Every finding on record at Momentum at South Bay for Rehabilation and Nursing

Based on observations, record review, and interviews during the Recertification Survey, initiated on 09/02/2025 and completed on 09/09/2025, the facility did not ensure a comprehensive person-centered care plan was implemented for each resident to meet the resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. This was identified for one (1) (Resident #57) of twelve (12) residents reviewed for Infection Control. Specifically, Resident #57 had a physician's order for Contact Precautions dated 08/12/2025; however, there was no Comprehensive Care Plan developed for Contact Precautions with measurable goals and interventions. The finding is:The facility's policy titled Comprehensive Care Plans and Resident meeting dated 04/28/2025 documented that a Comprehensive Care Plan for the resident's needs should be developed by 14 days of admission and no later than 21 days. Within fourteen days of the resident's admission, a comprehensive assessment of the resident's needs will be prepared and developed by the interdisciplinary team.Resident #57 was admitted with diagnoses including Enterocolitis (inflammation of the colon) due to Clostridium difficile, Benign Prostatic Hyperplasia (a condition in which the prostate gland is enlarged), and Bacteremia (bacteria in the bloodstream). The 5-day admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 13, indicating the resident is cognitively intact.A Baseline Care Plan dated 08/11/2025 documented contact isolation with interventions that included infection control per protocol.A physician's order dated 08/12/2025 documented that Resident #57 requires strict isolation contact precautions. This order was discontinued on 08/27/2025.A physician's order dated 08/27/2025 documented contact precautions.A review of the Comprehensive Care Plan revealed there was no documented evidence that a Comprehensive Care Plan with measurable goals and interventions for Contact Isolation was developed by 14 days of admission and no later than 21 days.During an observation on 09/02/2025 at 12:04 PM, Resident #57's room door had signage that documented Contact Enteric Precautions; doctors and staff must [put on] a gown and gloves at the door. Everyone must wash their hands with soap and water before and after care. The resident was not in the room and was unavailable for an interview.During an observation on 09/03/2025 at 8:40 AM, the precautions signage was still present on the doorway and documented Contact Enteric Precautions; doctors and staff must [put on] a gown and gloves at the door.During an interview on 09/08/2025 at 1:10 PM, Registered Nurse Manager #3 stated Resident #57 should have had a Comprehensive Care Plan developed for contact precautions.During an interview on 09/09/2025 at 8:48 AM, the Director of Nursing Services stated that a Comprehensive Care Plan should have been developed when the resident was placed on contact precautions. The admission nurse initiates a baseline care plan for contact precautions. The Infection Preventionist, Nurse Manager, or Nurse Supervisor is responsible for creating a Comprehensive Care Plan.10 NYCRR415.11(c)(1)

Based on observations, record review, and interviews during the Recertification Survey, initiated on 09/02/2025 and completed on 09/09/2025, the facility did not ensure a comprehensive person-centered care plan was reviewed and revised by the interdisciplinary team to reflect the resident's current status. This was identified for one (1)(Resident #1) (1)of one resident reviewed for Pressure Ulcers. Specifically, Resident #1's Comprehensive Care Plan was not updated to indicate the changes in the interventions related to offloading the resident's heels (both extremities). The finding is: The facility's policy, titled Pressure Ulcer Prevention and Care, dated 10/30/2024, documented to Avoid positioning the resident on a pressure injury. If unavoidable, attempt to limit the duration of the pressure on these areas. Resident #1 was admitted with diagnoses including Down Syndrome and Peripheral Vascular Disease (blood does not flow properly in the veins of the lower extremities). The 07/01/2025 admission Minimum Data Set assessment documented that the resident had severely impaired cognitive skills for daily decision making. The resident was dependent on facility staff for bed mobility and had one Stage 3 (full thickness loss of skin) pressure ulcer. A Comprehensive Care Plan titled Impaired Skin Integrity Right Heel, effective 07/13/2025, documented that the resident has a right heel pressure ulcer measuring 1.0-centimeter X 1.0-centimeter X 0.1 centimeter with 100% Pale Granulation tissue. Interventions included to float the resident's heels on a pillow. A review of the Certified Nursing Assistant care guide for September 2025 revealed there were no instructions to float the resident's heels on a pillow. The Care guide instructed the Certified Nursing Assistant that there is a right heel wound. A wound note dated 08/29/2025 documented on 08/27/2025 the resident's right heel pressure ulcer measured 0.2-centimeter x 0.2-centimeter x 0.1 centimeter and had 100% pink, minimal serous exudate, peri-wound dry skin. The treatment plan for the right heel Stage 3 pressure injury included to cleanse with normal saline, followed by honey gel and dry clean dressing daily, and as needed. The recommendations were to float the resident's heels with a pillow. During an observation on 09/02/2025 at 11:00 AM, Resident #1 was in their room in their bed without a pillow to offload their right heel. The resident was observed wearing bilateral heel booties with heels resting directly on the bed. During an observation of the wound care treatment to the resident's right heel on 09/04/2025 at 11:00 AM, the resident was observed again in heel booties without a pillow to offload the heels. Licensed Practical Nurse # 4 and Wound Care Registered Nurse # 3 performed the treatment. During the treatment, the resident was observed without restlessness. Wound Care Registered Nurse #3 was interviewed on 09/04/2025 at 11:05 AM and stated the resident does not use the pillow to offload their heels because the resident has restless legs. Wound Care Registered Nurse #3 stated they developed the care plan and initially implemented the intervention to float the heels with pillows; however, the resident had restlessness to their lower extremities, and the intervention to use the pillow to offload the heels should have been discontinued. During an interview on 09/04/2025 at 2:15 PM, Certified Nursing Assistant # 2 stated they were never instructed to put a pillow under the resident's legs. Certified Nursing Assistant # 2 stated they only applied the heel booties and had never seen the resident with a pillow under their legs while in bed. Certified Nursing Assistant # 2 stated, The resident does not move around much, and their legs are not restless. During an interview on 09/5/2025 at 12:35 PM, the Director of Nursing Services stated the Comprehensive Care Plan interventions included to float the resident's heels. The Director of Nursing Services stated the resident should have had a pillow under their heels to prevent further breakdown or skin deterioration, and the care plan should reflect the resident's current needs and interventions. 10 NYCRR 415.11(c)(2)(i-iii)

Based on observation, record review, and interviews, during the Recertification Survey and Abbreviated Survey (800725) initiated on 09/02/2025 and completed on 09/09/2025, the facility did not ensure that pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This was identified for one (1) (Resident # 92) of three (3) residents reviewed for Pain Management. Specifically, Resident #92 had a diagnosis of Spinal and Hip Fractures and had a physician's order for Acetaminophen (pain reliever) for 14 days on 08/05/2025. The pain medication order was not renewed after 14 days. The resident was evaluated by Pain Management Nurse Practitioner #2 on 09/07/2025 and recommended to continue Acetaminophen for pain management without reviewing the resident's physician's orders. The resident complained of a pain level of four (4) out of ten (10) on the morning of 09/09/2025 to the Rehabilitation staff. The resident was observed receiving therapy at 11:48 AM and complained of a pain level of six (6) out of ten (10) on the pain scale. The finding is:The facility's Pain Management Policy, effective November 2024, documented that the overall goals of care for residents with pain included identifying and assessing pain, monitoring treatment efficacy and side effects, reviewing active medication orders to ensure interventions were carried out as planned, and ensuring that pain interventions were consistent with the resident's plan of care. Resident # 92 was admitted with a Spinal, Hip, and Pelvic Fracture. The admission Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 14, demonstrating that the resident was cognitively intact. The Minimum Data Set documented that the resident experienced moderate occasional pain and that the resident was on a pain management program. The Comprehensive Care plan for pain and Right Hip Fracture, dated 08/01/2025 and 08/02/2025, respectively, included the interventions for monitoring for signs and symptoms of pain such as verbal complaints, facial grimacing, increased agitation, and moaning.The admission physician's order dated 08/01/2025 documented Acetaminophen 325 milligrams (pain reliever), two tablets (650 milligrams) every six hours as needed, and pain management consultation as needed. This order was discontinued on 08/05/2025. The physician's order dated 08/01/2025 documented to monitor for pain every shift. The pain management consult dated 08/05/2025 documented the resident's complaint of neck pain. The resident was on daily therapy and tolerated well. The assessment included muscle wasting, difficulty walking, and neck pain. Recommendations included changing the Acetaminophen order from as needed to 1000 every eight (8) hours. The physician's order dated 08/05/2025 documented to change Acetaminophen to 500 milligrams, two tablets (1000 milligrams) every eight hours for 14 days. This order was completed on 08/19/2025 and was not renewed. The Medication Administration Record for the period of 08/19/2025 to 09/07/2025 documented monitoring for pain every shift with a consistent score of 0 for each shift, signifying no presence of pain. The Nephrology consult dated 08/22/2025 documented no complaint of joint pain. The Surgery and Vascular consultation dated 08/26/2025 documented that the resident reported right hip pain and denied pain at rest. The recommendations included continuing with the current medical management.The Electronic Medical Record did not include other medical progress notes until 09/07/2025. The medical progress note dated 09/07/2025, written by the Pain Management Nurse Practitioner, documented a plan to continue Acetaminophen 1000 milligrams every eight hours for 14 days and management of pain progression with rehab [rehabilitation]. The note included no complaint of muscle pain. The assessment included neck pain. There was no indication of the severity of the pain level. The Physical Therapy note dated 09/09/2025 documented that the resident reported a pain level of four (4) out of ten (10) on a pain scale (where zero (0) is no pain and ten (10) is the highest amount of pain) lying in bed that morning. During an observation and interview on 09/09/2025 at 11:48 AM, the resident was observed in the Rehabilitation Therapy room receiving therapy with occupational and physical therapy staff. The resident stated they had pain in their right hip, and the pain level was six (6) out of ten (10) on a pain scale. The physician's order dated 09/09/2025 documented Acetaminophen 500 milligrams, two tablets (1000 milligrams) every eight hours.During an interview on 09/09/2025 at 11:50 AM, Occupational Therapist #1 stated, the resident has had occasional pain the past few weeks, but usually the pain improved after therapy, as reported by the resident. A review of the Occupational Therapy treatment encounter notes from 08/19/2025 to 09/09/2025 revealed no documentation regarding the resident's pain level, except for 09/09/2025, when the note indicated the resident had no pain. During an interview on 09/09/2025 at 11:52 AM, Physical Therapist #1 stated the resident has had complaints of pain off and on over the past few weeks, but the pain usually goes away after the therapy session, as per the resident. Physical Therapist #1 stated they usually notify nursing staff when the resident complained of a pain level above two (2) out of ten (10). A review of the Physical Therapy treatment encounter notes from 08/19/2025 to 09/08/2025 revealed no documentation regarding the resident's pain level. During an interview on 09/09/2025 at 12:35 PM, Registered Nurse Manager #2 stated Resident #92 was alert and oriented and was able to verbalize their needs. Registered Nurse Manager #2 stated they interacted with the resident regularly and asked the resident about their pain level; however, the resident did not report any pain to them, and the staff did not report the resident's complaint of pain. Registered Nurse Manager #2 stated they did not realize the Acetaminophen order was discontinued for Resident #92 on 08/19/2025 and was not reordered until 09/09/2025. During an interview on 09/09/2025 at 1:00 PM, Pain Management Nurse Practitioner #2 stated, I was not aware the Acetaminophen order ended on August 19. I usually review the medication administration records, but I do not always look at the administration of non-narcotic medications like Acetaminophen. When I saw the resident on September 7, I thought they were still on Acetaminophen and recommended it be continued. During an interview on 09/09/2025 at 1:10 PM, Certified Nursing Aide #3 stated that they are the regular nursing aide for the resident. They couldn't recall the resident ever complaining of pain and claim that they ask the resident if they are in pain on a routine basis. During an interview on 09/09/2025 at 1:30 PM, Licensed Practical Nurse #5 stated they were the medication nurse, and the resident reported their pain level was five (5) out of ten (10) today and was administered Acetaminophen as per the physician's orders. Licensed Practical Nurse #5 stated they did not recall the resident complaining of pain before. During an interview on 09/09/2025 2:21 PM, the attending Primary Physician #2 stated they ordered the pain medications for 14 days. They relied on staff to notify them of the resident's complaint of pain for them to reorder the pain medications. The attending Primary Physician #2 stated they were not notified of Resident #92's complaints of pain and were also not notified of the recommendations provided by Pain Management Nurse Practitioner #2 to continue the pain medication for the resident. During an interview on 09/09/2025 at 3:00 PM, the Medical Director stated the pain management consultant should have reviewed the resident's Medication Administration Record and communicated their recommendations to the attending physician.During an interview on 09/09/2025 at 3:30 PM, the Director of Nursing Services stated, Pain Management Nurse Practitioner #2 should have reviewed the resident's Medication orders to know the resident's current medications. Pain Management Nurse Practitioner #2 should have also communicated their recommendations to continue the pain medication for Resident #92 to the nursing supervisor, who then should have informed the Physician. 10 NYCRR 415.12

Based on observation, record review, and interviews, during the Recertification Survey and Abbreviated Survey (800725 ) initiated on 09/02/2025 and completed on 09/09/2025, the facility did not ensure that the medical care of each resident was supervised by a Physician, including monitoring changes in the resident's status and the need for changes in the treatment. This was identified for one (1) (Resident #92) of three (3) residents reviewed for Pain Management. Specifically, Resident #92 had a diagnosis of Spinal and Hip Fractures and had a physician's order for Acetaminophen (pain reliever) for 14 days on 08/05/2025. The pain medication order was not renewed after 14 days. The resident was evaluated by Pain Management Nurse Practitioner #2 on 09/07/2025 and recommended to continue Acetaminophen for pain management without reviewing the resident's physician's orders. Cross Reference- F697The finding is:The facility's Pain Management Policy, effective November 2024, documented that the overall goals of care for residents with pain included identifying and assessing pain, monitoring treatment efficacy and side effects, reviewing active medication orders to ensure interventions were carried out as planned, and ensuring that pain interventions were consistent with the resident's plan of care. Resident # 92 was admitted with a Spinal, Hip, and Pelvic Fracture. The admission Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 14, demonstrating that the resident was cognitively intact. The Minimum Data Set documented that the resident experienced moderate occasional pain and that the resident was on a pain management program. The Comprehensive Care plan for pain and Right Hip Fracture, dated 08/01/2025 and 08/02/2025, respectively, included the interventions for monitoring for signs and symptoms of pain such as verbal complaints, facial grimacing, increased agitation, and moaning.The admission physician's order dated 08/01/2025 documented Acetaminophen 325 milligrams (pain reliever), two tablets (650 milligrams) every six hours as needed, and pain management consultation as needed. This order was discontinued on 08/05/2025. The physician's order dated 08/01/2025 documented to monitor for pain every shift. The pain management consult dated 08/05/2025 documented the resident's complaint of neck pain. The resident was on daily therapy and tolerated well. The assessment included muscle wasting, difficulty walking, and neck pain. Recommendations included changing the Acetaminophen order from as needed to 1000 milligrams, every eight (8) hours. The physician's order dated 08/05/2025 documented to change Acetaminophen to 500 milligrams, two tablets (1000 milligrams) every eight hours for 14 days. This order was completed on 08/19/2025 and was not renewed. The medical progress note dated 09/07/2025, written by the Pain Management Nurse Practitioner, documented a plan to continue Acetaminophen 1000 milligrams every eight hours for 14 days and management of pain progression with rehab [rehabilitation]. The note included no complaint of muscle pain. The assessment included neck pain. There was no indication of the severity of the pain level. The Physical Therapy note dated 09/09/2025 documented that the resident reported a pain level of four (4) out of ten (10) on a pain scale (where zero (0) is no pain and ten (10) is the highest amount of pain) lying in bed that morning. During an observation and interview on 09/09/2025 at 11:48 AM, the resident was observed in the Rehabilitation Therapy room receiving therapy with occupational and physical therapy staff. The resident stated they had pain in their right hip, and the pain level was six (6) out of ten (10) on a pain scale. The physician's order dated 09/09/2025 documented Acetaminophen 500 milligrams, two tablets (1000 milligrams) every eight hours.During an interview on 09/09/2025 at 1:00 PM, Pain Management Nurse Practitioner #2 stated, I was not aware the Acetaminophen order ended on August 19. I usually review the medication administration records, but I do not always look at the administration of non-narcotic medications like Acetaminophen. When I saw the resident on September 7, I thought they were still on Acetaminophen and recommended it be continued. During an interview on 09/09/2025 2:21 PM, the attending Primary Physician #2 stated they ordered the pain medications for 14 days. They relied on staff to notify them of the resident's complaint of pain for them to reorder the pain medications. The attending Primary Physician #2 stated they were not notified of Resident #92's complaints of pain and were also not notified of the recommendations provided by Pain Management Nurse Practitioner #2 to continue the pain medication for the resident. During an interview on 09/09/2025 at 3:00 PM, the Medical Director stated the pain management consultant should have reviewed the resident's Medication Administration Record and communicated their recommendations to the attending physician.10 NYCRR 415.15 (b)(1)(i)(ii)

