Every finding on record at Parker Jewish Institute for Health Care & Rehab

Based on observation, record review, and interviews during an Abbreviated Survey (2582281), the facility failed to ensure that an injury of unknown source was reported to the New York State Department of Health. This was evident in 1 of 3 residents reviewed for accidents. Specifically, Resident #1 was found with an injury that was unobserved and/or unexplained that was not reported to the New York State Department of Health. The findings are:The facility policy titled Prevention of Patient/Resident Abuse/Neglect/Mistreatment/Exploitation with effective date of 10/20/2022 documented that injuries of unknown source are to be reported immediately to the facility leadership or other officials in accordance with State law. Resident #1 was admitted to the facility with diagnoses which included Hemiplegia/Hemiparesis of the left side, Contracture of the left hand, Pain, and Schizophrenia.The Quarterly Minimum Data Set 3.0 assessment dated [DATE] documented Resident #1 had intact cognition.Weekly Skin Lesion Assessment note dated 07/09/2025 documented Resident #1 had swelling and slight discoloration to the 4th right finger identified on 07/09/2025 that was acquired in house.An x-ray report dated 07/10/2025 documented on 07/09/2025 at 21:39 PM, Right hand x-ray was performed and right 4th finger swelling and discoloration indicated that the resident sustained 4th Proximal Inter-Phalangeal overlap suspicious for dislocation. There was generalized osteopenia otherwise no discrete lytic or blastic lesions.A care plan titled Actual Alteration in Skin Integrity, site, right 4th finger swelling dated 07/09/2025 documented 07/10/2025 involving one view was obtained of the right hand revealing an abnormal 4th Proximal Inter-Phalangeal overlap suspicious for dislocation.A care plan titled Psycho-social/Emotional/Mood/Wellbeing/Behavior/Risk of Harm dated 08/10/2025 documented Resident #1 was observed with reddish discoloration to the right 4th finger and slight swelling. Resident #1 was unable to account for how their finger became red. On 07/10/2025 the 4th right finger was diagnosed as an abnormal Proximal Inter-Phalangeal overlap suspicious for dislocation. Hospital Discharge Instructions dated 07/10/2025 documented Resident #1 was seen in the emergency department for hand pain. Resident #1 x-ray showed a small dislocation and fracture. Resident #1 was put in a splint and had the dislocation reduced.A medical progress note dated 07/10/2025 documented at 05:00 PM, Resident #1 was assessed to have right hand pain, swelling, blue discoloration on the digits of 2nd, 3rd, 4th, and 5th finger and unable to explain why their hand looked like that. Medical Progress note dated 07/10/2025 documented at 07:52 PM, Resident #1 was assessed to have visible swelling, deformation and ecchymosis. Resident #1 should be transferred to the emergency department for realignment.The Resident/Patient Occurrence Report/Investigation form documented time of the occurrence at 08:30 PM on 07/09/2025 in the room, documented Resident #1 was assessed to have swelling and slight dislocation of the right 4th finger and slight discoloration. There was no witness to the occurrence. The resident was transferred to Long Island Jewish for assessment and follow-up.The orthopedic progress note dated 07/10/2025 documented Resident #1 presented for evaluation of their right hand due to swelling seen by staff. Unclear if Resident #1 had any trauma. Unclear if Resident #1 may have injured themselves in the process. Recommend closed reduction and should be transferred to the emergency department for further evaluation.On 11/12/2025 at 09:07 AM the Clinical Director of Nursing was interviewed and stated that they were responsible for the investigative portion of the case. They received a report that there was swelling on Resident #1's right 4th finger with some discolored/reddish and believes that it was due to a self-inflicted injury. They stated there was no witness to the incident and the resident was unable to account for the injury and could not point out anyone responsible for the injury. The facility concluded that it was obvious of how the resident dislocated their finger, the resident had a self-inflicted injury and there was no need to report the incident to the Department of Health. On 11/12/2025 at 3:12 PM, the Director of Nursing was interviewed and stated this was not a reportable incident at the time because the resident only had swelling and there was no documented injury at the time of the assessment, and the swelling could have come from anything such as gout and that is the reason the resident was sent out to the hospital. 10 NYCRR 415.4(b)(2)

Based on observation and interviews conducted during the Recertification Survey dated 10/16/23 - 10/23/23, the facility did not ensure a safe, clean, comfortable, and homelike environment was maintained. This was evident in 4 resident rooms (Rooms 718, 725, 729, 730) on Unit 7. Specifically, water stains were observed on the ceiling tiles in 3 resident rooms (Rooms 725, 729, 730) and a window blind was observed to be missing in 1 resident room (room [ROOM NUMBER]). The findings are: On 10/17/23 at 9:43 AM and on 10/23/23 at 10:53 AM upon inspection of resident bathroom (room [ROOM NUMBER]), the Surveyor observed water stains on ceiling tiles. On 10/17/23 at 10:18 AM and on 10/23/23 at 11:54 AM, the Surveyor observed water stains on ceiling tiles in the resident bathroom (room [ROOM NUMBER]). On 10/17/23 at 10:22 AM and on 10/23/23 at 11: 53 AM, the Surveyor observed water stains on ceiling tiles in resident bathroom (room [ROOM NUMBER]). On 10/17/23 at 9:55 AM and on 10/23/23 at 11:42 AM, the Surveyor observed a missing window blind in resident room (room [ROOM NUMBER]). On 10/23/23 at 11:57 AM an interview was conducted with the Head Nurse regarding the brown colored stained ceiling tiles observed in resident rooms (725,729, 730). The Head Nurse stated, Whenever there are any environmental concerns the Certified Nursing Assistant (CNA) or nurse will report them to the head nurse, who will follow-up to make observations and to inform the maintenance staff to come in to address the situation. Immediate concerns are treated with urgency. Maintenance request forms can be found on the unit computers. Staff can check the status of the job order to know when the concern will be addressed. On 10/23/23 at 12:20 PM, an interview was conducted with Clinical Director of Nursing #2 (CDON) regarding the brown colored stained ceiling tiles observed in resident rooms (725,729, 730) and missing window blind in room [ROOM NUMBER]. The CDON stated, Rounds are done but not on a set schedule. If there are any findings, the maintenance staff will be notified via a work order. The maintenance department will follow-up. The Heads of all departments conducts environmental rounds. I am only familiar with the concern in the resident bathroom (room [ROOM NUMBER]) but have not completed an work order for that concern. I was not aware of the water stains in rooms #729 and #730 or the missing window blind in resident room [ROOM NUMBER]. On 10/23/23 at 12:42 PM, an interview was conducted with the Director of Building Services (DBS) regarding the the brown colored stained ceiling tiles observed in resident rooms (725,729, 730) and missing window blind in room [ROOM NUMBER]. The DBS stated, As of last month's review, there are no current work orders for the mentioned resident rooms (room [ROOM NUMBER], 725, 729, 730). Work was done on the ceiling recently in room [ROOM NUMBER], and a light bulb were replaced. The resident made it very difficult for the team by requesting only specific staff to complete the work. Those requests were honored. I was not aware that the water stains re-occurred on the bathroom ceiling (room [ROOM NUMBER]). Usually, a work order will be created by staff. Weekly department rounds are done. All computers in the facility are equipped for staff to complete work orders. 415.5(h)(2)

Based on observations, interviews, and record review conducted during the Recertification survey from 10/16/23 to 10/23/23, the facility did not ensure a safe, sanitary, and comfortable environment to prevent the transmission of infections and communicable diseases. Specifically, 1) contaminated linen was found in the clean linen room. 2) Linen bins were observed with numerous pieces of tape attached and with an unclean appearance, 3) Policy and Procedures titled Infection Prevention and Control Plan was not updated according to regulatory requirements. The findings are: Policy and Procedures titled Infection Prevention and Control Plan with last effective date 3/2020 documented as follows: The facility will maintain an infection prevention and control plan designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Policy and Procedures titled Storage, Collection, Transportation of Linen with last effective date 1/12/23 documented as follows: All linens will be stored, handled, transported, and processed in a manner that prevents cross contamination of infection to residents, staff, visitors, and the environment. On 10/20/23 at 11:05AM at the facility loading dock, the State Agent (SA) observed 4 dirty linen bins with residual tape and an unclean appearance. On 10/20/23 at 11:17 AM, the SA observed, in the hallway outside the clean linen room, 3 clean linen bins to have numerous pieces of residual tape attached and an unclean appearance. On 10/20/23 at 11:19 AM, the SA observed a laundry bin containing contaminated blankets located in the clean linen room. Blankets were not contained or covered by any barrier. On 10/20/23 at 11:22 AM, an interview was conducted with the Supervisor of Building Services (SBS) regarding the process of handling dirty and clean linen and laundry. The SBS stated as follows: Staff transports dirty linen in plastic bags contained in vendor provided and maintained bins which are brought down to the loading dock via the service elevator. Staff wear gloves and if laundry is very dirty will wear gowns. Dirty laundry is transported in the designated elevator and transferred outside to loading dock. A separate elevator for soiled linen and trash is used apart from other departments. Every night elevators are cleaned. Clean linen is handled in the clean linen room, top sheets are wrapped only, other items are not. Items are counted and added to linen carts and distributed to unit closets. There are no precautions for clean linen handling. Linen is covered on the carts which are cleaned weekly. The laundry bins are supplied, cleaned, and maintained by the vendor, FDR Services. On 10/20/23 at 04:54 PM, an interview was conducted with the Director of Building Services (DBS) regarding the process of handling dirty and clean linen and laundry. The DBS stated as follows: Dirty linen/laundry from the resident room is transported in the designated bag and kept in the soiled utility room. Building Services staff takes the bags down in bins via the service elevator to the loading dock for vendor pick-up which occurs daily. Bins are cleaned according to the vendor policy, which is between use. Clean linen is brought into the clean linen room after coming into the family, staff sort and take items to the units covered in carts. The nurse and other staff members distributes the items. Staff should not store any soiled or contaminated items in the clean linen room. Finding contaminated linen in the clean linen room is a first-time occurrence, rounds are conducted weekly which includes rounds of the unit utility rooms. Staff will be in-serviced. On 10/23/23 at 04:16 PM the Office Manager (OM) at FDR Services regarding the vendor's cleaning policy and procedures for the linen/laundry bins provided to the facility. The OM stated that the appropriate party will follow-up to answer all questions. The State Agent provided an email address for the vendor to share documentation regarding the infection control procedures related to the services provided to the facility. On 10/20/23 at 04:19 PM, an interview was conducted with the Clinical Director of Nursing #1/Director of Infection Control (DFC) regarding the facility infection control policies and procedures. The DFC stated as follows: The facilities policies and procedures were updated according to the last effective dates noted on each document provided at the survey entrance conference. The team does daily audits of each department and with employees, Department Heads are In-serviced regularly, and conducts rounds of each department. There is a special focus in Personal Protective Equipment (PPE) use, meal services, sanitization of equipment, and medication administration. All educators are involved. Rounds are conducted with the laundry department daily. The Infection Control team consists of 3 staff members. 415.19 (a)(1-3)

