Every finding on record at South Shore Rehabilitation And Nursing Center

Based on observation, record review, and staff interviews, during the Recertification Survey initiated on 08/11/2025 and completed on 08/15/2025, the facility did not maintain an effective pest control program. This was identified during the kitchen task. Specifically, the exit door from the kitchen, which is used to remove refuse and leads to the parking lot and garbage disposal bins, had an approximate half-inch gap at the bottom of the door.This is a repeat citation.The finding is:The undated facility policy titled Pest Control documented to maintenance of an effective pest control system. The facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents.On 08/11/2025 at 10:15 AM, during the initial kitchen tour conducted with the Food Service Director (Staff #7), the kitchen exit door leading to the parking lot and garbage disposal bins was observed to have an approximate half-inch gap at the bottom of the door.During an interview on 08/11/2025 at 10:15 AM, the Food Service Director stated they were unaware of the gap at the kitchen exit door. During an interview on 08/12/2025 at 2:32 PM, the Director of Environmental Services (Staff #6) stated the facility was cited for the same issue during the previous survey back in 2024, and the issue was addressed by installing a door sweep. The Director of Environmental Services stated they observed the sweep in place last week but believed it may have been dislodged by delivery staff. The Director of Environmental Services stated they found the door sweep on the floor near the area on 08/11/2025 and reinstalled it. The Director of Environmental Services stated that the door sweep served to deter both water intrusion and pests.During an interview on 08/12/2025 at 3:18 PM, the Administrator was interviewed and stated the door was immediately fixed following the previous survey and that a door sweep was installed to prevent water and pest entry. The Administrator stated they believed a food delivery staff knocked the door sweep loose and that it was later found under a nearby counter.10 NYCRR 415.29 (J)(5)

Based on record review and interviews during the Recertification Survey initiated on 08/11/2025 and completed on 08/15/2025, the facility did not ensure that Physician Responses (actions) documented on Monthly Medication Regimen Reviews were carried out to address irregularities identified by the Pharmacist. This was identified for three (3) (Resident #1, #32, and #12) of five (5) residents reviewed for Unnecessary Medications. Specifically, recommendations were provided by the Pharmacy consultant on the Medication Regimen Review Form for Resident #1, Resident #32, and Resident #12; however, the recommendations were not implemented, and there was no documented evidence in the residents' medical records that the identified irregularities were reviewed and what, if any, actions were taken to address the irregularities. The findings are: The facility's undated policy titled, Pharmacy Drug Regimen Reviews, documented the Consultant Pharmacist shall identify, document, and report possible medication irregularities for review and action by the Attending (Primary) Physician when appropriate. The Attending (Primary) Physician or licensed designee shall respond to the Drug Regimen Review within seven (7) days of receipt. The Primary Care Physician must document on the Drug Regimen Review Sheet if they agree or disagree with the recommendation and provide a brief clinical rationale if no change is to be made. The Primary Care Physician is responsible for completing the Drug Regimen Review Sheet to ensure compliance with the acceptable time frame for completion. The Medical Director will review the Drug Regimen Review Sheets on a regular basis and ensure the Physicians are compliant with documentation. 1) Resident #1 was admitted with diagnoses including Respiratory Failure, Cerebrovascular Accident, and Benign Prostatic Hyperplasia (prostate gland enlargement, potentially causing urinary problems). The 07/29/2025 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 1, indicating the resident had severe cognitive impairment. The physician's order, originally ordered on 04/23/2025 and most recently renewed on 08/05/2025, documented Flomax Oral Capsule 0.4 milligram (Tamsulosin HCl), give one (1) capsule via Gastrostomy Tube (feeding tube into stomach) in the evening for Benign Prostatic Hyperplasia. Review of the July 2025 and August 2025 Medication Administration Records revealed the resident received Flomax every day in July and in August 2025, until 08/06/2025. The medication was discontinued on 08/15/2025. A Pharmacy Monthly Medication Regimen Review dated 06/29/2025 documented Resident #1 has an order for Flomax via Gastrostomy-tube. This capsule should not be opened. Consider changing to Rapaflo. The response dated 07/01/2025 was documented by the Director of Nursing Services: Physician consulted. There was no documented evidence in the resident's medical record that the identified irregularity had been reviewed by the Physician, and what, if any, actions had been taken to address it. A Pharmacy Monthly Medication Regimen Review dated 08/08/2025 documented Resident has an order for Flomax via G-tube. This capsule should not be opened. Consider changing to Rapaflo. The response dated 08/11/2025 was documented by the Director of Nursing Services: continue with Rapaflo after delivery from pharmacy. There was no documented evidence in the resident's medical record that the identified irregularity had been reviewed by the Physician, and what, if any, actions had been taken to address it. During an interview on 08/13/2025 at 10:30 AM with the facility's pharmacy medication provider, Pharmacist #1 stated we have not received an order from the facility for Rapaflo; the last order for Flomax was 08/05/2025; Rapaflo was never ordered. As per the Flomax manufacturer's Highlights of Prescribing Information dated January 2016, the Flomax capsule should be swallowed whole and not opened or crushed due to the risk of increased side effects, including Hypotension (low blood pressure). During an interview on 08/13/2025 at 10:35 AM, the Director of Nursing Services stated that they signed the Medication Regimen Reviews and not the Physician. The Director of Nursing Services acknowledged that Rapaflo had not been ordered even though the responses on the Medication Regimen Reviews indicate that Flomax was supposed to be changed to Rapaflo. A physician's order dated 08/13/2025 documented Rapaflo Oral Capsule 4 milligram (Silodosin), give 1 capsule via G-Tube in the evening for Benign Prostatic Hyperplasia. 2) Resident #32 was admitted with diagnoses including Iron Deficiency Anemia (a condition in which the body does not have enough iron to produce healthy red blood cells). A Quarterly Minimum Data Set assessment dated [DATE] documented that a Brief Interview for Mental Status was not conducted because the resident was rarely or never understood, and the resident had severely impaired cognitive skills for daily decision making. The Minimum Data Set Assessment documented the resident had a feeding tube during the assessment period. A Comprehensive Care Plan titled Anemia last revised 02/19/2025, documented interventions including encouraging intake of food high in iron and Vitamin C, monitoring and reporting signs and symptoms of Anemia, and giving medications as ordered. A Physician's order dated 06/18/2025 documented to administer Ferrous Sulfate 325 milligram Tablet, one (1) tablet via a percutaneous endoscopic gastrostomy tube (a type of feeding tube) one (1) time a day for Anemia. The Medication Regimen Review dated 06/20/2025 documented the pharmacy recommendations, including to consider changing the Ferrous sulfate tablet to liquid form via a feeding tube. A response to the Medication Regimen Review dated 06/21/2025 documented that the Physician agreed to the recommendation. The response was signed by the Director of Nursing Services. There was no signature documented from the attending physician or the Medical Director on the Medication Regimen Review. The Medication Regimen Review dated 07/29/2025 documented pharmacy recommendations, including to consider changing Ferrous sulfate tablet to a liquid form for administration via a feeding tube. A response dated 07/31/2025 documented that the Physician agreed with the recommendation to change the Ferrous sulfate tablet to liquid form. The Medication Regimen Review form was signed by the Director of Nursing Services, and there were no signatures documented on the form by the attending physician or the Medical Director. A review of the Medication Administration Record from 06/2025 to 08/2025 revealed Resident #32 received Ferrous Sulfate 325 milligrams via a percutaneous endoscopic gastrostomy tube in tablet form. There was no documented evidence that the Physician's Order for Ferrous Sulfate for Resident #32 was changed from tablet form to liquid form following the pharmacy recommendations on 06/20/2025 and 07/29/2025. 3) Resident #12 has diagnoses that include Crohn's Disease (a type of inflammatory bowel disease that causes swelling and irritation of the tissues, called inflammation, in the digestive tract) and Anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues). The admission Minimum Data Set assessment dated 05.15.2025 documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognitive skills for daily decision making. The Physician's Order dated 05/23/2025 and last renewed on 07/22/2025 documented for the resident to receive Retacrit Injection solution 10000 units/milliliter (Epoetin Alfa-epbx) - inject 10000 units subcutaneously one time a day every Monday, Wednesday, and Friday for Anemia The Medication Regimen Review dated 07/28/2025 documented: Resident on Retacrit for Anemia. Consider adding Ferrous Sulfate. The response was documented by the Director of Nursing Services on 07/30/2025: Agree, Physician (MD) consulted. The Monthly Medication Regimen Review was not signed by the resident's Primary Care Physician. Review of the resident's Electronic Medical Record on 08/14/2025 at 11:30 AM revealed the resident was not receiving and had never received Ferrous Sulfate. During an interview on 08/14/2025 at 01:47 PM, the Director of Nursing Services stated they review the Medication Regimen Reviews for the facility and notify the attending physicians through electronic correspondence or verbal communication. The Director of Nursing Services stated they felt this process would be much faster than leaving the forms in the Physician's mailbox for the Physicians to review and document on the forms directly. The Director of Nursing Services stated the completed Medication Regimen Review forms were placed in the Medical Director's mailbox for the Medical Director to review and sign. They were not sure why the Medical Director did not sign the Medication Regimen Review forms for Resident #1, Resident #32, and Resident #12. The Director of Nursing Services stated they did not know the Physicians were responsible for documenting a response and signing the Medication Regimen Review form, as documented in the facility policy. The Director of Nursing Services stated they felt that they had to document responses on the form themselves in order to complete the review within three (3) days. The Director of Nursing Services stated the recommendations should have been put in place for Resident #1, Resident #32, and Resident #12, and the Physicians should be responsible for ensuring the recommendations were followed and orders were put in place accordingly. During an interview on 08/14/2025 at 02:25 PM, the Primary Physician stated they could not recall the Director of Nursing Services had notified them of the recommendations made by the Pharmacy Consultant for Resident #1, Resident #32, and Resident #12. The Primary Physician stated they were not aware they were supposed to document a response and sign on the Medication Regiment Review form. During an interview on 08/15/2025 at 02:46 PM, the Medical Director stated they expected the attending physicians to review the Medication Regimen Review forms for each resident, and even though the Director of Nursing Services may document a response on the form, they expect the physicians to review and sign off with their responses on the form. The Medical Director stated that recommendations that the physician agreed upon should be implemented within three (3) to seven (7) days. During an interview on 08/15/2025 at 03:23 PM, the Medical Director stated it was the facility policy that the Physicians sign their responses on the Medication Regimen Review forms. The Medical Director stated that they expected the attending Physicians to be aware of the facility's policy regarding Medication Regimen Reviews. 10 NYCRR 415.18(c)(2)

Based on observations, record review, and interviews during the Recertification Survey initiated on 08/11/2025 and completed on 08/15/2023, the facility did not ensure that it established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This was identified on one (second floor) of two nursing units. Specifically, the facility staff did not utilize appropriate personal protective equipment and did not perform hand hygiene to prevent the spread of infection.The finding is:The facility's policy titled Infection Control/Nursing/Contact Precautions, revised 11/2023, documented to prevent the transmission of organisms among residents, staff, and visitors. The decision to isolate a resident and the type of isolation required are determined by the source of infection, the mode of transmission, and the susceptibility of the host. Resident requiring specific isolation precautions will have a bin outside their room with personal protective equipment and signage indicating to see the nurse before entering the room.Resident #27 was admitted with diagnoses including Cerebrovascular Accident, Seizure Disorder, and Non-Alzheimer's Dementia. The 07/02/2025 Annual Minimum Data Set assessment documented a Brief Interview for Mental Status score of three (3), indicating the resident had severe cognitive impairment. The Minimum Data Set did not document that the resident was under isolation or quarantine for an active infectious disease.Resident #4 was admitted with diagnoses including Diabetes Mellitus, Seizure Disorder, and Respiratory Failure. The 05/17/2025 Annual Minimum Data Set assessment revealed no Brief Interview for Mental Status score, as the resident was in a persistent vegetative state. The Minimum Data Set did not document that the resident was under isolation or quarantine for an active infectious disease.The current physician's order for Resident #27 documented contact precautions related to (VIM CRE) Carbapenem-Resistant Enterobacteriaceae (CRE) (bacteria that have become resistant to some of the strongest antibiotics, including carbapenems) that produce [NAME] Integron-Encoded [NAME]- -Lactamase (VIM) (an enzyme produced by the bacteria that breaks down the antibiotic).A Comprehensive Care Plan for Resident #27 for Contact Precaution, created on 05/25/2024 and last updated on 07/19/2025, documented to maintain Contact Precautions at all times. Continue with the current care plan. Interventions included applying and removing personal protective equipment as per the Centers for Disease Control guidelines and maintaining contact precautions.The current physician's order for Resident #4 documented contact precautions secondary to Methicillin-resistant Staphylococcus Aureus (MRSA- infection caused by a type of staph bacteria that becomes resistant to many of the antibiotics used to treat ordinary staph infections) in the sputum and related to Carbapenem-Resistant Enterobacteriaceae (CRE) that produce [NAME] Integron-Encoded [NAME]- -Lactamase (VIM).A Comprehensive Care Plan for Resident #4, created 05/25/2024 and last updated 06/04/2025, documented that the resident was on Contact Precautions. Interventions included instructing family/visitors/caregivers to wear a disposable gown and gloves during physical contact with the resident, discard in the appropriate receptacle, and wash their hands before leaving the room.During an observation on 08/11/2025 at 12:00 PM, a Contact Precaution sign at the entry to Residents #4 and #27's room documented: everyone must clean their hands before entering the room and when leaving the room; put on gloves before room entry; discard gloves before room exit; put on gown before room entry, and discard the gown before room exit.During an observation on 08/11/2025 at 12:00 PM, Licensed Practical Nurse #3 was observed in Residents #4 and #27's room. Licensed Practical Nurse #3 was not wearing any personal protective equipment and was adjusting Resident #27's feeding tube pump.During an interview on 08/11/2025, immediately after the observation, Licensed Practical Nurse #3 stated they were not providing any close contact care and were just adjusting the feeding tube pump because the pump was alarming. Licensed Practical Nurse #3 looked at the Contact Precaution sign at the door and stated they were not sure whether Residents #4 and #27 were actually on contact precautions. Licensed Practical Nurse #3 did not wash their hands when they exited the room.During an observation on 08/13/2025 at 11:43 AM, Certified Nursing Assistant #3 was observed in Residents #4 and #27's room. Certified Nursing Assistant #3 was not wearing any personal protective equipment and was observed opening and closing drawers and closets.During an interview on 08/13/2025, immediately after the observation, Certified Nursing Assistant #3 stated they had just taken their gown off and placed it in the bin. They stated they should have kept the gown and gloves until they were ready to come out of the room. Certified Nursing Assistant #3 did not wash their hands when they exited the room.During an interview on 08/14/2025 at 10:10 AM, the Assistant Director of Nursing Services/Educator stated that staff are expected to adhere to the contact precautions and follow the instructions on the signage. During an interview on 08/15/2025 at 8:15 AM, the Director of Nursing Services, who was also the Infection Preventionist, stated all staff are expected to adhere to the contact precautions and wear personal protective equipment appropriately, and wash their hands when leaving the room.10NYCRR 415.19(a)(1-3)(b)(4)