Based on observations, record review, and interviews during the Recertification Survey initiated on 09/02/2025 and completed on 09/09/2025, the facility did not ensure it maintained an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This was identified for one (1) (Resident #57) of twelve (12) residents reviewed for Infection Control, and two (2) (Resident #19 and Resident #156) of two (2) residents reviewed during the Medication Storage task. Specifically, 1) Resident #57 had a physician's order for Contact Precautions due to Clostridium Difficile (a bacterium that causes severe diarrhea and intestinal inflammation) infection. Certified Nursing Assistant #4 was observed entering and exiting Resident #57's room without putting on and removing Personal Protective Equipment. 2) During the Medication Storage task, Licensed Practical Nurse #6 stated they clean the shared glucometer device with an alcohol wipe after each resident's use; however, the facility's infection control policy required the use of an Environmental Protection Agency (EPA) approved disinfectant to disinfect the shared glucometer device. The findings are:1) The facility policy titled Transmission-Based Precautions, dated 09/11/2024, documented that Transmission-Based Precautions will be initiated by a licensed nurse as per the physician's order. Contact Precautions will be used when there is evidence of multidrug-resistant organisms, including but not limited to Clostridium Difficile. Residents on contact precautions will have signage posted outside the resident's room. Resident #57 was admitted with diagnoses including Enterocolitis (inflammation of the colon) due to Clostridium difficile, Benign Prostatic Hyperplasia (a condition in which the prostate gland is enlarged), and Bacteremia (bacteria in the bloodstream). The 5-day admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 13, indicating the resident is cognitively intact. A Baseline Care Plan dated 08/11/202 documented contact Isolation with interventions that included infection control as per protocol. A physician's order dated 08/12/2025 documented that Resident #57 requires strict isolation contact precautions. This order was discontinued on 08/27/2025. A physician's order dated 08/27/2025 documented contact precautions.During an observation on 09/02/2025 at 12:04 PM, Resident #57's room door had signage that documented Contact Enteric Precautions; doctors and staff must [put on] a gown and gloves at the door. Everyone must wash their hands with soap and water before and after care. The resident was not in the room and was unavailable for an interview.During an observation on 09/03/2025 at 8:40 AM, Certified Nursing Assistant #4 sanitized their hands and proceeded to walk into Resident #57's room without putting on Personal Protective Equipment, including a gown and gloves. Certified Nursing Assistant #4 was subsequently observed walking out of the room a minute later and was carrying an empty breakfast tray to the food truck that was located right outside the resident's room. The signage was still present on the doorway and documented Contact Enteric Precautions; doctors and staff must [put on] a gown and gloves at the door. During an interview on 09/03/2025 at 8:48 AM, Certified Nursing Assistant #4 stated they did not put on Personal Protective Equipment because they were not going to touch the resident, and they did not think they needed to wear personal protective equipment.During an interview on 09/04/2025 at 11:37 AM, Registered Nurse Manager #3 stated every staff member needs to wear Personal Protective Equipment when going into a resident's room who is on contact isolation precautions, including when picking up or dropping off a meal tray.During an interview on 09/08/2025 at 8:47 AM, the Registered Nurse Infection Preventionist/Inservice Coordinator stated that contact precautions signage is displayed on the door with instructions to use the Personal Protective Equipment available outside the resident's room. The Registered Nurse Infection Preventionist/Inservice Coordinator stated that staff should put on the appropriate Personal Protective Equipment prior to entering the room, including when picking up a meal tray from inside the resident's room. During an interview on 09/09/2025 at 8:45 AM, the Director of Nursing Services stated they expect staff to follow the facility's infection control policy. The Director of Nursing Services stated that all staff should wear appropriate Personal Protective Equipment before entering a resident's room who is on contact precautions. 2) The facility policy titled Blood Glucose Monitoring, dated 06/04/2025, documented that the glucometer (used to measure how much glucose (sugar) is present in the bloodstream at a given moment in time) should be cleaned and disinfected between each resident test. Equipment needed to clean the machine included: The Environmental Protection Agency registered germicidal or bleach wipes must be approved for use in healthcare settings and for surface cleaning. The wipes must be effective against Human Immunodeficiency Virus, Hepatitis B Virus, and Hepatitis C Virus (purple top Sani wipe). Resident #19 was admitted with diagnoses including Type 2 Diabetes Mellitus, Arthritis, and Cerebral Ischemia (blood flow to the brain is reduced). The Minimum Data Set assessment, dated 06/21/2025, documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. The Minimum Data Set documented the resident received insulin one (1) of the seven (7) days in the assessment look-back period. A physician's order dated 06/18/2025 and renewed on 08/26/2025 documented inject insulin Lispro 100 units/per milliliter subcutaneously every day at 06:30 AM, 11:30 AM, 04:30 PM, and 09:00 PM. Monitor Blood Sugar, use sliding scale, if Blood Sugar is 181-240 milligrams per deciliter, give 4 units, if Blood Sugar is 241-280 milligrams per deciliter, give 6 units, if Blood Sugar is 281-320 milligrams per deciliter, give 8 units, greater than 320 or lower than 80 milligrams per deciliter, call the Physician.Resident #156 was admitted with diagnoses including Type 2 Diabetes Mellitus, Chronic Respiratory Failure, and Acute Kidney Failure. The Quarterly Minimum Data Set assessment, dated 06/22/2025, documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. A physician's order for Resident #156 dated 08/16/2025, and renewed on 09/04/2025, documented to check blood glucose twice a day at 06:00 AM and 09:00 PM; call the physician if the blood sugar levels are less than 60 milligrams per deciliter, or greater than 400 milligrams per deciliter. During the Medication Storage task on 09/04/2025 at 11:11 AM, the medication cart for Unit 2 F hall was observed with Licensed Practical Nurse #6. Licensed Practical Nurse #6 stated they clean the glucometer device with the alcohol pads before and after using the glucometer device for each resident who required blood glucose monitoring. Licensed Practical Nurse #6 stated they clean the Blood Pressure cuff with the purple germicidal wipe and the glucometer with an alcohol pad. Licensed Practical Nurse #6 stated they were educated to use different methods to clean the two items. Licensed Practical Nurse #6 then demonstrated that they clean the glucometer with an alcohol pad. Licensed Practical Nurse #6 stated they have the germicidal wipes on the medication cart, but only use them to clean the Blood Pressure cuff. Licensed Practical Nurse #6 stated there were only two residents in the unit who required blood sugar monitoring, Resident #19 and Resident #156. During an interview on 09/04/2025 at 11:32 AM, Registered Nurse Manager #3 stated that they also use alcohol pads to clean the glucometer device. Registered Nurse Manager #3 returned on 09/04/2025 at 2:27 PM and stated they wanted to clarify that the facility uses the germicidal wipes to clean the glucometer after each resident's use, not the alcohol wipes. During an interview on 09/08/2025 at 8:49 AM, Registered Nurse Infection Prevention/Inservice Coordinator stated the facility policy directs staff to use the germicidal wipes to disinfect glucometer devices after each use, not the alcohol pads. Registered Nurse Infection Prevention/Inservice Coordinator stated the alcohol pad would not disinfect the glucometer device from infectious organisms. Registered Nurse Infection Prevention/Inservice Coordinator stated staff should not use alcohol pads to clean the glucometer, and only germicidal wipes are acceptable. During an interview on 09/09/2025 at 8:45 AM, the Director of Nursing Services stated that staff members are required to sanitize the glucometer device using a germicidal wipe after each use. The Director of Nursing Services stated nurses must adhere to the facility's infection control policy and should not use an alcohol pad to clean the glucometer device. The Director of Nursing Services stated that the alcohol pad would not disinfect everything. 10 NYCRR 415.19(a)(1-3)

Based on observation, record review, and interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 00330563) initiated on 06/04/2024 and completed on 06/11/2024 the facility did not ensure Intravenous antibiotics were administered consistent with professional standards of practice and in accordance with physician's orders and the comprehensive person-centered care plan. This was identified for one (Resident #98) of one resident reviewed for Peripheral Intravenous Catheter. Specifically, Resident #98 was observed with a Peripheral Intravenous Catheter in their right arm. There were no physician orders for the placement of the Peripheral Intravenous Catheter and monitoring of the Peripheral Intravenous Catheter site. The finding is: The Facility's policy for Administration, Monitoring, and Maintenance of Intravenous Therapy dated January 2022, documented that the nursing staff must document an assessment of the Peripheral Intravenous Catheter site for phlebitis, infection, or infiltration at least once per shift. The Facility's policy for Medication Management Administration-Intravenous General dated January 2019, documented checking the Peripheral Intravenous Catheter for signs of infection, cleaning the Peripheral Intravenous Catheter with an alcohol wipe, and flushing the line as per the Physician's order. Resident #98 was admitted with diagnoses of Chronic Obstructive Pulmonary Disease, Lymphedema, and Acute and Chronic Respiratory Failure. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 14, which indicated the resident had intact cognition. The Comprehensive Care Plan for Risk for Infection related to Intravenous Access dated 6/10/2024 documented that the resident was at risk for infections related to Peripheral Intravenous Catheter use. The interventions included: the Registered Nurse was to change the dressing to the Intravenous site weekly and as needed, flush the Intravenous access line with 10 milliliters of Normal Saline after each medication and every shift when not in use or as per Physician order, monitor for signs and symptoms of infection such as redness, edema, warmth, and pain at the Intravenous site, and notify the Physician of abnormal findings. The Comprehensive Care Plan for Intravenous Therapy/Antibiotic Therapy dated 6/10/2024 documented interventions to monitor the Peripheral Intravenous Catheter site every shift and as needed. The physician's order dated 6/10/2024 documented to administer Rocephin 1-gram (Antibiotic) Intravenous Solution, infused by Intravenous route once daily for seven days for Acute Upper Respiratory Infection. The Medication Administration Record for June 2024 indicated that Resident #98 received Rocephin 1 gram Intravenously which started on 6/10/2024 at 9:00 AM once a day for seven days. There was no documentation on the Medication Administration Record or Treatment Administration Record for the placement of the Peripheral Intravenous Catheter and assessment of the Peripheral Intravenous Catheter site. Resident #98 was observed on 6/10/2024 at 10:09 AM resting in bed with a Peripheral Intravenous Catheter in their right arm. Resident #98 stated they were getting a new medication via the newly placed Peripheral Intravenous Catheter. Registered Nurse Manager #1 was interviewed on 6/11/2024 at 8:04 AM and stated there should be a physician's order for the placement and assessment of the Peripheral Intravenous Catheter. Registered Nurse Manager #1 stated on 6/10/2024 they received a verbal order for the Intravenous Antibiotic and the placement and assessment of the Peripheral Intravenous Catheter for Resident #98. The physician's order related to the use and assessment of the Peripheral Intravenous Catheter should have been transcribed onto the Medication Administration Record. Registered Nurse Manager #1 stated they forgot to write the physician's order for the insertion or monitoring of the Peripheral Intravenous Catheter, therefore, the physician's order did not get transcribed onto the Medication Administration Record. The Director of Nursing Services was interviewed on 6/11/2024 at 8:50 AM and stated there should be an order for the placement and the assessment of Peripheral Intravenous Catheter. The Director of Nursing Services stated whoever obtained the order from the Physician should have ensured the orders were entered into the Medication Administration Record. Physician #1 was interviewed on 6/11/2024 at 9:39 AM and stated they expect the nursing staff to follow the physician's orders and ask questions if needed. Physician #1 stated the nursing staff should check the Peripheral Intravenous Catheter site on all shifts and document their observations. The Peripheral Intravenous Catheter site should be checked each shift for redness, leaking, swelling, and signs and symptoms of infections. 10 NYCRR 415.12(k)(2)

Based on observation, record review, and interviews during the Recertification Survey initiated on 6/4/2024 and completed on 6/11/2024, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #90) of three residents reviewed for Infection Control. Specifically, Resident #90 had a physician's order for Contact Enteric Isolation due to Clostridium Difficile (C-Diff-bacteria that causes inflammation of the colon) infection. On 6/7/2024, Certified Nursing Assistant #4 was observed providing perineal care to Resident #90 after a bowel movement. When the perineal care was completed, Certified Nursing Assistant #4 removed their dirty gloves and put on a new pair of gloves without performing hand hygiene. Certified Nursing Assistant #4 then removed the used water basin from the overbed table, cleansed the overbed table, and exited the room wearing the same gloves. The finding is: The facility's policy and procedure titled Transmission-Based Precautions last revised on 3/28/2024, documented that while caring for a resident, change gloves after having contact with infective material, fecal material, and wound drainage. Remove gloves before leaving the room and perform hand hygiene. After removing gloves and washing hands, do not touch potentially contaminated environmental surfaces or items in the resident's room. Resident #90 was admitted with diagnoses of Acute Respiratory Failure, Irritable Bowel Syndrome, and Unstageable Pressure Ulcer to the Sacral Region. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of zero which indicated the resident had severely impaired cognition. The Minimum Data Set assessment documented that Resident #90 had an Unstageable (full-thickness tissue loss in which the actual depth of the wound is obscured) wound on the sacrum. A Comprehensive Care Plan (CCP) for Isolation and Contact Precaution dated 5/29/2024 documented interventions that included Isolation Precautions as per the physician's order and to maintain contact precautionary measures as per facility protocol which included Personal Protective Equipment use. A Comprehensive Care Plan (CCP) for Clostridium Difficile (C-Diff) dated 5/29/2024 documented interventions to monitor signs and symptoms of Clostridium Difficile (C-Diff) (such as watery, smelling, and blood-tinged stool and abdominal pain), stool cultures as per the physician's order, and to provide protective skin care. A physician's order dated 5/29/2024 documented Contact Precaution secondary to Clostridium Difficile (C-diff). A physician's order dated 5/29/2024 documented to apply honey gel to the Coccyx (sacral) area after normal saline cleanses followed by a Calcium Alginate (wound fabric that absorbs water) dressing and cover with border gauze daily and as needed. During an observation on 6/7/2024 at 10:00 AM, Certified Nursing Assistant #4 was observed inside the resident's room with Certified Nursing Assistant #5. A sign posted outside the room read Contact Enteric Isolation. The sign included instructions that all staff and visitors must wash hands with soap and water before and after care and use Personal Protective Equipment (PPE) including wearing a gown and gloves. Certified Nursing Assistant #4 and Certified Assistant #5 were both wearing gowns and gloves and were providing perineal (area between the anus and genitalia) care for Resident #90. An open wound, without a dressing, was observed on the Coccyx (tailbone-sacral) area. Resident #90 was continuously having loose bowel movements while Certified Nursing Assistant #4 was wiping the perineal area. Certified Nursing Assistant #4 discarded their gloves after the perineal care was completed and put on a new pair of gloves without performing hand hygiene. Certified Nursing Assistant #4 then cleaned and wiped the overbed table which was used to hold the water basin and other supplies during the perineal care and exited the resident's room, to discard the garbage bag, wearing the same gloves. Certified Nursing Assistant #4 was interviewed on 6/7/2024 at 10:39 AM and stated they forgot to perform handwashing after discarding the dirty gloves. Certified Nursing Assistant #5 was interviewed on 6/7/2024 at 11:00 AM and stated they were helping to position Resident #90 during care because the resident was very combative. Certified Nursing Assistant #5 stated when the wound dressing came off, they should have called a nurse because the wound was exposed to fecal material; however, the resident was getting very anxious and combative, and they wanted to complete the care. The Infection Preventionist was interviewed on 6/7/2024 at 2:28 PM and stated staff must follow the isolation precaution instructions before and after entering the resident's room. Resident #90 was placed on a Contact Isolation precaution secondary to the Clostridium Difficile infection. The staff must perform handwashing to minimize the spread of contamination. Certified Nursing Assistant #4 should have washed their hands after discarding the dirty gloves and before putting on the new gloves. The Director of Nursing Services was interviewed on 6/10/2024 at 2:02 PM and stated that because of Resident #90's continued symptoms of loose feces, the dressing on the sacral wound will always be saturated and prone to cross-contamination. The Director of Nursing Services stated that Certified Nursing Assistant #4 and Certified Nursing Assistant #5 should have alerted a nurse when the sacral wound dressing came off. The exposed wound bed could have gotten feces on it and become infected. The Director of Nursing Services stated handwashing is of utmost importance, especially with a diagnosis of Clostridium Difficile (C-diff). Certified Nursing Assistant #4 should have washed their hands after discarding their dirty gloves. 10 NYCRR 415.19(a)(1-3)