Based on observations, record review, and staff interviews conducted during the Recertification/Complaint survey conducted from 10/16/23 to 10/23/23, the facility did not ensure that Resident or Resident's representative were offered the opportunity to participate in the revision and/or review of the comprehensive care plan. Specifically, resident and resident's representatives were not consistently invited to participate in their care plan meetings. This was evident for 2 of 2 residents reviewed for care plans out of 38 residents. (Residents #354 and #380). The findings are: The facility Policy on Care plan/Family Meeting Attendance Sheet/Log dated 10/2021 documented, Attendance will be logged in each resident's electronic medical record, to reflect the attendees who participated, inclusive of a resident, family member and or staff member. 1) Resident #354 was admitted to the facility 02/01/2022, with diagnoses including, Cancer, Hypertension, Anxiety Disorder and Depression. The Annual Minimum Data Set (MDS) dated [DATE] documented the resident has intact cognitive status and is independent/supervision for most Activities of Daily Living. MDS also documented the resident participated in assessment; Resident has no family/significant other participated in assessment; and it is Very important for resident to have family, or a close relative involved in discussions about his/her care. On 10/16/23 at 09:42 AM Resident #354 was observed in their room during the initial pool process and was interviewed. Resident stated, they have been in the facility for more than a year and have not been invited for any care plan meetings. There is no documented evidence in the resident's electronic medical record to reflect that Resident #354 has been consistently participating in the Care Plan meetings. The facility's Care Plan Meeting Report - Significant Change dated 7/5/2022 documented: participant name and discipline to include: Nursing, Therapeutic Recreation, Medical Records, Clinical Nutrition/Dietary, Admissions/Social Work, Occupational Therapy/Physical Therapy/Rehab. There is no documented evidence that resident and/or a family/representative participated in the meeting. Care Plan Meeting Report - Significant Change dated 9/13/2022 documented participant name and discipline to include Nursing, Therapeutic Recreation, Medical Records, Clinical Nutrition/Dietary, Admissions/Social Work, Occupational Therapy/Physical Therapy/Rehab. There is no documented evidence that resident and/or family/representative participated in the meeting. Care Plan Meeting Report - Quarterly Review dated 3/14/2023 documented participant name and discipline to include Nursing, Therapeutic Recreation, Medical Records, Clinical Nutrition/Dietary, Admissions/Social Work, Occupational Therapy/Physical Therapy/Rehab. There is no documented evidence that resident and/or family/representative participated in the meeting. Care Plan Meeting Report - Quarterly Review dated 6/06/2023 documented participant name and discipline to include Nursing, Therapeutic Recreation, Medical Records, Clinical Nutrition/Dietary, Admissions/Social Work, Occupational Therapy/Physical Therapy/Rehab. There is no documented evidence that resident and/or family/representative participated in the meeting Care Plan Meeting Report - Annual Review dated 8/02/2023 documented participant name and discipline to include Therapeutic Recreation, Medical Records/Nursing, Clinical Nutrition/Dietary, Nursing, Occupational Therapy/Physical Therapy/Rehab, Admissions/Social Work. There is no documented evidence that resident and/or family/representative participated in the meeting. 2) Resident #380 was admitted to the facility 02/15/2023, with diagnoses including: Anemia, Congestive Heart Failure (CHF), Hypertension, Anxiety Disorder and Depression. The Quarterly Minimum Data Set (MDS) dated [DATE] documented the resident has intact cognitive status. The MDS also documented Resident #380 participated in assessment; Resident has no family/significant other participated in assessment. On 10/16/23 at 10:05 AM, Resident #380 was observed in their room during the initial pool process and was interviewed. Resident stated that they are not being invited for care plan meetings to discuss their plan of care, including discharge care planning. The facility's Care Plan Meeting Report - Quarterly Review dated 4/18/2023 documented participant names/discipline for the meeting to include Therapeutic Recreation, Nursing, Medical Records/Nursing, Clinical Nutrition/Dietary, Admissions/Social Work, Occupational Therapy/Physical Therapy/Rehab. There is no documented evidence that resident and/or family/representative participated in the meeting. Care Plan Meeting Report - Quarterly Review dated 7/11/2023 documented participant names/discipline for the meeting to include Therapeutic Recreation, Nursing, Medical Records/Nursing, Clinical Nutrition/Dietary, Admissions/Social Work, Occupational Therapy/Physical Therapy/Rehab. There is no documented evidence that resident and/or family/representative participated in the meeting. Care Plan Meeting Report - Significant Change Review dated 7/18/2023 documented participant names/discipline for the meeting to include Therapeutic Recreation, Nursing, Medical Records/Nursing, Clinical Nutrition/Dietary, Admissions/Social Work, Occupational Therapy/Physical Therapy/Rehab; There is no documented evidence that resident and/or family/representative participated in the meeting. On 10/20/23 at 10:49 AM, an interview was conducted with the Registered Nurse Case Manager, RN #1 who stated, the Social Worker (SW) sends mail to the residents for the care plan meetings. The SW goes to the resident's room to notify the resident and documents it in sigma care progress notes. The attendance is documented in the progress note. If the resident declines, it is documented by the Social Worker. RN #1 was unable to provide documented evidence that resident was invited for the meetings, or an attendance record that resident participated in any of the meetings. On 10/20/23 at 11:05 AM, an interview was conducted with Social Worker (SW #1). SW #1 stated that they go to residents' rooms before the meeting take place to inform them of the meeting and it is documented in the progress note. SW also stated that at the end of the meeting the attendance is documented in the progress notes, indicating the team members and resident/family member that attended the meeting. SW was unable to show the documented evidence that residents #354 and #380 were invited to their care plan meetings, or that residents participated in the care plan meetings. On 10/23/23 at 05:40 PM, The Administrator was interviewed, and stated that they are not aware that residents' invitation and attendance to their care plan meeting were not being properly documented. Administrator further stated that they have started an internal audit with the social work team to resolve the issue. 415.12(c)(2)(i-iii)

Based on observations, record review and interviews conducted during the Recertification survey, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice that were based on the comprehensive assessment, person-centered care plan, and the resident's choice. Specifically, a resident was not provided with treatment and care to address the resident's positioning needs. This was evident for 1 of 5 residents reviewed for Position, Mobility out of a sample of 38 residents. (Resident # 98) The findings are: The facility policy and procedure Pressure Ulcer/Injury Prevention and Care reviewed September 2018 documented 'when a patient/resident is identified as at risk for development of a pressure ulcer/injury, the CCP Team will initiate a care plan that recognizes the patient's/resident's needs and goals, the factors which place the patient/resident at risk of developing a pressure ulcer/injury and addresses the same with individualized interventions that are consistent with recognized standards of practice. These preventive interventions may include but are not limited to: Turning and positioning schedule when in bed, avoid pressure on existing pressure ulcer/injury. Resident #98 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had intact cognitive status. The MDS documented the resident required extensive assistance of 2 staff for bed mobility and dressing, and was totally dependent on staff for transfer, locomotion, and toilet use. The MDS also documented that resident is at risk of developing pressure ulcer and receiving skin and ulcer treatments including pressure reducing device for bed and turning/repositioning program. On 08/10/21 at 09:54 AM, Resident #98 was observed lying in bed in a supine position. During an interview, Resident #98 stated I am not able to turn myself in bed and nobody is helping me to turn and reposition when I need to change position. Resident #98 also stated that staff only assisted in turning when giving care in the morning before breakfast and later in the afternoon. On 08/10/21 at 12:23 PM, and at 02:59 PM, resident was observed in bed, still in a supine position. Resident #98 stated I need help to turn, nobody has turned me yet. On 08/11/21 at 08:01 AM, resident was observed sleeping in a supine position, and at 10:19 AM, resident was observed in bed, awake, and still in a supine position. On 08/11/21 at 02:07 PM, Resident # 98 was observed seated in a wheelchair, sitting beside the bed. Resident stated they had just been taken out of bed 15 minutes ago in order to get a haircut. On 08/12/21 at 09:12 AM, Resident #98 was observed in bed in a supine position, sleeping, and at 11:23 AM, resident was observed awake, still in bed in a supine position. On 08/16/21 at 08:11 AM, resident was observed in bed in a supine position, and at 10:47 AM, resident was still in bed in a supine position. Resident stated they had called to request help to be turned but no-one had helped them yet. The Comprehensive Care Plan (CCP) titled ADL Function/Rehab Potential dated 11/06/2019 revised 8/9/21 documented that resident required assistance of staff in performing ADLs, related to decline in range of motion, and is at risk for progressive decline in ability due to aging process and natural disease progression. Interventions included Nursing Rehab ROM: Please perform AAROM for BUE/BLE for 10 reps x 2 sets a day to prevent contractures. The Comprehensive Care Plan (CCP) titled Skin breakdown dated 11/06/2019 revised 7/6/2021 documented that resident is at risk for skin breakdown with interventions that included turn and position every 2 hours and as needed. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Turn and position every 2 hours. Resident CNA Documentation Record dated July and August 2021 contained no documented evidence that resident was consistently turned and repositioned from back to side every 2 hours as per order and as per resident's plan of care. On 08/16/21 at 11:02 AM, an interview was conducted with Certified Nursing Assistant (CNA) #1. CNA #1 stated that resident was seen in the morning when breakfast tray was taken to the room. CNA #1 also stated that the resident was checked before 10 am when the Charge Nurse (RN #2) notified the CNA that the resident needed to be repositioned. CNA #1 further stated that they were unable to turn the resident alone then because resident required assistance of 2 staff for turning, and everybody was busy at that time. CNA #1 stated that they went to provide care for another resident and had just finished and was about to ask for assistance to go and turn the resident. On 08/17/21 at 01:59 PM, an interview was conducted with CNA #2. CNA #2 stated that they are assigned to the resident when the regular CNA is not on duty. CNA #2 stated that resident can verbalize needs, and calls when in need of anything, will ask to be given urinal and to be turned and repositioned. CNA #2 also stated that the resident likes to come out of bed between 2 and 2:45pm, does not come out of bed on shower days as shower is given in the evening. CNA #2 also stated that the resident does not refuse to be turned when in bed, but sometimes will like to change position before 2 hours if the resident wants to use the urinal or to watch a program on the television. CNA #2 further stated that resident requires assistance of 2 strong staff to turn in bed, and sometimes it is difficult to find another staff readily available to assist when resident would like to be turned. On 08/16/21 at 11:11 AM, an interview was conducted with the Registered Nurse (RN) #2. RN #2 stated that the resident is supposed to be turned and repositioned in bed every 2 hours and as needed and taken out of bed in the afternoon after lunch. RN #2 also stated that the CNAs are made aware of interventions to be carried out when giving report and this is also indicated in the CNA accountability record. RN #2 further stated that the CNAs are reminded to check and turn the resident and to also apply the booty. RN #2 was unable to explain why the resident was not being turned and repositioned during the period of observation by the surveyor. On 08/16/21 at 11:20 AM, the RN/Unit Manager (RNUM) was interviewed. The RNUM stated that the resident requires total care and is taken out of bed after lunch around 2:00pm daily as per resident's request. The RNUM also stated that resident is alert and oriented, able to make needs known, is seen daily during rounds looking comfortable, engages in conversation when making rounds and has never reported that staff are not assisting in turning and repositioning as scheduled, and when needed. RNUM further stated that rounds are made frequently on the unit to monitor that staff are providing proper care to the residents as per plan of care. RNUM was unable to explain why resident was observed not being turned during the period of surveyor's observations. On 08/16/21 at 12:28 PM, the Rehab Director (RD) was interviewed. The RD stated that rounds are done regularly to ensure everything is being carried out as recommended, and as per resident's plan of care. RD could not explain why recommended interventions, such as turning and repositioning of resident were not being carried out as per order. 415.12