Based on observations, record review, and interviews during the Recertification Survey initiated on 08/11/2025 and completed on 08/15/2025, the facility did not ensure that it developed and implemented a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet each resident's medical, nursing, and mental and psychosocial needs. This was identified for one (1) (Resident #14) of three (3) residents reviewed for Skin Conditions and one (1) (Resident #32) of five (5) residents reviewed for Unnecessary Medications. Specifically, 1) Resident #14 had a diagnosis of Methicillin-Resistant Staphylococcus Aureus (a type of bacteria that is resistant to antibiotics) infection in the chest wounds. There was no care plan developed for the wound infection and the contact precautions. 2) Resident #32 was receiving treatment for their heart conditions, including an anticoagulant therapy and treatment for hypotension (low blood pressure). There was no documented evidence of a comprehensive care plan regarding the resident's cardiovascular status.The findings are: The facility's policy titled Comprehensive Care Plan, dated 03/2016, documented the interdisciplinary team will assess the resident's condition, develop a working comprehensive care plan for each resident, and establish realistic, individualized care goals utilizing the resident's active and potential problems and current standard of professional practice. Interdisciplinary team members will document the resident's problem-prone areas identified by the comprehensive assessment, design, and document specific interventions/approaches on the comprehensive care plan. The Interdisciplinary Team Coordinator will ensure that a resident's 21-day comprehensive care plan is complete, including, but not limited to: identified resident care problems or needs and interventions and/or approaches to be used. 1) Resident #14 was re-admitted with diagnoses including Methicillin Resistant Staphylococcus Aureus Infection, Disorder of the Skin and Subcutaneous Tissue, and Cellulitis (skin infection). The 05/26/2025 Entry Minimum Data Set assessment documented a Brief Interview for Mental Status score of eight (8), indicating the resident had moderate cognitive impairment. Resident #14 had a diagnosis of Septicemia (life-threatening infection in the blood). The Minimum Data Set did not document the presence of non-pressure-related ulcers, wounds, or skin problems. A current Physician's order dated 07/02/2025 documented contact precautions for Methicillin Resistant Staphylococcus Aureus Infection. The current Physician's order dated 07/24/2025 documented: cleanse the right and left chest wound with normal saline, apply collagen powder to the wound base, then pack the wound with Calcium Alginate (a highly absorbent wound dressing), and cover with Silicone Super absorbent three (3) times a week and as needed for Wound Care. A review of the Comprehensive Care plans revealed there was no care plan developed to indicate the resident had an infection in the chest wounds and was on contact precautions. During an observation and interview on 08/13/2025 at 11:09 AM, Resident #14 was lying in their bed. Resident #14 stated they had just received treatment for their wounds on the chest. A Contact Precaution sign was posted in front of Resident #14's room. Two (2) Certified Nursing Aides were observed donning (putting on) gowns and gloves prior to entry in the room with a Hoyer lift. During an interview on 08/14/2025 at 2:50 PM, Registered Nurse #1 stated the resident was readmitted in May 2025 with a bilateral chest wound and was placed on Contact Precaution due to Methicillin-Resistant Staphylococcus Aureus Infection in the wound. Registered Nurse # 1 stated that the admission nurse usually initiated all the care plans; however, other Registered Nurses were also responsible for ensuring care plans were developed and implemented to reflect the resident's needs. Registered Nurse # 1 stated that they were not aware that Resident #14 did not have a care plan for their Methicillin-Resistant Staphylococcus Aureus Infection and contact precautions. Registered Nurse #1 stated that the care plans should have been developed. During an interview on 08/14/2025 at 2:28 PM, the Director of Nursing Services, who is the facility's Infection Preventionist, stated that only a Registered Nurse can initiate a care plan, and they expect the Registered Nurse to develop a care plan for Resident #14's Methicillin-Resistant Staphylococcus Aureus Infection and contact precautions. 2) Resident #32 was admitted with diagnoses including Essential Hypertension and Idiopathic Hypotension (a type of low blood pressure that happens when standing up, with the exact cause unknown). The Quarterly Minimum Data Set assessment dated [DATE] did not document a Brief Interview for Mental Status score because the resident had severely impaired cognitive skills for daily decision making and was rarely or never understood. A Physician's order dated 06/18/2025 documented to administer Midodrine (a medication used to treat low blood pressure) 5 milligram Tablet, two (2) tablets via a percutaneous endoscopic gastronomy tube (a type of feeding tube) every eight (8) hours as needed for Systolic blood pressure (the top number in a blood pressure reading representing the pressure in the arteries when the heart muscle contracts) reading under 120 millimeters of mercury. A Physician's Order dated 06/18/2025 documented to administer Metoprolol Tartrate (a type of blood pressure medication) 25 milligram tablet, give half a tablet via a percutaneous endoscopic gastrostomy tube every 12 hours for Hypertension. A Physician's Order dated 06/18/2025 documented to administer Enoxaparin Sodium (a type of anticoagulant medication) Solution Prefilled Syringe 40 milligrams per 0.4 milliliters, inject 40 milligrams subcutaneously (layer of fatty tissue beneath the skin) one time a day for blood clot prevention. A Physician's Order dated 06/23/2025 documented to monitor orthostatic blood pressure sitting and lying weekly. A Cardiology Consult Note dated 07/02/2025 documented Resident #32 was seen for a follow-up for hypotension and monitoring. Recommendations included to continue monitoring the resident's blood pressure daily and continuing with the current dose of Metoprolol, Midodrine treatment, and Enoxaparin for Deep Vein Thrombosis (blood clot in the deep veins) prevention and bleeding precautions. The resident was clinically stable. There was no documented evidence that a comprehensive care plan was developed for Resident #32's Cardiovascular status and use of anticoagulant therapy. During an interview on 08/14/2025 at 11:45 AM, Registered Nurse #4, the unit nursing supervisor, stated that typically a care plan is initiated by the nursing supervisors upon admission, and the nursing supervisors may also update care plans as needed. Registered Nurse #4 stated a comprehensive care plan should be developed for all diagnoses and health concerns for each resident. Registered Nurse #4 stated they did not know why a care plan was not developed for Resident #32's Cardiovascular status and anticoagulation therapy use. During an interview on 08/14/2025 at 01:47 PM, the Director of Nursing Services stated a comprehensive care plan was meant to outline a resident's plan of care for a specific condition/concern with measurable goals and interventions for the nursing staff to follow and evaluate the resident's condition. The Director of Nursing Services stated a comprehensive care plan should have been developed for Resident #32 to reflect the resident's Cardiovascular status and anticoagulation therapy. 10 NYCRR 415.11(c)(1)

Based on observation, record review, and interviews during the Recertification Survey initiated on 08/11/2025 and completed on 08/15/2025, the facility did not ensure each resident received pharmaceutical services, including procedures that assure the accurate administering of all drugs and biologicals to meet the needs of each resident. This was identified for one (1) (Resident #75) of four (4) residents reviewed for Medication Administration. Specifically, during the medication administration observation for Resident #75 on 08/12/2025, Registered Nurse #6 did not check the placement of the gastrostomy tube before administering the medications.The finding is:The facility's policy titled Medication Administration via Feeding Tube, revised 06/2023, documented disconnect tube feeding (if in progress) and cap the tube; assess resident's abdomen; check tube placement and patency by either aspirating (pulling up with a syringe) gastric contents or auscultating (listening with a stethoscope as air is pushed into the stomach with a syringe) for instilled air.Resident #75 was admitted with diagnoses including Cerebrovascular Accident, Seizure Disorder, and Gastrostomy (feeding tube to stomach) Status. The 04/19/2025 Quarterly Minimum Data Set assessment documented no Brief Interview for Mental Status score, as the resident had severely impaired cognitive skills for daily decision making.The current physician's order documented to check patency of tube feed prior to any medication pass every shift, related to Gastrostomy Status.The current physician's order documented to start enteral feed (tube feeding) in the evening, Type Jevity 1.5, Total Formula Volume 1,200 cubic centimeters per day, Flow Rate 75 cubic centimeters/hour, Start time: 6:00 PM, Check for residual prior to initiation of feeding.During the medication administration observation on 08/12/2025 at 08:20 AM, Registered Nurse #6 prepared the following medications for Resident #75:Vitamin C 500 milligram tablet (supplement).Zinc 50 milligram tablet (supplement).Vitamin B-6 50 milligram tablet (supplement).Multivitamin tablet (supplement).Probiotic capsule (helps maintain a healthy balance of gut bacteria).Furosemide 20 milligram tablet (diuretic).Glycopyrrolate 1 milligram tablet (reduces stomach acid).Keppra Oral Solution 10 milliliters (100 milligrams per milliliter) (for convulsions).After Registered Nurse #6 completed preparing the medications (crushing the tablets because of the gastrostomy tube), the nurse applied all the appropriate personal protective equipment and then entered the resident's room. The nurse disconnected the tube feeding, flushed the tube, but did not check for the placement of the tube.During an interview immediately after the observation, Registered Nurse #6 stated they did not check for the placement of the gastrostomy tube before administering the medications via the tube, and should have.During an interview on 08/14/2025 at 10:10 AM, the Assistant Director of Nursing/Educator stated that the nurses are supposed to check for the placement of the gastrostomy tube by aspirating the gastric contents or by auscultation (listening with a stethoscope as air is pushed into the stomach with a syringe for instilled air) before administering the medications via the tube.During an interview on 08/15/2025 at 8:15 AM, the Director of Nursing Services stated the facility policy requires nurses must check for gastrostomy tube placement before administering medications through a gastrostomy tube.10 NYCRR 415.18(a)