Based on observation and staff interviews during the Recertification Survey started on 9/28/2022 and was completed on 10/5/2022, the facility did not follow proper sanitation practices to prevent the outbreak of foodborne illness. Specifically, on 9/29/2022 at 2:20 PM, the dish machine was observed running with a Wash temperature of 148 degrees Fahrenheit (F) and a Rinse temperature of 174 degrees F when the manufacturer specifications stated that the Wash temperature should be a minimum of 160 degrees F and the Rinse temperature be a minimum of 180 degrees F. The finding is: The facility's policy titled Sanitation of Dishware dated 1/12/2011 documented to take dishmachine temperatures three times per day to enable proper washing and sanitation. Procedures included: 1) dishmachine temperatures are taken after each meal is served and before washing the dirty dishes from the prior meal to ensure proper washing and sanitation; 2) The dishmachine temperatures are logged on the temperature sheets for each meal to ensure accuracy; 3) The dishmachine at the facility is a high temperature dishmachine. The Wash temperature should be 150-165 degrees F and the Rinse temperature should be 180 degrees F or above; 4) The dishmachine temperatures are logged by dish room personnel three times per day prior to washing the dishes; and 5) If there is a problem, staff are to notify the Supervisor immediately for repair and switch to emergency liquid sanitization. On 9/29/2022 at 2:25 PM, in the presence of the Food Service Director, the dishmachine was observed being operated by Dietary Aide #1. The temperatures of the gauges on the dishmachine read 148 degrees F for the Wash and 174 degrees F for the Rinse. Dietary Aide (DA) #1 was interviewed on 9/29/2022 at 2:28 PM and stated that they (DA #1) had been running the dishmachine from 12:30-1:00 PM to wash the dishes from the facility's Lunch meal. DA #1 stated that they (DA #1) did not look at the temperatures on the machine and they (DA #1) did not have a chance to write the temperatures down yet. The dishmachine Temperature Log for September 2022 was reviewed and the Lunch dishwashing temperature reading for 9/29/2022 was blank. The Food Service Director (FSD) was interviewed on 9/29/2022 at 2:30 PM and stated that they (FSD) always thought that the temperature of the Wash should be 140-160 degrees F and the Rinse temperature over 180 degrees F. The FSD stated that they (FSD) did not know the specifications for the facility's dish machine The FSD stated that the temperatures of the dishmachine should be taken before or during the running of the dishmachine. The FSD was re-interviewed on 9/29/2022 at 4:30 PM and stated that the specifications of the dishmachine documented that the Wash temperature should be at 160 degrees F and the Rinse temperature at 180 degrees F. The FSD was interviewed on 9/30/2022 at 12:40 PM and stated that they (FSD) would amend the facility's Sanitation of Dishware policy and include in the policy that the dishmachine should have a 160 degrees F temperature for Wash according to the specifications of the machine. The dishmachine service vendor invoice dated 9/30/2022 documented that the wash tank heating contractor had to be replaced and the thermostat adjusted on the dishmachine. The invoice also documented that the Wash temperature was now 170 degrees F and the Rinse temperature was 190 degrees F. 415.14(h)

Based on observation, record review, and staff interviews during the Recertification Survey started on 9/28/2022 and completed on 10/5/2022 the facility did not ensure that its medication error rate was not 5 percent or greater. This was identified for 2 of 33 opportunities during the medication pass observation, resulting in a 6 % medication error rate. Specifically, during the medication pass observation 1) Registered Nurse (RN) #1 administered a [MEDICATION(S)] tablet (a medication used to treat and prevent gastric and intestinal ulcers) to Resident # 91 while the resident was eating breakfast; however, the Physician ordered the medication to be administered on an empty stomach. 2) Licensed practical Nurse (LPN) #1 administered [MEDICATION(S)] (a medication used to treat nerve pain) to Resident # 302 at the wrong time. The finding is: The facility's policy titled Medication Administration-General, dated February 2016, documented that medications are administered to residents in a timely and accurate manner; the nurse will review the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 1) Resident #91 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/1/2022 Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident had severe cognitive impairment. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the [MEDICATION(S)] blister packet documented to administer [MEDICATION(S)] 1 gram tablet, give one tablet by oral route four times per day on an empty stomach, one hour before meals and at bedtime, at 9 AM, 1 PM, 5 PM, and 9 PM. During an observation on 9/29/2022 at 8:30 AM, the medication pass for Resident #91 was performed by Registered Nurse (RN) #1. The nurse crushed the [MEDICATION(S)] tablet, an iron tablet, and a Vitamin B 12 tablet together. RN #1 then mixed all the crushed medications in apple sauce and administered the medications to Resident #91 while the resident was eating their oatmeal. The resident had already completed eating the food that was on the breakfast plate. RN #1 was interviewed on 9/29/2022 at 10:51 AM and stated they (RN #1) were aware that the [MEDICATION(S)] tablet was supposed to be administered on an empty stomach. RN #1 stated they administered the medication [MEDICATION(S)] to the resident because the resident had not eaten that much of their breakfast yet. 2) Resident #302 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/4/2022 Admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 9/29/2022 at 8:58 AM the medication pass for Resident #302 was performed by Licensed Practical Nurse (LPN) #1. LPN #1 prepared the [MEDICATION(S)] capsule, as well as an iron tablet, an [MEDICATION(S)] (blood thinner) tablet, and a [MEDICATION(S)] (antidepressant) tablet for administration. After preparing the medications, LPN #1 donned an isolation gown and gloves; entered the resident's room with the medications in a cup, and administered the medications to Resident #302. After administration of the medications, LPN #1 removed the isolation gown and stated the medications were all given and the medications would be signed off in the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #1 was interviewed on 9/29/2022 at 10:55 AM. LPN #1 stated that they (LPN #1) gave the dosage of [MEDICATION(S)] at 9 AM because they (LPN#1) were so busy thinking about the C-Diff and mistakenly gave the medication that was not due for administration. RN #2, who was the in-service coordinator, was interviewed on 9/30/2022 at 12:56 PM. RN #2 stated both nurses (RN #1 and LPN #1) made medication errors and the residents' families and physicians were notified of the medication errors. RN #2 stated both nurses will have to be re-educated on medication administration. The Director of Nursing Services (DNS) was interviewed on 10/3/2022 at 8:00 AM. The DNS stated RN #1 and LPN #1 both made medication errors and both nurses will have to be re-educated. 415.12(m)(1)

Based on observation, record review, and interviews during the Recertification Survey initiated on 9/28/2022 and completed on 10/5/2022, the facility did not ensure that all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles. This was identified on one of four medication carts reviewed during the Medication Storage and Labeling Task. Specifically, Resident #80's two [MEDICATION(S)] insulin vials were observed opened with no date to indicate when the insulin vials were first opened. The finding is: The Facility's Medication Labeling Policy and Procedure dated 8/2021 documented that upon opening insulin pens/vials, the licensed nurse will write the date opened. Resident #80 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #80 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS further documented that Resident #80 received insulin injections 5 of 7 days during the MDS look-back period. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Cart on Unit 2 B was observed on 10/3/2022 at 2:50 PM with LPN #2. There were two insulin vials of [MEDICATION(S)] that were opened and not dated. LPN #2 stated that the two insulin vials belong to Resident #80 and both vials were opened and not dated. LPN #2 stated that they (LPN #2) did not know when the vials were first opened. The Director of Nursing Services (DNS) was interviewed on 10/5/22 at 11:20 AM. The DNS stated that the insulin vials are expected to be dated when they are first opened. 415.18(d)

Based on observations, record review and staff interviews during a complaint survey (#NY 182) conducted on 8/25/2022 through 8/26/2022 the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, 1) CNA #1 did not follow transmission-based (isolation) precautions for Resident #1 upon entering their room. 2) CNA #1 and CNA #2 did not follow transmission-based precautions prior to personal care for Resident #2. 3) CNA #1 and CNA #2, did not perform hand hygiene in between care of Resident#1 and Resident #2. The findings are: 1) Resident #1 was admitted to the facility on [DATE] with the following medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's Minimum Data Set (MDS) Assessment, dated 06/19/2022 documented a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment. Review of the facilities infection control policy titled, Infection Control: Staff Guidelines and dated 01/05/2020, documented: Nursing staff will/may initiate strict isolation measures on any resident that demonstrates potential for spreading communicable disease. Review of the facilities policy titled, Covid-19 Virus- Screening and Testing of Residents, dated 02/10/2022 documented: Signage to identify a resident for cohort: 1) blue signs are for residents under observation: Droplet, Contact Precautions, Strict Isolation. Red signs are for residents that are positive for COVID-19: Personal Protective Equipment used: N95 (respirator) mask with a surgical mask over it and eye protection. Gowns must be utilized with all direct care. All staff with proper Personal Protective Equipment may enter the resident's rooms. A Physician order, dated 08/19/2022, documented Strict Isolation, Droplet and Contact Precautions. Resident #1 was Covid Positive. The Comprehensive Care Plan (CCP), dated 08/19/2022, titled, at risk for COVID-19 due to pandemic outbreak and a Covid positive diagnosis. Interventions included: staff will wear a mask when within 6 feet from an individual. The Covid-19 test result revealed Resident #1 had a positive Covid-19 test result on 08/19/2022. During an observation on 08/25/2022 at 3:10 PM, CNA #1 was observed to entered Resident #1's room with two surgical masks across their (CNA#1s) face. CNA#1 was not wearing eye goggles, or a face shield as required per sign posted on Resident #1's door. The red sign documented, STOP Droplet and Contact Precautions everyone must Wear a fit tested N95 (respirator) mask, surgical mask over the N95 (respirator) mask and eye protection. Certified Nursing Assistant (CNA) #1 was interviewed on 08/25/2022 at 3:14 PM. CNA #1 stated that Resident #1's door had a sign posted for Transmission Based Precautions and they (CNA#1) were supposed to wear an N95 (respirator) mask. CNA #1 stated a red sign that is posted on a resident's door usually means a resident was positive with COVID. CNA#1 could not explain why they (CNA#1) did not follow facility policy on Transmission Based Precautions. The Director of Nursing Services (DNS) was interviewed on 08/26/22 at 1:24 PM. The DNS stated a red sign posted on the residents' door means the resident is Covid positive and on strict isolation contact and droplet precautions. The DNS stated the policy is to have a Single use of gowns, goggles, or a disposable face shield. Additionally, the DNS stated that CNA #1 should wear an N95 (respirator) mask, with a surgical mask over it or just an N95 (respirator). The DNS further stated that CNA #1 did not follow the facility policy to wear an N95 (respirator) mask and eye shield. The Administrator was interviewed on 08/26/2022 at 3:27 PM. The Administrator stated that Covid positive transmission-based precautions include gloves, gowns, N95 (respirator) with surgical mask over it and eye protection (goggles or shield). The Administrator also stated staff are required to wear a surgical mask over the N95(respirator), which CNA #1 failed to do. 2) Resident #2 was readmitted to the facility on [DATE], with the following medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2's Minimum Data Set (MDS) Assessment, dated 07/15/2022, documented that Resident #2's cognitive skills for daily decision making was severely impaired. Resident #2 required extensive assistance of two persons for toilet use and extensive assistance of one person for dressing and personal hygiene. Review of the facilities policy titled, Covid-19 Virus- Screening and Testing of Residents, dated 02/10/2022 documented: Signage to identify a resident for cohort: 1) blue sign rooms are for residents under observation: Droplet, Contact Precautions, Strict Isolation. Red signs on residents doors are for residents that are positive for Covid-19: Personal Protective Equipment used: N95 (respirator) mask with a surgical mask over it and eye protection. Gowns must be utilized with all direct care. All staff with proper Personal Protective Equipment may enter the resident's rooms. The Comprehensive Care Plan (CCP) for Resident #2, dated 07/12/2022 and titled: Covid at risk for Etiology: documented that Resident #2 was at risk for Covid-19 due to a pandemic outbreak. Interventions included: All staff will wear a mask within 6 feet of the resident and follow Covid-19 protocols and procedures. The Comprehensive Care Plan (CCP) dated 07/13/2022 and titled: Infection, documented status post [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician's Progress Note, dated 07/27/2022 at 8:00 PM, documented that Resident #2 had Covid 19. Certified Nursing Assistant #2 (CNA#2) was observed on 08/25/2022 at 3:20 PM, wearing two surgical masks and eye goggles while providing care to Resident #2. A blue quarantine sign was observed on the door of Resident #2's room that documented Quarantine, droplet and contact precautions, everyone must sanitize their hands before entering and exiting the room, wear fit tested N95 (respirator) mask, surgical mask, and eye protection. The sign also documented must change gown and gloves for each resident. Please ask resident to wear a mask during care and disinfect all re-usable medical and rehabilitation equipment. Certified Nursing Assistant #2 (CNA#2) and CNA #1 were observed on 08/25/2022 at 3:30 PM, entering Resident #2's room. CNA #2 had two surgical masks in place over their face with goggles and no gown and CNA #1 had two surgical masks on over their face, no goggles or gown. Certified Nursing Assistant #2 (CNA #2) was interviewed on 08/25/2022 at 3:30 PM. CNA #2 stated they (CNA#1 and CNA#2) entered Resident #2's room without proper N95(respirator) mask and gown. CNA #2 could not explain why they (CNA#1 & #2) did not follow facility policy on Transmission Based Precautions. Certified Nursing Assistant #2 (CNA#2) was interviewed on 08/25/2022 at 4:18 PM. CNA #2 stated they (CNA#1 & #2) went in Resident #2's room to assist CNA #1 with care of Resident #2 and did not wear gowns or N95 (respirator) masks. CNA #2 could not explain why they (CNA#1 & #2) did not follow facility policy on Transmission Based Precautions. The Director of Nursing Services (DNS) was interviewed on 08/26/2022 at 1:24 PM. The DNS stated for a blue quarantine sign the difference was full Personal Protective Equipment was required during direct care. The Administrator was interviewed on 08/26/2022 at 3:27 PM. The Administrator stated the staff communicate during the morning meeting about which residents are on isolation. Review of facility training/in-service titled, Respiratory Protection Standard, dated 05/11/2022, revealed CNA #2 had received training. 3 (A) Resident #2 was readmitted to the facility on [DATE], with the following medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2's Minimum Data Set (MDS) Assessment, dated 07/15/2022, documented that Resident #2's cognitive skills for daily decision making was severely impaired. The Comprehensive Care Plan (CCP), dated 07/12/2022, titled: Covid at risk for Etiology: documented that Resident #2 was at risk for Covid-19 due to the pandemic outbreak. Interventions included: All staff will wear a mask within 6 feet of resident, follow COVID-19 protocols and procedures. The Comprehensive Care Plan (CCP), dated 07/13/2022, titled: infection, status post [MEDICAL RECORD OR PHYSICIAN ORDER] . B) Resident #3 was admitted to the facility on [DATE] with the following medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3's Minimum Data Set (MDS) Assessment, dated 08/7/2022, documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Review of the facilities infection control policy, Hand Hygiene, dated 04/2018, documented Proper hand hygiene is required for the prevention of transmission of infectious diseases. Utilizing proper handwashing technique and appropriate use of hand sanitizer is a basic skill employees must possess. Policy: All personnel working in the long-term care facility are required to wash (sanitize)their hands before and after resident contact, after touching contaminated surfaces and when coming out of a room with posted precautions. Physicians' orders, dated 08/10/2022, documented an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Certified Nursing Assistant #2 (CNA#2) was observed on 08/25/2022 at 3:20 PM, to enter Resident #3's room and touch the bedside table. CNA#2 was then observed to exit Resident #3's room without performing hand hygiene and then proceeded to push a cart, with Styrofoam cups on top. Certified Nursing Assistant #1 (CNA#1) and CNA #2 were observed on 08/25/2022 at 3:30 PM. CNA#1 and CNA#2 entered Resident #2's room and provided care to Resident #2 without performing hand hygiene prior to entrance. Certified Nursing Assistant #2 (CNA#2) was interviewed on 08/25/2022 at 3:30 PM. CNA #2 stated they went into Resident #2's room and failed to wash or sanitize their hands before and after entry into the room. CNA#2 could not explain why they (CNA#2) did not follow facility policy on hand hygiene. Licensed Practical Nurse #1 (LPN #1) was interviewed on 08/25/2022 at 3:45 PM. LPN # 1 stated handwashing or hand sanitizing is required before and after coming out of the resident's room and after resident care. Licensed Practical Nurse #2 (LPN #2) was interviewed on 08/25/2022 at 3:49 PM. LPN #2 stated the staff should wash or sanitize hands before, and upon exiting the resident's room. Director of Nursing Services (DNS) was interviewed on 08/26/2022 at 1:24 PM. The DNS stated that hand hygiene should be performed before entrance of a resident's room and after removing Personal Protective Equipment. The DNS also stated staff are to wash hands or sanitize their hands in between glove changes. The Administrator was interviewed on 08/26/22 at 3:27 PM. The Administrator stated hand hygiene should be performed before and after care and in between resident service, and before and after room entrance and exit. RN #1 (Registered Nurse) was interviewed by telephone on 09/09/2022 at 11:15 AM. RN #1 stated they (RN#1) worked with DNS to educate staff to the facilities infection control protocols. RN #1 stated that CNA #1 and CNA #2, had been trained to perform hand hygiene upon hire. RN #1 stated the process to train staff was to first have staff understand and read the facility policies. Then to follow the policy/training provided. RN#1 stated handwashing competency was reviewed with facility staff, to wash hands for 20 seconds with soap and water or (hand sanitizer) along with return demonstration and included when hand hygiene was required. S483.80 (a) (1-3); (3)