Based on observations, record review, and staff interviews conducted during the recertification survey, the facility did not ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, an RN was observed using a glucometer for multiple residents without sanitizing the equipment in between the residents. This was evident during point-of-care testing for 3 of 12 residents observed during the Medication Administration Facility Task. (Resident #189, 75, & 11) The findings are: The facility policy titled EVENCARE Finger Stick Blood Glucose Monitoring dated 1/19 documented it is the policy of Parker Jewish Institute to monitor blood glucose of patients/residents effectively and accurately .Clean and disinfect the EvenCare G3 Blood Glucose Meter between patient tests using facility approved disinfecting wipes. On 08/11/21 at 08:06 AM, Registered Nurse (RN) #1 was observed checking residents' blood glucose on the 4th floor. RN #1 removed the glucometer from the medication cart and proceeded to perform fingerstick check for Resident #189. RN #1 was not observed sanitizing the glucometer before use. After completing the fingerstick, the nurse removed and discarded the test strip and then placed the glucometer in a black container in the medication cart without sanitizing or cleaning the glucometer. At 08:37 AM, RN #1 was observed removing the same glucometer, that had not been sanitized after prior use, from the medication cart. RN #1 approached Resident #75 and proceeded to perform a fingerstick. RN #1 then returned the glucometer to the medication cart. RN #1 was not observed sanitizing the glucometer before or after use. At 08:45 AM, RN #1 removed the glucometer from the medication cart and then proceeded to perform fingerstick for Resident #11. RN #1 was not observed sanitizing the glucometer before or after use. On 08/11/21 at 09:26 AM, RN #1 was interviewed. RN #1 stated that the glucometer was sanitized when they began the shift in the morning and was to be sanitized after checking 2 residents. RN #1 also stated that the glucometer was not sanitized in between the residents because they had a lot of things going on in their mind. On 08/11/21 at 09:57 AM, an interview was conducted with the Registered Nurse Unit Manager (RNUM). The RNUM stated that RN #1 works as a per Diem Nurse and had been given reports on the residents requiring blood glucose checks on the assignment. The RNUM also stated that the RN and all other nurses have been educated on infection control prevention protocol regarding the cleaning and sanitization of the glucometer. The RNUM could not explain why the RN failed to follow the protocol. On 08/18/21 at 10:30 AM, an interview was conducted with the Clinical Director of Nursing/Infection Control Protocol (DIP). The DIP stated that all the staff are given education on infection control protocols when newly hired and annually. Staff are spot checked daily at random on the units by the Infection Control Patrol team consisting of the Unit Manager, the supervisors, Director of Rehab, Infection Control Preventionist and the Director of Infection Control Protocol. The DIP also stated that if a breach is observed, staff are re-educated on all units and all shifts to prevent re-occurrence. The DIP further stated that the staff involved was given in-service and evaluated for competency on infection control and could not understand why such an error had been made by the staff. 415.19(a)(1-3)

Based on interviews and record reviews conducted during an abbreviated survey (NY 237), the facility did not ensure that an injury of unknow origin was investigated. Specifically, Resident #1 was observed with redness to the right shin and [MEDICATION NAME] Ointment and Dry Protective Dressing (DPD) were ordered and applied to the resident's right shin. Record review revealed that the redness to Resident #1's right shin was not investigated to ascertain the cause of the injury and to prevent potential abuse. The findings are: A facility policy and procedure titled Occurrence Reporting updated February 2017, documented an occurrence report is completed for each fall, injury, unexplained bruise, abrasion, burns, resident o resident altercation, and any other signs/ symptoms indicating that an event has occurred. An occurrence report is initiated so that the facility may obtain information relevant to each event as well as to obtain information for analysis of the cause of the event to prevent a reoccurrence. Resident #1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 08/03/2020 documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determined attention, orientation and ability to recall information) and scored 7/15 associated severely impaired cognition. Resident #1 reported to family member that a nurse shoved a table into her right leg causing injury. A physician's orders [REDACTED]. A Treatment Administration Record documented that Resident #1 received [MEDICATION NAME] Ointment to the right shin from 08/28/2020 to 09/02/2020. Review of the Facility's Occurrence Reports from 7/2020 to 9/2020, revealed that there was no investigation as to how Resident #1 sustained injury to the right shin that required treatment. On 09/21/2020 at 11:33 a.m., an interview was conducted with RN #2 who stated that she observed Resident #1 with light redness to the right shin on 08/27/2020. RN #2 called the Physician and obtained an order for [REDACTED]. A follow up interview was conducted with the DON on 10/15/2020 at 2:50 p.m. The DON stated, once there is a change in a resident's condition or an accident or incident occurs, it is brought to the RN's attention. She further stated that an assessment would be done, and the RN documents the findings. The DON further stated that the RN notifies the nursing supervisor and physician then initiates an incident report to investigate the findings if needed. 415.4(b)(1)

Based on interviews and record reviews conducted during an abbreviated survey (NY 237), the facility did not ensure that it maintained complete medical records on each resident. Specifically, there was no documented evidence that a resident had been evaluated for a skin condition for which a topical antibiotic ointment had been ordered. This was evident for 1 out of 3 residents sampled (Resident #1). The findings are: A facility policy and procedure titled to Documentation: Licensed Nurses (Narrative Notes) updated October 2018, documented all components of the patient/ resident care process, plan of care, evaluations and outcomes will be documented in the patient's/ resident's electronic medical records. The documentation must address patient/resident's medical/ psychosocial needs, capabilities and limitations. Licensed nurses will document via Narrative notes or template notes in the Progress Note section of the medical record. Resident #1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 08/03/2020 documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determined attention, orientation and ability to recall information) and scored 7/15 associated severely impaired cognition. physician's orders [REDACTED]. Treatment Administration Record documented that Resident #1 received [MEDICATION NAME] Ointment to the right shin from 08/28/2020 to 09/02/2020. There was no documented evidence in the medical record that a medical or nursing evaluation had been conducted of Resident #1's right shin. On 09/18/2020 at 1:30 p.m., an interview was conducted with Registered Nurse (RN) #1, who administered [MEDICATION NAME] Ointment on 08/29/2020, 08/30/2020 and 09/02/2020. RN #1 stated [MEDICATION NAME] Ointment was applied to the resident's right shin, but she could not recall Resident #1 having any redness, bruising or discoloration to the legs. On 09/18/2020 at 2:30 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated that RN #2 and the Physician did not document in Resident #1's medical record. The DON stated that an assessment should have been documented in the resident's medical record. On 09/21/2020 at 11:33 a.m., an interview was conducted with RN #2, who stated that she observed Resident #1 with light redness to the right shin on 08/27/2020. She called the Physician and obtained an order for [REDACTED].#2 further stated she completed an assessment of the resident but did not document the assessment findings in the resident's medical record. On 09/21/2020 at 2:12 p.m., an interview was conducted with Resident #1's primary Physician. The Physician stated that RN #2 called to inform him that she observed redness on Resident #1's right shin. The Physician also stated that he gave RN #2 a telephone order for [MEDICATION NAME] Ointment to apply to the reddened area. The Physician further stated that during an evaluation of the resident earlier that day he had not observed any redness to the right shin. The Physician also stated that he did not follow up on the order or document in the resident's medical record. 415.22(a)(1-4)