Based on observations, record review, and interviews during the Recertification survey initiated on 08/11/2025 and completed on 08/15/2025, the facility did not ensure each resident with a pressure ulcer received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing. This was identified for two (2) (Resident #16 and Resident #2) of two (2) residents reviewed for pressure ulcers. Specifically, 1) Resident #16 weighed 84.7 pounds and was observed lying in bed with the air mattress weight setting set at 350 pounds. 2) Resident #2 was observed with an air mattress with a low-pressure warning light illuminated on 08/11/2025, 08/12/2025, and 08/13/2025. When the mattress was replaced, the weight setting on the air mattress was set at 350 pounds. The resident's weight was 115 pounds.The findings are: A facility policy titled Impaired Skin Integrity last revised on 04/2018, documented once a resident is assessed, a plan of care for prevention and/or treatment plans for residents with wounds will be developed. The Physician will be notified, and orders will be obtained to correspond with the nursing assessment. Possible interventions that should be used include pressure relief devices such as heel pads, specialty mattresses, and/or chair cushions. A facility policy titled Air Mattress dated 01/2025 documented to provide an air mattress to residents when warranted. Air mattresses help to evenly distribute the resident's weight, facilitate air circulation, thereby preventing moisture build-up on the skin, and can improve blood circulation, further reducing the risk of developing pressure ulcers. It is the responsibility of the primary care nurse to ensure the mattress reflects the proper setting, dependent on the resident's weight. This setting may be adjusted in order to assist in transfer, to assist in turning and positioning, and to assist while providing care. The Alternating Pressure Low Air Loss Mattress manual documented after proper installation of the air mattress, determine the resident's weight and set the control knob to that weight setting on the control unit of the air mattress. Ensure the control unit is in good condition by checking if the indicators illuminate when the power is first turned on. 1) Resident #16 was admitted with diagnoses including Spondylosis with Radiculopathy (spinal degeneration that leads to nerve root compression), Adult Failure to Thrive, and Chronic Kidney Disease. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of three (3), indicating the resident had severe cognitive impairment. The Minimum Data Set assessment documented the resident was at risk for developing pressure ulcers; had two (2) unhealed, Stage three (3) (full-thickness tissue loss) pressure ulcers that were present upon admission; and used a pressure-reducing device for bed. A Comprehensive Care Plan titled Skin Integrity: The Resident has Actual Impairment to Skin Integrity last revised 07/11/2025, documented interventions including the use of an air mattress for pressure reduction, turn and position every two (2) to four (4) hours and as needed, and apply treatment as ordered by the Physician. The current Physician's Order documented an air pressure mattress related to wounds. No further instructions related to the air mattress settings were included in the Physician's order. A Braden Scale assessment dated [DATE] documented a score of 14, indicating the resident had a moderate risk of developing pressure ulcers. Review of the medical record documented the resident weighed 84.7 pounds on 8/6/2025. A Wound Care Consultation Note dated 08/07/2025 documented low air loss mattress per facility protocol, and to verify low air loss mattress inflation and settings. The resident had multiple wounds, including two (2) Stage three (3) pressure ulcers to the sacrum (a triangular bone at the base of the spine) and right ischium (the lower and back portion of the hip bone). During an observation on 08/12/2025 at 9:46 AM, Resident #16 was observed lying in bed on an air mattress with the weight setting set at 350 pounds. During a subsequent observation on 8/13/2025 at 10:29 AM, Resident #16 was observed lying in bed on an air mattress with the weight setting set at 350 pounds. During an interview on 08/13/2025 at 11:15 AM, Certified Nursing Assistant #1, the assigned Certified Nursing Assistant for Resident #16, stated they were responsible for checking if the mattress was deflated or leaking. Certified Nursing Assistant #1 stated they were not responsible for checking the weight setting on the air mattress. During an interview and observation on 08/13/2025 at 11:24 AM, in the presence of Registered Nurse #2, Resident #16 was lying in bed with the air mattress weight setting set at 350 pounds. Resident #16 stated their bed felt hard and uncomfortable. Registered Nurse #2 stated they usually check the air mattress settings for firmness and that the mattress was inflated during rounds and medication administration. Registered Nurse #2 stated they were not sure how the weight setting for the air mattress should be set. During an interview on 08/13/2025 at 11:45 AM, Registered Nurse #3, the nursing supervisor, stated that the unit nurses were responsible for checking the functioning and weight settings on the air mattress. Registered Nurse #3 stated Resident #16 weighed 84.7 pounds, and the air mattress setting should correspond with the resident's actual weight. Registered Nurse #3 stated the air mattress setting of 350 pounds was too high for Resident #16. During an interview on 08/15/2025 at 08:56 AM, the Wound Care Nurse stated it was not appropriate for Resident #16's air mattress to be set at 350 pounds as this did not reflect the resident's actual weight. During an interview on 08/15/2025 at 11:05 PM, the Vascular Surgeon, the Wound Care Consultant for the facility, stated they followed Resident #16 for wound care weekly. The Vascular Surgeon stated they recommended a low air low-air-loss mattress for Resident #16 to prevent wound deterioration and promote wound healing. The air mattress weight setting should be set according to the resident's weight. The air mattress weight setting of 350 pounds was not appropriate for Resident #16, especially when the resident is in bed for an extended period. During an interview on 08/15/2025 at 12:42 PM, the Director of Nursing Services stated the nurses on the unit were responsible for ensuring the air mattresses were set correctly for each resident according to the resident's weight. The Director of Nursing Services stated that the only occasion the mattress should be set at a higher weight setting is during transfers and turning, and repositioning. The air mattress for Resident #16 should not have been set at 350 pounds and should have accurately reflected the resident's actual weight. 2) Resident #2 was admitted with diagnoses including Diabetes Mellitus, Cerebrovascular Accident, and Anoxic (the brain deprived of oxygen) Brain Damage. The 08/05/2025 admission Minimum Data Set assessment documented no Brief Interview for Mental Status score as the resident had severely impaired cognitive skills for daily decision making; the resident was admitted with one Stage 4 pressure ulcer (full-thickness skin and tissue loss extending into muscle, tendon, or bone); two unstageable pressure ulcers due to coverage with slough/and or eschar (dead tissue), and three Unstageable-Deep Tissue Injury (damage occurs to underlying soft tissues) pressure ulcers. A Comprehensive Care Plan titled, Skin integrity: Resident has the potential for impaired skin integrity related to actual ulcers, impaired mobility, effective 07/31/2025, documented providing pressure relief interventions: elbow pads. The care plan did not include the use of an air mattress. The air mattress manual documented the Low-Pressure Indicator light warns that the air pressure is below a preset or user-defined level. The audible alarm is activated, accompanied by the Low-Pressure indicator, to alert that pressure is low. Press the alarm mute button to mute the audible alarm, and its indicator will flash. Pressure adjust knob: turn the soft/firm knob to set a comfortable pressure level. (This knob also has the weight settings.) The wound care consult note dated 07/31/2025 documented a Stage 4 sacral (triangular bone at lower back) pressure ulcer, 11 centimeters x 5 centimeters x 1.8 centimeters; a Stage 2 (partial thickness skin loss like a blister) left hip pressure ulcer measuring 2 centimeters x 2 centimeters x 0 centimeters; and a Diabetic wound to the left foot. The consult documented using the low air loss mattress as per facility protocol, and the low air loss mattress inflation and settings were verified. A review of the electronic medical record revealed the resident's weight was 115.5 pounds as of 08/06/2025. On 08/11/2025 at 10:25 AM, Resident #2 was observed in bed. The resident had an air mattress with a low-pressure light illuminated. The weight setting on the air mattress was 180 pounds. During an interview and observation on 08/12/2025 at 2:05 PM, Licensed Practical Nurse #2 observed Resident #2's mattress with the low-pressure light still illuminated. At this time, the resident was getting Rehabilitation Therapy while in bed. Licensed Practical Nurse #2 stated the low-pressure light was on because the resident was moving while receiving the therapy. The weight setting was set at 170 pounds. Licensed Practical Nurse #2 stated they will look at the mattress and try to figure out if there was a problem with the mattress causing the low-pressure light to be illuminated. If they were unable to resolve the low-pressure problem, they would call the central supply. On 08/13/2025 at 8:15 AM, Resident #2 was observed in bed. The low-pressure light for the air mattress was still illuminated, and the weight setting on the air mattress was set at 170 pounds. During an interview on 08/13/2025 at 8:20 AM, Director of Environmental Services #1 stated that no one had notified them yesterday about the mattress malfunction. During a re-interview on 08/13/2025 at 9:45 AM, Director of Environmental Services #1 stated the work order for the air mattress was put in this morning. The air mattress pump was damaged, which is why the low-pressure light was on. Director of Environmental Services #1 stated they replaced the mattress and the pump today. The low-pressure light indicates a malfunction of some kind and an indication to the nursing staff to alert them (Director of Environmental Services #1). On 08/13/2025 at 2:00 PM, Resident #2 was observed in a Geri chair beside their bed. A new air mattress was in place, and the air mattress's weight setting was set at 350 pounds. On 08/14/2025 at 9:00 AM, Resident #2 was observed in bed. The air mattress's weight setting was set at 350 pounds. During an interview and observation on 08/14/2025 at 9:05 AM, Registered Nurse Supervisor #4 observed the air mattress weight setting of 350 pounds and stated the air mattress should be set according to the resident's weight. Registered Nurse Supervisor #4 did not adjust the weight setting. Registered Nurse Supervisor #4 stated that all the nursing staff were responsible for monitoring the air mattress, and the nurses can adjust the air mattress's weight setting. Registered Nurse Supervisor #4 stated wound care rounds were done today with the wound consultant earlier in the morning, and had no explanation why the air mattress weight setting was set at 350 pounds. During an interview on 08/14/2025 at 10:10 AM, the Assistant Director of Nursing and Educator stated that the Certified Nursing Assistants should alert the nurse of any issues; the nurses can make adjustments to the air mattress setting. The air mattress weight setting should be consistent with the resident's weight. If there is any issue with the mattress, the nurses need to alert the maintenance department through the electronic notification system. During an interview on 08/15/2025 at 8:15 AM, the Director of Nursing Services stated the air mattress weight setting is supposed to be consistent with the resident's weight; all nursing staff are expected to monitor and adjust the weight setting and notify the Maintenance Department of the mattress malfunction through the electronic notification system. During an interview and wound care observation on 08/15/2025 at 9:40 AM, Licensed Practical Nurse Wound Care Nurse #1 stated the air mattress should be checked every shift by nursing staff to ensure proper weight setting and for any malfunctions. The weight setting on the air mattress should be consistent with the resident's weight, and if there is a malfunction, maintenance should be notified. During an interview on 08/15/2025 at 10:55 AM, the Vascular Surgeon, the Wound Care Consultant stated the facility has a protocol to double-check the weight settings on the mattresses on wound rounds and document that the settings were verified. The air mattress weight settings should be consistent with the resident's weight because this helps the wound heal. 10 NYCRR 415.12(c)(1)

Based on record review and interviews during the recertification Survey initiated on 08/11/2025 and completed on 08/15/2025, the facility did not ensure each resident received treatment and care in accordance with professional standards. Specifically, Resident #32 had an active physician's order for Midodrine (a medication used to treat low blood pressure) every eight (8) hours as needed when the resident's systolic blood pressure (the top number in a blood pressure reading representing the pressure in the arteries when the heart muscle contracts) was below 120 millimeters of mercury. Review of Resident #32's Medication Administration Record for July and August 2025 revealed that in 08/2025 the resident did not receive the medication as ordered for 16 out of 16 opportunities from 08/01/2025 to 08/13/2025; and in July 2025, the resident did not receive Midodrine for 26 of 29 opportunities. There were nine times when the blood pressure was not documented on the Medication Administration Record for July 2025. Additionally, there was no documented evidence on the Medication Administration Record that the resident's blood pressure was monitored every eight hours for the nurses to determine the need to administer Midodrine as per the physician's order.The finding is:The facility policy titled Administration of Drugs, last reviewed on 12/07/2007, documented all residents should be given the proper medication in the proper dosage via the proper route and at the proper time. Medications given on an as-needed basis shall be recorded on the medication administration record with an explanation entered. If a dose of a regular interval medication is withheld, the nurse shall record an explanatory nurse's note.Resident #32 was admitted with diagnoses including Essential Hypertension and Idiopathic Hypotension (a type of low blood pressure that happens when standing up, with the exact cause unknown). The Quarterly Minimum Assessment Data Set assessment dated [DATE] did not document a Brief Interview for Mental Status because the resident had severely impaired cognitive skills for daily decision making and was rarely or never understood.There was no documented evidence of a comprehensive care plan in the medical record relating to the resident's cardiovascular status.A Physician's Order dated 06/18/2025 documented to administer Metoprolol Tartrate (a type of blood pressure medication) 25 milligram tablet, give half a tablet via a percutaneous endoscopic gastrostomy tube (a type of feeding tube) every 12 hours for Hypertension.A Physician's order dated 06/18/2025 documented to administer Midodrine 5 milligram Tablet, two (2) tablets via a percutaneous endoscopic gastronomy tube (a type of feeding tube) every eight (8) hours as needed for a Systolic blood pressure reading under one hundred and twenty (120) millimeters of mercury.A review of Resident #32's Medication Administration Record for 08/2025 revealed the resident did not receive the medication as ordered for 16 out of 16 opportunities from 08/01/2025 to 08/13/2025. For July, the resident did not receive Midodrine for 26 of 29 opportunities. There were nine times when the blood pressure was not documented on the Medication Administration Record for July 2025.There was no documented evidence on the Medication Administration Record that the resident's blood pressure was monitored every eight hours for the nurses to determine the need to administer Midodrine as per the physician's order.During an interview on 08/14/2025 at 11:14 AM, Licensed Practical Nurse #1, the medication nurse, stated they were the regularly assigned nurse on the unit and were very familiar with Resident #32. Licensed Practical Nurse #1 stated the resident had an order for Midodrine as needed. The resident's blood pressure is checked before administering the blood pressure medications. Licensed Practical Nurse #1 stated Resident #32's systolic blood pressure on 08/12/2025 during the 7:00 AM-3:00 PM shift was 112 millimeters of mercury. Licensed Practical Nurse #1 stated they did not administer Midodrine because the resident did not have symptoms of lethargy, and the resident was not in any distress. Licensed Practical Nurse #1 stated they typically do not administer Midodrine to the resident because it was not necessary when the resident was asymptomatic and the blood pressure remained stable, despite the parameters on the physician's order.During an interview on 08/14/2025 at 11:36 AM, Registered Nurse #4, the nursing supervisor, stated the blood pressure parameters ordered by the physician for Midodrine were higher than what was typically ordered. Registered Nurse #4 stated the order for Midodrine would need to be clarified with the Physician.During an interview on 08/14/2025 at 02:25 PM, Primary Physician #1 stated nursing staff must administer medication as ordered, including following any parameters ordered by the Physician. Primary Physician #1 stated Midodrine should have been administered to Resident #32 if the blood pressure was recorded below 120 millimeters of Mercury.During an interview on 08/15/2025 at 12:53 PM, the Director of Nursing Services stated that nurses should have administered the Midodrine according to the blood pressure parameters as ordered.10 NYCRR 415.12

