Every finding on record at Upper East Side Rehabilitation And Nursing Center

Based on observation, record review, and interviews, the facility failed to ensure that daily nurse staffing information was prominently posted at the beginning of each shift in a clear, readable format accessible to residents and visitors. This was evident during the review of the facility's sufficient and competent staffing task.The findings include:The facility policy and procedure titled Posting of Nursing Staffing, last revised December 2025, stated the facility shall post daily the number of licensed and unlicensed nursing staff directly responsible for resident care along with the resident census. The policy further indicated that this information should be posted on a bulletin board accessible to staff, residents, and visitors. During observations conducted from 05/03/2026 through 05/04/2026, the State Surveyor did not observe daily nurse staffing information posted in the lobby or on the nursing units in a location readily visible to residents and visitors. The staffing information was posted inside a vestibule on a bulletin board that was not readily accessible or visible to residents and visitors.On 05/04/2026 at 2:30 PM, the State Surveyor observed the nurse staffing posting with the facility's Staffing Coordinator. The nurse staffing information was posted inside a glass door vestibule adjacent to the elevator. The posting was not prominently displayed or readily accessible to residents and visitors. On 05/04/2026 at 2:24 PM, the Staffing Coordinator was interviewed and stated that daily staffing sheet was posted right by the elevators after the glass doors, in the vestibule. The Staffing Coordinator further stated that the posting was for staff and supervisors to review schedules, and that the night shift nursing supervisor posts the staffing information in the evening while the Staffing Coordinator posts it in the morning.On 05/04/2026 at 2:52 PM, the Director of Nursing was interviewed and stated that the nurse staffing information was posted daily by the elevators inside the glass door vestibule for the employees to view. They further stated that the Staffing Coordinator posts the information each morning prior to the night shift. The Director of Nursing stated they never thought that the daily nurse staffing had to be posted for residents and visitors, they believed it was intended only for staff. On 05/04/2026 at 3:10 PM, the Administrator was interviewed and stated that nurse staffing was posted in the vestibule next to the elevator for staff use. They stated the Staffing Coordinator would be instructed to relocate the postings to ensure accessibility and visibility for residents and visitors. 10 New York Codes, Rules and Regulations 415.13

Based on observation, record review, and interviews, the facility failed to ensure that residents and/or their representatives were provided with a summary of the baseline care plan. This was evident for two (2) of three (3) residents reviewed for comprehensive care planning (Residents #2 and #292), out of 38 total sampled residents. Specifically, there was no documented evidence that Residents #2 and #292, and/or their representatives received a copy of the baseline care plan summary.The facility policy and procedure titled Care Planning Process, last revised July 2022, stated that the baseline care plan is to be developed within 48 hours of the resident's admission. The policy further indicated that the care plan summary is maintained in the resident's medical record and documents that the summary was provided to the resident and / or the resident's representative. 1. Resident #2 was admitted to the facility with diagnoses that included Atrial Fibrillation and Peripheral Vascular Disease. The Comprehensive Minimum Data Set (MDS) assessment dated [DATE] documented Resident # two's (2) cognition was intact. A Baseline Care Plan summary was completed for Resident #2 and signed off by the social worker on 03/29/2026. A review of the social service progress notes dated 04/01/2026 and 04/15/2026 revealed no documented evidence that Resident #2 or the resident's representative had been provided with a copy of the baseline care plan summary. On 05/03/2026 at 10:55 AM, Resident #2 was interviewed and stated that they did not recall receiving a copy of the baseline care plan and did not believe their spouse, who served as the resident representative had received a copy either. On 05/08/2026 at 10:35 AM, Social Worker #2 stated that baseline care plans are completed within 48 hours of admission and reviewed during the initial care plan meeting. Social Worker #2 stated that Resident #2's family representative participated in the care plan meeting by telephone and that a copy of the baseline care plan was left at the resident's bedside; however, they did not know what happened to the copy thereafter. On 05/08/2026 at 1:20 PM, the Director of Social Services stated that baseline care plans are to be completed within 48 hours of admission and provided to residents and/or their representatives during the initial care plan meeting or upon request. The Director of Social Services further stated that if a family representative is not present, the care plan may be left at the bedside or mailed. The Director acknowledged that there was no documented evidence in the medical record that a copy of the baseline care plan summary had been provided to Resident #2 or the resident's spouse. 