Based on interviews and record review conducted during an abbreviated survey (NY 262), the facility did not ensure that a resident wheelchair was safe to operate. This was evident for 1 out of 4 residents sampled (Resident #1). Specifically, Resident #1 had both legs amputated and required a wheelchair with anti-tippers. On 08/18/2018, Resident #1 was given a wheelchair without anti-tippers and on 08/23/2018, Resident #1 was observed on the floor in front of the elevator with the wheelchair tipped over. Resident #1 sustained a hematoma to the back of his head. The findings include: A facility Policy and Procedure on Wheelchair Reevaluation with effective date 11/10/2015 documented that residents whose positioning and seating needs require re-evaluation are referred to Occupational Therapy. This document also revealed that if the wheelchair is not available, the Occupation Therapy Department will implement the following: reviews the available wheelchairs waiting to be washed or repaired. Upon completion of needed work, the wheelchair is labeled and brought to the resident's room. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 08/10/2018 documented that Resident #1 had a Brief Interview of Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score 15/15 indicating intact cognition. Resident #1 required extensive assistance of 2 persons with transfer and was totally dependent on 1 person for locomotion on and off the unit. Review of the Nursing Instructions document for 08/2018, revealed no instructions regarding anti-tippers. A Comprehensive Care Plan (CCP) for Activity of Daily Living (ADL) and risk for declining Range of Motion (ROM) dated 08/03/2018, documented interventions for rear anti-tippers. A Nursing Note dated 08/23/2018 at 10:40 AM documented that at approximately 8:15 AM, Resident #1 was observed lying on the floor near the elevator and the Medical Emergency Respond Team (MERT) was called to the lower level basement. Resident #1's wheelchair was observed at his feet tipped over. Resident #1 reported that his wheelchair got stuck in the elevator gap. As the resident was trying to back out of the elevator, the wheelchair tipped over and he slipped out of the wheelchair. Upon assessment, the resident was noted with scant bleeding from the abrasion on the left side of the occipital (back of head). The Doctor's Progress Note dated 08/23/2018 at 10:29 AM documented that Resident #1 was assessed at 8:40 AM with stable vital signs, hematoma and a small skin abrasion to the back of the head. An ice-pack was applied to the hematoma. The Resident complained of dizziness and denied headache. Resident #1 will be transferred to the Hospital for Computed Tomography (CT)-Scan to rule out subdural hemorrhage. The physician's orders [REDACTED].#1 to the Hospital for CT-Scan of the head status [REDACTED]. The Facility Investigative Summary dated 08/23/2018 documented that on the afternoon of 08/18/2018 Resident #1's wheelchair was sent to housekeeping for cleaning. The Occupational Therapist Assistant (OTA) replaced Resident #1's wheelchair with a regular wheelchair without anti-tippers. The OTA stated that the anti-tippers were not available at that time. The OTA also stated that she notified the Registered Nurse (RN) on the unit that wheelchair was temporary and needed to be addressed by the therapist on 08/20/2018. The facility concluded that the OTA did not notify her supervisor or other member of the Rehabilitation Department that she provided Resident #1 with a wheelchair without anti-tippers. Physical Therapist #1 (PT #1) stated that she notified the Occupation Therapist (OT) that the wheelchair was switched. She did not check the wheelchair and did not notified her supervisor. OT did not remember to check the wheelchair for anti-tippers. The OTA was interviewed on 04/08/2019 at 12:18 PM and stated that the OT is responsible for assessing the residents for anti-tippers. She stated that on 08/18/2018 after 4:00PM, a nurse on Resident #1's unit notified her that the Resident's wheelchair was soiled, and that Resident #1 needed another wheelchair. The OTA stated that she looked for a proper wheelchair for Resident #1 but did not find one. She stated that she gave Resident #1 a temporary wheelchair, for bathroom purpose, without anti-tippers. She also stated that she told the nurse (does not remember name) on the unit that the wheelchair was temporary. The OTA stated that she did not write a note in Resident #1's chart regarding the temporary wheelchair. Upon inquiry, the OTA stated that Resident #1's initial wheelchair had front and back anti-tippers. The Assistant Head Nurse (AHN), who worked on 08/19/2018 on the 7-3 shift, was interviewed on 04/08/2019 at 1:30 PM. She stated that on 08/18/2018 in the afternoon, the resident notified her that his wheelchair was soiled, and the wheelchair was taken to be washed. She stated that she called OT to provide the resident with a temporary wheelchair and that the OTA came to see the resident to provide him with a proper wheelchair. She stated that she was not aware that Resident #1's temporary wheelchair had no anti-tippers. The assigned PT was interviewed on 04/08/2019 at 1:30 PM and stated that Resident #1 had both legs amputated. She stated that Resident #1 told her on 08/21/2018 (Tuesday), that on Saturday (08/18/2018) he soiled his wheelchair and that it was sent for cleaning. He also told her that he received another wheelchair. The wheelchair was sturdy, safe and secure during transfer and locomotion on unit and that Resident #1 had a session and was secured in the wheelchair without the anti-tippers. The PT staff also stated that she notified OT, that was assigned to Resident #1, that the temporary wheelchair had no anti-tippers. She stated that the following day she reminded OT that Resident #1 had no anti-tippers. The OT staff told her that he would take care of it. On 08/23/2018, Resident #1 fell as he was exiting the elevator. The OT staff was interviewed on 07/03/2019 at 1:13 PM and stated that Resident #1 was safe in the temporary wheelchair. He stated that he tried to find Resident #1's original wheelchair with the anti-tippers but could not find it. He also stated that Resident #1 needed the anti-tippers for extra precaution and that he could not find any anti-tippers. The Director of Rehabilitation was interviewed on 11/19/2019 at 4:06 PM and stated that the facility always has anti-tippers available. The therapist should have called the engineer department to get the anti-tippers installed on the wheelchair. The facility has engineers available through every shift. He also stated that since the incident the facility has no other incidents related to anti-tippers. The rehab staff has knowledge of wheelchair safety and proper management. A full house audit was conducted on 8/29/2018 to make sure that all residents who have amputation have anti-tippers on their wheelchairs. No issues were identified. On 08/23/2018-11/02/2018, rehab staff received in-service. Changes were made to the Policy and Procedure on Management and Assignment of Wheelchairs on 12/30/2018. A follow up interview was conducted with the Director of Rehabilitation on 11/26/2019 at 3:00 PM. He stated that the purpose of anti-tippers is to prevent the wheelchair from tilting over. The Assistant Director of Housekeeping was interviewed on 12/27/2019 at 3:12 PM. He stated that if a wheelchair needs to be washed, a CNA would bring the wheelchair downstairs with a sign stating that the wheelchair needs to be washed. It takes 15-20 minute to wash a wheelchair and a Housekeeping staff would return the chair back to the unit. A follow-up interview was done with the Director of Rehabilitation on 12/30/2019 at 12:40 PM. He stated that the Resident #1's incident was discussed during Quality Assurance Meeting on 09/27/2018 with no negative outcome. Results of the audit was also discussed on 10/25/2018 with no negative outcome. The facility implemented the following corrective actions: On 08/23/2018 to 11/02/2018, all Rehab Staff received in-service on Wheelchair and Devices. On 08/29/2018, a full house audit was conducted to identify any Residents with lower extremity amputation requiring anti-tippers on their wheelchairs. No issues were identified. On 08/29/2018, education provided to Rehab Staff on New Procedure for Documentation of wheelchair devices and other devices. 09/27/2018, Quality Assurance Meeting was held, and the incident was discussed. 10/25/2018, Audit results was discussed, and no negative findings noted. 12/30/2018, the facility reviewed and revised the Policy and Procedure on Management and Assignment of Wheelchairs. 415.5 (e)(1)(2)