Based on observations, record review, and interviews during the Recertification Survey and Abbreviated Survey (2572082) initiated on 08/11/2025 and completed on 08/15/2025, the facility did not ensure that each resident who is unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This was identified for one (Resident #24) of two residents reviewed for Activities of Daily Living. Specifically, upon several observations, Resident #24 was not clean-shaven, and their hair was mussed. Resident #24's plan of care indicated the resident was to receive scheduled showers at least two times per week. Review of the resident's record indicated Resident #24 received only one shower from 07/23/2025 to 08/12/2025.The finding is: The facility's undated policy titled Certified Nursing Assistant Plan of Care and Kardex documented that each resident will be provided with proper and safe basic nursing care by the Certified Nursing Assistant. The primary care nurse should update the Kardex (care instructions provided to the Certified Nursing Assistants) as needed for changes in activities of daily living. The Certified Nursing Assistant will bring to the attention of the primary care nurse or supervisor any area of the plan of care that is not completed or does not match the resident's current status.Resident #24 was admitted with diagnoses including Traumatic Brain Dysfunction, Aphasia (a disorder that causes difficulty speaking and understanding), and Anxiety Disorder. The 04/24/2025 admission Minimum Data Set assessment documented no Brief Interview for Mental Status score as the resident had severely impaired cognitive skills for daily decision making. The Minimum Data Set documented that it was very important to choose between a tub bath, shower, bed bath, or sponge bath and that the resident was dependent on staff for personal hygiene and bathing. The 07/19/2025 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of three (3), indicating the resident had severe cognitive impairment, unclear speech, and sometimes understands and sometimes understood.During an observation on 08/11/2025 at 10:10 AM, Registered Nurse Supervisor #7 was assisting Resident #24 into a temporary bed in another room while the bed in their room was being repaired. The resident's speech was unclear. The resident was unshaven, and their hair was mussed.During an observation on 08/12/2025 at 8:05 AM, Resident #24 was in bed. Certified Nursing Assistant #2 was in the room preparing to provide morning care to the resident. The resident was unshaven.During an observation on 08/12/2025 at 9:15 AM, Resident #24 was in the hallway. The resident was unshaven. The surveyor asked the resident if they would like to be shaved, and the resident appeared to state yes by shaking their head up and down. During an interview on 08/12/2025 at 8:10 AM, Certified Nursing Assistant #2 stated they did not shave the resident because the resident was combative during care this morning.Review of the Kardex as of 08/12/2025 documented that the resident's bathing schedule was on Tuesday and Friday on the 7:00 AM-3:00 PM shift. The resident required the extensive assistance of two staff members. There were no behavioral concerns documented in the Kardex.Review of the Certified Nursing Assistant accountability record from 07/23/2025 to 08/12/2025 revealed the resident received a shower on 7/26/2025 (Saturday); all other documentation reveals the resident received bed baths during that period.During an interview on 08/12/2025 at 1:43 PM, Certified Nursing Assistant #2 stated today was the first time they were working with Resident #24. Certified Nursing Assistant #2 stated the Kardex documented that the resident was due for a shower today (Tuesday), but they gave a bed bath because the resident was physically aggressive. Certified Nursing Assistant #2 stated that the bathing schedule on the Kardex meant showers. Certified Nursing Assistant #2 stated they notified the nurse (Registered Nurse Supervisor #5) and documented on the accountability record that they provided a bed bath to the resident.During an interview on 08/12/2025 at 2:40 PM, Registered Nurse Supervisor #5 stated the Certified Nursing Assistant told them that the resident (#24) did not get a shower today because the resident was agitated. Registered Nurse Supervisor #5 stated the resident should be getting showers twice a week and had no explanation as to why the resident was not getting showers. A nursing progress note, written by Registered Nurse Supervisor #5, dated 08/12/2025 at 3:18 PM, documented resident (#24) was alert and confused. The resident was combative this morning and, as a result, was not shaved or showered; however, the resident was given a bed bath. As needed Xanax (anti-anxiety medication) 0.5 milligram was administered with much relief.Review of progress notes from 07/26/2025 to 08/12/2025 revealed no documentation that the resident did not receive a shower due to behavioral issues.Review of the electronic medical record revealed that there was no comprehensive care plan for the Activities of Daily Living initiated until 08/13/2025.During an interview on 08/13/2025 at 2:25 PM, the Assistant Director of Nursing/Nurse Educator stated they reviewed Resident #24's electronic medical record and determined there was no documentation that the resident received showers as per their plan of care. The Assistant Director of Nursing/Nurse Educator stated that the resident has unpredictable, erratic behaviors, including grabbing and reaching for things, and that is probably why they did not get showers.A Comprehensive Care Plan, effective 06/10/2025, titled Behaviors, had an addition on 08/13/2025 by the Director of Nursing Services, documenting the resident has a behavior problem related to agitation and attempting to stand, combative and impulsive behavior during care, causing potential for a safety issue during shower.A Comprehensive Care Plan initiated 8/13/2025 initiated by the Director of Nursing Services titled Resident assessed for Activities of Daily Living status upon admission documented Certified Nursing Assistants will document support provided and self-performance for all Activities of Daily Living, Encourage resident to participate in Activities of Daily Living as per ability and personal preferences; Provide shower/bed bath, based upon resident's preference/ability, twice per week and as needed.During an interview on 08/14/2025 at 9:34 AM, Physical Therapist Rehabilitation Department Director #1 stated that due to behaviors, Resident #24 was dependent on two staff members for showers and requires two staff members to transfer to and from the shower chair.On 08/14/2025 at 10:48 AM, Resident #24 was observed being brought back to their bedside in a shower chair by Certified Nursing Assistant #2 and Concierge #1 after receiving a shower.On 08/14/2025 at 11:30 AM, Resident #24 was observed in the day room. The resident was groomed, showered, and shaved.During an interview on 08/15/2025 at 8:15 AM, the Director of Nursing Services stated the resident should have received showers twice a week. If the resident was combative during care, then it should have been documented, and the staff should have reviewed the current interventions and put new interventions in place to provide needed care to the resident.10 NYCRR 415.12(a)(3)

Based on observation, record review, and interviews during the Recertification Survey initiated on 08/11/2025 and completed on 08/15/2025, the facility did not ensure services provided as outlined in the comprehensive care plan met professional standards of quality. This was identified for one (1) (Resident #75) of four (4) residents reviewed for Medication Administration. Specifically, during the medication administration observation for Resident #75 on 08/12/2025, Registered Nurse #6 did not follow the five rights (right person, right time, right medication, right route, right dosage) of medication administration and poured liquid Keppra (a medication for seizures) from another resident's medication bottle without checking the label. Additionally, Registered Nurse #6 did not check the placement of the gastrostomy tube before administering the medications to Resident #75.Cross Reference F755-Pharmacy Services/Procedure/Pharmacist/RecordsThe finding is:The facility's policy, titled Administration of Drugs, reviewed 12/07/2007, documented to ensure that all residents are given the proper medication in the proper dosage, via the proper route, and at the proper time. The medication name, dosage, and dosage interval shall be read from the medication administration records. The label on each medication container shall be read three times when taking the medication container from the shelf or drawer, before pouring the medication, and when putting the medication back onto the shelf or into the drawer.The facility's policy titled Medication Administration via Feeding Tube, revised 06/2023, documented disconnect tube feeding (if in progress) and cap the tube; assess resident's abdomen; check tube placement and patency by either aspirating (pulling up with a syringe) gastric contents or auscultating (listening with a stethoscope as air is pushed into the stomach with a syringe) for instilled air.Resident #75 was admitted with diagnoses including Cerebrovascular Accident, Seizure Disorder, and Gastrostomy (feeding tube to stomach) Status. The 04/19/2025 Quarterly Minimum Data Set assessment documented no Brief Interview for Mental Status score, as the resident had severely impaired cognitive skills for daily decision making.The current physician's order documented to check patency of tube feed prior to any medication pass every shift, related to Gastrostomy Status.The current physician's order documented to start enteral feed (tube feeding) in the evening, Type Jevity 1.5, Total Formula Volume 1,200 cubic centimeters per day, Flow Rate 75 cubic centimeters/hour, Start time: 6:00 PM, Check for residual prior to initiation of feeding.During the medication administration observation on 08/12/2025 at 08:20 AM, Registered Nurse #6 prepared the following medications for Resident #75:Vitamin C 500 milligram tablet (supplement).Zinc 50 milligram tablet (supplement).Vitamin B-6 50 milligram tablet (supplement).Multivitamin tablet (supplement).Probiotic capsule (helps maintain a healthy balance of gut bacteria).Furosemide 20 milligram tablet (diuretic).Glycopyrrolate 1 milligram tablet (reduces stomach acid).Keppra Oral Solution 10 milliliters (100 milligrams per milliliter) (for convulsions).Registered Nurse #6 poured the Keppra oral solution for Resident #75 into a souffle cup without reading the bottle label. Although the medication was the same, the Keppra bottle had another resident's name on the label instead of Resident #75. The surveyor asked to see the Keppra medication bottle, which was when Registered Nurse #6 read the bottle label and realized the medication bottle was not for Resident #75. Registered Nurse #6 was unsure of what to do with the medication that was already poured and stated, I guess I will just use it, and later decided to discard the medication and re-poured the medication from the appropriate bottle. After Registered Nurse #6 completed preparing the medications (crushing the tablets because of the gastrostomy tube), the nurse applied all the appropriate personal protective equipment and then entered the resident's room. The nurse disconnected the tube feeding, flushed the tube, but did not check for the placement of the tube.During an interview immediately after the observation, Registered Nurse #6 stated they did not check for the placement of the gastrostomy tube before administering the medications via the tube, and should have.During an interview on 08/14/2025 at 10:10 AM, the Assistant Director of Nursing/Educator stated that the nurses are supposed to check for the placement of the gastrostomy tube by aspirating the gastric contents or by auscultation (injecting air into the gastrostomy tube while listening with a stethoscope over the stomach for a whooshing sound) before administering the medications. The Assistant Director of Nursing/Educator stated nurses must check the medication labels before dispensing the medication to ensure the right person, right time, right medication, right route, and right dosage.During an interview on 08/15/2025 at 8:15 AM, the Director of Nursing Services stated nurses are expected to follow the five rights of medication administration. If the nurse noticed they poured the medication from the wrong resident's bottle, they should have wasted the medication and started over. The Director of Nursing Services further stated the facility policy requires nurses must check for gastrostomy tube placement before administering medications through a gastrostomy tube.10 NYCRR 415.11(c)(3)(i)

Based on record review and interviews during the Recertification Survey initiated on 08/11/2025 and completed on 08/15/2025, the facility did not ensure its Facility Assessment considered specific staffing needs for each resident unit. This was identified during the Sufficient Nursing Staffing Task. Specifically, the Facility Assessment, last reviewed in July 2025, did not indicate nursing staffing (Certified Nursing Aides, Licensed Practical Nurse, and Registered Nurse) needs for each resident unit. The finding is:The facility's undated policy titled Facility Assessment documented the facility will evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the residents require. A detailed review of the resident population that included, but was not limited to resident census data, resident capacity, factors that affect the overall acuity of the residents, physical characteristics of the facility, and services currently provided. A review of the Facility assessment dated [DATE] revealed the Facility Assessment did not identify the resident units in the facility and did not indicate specific nursing staffing needs for each resident unit.During an interview on 08/12/2025 at 2:24 PM, the Administrative Assistant stated the facility had two (2) resident units (first and second floors) and they were responsible for the nursing staffing schedule for both floors. During an interview on 08/14/2025 at 1:49 PM, the Administrator stated they were responsible for developing and reviewing the Facility Assessment. The Administrator stated that the Facility Assessment did not consider specific nursing staffing needs per resident unit because they (the Administrator) were not aware that it was a requirement. The Administrator stated that nursing staffing needs should be considered by the first and second floors. During an interview on 08/14/2025 at 2:24 PM, the Director of Nursing Services stated they did not directly participate in developing the Facility Assessment but would provide input if necessary. The Director of Nursing Services stated they did not know that nursing staffing needs must be considered per resident unit. The Director of Nursing Services stated the Facility Assessment did not and should have considered the nursing staffing needs for each. 10 NYCRR 415.26

Based on observation and interviews during the Recertification Survey initiated on 4/7/2024 and completed on 4/11/2024, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, during the initial kitchen tour on 4/7/2024, a carton of frozen egg product, that was intended to be used on 4/8/2024 for the breakfast meal, was observed on a table thawing at room temperature. The finding is: The facility's undated policy titled, Thawing Frozen Raw Food documented to ensure the proper temperature is maintained during food storage, plan ahead to allow enough time for proper thawing; remove raw food from the carton and place it on a sheet pan; place the sheet pan on the bottom shelf of the refrigerator, never above the ready to eat food; do not let food stay out of the refrigerator for a long period of time. During the initial kitchen tour with First Cook #1 on 4/7/2024 at 9:00 AM, a carton of frozen egg product was observed on a table in the kitchen thawing at room temperature. The carton label documented: Frozen Egg Product, keep frozen at zero degrees Fahrenheit or below. First Cook #1 was interviewed on 4/7/2024 immediately after the observation and stated they (First Cook #1) removed the carton from the freezer at approximately 6:45 AM this morning (4/7/2024) and intended to use the egg product for tomorrow's breakfast. First Cook #1 stated they are going to put the product in the refrigerator and if it is not thawed by tomorrow morning, they will let the egg product carton sit in a water bath. Food Service Director #1 was interviewed on 4/8/2024 at 9:23 AM and stated after the frozen egg product was removed from the freezer, we let the product sit at room temperature for a couple of hours before putting it back in the refrigerator. Food Service Director #1 stated this is done to get the initial frost thawed out. Food Service Director #1 stated if the product is still frozen tomorrow when we need it for breakfast, we will run it under cold water. First Cook #1 was re-interviewed on 4/9/2024 at 08:30 AM and stated they placed the frozen egg product outside to thaw instead of placing it in the refrigerator because they were in a rush. 10NYCRR 415.14(h)

