater. There were 2 medications errors for 26 opportunities resulting in a 7.7% medication error rate. The issues included the administration of one medication at the wrong time and the crushing a delayed-release medication that was labeled on the box Do not crush. This is evidenced by the following: 1.Resident #727 had diagnoses that include hypothyroidism (a condition of the thyroid gland that can cause multiple health issues including heart issues), dementia, and congestive heart failure. Current Physician orders included, but not limited to: Synthroid 50 micrograms (mcg) daily at 6:00 AM for hypothyroidism with instructions to be given on an empty stomach before breakfast. During an observation on 11/7/23 at 8:30 AM Licensed Practical Nurse (LPN) #7 administered the Synthroid 50 mcg with four other morning medications. Resident #727 stated at the time that they had already eaten breakfast. During an interview on 11/7/23 at 1:42 PM, Resident #727 stated the medication is supposed to be given before breakfast, but the staff here bring it late all the time. During an interview on 11/7/23 at 3:57 PM, Registered Nurse Manager (RNM) #2 stated this medication should have been given at 6:00 AM before breakfast as scheduled. 2. Resident #144 had diagnoses that included gastroesophageal reflux disease (GERD), chronic kidney disease, and congestive heart failure. Current Physician orders included, but not limited to omeprazole 20 milligrams (mg) delayed release tablet daily for GERD and was scheduled for 9:00 AM. During an observation on 11/7/23 at 9:02 AM, LPN #11 crushed and added the omeprazole 20 mg medication to applesauce and administered it to Resident #144. Review of instructions on the omeprazole packaging with LPN #11 after the administration revealed instructions: Do Not Chew or Crush. During an interview on 11/7/23 at approximately 9:15 AM following the administration, LPN #11 stated that after review of the directions on the omeprazole packaging they should not have crushed the delayed release omeprazole. During an interview on 11/8/23 at 10:19 AM, LPN/Charge Nurse #8 stated normally staff mark the delayed release medications as Do not crush in the electronic medical record (EMR) when inputting the order. LPN #8 stated Resident #144 did not have Do not crush in their EMR under the omeprazole and should have. 415.12(m)(1)

Based on interviews and record review conducted during the Recertification Survey 11/2/23 - 11/8/23 the facility did not ensure that within 14 days after completion of a resident's assessment (a comprehensive assessment of a resident's functional capabilities, problems and the care required) they electronically transmitted encoded, accurate, and complete Minimum Data Set (MDS) Assessment data to the Centers for Medicare and Medicaid Services (CMS) System for 22 of 22 residents (Residents #243, 180, 238, 86, 162, 247, 244, 237, 99, 235, 103, 239, 29, 200, 245, 72, 65, 150, 69, 212, 116, and 167) reviewed. Specifically discharge MDS Assessments were not completed and were not submitted to CMS within 14 of completion per the regulations. This is evidenced by, but is not limited to the following: The Long-Term Care Facility Resident Assessment Instrument 3.0 version 1.18.11 dated October 2023 documented that: Resident Assessment Transmittal requirements: Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following: (i)Admission assessment. (ii) Annual assessment. (iii) Significant change in status assessment. (iv) Significant correction of prior full assessment. (v) Significant correction of prior quarterly assessment. (vi) Quarterly review. (vii) A subset of items upon a resident's transfer, reentry, discharge, and death. (viii) Background (face-sheet) information, for an initial transmission of MDS data on resident that does not have an admission assessment. 1. Resident #235 was discharged from the facility in May 2023. The Discharge MDS Assessment with an Assessment Reference Date (ARD- day of discharge), dated 5/31/23 was not submitted to CMS until after surveyor intervention on 11/6/233. 2. Resident #180 was discharged from the facility 7/5/23. The Discharge MDS Assessment had not been completed as of 11/8/23. 3. Resident #243 was discharged from the facility on 6/15/23. The Discharge MDS assessment dated [DATE] was not submitted until after surveyor intervention on 11/6/23. During an interview on 11/08/23 at 9:17 AM the MDS Nurse #1 and the Quality Assurance and Performance Improvement Coordinator (QAPI) #1 both stated that they along with the MDS Coordinator (not present for interview) do all the MDS Assessments including the Discharge Assessments and knew there was an issue getting them completed on time and were working on fixing the problem. During an interview on 11/8/23 at 1:53 PM the QAPI Coordinator added that the MDS' not being completed was identified by QAPI in August at a time when the facility census was increasing, and staff were doing several jobs. An additional MDS staff member was added, and a weekly audit was started but that the results had not been sent back to QAPI. 10 NYCRR 415.11

Based on observations, interviews and record review conducted during the Recertification Survey, completed on 1/28/22, it was determined that for one (first floor- Lilac) of two units reviewed for medication storage, the facility did not ensure that an accurate reconciliation of all controlled substances was maintained. Specifically, the Controlled Substance Record sheets which included reconciliation of narcotic medications and the signatures of staff members for each shift-to-shift count were not completed to validate the correct controlled substance count. This is evidenced by the following: The undated facility policy titled Narcotic Count documented that the facility will ensure that narcotic count is complete, and the keys are reconciled. Each medication administered must be logged on a controlled substance administration sheet and the balance must be reconciled between nurses. The procedure for surrendering controlled substances will be in accordance with Public Health Law. During medication storage review on 1/27/22 at 9:00 a.m., the Lilac unit shift-shift narcotic count sheets revealed multiple missing signatures to verify that the counts were properly completed by two nurses. From 1/1/22 to 1/26/22, there were nineteen missing signatures, from 12/1/21 to 12/31/21, there were five missing signatures and from 11/1/21 to 11/30/21 there were eight missing signatures to verify that the controlled substances count had been completed and were accurate. During an interview on 1/27/22 at 9:05 a.m., the Licensed Practical Nurse (LPN) said staff are expected to sign off the narcotic count at each shift to ensure the narcotic count is correct, and that they are taking the keys and the medication cart. The LPN said there should be no missing signatures on the narcotic shift to shift count sheet but is unaware of who is responsible for ensuring they are completed. During an interview on 1/27/22 at 1:49 p.m., the Director of Nursing (DON) stated that the narcotic count should always be done by two nurses each time the keys are surrendered and that they should always sign the narcotic count sheet each time they perform the narcotic count. The DON stated that use of agency nurses may be the reason for the missing signatures and that the Nurse Manager should make sure the sheets are signed. The DON stated that they were doing audits of the sheets at one time but does not remember when this was stopped. NYCRR 415.18(b)(1)(2)(3)

Based on interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 291), it was determined that the facility did not provide services and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable for one (Resident #2) of three residents reviewed. Specifically, the resident was not being ambulated as recommended by therapy and as requested by multiple medical teams. This is evidenced by the following: Resident #2 was admitted to the facility on [DATE] for rehabilitation with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 11/11/19, revealed the resident had moderately impaired cognition, had no behaviors or rejections of care, required extensive assistance of one staff member for ambulation, and used a wheelchair and/or walker. The Comprehensive Care Plan (CCP), dated 9/5/19, and the undated Certified Nursing Assistant (CNA) Kardex included that the resident required the assistance of one staff member and a walker, and to ambulate 30 to 50 feet twice daily. The CCP did not include the resident refused care. Review of the Physical Therapy Discharge Summary, dated 9/5/19, revealed that the resident was able to ambulate on level surfaces for 30 to 50 feet with a rolling walker and recommended to have supervision or touching assistance throughout the activity or intermittently. The resident refused to ambulate further than that and required much motivation to participate. Physician orders, dated 9/20/19 through 3/9/20, included to continue with Physical Therapy and weightbearing as tolerated with a walker per orthopedics. Review of the December 2019 Electronic Medical Record (EMR) Report (an electronic form used by CNAs to document Activities of Daily Living (ADLs, including ambulation) documented for ambulation of 30 to 50 feet, the activity did not occur for 47 of 60 opportunities. Review of the November 2019, December 2019, and January 2020 CNA Goal Sheet for ADLs (a second form used by the CNAs to document all ADLs) revealed 27 of 60 opportunities were not documented or refused in November 2019. There were no entries at all for ambulation in December 2019 and January until 1/17/20. Review of the November 2019 and December 2019 nursing progress notes included nine progress notes documenting that the resident refused to ambulate due to pain in November. There were no notes related to refusals in December. There was no documentation of medical notification. Review of medical consulting progress notes revealed the following: a. On 9/20/19, the Orthopedic follow-up note documented under Orders/Comments to continue with Physical Therapy and weightbearing as tolerated with a walker for ambulation. The resident was to continue to work with therapy and walk with their walker in order to go home. b. On 10/31/19, the Orthopedic follow-up note included to continue Physical Therapy with weightbearing as tolerated with a walker. c. On 11/8/19, the wound clinic notes included the resident's sacral wound was healing and to please encourage the resident to walk daily. d. On 12/10/19, the wound clinic notes included to please allow the resident to restart Physical Therapy. e. On 1/9/20, the wound clinic notes included to please restart Physical Therapy as daily activity was essential. f. On 1/30/20, the Orthopedic follow-up note included that the resident denied hip pain and stated they do not do much walking. It was documented under Orders/Comments to continue with Physical Therapy. Review of the Physical Therapy referral forms included the following: a. On 12/10/19, the wound clinic was requesting that Physical Therapy be restarted. The therapist's response was for the resident to attend the independent gym consistently. b. On 1/21/20, there was a second request from the wound clinic for the resident to restart Physical Therapy. The therapist response included that the resident had decreased participation with therapy (September 2019), and it was recommended to the family to work on ambulation with the resident in the independent gym. c. On 1/30/20, orthopedics was recommending continuing with Physical Therapy. The therapist response was that the family had agreed that the resident was non-compliant with Physical Therapy. The independent gym was recommended to which the resident agreed. Review of routine 30/60-day visit notes by the facility medical team (Nurse Practitioner and physicians) revealed that on 10/15/19 and 11/14/19 the medical team documented that the resident denied pain, had no musculoskeletal issues, and will continue with Physical Therapy and restorative therapy. When interviewed on 8/20/20 at 9:00 a.m. and 11:10 a.m., the Director of Nursing (DON) stated that the resident was transferred to another nursing home in March at the family's request. She said the resident had a behavior of non-compliance but it did not appear that it was addressed until 1/17/20. The DON said that the ambulation goal was inadvertently left off the December CNA Goal Sheet which could explain why it was not consistently done. She said that if a resident refused to ambulate the nurse should be notified, a therapy referral sent, and medical notified. The DON said that she was unsure if medical was notified. In an interview on 8/20/20 at 10:00 a.m., the CNA stated that they are responsible for ambulating residents if it is on their Goal Sheet. She said if a resident refuses to ambulate, the nurse should be notified. When interviewed on 8/20/20 at 11:30 a.m., the Physical Therapist stated that the resident was not ambitious, and she spoke with a family member and encouraged them to bring the resident to the independent gym, but the family member stated he refused to go. She said they put the resident on a walking program on the unit but was not aware that it was not being done consistently. When asked if therapy spoke to the resident at the time of the orthopedic and wound clinic requests, the therapist stated she usually does, but could not remember. She said she did not have any progress notes following the 9/5/19 discharge from therapy. The Physical Therapist said she did not pick the resident up for therapy again because they were supposed to be on the walking program on the unit. She stated they usually get the orthopedic follow-up notes, but she could not remember if they did for Resident #2 and was not sure if medical was aware. (10 NYCRR 415.12(e)(2))