Based on observations, record review, and staff interviews during the re-certification survey, the facility did not ensure a resident with limited range of motion (ROM) and mobility received appropriate treatment and services to increase range of motion and or to prevent further decrease in range of motion. Specifically, a hand roll and a splint device were not provided to the resident as per physician order. This was evident in 1 of 2 residents reviewed for ROM care and services (Resident #87). The finding is: The facility policy and procedure titled Adaptive Devices dated 07/2018 documented the following: Adaptive devices are provided when necessary to prevent a decline in a resident's range of motion or to maintain a resident's proper positioning in bed or in a chair. The nursing staff will provide or apply the devices to the resident as per the instructions provided and schedule determined on the CNA instructions. Resident #87 was admitted to the facility with [DIAGNOSES REDACTED]., and Depression. The Quarterly Minimum Data Set ((MDS) dated [DATE] documented that the resident had moderately impaired cognition. The MDS further documented that the resident required total assistance for all Activities of Daily Living (ADLs) and had impairments on both sides of upper and lower extremities. In addition, resident used a pressure reducing device for chair and bed. On 02/26/2019 at 12:18 PM, the resident was observed in the dining room asleep in a gerichair. The resident had contractures of bilateral upper and lower extremities. There was no device placed on either hand. A blue hand roll was observed resting on the resident's lap. A hand roll was also observed on a resident's night stand in the room. On 02/27/19 between 10:05 AM and 11:25 AM, the resident was observed seated in the gerichair in the lobby with no hand roll and no hand splint in place. On 02/27/19 at 12:35 PM, the resident was observed in the dining room with no hand roll or splint in place. Occupational Therapy (OT) progress note dated 12/13/2017 documented resident seen by OT as per nursing request due to tightness noted, decreased ROM in bilateral hands and right elbow. Nursing staff with noted difficulty on/off bilateral hand splints. Upon OT assessment, resident would benefit from restorative OT for proper splint management & fitting. CCP updated OT progress note dated 02/14/2019 documented OT re-evaluation and treatment in progress, P[NAME] established. Resident referred for OT services secondary to increased tightness, decreased PROM (Passive Range Of Motion) and overall difficulty applying splints to B/L (bilateral) UE's (upper extremities). physician's orders [REDACTED]. Adaptive Device: Right elbow splint to be worn 3 hrs BID (twice daily). Remove for skin check and hygiene from 7 AM to 3 PM and 3 PM to 11 PM. Right hand grip splint and left hand roll to be worn for 4 hours BID from 7 AM to 3 PM and 3 PM to 11 PM. Active Certified Nursing Assistant (CNA) instructions documented right hand grip splint, left hand roll BID, remove for skin check/hygiene. Right elbow splint 3 hours BID. On 03/04/19 at 10:03 AM, an interview was conducted with Certified Nursing Assistant (CNA#1). CNA #1 stated resident is positioned every 2 hours when in bed, and range of motion is done during dressing for upper and lower extremities. Hand splint is put on the right hand and hand roll on the left hand. The splint and hand roll are placed on the resident at about 10 AM when resident is taken out of bed and removed at about 2 PM after lunch when he is transferred back to bed. The hand rolls and the splint are removed regularly for skin check. On 03/04/19 at 11:47 AM, an interview was held with the Unit Manager /Registered Nurse (RN #1). RN #1 stated that the nurse on the unit is responsible for placing the devices and documenting the time the splint and hand roll is placed on the resident daily in order to monitor the time the devices are to be removed. There no specific times for placement of the device indicated in the physician's orders [REDACTED].>On 03/04/19 at 11:55 AM, an interview was held with the Registered Nurse (RN #2) who was on duty on the 7 AM to 3 PM shift on 2/26/19 and 2/27/19. RN #2 stated the order is checked for the timeframes to apply and to remove the devices. RN #2 also stated that the nurses are supposed to apply the devices, remove them and document as per order. The CNA's are instructed to monitor and ensure that the resident has the devices in place. No fixed time is assigned but the devices are always applied when the resident is taken out of bed and then removed after the stipulated time period has passed. On 03/04/19 at 12:34 PM, an interview was conducted with the Occupational Therapist (OT). The OT stated when the device is recommended, OT provides the device, places an order, initiates the care plan, in-services the CNA/Nurses, and updates the CNA profile The OT further stated that a screen is completed and they make rounds on the unit to see devices are properly placed. If there is a complaint with any device, there is communication between the nursing and the rehab to address the problem. The OT also stated that the time the device is placed is not specified by the rehab, they only specify the daily duration of the placement. The nursing staff determine the timing based on when the device is applied. 415.12(e)(2)

Based on observation and staff interviews during the Recertification survey the facility did not ensure that corridors were equipped with firmly secured handrails on 5 out of 13 nursing units. Specifically, loose handrails were observed on units 8 North, 6 North, 6 South, and 5 South; and on unit 4 North there were no handrails in the alcove area by rooms 424, 425, 426, and 427. The finding is: On 7/3/2017 at 9:15 AM on unit 8 North a loose handrail was observed across from the nursing station. The Registered Nurse (RN) on the unit observed the loose handrail and stated she would alert the maintenance department. On 7/3/2017 at 10:15 AM on unit 6 North a handrail adjacent to Room 624 was observed hanging on the wall in a slanted position. The observation revealed that one side of the handrail was pulled out of the wall. The RN on the unit observed the handrail and stated she would alert the maintenance department. On 7/3/2017 at 10:31 AM on unit 6 South one side of a handrail adjacent to Room 643 was loosely attached to the wall, and on the same unit near the South Service Area corridor a bracket that secures a handrail to the wall was broken and the handrail was loose. Both handrails were observed by the RN on the unit and she stated she would alert the maintenance department. On 7/3/2017 at 10:55 AM on unit 5 South there were loose handrails observed adjacent to Rooms 541 and 539, and a handrail adjacent to Room 538 was loosely attached to the wall. The handrails were observed by the RN on the unit and she stated that she would alert the maintenance department. On 7/3/2017 at 10:59 AM on unit 4 North an observation was made of an alcove area consisting of Rooms 424, 425, 426, and 427. There were no handrails present, rather than handrails there was a wooden ledge that could be leaned on. This was observed by the RN on the unit. She stated she would call the Engineering Department and report the observation. On 7/3/2017 at 11:09 AM the Director of Facilities Management was interviewed regarding the missing handrails on 4 North. He observed the area and stated there should be handrails in this area for rooms 424, 425, 426, and 427. On 7/6/2017 between 8:10 AM and 8:30 AM the loose handrails were identified on Units 6 North, 6 south, 5 South and 4 North and found to be secured to the walls with the exception of the handrail adjacent to Room 538. This handrail remained loosely attached to the wall. The RN on the unit observed the loose handrail and stated she would notify the maintenance department. On 7/7/2017 at 1:00 PM the Director of Facilities Management was interviewed. He stated maintenance workers are constantly monitoring for maintenance problems, and handrails are a number one priority. He stated that any staff member can report maintenance problems and request maintenance work from a computer, and then a work order is created. He provided work orders dated 7/3/17 that were created following the identification of the loose handrails on 6 South and 6 North, however, not for the other nursing units identified with loose handrails. 415.29

Based on record review and staff interviews during the Recertification survey the facility did not ensure that Comprehensive Care Plans were developed for each resident that included measurable objectives and time frames to meet a resident's medical and nursing needs that are identified in the comprehensive assessment. This was identified for 1 of 5 residents reviewed for Unnecessary Medications from a total Stage 2 sample of 29 residents. Specifically, a Comprehensive Care Plan (CCP) was not developed for Diabetes Mellitus for Resident #111. The finding is: Resident #111 was admitted to the facility in August 2016 with [DIAGNOSES REDACTED]. The 4/28/2017 Quarterly Minimum Data Set (MDS) assessment documented that Resident #111 had a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident was cognitively intact. The resident had Diabetes Mellitus identified as an active [DIAGNOSES REDACTED]. A CCP dated 8/13/2016 titled Nutrition and Hydration Needs documented that the resident was at risk for alteration in hydration and nutritional status due to Diabetes Mellitus. The most recent physician's orders [REDACTED]. The Registered Nurse (RN) Charge Nurse was interviewed on 7/7/2017 at 9:49 AM and stated that the RN on the unit is responsible for creating care plans. She stated that there currently was not a Diabetes care plan developed for Resident #111 and that she would create one. The RN Supervisor for the floor was interviewed on 7/7/2017 at 12:11 PM and stated some areas of Diabetes care are addressed on the Nutrition care plan, but there should be a care plan specifically developed for Diabetes. 415.11(c)(1)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that a plan of care was developed with measurable goals and interventions to address the care and monitoring of the resident's [MEDICAL TREATMENT] for one of one resident reviewed for [MEDICAL TREATMENT] in a total sample of thirty-one Stage 2 residents. (Resident #344) The finding is: Resident #344 has [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident was understood and was able to understand with a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident had intact cognitive skills for daily decision making. Section O - Special Treatments and Programs, documented the resident was receiving [MEDICAL TREATMENT]. The monthly Physician order [REDACTED]. The resident's [MEDICAL TREATMENT] Comprehensive Care Plan (CCP) dated 2/25/16 documented that the resident had a left AVF (Arteriovenous Fistula) and that the access site is monitored for infection, pain, drainage, and bleeding. It was not indicated on the CCP how often the resident's left AVF should be monitored. Review of Nursing [MEDICAL TREATMENT] Progress Notes dated 8/15/15 through 5/5/16 revealed that the resident's left arm AVF was monitored pre and post [MEDICAL TREATMENT] (three days a week). The 8 North Registered Nurse (RN), Head Nurse, was interviewed on 5/6/16 at 10:45 AM and stated that [MEDICAL TREATMENT] residents usually have their shunt site checked every shift and documented on the Treatment Administration Record (TAR). The RN also stated that sometimes when Physician Monthly Orders are renewed, orders disappear. The RN stated that she has now added the order in the computer for the resident's shunt site to be checked every shift. The Director of Nursing (DON) was interviewed on 5/6/16 at 12:40 PM and stated that the facility's policy was for resident [MEDICAL TREATMENT] to be monitored pre and post [MEDICAL TREATMENT] treatments (three days a week). The DON also stated that if a Physician ordered more frequent monitoring the site would be monitored more often. The DON further stated that she would take into consideration monitoring the sites more often. The resident's Primary Physician, in the presence of the Medical Director, was interviewed on 5/6/16 at 1:55 PM and stated that it was not necessary to monitor the resident's shunt site on non-[MEDICAL TREATMENT] days because the resident was a stable patient that he was very familiar with and that there could be minimal complications if the resident's shunt site was not monitored on a daily basis. 415.11(c)(1)