Based on observations, record review, and interviews during the Recertification Survey initiated on 4/7/2024 and completed on 4/11/2024, the facility did not provide a homelike environment and maintenance services to maintain a comfortable interior for three (Unit 1 North, Unit 1 South, and Unit 2 South) of four units observed during the environmental task. Specifically, Rooms 217 (Unit 2 South) 117 (Unit 1 South), 115, and 111 (Unit 1 North) had unrepaired water damage in the walls. Resident #60's room (Unit 1 North) was observed with holes in the wall due to the removal of the soap dispenser from the wall and the area was left unrepaired. The finding is: The facility's Quality of Life: Homelike Environment policy dated 4/2024 documented to provide residents with a comfortable and homelike environment. The facility staff and management shall maximize the characteristics of the facility that reflect a homelike setting including an inviting decor. The Resident Council Meeting minutes dated 2/21/2024 documented that a resident expressed that water is coming out from the walls in their rooms. The minutes documented that the Administrator stated that the plumber was scheduled to come to the facility on [DATE] and that the plumber had come in the past to fix the problem. A plumbing estimate dated 2/22/2024 documented leaking sanitary piping repairs were provided including opening of the sheetrock wall under the basin in room [ROOM NUMBER]; removal and replacement of leaking galvanized sanitary piping in the wall; installation of pipe, fittings, gaskets couplings hangers, and hardware, testing of repairs and removal of debris was completed. The estimate also documented that the contractor excluded all carpentry, sheetrock, spackling, painting tile, and flooring repairs. An initial facility tour on 4/7/2024 from 9:25 AM to 11:00 AM revealed the following: 1a) On Unit 2 South room [ROOM NUMBER] was observed on 4/7/2024 at 9:29 AM. On the wall outside of room [ROOM NUMBER], the wallpaper was peeling with some brown spots and exposed spackle. Inside room [ROOM NUMBER], the sink was observed on the left-hand side of the room entry. Above the sink, the wall was covered with a bubbled spackled area that crumbled upon touch. Under the sink, there were holes in the wall surrounding the pipes. The footboard on the right-hand side of the bathroom door was detached from the wall. 1b) During an observation on Unit 1 South on 4/7/2024 at 10:18 AM, room [ROOM NUMBER] was observed with peeling paint on the left wall by the room entrance. The sheetrock above the sink was crumbling. The wall below the room sink and the wall adjacent to the sink that leads to the bathroom were observed with ripped-up sheetrock and several water-damaged spots. 1c) On Unit 1 North following rooms were observed on 4/7/2024: -At 10:22 AM, room [ROOM NUMBER] was observed with a large, water damage that extended from the power outlet to behind the wardrobe set against the wall. There were also areas of exposed and crumbling sheetrock along that wall and under the room sink. -At 10:28 AM, room [ROOM NUMBER] was observed with ripped sheetrock and several large areas of water damage on the wall on the right side of the alcove leading to the bathroom entry. 1d) Resident #60 was admitted to the facility with the diagnoses of Parkinson's Disease, Coronary Artery Disease, and Hyperlipidemia. The Quarterly Minimum Data set assessment dated [DATE] documented Resident #60 had a brief interview for mental status assessment score of 14, indicating intact cognition. During an observation on 4/7/2024 at 10:30 AM Resident #60 was observed seated in a wheelchair in their room on Unit 1 North. Resident #60 stated they have heard complaints about leaking problems from other residents in the facility. Resident #60 stated there was significant water damage in room [ROOM NUMBER] that looked bad and they felt sorry for the residents who live in that room in that condition. Resident #60 stated that the maintenance staff did not finish projects and pointed to the two holes in the wall at the entrance wall above the sink. Resident #60 stated approximately 3 months ago the maintenance worker moved the soap dispenser to the right on the wall but left the unrepaired holes. Resident #60 stated they have requested for the holes to get patched up several times and the maintenance worker told Resident #60 that they would return to repair but never did. A review of facility work orders from 1/1/2024 to 4/10/2024 revealed no work orders for rooms 111, 115, 117, and Resident #60's room to address damaged walls. The facility work order report generated on 4/11/2024 documented work order number 1625 for the damaged walls in room [ROOM NUMBER] was opened by the Administrator on 2/21/2024 at 4:37 PM. On 4/11/2024 at 10:48 AM the Director of Maintenance toured rooms 111, 115, 117, 217, and Resident #60's room with the surveyor. The Director of Maintenance stated that the bubbling in the wall in room [ROOM NUMBER] could be related to water seeping from the outdoor facing wall. The Director of Maintenance stated that the walls are made of concrete and the water can get into the walls without a waterproof barrier. The Director of Maintenance stated that the torn sheetrock could be the result of banging a wheelchair or seat against the wall. The Director of Maintenance stated that they were not made aware of the damaged walls in room [ROOM NUMBER] and did not know if there were any work orders placed for repairs. The Director of Maintenance stated that in room [ROOM NUMBER], the wall from the room entry is shared with the communal shower room. There could have been some water damage from the shower room. The Director of Maintenance stated that they were not aware of the condition of the walls in room [ROOM NUMBER] and did not know if there were any work orders placed for repairs. The Director of Maintenance stated that room [ROOM NUMBER] was affected by the broken main drainpipe in room [ROOM NUMBER] since 2/21/2024. The walls were damaged due to water leaking into rooms [ROOM NUMBER] from room [ROOM NUMBER]. The Director of Maintenance stated a plumber repaired the affected pipes but could not recall the exact date. The Director of Maintenance and the Assistant Director of Housekeeping repaired the damaged walls in rooms [ROOM NUMBERS] in early March 2024. The Director of Maintenance stated that they used the waterproof sheetrock in room [ROOM NUMBER] but did not extend the sheetrock to the entire wall because they needed more materials. The Director of Maintenance stated the wallpaper outside of room [ROOM NUMBER] was not repaired because they had to get the wall sampled for mold before they closed it up. The Director of Maintenance stated that they do not recall when they sent a sample to the vendor for mold testing. The Director of Maintenance stated that the soap dispenser anchors came loose in Resident #60's room and the soap dispenser was reattached in a different location. The Director of Maintenance stated that the Assistant Director of Housekeeping did the repairs and that the holes should have been patched up after the soap dispenser was re-attached to the wall. The facility did not provide documented evidence of mold testing for the wall outside of room [ROOM NUMBER]. Licensed Practical Nurse #2 was interviewed on 4/11/2024 at 11:38 AM and stated that they have been the supervisor for the first floor for the last six months and were not aware of the damages on the walls in Resident #60's room and in room [ROOM NUMBER], or 115. Licensed Practical Nurse #2 stated If they were made aware of the damages they would have placed a work order for the maintenance to repair the damage in the rooms. Certified Nurse Aide #7 was interviewed on 4/11/2024 at 11:34 AM and stated they have worked with Resident #60 for the last three months and the holes from the soap dispenser were always there. Certified Nurse Aide #7 stated they did not put in a request or report the issue to anyone. The Director of Nursing Services was interviewed on 4/11/2024 at 12:30 PM and stated nursing staff are expected to report any maintenance issues to the Nursing Supervisor who in turn should place a work order. The housekeepers and Maintenance staff are also expected to make note of any disrepair in the residents' rooms. The Administrator was interviewed on 4/11/2024 at 12:39 PM and stated they were aware that the facility needed improvement with the aesthetic of the building. The Administrator stated that they intended to hire additional staff to do maintenance work. The Administrator stated that they started working at the facility on 5/8/2023 and after they caught up with adjusting to the facility, they felt that the resident rooms needed work. The Administrator stated the Director of Maintenance needs to have the work orders organized and track when repairs are needed. The Administrator stated that they also intended to implement routine environmental checks so that the maintenance staff could identify environmental concerns and repair them as needed. 10 NYCRR 415.5(h)(2)

Based on observation, record review, and interviews during the Recertification Survey initiated on 4/7/2024 and completed on 4/11/2024, the facility did not ensure it maintained an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #55) of one resident reviewed for Pressure Ulcers. Specifically, on 4/11/2024 Resident #55 was on contact precautions for Candida Auris (a fungal infection). There was a contact precautions sign at the doorway directing staff and visitors to wear appropriate personal protective equipment. The Director of Maintenance was observed in the resident's room examining the resident's air mattress and coming in substantial contact with the resident's environment (bed sheets, privacy curtain, air pump). The Director of Maintenance was not wearing any personal protective equipment. The finding is: The facility's policy titled Contact Precautions, last revised 11/2023, documented it is the policy of the facility to prevent the transmission of organisms among residents, staff, and visitors. The decision to isolate a resident and the type of isolation required is determined by the source of infection, the mode of transmission, and the susceptibility of the host. The purpose is to enhance interdisciplinary communication in regard to individual isolation and the accompanying precautions needed. Resident #55 was admitted with diagnoses including Respiratory Failure, Seizure Disorder, and an infection with a Multidrug-Resistant Organism. The 1/6/2024 Quarterly Minimum Data Set assessment documented no Brief Interview for Mental Status score as the resident had severely impaired cognitive skills for daily decision-making. A physician's order dated 11/17/2023 and active as of 4/11/2024 documented Contact Isolation: Candida Auris infection. The physician's order did not include the site of the infection. A Comprehensive Care Plan titled, Resident is on Contact Isolation secondary to Candida Auris effective 10/13/2023 and last revised 11/17/2023, documented staff will maintain contact precautions at all times, always perform proper hand hygiene, and apply and remove personal protective equipment as per Centers for Disease Control guidelines. A nursing progress note dated 11/17/2023 documented a prevalence survey (A data collection tool used to identify the number of people with a disease or condition at a specific point in time) mandated by the New York State Department of Health (NYSDOH) on 11/14/2023 for Candida Auris was conducted. The laboratory results were received on 11/17/2023 and this resident (#55) tested positive for Candida Auris infection and was placed on contact isolation. During an observation of Resident #55's unit, a precaution sign was observed posted outside Resident #55's door on 4/11/2024 at 8:55 AM. The sign documented Contact Precautions, Everyone Must: clean their hands, including before entering and when leaving the room; put on gloves before room entry, discard gloves before room exit; put on gown before room entry, discard gown before room exit. Wound Care Nurse #1 was interviewed on 4/11/2024 at 9:00 AM and stated Resident #55's air mattress has had a problem, the weight has to be set at a higher amount or the mattress deflates. Wound Care Nurse #1 stated the Maintenance Director was aware that the air mattress had to be replaced. Maintenance Director #1 was interviewed outside Resident #55's room on 4/11/2024 at 9:10 AM. Maintenance Director #1 stated they knew nothing about Resident #55's mattress problem and then entered Resident #55's room without putting on a gown or gloves and did not wash their hands. Maintenance Director #1 handled the air mattress pump and then walked to the side of the resident's bed, touched the bed sheets, felt the mattress, and came in contact with the privacy curtain. The resident was in bed at this time. When Maintenance Director #1 came out of the room, the surveyor directed the Maintenance Director to the contact precautions sign and the need for personal protective equipment. Maintenance Director #1 stated they went into the room without personal protective equipment because they thought addressing the air mattress malfunction was an emergency. Maintenance Director #1 stated they were going to the basement to remove and wash their clothing. The Director of Nursing Services, who was also the Infection Preventionist, was interviewed on 4/11/2024 at 11:31 AM and stated Maintenance Director #1 should have worn full personal protective equipment as the sign indicated, especially because the resident was on contact precautions for Candida Auris infection, which is a Multidrug-Resistant Organism. The Director of Nursing Services stated checking the resident's mattress was not an emergency, and the personal protective equipment should have been put on prior to entering the resident's room to prevent the spread of the infection. 10 NYCRR 415.19(a)(1-3)

Based on observation, record review, and interviews during the Recertification Survey initiated on 4/7/2024 and completed on 4/11/2024 the facility did not ensure that it maintained medical records for each resident in accordance with accepted professional standards and practices. This was identified for one (Resident #39) of five residents reviewed for Unnecessary Medications. Specifically, Resident #39 had a physician's order to self-administer their insulin and obtain their blood glucose via finger stick. The results of the blood glucose readings and self-administered insulin dosage were not accurately recorded in the resident's medication administration record on 4/9/2024 at 11:30 AM. The finding is: The facility's policy titled, Self Medication, dated 2/2003, documented it is the responsibility of the primary team nurse to check with the resident all the dispensed medication was given, sign documentation in the medication administration record, including date and time; and monitor resident on a self-medication program on a daily basis Resident #39 was admitted with diagnoses including Diabetes Mellitus, Morbid Obesity, and Depression. The 3/7/2024 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. A physician's order dated 1/31/2023 and effective as of 4/9/2024 documented the resident may keep insulin at the bedside, perform their own blood sugar checks, and self-administer medication. A physician's order dated 1/31/2023 and effective as of 4/9/2024 documented Novolin insulin, FlexPen injector 100 units/milliliter (Insulin Regular Human), Inject as per sliding scale subcutaneously before meals and at bedtime for diagnosis of Type 2 Diabetes Mellitus. If the fingerstick is: 150 milligrams per deciliter- 199 milligrams per deciliter then administer 4 units of insulin, 200 milligrams per deciliter - 249 milligrams per deciliter then administer 6 units of insulin, 250 milligrams per deciliter - 299 milligrams per deciliter then administer 8 units of insulin, 300 milligrams per deciliter - 349 milligrams per deciliter then administer 10 units of insulin, 350 milligrams per deciliter - 400 milligrams per deciliter then administer 12 units of insulin and Call a physician for blood sugar of less than 70 or greater than 400. On 4/9/2024 at 11:30 AM the surveyor observed Resident #39 check their blood glucose and administer insulin before the lunch meal. The insulin and fingerstick supplies were kept on the resident's overbed table inside a bag with the resident's name and medication label documenting the physician's order. There was also a sliding scale chart on the resident's overbed table, consistent with the physician's order. The resident's blood sugar reading was 255 milligrams per deciliter. The resident administered eight (8) units of insulin to their abdomen, as per the sliding scale. There were no concerns identified with the resident's ability to check blood sugar via the finger stick and to administer their insulin. A review of the medication administration record for 4/9/2024, 11:30 AM, revealed Licensed Practical Nurse #2 documented the blood sugar reading was 210 milligrams per deciliter and six (6) units of insulin was administered. Licensed Practical Nurse #2, who was the covering medication nurse on 4/9/2024 for Resident #39, was interviewed on 4/10/2024 at 8:24 AM and stated We have to just go by what the resident tells us; unfortunately, we ask the resident to call us when it is time to check the blood glucose and administer insulin, but they (the resident) do not call us. Licensed Practical Nurse #3, who was the regularly assigned medication nurse for Resident #39, was interviewed on 4/10/2024 at 8:31 AM. Licensed Practical Nurse #3 stated they always go into the resident's room to watch the resident check the blood glucose and administer insulin so that they (Licensed Practical Nurse #3) know exactly what to document in the medical record. Registered Nurse #4, the second-floor supervisor, was interviewed on 4/10/2024 at 8:52 AM. Registered Nurse #4 stated the nurses watch the resident when the resident checks the blood glucose. The nurses also ensure the resident is administering the right insulin dosage. The nurse is not supposed to just rely on the resident to provide the information. The nurses should verify the blood sugar reading on the glucometer and ensure the resident administers the right insulin dose as per the sliding scale. The Director of Nursing Services was interviewed on 4/10/2024 at 10:24 AM and stated even though the resident has the order to self-administer their medications and perform their blood sugar checks, as per the facility policy, the nurses should watch the resident check the blood glucose and give insulin just to ensure it is being done correctly and the documentation is accurate. 10 NYCRR 415.22(a)(1-4)