Based on interviews and record reviews conducted during the Abbreviated Survey (complaint #NY 954), it was determined that for one (Resident #1) of three residents reviewed, the facility did not notify the resident's representative when the resident was diagnosed with [REDACTED]. This is evidenced by the following: Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 8/26/19, revealed the resident had severely impaired cognition. A Resident Representative Communication Guidelines form, signed by the designated representative on 4/29/19, revealed that the representative was to be informed of the following additional changes in condition, if they occur; changes in condition such as minor illness with a temperature greater than 101 degrees. An incident without apparent injury and/or incidents with abrasion and bruise only, and changes in medication. A physician's progress note, dated 9/18/19, revealed that the resident was seen for an acute visit secondary to increased confusion as well as emesis. The resident was started on a clear liquid diet. The assessment and plan section of the form revealed that the resident had a fever and chills, and blood work and a urinalysis would be obtained. A physician's progress note, dated 9/26/19, revealed that the resident had tested positive for a Urinary Tract Infection [MEDICAL CONDITION] and an order was written to start the resident on [MEDICATION NAME] (antibiotic) 100 milligrams (mg) by mouth every 12 hours for ten days and to encourage fluids. A nursing progress note, dated 9/26/19, revealed that the lab results for the urinalysis were reviewed with the Nurse Practitioner. The resident had a UTI and was started on [MEDICATION NAME]. The note did not specify whether the resident's representative had been notified of the lab results or that the resident was started on an antibiotic. A review of nursing notes, from 9/26/19 through 10/3/19, did not include any documentation that the resident's representative had been notified that the resident had a [DIAGNOSES REDACTED]. A Social Work progress note, dated 10/3/19, revealed that a family meeting had been held with the resident's representative in attendance, and it was noted that the resident had a UTI and was being treated with [MEDICATION NAME] which had started on 9/26/19. When interviewed on 2/5/20 at 12:15 p.m., the Director of Nursing (DON) stated that there was not a specific policy regarding notification of family/representatives. She said that each resident has a notification form in their medical record that identifies when to notify the resident's representative and for what. At 2:40 p.m., the DON shared that via a telephone call, the Unit Nurse Manager said that she had forgotten to call the resident's representative, that during the family meeting on 10/3/19, the family was made aware that the resident had a UTI and was on an antibiotic, and she apologized for not notifying them. (10 NYCRR 415.3(e)(ii)(b-c))

Based on observations, interviews, and record review conducted during the Recertification Survey, it was determined that for one (Resident #71) of four residents reviewed for pressure ulcer care and for five (Melody, Country, Park Ave, Lilac, and the Memory Unit) of six residential living units, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection. Specifically, a staff member did not maintain proper infection control practices during wound care, and ice coolers used to transport ice and water for resident water pitchers were not consistently washed, rinsed, sanitized, or air dried between use. This is evidenced by the following: 1. Resident #71 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 4/2/19, revealed the resident was cognitively intact and had two Stage II (partial loss of thickness of skin) and two Stage IV (full thickness tissue loss) pressure ulcers. Review of the facility policy, Clean Dressings, dated 10/24/09, revealed clean dressings are applied to wounds to protect and prevent infection. The procedure included, but was not limited to, creating a field with paper towel and or drape, washing hands, donning gloves, removing soiled dressings and discarding in a plastic bag, disposing of gloves, washing hands, donning gloves, cleansing the wound, applying prescribed medication as ordered, applying dressings, removing gloves and discarding in a plastic bag and washing hands. During an observation of wound care on 7/11/19 at 10:21 a.m., a Licensed Practical Nurse (LPN) and Registered Nurse Manager (RNM) applied gowns and gloves prior to entering the resident's room. A sign on the resident's door frame instructed contact precautions. The LPN set a basin of dressing supplies on the resident's bed, removed the soiled dressings from the resident's left foot, washed the wound, obtained supplies from the basin, and applied an [MEDICATION NAME] dressing and gauze pad and wrapped it with Kling. The LPN did not change gloves and/or perform hand hygiene in between removal of the soiled dressings and/or application of the new dressing. After completing the treatment to the left foot, the LPN removed her gloves and performed hand hygiene. The RNM removed the dressing from the left ischium and placed the soiled dressing on the resident's bed sheets. The LPN cleansed the wound and with a gloved hand applied [MEDICATION NAME] (moisture barrier) to the wound bed and covered the wound with a dressing. The LPN did not change gloves and/or perform hand hygiene between cleansing of the wound, application of the ointment, or application of the new dressing. The LPN then moved the basin with dressing supplies from the resident's bed to the overbed table and then to the top of a dresser. After settling the resident in bed, the LPN removed her gloves and gown and washed her hands before leaving the resident's room. During an interview on 7/11/19 at 10:42 a.m., the LPN stated she changes her gloves when they become soiled and when moving from one wound to another wound. The LPN stated gloves should be changed after removing the old dressing and before applying a clean dressing. The LPN stated she should have had a barrier between the basin of supplies and the resident's bed. The LPN said the soiled dressing should not have been placed on the sheets. She said she was going to change the bed later. When interviewed on 7/12/19 at 10:19 a.m., the Director of Nursing said that gloves should be changed after removing the old dressing. She said that hand hygiene should be performed either by washing or using hand sanitizer and new gloves donned before applying a clean dressing. 2. Review of a facility policy, Ice Machines and Ice Storage Chests, dated 5/18/12, directs that ice chests will be maintained in a safe and sanitary condition to assure a safe and sanitary supply of ice. Keep the ice scoop on a clean hard surface when not in use. Clean and sanitize the cooler, pitcher and ice scoop daily. The cooler will be put through the dishwasher on the neighborhood daily, generally in the evening. Dining Services staff will run the cooler, ice scoop and water pitcher through the dish machine to disinfect it as the last cycle of the evening. Once run through the dish machine, the items will be left in the rack on the dish washer to dry. After ice is passed, the cooler is to be emptied, dried out with paper towels, tilted forward, and left slightly open to dry on the wheeled cart. Observations and interviews conducted on 7/11/19 included the following: a. At 9:06 a.m., on the second floor, there was an ice cooler on a cart in the hallway outside room D235/Melody. There was a pink water pitcher stored inside the cooler in the ice. b. At 10:58 a.m., on the first floor, there was an ice cooler on a cart in the D-unit dining room/Country. There was a pink water pitcher floating in melted ice water inside the cooler. c. At 2:02 p.m., a Registered Nurse (RN) said the ice machine was down for Country. She said the staff used an ice cooler filled with water and ice for resident's water pitchers. She said that was not the usual practice for passing ice water. d. At 2:16 p.m., on the first floor, there was an ice cooler on a cart in the B-unit dining room/Park Ave that was half full of water. At that time, the Director of Food Service said the ice had melted and the cooler should have been emptied, then washed, rinsed and sanitized. e. At 2:25 p.m., on the second floor, there was an ice cooler on a cart in the B-unit dining room/Lilac that was about one half full of ice with a pink pitcher inside (the handle was in the ice). At that time, Certified Nursing Assistant (CNA) #1 said Personal Care Assistants (PCAs) use the coolers to pass ice for water pitchers. CNA #1 said she does not know if the coolers are ever cleaned. Observations and interviews conducted on 7/12/19 included the following: a. At 9:30 a.m., on the third floor/Memory Unit, PCA #1 said that the ice and pink scoop should not to be left in the cooler. She said after passing ice, the cooler should be emptied and wiped with a Cavi (sanitizing) wipe. PCA #1 said the cooler was not run through the dish machine on the day shift. She said that she does not know if the cooler was ever sanitized in the dish machine. b. At 9:34 a.m., Kitchen Worker #1/Memory Unit said she has nothing to do with the ice coolers and never puts them through the dish machine. Kitchen Worker #1 said the ice cooler was too big to fit inside the unit dish machine and would need to be taken to the Main Kitchen for cleaning. c. At 9:38 a.m., Licensed Practical Nurse (LPN) #1/Memory Unit said a PCA or CNA fills the cooler with ice and uses it to fill the resident's water pitchers every shift. LPN #1 said the cooler was supposed to be cleaned between shifts and put through the dish machine by a Kitchen Worker. d. At 9:46 a.m., on the second floor/Lilac Unit, PCA #2 said she fills the cooler with water and ice and then goes room to room to fill water pitchers. She said there was one cooler for use on the Lilac Unit. At that time, the ice cooler in the Rose/Blue dining room was closed tight and PCA #2 said she had not used it that day. When the lid was opened, there were visible water droplets inside the cooler. e. At 9:52 a.m., on the second floor/Lilac Unit, PCA #3 said she had not used the ice cooler that day. f. At 9:56 a.m., on the second floor/Lilac Unit, Kitchen Worker #2 said the PCA or CNA usually brings him the ice cooler to be cleaned but it does not always fit inside the dish machine. He said the coolers are to be air dried overnight. Kitchen Worker #2 looked inside the cooler and said he could see water which meant it had not been air dried. When interviewed on 7/12/19 at 10:19 a.m., the Director of Nursing said the PCAs and CNAs are responsible to pass ice water. She said the ice cooler should be emptied between uses and tipped to dry out. She said the scoop should not be left inside the cooler. (10 NYCRR 415.19, 14-1.87)

Based on interviews and record review conducted during the Recertification Survey, it was determined that for 8 (Resident #3, #21, #78, #94, #162, #179, #202, and #224) of 15 residents reviewed for Baseline Care Plans, the facility did not consistantly develop and implement a thorough Baseline Care Plan within 48 hours of admission that included instructions needed to provide effective person centered care and/or provide the resident or representative with a written summary of the Baseline Care Plan. This is evidenced by, but not limited to, the following: Review of the facility policy Baseline and Comprehensive Care Plan, dated 2/8/17, revealed the facility will develop and implement a Baseline Care Plan within 48 hours of admission and include minimum healthcare information including, but not limited to, physician orders, dietary orders and therapy services. The facility will provide the resident and their representative with a summary of the Baseline Care Plan. 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 6/17/19, revealed the resident was cognitively intact. The Baseline Care Plan, dated 6/13/19, did not include goals, services and treatments being provided or dietary and physician orders which was documented as attached. There was no documentation that the written summary had been reviewed and a copy provided to the resident and or representative. When interviewed on 7/12/19 at 11:07 a.m., Registered Nurse (RN) #1 stated upon admission each resident receives a packet that includes their diet, medication orders, and treatments. She said there should be documentation that the packet was provided and reviewed. 2. Resident #78 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 4/11/19, revealed the resident had severely impaired cognition. The Baseline Care Plan, dated 3/26/18, did not include the diet and or physician orders which was documented as attached. There was no documentation that the written summary had been reviewed and a copy given to the resident's representative. When interviewed on 7/12/19 at 10:00 a.m., the Director of Nursing (DON) stated that the Baseline Care Plan should include the reason the resident was admitted , physician orders, medications, and elopement risk. The DON said that she expects the RN to review the Baseline Care Plan with the resident and or representative and provide them with a copy. She said a copy of the information provided should be kept in the medical record. 3. Resident #21 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 4/9/19, revealed the resident had severely impaired cognition. review of the resident's medical record revealed [REDACTED]. When interviewed on 7/12/19 at 12:04 p.m., RN #2 stated a Baseline Care Plan could not be found for the resident. She stated there was no documentation that a Baseline Care Plan was developed or a copy was provided to the resident's representative.