Based on interviews and record review during an abbreviated survey, the facility did not notify the resident ' s legal representative or an interested family member when there was a need to alter treatment significantly. This was evident for 1 of 3 sampled residents (Resident #1). Specifically, the Physician ordered a Surgical Wound Consultation to evaluate for surgical wound debridement of Resident #1 ' s unstageable pressure ulcer. The Surgical Wound Consultant debrided the pressure ulcer. There was no evidence that the resident ' s family was notified of the debridement prior to the procedure. Complaint # NY 118 The findings include: Resident #1 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 6/19/15 Minimum Data Set (MDS) 3.0 documented that the resident ' s cognitive skills were moderately impaired. The 6/12/15 weekly [MEDICAL CONDITION] assessment documented that the resident ' s left buttock pressure ulcer measured 13 centimeter (cm) x 7 cm with eschar. The 6/23/15 physician's order [REDACTED]. The 6/24/15 surgical wound consultation note documented that the consultation was requested for debridement of the pressure ulcer. The consultant ' s findings and recommendations documented that the resident had a decubitus ulcer to the left gluteal area, elongated measuring 12 cm x 4.5 cm with tapering ends covered with necrotic tissue. The consultant ' s note documented that the debridement procedure was done and suggested to wash the area with soap and water and cover with dry gauze. The 6/25/15 nurse ' s progress note documented that the resident was seen by the doctor for a bedside debridement of the left buttock wound. The resident ' s medical record from 6/23/15 to 6/30/15 had no documented evidence that the resident ' s family was notified of the debridement of the pressure ulcer. The 7/1/15 nurse ' s note at 8:10AM documented that the resident ' s husband came to the unit at 6:50AM and wanted his wife to be transferred to the hospital because he stated that someone performed surgery on his wife. The 7/1/15 nurse ' s note at 2:36PM documented that at 7:00AM the nurse observed that the resident ' s husband appeared very upset. The husband stated someone performed surgery on my wife without my consent and I already called 911. The facility ' s 9/2012 Policy and Procedure for Notification of Condition Change documented that the facility immediately informs the resident ' s health care surrogate or health care proxy when there is a significant change in status or condition, such as new pressure ulcer, infection, changes in medication or treatment plan. The primary physician/designee notifies the resident's health care surrogate or proxy when there is a need to alter treatment significantly, such as commencing a new form of treatment. The facility had no notification policy and procedure specific to bedside debridement. On 12/14/15 at 2:02PM, an interview was conducted with the Registered Nurse Manager (RNM). The RNM stated that the nurse reports to the physician of the condition of the wound. The physician assesses the pressure ulcer and decides if a surgical consultation is needed for possible debridement. The RNM stated that the Attending Physician ordered a surgical consultation for Resident #1, and a surgeon came and performed a bedside debridement. The RNM stated that the facility does not have specific protocol about bedside debridement. She stated that the Attending Physician usually informs the family about surgical procedures. The RNM stated that she was not sure if Resident #1 ' s husband was informed of the debridement. The RNM stated that she did not see any documentation in the medical record that the husband was informed about the debridement. On 12/14/15 at 2:32PM, an interview was conducted with the Attending Physician. The Physician stated that if she sees something in the wound that needs further intervention, she makes a referral for a surgery consult. The Physician stated that the surgeon evaluates the wound and makes a determination if a debridement is needed, then debrides the wound at bedside. The Physician stated that she would not call to inform the family if it is not a life threatening situation or doing something as part of the routine care. The Physician stated that she told Resident #1 ' s husband that she will take care of the wounds, but did not specifically discuss that the wound would be debrided because it is part of routine wound care. The Physician stated that the family consent is not required to do a surgery consult, but the surgeon who is doing the procedure should notify the family. On 12/14/15 at 4:16PM, an interview was conducted with the Clinical Director of Nursing (CDON). The CDON stated that the Attending Physician orders [REDACTED]. The CDON stated that the Attending Physician will discuss with the family about treatment plans, such as debridement. The CDON stated that the facility does not have specific policy for bedside debridement. On 1/6/16 at 12:34PM, an interview was conducted with the Surgical Consultant. The Consultant stated that she observed a necrotic tissue on Resident #1 ' s left gluteal area and performed debridement of the wound. She stated that normally she does not call the family for wound debridement, unless she gets a specific request. She stated that her understanding was that the Attending Physician would inform the family of the treatment plan when the surgical consult request is written. She stated that the Attending Physician or the unit staff should have called and informed the family about the wound debridement. 415.3(3)(2)(ii)(c)

Based on observations, record review and interviews the facility did not ensure that Infection Control Procedures were followed during the Medication Pass observation. Specifically, a Registered Nurse (RN): 1. failed to adhere to hand hygiene practices prior to preparing and administering an injectable medication. 2. failed to don Personal Protective Equipment (PPE) - (a yellow paper gown) prior to entering a resident's room who is on Contact Precautions. This resulted in no actual harm with potential for more than minimal harm. The finding is: On 4/15/15, at 5:31 PM approximately, the RN was observed during Medication Pass. The RN did not wash his hands with soap and water before he donned a pair of latex gloves, cleaned the top of the [MEDICATION NAME] Insulin bottle with an alcohol prep pad and withdrew 8 units of insulin into a Insulin Syringe. He walked past a cart containing PPE directly outside of the resident's room. The RN walked past two (2) posted signs that read " See nurse before entering." These signs were posted on the right and left of the doorway. When he reached the resident's bed he turned and waved his hand for this State Agent (SA) to enter the room. Immediately, the SA inquired about the signs stating: "Please see Nurse before entering." The RN immediately exited the room and stated that the resident is on Contact precautions and named the organism. The RN stated that he forgot to wear a gown. The RN immediately removed his gloves and put on a yellow isolation gown. He dons a new pair of latex gloves, entered the room and administered the Insulin to Resident #662. He removed his gloves and gown inside the resident's bathroom and discarded them in the garbage. After leaving the resident's room, the RN washed his hands with soap and water at the sink located in the hallway. On 4/16/15 the facility's Infection Prevention and Control Policy/Procedure was reviewed. Subject: Clostridium Difficile (C. diff): protocol. It documented: this policy provides guidelines for control and prevention of the spread of [DIAGNOSES REDACTED]. Under treatment, the following is documented: # 8. Wash hands with antimicrobial soap and water when caring for patients/residents with [DIAGNOSES REDACTED]icile. #9. Staff will wear the appropriate PPEs (i.e. gloves, gown) when providing care. On 4/15/15 at approximately 5:43 PM the RN was interviewed and stated that he forgot to put on the PPE. He stated that he knows that the resident is on contact precautions and he should wear PPE before entering the room when he is providing care to the resident. He stated that approximately two (2) weeks ago he received In-service on the facility's Policy and Procedure of hand hygiene and Infection control. Lastly, he stated that he knows he should have washed his hands before administering the injection to the resident and after the administration of Insulin to the resident. On 4/16/15, at approximately 2:36 PM, an interview with the Inservice Educator (an RN) was conducted. She stated that when the GI (gastrointestinal) outbreak occurred there was a team effort to in-service the entire staff on Infection Prevention and Control. All of the staff on all shifts and in all departments were included in the In-Services. 415.19(a)(1-3)

Based on record review and interviews, the facility did not ensure that expired residents' funds were conveyed within 30 days. This was evident 3 of 3 closed records reviewed for Personal Funds (Resident #s 959, 550, and 961). This resulted in potential for no more than minimal harm. The findings are: 1) Resident #959 was a [AGE] year-old who expired in the facility on [DATE]. The Resident Trust Fund Statement dated [DATE] documented that a check withdrawal was made on [DATE] for the total amount of the resident's funds ($4040.63). A letter addressed to the Public Administrator dated [DATE] with an enclosed copy of a check documented that the balance of $ 4040.63 was disbursed from the residents' account. 2) Resident #961 was a [AGE] year-old who expired on [DATE]. The Resident Trust Fund Statement dated [DATE] documented that a check withdrawal was made on [DATE] for the total amount of the resident's funds ($12.00) A letter addressed to the Public Administrator dated [DATE] with an enclosed copy of a check documented that the balance of $ 12.00 was disbursed from the residents' account. 3) Resident # 550 was a [AGE] year-old who expired on [DATE]. The Resident Trust Fund Statement dated [DATE] documented that a check withdrawal was made on [DATE] for the total amount of the resident's funds ($978.87) A letter addressed to the Public Administrator dated [DATE] with an enclosed copy of a check documented that the balance of $978.87 was disbursed from the residents' account. The resident's funds for residents # 959, # 961, and # 550 were not disbursed within 30 days. On [DATE] at 1:38 PM, the Vice President of Finance was interviewed and stated that we wait 30 days to allow time for the billing statement to be processed. He further stated that after 30 days, any money the resident has can be used to pay money owed or it can be disbursed to the family or the public administrator. The Facility policy for Residents' Personal Accounts- Refunds Upon discharge date d ,[DATE] documented: "...After 30 days, the patient's Inpatient Account will be checked to see if a private pay balance still exists. If so, the PIA balance will be applied to the patient's Inpatient Account as per the admission agreement. If the patient's private pay Inpatient balance has been satisfied, the refund will be processed. If the patient has died : The Finance Department will release funds according to the estate laws of New York State....For all...Medicaid residents, where there is not request for the resident's personal account, the Finance Department will forward the funds to the Public Administrator...". 415.26(h)(5)(iv)