2. Resident #292 had active diagnoses that included Mild Cognitive Impairment and Major Depressive Disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #292 was cognitively impaired and that the resident's family participated in assessment and goal setting. A Baseline Care Plan form was completed for Resident #292 on 03/18/2026; however, there was no signature from the resident or resident representative. Documentation on the form indicated that the resident was unable to sign due to cognitive deficits and that attempts to contact the spouse were unsuccessful. Review of the medical record revealed no documented evidence that Resident #292 or the resident's representative had been provided with a copy of the baseline care plan summary. On 05/07/2026 at 3:26 PM, Social Worker #1 stated that baseline care plans are completed within 48 hours and reviewed during care plan meetings. Social Worker #1 stated that residents or representatives are asked to sign the baseline care plan during the meeting and that copies may be mailed or picked up upon request. Social Worker #1 further stated that Resident #292's spouse, who was the designated representative, did not attend the care plan meeting. A voicemail was left informing the spouse that a copy of the baseline care plan summary was available for pickup. On 05/08/2026 at 10:22 AM, the Director of Social Work stated that baseline care plans are completed within 48 hours of admission and that all residents have the right to receive a copy of the baseline care plan summary. The Director further stated that if a resident is not alert and oriented, the representative is contacted and efforts to reach the representative should be documented in the medical record. The Director acknowledged that there was no documented evidence that Resident #292 or the resident's spouse had been provided with a copy of the baseline care plan summary. On 05/08/2026 at 1:50 PM, the Director of Nursing Services stated that they were not familiar with matters related to residents' baseline care plans. 10 New York Codes, Rules and Regulations 415.11(c)

Based on interview and record review conducted, the facility did not have evidence that all alleged violations were thoroughly investigated. This was evident for one (1) out of seven (7) residents (Resident #1) reviewed for abuse. Specifically, Resident #1 reported that on 08/20/2025 a middle-aged worker (later identified as Certified Nursing Assistant #1) came into their room to change their brief between the hours of 11:30 PM and midnight and punched them in the face. There was no documented evidence that the facility took measures to facilitate Resident #1's ability to identify the person alleged to have assaulted them.A review of the facility's investigation found that it dismissed the resident's claim that they were assaulted by Certified Nursing Assistant #1 because the facility found that Certified Nursing Assistant #2 (who did not fit the description given by the resident) provided incontinent care to Resident #1 on 08/21/2025 between 3:30 AM and 4:00 AM. A review of the unit assignment sheet revealed that Certified Nursing Assistant #1 was not assigned to provide care to Resident #1 but provided safety checks on the unit between 11:30 PM to midnight on 08/20/2025 and was observed in Resident #1's room at that time.The findings include:The facility's policy and procedure title Reporting and Investigation of Resident Abuse, Neglect, Misappropriation/Exploitation and Mistreatment last revised on 10/2022, documented all personnel have the responsibility to report any incident or suspected incident of resident abuse, including injuries of an unknown source. The facility shall conduct a thorough investigation of all alleged violations involving exploitation, mistreatment, neglect or abuse, and misappropriation of resident property and comply with stated reporting regulations. Alleged violations and results of investigations shall be reported immediately to administrator/Director of Nursing Service.Resident #1 was admitted to the facility with diagnoses of Adjustment Disorder, Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure.The Minimum Data Set (a resident assessment tool) dated 06/24/2025 documented Resident #1 had intact cognition.A review of the facility's Investigation dated 08/21/2025 documented Resident #1 reported to Activities Department staff that last night at approximately 11:30 PM to midnight, a worker came into their room and engaged in a conversation, joking around then suddenly punched them in the face. A complete body assessment was done and there were no visible injuries noted. Resident #1 was re-interviewed and alleged that the person is a female middle aged with lighter skin, who punched them in the face. Resident #1 stated they had interactions with this staff member before, and the staff was not friendly. Resident #1 stated that the staff member came into their room to change their brief. A review of the unit staffing revealed Certified Nursing Assistant #1 was not assigned to Resident #1 and that Certified Nursing Assistant #2 was assigned to Resident #1 from 08/20/2026 to 08/21/2026 and provided care to Resident #1 at approximately 3:30 AM - 4:00 PM on 08/21/2026 and has a dark complexion and did not fit Resident #1's description. Certified Nursing Assistant #1, who was not assigned to Resident #1, provided rounding on 08/20/2026 to 08/21/2026 at 11:30 PM to midnight and stated Resident #1 was asleep during rounding. Both Certified Nursing Assistants stated they did not punch Resident #1. Resident #1's roommate who is alert and oriented x three (3) stated they never witnessed staff member punching Resident #1 in the face. Law enforcement was notified and Resident #1 refused to speak to the Police Officers. The facility investigation concluded that there was no evidence that physical abuse, neglect or mistreatment had occurred. The investigation also revealed that Certified Nursing Assistant #1 