Based on record review and interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 00326378) initiated on [DATE] and completed on [DATE], the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, facility administration allowed an unlicensed, graduate nurse to work in the capacity of a Registered Nurse until [DATE], almost four months beyond the Public Health Emergency (PHE) waiver expiration date of [DATE]. The finding is: Executive Order Number 4.22 dated [DATE] documented the Executive Order number 4 was extended until [DATE] which included a temporary Suspension and Modification of Subdivision 5 of Section 6907 of the Education Law and Regulations to the extent necessary to permit graduates of registered professional nurse and licensed practical nurse licensure qualifying education programs registered by the State Education Department to be employed to practice nursing under the supervision of a registered professional nurse and with the endorsement of the employing hospital or nursing home for 180 days immediately following graduation. The facility's undated policy titled Employment of Limited Permit Nursing Staff documented that in accordance with the New York State Education Law, the State Education Department issues limited permits that authorize the practice of nursing under the immediate and personal supervision of a registered professional nurse. An applicant for a limited permit must have completed all requirements for licensure except the licensing examination. The Nursing Home Facility Incident Report dated [DATE] documented that in the course of doing employee audits, it was discovered that Unlicensed Graduate Nurse #1 was hired by the facility in February of 2023 by the previous Administration, and their Nursing Diploma from college was dated May of 2021. Unlicensed Graduate Nurse #1 had never obtained their license. Unlicensed Graduate Nurse #1 was immediately terminated and reported to the Office of Professions. The facility's current Director of Nursing Services was interviewed on [DATE] at 10:10 AM and stated that they started working at the facility in April of 2023. The Director of Nursing Services stated that in October of 2023, they conducted an audit to make sure that all Nursing staff had their current licenses and Cardiopulmonary Resuscitation (CPR) credentials were up to date and discovered that Unlicensed Graduate Nurse #1 was still working in the facility as an 11:00 PM-7:00 AM Registered Nurse without a license. The Director of Nursing Services stated that unlicensed Registered Nurses were no longer allowed to practice as Registered Nurses because the limited COVID-19 Public Health Emergency waiver had expired sometime at the end of [DATE]. The Director of Nursing Services further stated that Unlicensed Graduate Nurse #1 was terminated by the facility on [DATE]. The Administrative Assistant was interviewed on [DATE] at 11:30 AM and stated they had made the prior Director of Nursing Services aware that Unlicensed Graduate Nurse #1 had not fulfilled the criteria of providing a test date to obtain their license. The Administrative Assistant stated they had always been in charge of keeping track of the license expiration dates of the Nurses; however, the prior Director of Nursing Services had told them (Administrative Assistant) that they (Director of Nursing Services) were in charge of the licenses of the Nurses. The Administrative Assistant stated they thought the prior Director of Nursing Services would follow up with Unlicensed Graduate Nurse #1. The Administrative Assistant stated that no one in the facility had told her them that the COVID-19 Public Health Emergency waiver related to the use of Unlicensed Nurses had expired in June of 2023. The facility's Administrator was interviewed on [DATE] at 10:15 AM and stated that Unlicensed Graduate Nurse #1 should never have been allowed to work as a Registered Nurse in the facility after the COVID-19 waiver expired in June of 2023. 10 NYCRR 415.26

Based on observation, record review, and interviews during the Recertification Survey initiated on 4/7/2024 and completed on 4/11/2024 the facility did not ensure a resident requiring dialysis services received such services consistent with professional standard of practice. This was identified for one (Resident #31) of two residents reviewed for Dialysis. Specifically, Resident #31, who receives Dialysis treatment three times a week, was observed on 4/7/2024 with swelling to their left upper arm. Resident #31 returned from their dialysis treatment on 4/6/2024 with recommendations to apply warm compresses to the left upper arm. The recommendations were communicated from the dialysis center staff to the facility staff via a Dialysis Communication Notebook. The facility staff did not address and apply the warm compresses to the resident's right upper arm as indicated by the Dialysis center. The finding is: The facility policy and procedure titled, Patient Care for Dialysis last reviewed on 9/2018 documented to ensure a maximum state of wellness and control of renal disease in dialysis patients, consistent method of communication among dialysis units, personnel, attending physicians, and nursing unit staff are essential. A Dialysis Communication Book will be prepared for the admission of all dialysis patients. This individual book will accompany each patient at every dialysis session and will contain timely, pertinent patient information, direction, and questions relevant to the care of the patient. The Licensed Nurse's responsibility, at the time of pickup, is to make sure the patient has his/her Dialysis Communication Notebook and at the time of return from the dialysis center, complete a post-dialysis assessment; read the Dialysis Communication Book and any recommendations in the dialysis notes should be addressed. Resident #31 was admitted with diagnoses of End-Stage Renal Disease, Right Ankle and Foot Acute Osteomyelitis (bone infection), and Type II Diabetes. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated that Resident #31 had intact cognition. Resident #31 was dependent on staff for all Activities of Daily Living (ADL). The Minimum Data Set documented the resident received Dialysis treatment. A Physician's Order dated 9/22/2023 documented, dialysis treatment every Tuesday, Thursday, and Saturday. A Comprehensive Care Plan (CCP) for Dialysis dated 9/7/2023 documented interventions including to check access dressing, to communicate patient information with the dialysis center via a Communication Notebook, and to monitor for peripheral edema (swelling). A Progress Note dated 4/6/2024 at 3:05 PM, written by Licensed Practical Nurse #3, documented that Resident #31 returned from dialysis treatment at 2:45 PM. No distress was noted. Safety precautions were maintained. Resident #31 was observed on 4/7/2024 at 9:35 AM. Resident #31 was lying in bed and was wearing a short-sleeved hospital gown. The resident's left arm was observed to have swelling above the Arteriovenous Fistula (AVF-a connection that's made between an artery and a vein for dialysis access). Resident #31 was interviewed on 4/7/2024 at 9:35 AM and stated the nurses do not check the Communication Notebook after they return from the Dialysis treatment. Resident #31 stated the swelling on their left arm started while they were at Dialysis on 4/6/2024. Resident #31 stated when they returned from the dialysis center they told Licensed Practical Nurse #3 about the swelling. A review of the Dialysis Communication Notebook revealed that on 4/6/2024 the dialysis center documented recommendations for the facility staff to apply warm compresses to Resident #31's left arm (Dialysis access site) to reduce swelling. The 7:00 AM-3:00 PM Registered Nurse Supervisor #3 was interviewed on 4/7/2024 at 12:10 PM and stated that they did not notice any swelling on Resident #31's left arm on 4/6/2024 and 4/7/2024. Registered Nurse Supervisor #3 Stated the resident normally returned from their dialysis treatment at 2:45 PM. Licensed Practical Nurse #3 received the resident on 4/6/2024 when the resident came back from the dialysis and should have written a progress note and called the physician for orders related to the recommendations made by the dialysis center. Registered Nurse Supervisor #3 stated they would call to notify the Physician now about the swelling on Resident #31 left arm. The Registered Nurse from the dialysis center was interviewed on 4/10/2024 at 8:03 AM and stated that the Dialysis Center utilized the Communication Notebook for Resident #31. The Registered Nurse from the dialysis center stated they expected the facility staff to ensure the Communication Notebook is reviewed before and after dialysis for any communication and new recommendations provided by the dialysis center. Licensed Practical Nurse #3 was interviewed on 4/10/2024 at 10:42 AM and stated they received Resident #31 on 4/6/2024 at 2:45 PM when the resident returned from the dialysis center. Licensed Practical Nurse #3 stated they checked Resident #31's vital signs and gave the resident their medications. Licensed Practical Nurse #3 stated they forgot to check the Dialysis Communication Notebook. The Director of Nursing Services was interviewed on 4/10/2024 at 2:19 PM and stated the nurse should have assessed Resident #31 after the resident returned from their dialysis treatment. The assessment should have included vital signs, skin checks for the thrill (vibration sound by blood flowing through the fistula, and can be felt by placing fingers just above the incision line) and bruit (a whooshing sound near the fistula incision site), and monitoring of the dressing on the fistula site for any bleeding. The Director of Nursing Services stated that the Dialysis Communication Notebook should be checked after a resident comes back from the dialysis treatment to make sure any recommendations from the dialysis center are followed promptly. 10 NYCRR 415.12

Based on observation, record review, and interviews during the Recertification Survey initiated on 4/7/2024 and completed on 4/11/2024 the facility did not ensure that each resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. This was identified for one (Resident #55) of one resident reviewed for Pressure Ulcers. Specifically, Resident #55 had multiple Stage 4 pressure ulcers to the sacrum, right upper back, and left upper back. The resident was utilizing an air mattress as per the physician's order. The weight setting on the resident's air mattress was set at 240 pounds, while the resident's most recent weight was recorded as 123 pounds. The facility staff were unable to adjust the air mattress weight setting according to the resident's weight to provide appropriate pressure relief to the affected areas. The facility nursing staff reported the malfunction to the maintenance department; however, the mattress was not repaired. The finding is: The facility policy titled Impaired Skin Integrity, dated 5/2018, documented the skin integrity program will use a multidisciplinary approach for the prevention and treatment of wounds; the policy purpose is to reduce the incidence of pressure sores through effective assessment, prevention, and treatment; the wound team members are the facilitators of the skin integrity program, collaborating to develop and initiate prevention and healing continuums that provide a comprehensive plan of care. For Stage 4 pressure ulcers, a specialty mattress is an intervention to relieve pressure. Resident #55 was admitted with diagnoses including Respiratory Failure, Seizure Disorder, and an infection with a Multidrug-Resistant Organism. The 1/6/2024 Quarterly Minimum Data Set assessment documented no Brief Interview for Mental Status score as the resident had severely impaired cognitive skills for daily decision making. The Minimum Data Set assessment documented that the resident had one Stage 2 pressure ulcer, one Stage 3 pressure ulcer, and three Stage 4 pressure ulcers. Resident #55 is a ventilator-dependent resident. A physician's order dated 7/3/2023 and last renewed on 4/11/2024 documented to use an air mattress related to wound care. A Comprehensive Care Plan titled, The Resident has Actual Impairment to Skin Integrity Related to Wound Care (Sacrum), initiated 7/1/2023 and last updated 3/2/2024, documented use of the Low Air Flow Mattress and for staff to identify potential causative factors related to impaired skin integrity and eliminate/resolve where possible. Resident #55's most recent weight documented in the electronic medical record dated 3/27/2024 was 123.8 pounds. The wound care consult dated 4/4/2024 documented the resident has a Stage 4 pressure ulcer to the sacrum, Stage 4 pressure ulcer to the right upper back, Stage 4 pressure ulcer to the left upper back, and an unstageable pressure ulcer to the left elbow. The wound care consult documented to utilize the pressure redistribution mattress as per facility protocol. A physician's order dated 10/17/2023 and last renewed on 4/11/2024 documented to cleanse the sacral wound with normal saline, pat dry, then loosely pack with calcium alginate (a highly absorbent wound dressing) rope to undermining (significant erosion occurs underneath the outwardly visible wound margins), then honey fiber to the wound bed, cover with foam dressing daily and when needed every day-shift. Resident #55 was observed in bed on 4/11/2024 at 8:38 AM. The air mattress weight setting dial was set to 240 pounds. Licensed Practical Nurse #1 (medication nurse) was interviewed on 4/11/2024 at 8:55 AM and stated they do not touch the weight setting on the air mattress; Licensed Practical Nurse #1 stated that is the wound care nurse's job. Wound Care Nurse #1 (Licensed Practical Nurse) was interviewed on 4/11/2024 at 9:00 AM. Wound Care Nurse #1 stated Resident #55's air mattress has had a problem, the weight has to be set at a higher setting than the resident's actual weight or the mattress deflates. Wound Care Nurse #1 stated the Maintenance Director was aware that the mattress had to be replaced. Wound Care Nurse #1 stated maintenance issues have to be reported via a computerized maintenance request reporting system and sometimes the issues are reported verbally to the Maintenance Director. Maintenance Director #1 was interviewed on 4/11/2024 at 9:10 AM and stated they knew nothing about Resident #55's air mattress problem. Maintenance Director #1 then went into Resident #55's room and was observed pressing on the resident's air mattress. The resident was in bed at this time. Maintenance Director #1 came out of the resident's room and acknowledged the weight setting on the air mattress was set at 240 pounds and there was an indicator light on the pump indicating low pressure. Maintenance Director #1 stated the nursing staff would have to get the resident out of bed because they (Maintenance Director #1) have to examine the mattress more closely. On 4/11/2024 at 10:11 AM the sacral Stage 4 pressure ulcer treatment was observed, which was performed by Registered Nurse #5 (treatment nurse). Certified Nursing Assistant #6 assisted Registered Nurse #5 during the treatment. The air mattress weight setting was set at 240 pounds. The sacral wound was approximately 4 centimeters long, 6 centimeters wide, and 1 centimeter deep with undermining (tissue loss underneath the visible wound boundaries) present. The wound dressing that was removed was completely saturated with serosanguinous (blood-tinged) drainage. Wound Care Nurse #1 was re-interviewed on 4/11/2024 at 10:41 AM. Wound Care Nurse #1 stated they searched the electronic maintenance reporting system and could not find any maintenance requests related to Resident #55's air mattress. Assistant Housekeeping Director #1 was interviewed on 4/11/2024 at 11:02 AM and stated they were not aware of any concerns related to Resident #55's air mattress until this morning. Assistant Housekeeping Director #1 further stated there were no requests regarding Resident #55's air mattress malfunction. Registered Nurse #4, Second Floor Supervisor, was interviewed on 4/11/2024 at 11:19 AM. Registered Nurse #4 stated they (Registered Nurse #4 and Wound Care Nurse #1) have told the Maintenance Director numerous times about Resident #55's air mattress malfunction. The mattress loses the pressure and deflates. Requests in the electronic system were placed; however, they (Registered Nurse #4) could not recall when and who had placed the request in the electronic system. Registered Nurse #4 stated they did not know since when the air mattress was not working properly. The Assistant Director of Nursing Services was interviewed on 4/11/2024 at 11:21 AM and stated the nursing staff enters the maintenance request in the system and if the Maintenance Director closes out the request in the system indicating the request has been acted upon, the request disappears from the system and is no longer available. The Director of Nursing Services was interviewed on 4/11/2024 at 11:31 AM and stated the air mattress weight setting should be consistent with the resident's weight to provide for optimal healing. The Director of Nursing Services stated the mattress should have been replaced when the problem was first identified, and staff should have followed up to ensure that the mattress was working properly. The wound care Nurse Practitioner #1 was interviewed on 4/11/2024 at 12:14 PM and stated the weight setting on the air mattress should correspond with the resident's weight. An inappropriate weight setting could adversely affect wound healing. 10 NYCRR 415.12(c)(2)