Based on record review and staff interviews during the Recertification Survey the facility did not ensure that Drug Regimen Reviews were acted upon for each resident. This was identified for one (Resident #62) of seven residents reviewed for Unnecessary Medications. Specifically, Resident #62 had a Drug Regimen Review dated 12/29/19 that recommended a re-evaluation of the medications [MEDICATION NAME] ([MEDICATION NAME]) tablet and [MEDICATION NAME] (ointment), prescribed for Pruritis (itching), because these medications did not have stop dates. The response from the Physician did not address the pharmacist's concern regarding stop dates. The finding is: The facility's policy, dated 12/31/18, titled Drug Regimen Review, documented that the Attending Physician or Extender will address issues and document in the Electronic Medical Record (EMR) or the report within 14 days. Resident #62 has [DIAGNOSES REDACTED]. The 11/27/19 Admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident had moderately impaired cognition. The MDS also documented the resident had no skin problems. A Comprehensive Care Plan (CCP) effective 1/16/2020 titled Chronic Pruritis documented interventions to follow up with Dermatology as needed and to monitor the effectiveness of the treatment plan. A Dermatology consult dated 12/12/2019 documented the resident was seen by the Dermatologist due to a rash to the shoulders, back, abdomen, and left thigh. The medications prescribed were [MEDICATION NAME] 10 milligrams (mg), one tablet at bedtime, for 30 days; and [MEDICATION NAME] 0.1%, a small amount of ointment twice a day for 30 days. A physician's orders [REDACTED]. There was no stop date in the order. A physician's orders [REDACTED]. There was no stop date in the order. A Pharmacy Consult report, dated 12/29/19, documented that the resident was receiving the following medications without an end date: [MEDICATION NAME] ([MEDICATION NAME]) 10 mg every day and [MEDICATION NAME] 0.1% twice a day. The Pharmacist Consultant requested to re-evaluate, consider stop date/parameters on medications and evaluate and monitor efficacy and continuation of treatment. Review of the Pharmacy Consultation in the EMR did not reveal a response from the Physician. The Physician was interviewed on 1/16/20 at 1:29 PM. He stated he did have a conversation on 12/29/19 with nursing regarding the Pharmacy consult. He stated he did not put an end date on the medications because he was waiting for the resident to return to the Dermatologist, but he stated there was no date for the Dermatology appointment or an order for [REDACTED].>The Director of Nursing Services (DNS) was interviewed on 1/16/2020 at 2:35 PM. She stated the Physician electronically signed that he had seen the consult in the EMR on 12/29/2019, but the Physician did not provide a response. She stated that she had to call the doctor because the pharmacy recommendations were not addressed. She stated she hand wrote the discussion she had with the doctor on a printout of the pharmacy report. The DNS's hand-written statement on the 12/29/19 Pharmacy Consult was as follows: Signed off by Physician on 12/29/19. Discussed-disagree, was Dermatology recommendation. Continue with current treatment. The discussion with the Physician did not address stop dates for the medications. Review of the (MONTH) 2020 Medication Administration Record [REDACTED]. The Medical Director was interviewed on 1/21/20 at 10:56 AM. He stated that the Primary Physician might have misunderstood the question that was being asked by the pharmacist. He stated the end date for the medications should have been addressed. 415.18(c)(2)

Based on record review and interviews during the Recertification Survey the facility did not ensure that the Antibiotic Stewardship program included antibiotic use protocols and a system to monitor antibiotic use for 1 (Resident #22) of 2 residents reviewed for Urinary Tract Infection [MEDICAL CONDITION]/Catheter Use. Specifically, Resident #22 was prescribed [MEDICATION NAME] 100 milligrams (mg) from 6/14/19, and the antibiotic stewardship program did not have a [MEDICATION NAME] antibiotic use protocol in place. The finding is: The facility antibiotic stewardship program dated (MONTH) (YEAR) documented that the Infection Preventionist was the committee chairman. The antibiotic surveillance form communicates the affected resident, location in facility, date symptoms first noted, signs and symptoms, antibiotic ordered, and days of treatment. The stewardship program further documented that when placing orders, include microbiology cultures, and when cultures come back, take an antibiotic time out to determine if the antibiotic is still warranted and if it is effective against the organism. Resident #22 was admitted to the facility with the [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #22 had a Brief Interview for Mental Status (BIMS) Score of 3, indicating severely impaired cognition. The MDS documented that Resident #22 received an antibiotic 7 out of 7 days but did not have a [DIAGNOSES REDACTED]. The Urology consultation dated 6/14/19 documented that Resident #22 presented with a chief complaint of recurrent UTI. The Urologist recommendations included to attempt [MEDICATION NAME] 100 milligrams (mg) daily. The Urologist documented that the use of [MEDICATION NAME] may select [MEDICATION NAME] Resistant Bacteria. If Resident #22 has a symptomatic UTI during therapy, treat with [MEDICATION NAME] 250 mg for 5 days. The physician's orders [REDACTED]. The order was renewed on 7/12/19, 8/4/19, 9/23/19, 10/16/19, 11/8/19, 12/1/19 and 1/16/20. A nursing progress note dated 10/3/19 documented the Licensed Practical Nurse (LPN) spoke with the Physician (MD) at the family's request, the MD [MEDICATION NAME] mg twice a day for 5 days for [MEDICATION NAME] measures. Urine Specimen ordered for Urinalysis, Culture and Sensitivity (UA, C&S). Th physician's orders [REDACTED]. The RN Unit Manager was interviewed on 1/21/20 at 9:30 AM. The RN stated that Resident #22 has a history of frequent UTIs. The RN stated the resident was diagnosed with [REDACTED]. The RN stated the Urologist recommended daily [MEDICATION NAME] use of the antibiotic, [MEDICATION NAME], to reduce the recurrence of UTIs and to follow up in 1 year. The RN stated Resident #22 became symptomatic of a UTI on 10/3/19 and was [MEDICATION NAME] treatment. The RN stated Resident #22 was continuously given [MEDICATION NAME] 100 mg from 6/14/19 to present. The RN further stated Resident #22 did not have a time out period throughout the trial of antibiotic therapy. The Physician was interviewed at 1/21/20 at 10:30 AM. The physician stated that Resident #22 was prescribed [MEDICATION NAME] 100 mg to help reduce the frequency of UTIs. The Physician stated that Resident #22 presented with symptoms of a UTI in (MONTH) 2019, and the resident's family member advocated for continuing the [MEDICATION NAME]. The Physician stated that he felt that the [MEDICATION NAME] was effective in reducing the recurrence and decided to continue the therapy to the present day. The Infection Preventionist (IP) was interviewed on 1/21/20 at 11:13 AM. The IP stated that Resident #22 was not included in his antibiotic usage statistics because there is no facility-wide surveillance of [MEDICATION NAME] use of antibiotics. The IP stated the residents who were prescribed antibiotics for [MEDICATION NAME] reasons are only care planned for the use of antibiotics and monitored for signs and symptoms of active UTI at the nursing level. The IP stated that microbiology cultures are only obtained in the presence of symptoms of a UTI and time-out periods do not apply to residents who use antibiotics [MEDICATION NAME]. The IP stated only residents who have an active infection and use antibiotics are included in the facility-wide antibiotic surveillance. The IP stated that information about the residents who have an active infection is collected and presented during Quality Assurance (QA) meetings for review. The IP stated that Resident #22 was not included in the most recent Infection Surveillance Report presented to QA on 1/10/20. The antibiotic stewardship program plan does not specify a separate protocol for [MEDICATION NAME] antibiotic use. 415.19(a)(1-3)

Based on observation, staff interview, and record review during the Recertification Survey the facility did not ensure that residents with pressure ulcers received care consistent with professional standards of practice for 3 (Residents # 101, # 130, and # 344) of 3 residents reviewed for pressure ulcers. Specifically, 1) Resident #101 developed a Stage IV Pressure Ulcer (P/U) between the thumb and second finger of the left hand. There was no thorough assessment performed of the original open wound when initially identified. 2) Resident #130 was identified with a dry scabbed area to the left posterior ankle on 5/16/18 and there was no documented evidence that the wound was being monitored daily or a protective dressing applied until 5/20/18 when the area worsened and 3) Resident #344 was admitted to the facility with a Stage 2 pressure ulcer; however, the wound was not properly assessed until three days after admission. The findings are: The facility Policy and Procedure effective dated 5/2012 documents: #1.The RN will refer any resident who is at risk for skin breakdown to the wound care nurse or physician for determination of treatment regime. #6 the Skin Risk Assessment tool is the instrument used to assess and predict pressure ulcer risk. #8 Measurements are to be done by the Wound Care Nurse and Wound Care Physician or their designee. Treatment Guidelines include #1 All pressure ulcers noted on admission or newly developed must be reported to the Nurse Manager/Supervising RN. 1) Resident #101 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment documented the resident had a BIMS score of 8, indicating that the resident had moderately impaired cognition. The MDS documented the resident was totally dependent on staff for personal hygiene and bathing. The assessment documented that the resident was at risk for Pressure Ulcers and that there were no current unhealed Pressure Ulcers. A facility Pressure Ulcer Investigation dated 7/20/18 documented that a Stage II P/U was discovered on the resident's left thumb. The Braden Score was documented as 17, indicating that the resident was at moderate risk for P/U. The investigation lacked any further description of the wound. The physician's orders [REDACTED]. A Nurse's Note (N/N) dated 7/20/18 at 2:56 PM documented the resident was ordered [MEDICATION NAME] for the skin opening between the first and second digit of the left hand. The N/N did not document any further assessment of the wound. The Comprehensive Care Plan (CCP) titled, Actual Pressure Ulcer, dated 7/23/18, documented the resident had a Stage II Pressure Ulcer, location of the left thumb The CCP was not updated when the P/U was identified to have deteriorated to a Stage IV on 7/23/18. The Wound Report Sheet, completed by the Wound Care Nurse/Registered Nurse (RN), was completed by the Wound Care/RN on 7/23/18. The RN documented the left thumb was a Stage IV Pressure Ulcer measuring 1.0 X 0.5 X 0.3 centimeters (cm). The wound was described as moist with red wound bed and white tendon exposure. The N/N titled Wound Care dated 7/23/18 at 2:00 PM by the Wound Care/RN documented that the resident was assessed for the left hand wound with measurements of 1.0 X 0.5 X 0.3, with a small amount of drainage and red granular tissue with tendon visible. A Physician's Assessment/Progress Note dated 7/23/18 by the Physician's Assistant (PA) identified the resident with a new wound to the left thumb measuring 1 X 0.5 cm with visible tendons. The note documented a Stage IV to the left thumb and ordered Collagen to the wound. The physician's orders [REDACTED]. The Wound Care Physician (MD) assessed the resident's left thumb wound on 7/25/18 and documented a Stage IV Pressure Ulcer with 100 % tendon exposure. The Wound Care/RN was interviewed on 9/21/18 at 11:30 AM. The RN stated that the actual, complete assessment of the wound was done by the Wound Care/RN on 7/23/18. The Wound/RN stated that the wound could definitely have declined from a Stage II identification on 7/20/18 to the Stage IV identification on 7/23/18. The Wound Care/RN stated that the wound was first described as an open blister which would be a Stage II. The RN stated that she had not actually assessed the wound on 7/20/18 when it was documented as a Stage II, and when the tendon was visible on her assessment on 7/23/18 it was a Stage IV. The resident's attending Physician/MD was interviewed on 9/24/18 at 8:56 AM. The MD stated that the resident had significant potential for Pressure Ulcers. The MD Stated that the Physician's Assistant (PA) was called on 7/20/18 and initiated a telephone order based on the description given by the RN. The Director of Nursing Services (DNS) was interviewed on 9/24/18 at 9:35 AM. The DNS stated that the Wound Care/RN did the measurements and actually observed the wound on Monday 7/23/18. The resident's regular Certified Nurse Assistant (CNA) was interviewed on 9/24/18 at 11:42 AM. The CNA stated that the resident had splints since her admission and that they were being worn at all times during the month of (MONTH) (YEAR). The CNA stated that a different type of splint is being used and it is removed for hygiene and at night. The CNA stated that the resident had a piece of skin hanging off the thumb area and reported it to the nurse on Friday, 7/20/18. The covering RN who documented the only N/N on 7/20/18 was interviewed on 9/24/18 at 12:37 PM. The RN stated that the CNA reported the skin opening and that she, the RN, obtained the order but did not assess the wound. The Unit RN/Manager was interviewed on 9/25/18 at 11:08 AM. The RN stated that the P/U had not been staged by the Unit RN. The RN stated that she had done measurements, however, she does not stage P/Us and did not do any further assessment. The RN stated that she forwards information to the Wound Care/RN for assessment and staging and stated that the measurements were not documented in the medical record. The PA was interviewed on 9/25/18 at 11:24 AM. The PA stated that the RN/Manager called the PA on Friday, 7/20/18, and the RN was given a telephone order for the open area. The PA stated that when the resident was examined on Monday, 7/23/18, it was a Stage IV and the tendon was visible at the time. The PA then changed the order. The left hand wound between the thumb and left second finger has healed on observation on 9/25/18 at 9:50 AM. The DNS was interviewed on 9/26/18 at 2:08 PM. The DNS stated that an RN can measure the wound but only the Wound Care/RN or Physician will stage them. 2) Resident #130 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short term and long memory problems and was severely impaired for daily decision making. The resident required extensive to total assist of one to two staff members for all activities of daily living. The resident was at risk for pressure ulcers and had a Stage 4 pressure ulcer measuring 1.5 centimeter (cm) by 1.0 cm x 0.2 cm. A dressing change observation of the resident's left posterior ankle PU was conducted on 9/26/18 at 7:35 AM with LPN #5 and RN #1. The wound bed was noted with tendon exposure, was clean, and free of odor. There was no signs and symptoms of infection. A Comprehensive Care Plan (CCP) dated 2/16/18 documented the resident had potential for alteration in skin integrity. The goals were for the resident's skin to remain intact. Interventions included to turn and position the resident every 2-4 hours and as needed (PRN). A Braden Scale dated 5/11/18 documented a Score of 12 which indicated the resident was at high risk for pressure ulcer development. A Nurse's note dated 5/16/18 at 2:15 PM titled Wound Care documented the left posterior ankle was noted with a dry tan-brownish scab. The edges were intact, the upper aspect was reddened, and the dorsal aspect was swollen but no redness was noted. The left lower extremity was contracted and a dry protective dressing (DPD) was applied. A Pressure Ulcer Investigation dated 5/16/18 documented an Unstageable Pressure Ulcer (PU) to the resident's left posterior ankle. New interventions included to apply Moisture barrier cream every shift, treatment daily as per order; pressure relieving mattress, cushioned calf and foot board, turning and positioning every two hours and to off load the heels. The preventative measures in place prior to the PU discovery were pressure relieving device, highback wheel chair with calf board and foot rest. The conclusion section of the investigation was not completed regarding why the PU was unavoidable. A Wound Report Sheet dated 5/16/18 documented an unstageable PU to the left posterior ankle measuring 2.1 centimeter (cm) x 1.8 cm x 0 cm. The wound bed was 100% black and the wound margins were reddened. The current treatment was a DPD. A CCP dated 5/16/18 documented a PU to the left posterior ankle. The goal was for left ankle to demonstrate healing x 60 days. Interventions included treatment as ordered, and turn and position program every 2-4 hours and PRN. A physician's orders [REDACTED]. A Wound Report Sheet dated 5/24/18 documented a Stage III PU to the resident's Left posterior Ankle measuring 2.0 cm x 1.5 cm x 0.2 cm. The wound bed was 100% red. A Wound Report Sheet dated 5/30/18 documented a Stage IV PU to the resident's left posterior ankle measuring 2.5 cm x 1.2 cm x 0.2 cm. The wound bed was 10% red and with tendon exposure. Review of the physician's orders [REDACTED]. A Review of the Treatment Administration Record (TAR) dated (MONTH) (YEAR) revealed from 5/16/18 to 5/19/18 there was no documented evidence that a DPD was ordered or being administered to the resident's Left Achilles. A review of the resident's medical record lacked documented evidence that the Physician was notified of the resident's alteration in skin integrity on 5/16/18. A Certified Nursing Assistant Assignment and Accountability Record (CNAAAR) dated (MONTH) (YEAR) was reviewed and lacked documented evidence of preventative pressure ulcer measures for the resident's feet. The record also lacked documented evidence that turning and positioning and checking the resident's skin was included in the resident's plan of care prior to 5/16/18. On 5/18/18 padding was added to the resident's foot cradle. The CNAAAR dated (MONTH) (YEAR) to (MONTH) (YEAR) documented bilateral heel boots while in bed, and to off load the resident's heel while in bed and in a chair. The CNAAAR also documented to monitor the resident's skin integrity, to report changes to the nurse, and to turn and position the resident every two hours. The CNAAAR dated 8/2018 to 9/2018 documented to turn and position the resident every two hours, pillows between bilateral lower extremities. During an interview conducted on 9/24/18 at 3:38 PM with the Wound Care Registered Nurse (RN #1), she stated the staff nurse brought to her attention that the resident had a dry scab on her left ankle. The RN stated that she assessed the wound and at the time of the assessment the wound was unstageable and a dry protective dressing (DPD) was applied. The RN stated after the assessment she discussed the findings and the treatment plan with the unit staff nurses and that she or the unit nurses could have notified the Physician to obtain an order. The order is then entered into the electronic medical record. The RN stated that she did not notify the Physician of the Unstageable Pressure Ulcer (PU) and that she believed the Unit Manager had notified the Physician. The RN further stated that the treatment plan was a DPD daily and that there should have been a physician's orders [REDACTED]. During a subsequent interview conducted on 9/26/18 at 2:53 PM with RN #1, she stated that heel float booties, turning and positioning (T/P), pillows to aid in positioning and a pressure relief (Gravity-7) air mattress were in place prior to the identification of the wound on 5/16/18. The RN further stated that after the wound was identified extra padding was initiated on the resident's calf board. During an interview conducted on 9/24/18 at 3:51 PM with RN #2 Unit Manager, she stated that it was brought to her attention by the treatment Licensed Practical Nurse (LPN) on 5/16/18 that there was a scabbed area to the resident's left ankle. The RN stated after she assessed the resident's left ankle she notified the wound care nurse but did not document her assessment. The RN stated after discussing the treatment plan with the Wound Care nurse an order should have been obtained and then entered into the electronic medical record by the LPN treatment nurse. The RN stated that she did not notify the Physician of the Unstageable PU; however, she was responsible for notifying the Physician after the wound was identified. During an interview conducted on 9/25/18 at 11:22 AM with the day shift medication Licensed Practical Nurse (LPN #2), she stated that on 5/16/18 the CNA brought to her attention during morning care that the resident had a scabbed area to the left ankle. The LPN stated that she went with the CNA to the resident's room and observed a scabbed area to the resident's left ankle, then she went and notified the charge RN. The LPN stated that she was not the treatment nurse on 5/16/18, but happened to be down the hall when the CNA brought the change in the resident's skin integrity to her attention. The LPN further stated that she did not notify the Physician regarding the change in the resident's skin integrity and did not know who did. During an interview conducted on 9/25/18 at 11:33 AM with CNA #2, she stated that she was the resident's caregiver for the last nine months. The CNA stated that every day at the start of her shift she checks the resident's skin and if something was wrong she reports it to the nurse. The CNA stated that the first time she saw a change in the resident's skin was on 5/16/18 when she saw a little sore and she reported it to the nurse. The CNA stated the resident gets out of bed every day on her shift and the resident wears a non-skid sock; however, on the night shift she wears heel booties. During an interview conducted on 9/25/18 at 1:10 PM with the Physician, he stated the resident was identified with a scab on 5/16/18. The area opened on 5/20/18 and treatment was started. The Physician stated that he was notified in passing about the scabbed area to the resident's left ankle but things are not always written down. He stated that he did give an order for [REDACTED]. The Physician stated that his expectation is that orders given are entered into the computer and are administered to the resident. The Physician stated the resident's PU was not addressed in his note until his monthly note in June. During an interview conducted on 9/26/18 at 7:59 AM with the treatment LPN #5, she stated that she was not on duty 5/16/18 when the wound was identified; however, once a physician's orders [REDACTED]. The LPN stated that she was the treatment nurse on duty on 5/17/18 and 5/18/18 but was not involved in applying a DPD to the resident's left foot. The LPN stated not until an order is in place does she administer treatment for [REDACTED]. The LPN stated that an order is required for a DPD and that it is transcribed in the TAR to be carried out by the nurses. During an interview conducted on 9/26/18 at 8:12 AM with the treatment LPN #6, she stated that she was on duty when the PU was identified to the resident's left ankle; however, the resident was seen by the wound care RN. The LPN stated that on 5/16/18 a DPD was applied to the resident's left ankle and that she believed the resident was receiving a DPD daily until the wound opened. The LPN stated that she was on duty on 5/19/18 and that she was sure she applied a DPD to the resident's left foot. A review of the TAR dated 5/2018 with the LPN present, lacked documented evidence that a DPD was being applied to the resident's left ankle. The LPN then stated that she could not give a definitive answer that she applied a DPD to the resident's ankle. During an interview conducted on 9/26/18 at 2:03 PM with the DNS, she stated that she could not say why the wound to the resident's left ankle was not identified prior to an unstageable pressure ulcer. The DNS stated that the resident's skin was checked daily by the CNAs and a verbal report is given to the charge nurse if there are any changes in skin integrity. The DNS stated that on 5/16/18 a DPD was applied to the resident's left ankle and that an order for [REDACTED]. 3) Resident #344 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 9/21/2018 Admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 4, indicating the resident was severely cognitively impaired. The MDS documented that the resident had one Stage 2 pressure ulcer present on admission. A CCP titled Actual Ulcer/Wound, with an initiated date of 9/14/2018, documented the resident was admitted with a Stage 2 sacral pressure ulcer. The body illustration in the initial nursing assessment, dated 9/14/2018, documented that the resident had a small open area to the left buttock area and blanchable redness to the right buttock. There was no information in the ulcer assessment section (type, site, stage, length, width, or depth). The admission nursing note, dated 9/14/2018 at 9 PM, written by the 3 PM-11 PM admission nurse, documented that the resident had a small open area to buttocks. The note did not indicate what type of wound it was, which side, and did not include any other assessment information regarding the wound. A physician's orders [REDACTED]. The wound care RN's progress note, dated 9/17/2018, documented Stage 2 small open area at sacral area, size 0.8 x 0.4 x 0.1, red, periwound skin intact, pink in color. The wound treatment was observed on 9/21/2018 at 8:44 AM. The treatment was performed by the LPN treatment nurse who was assisted by the RN wound care nurse. There was a reddened area that extended from the sacrum to the upper left buttock and there were two separate areas of open skin, approximately 1 cm x 1 cm, each within the reddened area. There were no signs and symptoms of infection. The wound care RN was interviewed on 9/21/2018 at 10:11 AM. She stated that the first time she assessed the wound was on 9/17/2018 (Monday) and there was only one open area of skin. She stated it was a Stage 2 pressure ulcer. When asked about the two open areas of skin that were observed during wound care, she stated she was not at the right vantage point during wound care to confirm the two open areas, but in her opinion the area was improving. The admission RN was interviewed on 9/24/2018 at 9:06 AM. She stated she should have elaborated more on the wound assessment and that she did not think it was a pressure ulcer. The wound care RN was re-interviewed on 9/24/2018 at 9:35 AM. She stated she created the Actual Ulcer/Wound CCP on 9/17/2018. She stated the care plan initiation date of 9/14/2018 indicated the onset of the wound. She further stated she did not see the resident on 9/14/2018. The Director of Nursing Services (DNS) was interviewed on 9/24/2018 at 1:30 PM. She stated that the admission nurse could have done a more thorough assessment, and that it was not routine policy for the admission nurse to size the wound. In addition, she stated the Actual Ulcer/Wound care plan initiation date should have been 9/17/2018. 415.12(c)(1)