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #33) of one resident reviewed for enteral nutrition, the facility did not have a mechanism in place to ensure that the administration of enteral nutrition and additional water ordered for flushes was consistent with and followed physician orders, and staff were not consistently using the feeding pump as directed. This is evidenced by the following: Resident #33 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 4/1/19, revealed the resident had severely impaired cognition, weighed 177 pounds with no history of recent weight loss or gain, and the daily use of a tube feeding. A facility policy, General Guidelines for Use of Enteral Feeding Pump, dated 10/29/09, directs that the the feeding solution, tubing and formula container is changed every 24 hours. The feeding container and tubing are to be labeled with date, time, and initialed when initially hung. The physician's orders [REDACTED]. The current physician orders [REDACTED]. Review of the (MONTH) 2019 Intake and Output Record from 7/1/19 to 7/10/19, revealed the daily intake of tube feeding and free water was 3762 cc. The record did not include the amount of tube feeding given per day. In an observation on 7/9/19 at 8:57 a.m., a 1,000 ml bottle of [MEDICATION NAME] 1.2 Cal had been hung. There was no information documented on the label. The pump was a Covidien Kangaroo epump and the display read: rate 60 ml per hour 1,678 ml delivered. Observations and interviews conducted on 7/11/19 included the following: a. At 12:28 p.m., Licensed Practical Nurse (LPN) #1 said she had turned the tube feeding off as ordered at noon, even though the pump display read that 90 ml more of tube feeding needed to infuse. She said the resident needed his time off the tube feeding. LPN #1 said that the pump had not been cleared as the amount infused read 2,258 ml and she was unable to determine how much had actually been delivered in the last 24 hours. b. At 12:39 p.m., the Registered Nurse Manager (RNM) asked LPN #1 if the pump had beeped (for completion of tube feeding delivery) before she turned it off. LPN #1 said it did not beep but she turned it off anyways because the pump display read that 2,258 ml, had been given from 5:00 a.m. that morning. c. At 1:19 p.m., the Registered Dietitian (RD) said the current nutrition care plan (reviewed with surveyor) was for weight maintenance based on the current tube feeding order. She said the current order provides 1,200 ml of tube feeding and 1,230 ml free water flush to provide a total volume of 2,430 ml per day. The RD said the facility policy was to provide 90 ml water with each med pass. She said the resident has eight med passes per day, so receives an additional 720 ml water per day. The RD reviewed the (MONTH) 2019 Intake and Output Record and said the tube feeding and water amounts were not separated for individual tally. The RD said as she interpreted the Intake and Output information the daily amount recorded for the tube feeding was consistently 1140 ml per day or 60 ml below the ordered amount. The RD said the total volume per day was consistently recorded as 3,762 ml which meant the total volume of free water given was 1,332 ml (greater than the ordered amount). Interviews conducted on 7/12/19 included the following: a. At 10:34 a.m., the RNM said she reviewed the Intake and Output Record and found a consistent daily total of 1,140 ml. She said the Intake and Output Record had been set up wrong from the start. She said the resident receives 60 ml water per med pass, and has seven med passes per day, so gets a total of 420 ml per day, not 720 ml. b. At 11:08 a.m., the RD said the resident was showing a weight gain trend which she would not expect since the tube feeding was being given below order. She said that Liquacel (a modular protein) had been increased recently, from twice to three times a day, providing an additional 100 calories per day which may have offset the loss of calories from the tube feeding. c. At 11:51 a.m., LPN #2 said the night shift tallies the 24 hour Intake and Output Record and the tube feeding volume has never been separated out. d. At 11:52 a.m., the RNM said the evening shift tallies the 24 hour intake and the amount of tube feeding and water flushes have never been separated. (10 NYCRR 415.12(g)(2))

Based on interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #163) of six residents reviewed for unnecessary medications, the facility did not ensure that each resident's drug regimen remained free from unnecessary medications. The issue involved the lack of documentation of what precipitated the resident's behavior, non-pharmacological interventions attempted prior to the administration of a one time dose of an antipsychotic medication and the effectiveness. This is evidenced by the following: Resident #163 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED].>[MEDICAL CONDITION] (stroke), depression and anxiety. The Minimum Data Set Assessment, dated 5/15/19, revealed the resident was cognitively intact and exhibited no behaviors. The Comprehensive Care Plan for verbal abuse, dated 10/25/18, revealed the resident can be verbally abusive to others. Interventions included to encourage her to calm down, remind her that becoming so upset and yelling was not going to help her but only going to make her feel worse (can raise blood pressure, etc), encourage her to try and listen to her music, use serenity prayer, deep breathing, sitting outside or trying her aromatherapy. If she brings a problem to staff, let her know it will be referred to the appropriate person and remind her to have patience. A nursing progress note, dated, 6/19/19, revealed the resident was very upset, screaming and crying that no one cares about her, calling the staff names and being verbally abusive. The resident keeps asking for something now. The physician was called and an order for [REDACTED]. There was no other documentation regarding the resident's behavior that day (6/19/19) or the day before or after the incident. Interviews conducted on 7/11/19 includes the following: a. At 11:12 a.m., the Licensed Practical Nurse (LPN) said certain staff add to the resident's anxiety, she likes familiarity and routine. She said if the resident was screaming and yelling she talks calmly to her, gives reassurance and works through it with the resident. The LPN said she documents that information. She said the resident has asked her to document that she was having anxiety. After reviewing the 6/19/19 note, the LPN said she did not work that day; however, the progress note should have included what happened prior to the resident's behavior, interventions that were attempted, and the outcome. The LPN said it should be documented when the [MEDICATION NAME] was given, and how the resident tolerated the injection. b. At 11:46 a.m., the Registered Nurse (RN) who wrote the 6/19/19 note said that the LPN reported to the Registered Nurse Manager (RNM) that the resident was having behaviors and needed something for anxiety, and wanted it NOW. The RN said she called the doctor and told him the resident was anxious. She said the staff tried talking to the resident, but she was insisting, and the doctor ordered the [MEDICATION NAME]. She said that both the LPN and RNM that were working that day should have documented what interventions were attempted and the effectiveness. c. At 11:58 a.m., the RNM said that she expects staff to try and find out what is bothering the resident, try to calm her down or remove her from a situation, and attempt aromatherapy. She said staff could find someone that the resident was comfortable talking to before administering any antipsychotic medication. She said staff are expected to document interventions that were attempted. The facility policy for as needed Medication Orders, dated 11/6/14, includes as needed orders are acted upon based on the occurrence of a specific indication or symptom. [MEDICAL CONDITION] medications require documentation of non-pharmacological interventions attempted unsuccessfully prior to as needed use. (10 NYCRR 415.12(l)(1)(2))

Based on interviews and record reviews conducted during the Abbreviated Survey (complaint #NY 117) completed on 9/21/18, it was determined that for one (Resident #1) of three residents reviewed for significant medication errors, the facility did not ensure that each resident was free of significant medication errors. The issue involved Registered Nurse #1 entered a blood pressure medication ([MEDICATION NAME]) into the electronic medical record incorrectly as [MEDICATION NAME] (an anti-neoplastic medication) and submitted the orders to the pharmacy without review or the signature of a physician, and the nurses administered the medication for 11 days. The nurses admitted that they were unaware of what the medication was but did not look it up. The resident became increasingly ill and was hospitalized with [DIAGNOSES REDACTED], [MEDICAL CONDITION], weight loss, and oral and [MEDICAL CONDITION] candidiasis. This is evidenced by the following: Review of the (YEAR) Nursing Drug Handbook revealed that [MEDICATION NAME] is an anti-neoplastic medication used for [MEDICAL CONDITION]. The action is to inhibit RNA and DNA synthesis. The adverse reactions include, but are not limited to, nausea, vomiting, anorexia (loss of appetite), painful oral ulcers, diarrhea, pancreatitis (inflammation of pancreas), gastrointestinal ulceration, leukopenia (decrease in white blood cells which can cause infections), [MEDICAL CONDITION] (low platelet count which can cause reduced ability to stop bleeding), [MEDICAL CONDITION] (low red blood cell levels), and myelosuppression (decreased bone marrow activity). The nursing considerations included that a [DIAGNOSES REDACTED]. The supervising physician must be knowledgeable in assessing response to [MEDICAL CONDITION]. Watch for signs of bleeding and infection. Elderly patients have an increased risk of adverse reactions; monitor them closely. The (MONTH) 2008 facility policy, admission orders [REDACTED]. Review of the (MONTH) (YEAR) facility policy, Practitioner's Orders/Computerized Physician order [REDACTED]. Verify with the practitioner any dose or order which appears inappropriate considering the resident's age, condition or diagnosis. The nurse receiving a verbal/telephone order must enter it in the resident's electronic health record via the CPOE system. The nurse must enter a nurse progress note documenting receipt of the order including the date and time it was received. Once the order is received, a nurse will perform a second level order authentication by confirming a nurse progress note is present to document the order before electronically signing off to verify the accuracy of the order. Medication will not be administered until clarification is received. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 8/2/18 Minimum Data Set Assessment revealed that the resident was cognitively intact. Review of the 7/26/18 Hospital Discharge Summary medication list included [MEDICATION NAME] 50 milligrams (mg) by mouth three times a day but does not include [MEDICATION NAME]. Review of the physician's orders [REDACTED]. Review of the Nurse Practitioner (NP) and physician notes revealed hypertension but no history or [DIAGNOSES REDACTED]. There was no documentation in the Electronic Health Record (EHR) progress notes that the admission orders [REDACTED] Review of the 8/7/18 facility Medication Error Report and Investigation revealed that on 8/7/18, the hospital called the Registered Nurse (RN) Manager, questioned him about the use of [MEDICATION NAME], and requested a copy of the facility's EMAR. The investigation concluded that on 7/26/18 the RN Manager made a data entry error in the resident's EHR by entering an order for [REDACTED]. A LPN did a second level order authentication on 7/31/18 and did not question the [MEDICATION NAME]. The physician reviewed and signed the orders on 8/1/18 by looking at the hospital discharge summary, not the EHR orders or EMAR. The facility interviewed the nurses who administered the [MEDICATION NAME], and they admitted they were not familiar with the medication but because it had the [DIAGNOSES REDACTED]. Review of the weight record revealed that the resident weighed 171 pounds on 7/30/18, 170 pounds on 8/1/18, 166 pounds on 8/3/18, and 155 pounds on 8/6/18. The resident had a significant weight loss of 16 pounds in seven days which is 9 percent of her body weight. Interviews conducted on 9/13/18 included the following: a. At 3:50 p.m., Licensed Practical Nurse (LPN) #1 who works day and evening shift and administered [MEDICATION NAME] to the resident, said that he did not know what [MEDICATION NAME] was and did not look it up. He stated that he knows he should look up medications he is not familiar with for the diagnosis, interactions, and side effects. b. At 4:18 p.m., the RN Charge on the 4:00 p.m. to 12:00 a.m. shift stated she did not verify the admission orders [REDACTED]. She said it was her understanding that the nurse who enters the medications on the EHR is the one who reviews them with the physician. The RN Charge stated that on 7/26/18 she called the physician to get a bowel order for the resident, and the physician did not mention the other admission orders [REDACTED]. Interviews conducted on 9/14/18 included the following: a. By telephone at 9:43 a.m., the family member said that on Sunday, 7/29/18, the resident developed a sore throat, had difficulty swallowing, and had phlegm and mucous. The resident could not eat and was choking. The family member said she made the RN Manager and the nurses that were treating the resident aware of that. The family member said at first the facility thought it was related to her intubation for the hip surgery. She said the RN Manager told her speech therapy saw the resident. She said the resident could not swallow pills and staff crushed the medication and continued to administer the medication. The family member said that on 8/6/18 the family demanded that a weight be taken and it revealed the resident lost 16 pounds. The family member said they were taking the resident to the hospital. At that time, the RN Manager called the physician and an order was received to transfer the resident to the hospital. Per the family member, the resident's white blood count was found to be depleted. She said the hospital approached the family and the resident with the facility's medication list and asked why the resident was taking [MEDICATION NAME] for hypertension. She said both the resident and the family member reported she was not taking it. She said the hospital called the facility and obtained the EMAR. b. At 9:50 a.m., the physician/Medical Director stated that the hospital discharge summary medication list is used as a reference for the facility orders, and they are not actual orders. He said that he thought that the NP had been notified of the admission and reviewed the medications for the resident. The physician/Medical Director said when he saw the resident on 8/1/18, he reviewed the hospital discharge summary, not the EHR, and then signed the orders on the EHR. He said he does not have time to look at each individual medication because there are a lot of medications and not much time, so he clicks approve all at the top of the screen to sign for all the orders. The physician stated he did not see that the resident was receiving [MEDICATION NAME] but is familiar with the medication. He said the major side effect is bone marrow suppression which leads to opportunistic infections. He said that is what happened to the resident, causing her to have [DIAGNOSES REDACTED], oral and [MEDICAL CONDITION] candidiasis, and possibly pneumonia. He said if the nurses do not know what a medication is, he expects them to question it, but he said he also expects the EMAR system to be correct. c. At 10:44 a.m., the Certified Nursing Assistant (CNA) stated that the resident began to have difficulty eating because she was visibly shaking. The CNA said she came to the dining room and asked for assistance in eating which was unusual because she used to always feed herself. The CNA could not remember exactly when that happened but thought it was around the time she was diagnosed with [REDACTED]. d. At 10:52 a.m., LPN #2 said she gave the [MEDICATION NAME] on several occasions and even though she was not familiar with the medication, she did not look it up. She said medications that have not been signed by the second nurse or the physician will still appear on the EMAR to be administered. LPN #2 said the resident complained of a sore throat and then started having trouble swallowing and was coughing up a lot of phlegm. She said when the resident was first admitted she took her medications whole in applesauce and as she had increasing difficulty swallowing, she needed her medications crushed. e. At 1:29 p.m., the Director of Pharmacy Operations for the contracted pharmacy stated that the pharmacist should have questioned the order for [MEDICATION NAME] for hypertension. f. At 2:00 p.m., the RN Manager stated that he entered the [MEDICATION NAME] incorrectly as [MEDICATION NAME] because when he entered capt the only medication that came up was [MEDICATION NAME]. He said he saw 50 mg on the discharge summary and 50 mg came up on the screen so he clicked on it. He said he missed the fact that the screen included an anti-neoplastic. The RN Manager said he has to enter a [DIAGNOSES REDACTED]. The order then went to the pharmacy electronically, because he said he enters each medication immediately rather than waiting until they are all typed in. He said he did not have a LPN check these orders because the orders were not complete. He said the resident still needed orders for wound care, vital signs, advance directives, and an order to have a LPN review the admission orders [REDACTED]. He said he verbally told the RN and the RN Charge that the admission was not complete. He said that is standard procedure that these evening RNs finish the admission on all residents unless he says he completed the admission. The RN Manager said it is usually the evening RNs job to contact the medical provider when they finish the admission work and go over the orders. He said that when the nurses review the orders with the provider, they review the hospital discharge summary medications, not what is on the EHR. He stated he did not review any orders with the medical provider for the resident on 7/26/18. The RN Manager stated that on 8/7/18 he received a call from the hospital, they asked for a copy of the EMAR, and they said they were looking into the [MEDICATION NAME] medication. He said he immediately pulled the chart and looked at what happened with the transcription error and called the Assistant Director of Nursing (ADON). g. At 3:33 p.m., the NP stated that she does not routinely sign admission orders [REDACTED]. The NP said she was not familiar with [MEDICATION NAME] and thinks she was going to look it up but got interrupted. Interviews conducted on 9/17/18 included the following: a. At 1:30 p.m., the ADON stated she is responsible for investigating medication errors. The ADON said for this case the RN Manager admitted to her that he put the wrong medication in the EHR orders and did not review the medications with the physician. b. At 2:37 p.m., the pharmacist from the contracted pharmacy stated she thinks that she questioned the [MEDICATION NAME] when she saw the order. She said she thinks she put the blister pack aside to investigate but does not know how it got delivered. She said administering [MEDICATION NAME] to a resident who does not need it is a significant medication error. The pharmacist said [MEDICATION NAME] is a toxic medication that affects all blood cells and kidney and liver functions. She stated that it inhibits DNA and RNA synthesis (production) and causes [DIAGNOSES REDACTED] (low white blood cell count), [MEDICAL CONDITION] and bone marrow suppression. c. At 3:20 p.m., LPN #3 said she had some extra time on 7/31/18 so she checked physician's orders [REDACTED]. She said the admission orders [REDACTED]. LPN #3 said when she checks admission orders [REDACTED]. LPN #3 said she administered the [MEDICATION NAME] and did not know what it was but saw that the [DIAGNOSES REDACTED]. d. At 5:15 p.m., the RN that works 10:00 a.m. to 6:00 p.m., said she cannot remember completing any part of the resident's admission and does not remember being asked to call the physician or do anything with the orders. She said she knew the resident was having trouble swallowing and had a diet change. The resident told the RN she was doing better with soup ,and the family said that the resident is saying she is better but she is not. e. At 5:45 p.m., the Director of Nursing stated that all orders should be reviewed with the physician before they are sent to the pharmacy. She said the RN Manager admitted that he did not do that for the resident's admission orders [REDACTED]. She said that is [MEDICATION NAME] outside of your scope of practice and is not allowed. Interviews conducted on 9/18/18 included the following: a. At 10:19 a.m., LPN #4 said that when she checks admission orders [REDACTED]. She said that she remembers that evening LPN #1 asked her to check some admission orders [REDACTED]. LPN #4 said she remembers having a question about one medication and asking a RN to review it, but does not remember if it was about this resident. LPN #4 said she gave the [MEDICATION NAME] and did not know what it was or did not look it up. She said she does not know why she did not look it up but knows it was wrong. b. At 11:10 a.m., the Administrator stated that he was notified about the medication error, and after investigation, they concluded that the RN Manager was not compliant with the medication order entry policies and procedures because he had selected the wrong medication. Also, he admitted that he did not review the medication profile with the physician. The Administrator said that he expects all orders and medications to be reviewed with the physician prior to submitting them to the pharmacy. He said if nurses are not familiar with a medication, he expects them to look the medication up. Review of the 8/15/18 hospitalization summary revealed that the resident presented with dysphagia (difficulty swallowing), hoarseness, 15 pound weight loss, pancytopenia (reduction in white and red blood cells and reduction in [DIAGNOSES REDACTED]s which fight infection), tooth pain with possible dental infection, oral thrush (fungal infection in the mouth), [MEDICAL CONDITION] (fungal infection in the esophagus), and angular chelitis (painful, red, swollen patches in the corners of the lips). The resident was unable to swallow and was given medications intravenously (tube inserted in a vein) and given food through a feeding tube (tube inserted into the stomach). It was revealed that the resident was receiving [MEDICATION NAME] in error in the nursing home prior to admission to the hospital. High suspicion of immunosuppression from [MEDICATION NAME] and recent steroids for [MEDICAL CONDITION] exacerbation and antibiotics for pneumonia. Review of the 8/7/18 Hematology Consult note revealed in reviewing her medications, she had been given [MEDICATION NAME] 50 mg three times a day for hypertension and this was likely unintentional. She has no indication for this medication and has been taking it since 7/26/18. We find no indication in her chart or upon history that she should be taking this [MEDICAL CONDITION], which is an antimetabolite (medications used [MEDICAL CONDITIONS]). Though the dose is normally 50 mg, I could not find any indications in which it would be given three times a day. Myelosuppression (A condition in which bone marrow activity is decreased resulting in fewer red blood cells, white blood cells, and platelets - a side effect of [MEDICAL CONDITION] treatments), including [MEDICAL CONDITION] and leukocytopenia (low white blood cell count) nadir (this is a term used to describe the point [MEDICAL CONDITION] treatment when blood counts are at their lowest, white blood cell counts usually reach nadir within 7 to 14 days following the last [MEDICAL CONDITION] treatment) at about 14 days, though she was taking higher doses than recommended. This myelosuppression may be prolonged, and we may yet see an effect of [MEDICAL CONDITION] (low number of platelets in blood). (10 NYCRR 415.12(m)(2))