Based on observations, resident and family interviews and record reviews during a Recertification Survey, the facility did not ensure sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. Specifically, 2 of 17 alert and lucid residents interviewed in Stage one (Residents #627 and 868), stated that there is not enough staff available to make sure the care and assistance they need is received without having to wait a long time. One of three family interviews for Resident #593 reported that there was not enough staff available in this facility to make sure that residents obtained the care and assistance they required without having to wait a long time. The Facility's Floor Community Monthly Meeting Minutes for 5 months ( September 2011 through January 2012) documented 4 resident complaints regarding inadequate staffing and delayed call bell response on three different units. This resulted in no actual harm with a potential for more than minimal harm, which is not an immediate jeopardy. The finding is: During stage 1 census sample interviews on 1/2/12 and 1/3/12, with (17) alert and lucid resident's ( two residents, #627 and #868 ) stated that they did not feel there is enough staff available to make sure they received the care and assistance they needed without having to wait a long time. Resident 627 stated :"I think they can improve on staffing, I think they need more help." Resident 868 stated that, " I wait for 2-3 hrs, they are always complaining, they say sometimes they need two people, have to go for lunch, go on their break, or there is another patient in the bathroom." During stage 1 census family interviews conducted on 1/2/12 and 1/3/12, one (resident #593) out of three families interviewed stated that they did not feel there was enough staff available to make sure they obtained the care and assistance they needed without having to wait a long time. A total of 5 Certified Nurses Assistants were interviewed on 2/6/12 between 1:30 and 2:30 PM. CNA # 3 stated that 3-4 days out of 5 she cares for 11 residents. She stated that, "the management says we are short, sometimes it's very hard because the resident's are waiting for you, you can do only so much and can only go that fast. If some one is on break, there is only one person to answer bells, it gets crazy. Sometimes 3-4 residents want to go to the toilet or want to get things done at the same time. You can only help one resident at a time. Nurses usually call down to see if we can get extra staff, but it does not happen". Floor Community Monthly Meeting Minutes for 5 months ( September 2011 through January 2012) documented 4 resident (September 2011, 8th Floor, October 2011, 4th floor, December 2011, 6th floor and January 2012, 4th floor) complaints regarding inadequate staffing and delayed call bell response. The following resident complaints regarding care were documented in the Facility's Community Monthly meeting minutes: 8th Floor 9/6/11 Meeting: One resident, stated, "often time when in bed for the evening resident will ring the bell for assistance. If her CNA is on break no one answers the bell until her CNA comes back from break, She believes more CNA's are needed on specific shifts, one is not enough. The resident also complained about Breakfast starting late because all staff is not present." 4th Floor 10/11/11 Meeting: One resident stated that the CNA's take too long to answer the call bell, also stated that the CNA's worked very hard. Another resident stated that food needs to be cut up for him and by the time they do it and he gets the tray the food is cold." 6th floor, 12/29/11 Meeting: One resident stated that at certain hours of the day, especially meal times, there are no staff behind the nursing desk. 4th Floor 1/17/12 Meeting: One resident alleged that the aides seem to take their dinner break all at the same time and are not available to toilet residents, after residents eat. Director of Recreation was interviewed on 2/7/12 at 2:00PM. He stated that his Department schedules and facilitates the Floor Community Monthly Meetings. He stated that the Departments are present at the meetings so they should resolve issues pertaining to their disciplines. He also stated that if the relevant Department is not present for the issues raised, he personally fills out a form and delivers it to the Department head, who has 10 days to resolve, the issue. He stated that a copy of the form and the response goes to the next Community meeting. During interviews of direct care staff, a staff member who requested to remain anonymous stated that the unit he was assigned to (a long term care unit) is frequently short of staff on the evening shift. The staff member stated that there is usually one nurse to cover both the northeast and northwest side of the building on which 42 residents reside and that there have been times when one nurse covered the whole floor, which included northeast,(NE) northwest (NW) and southeast (SE), southwest (SW). The staff member further stated that there is usually only one CNA (Certified Nursing Assistant) assigned to the NE and the NW and when one is on break then there is only one CNA to cover the whole unit. The staff member stated at times he had heard staff be short with the residents, telling them that they don't have time to help them because they are the only CNA on the unit or that they went to the bathroom [ROOM NUMBER] hours ago and they would have to wait. The staff member stated that he knows the residents on the unit well and that they frequently ask him for help and have told him that staff will answer the call bell and tell them they will be back and they don't come back for long periods of time or they are told that they have to wait for their CNA to return from dinner break. The Staff member stated that he has to explain to the residents that there are certain things he can't do for them (i.e.: assist to the toilet, help them get in and/or out of bed.) He further stated he would go to the nurse or CNA and let them know when a resident required assistance. The staff member also stated that he has reported responses by a CNA to the nurse that he felt were inappropriate. An evening tour was conducted on the 8 South Dementia Unit on 2/6/12 at 4:30 PM. Observations of the staffing included: *there are 2 sides to the unit east and west, on each side there are "clusters" which include 2-3 tables positioned together where residents are seated for the day for meals, and activities. There is a TV at each cluster. On entrance to the unit there were 2 CNA staff observed to be seated at the first SE cluster with 4-5 residents. One CNA was looking at a magazine, the other CNA was just sitting, neither was engaged with the residents at the table. At the center cluster on the 8 SE unit 5 residents were seated at the table, one resident in a room adjacent to the cluster was calling out and had removed her nightgown, there were no staff visible at this cluster. At the 3rd SE cluster 6 residents were seated at a table, the TV was on, there were no staff present. On the SW side of the unit 4 residents were seated at a cluster the TV was on, a nurse and a unit receptionist were at the nursing desk which was visible from the cluster and is located on the SW side of the unit. The Nurse stated that there was an evening nurse on and that she (the day nurse) was leaving for the day along with the unit receptionist. At the 5th cluster on the SW side of the unit 5 residents were observed to be seated at the table with the TV on. A staff member was observed to be in a room caring for a resident. At the 6th SW cluster 5 residents were seated at the table and no staff were present. During an interview on 2/6/12 at 5:15 PM with a CNA that is assigned to the unit, the CNA stated that there are usually 4-5 CNA's on the unit and 1 nurse. The CNA stated that she is usually assigned 8-9 residents and sometimes more depending on staffing, and that all the residents require total care including feeding. The CNA stated that some of the residents may pick at their food but due to dementia they have to be assisted to complete a meal. The CNA stated that there are many times that they are still feeding resident's at 7 PM. During an interview on 2/6/12 at 5:30 PM, with the 8 South unit Licensed Practical Nurse (LPN), she stated that she was the only nurse on the unit to do all the medications and treatments. The LPN stated that due to Dementia some residents take longer to administer their medications to. The LPN stated that the CNA's know their assignments and are responsible to cover each other and to monitor all the clusters. The Director of Nursing was interviewed on 2/7/12 at 2:30PM. She stated that she had not been made aware of any staffing issues raised in the Floor Community Monthly Meetings. The DNS acknowledged there was a problem with employee staffing and further stated that she was not aware of residents' concerns regarding long wait times for call bells. She stated residents should not have to wait a long time to receive care. 415.13(a)(1)(i-iii)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that Accident/Incidents (A/I) were thoroughly investigated for 1 of 3 records reviewed for A/I in a total of 32 sampled residents (Resident # 369). This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The finding is: Resident # 369 has [DIAGNOSES REDACTED]. The progress notes documented that on 1/19/12 at 9:15 AM, the resident was found sitting on the wheelchair pedal in her room. "She was trying to reach the side table and slid down". The resident sustained [REDACTED]. On 2/2/12 at 10:00 AM the resident was interviewed and stated she was trying to go to bathroom, lost her balance and fell . The resident was not able to recall where the call bell was situated on the day of the fall. The Comprehensive Care Plan (CCP) dated 1/9/12 identified the resident as being at risk for falls. Interventions included "Ensure call bell is in reach". The Minimum Data Set ((MDS) dated [DATE] documented that the resident is able to understand and be understood and the resident had a fall in the last 2-6 months. The resident required extensive assistance with one person physical assistance in transfers (how resident moves between surfaces including to or from: bed, chair, wheelchair) and required extensive assistance with one person physical assistance to be in a standing position (excludes to/from bath/toilet). The residents occurrence report dated 1/19/12 documented that the resident's call bell was not available and was not within reach. The report did not document an investigation to determine whether or not the resident had requested assistance prior to the fall to rule out neglect. On 2/7/12 at 12:15 PM , the Registered Nurse (RN) Manager was interviewed and stated that the call bell was not in reach before the resident fall due to the resident turning her wheelchair away from the bed. She further stated that she recalls the resident's call bell light was not on at the time of the incident and this should have been documented in the report. 415.4(b)(l)(ii)