Based on observations, record review, and interviews during the Recertification Survey initiated on 4/7/2024 and completed on 4/11/2024, the facility did not ensure that a comprehensive person-centered care plan was developed or implemented for each resident to meet a resident's medical and nursing needs. This was identified for one (Resident #47) of one resident reviewed for Limited Range of Motion. Specifically, Resident #47 had a physician's order for a hand roll to be worn on the right hand at all times due to limited mobility. Resident #47 was observed multiple times without the hand roll as per the physician's order. The finding is: The facility's policy and procedure titled, Comprehensive Care Plan last revised on 3/2016, documented that all residents will have an individualized interdisciplinary care plan developed by the interdisciplinary care plan team on admission, annually, and upon identification of significant change in condition. Resident #47 was admitted with diagnoses of Acute Respiratory Failure, Chronic Inflammatory Demyelinating Polyneuritis (a neurological disorder that involves progressive weakness and reduced senses in the arms and legs), and Type II Diabetes. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12 which indicated Resident #47 had moderate cognitive impairment. A Comprehensive Care Plan (CCP) for skin integrity dated 2/9/2024 documented interventions including to check the area under braces and positioning devices during care and to implement Range of Motion as per the physician's order. A physician's order dated 2/14/2024 documented a hand roll to be worn on the right hand at all times and removed for skin checks and hygiene. The Certified Nursing Assistant Accountability Record (Resident care instructions provided to the Certified Nursing Assistants) dated 4/8/2024 documented that a hand roll must be worn on the right hand at all times and to be removed for skin check and hygiene. Resident #47 was observed on 4/7/2024 at 9:00 AM lying in their bed. The resident was not wearing a hand roll on their right hand as per the physician's order. Resident #47 was observed on 4/8/2024 at 6:46 AM. Resident #47 was in bed and was not wearing a hand roll on the right hand. Certified Nursing Assistant #2 was interviewed on 4/8/2024 at 10:46 AM and stated that they are not the regularly assigned aide for Resident #47 and were assigned to care for the resident on 4/8/2024. Certified Nursing Assistant #2 stated they did not know that Resident #47 needed a hand roll because they were not familiar with the resident's care needs. Certified Nursing Assistant #2 stated they did not check the Certified Nursing Assistant Accountability Record before caring for Resident #47. Resident #47 was observed on 4/9/2024 at 10:36 AM. Resident #47 lying in their bed and was not wearing a hand roll on their right hand. A hand roll was observed on top of the nightstand. Certified Nursing Assistant #3 was interviewed on 4/9/2024 at 10:50 AM and stated they normally applied the hand roll after the resident received the morning care and was ready for their physical therapy. At times Resident #47 refused to use the hand rolls. Certified Nursing Assistant #3 stated they reported the refusal to the nurse in charge; however, could not recall when. The Assistant Occupational Therapist was interviewed on 4/9/2024 at 1:25 PM and stated Resident #47 participated in rehabilitation therapy and was normally wearing a hand roll on the right hand. There were times when Resident #47 requested to take the hand roll off. The Assistant Occupational Therapist stated that Resident #47 could take off the hand roll with their left hand. Registered Nurse #4, the Unit Supervisor, was interviewed on 4/9/2024 at 2:08 PM and stated the Certified Nursing Assistants are responsible for applying the hand roll for Resident #47 and the nurses on the unit are responsible for making sure that the hand roll is applied as per the physician's order. Registered Nurse #4 stated they were not aware that Resident #47 was refusing the hand roll use. The Director of Rehabilitation Services was interviewed on 4/10/2024 at 9:39 AM and stated that they were not aware of Resident #47's refusal of the hand roll. The Director of Rehabilitation Services stated that the nurses on the unit should have reported the refusals to the Unit Supervisor who would then report to the Rehabilitation Therapy Department. The Occupational therapist would then evaluate the need for the device or an alternative device for Resident # 47. The Director of Nursing Services was interviewed on 4/10/2024 at 2:58 PM and stated Resident #47 should be wearing the hand roll to prevent further contractures. The Director of Nursing Services stated if the resident was refusing to use the hand rolls then the Certified Nursing Assistants should have reported the resident's refusal to the nurses for further assessment and evaluation. 10 NYCRR 415.11(c)(1)

Based on record review and interviews during the Recertification Survey and Extended Survey (NY 00321584), the facility did not ensure that it reported each injury of unknown origin to the New York State Department of Health within 24 hours as required. This was identified for one (Resident #35) of four residents reviewed for Discharge. Specifically, on 8/5/2023 Resident #35 was identified by facility staff with discoloration and swelling to the right arm; an x-ray on 8/6/2023 confirmed an acute oblique fracture of the distal radius (a fracture that is on an angle of one of the bones in the forearm that connects to the wrist). The incident was not reported to the New York State Department of Health until 8/7/2023. The finding is: The facility's policy titled, Resident Accident/Incident Report last revised 4/2018, documented it is the responsibility of the Director of Nursing Services/Administrator to notify the New York State Department of Health within five working days of the occurrence when an accident/incident involves alleged abuse. Resident #35 was admitted with diagnoses including Seizure Disorder, Respiratory Failure, and Anoxic Brain Damage (brain damage due to cessation of blood supply to brain tissue). The 6/29/2023 Quarterly Minimum Data Set assessment documented no Brief Interview for Mental Status score because the resident was documented as comatose (deep unconsciousness). A nursing progress note, written by the former Assistant Director of Nursing/Risk Manager, dated 8/5/2023 at 2:21 PM documented resident was noted with mild swelling and discoloration to the right hand and wrist. A Physician was notified and an order was given to obtain a right wrist hand x-ray and Doppler. An x-ray report dated 8/6/2023 documented an acute oblique fracture of the distal radius. A nursing progress note dated 8/6/2023 documented that the resident was sent to the hospital for further evaluation as per the physician's order. A nursing progress note dated 8/7/2023 documented the resident returned from the hospital with the right wrist soft cast. A review of the Accident and Incident report dated 8/7/2023 documented, on 8/5/2023 at approximately 2:00 PM the resident was observed with mild swelling and an area of discoloration to the right hand/wrist measuring 10 centimeters by 6 centimeters. An investigation was immediately initiated and statements from staff were collected. As per staff reports there was no discoloration observed prior to 8/5/2023. The report concluded that although the cause of this investigation is undetermined at this time, the resident's care plan was followed by staff, it is reasonable to conclude that there is no cause to believe any alleged abuse, neglect, or mistreatment regarding this resident occurred. The incident was reported to the New York State Department of Health on 8/7/2023 at 9:55 AM by the Director of Nursing Services. The current Assistant Director of Nursing/Risk Manager was interviewed on 4/10/2024 at 11:15 AM and stated the former Risk Manager, who had completed the investigation related to the injury of an unknown origin for Resident #35, is no longer employed at the facility. The current Assistant Director of Nursing/Risk Manager stated the Director of Nursing Services was responsible for reporting all reportable incidents to the New York State Department of Health. The Director of Nursing Services was interviewed on 4/10/2024 at 12:12 PM and stated they knew that an injury of unknown origin should be reported within 24 hours. The incident related to Resident #35 was identified on the weekend (8/5/2023) and they (Director of Nursing Services) did not find out about the incident until Monday (8/7/2023) during the morning report. The Director of Nursing Services stated they then reported the incident of injury of unknown origin to the New York State Department of Health, which should have been completed within 24 hours. 10NYCRR 415.4 (b)(2)

Based on observations, record review, and interviews during the Recertification Survey initiated on 4/7/2024 and completed on 4/11/2024, the facility did not ensure that the staff implemented and provided care and services according to resident's needs and professional standard of practice for each resident with a feeding tube. This was identified for one (Resident # 302) of three residents reviewed for Tube Feeding. Specifically, on 4/7/2024 at 9:28 AM and 4/8/2024 at 6:11 AM, Resident #302 was observed receiving enteral tube feeding; the enteral tube feeding and the water bags were observed hanging on a feeding tube stand without a label including the resident's name, and the time the tube feeding was started. The finding is: The facility's Policy and Procedure titled, Enteral Feeding last revised in 12/2018 documented that the enteral tube feeding will be administered as per the order of a License Independent Practitioner to provide liquid nourishment and/or medication into the stomach through a gastrostomy/ jejunostomy tube when a resident cannot or will not take it by mouth. The feeding bottle must be labeled with the resident's information, including the resident's name, room number, date, start time, and rate. Resident #302 was admitted with diagnoses that included Respiratory Failure, Gastrostomy status, and Type II Diabetes. The Minimum Data Set assessment was not completed for Resident #302 as the resident was recently admitted to the facility. A Nursing Admission assessment dated [DATE] documented that Resident #302 was unable to make their needs known and could not communicate. Resident #302 required one-person assistance with all Activities of Daily Living (ADL). The Physician's order dated 4/5/2024 documented to administer [NAME] Farms 1.5 peptide (tuber feeding formula)1000 cubic centimeters per day with a flow rate of 50 cubic centimeters per hour via gastrostomy tube. The order was discontinued on 4/8/2024. The Comprehensive Care Plan (CCP) for Tube Feeding dated 4/6/2024 documented interventions to assess placement and patency of the tube. Monitor for signs and symptoms of aspiration, and intolerance. Ensure the head of the bed is elevated at 30 degrees or more during feeding and one hour after the feeding. A Nutritional/Admission assessment dated [DATE] documented that Resident #302 was to receive Nothing by Mouth (NPO) including liquids except through Tube Feeding. The Physician's order dated 4/8/2024 documented to administer Glucerna 1.5 (tube feeding formula), 1000 cubic centimeters, per day with a flow rate of 50 cubic centimeters per hour. Water Flushes via the feeding pump (an enteral pump that delivers thick formula) 50 cubic centimeters per hour for 20 hours at the start of feeding one time a day. During an observation on 4/7/2024 at 9:28 AM, Resident #302 was observed receiving enteral tube feeding via a feeding pump. The enteral feeding bag and a water bag were observed hanging from the feeding tube stand. The enteral tube feeding bag and the water bag did not have a label to identify the resident's name, the time feeding was started, and the feeding directions as prescribed by the Physician. In a subsequent observation on 4/8/2024 at 6:11 AM, Resident #302 was observed receiving enteral tube feeding via a feeding pump. The enteral feeding bag and a water bag were observed hanging from the feeding tube stand. The enteral tube feeding bag and the water bag did not have a label to identify the resident's name, the time feeding was started, and the feeding directions as prescribed by the Physician. Licensed Practical Nurse #1 was interviewed on 4/8/2024 at 6:11 AM and stated they did not start the enteral feeding and did not know there was no label on Resident #302's enteral bag. Licensed Practical Nurse #1 stated the enteral feeding was already running when they came in for the 11:00 PM-7:00 AM shift. Licensed Practical Nurse #1 Stated they should have checked the enteral tube feeding bag before pouring the [NAME] Farms 1.5 peptide (tube feeding formula) during their shift to ensure that a label was in place. Licensed Practical Nurse #3 was interviewed on 4/10/2024 at 11:07 AM and stated that they did not notice the enteral tube feeding bag was not labeled on 4/7/2024 during their 7:00 AM-3:00 PM shift. Licensed Practical Nurse #3 stated that they should have checked the enteral tube feeding bag when they administered the enteral feeding for Resident #302 during the 7:00 AM-3:00 PM shift to ensure a label was in place. The Director of Nursing Services was interviewed on 4/10/2024 at 2:09 PM and stated that it was not the responsibility of one shift to ensure a label was in place. All nurses should have checked and ensured that the enteral tube feeding bag had a label that included the name of the resident, room number, date, and start time. 10 NYCRR 415.12(g)(2)