Based on interviews and record reviews conducted during the Abbreviated Survey (complaint #NY 117) completed on 9/21/18, it was determined that the facility did not ensure that the care for one (Resident #1) of three residents reviewed for physician's orders [REDACTED]. Specifically, the physician and Nurse Practitioner (NP) did not review or sign medical orders timely and did not identify an inappropriate medication and diagnosis. This is evidenced by the following: The (MONTH) 2008 facility policy, admission orders [REDACTED]. Review of the (MONTH) (YEAR) facility policy, Practitioner's Orders/Computerized Physician order [REDACTED]. Verify with the practitioner any dose or order which appears inappropriate considering the resident's age, condition or diagnosis. The nurse receiving a verbal/telephone order must enter it in the resident's electronic health record via the CPOE system. The nurse must enter a nurse progress note documenting receipt of the order including the date and time it was received. Once the order is received, a nurse will perform a second level order authentication by confirming a nurse progress note is present to document the order before electronically signing off to verify the accuracy of the order. Medication will not be administered until clarification is received. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 8/2/18 Minimum Data Set Assessment revealed that the resident was cognitively intact. Review of the 7/26/18 Hospital Discharge Summary medication list included [MEDICATION NAME] 50 milligrams (mg) by mouth three times a day but does not include [MEDICATION NAME]. Review of the physician's orders [REDACTED]. The NP visit note on 7/27/18 included, Medication profile reviewed, and hypertension is poorly controlled, continue [MEDICATION NAME] (anti-hypertensive) as well as [MEDICATION NAME] (anti-hypertensive), [MEDICATION NAME] (anti-hypertensive), and Purinethol (anti-neoplastic). ***{Purinethol is the generic name for [MEDICATION NAME].} It further included that the case was discussed with the covering physician who agreed with the current plan of care at that time. The 8/1/18 physician's history and physical report included that the medication profile was reviewed. To continue with [MEDICATION NAME] ([MEDICATION NAME]), [MEDICATION NAME] ([MEDICATION NAME]), and [MEDICATION NAME] for hypertension. Review of the 8/6/18 physician's note revealed the resident is being treated with an antibiotic for pneumonia and is feeling better. Review of the NP and physician notes revealed hypertension but no history or [DIAGNOSES REDACTED]. There was no documentation in the Electronic Health Record (EHR) progress notes that the admission orders [REDACTED]. Review of the 8/7/18 facility Medication Error Report and Investigation revealed that on 8/7/18, the hospital called the Registered Nurse Manager (RNM), questioned him about the use of [MEDICATION NAME], and requested a copy of the facility's EMAR. The investigation concluded that on 7/26/18 the RNM made a data entry error in the resident's EHR by entering an order for [REDACTED]. The physician reviewed and signed the orders on 8/1/18 by looking at the hospital discharge summary, not the EHR orders or the EMAR. Interviews conducted on 9/14/18 included the following: a. At 9:50 a.m., the Physician/Medical Director stated that the hospital discharge summary medication list is used as a reference for the facility orders, and they are not actual orders. He said he thought that the NP had been notified of the admission and reviewed the medications for the resident. He said when he saw the resident on 8/1/18, he reviewed the hospital discharge summary, not the EHR, and then signed the orders on the EHR. He said he does not have time to look at each individual medication because there are a lot of medications and not much time, so he clicks approve all at the top of the screen to sign for all the orders. The physician stated he did not see that the resident was receiving [MEDICATION NAME] but is familiar with the medication. He said he sees residents within four to seven days of admission and signs the orders and that the resident is receiving medications during that time. He said that since the incident, the nurses always call him to review admission medications but prior to the incident, that did not always happen. b. At 2:00 p.m., the RNM stated that he did not review any orders with the medical provider for the resident on 7/26/18. He said that the NP was given a copy of the hospital discharge summary and the EMAR on 7/27/18 and 7/31/18 during resident visits. The RNM said that on 8/1/18 the physician conducted his admission visit and was given a copy of the hospital discharge summary and the EMAR. c. At 3:33 p.m., the NP stated that she does not routinely sign admission orders [REDACTED]. The NP said she was not familiar with [MEDICATION NAME] and thinks she was going to look it up but got interrupted. She said that if the progress note included that she reviewed the medications then she must have reviewed them. Interviews conducted on 9/17/18 included the following: a. At 1:30 p.m., the Assistant Director of Nursing stated she is responsible for investigating medication errors, and in that case, the RNM admitted to her that he entered the wrong medication in the EHR orders and did not review the medications with the physician. b. At 5:15 p.m., the RN that works 10:00 a.m. to 6:00 p.m. said she cannot remember completing any part of the resident's admission and does not remember being asked to call the physician or do anything with the orders. c. At 5:45 p.m., the Director of Nursing (DON) stated that all orders should be reviewed with the physician before they are sent to the pharmacy. She said that the RNM admitted that he did not do that for the resident's admission orders [REDACTED]. She said that is [MEDICATION NAME] outside your scope of practice and is not allowed. Interviews conducted on 9/18/18 included the following: a. At 11:10 a.m., the Administrator stated that he was notified about the medication error, and after investigation concluded that the RNM was not compliant with the medication order entry policies and procedures because he had selected the wrong medication. Also, the RNM admitted that he did not review the medication profile with the physician. The Administrator said that he expects all orders and medications to be reviewed with the physician or NP prior to submitting them to the pharmacy. He stated that he expects the medical staff to sign the orders within 48 hours as per regulation. The Administrator said he expects that when the physician and NP write they have reviewed medications, that they have ensured that all the medications are authenticated as prescribed for the resident, and that they are the correct medication and [DIAGNOSES REDACTED]. b. At 1:28 p.m., the NP stated that she has not received any education or training since the medication error incident occurred. She said she had not received any information on changes made to the EHR system, pharmacy, or policies and procedures. c. At 1:50 p.m., the DON said the physician was involved in the Quality Assurance meeting when the causes of the incident were discussed. She said the physician and the NP were not given any education or training in regards to that incident. (10 NYCRR 415.15(b)(1)(i)(ii))

Based on interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 000) completed on 6/11/18, it was determined that for one (Resident #1) of three residents reviewed for accidents, the facility did not ensure that each resident received adequate supervision and assist to prevent accidents. Specifically, Certified Nursing Assistant (CNA) #1 failed to follow the resident's Comprehensive Care Plan (CCP), the facility policies, and the Registered Nurse's (RN) instructions for ambulation and transfers resulting in a fall with major injury. This is evidenced by the following: The facility policy, Ambulation, reviewed/revised 1/30/08, included the use of a gait belt unless otherwise specified in the care plan. The facility policy, Mechanical Lifts, dated 4/2/12, included assist of one staff member unless the resident's plan of care specifically requires two staff members when determined by RN judgement or therapy evaluation to be unable to transfer independently. The facility policy, Accident and Incident Investigation/Fall Prevention Protocol, reviewed/revised 8/11/15, included that staff are not to move the resident until a RN completes an assessment and determines movement of the resident is safe. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 4/24/18, revealed that the resident was cognitively intact and required physical assist of staff for transfers and ambulation. The CCP, dated 4/30/18, and the current CNA Kardex included one assist with roller walker for transfers and ambulation. Under gait belt (yes or no) the Kardex is blank and the CCP does not include mention of a gait belt. The Resident Incident Report, dated 5/14/18, revealed that at 12:07 p.m. the resident fell on the floor. RN #1's assessment revealed that the resident was on her right side on the floor in the dining room with the walker against the counter and a gait belt still attached to the walker. The assessment revealed a small hematoma (bleeding under the skin) to the right temporal region and a right elbow skin tear. The resident reported pain with rotation of the right lower extremity. The resident stated this is her baseline as this was the hip she had previously replaced. RN #1's conclusion indicated right upper and lower extremities pain post incident, x-rays ordered, and steri-strips applied to the right elbow. The Portable Service Requisition, dated 5/14/18 at 8:19 p.m., revealed that the resident was unable to move her leg or completely straighten or bend her elbow to 90 degrees. Review of the x-ray report, dated 5/14/18, included displaced [MEDICAL CONDITION] hip and possible [MEDICAL CONDITION] pubic rami (pelvis). The facility Incident Investigation Report, amended on 5/24/18, concluded that CNA #1 should have used a gait belt and should have ambulated at the resident's side (as opposed to walking behind with the wheelchair). The facility's summary of evidence collected also included that CNA #1 then proceeded to manually lift the resident from the floor to a standing position by kneeling behind and lifting the resident under her arms contrary to direction from RN #1. Interviews conducted on 5/24/18 included the following: a. At 1:30 p.m., the Director of Nursing (DON) stated that the resident should be one assist with gait belt and wheelchair follow and CNA #1 did not use the gait belt. The DON stated that use of the gait belt is part of the facility ambulation policy. The DON stated that on 5/14/18, CNA #1 also removed the resident from the floor by scooping the resident up into her wheelchair. The DON stated that after lunch, the Licensed Practical Nurse (LPN) #1 reported that the resident did not want to stand and was directed to use the ceiling lift with two assists, but CNA #1 transferred the resident to bed without a second assist. b. At 2:10 p.m., CNA #2 stated that on 5/14/18 at lunch time, the resident was on the floor in the dining room, and CNA #1 was standing over the resident. CNA #2 said that the gait belt is always used when walking the resident, and she has never seen CNA #1 use a gait belt. CNA #2 said she then observed CNA #1 lift the resident straight up and sit her in her wheelchair. c. At 2:30 p.m., LPN #1 stated that on 5/14/18, after the resident fell , the resident was seated at the dining room table with a bandage and ice pack on her head and elbow and complained of right arm pain. LPN #1 said that during lunch, the resident complained of right hip pain. At approximately 1:15 p.m., CNA #1 reported that the resident was having a hard time with her right foot, and CNA #1 wanted to know how to transfer the resident into bed. LPN #1 said that RN #1 told him to use the ceiling lift. LPN #1 stated that he told CNA #1 to use the ceiling lift and get help but LPN #1 said that he did not