was suspended because they fit Resident #1's description. There was no documented evidence that the facility took measures to facilitate Resident #1's ability to identify the person they alleged to have assaulted them. Certified Nursing Assistant #2 was not removed from direct access to residents during the investigation.A review of the Daily Resident Room Check (30 minutes) document dated 08/20/2025 for the 11:00 PM - 7:00 AM shift revealed Resident #1 was in bed asleep from 11:30 PM through 3:00 AM as evidence by Certified Nursing Assistant #1 and Certified Nursing Assistant #3's signatures. At 3:30 AM incontinent care was provided to Resident #1 as evidenced by Certified Nursing Assistant #2's signature.A review of the unit Assignment Sheet dated 08/20/2025 for 11:00 PM - 7:00 AM (08/21/2025) shift showed Certified Nursing Assistant #2 was assigned to Resident #1.Former Director of Nursing who investigated the alleged allegation of abuse no longer works at the facility and whereabouts are unknown.During an interview on 04/15/2026 at 9:49 AM, Resident #1 stated they recalled that the incident took place on 08/20/2025 at 11:00 PM to 08/21/2025 midnight. Resident #1 stated that a staff member came into their room to clean them, and that the staff member joked around with them then suddenly punched them in the face. Resident #1 stated they do not recall where on their face they were punched but that the person who punched them was light skin. Resident #1 also stated they recalled being punched above the belt. Resident #1 stated they never felt pain, and they did not scream or call out for help. Resident #1 stated they have not seen the staff member since incident. Resident #1 stated that two (2) Police Officers came into their room, but they did not speak to the Officers as they did not call them.During a follow up interview with Resident #1 on 05/01/2026 at 3:06 PM, Resident #1 stated that the light skin person who punched them is the same person who provided care to them. Resident #1 went on to say that the staff punched them while they were providing care. Resident #1 stated they are unsure how many times they were punched and do not recall if the light was on.During an interview on 04/15/2026 at 11:50 AM, Certified Nursing Assistant #1 stated they worked on Resident #1's unit from 08/20/2025 to 08/21/2025 on the 11:00 PM to 7:00 AM shift. Certified Nursing Assistant #1 stated they took turns performing rounding at different times during the shift. Certified Nursing Assistant #1 stated they recalled Certified Nursing Assistant #2 in Resident #1's room providing care to them when they were conducting one of their rounding (unsure of time) on 08/21/2025. Certified Nursing Assistant #1 stated they did not witness Certified Nursing Assistant #2 punched or argued with Resident #1. Certified Nursing Assistant #1 stated they were not assigned to Resident #1 but provided rounding in Resident #1's room. Certified Nursing Assistant #1 stated they were suspended for two days.During an interview on 04/15/2026 at 12:21 PM, Certified Nursing Assistant #2 stated they worked on 08/20/2025 on the 11:00 PM to 7:00 AM shift and was assigned to Resident #1. Certified Nursing Assistant #2 stated they work as a floater, and this was not the first time being assigned to Resident #1. Certified Nursing Assistant #2 stated Resident #1 did not report that they were punched by anyone and never complained of feeling pain or discomfort. Certified Nursing Assistant #2 stated there was no verbal or physical altercation between them and Resident #1 and that they did not punch Resident #1 in the face. Certified Nursing Assistant #2 stated they were not suspended.During an interview on 04/15/2026 at 12:39 PM, Director of Social Service #1 stated after they received notice of the alleged allegation of abuse, they and Registered Nurse Supervisor #2 immediately interviewed them. Director of Social Service #1 stated that Resident #1 reported that a light skin middle-aged staff came into their room to change them and that the staff punched them in the face on 08/20/2025 between 11:00 PM to midnight, in the early hours on 08/21/2025. Director of Social Service #1 stated Resident #1 reported that the staff person was not friendly. Director of Social Service #1 stated Resident #1 said it was not the first time this staff person had worked with them. Director of Social Service #1 stated Resident #1 was assessed by Registered Nurse Supervisor #2 with no visible injuries. Director of Social Service #1 stated that Certified Nursing Assistant #1 was the only light skin person who worked on the unit on that night, however, Certified Nursing Assistant #1 was not assigned to Resident #1 and did not provide care to them. Director of Social Service #1 stated that Certified Nursing Assistant #1 denied punching Resident #1. Director of Social Service #1 stated they interviewed Resident #1 twice and Resident #1 stated it was a light skin person who punched them in the face. Director of Social Service #1 stated based on Resident #1's description, that Certified Nursing Assistant #2 did not fit the description. During an interview on 04/16/2026 at 12:53 PM, the Director of Nursing stated they were on vacation when the alleged allegation was reported and that they do not recall the incident. The Director of Nursing stated if they had conducted the investigation they would have investigated and suspended both Certified Nursing Assistant #1, who conducted rounding, and Certified Nursing Assistant #2, who was assigned and provided care to Resident #1, while the investigation was pending. The Director of Nursing stated Certified Nursing Assistant #1 was suspended because of Resident #1's description.During an interview on 04/17/2026 at 2:21 PM Registered Nurse Supervisor #1 stated they worked on 08/20/2025 on the 11:00 PM - 7:00 AM (08/21/2025) shift but was not notified of the alleged allegation of abuse. Registered Nurse Supervisor #1 stated they were informed by the former Director of Nursing that Resident #1 reported an allegation of abuse on the 11:00 PM - 7:00 AM shift. Registered Nurse Supervisor #1 stated they went to Resident #1's room and performed a body assessment and they observed no redness, discoloration, bruising, or visible injuries and Resident #1 had no complaint of pain. 10 New York Codes, Rules, and Regulations 415.4(b)(3)