Based on observation, interview and record review during an abbreviated extended survey (Complaint# NY 391) the facility failed to have a system in place to ensure medications were labeled accurately and in accordance with professional standards for one of five residents reviewed for Pharmaceutical Services (Resident #1). Specifically, Resident #1 had an order to receive [MEDICATION NAME] 450 milligrams (mg) each night. The pharmacy delivered [MEDICATION NAME] 20 mg (an antihypertensive medication) labeled as [MEDICATION NAME] for the resident. The nursing staff recognized a change in the appearance of the tablets, however, did not verify that it was the same medication as ordered ([MEDICATION NAME] 450 mg). Subsequently, the resident was administered the wrong medication approximately 20 times and experienced uncontrolled [MEDICAL CONDITION] (low blood pressure), poor appetite and mood decompensation. The resident was admitted to the hospital with [REDACTED]. This resulted in actual harm and potential for serious harm for all residents receiving medication from the vendor pharmacy that is Immediate Jeopardy. The findings are: The Pharmacy policy titled Dispensing of Medications dated 10/2013 documented that the Pharmacist will verify medication orders and dispense medications in accordance to the needs of the patient. The Pharmacy Service Provider Agreement, between the facility and the vendor pharmacy, dated 1/24/17 documented that the pharmacy was responsible to label all products in accordance with applicable laws. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 3/7/2018 documented the resident's cognitive status as moderately impaired. The resident had no behaviors and received antipsychotic and antidepressant in the last 7 days. The Comprehensive Care Plan (CCP) titled [MEDICAL CONDITION] (CAD) dated 11/26/2015 documented the resident had CAD related to [MEDICAL CONDITION] and Hypertension. Interventions included give all cardiac medications aspirin and potassium as ordered by the physician, monitor and document side effects and report to the physician. The CCP titled [MEDICAL CONDITION] Disorder/ Depression/[MEDICAL CONDITION] disorder dated 1/19/2016 and Psychoactive Drug Use dated 3/16/16 documented the resident was on antidepressant medication and had a potential for adverse effect of psychoactive drug use related to Anxiety, agitation, [MEDICAL CONDITION], behaviors, [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder. Interventions included to administer [MEDICATION NAME] (an antipsychotic medication) ER (extended release), monitor for changes in mood or behavior, monitor side effects and effectiveness. The Medication Review Report (physician's orders [REDACTED]. The Electronic Prescription Resupply Request for [MEDICATION NAME] 450 mg Extended Release ER was recertified on 4/27/18 and was requested to be refilled on 4/29/18. The pharmacy Packing Slip dated 4/30/18 documented [MEDICATION NAME] tablet 450 mg ER 30 tablets with prescription number 503 was delivered and accepted by the facility staff on 4/30/18. The Nursing Progress Notes (NPN) dated 5/10/18 documented the resident was very confused and had a hard time complying with medication administration. On 5/13/2018 the resident had period of confusion and his Blood Pressure (BP) was lower than usual 87/60 mmHg (normal 120/80mmHg). The NPN dated 5/15/18 through 5/22/18 documented the resident's systolic BP ranging from 93-133mmHg and diastolic BP ranging from 56-76mmHg. The resident had poor appetite, sluggish response and confused thought process. The resident exhibited combative behavior with agitation on 5/17/18, 5/18/18, 5/20/18 and 5/22/18. The Therapeutic Drug Monitoring report dated 5/18/18 and 5/21/18 documented a [MEDICATION NAME] level of less than 0.2meq/L (normal range 0.6-1.2 meq/L). The Nurse Practitioner (NP) progress note dated 5/22/18 documented the resident was striking staff without notice. The [MEDICATION NAME] level was less than 0.2 meq/L. The NPN dated 5/23/18 at 2:43 PM by the Licensed Practical Nurse (LPN) documented the resident continued to be very combative towards staff while receiving care. The resident had very poor appetite and often observed spaced out throughout the shift. His BP was 100/62mmHg. The Psychiatry consult dated 5/23/18 documented the resident had a change in status over past 2 weeks, eating poorly and his mood was clearly decompensated. The resident was withdrawn with sparse/non-spontaneous speech and depressed mood. His serum [MEDICATION NAME] level was less than 0.2meq/L. The psychiatrist recommended to start [MEDICATION NAME] 300 mg for two nights, then increase [MEDICATION NAME] to 450 mg and obtain serum [MEDICATION NAME] level on 5/29/18. The NP progress note dated 5/23/18 at 5:17 PM documented the NP received a call and a text from nursing staff that the resident was very agitated, combative, refused to eat, drink and take his medications. The case was discussed with the Primary Medical Doctor (PMD) and the PMD agreed that the resident be transferred to hospital for evaluation of change in mental status. The resident had been sick and showed signs [MEDICAL CONDITION] with low BP. As per nursing the resident became more erratic . The Psychiatrist arrived and he reviewed the resident's file and medications. The Psychiatrist informed the NP that he was skeptical about the [MEDICATION NAME] tablet that was being administered to the resident. Gray pill with letter S and # 343 was written on each side of the pill. The nursing staff informed the psychiatrist that they had been getting a new form of [MEDICATION NAME] pill for about 2 months. The NP investigated and found that the tablet the nurses thought was [MEDICATION NAME] was [MEDICATION NAME] 40 mg tablet, an ace inhibitor. The NP reported this to the Medical Director (MD) and the Director of Nursing (DON). The medication was removed from the cart. The Medication Review Report lacked documented evidence of an order for [REDACTED]. The Medication Administration Record (MAR) for 5/2018 documented [MEDICATION NAME] 450 mg tablet orally at bedtime for [MEDICAL CONDITION] Disorder, was signed for as administered daily from 5/1/18 through 5/22/18 at 9:00PM. The [MEDICATION NAME] 450 mg was administered as a stat dose on 5/22/18 at 1:25 PM. The Therapeutic Drug Monitoring report for [MEDICATION NAME] dated 5/23/18 documented a [MEDICATION NAME] level of less than 0.2meq/L. The NP progress note dated 5/24/18 at 10:30 AM documented the resident was combative, afraid and impulsive. He was physically aggressive towards staff and had removed his intravenous (IV) line. The BP at 10:25 AM was documented as 77/44 mmHg and at 11:01 AM it was 101/56mmHg. The resident was restless, confused, aggressive, impulsive, combative, clingy and afraid. The NPN dated 5/24/18 at 4:28 PM by the DON documented a telephone order obtained from the MD to start IVF ½ NS at 60cc/hr and continue to monitor. The resident had poor oral intake. The BP at 2:30 PM was 81/51mmHg. The MD was made aware and ordered to transfer the resident to hospital for unstable BP. The NPN dated 5/24/18 at 6:49 PM by the Registered Nurse (RN) documented the resident's BP kept fluctuating despite bolus and continues IV fluid therapy. The MD ordered to transfer the resident to the hospital and the resident left the unit at 3:45 PM with a BP of 99/51mmHg. He was admitted to the hospital with [REDACTED]. The undated and unsigned facility investigation documented the resident started having increased episodes of combative behavior and decreased oral intake. The resident received antibiotic [MEDICATION NAME] and cardiology, urology and neurology consults were ordered. On 5/23/2018 the psychiatrist asked to see the medication. He found that the blister pack that was labeled as [MEDICATION NAME] contained a pill that looked different in appearance. The pharmacy confirmed the pill in blister pack labeled as [MEDICATION NAME] (a round light grey pill with #343 on one side and letter S on one side) to be an ace inhibitor, [MEDICATION NAME], commonly used for Hypertension. On 5/24/18 the resident had an episode of combative behavior and his blood pressure (BP) was 77/44mmHg. The resident was given D5 ½ bolus IV fluid then increased to 60cc/hr. The resident had poor oral intake with sips of milk and small cup of fruit cake. The resident's BP after the IV fluids was 81/51mmHg. The MD was informed and ordered resident to transfer to the hospital. The resident was admitted with [MEDICAL CONDITION]. The Medication Incident Report dated 5/24/18 documented the resident received [MEDICATION NAME] instead of [MEDICATION NAME]. The blister pack was labeled as [MEDICATION NAME] 450 mg. All nursing staff was educated to report any changes in the appearance of a medication. A photocopy of the blister pack labeled with Resident #1's name showed that it was refilled on 4/30/2018. The blister pack was labeled as [MEDICATION NAME] tab 450 mg ER (Escalate) 1 tablet by mouth at bedtime. There were 5 of 30 remaining pills in the blister pack. The hospital record Emergency Department (ED) notes dated 5/24/18 documented the patient recently started to have some behavioral disturbances and had labs checked and found that his [MEDICATION NAME] was low. The Psychiatrist saw the patient on 5/23/18 and found that the pills that were sent from the pharmacy in the blister packet were not [MEDICATION NAME] and upon further investigation it was found that patient had been receiving 20 mg [MEDICATION NAME] twice daily for the past 3-4 weeks. The patient was admitted for [MEDICAL CONDITION] that resolved with IV fluid and discontinuation of [MEDICATION NAME]. The patient could not keep up with oral fluid intake and had a feeding tube placed for nutrition and hydration. The NP was interviewed on 5/29/18 at 2:23 PM and stated that approximately 2-3 weeks ago nursing reported to her that the resident had low BP and was exhibiting behaviors of aggressiveness and poor oral intake. Resident #1 was not on any antihypertensive medication. The serum [MEDICATION NAME] level drawn on 5/17/18 and was excessively low. On 5/22/18 an extra dose of [MEDICATION NAME] 450 mg stat was ordered and administered. Resident #1 was still erratic with behaviors and was not doing well. On 5/23/18 the NP ordered to send Resident #1 to hospital; the Psychiatrist who was familiar with Resident #1 was present in the building and was consulted. The Psychiatrist reviewed the blood [MEDICATION NAME] level and asked the nurse to show him the [MEDICATION NAME] pill that was being administered to the resident. The Psychiatrist told the NP that the pill in the blister pack did not look like the [MEDICATION NAME] pill. From the marking on the pill it was discovered that it was [MEDICATION NAME] an ace inhibitor. The NP stated that nursing told the Psychiatrist on 5/23/18 that they were receiving the new [MEDICATION NAME] pills from the pharmacy for last 2 months. The nurses did not report to the NP that there was a change in pill color, shape or form. The resident continued to show behaviors and had low BP. On 5/24/18, the NP received several phone calls that Resident #1 was combative, scared and his BP was 77/44mmHg (low). The low BP was troublesome because the resident was not getting better even with interventions such as intravenous fluid. The NP stated Resident #1 had a low blood pressure and a change in mental status because of the wrong medication ([MEDICATION NAME]) he received for last 2 months. Resident #1 was combative, anxious, scared and refused care and medications. The Psychiatrist was interviewed on 5/29/18 at 4:14 PM and stated he knew Resident #1 for a while and treated him prior to his admission to the facility. Resident #1 was psychiatrically stable for the past 2 years. Resident #1 started to show changes in his behavior and a drop in BP since last week. The serum [MEDICATION NAME] level was tested and was essentially undetectable, less than 0.2meq/L. The Psychiatrist was in the facility on 5/23/18 and saw the resident slumped in the chair and not responding; he was depressed. The Psychiatrist reviewed the chart, the family member told the Psychiatrist about the low BP and the NP's plan to transfer the resident to the hospital. The psychiatrist thought that the resident was not taking his medication ([MEDICATION NAME]). RN #2 assured him that the resident had been taking his medications and that the pill was recently changed from a white pill to a gray pill. It was the first time the psychiatrist was informed of a change in pill color by the nurse. The blister pack was labeled [MEDICATION NAME] 450 mg. He did not see a [MEDICATION NAME] pill that looked like the pill in the blister pack. He searched the internet for the round gray pill with letter S and #343 and discovered that the pill in the blister pack was [MEDICATION NAME], an ace inhibitor. The DON was notified and she called the Pharmacy. The pharmacy confirmed that the pill in the blister pack was not [MEDICATION NAME]. This was the second month Resident #1 had gotten the wrong medication as per RN #2. On 5/24/18, the psychiatrist got a call from the hospital that the resident was admitted to the hospital and his blood pressure could not be stabilized. The Psychiatrist saw Resident #1 on 5/29/18 and found him to be more withdrawn. Resident #1 had no [MEDICATION NAME] for approximately a month, if the [MEDICATION NAME] was suddenly stopped it could cause decompensation resulting [MEDICAL CONDITION] depression. Resident #1 become depressed and was not eating, talking or getting out of bed. The BP was a separate issue. Psychiatrist stated that tapering [MEDICATION NAME] is very difficult and if needed it should be tapered slowly over many months. RN #2 was interviewed on 5/29/18 at 4:45 PM and stated she was the regular medication nurse and administered [MEDICATION NAME] medication for the resident most evenings (13 doses in 4/2018 and 11 doses in 5/2018). RN #2 noticed (could not recall the date) that the [MEDICATION NAME] pill color was different (changed from white or yellow to gray) when a new blister pack was delivered from the pharmacy. RN #2 stated she questioned the change in color in her own mind and did not ask anyone else about it. RN #2 stated if she noticed a change in appearance of the medication she would not know what to do because medications came in a variety of colors and shapes and it was not unusual to see the changes. RN #2 stated she noticed a change in Resident #1's behavior. On 5/13/18 his BP was low, 87/60mmHg (usual BP 120/70mmHg). RN #2 informed the RNS and spoke with the PMD. Resident #1 was given IV fluids. His BP remained low. Resident #1 became aggressive and had poor appetite. His [MEDICATION NAME] level was also low. The NP increased the [MEDICATION NAME] dose and gave an extra dose of 450 mg stat and added 300mg [MEDICATION NAME] in addition to the existing 450 mg dosage. The Psychiatrist and RN #2 checked the medication in the blister pack. The Psychiatrist discovered that the medication in blister pack was not [MEDICATION NAME], it was [MEDICATION NAME]. RN #2 stated she was not informed by the vendor pharmacy of any change in the color or form for any medication when there was a change in the manufacturer. RN #2 was not sure how many doses Resident #1 received from the blister pack that was delivered on 4/30/18 and was labeled as containing [MEDICATION NAME] 450 mg. The DON was interviewed on 5/30/18 at 3:28 PM and she stated she was informed by the MD (who was informed by the NP) that an un-prescribed medication was administered to Resident #1. The DON retrieved the blister pack and upon investigation the blister pack labeled as [MEDICATION NAME] 450 mg contained [MEDICATION NAME] 40 mg. On 5/24/18 the resident was sent to the hospital because of a drop in his BP. The DON was not made aware of a change in the medication ([MEDICATION NAME]) color. During an investigation the nurse told her that approximately a month ago she (RN#2) had noticed a change in [MEDICATION NAME] pill color from white to gray. The DON stated the nurse was expected to question the medication that looked different. The nurse however, was not expected to know the color and shape of the pill. The nurse was expected to research the medication if unfamiliar with the medication. The DON was unaware of the facility policy and procedure related to obtaining drug information from drugs.com as documented in the facility policy. The Administrator was interviewed on 5/30/18 at 4:23 PM, and stated he was made aware of changes in Resident #1's behavior. He asked the Psychiatrist to evaluate Resident #1. Psychiatrist requested to see the medication given to Resident #1 and noticed pill that did not look familiar to him. The facility investigation revealed there that there was a mishap on the pharmacy end. The Administrator stated that the nurses administered the medications by checking the electronic MAR and label on the blister pack. The Administrator did not expect that the nurse would know color and shape of each pill. The nurses were expected to follow the MAR and ensure the label was correct and matched with the physician's orders [REDACTED]. The Administrator stated there was no change in medication policy, it was a pharmacy problem and the pharmacy should have dispensed the medication accurately. The MD was interviewed on 5/30/18 at 5:25 PM and he stated that about 2-3 days ago the Psychiatrist saw blister pack and stated the medication did not look like [MEDICATION NAME] and the Pharmacy confirmed the medication in the blister pack was a BP medication [MEDICATION NAME] 40 mg. Resident #1's BP was low 90/70mmHg. The MD stated it was hard to say if the low BP was from the taking [MEDICATION NAME]. The MD stated that one pill would not lower the resident's BP. The MD was not aware that Resident #1 received multiple doses of the ace inhibitor medication. The MD stated there was a medication error. He did not know what was expected of the nurses and he had nothing to do with nursing department. The MD was unaware of the interventions put in place by the vendor pharmacy to correct the issue. The Licensed Practical Nurse (LPN) #1, Registered Nurse (RN) #1, LPN #2 and LPN #3 were interviewed separately on 5/29/18 . They stated they had administered [MEDICATION NAME] 450 mg to Resident #1 as indicated by their signature on the MAR. They all stated they were not familiar with the color and shape of [MEDICATION NAME] tablet because it was not a common medication that they administered and therefore would not notice any change. They checked the label of the medication against the electronic MAR and the physician order. They ensured that they were administering the medication to the right patient, right medication, right dose, right route and at the right time. They all stated they would search online or on their own applications if they wanted to look up a medication they were not familiar with. The nurses stated that they noticed Resident #1 was more agitated and combative and his BP was lower than his normal range for aproximately two weeks prior to his admission to the hospital. 415.18(d)