see how CNA #1 transferred the resident into bed. d. At 3:00 p.m., the Administrator stated that CNA #1 will be terminated. The Administrator said that another statement was received on 5/17/18 indicating that CNA #1 had transferred another resident without use of a gait belt. The Administrator said that CNA #1 initially said that LPN #1 assisted him with the ceiling lift, and then admitted that he did not have assistance for the transfer. e. At 3:05 p.m., CNA #1 stated that on 5/14/18, he walked the resident to the dining room with the walker following behind the resident with the wheelchair. CNA #1 said that was the way he always walked the resident and has never used a gait belt. CNA #1 said that he did not use the gait belt because the resident was walking fine and said she was okay. CNA #1 stated that it was a lack of judgment. CNA #1 said that he went against the RN's orders to use a lift to remove the resident from the floor, and lifted her with both feet on the floor and placed her in the chair. The resident complained of right leg pain when transferred. After lunch the resident complained that she could not put pressure on her right foot and it hurt. The LPN suggested that they use the ceiling lift, and CNA #1 said he transferred the resident alone using the lift and that the LPN might have told him to use a second person. CNA #1 said about 40 percent of the time, he does not use a gait belt for all residents. CNA #1 said that the gait belt is always supposed to be used for transfers and ambulation, and he does not think the resident would have fallen if he used the gait belt. When interviewed on 6/7/18 at 11:00 a.m., RN #1 stated that on 5/14/18, she was notified of the resident's fall at 12:15 p.m. and noted the resident on the floor in the dining room on her right side. RN #1 stated that CNA #1 picked the resident up before the CNAs returned with a lift. RN #1 stated she saw the resident's gait belt looped around the resident's walker at the time of the fall. RN #2 asked CNA #1 what he was doing pointing to the resident's gait belt. CNA #1 responded something like my bad. RN #1 stated after the incident, CNA #1 worked a double (6:00 a.m. to 10:00 p.m.) on the same unit and violated another resident's care plan for not using a gait belt. RN #1 stated that the gait belt is standard for all one and two assist residents for ambulation and transfers, unless otherwise indicated in the care plan. RN #1 stated that when using the ceiling lift, she would have expected two assists would have been used because of the resident's complaints of hip pain. During an interview on 6/8/18 at 2:10 p.m., RN #2 stated that on 5/14/18 at approximately 12:10 p.m., she was notified that the resident was on the dining room floor. She noted a right temple hematoma and the resident's lower extremities were externally rotated. The resident rubbed her right thigh and said that it hurt a little but she always has pain in that leg. RN #2 stated she gave directive to get the Hoyer lift for transfer of the resident off the floor and noted that the gait belt was on the resident's walker. RN #2 stated that she asked CNA #1 What is this motioning to the gait belt, and CNA #1 stated he knew but added that the resident walks so good. RN #2 stated that, while waiting for the lift, CNA #1 full body lifted the resident with both forearms under the resident's arms and scooped the resident. RN #2 stated that the resident's feet were on the floor during the transfer, and CNA #1 said the resident was light and he was not thinking. When interviewed on 6/11/18 at 11:00 a.m., the Medical Director stated that the resident is contact guard at the very least, at times assistance, and the gait belt would definitely have helped. The Medical Director stated that the facility has a specific policy on how to lift a resident off the floor that should have been followed as directed by the RN, and lifting up and placing the resident in a chair by CNA #1 would not be in the guidelines. The Medical Director said that the transfer performed by CNA #1 could cause harm, and if CNA #1 put the resident's legs on the floor, it could have abducted, been taken out of the pocket (moving the leg away from the body causing the hip to come out of its joint), and caused a bleed and laceration to the femoral artery. (10 NYCRR 415.12 (h)(2))

Based on observations, resident and staff interviews, and record reviews, it was determined that for one of one resident reviewed for pain management, facility staff failed to provide the necessary care and services to attain and maintain the resident's highest level of physical functioning. Specifically, Resident #424 sustained unresolved pain and associated side effects. This resulted in actual harm that is not immediate jeopardy, and is evidenced by the following: Resident #424 was admitted to the facility for rehabilitation on 5/11/13 with [DIAGNOSES REDACTED]. Pain medications listed on the hospital discharge summary, dated 5/11/13, includes [MEDICATION NAME], 8 milligrams (mg) every two hours as needed; [MEDICATION NAME], 10 mg at bedtime; [MEDICATION NAME], 20 mg by mouth twice a day; and [MEDICATION NAME] (anxiety), 1 mg every eight hours as needed. The facility's physician orders, dated 5/11/13 upon admission, included [MEDICATION NAME], 8 mg every two hours as needed; [MEDICATION NAME], 10 mg at bedtime; [MEDICATION NAME] 20 mg by mouth twice a day; [MEDICATION NAME] (pain) 5 mg/500 mg one tablet by mouth every six hours as needed until [MEDICATION NAME] is available; and [MEDICATION NAME], 1 mg by mouth every eight hours as needed. A telephone order, dated 5/11/13 at 3:00 p.m. from the physician includes [MEDICATION NAME] (pain) 10 mg by mouth every eight hours and to reevaluate on Monday. Documentation on the Admission Nursing Assessment, dated 5/11/13, shows that the resident is alert and oriented and has good short and long-term memory. Also, the resident's pain was described as 2 (mild) of 5 with movement and 5 (severe) with lots of movement. Review of the May 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no documentation on the back of the MAR indicated [REDACTED]. The medication was marked discontinued on 5/13/13 and restarted on 5/15/13 at 4:00 p.m. In a physician's orders [REDACTED]. A physician's orders [REDACTED]. Another order that day, not timed, included [MEDICATION NAME] 20 mg by mouth twice daily and 10 mg at bedtime. Review of the physician's history and physical, dated 5/13/13, revealed a history of chronic pai[DIAGNOSES REDACTED] and chronic opioid dependence. Medications at home included [MEDICATION NAME], 20 mg twice a day and 10 mg at bedtime; and [MEDICATION NAME], 8 mg every four hours as needed. The resident complained of severe pain. The physician's plan included measures towards detoxification by tapering the resident off [MEDICATION NAME] and [MEDICATION NAME]. On 5/13/13, the Physical Therapist (PT) documented on the Plan of treatment for [REDACTED]. The PT note, dated 5/20/13 for the period of 5/13/13, also noted complaints of left lower extremity pain. When observed on 5/15/13 at 1:51 p.m., the resident was lying in bed and was restless and frequently changing his position. In the physician's visit, dated 5/15/13, the physician documented that the resident's expressed chief complaint is pain control, which was validated in discussion with the resident's oncologist. The resident's oncologist recommended that [MEDICATION NAME] be restarted in addition to a low dose of [MEDICATION NAME]. Documentation of the resident's pain on the pain scale in the nurses' progress notes is as follows: a. On 5/11/13 and 5/12/13, [MEDICATION NAME] was given for pain of 5 with relief at 2. b. On 5/13/13, the resident was yelling out for staff. Routine [MEDICATION NAME] 10 mg and [MEDICATION NAME] 5/500 mg was given for pain of 5 with no relief. [MEDICATION NAME] 1 mg was given for increased anxiety due to pain. Another entry on 5/13/13 revealed [MEDICATION NAME] was given for pain of 5+ without a relief scale entry. c. On 5/14/13, [MEDICATION NAME] was given at 10:45 p.m. for pain of 5. The relief score was not entered, and [MEDICATION NAME] was given for increased anxiety. Another entry on 5/14/13 revealed the [MEDICATION NAME] was given for pain at 3, with relief of 1 to 2. d. On 5/15/13, routine Tylenol was given at 12:00 a.m. for pain of 5+ with little to no effect. At 1:30 a.m., [MEDICATION NAME] was given for pain of 5+. No relief score was entered. e. On 5/16/13, the resident was given routine [MEDICATION NAME] for pain of 3 to 4 with relief of 0 to 1. The yellow narcotic sheet for [MEDICATION NAME] 10 mg tablets for this resident reveals the resident received his first dose on 5/15/13 at 4:00 p.m. Review of the Intake and Output Record revealed that between 5/11/13 and 5/15/13, the resident refused four meals, ate nothing at three meals, ate 50 percent of the meal at five meals, and one meal was left blank. From 5/16/13 to 5/21/13 the resident ate 25 percent of four meals, 50 percent of nine meals, and ate 100 percent of three meals. There were no refusals. Review of the weight sheet revealed that the resident lost 4 pounds between 5/13/13 and 5/20/13. During an interview on 5/15/13 at 1:51 p.m., the resident stated he has had pain in his leg since 5/11/13 when he was admitted and has not been receiving his [MEDICATION NAME] and [MEDICATION NAME] because the physician will not order them. He stated he has considered leaving the facility against medical advice because he had not received his [MEDICATION NAME] or [MEDICATION NAME]. Interviews on 5/17/13 were as follows: a. At 1:15 p.m., regular day shift Certified Nursing Assistant (CNA) #1 stated that after the first few days the resident was in more pain. CNA #1 stated that when she arrived on 5/15/13 at 6:15 a.m., the resident was in a lot of pain and was just beside himself. CNA #1 stated that the resident gave her a note with [MEDICATION NAME] and [MEDICATION NAME] written on it and said he needed these medications. CNA #1 reported that she handed the note to the Registered Nurse (RN)/Charge Nurse on the night shift. b. At 1:27 p.m., the regular day shift Licensed Practical Nurse (LPN) #1 stated that there was no [MEDICATION NAME] and [MEDICATION NAME] available in the facility that weekend. LPN #1 stated the resident was in pain, was very upset, and asked for pain medication a lot when he was not on [MEDICATION NAME]. Also, the resident has not asked for pain medication since he began to receive [MEDICATION NAME]. c. At 1:47 p.m., the RN Neighborhood Manager stated that she was not aware of the issue until 5/15/13 when the resident's family member confronted her about the lack of physician orders [REDACTED]. The resident's oncologist recommended that the resident's [MEDICATION NAME] be reordered and this was done. d. At 2:25 p.m., the facility's physician stated that upon admission the resident was on [MEDICATION NAME] and [MEDICATION NAME]. The physician stated he did not believe anyone should be on that much pain medication. The physician stated that when nursing staff called him about the [MEDICATION NAME] and [MEDICATION NAME] on 5/11/13, he ordered [MEDICATION NAME] every 8 hours and to reevaluate on 5/13/13. The physician stated that on 5/13/13, he discontinued the [MEDICATION NAME] and [MEDICATION NAME] because the resident only asked for pain medications twice a day. He stated that on 5/14/13 when he talked to the pain clinic Nurse Practitioner who stated the resident was on the medications for hip pain and it could be decreased because he should be in less pain post operatively. The physician stated that on 5/15/13 when a family member insisted, he called the resident's oncologist who said the resident should remain on the [MEDICATION NAME] until his dependence could be evaluated in the office. Interviews on 5/20/13 were as follows: a. At 8:25 a.m., the resident reported that he has bone pain from [MEDICAL CONDITION], leg pain from surgery, pain in his fingers from graft vs. host disease, and back pain from the bed. The resident stated that he is a patient at the pain center at Strong Memorial Hospital and has been treated with [MEDICATION NAME] for his pain