Based on observation, record review and staff interviews during the recertification survey, the facility did not develop a Comprehensive Care Plan (CCP) for a resident with limited Range of Motion of the lower extremities. This was evident for one of three residents reviewed for Accidents/Falls. Specifically, Resident # 56 was observed with contractures of both lower extremities. There was no CCP developed with specific goals and interventions addressing the contractures. The finding is: The facility policy titled Comprehensive Care Plans (CCP) and Resident/Patient meeting effective 11/17 .2 Section 1-The purpose of the assessment is to accurately communicate the resident's capability to perform daily life functions and to identify significant impairments in functional capacity and the plan suggested by the CCP team for improvement/maintenance for each of the resident's primary care issues. Resident # 56 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) Score of 6, indicating severe cognitive impairment. The MDS documented that the resident required the assistance of two staff members for bed mobility, was totally dependent on two staff members for transfers, and was non- ambulatory. The resident had impairment in Range of Motion (ROM) on both sides of the lower extremities. The Rehab Screening form dated 2/9/18 documented that the resident had limited ROM of both sides of lower extremities with limitations in knee extension and contractures of both ankles. The Certified Assistant Assignment and Accountability Record for (MONTH) (YEAR) did not include ROM instructions as part of the CNA assignment. An Annual Rehab Screening dated 8/9/18 documented that the resident had limitations in ROM with limited extension of both knees and contractures of the lower extremities. The Activities of Daily Living CCP, dated 8/3/18 and updated on 8/17/18 and 9/8/18 did not include the limitations in ROM of the lower extremities. In addition, there was no mention of the contractures nor any plan to prevent further contractures. The resident was observed on 9/19/18 at 9:45 AM. The resident was in a low bed with both legs visibly contracted. A second observation was made on 9/19/18 at 12:30 PM. The resident was observed in the dining room, positioned in a high back recliner with side support. Both legs were visibly contracted and the resident was leaning on left side. The Unit Manager/Registered Nurse (RN) was interviewed on 09/26/18 at 10:13 AM and stated the resident can move her upper body at times. The RN further stated that the CCP addressing the resident's mobility should have included the contractures. The Director of Nursing Services (DNS) was interviewed on 9/26/18 at 11:14 AM. The DNS stated that the facility does not have a specific CCP for contractures. The DNS stated that the resident's contractures should have been addressed by the team. The Director of Rehabilitation was interviewed on 9/26/18 at 12:28 PM and stated that the resident's plan of care is reviewed by the entire team for each care area. 415.11(c)(1)

Based on record review and staff interview during the Recertification Survey, the facility did not ensure that for 1 (Resident # 113) of 5 residents reviewed for Unnecessary Medications 1) non-pharmacological interventions were documented prior to the administration of a PRN (as needed) [MEDICAL CONDITION] drug ([MEDICATION NAME]). In addition, 2) the resident's antipsychotic medication ([MEDICATION NAME]) was doubled on the second day after the resident was admitted to the facility without documented clinical indications for the increase. The finding is: Resident #113 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The 30-day Minimum Data Set (MDS) assessment dated [DATE] documented that the resident was rarely/never understood and could rarely/never understand. The resident also had severely impaired cognitive skills for daily decision making with long and short term memory problems. The resident received Antipsychotic and Antianxiety medications. 1) The Physician order [REDACTED]. The Physician order [REDACTED]. The Physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. The Nurse's Notes dated 8/9/18 at 2:00 PM, 8/10/18 at 2:00 PM, 8/11/18 at 2:00 PM, 8/12/18 at 2:00 PM, and 8/13/18 at 1:00 PM documented that the prn [MEDICATION NAME] was administered due to the resident having frequent verbal outbursts. There were no non pharmacological interventions documented prior to the administration of the [MEDICATION NAME]. The Licensed Practical Nurse (LPN #3) Medication Nurse who administered the prn [MEDICATION NAME] on 4 occasions on the 7:00 AM-3:00 PM shift on 8/9/18, 8/11/18, 8/12/18, and 8/13/18 was interviewed on 9/24/18 at 11:30 AM. LPN #3 stated that when the resident would have verbal outbursts she would try to give the resident something to eat because she liked to eat. LPN #3 stated that she would ask the resident what was wrong, but the resident could not describe what was the matter. LPN #3 also stated that she should have written in the Nursing Notes what non pharmacological interventions she had done prior to administering [MEDICATION NAME]. The LPN (LPN #4) Medication Nurse who administered the prn [MEDICATION NAME] on the 7:00 AM-3:00 PM shift on 8/10/18 was interviewed on 9/24/18 at 11:45 AM. LPN #4 stated that when the resident would have verbal outbursts she would offer her something to eat or play music on her CD player for her. LPN #4 stated she had been inserviced on documenting non-pharmacological interventions before administering a [MEDICAL CONDITION] ([MEDICATION NAME]). LPN #4 stated that she guessed it was a mishap that she had not. The Director of Nursing Services (DNS) was interviewed on 9/24/18 at 1:30 PM. The DNS stated that she would expect the Nurses to document what non-pharmacological interventions were done prior to giving the resident the prn [MEDICATION NAME]. 2) The Physician order [REDACTED]. This order was discontinued (d/c'd) 8/8/18. The [MEDICAL CONDITION] Medication Comprehensive Care Plan (CCP) dated 8/7/18 documented under Interventions: Behavior modification techniques and non-pharmacological interventions attempted prior to implementing standing/prn [MEDICAL CONDITION] medications. The Physician order [REDACTED]. This order was d/c'd on 8/9/18. The Physician order [REDACTED]. The Initial Psychiatric Evaluation dated 8/9/18 documented that the resident screamed almost continuously and other residents complained about it. The evaluation also documented that the resident's family member informed the Physician Assistant (PA) that the resident had been taking 5 mg of [MEDICATION NAME] three times daily at home. The Psychiatrist was interviewed on 9/24/18 at 1:55 PM and stated that he doubled the resident's dose of [MEDICATION NAME] on her second day in the facility based on what she had been taking at home and that other resident's were complaining about her screaming. On 9/26/18 at 3:30 PM the facility's Physician Assistant (PA) was interviewed and stated that the resident's family member was concerned about the resident's yelling and wanted her back on the 5 mg dosage that she was on at home. 415.12(l)(2)(i)

Based on record review and staff interviews during the Recertification Survey the facility did not ensure that, in accordance with accepted professional standards and practices, medical records were accurately documented, for one (Resident #195) of one resident reviewed for non-respiratory or non-urinary infections. Specifically, Resident #195 has a peripherally inserted central catheter (PICC), which requires a Registered Nurse (RN) to change the dressing. Review of the (MONTH) (YEAR) treatment administration record (TAR) revealed the dressing change was being incorrectly signed by a Licensed Practical Nurse (LPN) rather than the RN when the dressing was changed. The finding is: Resident #195 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 9/17/2018 Admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 7, indicating the resident was severely cognitively impaired. The MDS documented that the resident was receiving intravenous (IV) medications. The initial nursing assessment, dated 9/10/2018, documented that the resident had a PICC in his right arm. A comprehensive care plan (CCP) titled IV Therapy/IV Meds, dated 9/10/2018, documented that the resident was receiving IV medications for [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Additional physician's orders [REDACTED]. Review of the (MONTH) (YEAR) TAR revealed a LPN signed on 9/15/2018 and 9/22/2018 for the weekly PICC line dressing change. The LPN whose initials appeared on the TAR for both weekly PICC line dressing changes was interviewed on 9/25/2018 at 2:40 PM. She stated she did not change the PICC dressing. She stated she thinks the RNs who did the dressing changes signed for it using the LPN's computer login. A RN who worked on 9/22/2018 was interviewed on 9/26/2018 at 9:50 AM. She stated she changed the PICC dressing on 9/22/2018. She stated she may have thought that she was logged in, or the screen must have been left open and she signed inadvertently thinking that it was her login screen. The RN who did the PICC dressing changes on 9/15/2018 was unavailable. The Director of Nursing Services (DNS) was interviewed on 9/26/2018 at 11:46 AM. She stated the LPN has to make sure she signs out of her computer after she is done, and everyone has to sign in to the computer under their own name. 415.22(a)(1-4)