Based on observation, interviews, and record review conducted during the Recertification survey from 1/16/2024 to 1/23/2024, the facility did not ensure a resident's preferences were incorporated in developing care plan goals. This was evident for 1 (Resident #38) of 38 total sampled residents. Specifically, Resident #38 requested chocolate Ensure and was served with vanilla Ensure. The findings are: The facility policy titled Food Preferences dated 10/2021 documented the facility will provide individualized and person-centered care to its residents, ensuring dietary preferences of residents are respected, appropriately accommodated, and align with their nutritional needs. Resident #38 had diagnoses of malnutrition and dementia. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #38 was moderately cognitively impaired. On 1/17/2024 at 1:05PM, Resident #38 was interviewed and stated the facility provided vanilla Ensure supplements even though Resident #38 informed staff they prefer chocolate Ensure. Resident #38 stated they refused to drink the vanilla Ensure because it was too sweet. The facility used to provide them with the chocolate Ensure in November 2023. During the interview, an 8-ounce carton of vanilla Ensure was observed on the Resident #38's lunch meal tray. The vanilla Ensure had a printed label that documented Ensure Plus Chocolate: No Vanilla. On 1/22/2024 at 8:38AM, Resident #38 was observed in their room with their breakfast tray that contained 2 cartons of vanilla Ensure labeled Ensure Plus Chocolate: No Vanilla. The Comprehensive Care Plan related to nutrition deficit initiated 2/9/2016 and last reviewed 12/15/2023 documented Resident #38 was at risk for malnutrition and the resident's food preferences, likes, and dislikes should be offered and encouraged. The Treatment Administration Record for December 2023 and January 2024 documented Resident #38 received 8 ounces of Ensure Plus three times daily due to suboptimal intake. On 1/22/2024 at 12:32PM, Dietician #3 was interviewed and stated they were aware Resident #38 would not drink the vanilla Ensure because it was too sweet. The Ensure supplements were labeled with Resident #38's preference for the chocolate even though the Ensure being served to Resident #38 was vanilla. The Ensure supplement was important for Resident #38 because their weight fluctuated. On 1/22/2024 at 12:44 PM, the Dietary Supervisor was interviewed and stated they were aware Resident #38 was being served vanilla Ensure that was inaccurately labeled Chocolate. The Dietary Supervisor would offer chocolate-flavored alternatives to Resident #38 because the facility was unable to stock chocolate Ensure since November 2023 due to supply issues. On 1/22/2024 at 4:54 PM, the Regional Dietary Director was interviewed and stated there were manufacturer's supply issues with chocolate Ensure and it was unavailable for the last few weeks. 10 NYCRR 415.11(c)(2)(i-iii)

Based on observation, interviews, and record review conducted during the Recertification survey 1/16/2024 to 1/23/2024, the facility did not ensure food was stored in accordance with professional standards for food safety. This was evident for 1 (8th Floor) of 13 resident unit pantries. Specifically, the 8th Floor pantry refrigerator temperature was above 41 degrees Fahrenheit and contained undated and unlabeled melted ice cream in the freezer. The findings are: The facility policy titled Food Storage dated 5/2018 documented refrigeration temperatures are to be maintained at 41 degrees Fahrenheit or less. The facility policy titled Pantry Refrigeration Cleaning dated 11/2017 documented the pantry refrigerator will be cleaned, temperatures monitored, and documentation maintained to ensure optimal conditions for refrigerated items. On 1/19/2024 at 4:10 PM, the 8th Floor pantry refrigerator was observed in the presence of Registered Nurse #1. The internal temperature of the refrigerator was 55 degrees Fahrenheit. Undated and unlabeled containers of melted ice cream were in the freezer compartment of the refrigerator. On 1/22/2024 at 8:15 AM, Registered Nurse #1 was interviewed and stated the pantry refrigerator had a timer set to defrost daily. Registered Nurse #1 was unable to explain the reason the Maintenance Department set the defrost timer for the afternoon of 1/19/2024. On 1/22/2024 at 9:40 AM, the Director of Maintenance was interviewed and stated the pantry refrigerator defrost timer was set for 12 AM to 2 AM. The internal temperature of the refrigerator should hold above 41 degrees Fahrenheit during this process. The 8th Floor pantry refrigerator may have been unplugged which caused it to have an internal temperature of 55 degrees Fahrenheit. 10 NYCRR 415.14(h)