for almost four years. The resident explained that [MEDICATION NAME] does not relieve his pain. He also said this has been the worst pain in his life and that he felt terrible while not on the [MEDICATION NAME]. The leg still hurt even after therapy. He was not able to get comfortable, could not sleep, was restless, dizzy, and he told everyone how he was feeling. Also, since receiving the [MEDICATION NAME] he felt pretty good, and the restlessness and difficulty sleeping has gone. b. At 1:47 p.m., the Omnicare Pharmacist stated that if a resident was on [MEDICATION NAME] for a long time, over a month, the medication would have to be tapered, not discontinued. He stated that 50 mg of [MEDICATION NAME] is not a beginning dose. Residents could experience withdrawal symptoms like nausea, diarrhea, sweating, elevated temperature, heart rate, blood pressure, and increased pain four days after the last dose. Interviews on 5/21/13 were as follows: a. At 8:30 a.m., the Physical Therapy Aide (PTA) stated she had worked with the resident starting on 5/13/13. She stated that for the first few days through 5/15/13, the resident complained of pain in his left leg, yelled out at intervals, and was argumentative. He told her he was not getting his pain medications. The PTA stated that the resident complained of pain while doing the exercises asked of him, especially if his leg was touched. The PTA also said that he improved after 5/15/13. She stated she was concerned how much his pain inhibited him but had not reported this because she thought everyone already knew about it. b. At 8:51 a.m. and 2:16 p.m., the Director of Nursing (DON) said she did not know if [MEDICATION NAME] can be discontinued without a taper, that she would have to look it up. She stated that the resident's name came up in morning report, but she thought the situation was taken care of. She stated she became involved in Resident 424's case when the Charge Nurse told her the resident was yelling and in a lot of pain on 5/15/13. The DON spoke to him about the pain. The resident was definitely upset that his medications were changed, and he said his pain was generalized. The DON looked at what he just had for pain medication and called the oncall physician to get another dose. The DON stated that if a resident continues to complain of 5+ pain, she would expect the nurse to contact the physician. c. At 10:20 a.m., the resident was asked about his appetite. He stated he was not hungry the first few days in the facility, had nausea but no vomiting, and had no appetite. He said the staff knew he was not eating because they brought the trays in and brought them back out. They could see that he had not eaten much. d. At 11:00 a.m., the day shift RN Supervisor stated that she called the physician and reviewed Resident #424's medication on admission on 5/11/13. The RN Supervisor asked the physician to call in the [MEDICATION NAME] and the [MEDICATION NAME] to the pharmacy, and the physician said he would not do that. She stated he said the medications would be reviewed on 5/13/13. She told the physician that the resident was anxious and concerned because he was not on [MEDICATION NAME] and [MEDICATION NAME]. The physician replied that the [MEDICATION NAME] will cover him, and he will not have withdrawal. The RN Supervisor stated she was aware the resident had a long term [DIAGNOSES REDACTED]. e. At 3:22 p.m., the full-time evening shift CNA #2 stated that on 5/11/13 the resident was yelling in pain and swore once. She stated she could tell he was in a lot of pain in his leg, and he yelled when he was transferred. Interviews on 5/22/13 were as follows: a. At 10:10 a.m., the resident's oncologist from the pain clinic was interviewed by telephone. The oncologist explained that the resident has longstanding pain from [MEDICAL CONDITION], the hip, and various other medical reasons but was fairly well compensated on the pain medications he was on. The oncologist stated he would not stop the [MEDICATION NAME] and [MEDICATION NAME] unless it was an emergency. He would taper them The oncologist also said that he called the facility physician and told him the resident should go back on the medications he had been on prior to admission. b. At 10:21 a.m. in a meeting with the Deputy Director, the DON, and the Medical Director (also the facility physician), the Medical Director stated that he is not a pain specialist and that he knew the resident was being seen at a pain clinic. His intent was to taper and try to lower the dose of narcotics for pain control. On 5/15/13 after speaking to the oncologist at the pain center, he was told that the resident was on [MEDICATION NAME] for neuropathic pain from [MEDICAL CONDITION]. The oncologist stated that if he wanted to detoxify or taper the resident, it should not be while the resident is at the nursing home. He should put the resident back on the medications, and the oncologist would handle the detoxification with the pain clinic. The Medical Director stated that when a resident is on long-term narcotics, it is difficult to assess what is actual versus perceived pain. He stated he treats mostly objective pain, not subjective pain. c. At 11:58 a.m., the facility's pharmacist consultant was interviewed by telephone. He said that he has extensive training in pain management and explained that [MEDICATION NAME] is a very difficult medication to manage. He stated that when a decision is made to convert a resident to a different narcotic, an [MEDICATION NAME] chart is used. Also, [MEDICATION NAME] is a unique medication, tends to hit more opiate receptors, has a long half life, and is not as easily converted or adjusted as other medications are. The pharmacy consultant stated that he was not consulted about how to manage this resident's pain medications. However, if he had been, he would have advised the physician to taper slowly. The facility's policy, "Pain Management," dated 2/3/10, directs the care planning team to meet to review individual residents with unmanaged pain and to reevaluate pain management interventions. (10 NYCRR 415.12)

Based on staff interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 416), it was determined that for 2 (Residents #1 and #2) of 17 residents reviewed for errors in medication administration, the facility failed to ensure that all residents admitted to the facility accurately received all physician prescribed medications. The facility also failed to thoroughly investigate the incident upon discovery of a significant medication error and take action to prevent other medication errors. Specifically, Resident #1, who had a physician order dated 6/7/11 for [MEDICATION NAME] ([MEDICATION NAME]--an anti-depressant) 25 milligrams (mg) daily, received the incorrect medication, [MEDICATION NAME] 25 mg (a psoriasis medication) over a 26-day period from 6/7/11 to 7/5/11. This incorrect medication order for [MEDICATION NAME] was carried over and entered onto the MEDICATION ORDERS FOR [REDACTED]. The facility did have systems in place, which included verification of medications upon delivery from the pharmacy; triple checks when orders are written; and month-to-month verification of Medication Administration Records (MAR). However, those systems failed. In addition, an interview with the pharmacist revealed the pharmacy technician entered the wrong medication into the computer. Resident #2, who had a physician order dated, 7/08/11, to reduce the dose of [MEDICATION NAME] (an antipsychotic) from 75 mg to 50 mg every evening, did not receive the decrease in [MEDICATION NAME] as ordered for a two-day period. This resulted in no actual harm for Resident #1 and Resident #2, and the potential for serious harm for all other residents in the facility, which resulted in IMMEDIATE JEOPARDY AND SUBSTANDARD QUALITY OF CARE TO RESIDENT HEALTH AND SAFETY. The Immediate Jeopardy was removed on July 11, 2011, prior to survey exit. This is evidenced by the following: 1. Resident #1 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 6/15/11, revealed that the resident's cognition is severely impaired. Review of the medical record revealed that this resident did not have a [DIAGNOSES REDACTED]. Review of the physician orders, dated 6/7/11, documented to give [MEDICATION NAME] 25 mg (a medication used to treat depression) every day at bedtime. Review of a nursing progress note, dated 6/7/11 at 12:20 p.m., revealed that the physician had seen the resident and started a low dose of [MEDICATION NAME], an antidepressant, at bed time. Nursing planned to monitor the effectiveness of this medication. Review of the pharmacy Proof of Delivery Shipment Detail sheet, which was signed by the receiving nurse on 6/7/11 at 9:48 p.m., revealed that the nurse signed for the incorrect medication, [MEDICATION NAME] 25 mg. The pharmacy proof of delivery sheet shows that [MEDICATION NAME] 25 mg capsules were delivered to the facility on [DATE] and 6/9/11 for this resident. The Comprehensive Care Plan, dated 6/8/11, related to [MEDICAL CONDITION] drug use, documented that the resident will not have side effects from antidepressant medication. Review of the June 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Twenty-two sets of initials documented that [MEDICATION NAME] was administered by five different nurses between 6/7/11 and 6/30/11 (two doses were refused during this time). The nurses had administered [MEDICATION NAME] in error, as this was the medication that was delivered and signed for from the pharmacy by the receiving medication nurse. An observation with the Director of Nursing (DON) on 7/8/11 at approximately 10:30 a.m. revealed that there were 26 doses used from a blister pack of [MEDICATION NAME] 25 mg capsules. This blister pack was dated 6/7/11 and marked with the resident's name. Instructions were to give one capsule by mouth at bedtime. The capsule was described as brown, yellow, and oblong. The July 2011 preprinted orders from the pharmacy included [MEDICATION NAME], the incorrect medication. This MAR indicated [REDACTED]. Review of the July 2011 MAR indicated [REDACTED]. This medication was signed off as given by nursing staff from 7/1/11 through 7/4/11. Review of the record revealed that there was no physician's order for [MEDICATION NAME]. An undated Medication Discrepancy Error Report shows that the pharmacist was notified of the medication error on 7/5/11. An Incident Accident Report (I/A), dated 7/5/11, included the following: [MEDICATION NAME] 25 mg ordered by mouth at bed time, pharmacy sent [MEDICATION NAME] 25 mg. This report explained that when the Nurse Practitioner (NP) reviewed the record on 7/5/11, she discovered that [MEDICATION NAME], the incorrect medication, was included in the July 2011 physician orders. The pharmacy was immediately notified, and labs were drawn per physician orders. Physician orders, dated 7/5/11, included to discontinue [MEDICATION NAME] 25 mg at bedtime and to start [MEDICATION NAME] 25 mg at bedtime. The facility's policy entitled, "Medication Errors from the Pharmacy," dated 3/22/10, directs staff who receive medications from the pharmacy to report errors in delivery immediately to the person delivering the medication and to follow up with a written Pharmacy Dispensing Error Report. The facility's undated policy entitled, "Practitioner Orders and MAR indicated included that the LPN will review orders. Corrections/deletions and/or additions will be made on these by two separate LPNs to verify accuracy. The LPN then signs with signature and date of review. Interviews conducted on 7/8/11 revealed the following: a) At 10:05 a.m., the Director of Nursing (DON) revealed that she was made aware of a medication error for this resident and that the Registered Nurse Manager (RNM) reported the error to the pharmacy. She added that the pharmacy sent the wrong medication, and the nurses gave the wrong medication. b) At 10:05 a.m., the RNM stated that the family had called on 6/7/11 and stated that the resident had been on [MEDICATION NAME] in the past. The RNM stated that she told the Nurse Practitioner (NP) about the request. The NP ordered [MEDICATION NAME] 25 mg on 6/7/11. The pharmacy delivered [MEDICATION NAME] 25 