Based on observation, record review and staff interviews during the recertification survey, the facility did not ensure that medical records were accurately documented. This was evident for 1 of 1 resident reviewed for death (Resident #293) and two of three residents reviewed for Urinary Incontinence (Resident's #119 and #168), in a total Stage 2 sample of 17 residents. Specifically, 1) Resident #293's, Physician's Assessment/Progress Note lacked complete documentation reflecting the resident's Advance Directives, Date of Birth, Consultations, Laboratory results and Room Number. 2) Resident #119 was identified to have a decline in bladder function from always continent to frequently incontinent and there was no documented evidence that a physician's bladder assessment was completed to determine the cause/type of the decline. 3) Resident #168 was identified to have a decline in bladder function from occasionally incontinent to always incontinent and there was no documented evidence that a physician's bladder assessment was completed to determine the cause/type of the decline. The findings are: 1) Resident #293 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. A Hearing/Speech/Language/Dysphasia Screening Form Consultation dated 2/9/17 was completed. A Do Not Resuscitate (DNR) form was signed and in effect by the resident on 2/17/17. laboratory results dated [DATE] were completed. A Physician's Assessment/Progress Note dated 2/22/17 had no documented evidence that the resident had a DNR order. There was a space under the title of Advance Directives that could have been checked by the Physician but was blank. Additionally, the Physician's assessment/Progress Note had missing information regarding the resident's Date of Birth, Weight, Room Number, Consultations and Laboratory test results. An interview was held with the Director of Nursing Services (DNS) on 4/7/17 at 10:30 AM. The DNS reviewed the Physician's Assessment/Progress Note dated 2/22/17 and stated that there was missing information and that the form should be filled out completely by the Physician. The Physician was not available for interview. 2) Resident #119 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A 5-day Admission Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #119 had clear speech, could understand and be understood. The resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating that Resident #119 was cognitively intact. The resident required extensive assistance of two staff members for toileting and was always continent of bladder. The Nursing Admission Evaluation, Comprehensive Admission Assessment (CAA) section 6 Urinary Incontinence dated 1/11/2017 documented under the Comment section that Resident #119 was continent of bladder. A Readmission Significant Change MDS assessment dated [DATE] documented the resident's continency status had declined and the resident was now frequently incontinent of urine. The Nursing Admission Evaluation, CAA section 6 Urinary Incontinence dated 2/28/2017 documented under the Comment section that Resident #119 had a significant change in continence and was frequently incontinent of bladder. The Physician's Assessment/Progress notes dated 1/28/2017 through 4/2/2017 were reviewed. The notes did not address the change in the resident's continence status. An interview was conducted on 04/05/2017 at 10:11 AM with the Certified Nursing Assistant (CNA) who cares for Resident #119. The CNA stated that since the resident returned from the hospital he has been incontinent, but has improved a great deal, since he is in less pain. The CNA stated that the resident can tell her when he needs to use the toilet and has accidents only occasionally, sometimes in his sleep. An interview was conducted with the Minimum Data Set (MDS) Registered Nurse (RN) on 04/07/2017 at 9:45 AM. The RN stated that she completes the MDS for the 2 West unit and was familiar with Resident #119. The RN stated that the resident had triggered for a significant change MDS when he returned from the hospital due to a change in continence. The RN stated that either she or the RN Unit Manager would update the Comprehensive Care Plan (CCP) to reflect the resident's current status. The RN was not aware if the physician had a form for bladder assessment to determine the type of incontinence. An interview was conducted with the resident's Primary Care Physician on 04/07/2017 at 1:00 PM. The Physician stated that he would document in the residents' progress note the resident's continence status, and that it must have been an oversite if not there. The Physician stated that without the chart he could not say what he had written on the assessment/progress note form. The Physician stated that he was not sure if there is a form or a section on the assessment form that was specific to a resident's continence status and that they (the facility) would have to review the documentation they use for assessment of the residents so they can include the continence status, reason for incontinence and potential of the residents to regain continence. 3) Resident #168 had [DIAGNOSES REDACTED]. Resident #168 was admitted to the facility on [DATE], and was readmitted to the hospital on [DATE] to Rule Out a GI (Gastrointestinal) bleed. The resident was readmitted to the facility on [DATE], then discharged to the hospital on [DATE] for a blood transfusion and was readmitted to the facility on [DATE]. The resident was discharged home on[DATE]. The Initial Nursing assessment dated [DATE] documented that Resident #168 was incontinent of urine. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #168 had clear speech, could understand and be understood. The resident had a Brief Interview for Mental Status (BIMS) score of 14 indicating that Resident #168 was cognitively intact. The resident required extensive assist of one staff person for toilet use. The resident was occasionally incontinent of urine. The Significant Change MDS dated [DATE] documented that Resident #168 had a BIMS score of 13 indicating that the resident was cognitively intact. The resident required extensive assist of one staff member for toileting and the resident was now always incontinent of urine. The Nursing Admission Evaluation, CAA section 6 Urinary Incontinence dated 12/19/2016 documented that Resident #168 had been incontinent of bladder since re-admission and that the resident was placed on a bladder schedule. The physician progress notes [REDACTED]. Review of the Physician Assessment/Progress Note form does not include an assessment of continence. The Physician Admitting/Annual History and Physical dated 12/12/2016 documented the GU ([MEDICAL CONDITION]) system section as normal. There was no area on the form that documented the resident's continence status. The Physician's Assessment/Progress notes dated 12/14/2016 through 2/8/2017 were reviewed. The notes did not include an assessment of the resident's continence status. An interview was conducted with the Registered Nurse (RN) Director of Nursing Service (DNS) on 04/07/2017 at 11:20 AM. The DNS stated that she was sure that the physician's assess the resident's continence status. The DNS did not state if the physician assessment would be documented in the medical record. An interview was conducted with the resident's Primary Care Physician on 04/07/2017 at 12:33 PM. The Physician stated that he recalled Resident #168 and that the resident went home to reside with her son. The Physician stated that he discusses the resident's continence status with the nursing staff and knows that the staff have a plan of care for the residents. An interview was conducted on 04/07/2017 at 12:47 PM with the RN unit manager of unit that Resident #168 had resided on. The RN stated that she was not aware of a specific form that the physician uses for continence assessment, but that the physician does sign off on the resident's care plan meeting minutes. 415.22(a)(1-4)