Based on observation, record review, and interviews, conducted during the recertification and abbreviated (NY00294833) survey from 1/16/2024 to 1/23/2024, the facility did not maintain an effective pest control program to keep the facility free from pests and rodents. This was evident in 1 (8th Floor) of 13 resident units. Specifically, a live roach was sighted in the 8th Floor pantry refrigerator. The findings are: The facility policy titled Pest Control dated 1/2018 documented an integrated pest control program was established and maintained. On 1/19/2024 at 4:10 PM, a roach approximately 1-inch long was observed running crawling out of the 8th Floor pantry refrigerator as the door was opened. The roach ran into a corner of the pantry and hid. The Pest Control Service Inspection Report dated 5/26/2023 documented roach gel was used to treat the kitchen, baseboards and interior. On 8/17/2023, the exterminator documented the 11th Floor had multiple cockroaches in resident rooms that were caught on glue boards. Spot application of roach gel was done and glue boards were replaced on the 11th and 7th Floors. The Pest Control Service Inspection Report dated 10/5/2023 documented the kitchen, 4th Floor, 7th Floor, and 12th Floor had roach activity. Roach gel was applied and glue boards were replaced. The exterminator documented on 1/12/2024 roaches were observed on the 4th, 5th, 6th, 7th, 8th, 10th, and 12th Floor pantries. Roach gel was applied in each of the pantries. There was no evidence an effective pest control program was maintained to prevent the spread of roach infestation in the facility. On 1/22/2024 at 9:40 AM, the Director of Maintenance was interviewed and stated the facility had a contract with a Pest Control Company that comes twice weekly to treat areas of concern for infestation. On 1/23/2024 at 11:03 AM, the Housekeeping Director was interviewed and stated the Pest Control Company treated the 8th Floor for roaches on 1/12/2024. 10 NYCRR 415.29(j)(5)

Based on observation, interviews, and record review conducted during the Recertification Survey from 01/16/2024 to 01/23/2024, the facility did not ensure resident menus and dietary preferences were followed. This was evident for 1 (Resident #58) of 38 total sampled residents. Specifically, Resident #58 did not receive food items listed on the tray ticket during mealtime. The findings are: The facility policy titled Tray Ticket Identification and Labeling dated 4/2019 documented resident food trays are accurately identified with the meal, diet type, type of fluid, food likes and dislikes to ensure accurate food delivery and diet to residents. Resident #58 had diagnoses of diabetes mellitus and gastric esophageal reflux disease. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #58 was cognitively intact and required a therapeutic diet. On 1/22/2024 at 7:58 AM, Resident #58 was observed in bed with their breakfast tray in front of them. Resident #58 stated the food items on the tray did not match the tray ticket. The tray ticket on Resident #58 ' s tray documented 1 soft roll, 1 dinner roll, and 1 Danish. The tray was observed and did not contain the soft roll, dinner roll, or Danish listed on the try ticket. The Grievance/Complaint Form dated 10/1/2023 documented Resident #58 reported receiving an incomplete dinner tray on 10/1/2023 and, over the last 6 months, was offered cold food and sandwiches as an alternative to missing tray items. The charge nurse would check the meal tray prior to serving it to Resident #58, ensure the tray ticket matched the food items on the tray, and call the kitchen as soon as possible for missing food. On 1/22/2024 at 4:16 PM, Registered Nurse #5 was interviewed and stated tray tickets were compared to food items on the meal trays to ensure thy matched. Registered Nurse #5 called the kitchen to send missing food items or to request a new tray when the tray ticket did not match the food served. Registered Nurse #5 did not notice Resident #58 ' s meal tray did not contain everything listed on the tray ticket. 01/22/2024 at 8:46 AM, the Regional Director of Social Work was interviewed and stated, in response to Resident #58 ' s grievance, the nurse was supposed to check the resident ' s tray ticket prior to delivering the meal tray. If the tray ticket did not match the food served, staff requested missing food items from the kitchen. 10 NYCRR 415.14(c)(1-3)

Based on interview and record review conducted during a recertification (HT7E11) and abbreviated survey (NY 377) completed on 8/31/2021, the facility did not ensure all alleged violations involving abuse immediately, but not later than 2 hours after the allegation is made, to the State Survey Agency. Specifically, the facility did not report allegations of resident-to-resident abuse to the New York State Department of Health (NYSDOH) within 2 hours. This was evident for 2 of 3 residents reviewed for Abuse (Resident #26 and Resident #415). The findings are: The policy and procedure titled Accident reporting and investigation-NY effective 11/2016 documented the nurse supervisor will inform the Director of Nursing (DON)/Administrator of any allegation of abuse/neglect or serious incidents. Summarize and document the resident account of the incident in the progress notes, appropriate section of the accident report and investigation form unless the resident objects or is unable to provide such information as a result of cognitive impairment. The policy and procedure titled Reporting and Investigation of Resident Abuse, Neglect, Misappropriation/ Exploitation and Mistreatment effective 11/2017 documented the facility will ensure that all alleged violations involving, abuse, neglect, exploitation or mistreatment including injuries of unknown source are reported immediately but no later than 2 hours after the allegation is made, if involves abuse or result in serious bodily injury or not later than 24 hours if the allegation does not involve abuse and do not result in serious bodily injury. The facility shall ensure that alleged violations involving