mg, which the nurses administered. The RNM reported that the NP discovered that the resident was receiving the wrong medication on 7/5/11, when reviewing the effectiveness of the [MEDICATION NAME]. The RNM stated that she notified the pharmacy of the error, and the proper medication was then dispensed to the facility. c) At 10:40 a.m., the NP stated that she determined on 7/5/11, while following up on the [MEDICATION NAME] order, that the resident was receiving [MEDICATION NAME] 25 mg instead of [MEDICATION NAME] 25 mg. The NP said that the [MEDICATION NAME] could affect cholesterol levels, so she ordered lab work, including a cholesterol panel. The NP stated that the lab work results indicated that the resident did not suffer any ill effects from receiving the [MEDICATION NAME]. d) At 10:55 a.m., the DON stated that it was her expectation that the nurses check the delivery ticket with the medications to make sure that the medication delivered is the correct medication. The DON reported nursing staff involved were being reeducated regarding medication administration procedures. However, not all of the nurses involved had been retrained at this time. She stated that the RNM was starting today to write up some documentation regarding the reeducation. In a joint observation at this time, the DON and surveyors reviewed the resident's photocopied medication blister pack cards. One card, dated 6/7/11, was labeled [MEDICATION NAME] 25 mg described as a brown, yellow oblong pill. The replacement card, dated 7/5/11, was labeled [MEDICATION NAME] HCL 25 mg ([MEDICATION NAME]) described as a light green oval pill. e) At 11:50 a.m., the RNM stated the day and evening Licensed Practical Nurses (LPNs) do the first and second reviews of the month-to-month MARs. The LPNs put check marks on the MARs to indicate that the medications are correct. The night shift LPN does the third review and puts a check mark to indicate the medications are correct. She added that the nurses know that they are responsible for knowing the medications that they give to the residents. f) At 12:50 p.m., the DON stated it is her expectation that the nurses pass medications using the five rights of medication pass. She stated that if the nurse does not know what the medication is, then she needs to look it up. They should also compare the written description of the medication with the actual pill. The DON stated that the new monthly MARs are supposed to be compared to the previous month's MARs for accuracy, and the new interim orders are added onto the new MARs. She did not know if the LPNs involved in Resident #1's medication error were also reeducated in the end of month MAR indicated [REDACTED] g) At 1:55 p.m., a LPN stated that she gave the incorrect medication and added she should not have. h) At 2:00 p.m., via telephone interview, the pharmacist stated that on 7/5/11, he received a call from the RNM, who stated that the resident received and was given the wrong medication. The pharmacist stated that the pharmacy technician inputs the new physician orders into the computer. A pharmacist then checks the orders for accuracy. He added that the error should have been caught at the pharmacy. 2. Resident #2 has [DIAGNOSES REDACTED]. Review of the July 2011 MAR indicated [REDACTED]. The resident continued to receive the 75 mg dose on 7/8/11 and 7/9/11. Staff interviews, verifying reeducation regarding medication administration procedures, evidence that the facility had conducted a facility-wide audit of all medication cards against physician orders for accuracy, and review of the facility's allegation of compliance letter, dated 7/11/11, determined that Immediate Jeopardy was removed on 7/11/11, prior to survey exit. The facility implemented the following interventions: a) An audit to verify accuracy was completed on 7/8/11 to review dispensed medication against the MARs. b) A meeting was held on 7/8/11 with all Registered Nurses (RNs) to discuss the medication error concerning Resident #1 and to review the Practitioner Orders and MAR indicated [REDACTED]. c) All 7/8/11 evening shift nursing personnel were retrained in the following policies: 1) Practitioner Orders and MAR indicated [REDACTED]. All subsequent shifts were retrained prior to the start of their shift and completed a test after training. Any employee receiving less than a 100 percent on the post-test received retraining. d) All physician orders were reviewed for completeness, legibility, and accuracy for May, June, and July 2011. The reviewed orders were compared against the MARs for transcription accuracy. The MARs were then compared to the medications dispensed by the pharmacy. e) Three pharmacists conducted an audit for accuracy of content, accuracy of label descriptors, and completeness of label descriptors. Medications lacking complete descriptors were replaced. f) A special Quality Assurance committee was convened on 7/11/11 to review the issue and review corrective action plans. The Medical Director attended the meeting. g) On 7/11/11, all Medical Typists were retrained in the policy and procedure for Practitioners' Orders/Transcribing of Orders. h) On 7/11/11, the pharmacy was directed to not accept orders that did not contain a [DIAGNOSES REDACTED]. i) A plan was put in place for all transcribed physician orders obtained during the next 30 days to be reviewed by a second RN. j) Orders faxed to the pharmacy will be compared against the delivery manifest upon medication delivery. k) The DON or designee will conduct an audit of medication transcription twice weekly for 30 days, weekly for the next 30 days, and monthly thereafter. The results of the audit will be reported to the monthly QA committee, and corrective action will be taken immediately. (10 NYCRR 415.12(m)(2))

Based on staff interviews and record review, it was determined that for one of two residents reviewed for quality of care, the facility did not provide the necessary care and services to meet the resident's highest level of physical functioning. The issue involved lack of timely bowel management resulting in hospitalization for a fecal impaction for Resident #355. This resulted in actual harm that is not immediate jeopardy, and is evidenced by the following: Resident #355 was admitted to the facility on [DATE] after hospitalization for surgical repair of a left [MEDICAL CONDITION] and has [DIAGNOSES REDACTED]. The Nursing assessment dated [DATE] lacked the date of the resident's last bowel movement (BM). Admission physician (MD) orders included Senna S (laxative), Acidophilus (stimulates growth of beneficial bacteria in the intestines) for bowel management, [MEDICATION NAME] sulfate (iron supplement) for [MEDICAL CONDITION], and [MEDICATION NAME] (narcotic) for pain. The MD Admission History and Physical, dated 3/1/11, documented the presence of bowel sounds in the resident's abdomen and that the abdomen was soft, non tender, and free of masses. The facility's Intake and Output record, dated 3/1/11, showed that the resident had extra large loose stool on the day shift. The Interdisciplinary Care Plan, dated 3/2/11, showed that the resident needed the assistance of one for toileting and lower body hygiene. On 3/2/11, MD orders discontinued Senna and requested collection of a stool sample to evaluate for a [MEDICAL CONDITION] (C. dif) intestinal infection because the resident had a loose stool on 3/1/11. Review of records from 2/28 through 3/7/11 revealed that nursing progress notes lacked reference to the resident's bowel activity until 3/7/11. Toileting Schedules included documentation that the resident was routinely toileted, and the last documented BM (large loose stool) on the Bowel Movement Records for this resident was on 3/1/11 day shift. The Medication Administration Records for these dates showed that the resident received Milk of Magnesia on the 3/7/11 day shift without results. There was no evidence in the record to show that a stool sample had been collected or tested for C. dif. This shows that the resident did not move her bowels for six consecutive days. In addition, nursing notes showed over these six days that the resident experienced increased agitation and confusion, a fall, and decrease in food and fluid intake. The Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident's cognitive skills for daily decision making are moderately impaired. This MDS also documented that the resident was always continent of bowel and was not constipated. A Nursing Progress Note and a Medical Evaluation and Treatment plan, both dated 3/7/11 in the evening, both documented that the resident appeared to be weak and increasingly listless, had sluggish bowel sounds, and decreased appetite and decreased food and fluid intake. The MD then ordered a discharge to the hospital for further treatment. The Emergency Department Provider Record, dated 3/7/11, documented that the resident was given three soap suds enemas and was manually disimpacted of stool. The resident was discharged back to the facility later that day with an order to take [MEDICATION NAME] of magnesia (laxative) in the morning. Interviews conducted on 5/25/11 are as follows: a) At 12:33 p.m., a Licensed Practical Nurse (LPN) stated that night staff review the BM list every night and report those residents who have not had a BM in three days. The night nurse reviews the BM logs and documents any resident that needs to be reviewed on the 24-hour report. Treatment is started using medications currently ordered by the MD, usually Milk of Magnesia. The Certified Nursing Assistants (CNAs) record BMs in the Intake/Output book and the computer program. The LPN further stated that residents are reviewed for an eight shift period instead of nine, and after four days they may receive a suppository. Additionally, the LPN said that if the resident was complaining of pain, he would check their abdomen. b) At 12:38 p.m., a CNA reported that she logs BM's on the Intake/Output papers and records information in the computer. The BMs are written on a pink sheet. After the third day, she lets the nurse know if the resident has not had a BM. The CNA said nursing is supposed to check the paper BM logs. c) At 1:35 p.m., a Registered Nurse (RN) explained that the information placed in the computer is kept indefinitely and should be the same as what is written on the pink sheets. The pink sheets are the, "record." The RN further described the facility's BM policy. The facility uses an Intake/Output sheet to record BMs, and this is usually done by CNAs. The LPNs monitor BM sheets, and if a resident has not had a BM in three days, they are offered an as needed bowel medication. The running sheets (24-hour reports) now include a place to document, "last BM" to make sure no one is missed. d) At 2:57 p.m., the Medical Director said that she had been made aware that the resident had been hospitalized for [REDACTED]. The Medical Director also said that treatment could have been provided by any provider; however, no provider had been contacted about the resident's bowel issues. e) At 5:41 p.m., the DON stated the most reliable source of residents' bowel history are the "pink sheets," the paper documentation. In an interview on 5/26/11 at 8:39 a.m., the DON stated that the RN checked for bowel sounds on the day the resident was discharged and could hear them. They did not think to rule out a high impaction because they thought she had[DIAGNOSES REDACTED]icile from recent antibiotic use. The undated facility policy related to constipation directs staff to assess the resident for signs and symptoms and to call the MD immediately when a resident has hard compacted stool or if a resident has had two or fewer bowel movements in one week. The facility's policy entitled, "LPNs: Regarding BM List," dated 10/20/08, revealed that the BM list is a very important tool. CNAs are responsible for filling out the form at the end of every shift. LPN responsibility is to look at the BM sheet at the beginning of their shift to see who has not moved their bowels in more than 72 hours and to initial this form, to start medication, check bowel sounds, monitor for abdominal distention/pain, and then report to the RN. (10 NYCRR 415.12)