Based on record review and staff interview during an abbreviated survey the facility did not ensure that the necessary care and services to attain and maintain the highest practicable physical, mental and psychosocial well-being were provided for three of three residents reviewed for Quality of Care. Specifically, 1) Resident #1 was transported to a [MEDICAL TREATMENT] center that was not his usual [MEDICAL TREATMENT] center and received a [MEDICAL TREATMENT] treatment that was not his treatment. 2) Resident #2 was scheduled for a [MEDICAL TREATMENT] treatment at 5:00 AM and did not receive his treatment until 6:30 PM, after the resident brought it to staff attention and 3) Resident #3 had a Perma Cath in the right chest wall that was not being monitored on a consistent basis. This resulted in no actual harm with a potential for minimal harm that was Immediate Jeopardy and Substandard Quality of Care to resident health and safety. The Immediate Jeopardy was removed on [DATE] prior to the completion of the survey. The facility put corrective measures in place prior to the exit. Complaint #NY 9302 The Findings are: 1) Resident #1 is a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was admitted to the facility for Short Term Rehabilitation status [REDACTED]. Physician order [REDACTED]. - [MEDICAL TREATMENT] Lab on M/W/F of the week. - Type of access: Perma -Cath Right chest wall. -Schedule: Every week on Monday-Wednesday-Friday at 5:00 AM. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #1 had a Brief Mental Status Score of 13 indicating that the resident was cognitively intact. The MDS also documented that the resident received [MEDICAL TREATMENT] treatments. The Comprehensive Care Plan dated [DATE] titled [MEDICAL TREATMENT] documented as the problem :End Stage [MEDICAL CONDITION] evidenced by [MEDICAL TREATMENT] 3 times weekly. [MEDICAL TREATMENT] port to Right Chest/Neck. Interventions included but were not limited to: - Monitor vital signs on return from [MEDICAL TREATMENT] -Record resident pre/post [MEDICAL TREATMENT] weight on return from center - Check access site for bleeding, swelling, redness, infection etc. - Review comments in communication log book and take appropriate actions as indicated -Maintain ongoing dialogue with [MEDICAL TREATMENT] center - [MEDICAL TREATMENT] Days: Mon/Wed/Fri. Review of the [MEDICAL TREATMENT] Communication Book for Friday [DATE] documented: 5:00 AM Patient #1 left for [MEDICAL TREATMENT] in stable condition with care of the transportation company. Vital Signs (VS) were documented, a notation that medication was administered and that a sandwich was sent with the patient. There was no documentation from the [MEDICAL TREATMENT] center post treatment. The [MEDICAL TREATMENT] Communicating Book stated on the front cover the days and hours the resident attends [MEDICAL TREATMENT]. The information is repeated on the inside front cover, and also includes the name of the [MEDICAL TREATMENT] center. The Nursing Progress Notes (NPN) dated [DATE] documented at 5:00 AM that the resident left for [MEDICAL TREATMENT] stable in care of the transportation company. The NPN documented at 3 PM on [DATE] that the resident was noted to have some confusion and lethargy. Vital signs were B/P (blood pressure) ,[DATE], Temperature (T) 98.2, Heart Rate (HR) 62, and Respiratory Rate (RR) 22. The NPN also documented that the Physician Assistant was notified of the residents confusion after return from [MEDICAL TREATMENT]. The NPN documented that the resident stated he was just tired. A progress note at 9 PM documented that Resident #1 vital signs were B/P ,[DATE], P (Pulse) 74, R (Respiratons) 18, and that he had no s/s (signs/symptoms) of confusion. A subsequent progress note dated [DATE] documented the resident's vital signs were B/P ,[DATE], P 104, R 18, PO2 (pulse oximetry) 95%. The NPN also documented that the [MEDICAL TREATMENT] shunt was monitored and that the resident left for [MEDICAL TREATMENT] at 4 AM as per MD order. The NPN dated [DATE] at 11:30 AM documented that the resident returned from [MEDICAL TREATMENT], vital signs were monitored, medications were administered Will continue to monitor. On [DATE] at 3:30 PM the NPN documented by the evening Registered Nurse (RN) Nursing Supervisor that Resident #1 was taken this morning to an alternate [MEDICAL TREATMENT] center. Patient received [MEDICAL TREATMENT] at the wrong facility, on the wrong day for another patient by the same name. Patient informed of error, Medical Doctor informed. STAT CBC, CMP ordered, Vital Signs monitored. Patient reported feeling fine. The NPN documented at 10 PM that the labs returned no significant change from previous labs. Physician Assistant aware. Patient alert and verbal. No distress noted at this time Vital signs documented. The resident reported feeling fine. Review of Laboratory values dated [DATE] obtained at 4:05 PM documented that the resident's Potassium level was within normal limits. On [DATE] at 11:45 PM the NPN documented that the patient noted to call for assistance, Certified Nursing Assistant (CNA) reported to room. Patient complained of difficulty breathing. CNA reported to nurse. When CNA and Licensed Practical Nurse (LPN) returned to room patient was nonresponsive. No respirations, no pulse, no blood pressure obtained Cardiopulmonary Resuscitation 911 called, AED applied started to have spontaneous breathing, Emergency Medical Staff (EMS) arrived the patient coded a second time and CPR was initiated by EMS. patient transported to Hospital emergency room . MD aware, daughter aware. A NPN dated [DATE] at 2 AM documented that the resident was admitted to at 12:50 AM with [DIAGNOSES REDACTED]. During a subsequent interview with the Director of Nursing Service and the Administrator on [DATE] they acknowledged that Resident #1 expired in the hospital a few days following the transfer. On [DATE] at 1:00 PM the Registered Nurse (RN) who works at the [MEDICAL TREATMENT] center that Resident #1 normally attends was interviewed. The RN familiar with Resident #1 stated that Resident #1 had been coming to the center for a long while and that the center has to keep a close eye on him due to noncompliance. The RN stated that the resident record revealed that he received a treatment on Friday [DATE] that lasted 179 minutes (2 hours, 59 minutes) and that his usual treatment is 4 hours. The RN stated that there was no documentation in the record or on the schedule that the resident was to return to the center on [DATE] for a second treatment. The RN stated that the communication log books are not always accurate and that if there was important information to relate to the nursing home the [MEDICAL TREATMENT] center would call. The RN stated that the Nephrologist sees Resident #1 weekly to reevaluate his treatment. The RN stated that he was not aware that the resident was in the hospital or that he had received a treatment at an alternate [MEDICAL TREATMENT] center. On [DATE] at 1:20 PM the RN Clinical Manager at the [MEDICAL TREATMENT] center that Resident #1 was transported to on [DATE] was interviewed. The Manager stated she was familiar with the situation that had occurred on Saturday [DATE] and the facility (the [MEDICAL TREATMENT] center) made an error. The Manager stated that they were expecting a new resident by the same name as Resident #1. The clinical manager stated the resident they expected was coming to the center for his first treatment out of the hospital. She stated that staff at the [MEDICAL TREATMENT] center did not follow protocol, which is to confirm the resident's name and date of birth. She stated that the staff only confirmed the resident's name. The Manager further stated that the Charge Nurse at the [MEDICAL TREATMENT] center received a call from the Nursing Supervisor at the resident's nursing facility on Saturday [DATE] at approximately 2:00 PM stating that the wrong resident had been sent in the morning for a [MEDICAL TREATMENT] treatment. The manager stated that the Director of Operations and the Medical Director were contacted and arrangements were made for the other resident (Resident #2) to come in later that day for a [MEDICAL TREATMENT] treatment. An interview with the Registered Nurse Manager (RNM) 7:00 AM- 3:00 PM shift was conducted on [DATE] at 3:00 PM. The RNM stated that she had worked Friday [DATE] and that she was familiar with Resident #1. The RNM stated that the resident had returned from a [MEDICAL TREATMENT] treatment on Friday [DATE] at approximately 11:30 AM. The RNM stated that the resident complained of being cold and tired. She stated that she called the [MEDICAL TREATMENT] center to check what Resident #1's vital signs were when he finished his treatment. The RNM stated that the [MEDICAL TREATMENT] center nurse did not state that the resident was scheduled to return to the center the next day. On [DATE] at 2:20 PM an interview was conducted with the Licensed Practical Nurse (LPN) that worked the 3:00 PM -11 PM shift and the 11:00 PM to 7:00 AM shift on [DATE]-[DATE]. The LPN stated that she was familiar with Resident #1 and that she worked the 3:00 PM to 11:00 PM and the 11:00 PM to 7:00 AM shift on Friday [DATE] into Saturday [DATE]. The LPN stated that she received a call from the transportation company stating that they were coming to the facility for a 4:00 AM pick-up for Resident #1 to transport him to [MEDICAL TREATMENT]. The LPN stated the resident had in the past had a second [MEDICAL TREATMENT] treatment so she didn't think that it was unusual for him to be picked up. She further stated that the Certified Nursing Assistant reported to her that the resident told her he had gone to [MEDICAL TREATMENT] Friday morning and that his center does not open that early. The LPN reported what the resident said to the nursing supervisor and also asked the supervisor to bring up a breakfast for the resident to take with him to [MEDICAL TREATMENT]. The LPN stated that the resident left with transportation at 4:00 AM. She further stated that the resident called the facility between 4:30 and 5:00 AM to report he was at the wrong [MEDICAL TREATMENT] center. He then called a second time and spoke with the Nursing Supervisor . The LPN stated that the Nursing Supervisor informed her that the [MEDICAL TREATMENT] center had information on the resident. The LPN stated that she did not check with Resident # 1's actual [MEDICAL TREATMENT] center and that she was not aware that there were two residents in the facility with the same name. An interview with the 11:00 PM to 7:00 AM Certified Nursing Assistant (CNA) who worked on [DATE] -[DATE] with Resident #1 was conducted on [DATE] at 4:30 PM. The CNA stated that the LPN asked her to inform Resident #1 that he would be picked up for [MEDICAL TREATMENT] on [DATE] at 4:00 AM. The CNA stated that the resident told her he had gone to [MEDICAL TREATMENT] this morning (Friday AM) and that his regular schedule was Monday-Wednesday-Friday and also that the [MEDICAL TREATMENT] center he goes to does not open that early in the morning. The CNA stated she reported what the resident told her to the LPN on duty. The LPN contacted the Nursing Supervisor and the CNA was instructed to let the resident know he should be ready for transportation at 3:45 AM. The CNA then stated that Resident #1 came up to the nurses desk at 3:55 AM, received his medications and again stated that the [MEDICAL TREATMENT] center doesn't open at 4:00 AM. At that time the transportation company was present and the CNA heard the driver state that he transports every day and the [MEDICAL TREATMENT] center is open at 4:00 AM. The CNA stated that the resident left with the transportation company. The CNA stated she was not aware there was a second resident in the facility with the same name (Resident #2) as Resident #1. The CNA stated that there is a name alert policy, and that an orange sticker is on the residents chart and written in red on the Certified Nursing Assistant Accountability Record (CNAAR). The CNA stated that she did not recall seeing a name alert for Resident #1. The 7:00 AM-3:00 PM LPN who worked Saturday [DATE] was interviewed on [DATE] at 7:10 PM. The LPN stated that Resident #1 returned from [MEDICAL TREATMENT] on Saturday at 11:35 AM. The LPN stated that she was a float nurse and had worked with Resident #1 on two other occasions. She stated that the resident was tired when he returned from [MEDICAL TREATMENT], that she had difficulty getting the resident's pulses so she called the supervisor. The LPN stated that she saw the resident on medication pass around 2:00 PM and that he was feeling better after a nap. The LPN stated that she was not informed until the end of her shift that the resident had gone to an alternate [MEDICAL TREATMENT] center. An interview was conducted with the Registered Nurse Supervisor (RNS#2) who worked on Saturday [DATE] from 7:00 AM to 3:00 PM, on [DATE] at 5:15 PM. The RN stated the LPN had called her to assess Resident #1's pulse when the resident returned from [MEDICAL TREATMENT] at approximately 1:00 PM. The RN stated she assessed the resident at that time. An interview was conducted with with the Medical Director on [DATE] at 3:30 PM. The Medical Director stated that he was made aware on Monday ([DATE]) that Resident #1 was transported to an alternate [MEDICAL TREATMENT] center and that he received a treatment that was ordered for a different resident (Resident #2). The Medical Director stated that Labs were collected for Resident #1 on a STAT order when he returned from the [MEDICAL TREATMENT] center on Saturday. The Medical Director stated that review of the labs revealed that the critical levels for [MEDICAL TREATMENT] were, if anything, better than the resident's previous labs. The Medical Director stated that the first thing the administrative team discussed was prevention, how to ensure something like this does not happen again. He stated that the team had reviewed and revised policies and procedures regarding residents' receiving [MEDICAL TREATMENT] and [MEDICAL TREATMENT] transport. The Medical Director further stated that he had contacted the Nephrologist at the hospital that Resident #1 was admitted to on Saturday night, as well as the Nephrologist that attends to residents at the nursing facility. Both physicians reported to him that the resident's laboratory reports revealed that the extra [MEDICAL TREATMENT] treatment would not be the cause of the residents' current cardiac status. An interview was conducted with Resident #1's Primary Care Physician (PCP) on [DATE] at 3:50 PM. The PCP stated that he was notified on Saturday ([DATE]) at approximately 2:00 PM, as soon as the team realized that Resident #1 had been taken to an alternate [MEDICAL TREATMENT] center, that the resident received an extra treatment and a treatment that was not his usual orders. The PCP stated the question for me is obvious, how could this happen? The PCP stated that he ordered STAT lab work and that the results of the labs revealed that the resident's Potassium level was right on, which was very comforting. The PCP further stated that the resident had a cardiac event later in the day that would be hard to relate to [MEDICAL TREATMENT] treatment. If anything [MEDICAL TREATMENT] would have helped the situation. An interview was conducted on [DATE] at 4:20 PM, with Resident #1's Nephrologist at the [MEDICAL TREATMENT] center that the resident regularly attends . The Nephrologist stated how is this possible, crazy, never in [AGE] years have I heard of such a thing in response to the information that Resident #1 was transported to a [MEDICAL TREATMENT] center that was not his usual [MEDICAL TREATMENT] center, on an unscheduled day and received a [MEDICAL TREATMENT] treatment that was not his usual treatment. The Nephrologist stated that the resident was a very sick person with many comorbidities. The Nephrologist stated that the Labs were reviewed , and the only weight available from [DATE] was the post [MEDICAL TREATMENT] weight from the alternate [MEDICAL TREATMENT] center. The Nephrologist stated that the reported lab results were OK and that not to justify the error but that the extra treatment was good for the resident. The Nephrologist also stated that the [MEDICAL TREATMENT] treatment on Saturday would not have caused the cardiac event. The RN (RN Supervisor #1) Nursing Supervisor who worked on [DATE]-[DATE] 11:00 PM to 7:00 AM was interviewed on [DATE] at 5:00 PM. The RN stated that she received a call from the resident between 4:30 and 5:00 AM and that the resident told her that he had not been told he was being taken to a different [MEDICAL TREATMENT] center. The RN reported that Resident #1 told her that the [MEDICAL TREATMENT] center had his information. The RN stated she did not speak to the nurse at the [MEDICAL TREATMENT] center. The RN (#1) stated that she was not aware that Resident #2 was scheduled to have a [MEDICAL TREATMENT] treatment on Saturday ([DATE]). The RN stated that she had completed Resident #2's admission assessment but did not remember the residents' name . The RN stated she had not received communication from the prior shift that Resident #2 was scheduled for a [MEDICAL TREATMENT] treatment. An interview was conducted with the Registered Nurse (RN) (RN Supervisor #2) Nursing Supervisor who worked on Saturday [DATE] from 7:00 AM to 3:00 PM, on [DATE] at 5:15 PM. The RN stated that she was aware that Resident #1 had returned from [MEDICAL TREATMENT] at approximately 1:00 PM. The RN stated that at approximately 2:00 PM she received a call to see a resident on the second floor. The RN stated that when she went to see the resident on the second floor, the resident (Resident #2 who had the same name as Resident #1) asked her why he had not yet gone to [MEDICAL TREATMENT]. The RN stated that she called Resident #2 [MEDICAL TREATMENT] center to question why Resident #2 had not yet been picked up for [MEDICAL TREATMENT] and at that time became aware that the wrong resident (Resident #1) was sent to the [MEDICAL TREATMENT] center in the morning, [DATE] at 4:00 AM. The nurse at the [MEDICAL TREATMENT] center reported that Resident #1 was fine when he left the alternate center and that arrangements would be made to transport Resident #2. The RN stated that she she notified Resident #1 of the error, and called the resident's PCP. The Administrator was interviewed on [DATE] at 6:00 PM. The Administrator stated that he was made aware on Monday [DATE] of the situation of Resident #1 being transported to a [MEDICAL TREATMENT] center on Saturday [DATE] that was not his usual [MEDICAL TREATMENT] center or his usual [MEDICAL TREATMENT] day, and that Resident #1 received a [MEDICAL TREATMENT] treatment that was not his usual treatment. The Administrator stated that an investigation had been initiated and that it was still in progress. The Administrator stated that Policies and Procedures were being reviewed. The Medical Director and Resident #1's Primary Care Physician had been contacted. The Director of Nursing (DNS) and the Assistant Director of Nursing (ADNS) were interviewed on [DATE] at 6:20 PM. The ADNS stated that she had been made aware by the Admissions Office that there was a resident being admitted with the same name as another resident in the facility on [DATE]. The ADNS stated that she immediately met with the admissions office to make sure the residents were placed on different floors and their charts reflected a name alert. The ADNS stated that Resident #1 had a middle name and his records were all updated to reflect his middle name. Name alerts were placed on the residents binders and on the CNAAR. The ADNS stated that both residents were [MEDICAL TREATMENT] patients and that the [MEDICAL TREATMENT] communication sheet on the 2nd floor was updated to reflect Resident #2's [MEDICAL TREATMENT] days and time of pick-up. 2) Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident had orders to attend [MEDICAL TREATMENT] three times a week. Review of Resident #2's Face Sheet revealed that Resident #2 was scheduled at the [MEDICAL TREATMENT] center on Tuesday, Thursday and Saturday with a 4:45 AM pick up time for a 5:30 chair time. Physician order [REDACTED].#2 was to have the AV (Arteriovenous ) Fistula Site to the right chest wall monitored every shift for signs of infection every shift. A second order documented that the new AV Fistula site to the left arm was to be monitored for signs of infection every shift A physician's orders [REDACTED].# 2 had orders for [MEDICAL TREATMENT] Tuesday, Thursday and Saturday. The Residents' 5 day Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #2 had a Brief Mental Status Score of 15 indicating that the resident was cognitively in tact. The MDS also documented that the resident received [MEDICAL TREATMENT]. The Initial Nursing Admission assessment dated [DATE] documented that Resident #2 has [MEDICAL TREATMENT] three times a week. The initial Nursing Progress Note (NPN) dated [DATE] at 9:00 PM documented that Resident #2 had [MEDICAL TREATMENT] TIW (three times per week) at a hospital center. A NPN dated [DATE] at 7:00 PM documented that Resident #2 left for [MEDICAL TREATMENT] at 6:30 PM. The resident's [MEDICAL TREATMENT] communication book documented on the cover that the resident attended [MEDICAL TREATMENT] Tuesday/Thursday/Saturday at 4:45 AM . The inside cover of the [MEDICAL TREATMENT] communication book documented the free standing site that Resident #2 was to have his [MEDICAL TREATMENT] at and the days and time. The only note documented in the [MEDICAL TREATMENT] communication book documented : ,[DATE] Post TX (treatment) VS (Vital signs) ,[DATE], p (pulse) 75, T (temperature) 98. Pt (patient) tolerated TX well. There was no signature after the note. The Comprehensive Care Plan dated [DATE] titled: [MEDICAL TREATMENT] listed as the problem, End Stage [MEDICAL CONDITION] as evidenced by [MEDICAL TREATMENT] 3 times weekly, Saturday, Tuesday, Thursday. During an interview on [DATE] at 5:15 PM with the Registered Nurse (RN) Nursing Supervisor who worked on Saturday [DATE] from 7:00 AM to 3:00 PM the RN stated that she works at the facility 4 days a month on Saturday and Sunday. The RN stated that at approximately 2:00 PM on Saturday [DATE] she received a call to see a resident on the second floor. The RN stated that when she went to see the resident on the second floor, the resident (Resident #2 who had the same name as Resident #1) asked her why he had not yet gone to [MEDICAL TREATMENT]. The RN stated that she called Resident #2 [MEDICAL TREATMENT] center to question pick-up and at that time became aware that the wrong resident (Resident #1) was sent to the [MEDICAL TREATMENT] center in the morning [DATE] at 4:00 AM. The nurse at the [MEDICAL TREATMENT] center told the RN Nursing Supervisor that arrangements would be made to transport Resident #2 for a [MEDICAL TREATMENT] treatment. An interview was conducted on [DATE] at 3:50 PM with the Licensed Practical Nurse (LPN) that worked on Resident #2's nursing unit on [DATE]-[DATE] 11:00 PM- 7:00 PM. The LPN stated she knew of Resident #2 and that he was a new resident. The LPN stated that she did not receive report from the previous shift that the resident was scheduled for [MEDICAL TREATMENT] in the morning ([DATE]). The LPN stated that the resident was listed on the 24 hour report but only with information that he was a new resident. There was no information regarding [MEDICAL TREATMENT]. The LPN stated that there is a calendar on the unit that all the resident ' s appointments are listed on and that the resident was not scheduled on the calendar. The LPN further stated that there is a list of residents that attend [MEDICAL TREATMENT] with information on the days, times and center and that the residents name was not on the list most likely since he was new they (administrative staff) had not gotten to it yet. The LPN who worked on the 2 E unit on [DATE] from 7:00 AM-3:00 PM was interviewed on [DATE] at 1:55 PM. The LPN stated that she works for an agency but remembered Resident #2 and that the resident was new to the unit. The LPN stated that she did not recall receiving report that Resident #2 was scheduled to attend [MEDICAL TREATMENT] on Saturday ([DATE]). The LPN stated that there is a binder on the unit that contains special information on the residents and residents that go to [MEDICAL TREATMENT] would have information in that binder. The LPN stated she had administered the residents medication and she did not recall seeing [MEDICAL TREATMENT] days or times listed on the physician orders [REDACTED].#2. The Registered Nurse (RN ) Nursing Supervisor who worked on Friday [DATE] and Saturday [DATE] from 3:00 PM to 11:00 PM was interviewed on [DATE] at 5:00 PM. The RN stated she received report from the day nursing supervisor when she came on duty Saturday [DATE]. The RN stated that it was reported to her by the day Nursing Supervisor that the wrong resident was taken to the wrong [MEDICAL TREATMENT] center and it was not the resident's usual day of [MEDICAL TREATMENT]. The RN stated that it was reported to her that the [MEDICAL TREATMENT] center, that the wrong resident attended (Resident #1), was contacted and that they would be arranging transportation for Resident #2 (who had been scheduled to be picked up for [MEDICAL TREATMENT] at 4:00 AM) to be taken to [MEDICAL TREATMENT]. The RN Nurse Manager who works 7 AM-3:00 PM on the 2nd floor nursing E unit, was interviewed on [DATE] at 5:20 PM. The RN stated that she had worked on Friday [DATE] and had introduced herself to Resident #2. The RN stated that she was aware that Resident #2 received [MEDICAL TREATMENT] and that she had called and confirmed the resident's appointment with the [MEDICAL TREATMENT] center for Saturday morning. The RN stated that there is a list of [MEDICAL TREATMENT] resident's on the nursing unit and that every nurse is aware they are to check the list. The RN also stated that there is a special needs binder on every nursing unit, that includes residents' that go out to [MEDICAL TREATMENT], and that the nursing staff should be checking the binder on a daily basis. The RN stated that when she reported off to the 3:00 PM - 11:00 PM shift on [DATE], she reported that Resident #2 had [MEDICAL TREATMENT] scheduled for Saturday morning. The RN stated that she had discussed the schedule with the resident , who was alert and oriented x 3, and that arrangements were made with dietary for breakfast and lunch to go with the resident on Saturday morning. The RN stated that she was aware of the name alert for the resident and the resident's chart and the CNAAR had the name alert codes placed on them and now they were also putting a name alert sign on the residents doors. The Social Worker (SW), Clinical Assessor was interviewed on [DATE] at 5:30 PM. The SW stated that prior to discharge the hospital set up Resident #2's [MEDICAL TREATMENT] treatment at the [MEDICAL TREATMENT] center. The SW stated that Resident #2 was scheduled to go to [MEDICAL TREATMENT] on Tuesday, Thursday, and Saturday, and that the resident would be picked up at 4:45 for a 5:30 chair time. The SW stated that she set up transportation with the transportation company and that all the information was generated to the Admission person on duty at the nursing facility. The SW stated she gave report to the Admissions person who would add the information on the residents face sheet. An interview was conducted with the RN Admissions (covering ) on [DATE] at 7:00 PM. The Admissions RN stated that she remembered receiving Resident #2's information. The RN stated that she had completed the residents face sheet and documented on the face sheet the days, time and center that Resident #2 would go to for [MEDICAL TREATMENT]. The RN further stated that she makes up the [MEDICAL TREATMENT] communication books for the unit and documents the resident days and time right on the front of the book. The RN stated she puts the name and telephone # for the [MEDICAL TREATMENT] center on the book and then delivers the book to the unit. The RN stated that she thought she left the book with the Nurse manager on the 2 E unit, but wasn't sure. 3.) Resident # 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident Preadmission Screening Information (PRI) dated [DATE], documented on that Resident #3 had a Perma-Cath inserted to right chest wall for [MEDICAL TREATMENT] on [DATE]. The resident was scheduled for [MEDICAL TREATMENT] on Monday, Wednesday and Friday. The Minimum Data Set Assessment (MDS) admitted d [DATE] documented that Resident #3 had a Brief Mental Status (BIMS) Score of 15 indicating that the resident was cognitively intact. The MDS documented that the resident required extensive assistance of one staff for all Activities of Daily Living, except for eating, which required set up and supervision. The MDS also documented that the resident received [MEDICAL TREATMENT] treatments. The Nursing Admission assessment dated [DATE] documented that Resident #3 had [DIAGNOSES REDACTED]. End Stage [MEDICAL CONDITIONS]/[MEDICAL CONDITION]. The Admission Assessment did not document that the resident had a Perma-Cath inserted in the right chest wall. The Nurses Notes (NN) dated [DATE] documented that Resident #3 had [MEDICAL TREATMENT] M/W/F at the [MEDICAL TREATMENT] center. There was no documentation that the resident had an AV shunt in the left arm nor a Perma-Cath present in the R chest wall. On [DATE] at 4:00 AM a progress note documented that the L arm AV fistula + thrill/bruit, there was no documentation of the R chest wall Perma-Cath. A Nurses Note date [DATE] at 3:00 PM documented that the R chest wall port was intact. Nurses Notes reviewed between [DATE] and [DATE] revealed that there was no documentation that the R chest wall Perma-Cath was being monitored. A progress note dated [DATE] at 9:00 PM documented that as per the [MEDICAL TREATMENT] center Pt. (patient) needs an appointment with the surgical center secondary the catheter not working properly. A progress note dated [DATE] at 3:00 PM documented NPO (nothing by mouth ) after midnight tonight .appointment Re: ( R) CW (chest wall ) Port not operating . A progress note dated [DATE] at 3:00 PM documented Out to procedure/[MEDICAL TREATMENT]). Further review of the Nurses Notes revealed there was no assessment following the residents' procedure on [DATE] and no documentation that the (R) chest wall Perma-Cath was monitored until [DATE] at 2:30 PM. Nurses Progress notes reviewed [DATE] through [DATE] revealed there was no documented monitoring of the (R) chest wall Perma-Cath. Nurses Progress notes reviewed [DATE] at 3:00 PM through [DATE] revealed there was no documented monitoring of the (R) chest wall Perma-Cath. A Renal Consult dated [DATE] documented that Resident #3 was S/P (status [REDACTED]. A Surgical Consultation Report dated [DATE] documented : #1 Sluggish Blood flow from ports #2 Exchanged Catheter #3 Perform [MEDICATION NAME] Sheath Stripping as well Recommendations included: Recommend return to Surgery center within one month for Fistula evaluation and initiation of maturation if necessary. A Surgical Consult dated [DATE] documented: S/P (L) radiocephalic AVF. Patient with no complaints. Fistula measuring 6 millimeters Recommendations; OK to use for [MEDICAL TREATMENT] Follow-up in 3 weeks for Perma-Cath removal if AVF utilized without issues. The Physician Admission History and Physical dated [DATE] documented that Resident #3 had [DIAGNOSES REDACTED]. The Physician also documented fistula checks. A subsequent Physicians Assessment/Progress note dated [DATE] documented that the resident's plan for [MEDICAL CONDITION] included c/w (chest wall) [MEDICAL TREATMENT]. The Physician order [REDACTED]. The Medication/Treatment Administration Records (MAR/TAR) for [DATE] through [DATE] were reviewed. There was no documentation on the MAR/TAR that Resident #3's (R) chest wall Perma - Cath was being monitor