mistreatment, neglect or abuse including significant injuries of unknown source are reported immediately to the administrator of the facility or their designee and when required by law/regulation ensure timely notification of the Department of Health (DOH). Resident #344, the Aggressor, was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #344 had moderately impaired cognition. The Plan of Care note on 12/30/2020 at 6:00 PM documented that the RN Supervisor (RN #3) was notified by RN #5 that Resident #344 had an altercation with 2 residents. The residents were separated, assessed, and unable to state what happened. Resident #344 has baseline behaviors of walking around the unit wandering, and is difficult to redirect. Doctor and emergency contact #1 notified and transferred to [NAME] psych for further eval, psychiatry/psychology eval placed, resident placed on 1:1 monitoring awaiting ambulance and resident #344 left unit at 4:50PM with two escorts. 1) Resident #26, the victim, was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set 3.9 (MDS) assessment dated [DATE] and 11/25/2020 documented severely impaired cognition. The Plan of Care Note on 12/30/2020 at 5:47 PM documented that the writer was informed by the Registered Nurse Charge Nurse (RN # 5) that Resident #26 had an altercation with another resident approximately at 1:30pm. Resident #26 was assessed and on interview Resident #26 stated, Resident #344 grab their right fourth finger. Noted Resident #26 had swelling, superficial bruising and complained of pain in the right 4th finger. Resident #26 was able to move the right fourth finger, and an ice pack was applied. Interventions documented the two residents were separated immediately, doctor notified and ordered stat x-ray of right fourth finger, ice pack, psychology/psychiatry consult status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Accident and Incident report on 12/30/2020 at 1:30PM documented Resident #344 was involved in an altercation with Resident #26. Resident #26 sustained a wound and swelling on the right 4th finger. The RN statement on 12/30/2020 documented RN #5 was approached by Resident #26 who sated that Resident #344 went into their room and grabbed their right hand and pulled. Review of the NYS DOH Automated Complaint Tracking System (ACTS) Complaint/ Incident Investigation Report for compliant NY 377 documented the facility reported the altercation between Resident #26 and Resident #344 to NYSDOH on 12/30/2020 at 5:37 PM. The time of the occurrence was 12/30/2020 at 1:30 PM. This allegation of resident-to-resident abuse was reported 4 hours and 07 minutes after incident. 2) Resident #415, the victim, was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #415 had severely impaired cognition. The Health Status note on 12/30/2020 at 3:38 PM, documented the social worker informed writer Resident #415 had an altercation with Resident #344 at approximately 2:50 PM, resident separated immediately, no visible injury, no complaint of pain or any form of discomfort. Resident not able to describe what happened during interview due to cognitive impairment dx dementia, unable to reach emergency contact #1 and called emergency contact # 2 no replay message left via voicemail to call back. Doctor notified and ordered psychiatry/psychology. The Accident/Incident Report dated 12/30/2020, documented the Certified Nursing Assistant (CNA #3) reported an incident occurred on 12/30/2020 at 2:15 PM. Resident #344 was last seen at 2:00 PM in the hallway walking around. CNA #3 was in the hallway and heard screaming and entered Resident #415's room. CNA #3 saw Resident #344 standing behind the door and Resident #415 standing by their bed. The Social Worker (SW) completed a statement after interviewing the residents dated 12/30/2020. The SW statement documented Resident #344 came into Resident #415's room, grabbed the TV remote control from the resident's roommate, and threw it Resident #415. Resident #415 expressed I am not physically hurt, just psychologically and did not wish to say or show which part of their body the remote control hit. Resident #415 replied, it hit me on my body. SW documented it was an unwitnessed incident, but CNA # 3 came to assist in the room when they heard Resident #415 shouting. The incident report and investigation summary documented this occurrence will be reported to DOH, as it was an unwitnessed resident-to-resident alteration. Documented that Resident #415 was transferred to another unit and Resident #344 was transferred to hospital for further evaluation. Review of the NYS DOH Automated Complaint Tracking System (ACTS) Complaint/ Incident Investigation Report for compliant NY 377 documented that the facility submitted an addendum on 12/30/2020 at 6:24 PM to report the incident that occurred between Resident #415 and Resident #344 on 12/30/2020 at 2:50 pm. The incident was submitted 3 hours and 34 minutes after it occurred. During an interview on 08/30/2021 at 10:31 AM, CNA #3 stated any incident should be reported to the charge nurse and the Director of Nursing (DON). During an interview on 08/30/2021 at 10:58 AM, the Registered Nurse Charge Nurse (RN #5) stated they only recalled the incident involving Resident #26 that occurred on 12/30/2020. CNA #3 reported the incident to RN #5 and the Registered Nurse Supervisor (RN #3) was informed. RN #3 responded to the unit and assessed the situation. Resident #344 entered Resident #26's room and grabbed Resident #26's belongings. Resident #26 screamed and attempted to get back their belongings when Resident #344 grabbed Resident #26's finger forcefully. During an interview on 8/26/2021 at 4:30 PM, the Supervisor (RN #3) stated that they could not recall