Based on staff interviews and record review during an abbreviated survey the facility failed to ensure that residents were free of significant medication errors as evidenced by: A Physician wrote an incomplete order for [MEDICATION NAME] R Insulin. The order did not specify the dose to be administered to the resident. The incomplete order written by the Physician was not reconciled and the resident subsequently received a high dose of [MEDICATION NAME] R Insulin resulting in a significant medication error and hospitalization . This was evidenced in 1 of 5 residents (Resident is #1). This resulted in actual harm for Resident #1 and the potential for serious harm for all Diabetic residents that is Immediate Jeopardy to resident health and safety and substandard quality of care. Complaint # NY 399 The findings are: Resident #1 was admitted to the facility for short term rehabilitation and pain management at approximately 11:30AM on Saturday [DATE]. Her [DIAGNOSES REDACTED]. She required assistance with transfers and ambulation. Resident #1 ' s [DATE]-12:37PM Medication order (ID# 1) was written for " [MEDICATION NAME] R 100 unit/mL Injection-Inject by subcutaneous route 3 times per day every day at 7:00AM; 11:00AM; 4:00PM. Monitor Blood Sugar for [DIAGNOSES REDACTED]. The order did not specify the dosage for sliding scale Regular Insulin coverage. The [DATE] 12:53PM Admitting Physician #1 ' s Progress note indicated that the " admission is done, History and Physical is in the chart " . The Admitting History and Physical noted that Resident #1 was on " [MEDICATION NAME] 5 mg. daily by mouth and sliding scale coverage with Regular insulin " for Diabetes. The [DATE]-12:48PM Nursing progress note recorded that alert and responsive Resident #1 felt " cold and clammy " and a finger stick blood sugar (F/S) of 226mg/dLwas obtained. The Admitting Physician (#1) was made aware of this reading and gave a verbal order to administer 2 units insulin. Resident #1 ' s Medication Administration Record (MAR) documented that [MEDICATION NAME] R 100 unit/mL injection was administered on [DATE] at 1:33PM. No insulin dosage appears on the MAR entry. During a [DATE]-11AM interview with the [DATE] 7AM- 3PM Licensed Practical Nurse (LPN) #1 who authored the [DATE] 12:48PM nursing note she stated that 2 units of [MEDICATION NAME] R Insulin were administered to Resident #1 at approximately 12:15PM based on the Physician ' s verbal order. LPN #1 stated that she thought that Physician #1 was going to include insulin coverage on the admitting orders which were in process. LPN #1 noted she was not able to enter the administration of the medication in the Sigma Care system at the time it was actually administered and that the Medication Administration Record (MAR) registered a later time. She further stated that she and Physician #1 had no further discussion concerning Resident #1 ' s ongoing diabetic management. She further stated that she did not reconcile the physician's order [REDACTED]. Registered Nurse (RN) #4 who performed Resident #1 ' s [DATE] nursing admission assessment and wrote a [DATE]-12:08AM Nursing Progress note was interviewed on [DATE] at 3:55PM. He stated that he performed the assessment between 3:30 and 4PM and that the resident was stable. RN #4 stated that he told the assigned ,[DATE]PM LPN #2 to reconcile the resident ' s insulin orders with the Physician as the medication order did not clarify how much insulin should be given. He stated that he was assigned to another unit that evening and did not reconcile Resident #1 ' s physician's order [REDACTED]. The Medication Administration Record (MAR) documented that no insulin was administered to Resident #1 during the [DATE] ,[DATE]PM shift. The [DATE] (11PM-7AM) progress notes continued to describe Resident #1 as alert, responsive and in no acute distress. The Medication Administration Record (MAR) documented that [MEDICATION NAME] R 100unit/mL injection was administered on [DATE] at 6:50AM by Registered Nurse #5. During a [DATE] 6AM interview with Registered Nurse #5 assigned to Resident #1 on the [DATE] 11PM-7AM) shift she stated that the resident ' s F/S was 185 mg/dL that morning; and that she did not administer the 6:50AM insulin dose that was documented in the MAR. She further stated that she " reconciled and signed the physician's order [REDACTED]. Resident #1 ' s MAR documented the [DATE]-12:35PM administration of [MEDICATION NAME] R 100 unit/mL injection and F/S of 300, by the [DATE], 7AM-3PM Licensed Practical Nurse #1. During the [DATE]-11AM interview with the [DATE] 7AM-3PM Licensed Practical Nurse (LPN) #1 she stated that when she obtained the F/S of 300 mg/dL she called Physician #3 who advised that LPN #1 hold insulin coverage for Resident #1 and that a note would be documented to reflect this Physician order. An addendum Physician #3 order dated [DATE]-11:08AM stated " Please note for [DATE] for finger stick glucose of 300 told nursing staff (LPN #1) no insulin coverage for this finger stick glucose times one and told nursing staff I would write the prescription to hold this insulin coverage but I forgot to enter it in the computer for this finger stick glucose at 12 Noon on [DATE]. Resident (#1) received no insulin coverage for this finger stick glucose " . Resident #1 ' s MAR documented a [DATE]-5:28PM F/S of 301mg/dL and the administration of [MEDICATION NAME] R 100 unit/mL injection by the [DATE], ,[DATE]PM Licensed Practical Nurse #2, who had worked the previous evening and been asked to clarify the insulin order. Licensed Practical Nurse (LPN) #2 who had worked the preceding evening and had been asked to clarify the insulin order was assigned to Resident #1 on the [DATE] ,[DATE]PM shift. The progress note she authored on [DATE] at 11:08PM stated that the resident was stable and had no complaint of pain. LPN #2 ' s [DATE] statement in the [DATE] facility investigation read " I administered dose 100u/mL to patient ...I gave insulin after dinner ...No signs/symptoms of [DIAGNOSES REDACTED] noted at that time. Patient alert and responsive " . A [DATE] statement in the facility investigation from the [DATE] (11PM-7AM) Licensed Practical Nurse #3 indicated that Resident #1 was awakened for Tylenol administration on [DATE] at 1AM and returned to sleep. Resident #1 ' s MAR documented a [DATE]-7:43AM F/S of 136 mg/dL and the administration of [MEDICATION NAME] R 100 unit/mL injection by the ,[DATE]-,[DATE], 11PM-7AM, Licensed Practical Nurse #3. No Insulin dose appeared on the Medication Administration Record (MAR) entry. During a [DATE]-6:20AM interview with the [DATE] (11PM-7AM) LPN #3 she stated that she was in process of order reconciliation for the resident ' s [MEDICATION NAME] when she was alerted by staff that Resident #1 was not responsive. She stated that she had made an error in the MAR and entered 136 mg/dL but that the glucometer reading actually registered " Lo " . LPN #3 stated that she " absolutely did not administer any insulin to the resident " and was not aware that the MAR documented that it had been administered. She stated that RN#5 and Physician #3 responded immediately and 911 was called. The [DATE]-7:04AM Physician #3 Progress Note documented that Resident #1 was unresponsive with F/S reading of 29mg/dL. Two amps of [MEDICATION NAME] and D50 and D5W were given intravenously and the F/S rose to 288 mg/dL, but the resident remained unresponsive and was transferred to the emergency room and was admitted to the hospital. The receiving hospital advised that the resident expired on [DATE]. During a [DATE] 9:30AM interview with the Vice President of Patient Care Services she stated that the facility uses a " triple fail-safe " system where in the Physician, Nurses and Pharmacy review orders to ensure they are correct. She noted that the Pharmacy was not staffed on the holiday weekend and did not review the order. During a [DATE] 12:15PM interview with the Assistant Vice President of Quality Management and Regulatory Affairs she stated that insulin is a stock item on the nursing units and was readily available. During a [DATE] 12:30PM interview with the Clinical Director of Nursing she stated that the staff that signed for administration of [MEDICATION NAME] R 100 units on [DATE] at 6:50AM, on [DATE] at 12:35PM and [DATE] at 7:39AM did not correctly enter data in the electronic medical record system to reflect that the medication was not administered. During a [DATE] 2:20PM interview with the day shift Registered Nurse Supervisor (#6) she stated that three nursing medication reviews were required for reconciliation when orders and medication administration records were in paper format. The current electronic system requires two nursing staff to review and reconcile MD orders. She stated that every shift is responsible to look at the reconciliation screen where the orders pop up and call the Physician if there is a question concerning an order. The ,[DATE] policy for " Medications: 28 day cyclic reorder " designated that once the paper orders were picked up and implemented by staff on the ,[DATE] and ,[DATE] shifts they were to be checked by the nurse on the next two shifts to ensure that they have been picked up correctly. This policy preceded the introduction of the Electronic Medical Records which were implemented in [DATE]. During a [DATE] 3PM interview with the Vice President of Patient Care Services she stated the facility would review and update the medication reconciliation policies and reorganize them to include the electronic medical record format. The nursing staff has been in-serviced regarding reconciliation procedures. The facility implemented corrective actions to remove the immediacy and completed the following interventions prior to the team exit resulting in an IJ Removed designation. The facility has initiated a plan of correction that included the discipline and suspension of a Medical Doctor and a Licensed Practical Nurse relative to a significant medication error; counseling was provided to the nurses who were responsible for checking and reconciling the physician's order [REDACTED]. scale insulin. Audits are being conducted of all Comprehensive Care Plans for residents with the [DIAGNOSES REDACTED]. 415.12(m)(2)

Based on staff interviews and record review during an abbreviated survey Physician #1 did not ensure that a physician's order [REDACTED]. An order was written for insulin without specific dosage or sliding scale parameters and the resident received a high dose of [MEDICATION NAME] R insulin. This resulted in a significant medication error and hospitalization . This was evidenced in one of five residents. (Resident is #1) This resulted in actual harm for Resident #1 and the potential for serious harm for all Diabetic residents that is Immediate Jeopardy to resident health and safety. Complaint # NY 399 Resident #1 was to the facility at approximately 11:30AM on Saturday 7/2/11. Her [DIAGNOSES REDACTED]. The resident was admitted to the facility for short term rehabilitation and pain management and required assistance with transfers and ambulation. Resident #1 ' s 7/2/11-12:37PM Medication order (ID# 1) was written for " [MEDICATION NAME] R 100 unit/mL Injection-Inject by subcutaneous route 3 times per day every day at 7:00AM; 11:00AM; 4:00PM. Monitor Blood Sugar for [DIAGNOSES REDACTED]. The order did not contain dosage (# of units) and no parameters were set for the sliding scale Insulin coverage. The 7/2/11 12:53PM Physician #1 ' s Progress note indicated that the " admission is done, History and Physical is in the chart " . The Admitting History and Physical noted that Resident #1 was on " [MEDICATION NAME] 5 mg. daily by mouth and sliding scale coverage with Regular insulin " for Diabetes. Resident #1 ' s MAR indicated [REDACTED]. LPN #2 administered 100 units of [MEDICATION NAME] R (Regular) insulin. The Licensed Practical Nurse (LPN #2) who had worked 7/2/11 3-11PM and had been asked to clarify the order by the Admitting Registered Nurse (#4) was assigned to Resident #1 on the 7/3/11 3-11PM shift. The progress note she authored on 7/3/11 at 11:08PM stated that the resident was stable and had no complaint of pain. The 7/3/11 3-11PM LPN #2 ' s 7/4/11 statement in the 7/11/11 facility investigation read " I administered a dose of 100u/mL to patient ...I gave insulin after dinner ...No signs/symptoms of [DIAGNOSES REDACTED] noted at that time. Patient alert and responsive " . During a 7/11/11 2:45PM interview with the on-call Physician (#3) who worked on 7/3/11 and 7/4/11, she stated that Physicians can use a built in protocol for sliding scale insulin coverage (as per Sigma Care Electronic Records) or design their own; specifying the timing and frequency of finger stick (F/S) and coverage dosing. The Physician stated that during a resident ' s initial adjustment to the facility there is often a concern about appetite and that sliding scale coverage is indicated. She observed that Resident # 1 ' s 7/2/11 [MEDICATION NAME] order was not complete. Physician #3 responded to the unit at 6AM on 7/4/11 finding Resident #1 unresponsive with a finger stick blood sugar (F/S) of 29 mg/dL (The American Diabetic Association ' s acceptable range for a person with a [DIAGNOSES REDACTED]. The Physician also observed that the resident had co-morbidities that might have been factors in her change of condition. During a 7/13/11 3:30PM interview with the Medical Director he stated that 100% of the Physicians had been re-inserviced regarding complete orders. The Medical Director understood that both Physician #1 and the 7/2/11 7AM-3PM Licensed Practical Nurse (#1)both thought that they had entered a sliding scale protocol and had discussed the meal schedule for Resident #1 before the Physician was called for two emergencies and asked staff to call for any additional questions. The 1/6/11 Pharmacy Policy and Procedure for Medication Orders stated " Physician ' s medication orders will be accurately written by the physician to include the name, dose, frequency and route and when received electronically by the Pharmacy will be processed in a timely manner to ensure accurate administration of all physician's order [REDACTED]. The facility implemented corrective actions to remove the immediacy and completed the following interventions prior to the team exit resulting in an IJ Removed designation. The facility initiated a plan of correction that included the discipline and suspension of the Medical Doctor (Physician #1)who initiated the order and 8/8 Physicians were provided with in-service education reviewing the criteria for orders involving diabetic care and treatment including sliding scale insulin. 415.15(b)(2)(iii)