Based on staff interviews and record review during an abbreviated survey it was determined that the administration failed to ensure that there were systems in place to ensure that each resident reached and maintained the highest practicable physical, mental and psychosocial well-being. Specifically, 1) the Administration failed to ensure that there was a system in place to accurately identify that residents with similar names were receiving the correct treatments. Additionally, 2) the Administration failed to ensure that staff were effectively responding to resident's communication. This resulted in no actual harm with a potential for minimal harm that was Immediate Jeopardy and Substandard Quality of Care to resident health and safety. The Immediate Jeopardy was removed on 9/15/2015 prior to the completion of the survey. The facility put corrective measures in place prior to the exit. Cross Reference: F 309 Necessary Care/services for the highest practicable physical, mental well being Complaint Number: 9302 The findings are: 1) Resident #1 was transported to a [MEDICAL TREATMENT] center that was not his usual [MEDICAL TREATMENT] center and received an extra [MEDICAL TREATMENT] treatment that was not ordered by the resident's physician. Resident #2 was scheduled for a [MEDICAL TREATMENT] treatment at 5:00 AM and did not receive his treatment until 6:30 PM, after the resident brought it to staff attention. The unit nursing staff were not aware that there was two resident's in the facility with the same name that both received [MEDICAL TREATMENT] treatments. 2) The facility received a call from the transportation company that contracts with the facility stating that they were coming to the facility on [DATE] for a 4:00 AM , pick-up for Resident #1 to transport him to [MEDICAL TREATMENT]. Resident #1 reported to the facility he had gone to [MEDICAL TREATMENT] Friday (8/28/15) morning and that the [MEDICAL TREATMENT] center he attends did not open that early. Despite the resident's concern the resident was transported to the [MEDICAL TREATMENT] center at 4:00 AM. The resident called the facility between 4:30 and 5:00 AM to report he was at the wrong [MEDICAL TREATMENT] center and spoke with the Nursing Supervisor. The staff did not take steps to confirm that Resident #1 was scheduled for a [MEDICAL TREATMENT] treatment on 8/29/15, nor did the staff contact the resident's actual [MEDICAL TREATMENT] center to question if the resident was scheduled to receive a treatment at an alternate facility. The Policy and Procedure Titled: Name Alert for residents with the same last name, dated 7/2015 and updated 8/31/15, documented that: 1) name alerts would be placed on the spine of the resident's charts, on the CNA accountability sheet for both residents and posted on the door for both resident. (the door alert was added on 8/31/15) 2)Patients/Residents will be placed on different units as much as possible 3)Patients/Residents will not be assigned to the same doctor if possible. 4)Patients/Residents photographs will be taken within 24 hours of admission and will be uploaded to the Sigma system (electronic medical record) The Policy and Procedure Titled: Transports/[MEDICAL TREATMENT] Transports dated 9/1/15 included documentation that initial protocols were updated. The original protocol documented that: 1) transported departures will be completed by a licensed nurse 2) Nursing Staff must review the active physician's orders [REDACTED]. 3) All [MEDICAL TREATMENT] patients orders (schedules/dates/times and destinations) will be summarized and kept at the nursing station for reference and be maintained by the RN unit manager and updated as needed by the licensed nursing staff. Interviews with the nursing staff revealed that nursing staff on the 1st floor were not aware that there were two resident's in the facility with the same name and that both residents received [MEDICAL TREATMENT] treatments. Interview with the 11:00 PM -7:00 AM LPN on the 1st floor revealed that the Physician Order's were not confirmed for Resident #1 scheduled [MEDICAL TREATMENT] days (Monday/Wednesday/Friday). Nursing staff did not contact Resident #1's [MEDICAL TREATMENT] center to confirm schedule for an extra treatment at an alternate [MEDICAL TREATMENT] center. Staff did not not respond to Resident #'s 1 reports that the [MEDICAL TREATMENT] center that he attends did not open at the hour he was being picked up nor when he reported he was at the wrong [MEDICAL TREATMENT] center. Interviews with the nursing staff revealed that nursing staff on the 2nd floor were not aware that there were two resident's in the facility with the same name and that both resident's received [MEDICAL TREATMENT] treatments. Staff interviewed on the 2nd floor were not aware that Resident #2 was scheduled for a [MEDICAL TREATMENT] pick-up on Saturday 8/29/15 at 4:00 AM. An interview was conducted with the Administrator on 9/3/2015 at 6:00 PM. The Administrator stated that he had been made aware that Resident #1 was transported to an alternate facility and received a [MEDICAL TREATMENT] treatment that was not ordered for the resident. The Administrator further stated that staff should have listened to and taken further action when the resident reported that the [MEDICAL TREATMENT] center that he attends did not open at the hour he was being transported and when the resident called to report that he was transported to an alternate [MEDICAL TREATMENT] center. The Administrator stated that an investigation was initiated, that the medical director was contacted and that polices and procedures were being reviewed and revised. The facility employed corrective measures prior to the completion of the survey that removed the IJ. These measures included: 1) The Name Alert and Transports/[MEDICAL TREATMENT] Transports polices and Procedures were reviewed and revised. 95% of facility staff were inserviced on the revised policy and procedures. 2) 95% of facility staff were re-educated on the topic of Resident Communication 415.26

Based on record review and staff and resident interviews during the standard survey the facility did not ensure that necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the plan of care was provided. This was evident for 1 of 40 residents reviewed in stage 1. Specifically, Resident #353 was not administered 6 doses of a medication for pain and muscle spasms. This resulted in actual harm that is not immediate jeopardy. The finding is : Resident #353 is [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Social Worker documented a Brief Interview for Mental Status (BIMS) score of 15 (cognition intact). An Initial Pain Assessment (IPA) dated 3/19/14 documented that the resident has pain 7 of 10 ( on a pain scale of 1 - 10) and that the pain is an ache and the resident feels it all over. The IPA also documented that medication ( non specific) helps to relieve the pain. A Comprehensive Care Plan (CCP) dated 3/22/14 titled pain (due to Peripheral [MEDICAL CONDITION] and Chronic Pain) documented to encourage the resident to ask for pain medications when needed. To monitor and report changes to the Physician. A Pain Scale Assessment Tool (PSAT) dated 3/26/14 documented that the resident had pain in her feet, arms and hands. The pain was an ache and a 7 on a pain scale of 1-10. The PSAT also documented that the residents pain affects her appetite. A Physician order [REDACTED]. A side effect documented in the ( web MD) that the dose should be tapered gradually over a minimum of 1 week and not be stopped suddenly or it can cause headaches,nausea, trouble sleeping and anxiety. A physician progress notes [REDACTED]. The PPN also documented that this was the dosage the resident took when she was at home. A POF dated 3/24/14 documented to increase [MEDICATION NAME] to 100 mg three times a day. A POF dated 3/31/14 documented to hold [MEDICATION NAME] 100 mg three times a day until it arrives from the pharmacy then discontinue the old order. An Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A physician progress notes [REDACTED]. There is no documented evidence in the medical record that the resident was monitored for adverse effects from the missed doses of the [MEDICATION NAME]. An interview was held with the resident on 4/1/14 at 12:00 PM .The resident stated that she missed doses of her [MEDICATION NAME] for pain and spasms and that the facility told her that they ran out of the medication and that it would not be available for a few days. The resident also stated that she is in pain and has muscle spasms and needs her [MEDICATION NAME] and that she has been taking it for a very long time. An interview was held on 4/9/14 at 8:30 AM with the Registered Nurse (RN) Charge Nurse. The RN stated that she was informed on 4/1/14 that the resident needed her [MEDICATION NAME] reordered. The RN stated that she called the resident's Physician to request a prescription for the [MEDICATION NAME] which had run out on 3/31/14. The RN stated that the Physician called the pharmacy and faxed a prescription for the [MEDICATION NAME] on 4/1/14. The RN further stated that the medication nurse should re order the medication and call the Physician for a Prescription before the medication runs out usually three days prior. The RN also stated that the [MEDICATION NAME] was in the facility on 4/1/14 at 10:00 PM and that the LPN that worked on 4/2/14 did not give the resident the 9:00 AM medication , that she must not have realized that the medication was available. The RN was not aware that the resident was in more pain and had an increase in muscle spasms when the [MEDICATION NAME] was on hold. An interview was held with the Pharmacist on 4/9/14 at 9:15 PM. The Pharmacist stated that on 4/1/14 at 12:11 PM the prescription for [MEDICATION NAME] was received from the Physician. The Pharmacist also stated that the facility received the [MEDICATION NAME] from the pharmacy on 4/1/14 at 9:54 PM. An interview was held with the Licensed Practical Nurse (LPN) that worked on unit 2 on 4/9/14 11:45 AM. The LPN stated that the policy is to re order the medication when a 3 day supply of the medication is left. If the medication needs a prescription from the Physician they would call to inform the Physician. The medication nurse would order the medication and inform the Physician. An interview was held with the LPN medication nurse (who worked on 3/28/14 3 days prior to the last dose of the [MEDICATION NAME] on 3/31/14). The LPN stated that the policy is to reorder the medication 3 days prior to the last dose. The LPN also stated that she could not remember why the [MEDICATION NAME] was not reordered for Resident #353 and that it should have been reordered and could not recall if the resident was in pain. An interview was held with the Director of Nursing Services (DNS) on 4/9/14 at 12:05 PM. The DNS stated that the facility has a contract with the Pharmacy next door to the facility for emergency medications, but that the Pharmacy was not used to get the [MEDICATION NAME]. The DNS also stated that she spoke to the LPN that did not give the [MEDICATION NAME] on 4/2/14 at 9:00 AM and the DNS stated that the LPN stated to her it was an oversight. The DNS also stated that the [MEDICATION NAME] should have been ordered by the nurses before the medication ran out. An interview was held with Resident # 353 on 4/9/14 at 11:00 AM. The resident stated that she missed a few days of her [MEDICATION NAME] and that the staff told her that the medication ran out and that she had to wait until it came in from the pharmacy. The resident stated she got angry at the nurse. The resident also stated that she said to the nurse that there was a pharmacy right next door why can't you get it from there and that she needed it for her [MEDICAL CONDITION] pain and muscle spasms. The resident further stated that for the time she did not receive the [MEDICATION NAME] she and severe pain, muscle spasms, decreased appetite, anxiety and had trouble sleeping. The resident also stated that she received [MEDICATION NAME] during that time but it was only effective for a short time and that she informed the nurse ( can't remember name, no name tag on). The resident stated that the Physician increased the [MEDICATION NAME] because she had the pain and muscle spasms about a week prior then the facility ran out and now that she has been getting the [MEDICATION NAME] three times a day for the past week she feels much better. An interview was held with Resident # 353's mother on 4/9/14 at 11:15 AM. The resident's mother stated that the resident told her that she was in pain and had muscle spasms because she did not receive the [MEDICATION NAME] and that she could not understand why the facility ran out of the medication when there was a Pharmacy right next door. The resident's mother also stated that since the [MEDICATION NAME] was given for the last week 3 times a day the resident stated to her that she has been much more comfortable with much less pain and muscle spasms. An interview was held with the resident's Certified Nurses Assistant (CNA) on 4/9/14 at 12:00 PM. The CNA stated that the resident stated to her that she was in pain almost every hour or two and that she would report it directly to the medication nurse. An interview was held with the resident's Physician on 4/9/14 at 1:00 PM. The Physician stated that he was aware that the medication should not be stopped suddenly and that it was unfortunate that the facility ran out of the [MEDICATION NAME]. 415.12

Based on observation, record review, staff and resident interview during the recertification survey the facility did not ensure that residents are free of any significant medication errors. This was evident for 1 (Resident #201) of 8 residents observed during a medication pass observation. Specifically, during a medication pass observation, a Licensed Practical Nurse (LPN) instilled drops that was labeled for the ears into the resident's eyes. The resident complained of burning and itching for several days. This resulted in actual harm that is not immediate jeopardy. The finding is: Resident #201 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of (15) which indicated that the resident's cognition was intact and vision was severely impaired. A Nurse's Note (NN) dated 5/18/12 at 11:00 AM documented resident complained of wax build up in both ears. The Physician was made aware and a Telephone order was obtained for [MEDICATION NAME] Otic Solution 3 Drops AU (both ears) TID for 7 Days. An Interim Physician order [REDACTED]. During a medication administration pass, on 5/22/12 at 9:35 AM, a LPN medication nurse was observed instilling drops in Resident #201 eyes. The nurse administered the drops first in the resident's right eye and the resident flinched. The nurse then instilled drops in the left eye and the resident again flinched and complained of burning after the nurse instilled the drops in the left eye. The medication nurse was heard saying "I know, I know it burns". As the LPN was walking back to the medication cart the nurse explained the eye [MEDICAL CONDITION] handed the vial to the surveyor. A review of the label on the vial revealed the following: Antibiotic ear solution 3 drops in both ears 3 times daily for 7 days for Cerumen (Antibiotic Ear Solution For The Ears). A Medication Administration Record (MAR) dated 5/2012 documented on 5/18/12 [MEDICATION NAME] Otic Solution 3 Drops "AU or OU" (It was not clear on the MAR. It appeared to have been written over and therefore difficult to read) TID X 7 Days for Cerumen. The Medication nurse was interviewed immediately on 5/22/12 at 9:36 AM. The medication nurse stated that the resident just received eye drops. The nurse read the label on the vial and stated when she read the MAR it said OU and she thought it was eye drops. An interview was conducted on 5/22/12 at 10:00 AM with the Resident #201. The resident stated that the Physician prescribed eye drops for her late this past Friday (5/18/12). The resident stated that the drops came late and that she received 2 doses of drops in her eyes on Saturday, 3 doses on Sunday and Monday and one dose so far today. The resident stated when she first received the drops that it burned only in the left eye. However from Sunday to present it has been burning in both eyes. The resident stated that she was having some problem with her hearing and that she lost her hearing in the left ear. The resident stated that she received ear drops only on Sunday and Monday. The resident further stated that she was now having some itching in her eyes. An interview was conducted with the Pharmacist on 5/22/12 at 10:35 AM. The Pharmacist stated that the Antibiotic Ear Drops should be given in the ear only as directed on the label of the vial. The Pharmacist further stated that the ear drops should not be administered in the eyes. An interview was conducted on 5/22/12 at 10:45 AM with the Medical Director (MD). The MD stated that the PH in the ear drops was different and that the resident would feel stinging if instilled in the eyes. The MD stated that he would expect the medication nurse to investigate why the drops sting. In a subsequent interview on 5/22/12 at 2:45 PM with the Medication Nurse, the LPN stated that she worked this past weekend and that she administered drops in the resident's ears on Sunday, Monday and Tuesday. The LPN stated that when she checked the MAR she observed AU was changed to OU which meant both eyes. The LPN also stated that at the time she was not thinking and that it was when the surveyor brought it to her attention that she realized the drops were for the resident ears. The LPN further stated that on Monday when she reviewed the MAR, OU was not documented on the MAR. The LPN stated when she saw OU on the MAR she should have questioned why it was changed. Additionally, the LPN stated that the resident only complained of burning when the drops were instilled in the left eye. An interview was conducted on 5/22/12 at 3:00 PM with the evening shift medication nurse. The LPN stated she administered medication to the resident on 5/21/12 and that the resident only received Hi-Cal and ear drops on the evening shift. The LPN stated that she did not recall how many drops the resident received in the ear but did recall that she only received Hi-Cal and ear drops on the evening shift. In a subsequent interview with Resident #201 on 5/24/12 at 2:00 PM. The resident stated that her eyes still burn but that it was getting better. The resident further stated she was experiencing itching in her eyes. The facility's Policies, Procedures and Information on Medication Administration effective 7/2011 documented the nurse will "Compare the medication name, strength, and dosage schedule on the medication administration record against the prescription label, and always check (3) times prior to administration of medication". 415.12(m)(2)