the incidents, but an incident a report is completed by the Charge Nurse as soon as staff report the incident. The incident report is given to the Director of Nursing (DON) with the documentation for review. During an interview on 08/30/2021 at 1:36PM, DON stated that that the staff reported the altercations involving Resident #415 and Resident #26 to the DON. The DON stated they were on the unit when the incident between Resident #26 and Resident #344 occurred. The residents were separated and Resident #26's room was changed. The accident/incident report was initiated, informed family, social worker and medical provider according to policy. The DON reported the incidents to NYSDOH. The DON stated that they are aware that they have to report the incident within 2 hours. The reporting was delayed because they were conducting interviews, obtaining staff statements, and providing for safety of the residents. The second incident with Resident #415 occurred close to the change of shift. During an interview on 08/30/2021 at 03:37 PM, the Administrator stated the incidents were brought to their attention, but they could not recall when they were notified. Incidents should be reported to NYSDOH within 2 hours of the occurrence. The Administrator was not aware that the reporting was submitted outside of the timeframe. The incident submittal is done by the DON for clinical matters. 415.4(b)(1)(i)

Based on record review and staff interviews conducted during the Recertification and Abbreviated survey (NY00277772), the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, a resident hospitalized for Psoriasis was not sent to a follow-up Dermatology appointment scheduled by the hospital. This was evident for 1 of 1 residents reviewed for Quality of Care (Resident #341). The finding is: Resident #341 was admitted to the facility with diagnoses which include Psoriasis, Diabetes Mellitus without complications, and Hypertension. The admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] and Quarterly MDS dated [DATE] documented the resident was cognitively intact. No skin issues were documented in the MDS. On 08/23/21 at 03:19 PM, the complainant was interviewed and stated being the POA (Power of Attorney and Health Care Proxy). The complainant stated Resident #341 has eczema and that flared up really bad in February and was hospitalized as a result. The resident was transferred to the nursing home for rehabilitation and would require a specialist visit. The complainant stated the facility was informed by the hospital's physician and the complainant of the scheduled appointment with the specialist. On the day of the appointment the complainant called the facility about the appointment and a charge nurse on the morning shift stated the resident could be seen by the doctor at the facility. On 08/27/21 at 09:12 AM, the complainant stated the facility didn't schedule the appointment or transportation and acted as if they were not aware of appointment. Complainant stated the call was being bounced around to several staff but finally spoke to a charge nurse who stated the facility did this a lot because of the Coronavirus (COVID-19) and would try to get an appointment with facility's physician which occurred two weeks later. On 08/30/21 at 10:22 AM Resident #341 was interviewed but could not recall the appointment or speaking to the physician about the appointment. The Hospital's Patient Review Instrument (PRI) dated 02/12/2021 documented primary diagnosis of Psoriasis. The PRI documented history of present illness: the rash has been present for months and is slowly worsening. It is diffused but worst on her back and legs and associated with itching that keeps her up at night. The patient has not had followup with dermatology. Psoriasis treatment included Triamcinolone 0.1% ointment twice a day (BID) x 14 days and wound care. The Consult orders documented a skin/wound care referral on 02/12/2021 for Psoriasis with skin breakdown on the back and legs. Per note, the instructions/recommendation are: Triamcinolone 0.1% ointment (BID) x 14 days. Consider a nursing home for more monitored care. The Hospital Discharge summary dated [DATE] documented discharge date as 02/23/2021. Psoriasis is documented as the admitting and discharge diagnosis. The resident presented with worsening psoriasis, difficulty with self-care at home and had a good clinical response to initial treatment modalities. The discharge summary documented dermatology had been consulted at the onset, and an outpatient dermatology appointment was scheduled for 03/05/2021 at 1PM. A Comprehensive Care Plan (CCP) initiated 02/24/2021 documented the resident has a rash and the area will show signs of healing. The CCP intervention included to monitor skin rashes for increased spread or signs of infection. For dry and flaky use high quality moisturizers to rehydrate skin and to monitor change in medical/status/condition/risk factors for interference with goal attainment. i.e. change in intake, signs of infection, episodic illness/event. The CCP initiated 02/23/2021 documented potential/actual impairment to skin integrity r/t fragile skin, psoriasis. The CCP goal is to maintain skin integrity and area will show signs of healing. The CCP interventions include avoid scratching and skin hands and body parts from excessive moisture, keep skin dry and clean. Use lotion on dry skin and do not apply on site of injury. Monitor signs and symptoms of infection and wound changes. Notify MD and initiate interventions per MD order. Physician Order documented Triamcinolone Acetonide Cream 0.1 % apply to affected areas topically every shift for Psoriasis from 02/24/2021- 03/03/2021. Nystatin Powder 100,000 UNIT/GM apply topically one time a day to the back began on 04/19/2021. The progress notes from 02/25/2021 to 03/05/2021 make no reference to the scheduled Dermatology follow-up appointment. The MD Progress Notes dated 02/26/2021, 03/03/2021, and 03/24/2021 do not address the resident's skin or the 03/05/2021 pre-scheduled dermatological appointment. The Dermatology Form (referral) signed 03/05/2021 documented reason for consultation as generalized itchiness. The MD Progress Note dated 04/18/2021 documented chief complaint as a followup visit for fungal rash on back and Nystatin powder ordered, but does not provide details related the examination of the resident's skin. There was no documented evidence the facility attempted to ensure Resident #341 attended the Dermatology appointment on 3/5/2021 or rescheduled the appointment. On 08/27/21 at 03:00 PM, and interview was conducted with a Corporate Nurse (CN). The CN stated if there is an appointment scheduled from the hospital, the physician is notified of the appointment by the nurse who inputs the orders. The Appointment Coordinator schedules appointments and transportation and an escort if needed. The CNA stated there is no evidence the Physician was informed about the Dermatology appointment or that Resident #341 received a Dermatology consult. The CN stated the in-house Dermatology referral was generated by mistake because it is only used by in-house doctors. The CN could not state why the consult was not followed through. The CN stated the physician also reviews resident's discharge documents. On 08/30/21 at 01:25 PM, an interview was conducted with the Physician. The Physician stated the resident's psoriasis had no exacerbation during their stay at the facility. The Physician was not aware of the Dermatology appointment scheduled per the Discharge Summary, and it was clearly missed. The Physician stated they can follow-up with the resident about the Dermatology appointment. The Physician stated follow-up appointments are scheduled by nursing and administration. The Physician stated the administration team will inform the resident/family that the appointment is being scheduled. On 08/27/21 at 03:54 PM, an interview was conducted with the Medical Director (MD). The MD stated the hospital generates multiple appointments. If the patient is stable, the MD frequently disagrees with the appointments, feeling it is not good practice. The MD reviewed the resident's chart and stated it does not mention wounds or infection. There was a fungal rash in April, and the treatment was positive. If patients come in with an appointment from the hospital, the need for the appointment is assessed. The MD stated the MD will put the appointment into the system when they feel there is a need. The decision is discussed with the resident. The MD stated every conversation that is had with residents cannot be documented. The Medical Director asked if there was a need for a follow-up appointment two weeks after discharge. 415.5(b)(1-3)

Based on observations, interviews, and record review conducted during the Recertification survey, the facility did not ensure that services and treatments were provided to prevent further decrease in ROM or mobility. Specifically, carrot splints and heel boots were not applied as ordered. This was evident for 1 out of 1 residents reviewed for Position and Mobility out of a sample of 38 residents. (Resident #59). The finding is: The policy titled Application and Management of Splint/Brace/Immobilizer dated 11/17 documented to provide the patient/resident with pressure relieving devices on the bed and in the chair. Nursing staff is responsible to follow the scheduled time that devices are to be worn. Resident #59 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] and Quarterly MDS dated [DATE] documented the resident had severely impaired cognition. The resident was mostly dependent on staff for Activities of Daily Living (ADL) and had Range of Motion (ROM) impairment of both sides of the upper and lower extremities. On 08/23/21 at 11:21 AM and 01:27 PM, Resident #59 was observed in bed sleeping with hands closed and feet curved. There were no devices in place on the hands or feet. On 08/24/21 at 10:31 AM and 11:39 AM, Resident #59 was observed in bed sleeping with hands closed and feet curved. There were no devices in place. On 08/24/21 08/24/21 01:17 PM, the resident was observed awake in bed with no devices in place on the hands or feet. On 08/24/21 at 04:05 PM, Resident #59 was observed in bed with no devices in place on both hands. On 08/25/21 at 01:17 PM and 08/27/21 01:12 PM, Resident #59 was observed in bed with both hands closed and no hand devices in place. A Comprehensive Care Plan (CCP) for Physical Mobility, initiated 05/28/2017, documented the resident will remain free of complications related to immobility, including contractures, thrombus formation, and skin-breakdown. The CCP interventions included that carrot splint and pressure relieving heel boots to be worn at all times, remove for skin checks, hygiene, and ROM. A CCP initiated 12/08/2020 documented the resident to be free of skin breakdown. The CCP interventions included that the carrot splint and pressure relieving heel boots to be worn at all times, remove for skin checks, hygiene, and ROM. The Annual Therapy Screening Form dated 03/02/2021 documented range of motion (ROM) as impairment of both sides for upper and lower extremities. The form documented that the resident had carrot splints and pressure relieving heel boots. The Active Orders as of 08/30/2021 documented that carrot splint and pressure relieving heel boots are to be worn at all times, remove for skin checks, hygiene, and range of motion (ROM) started on 06/01/2021. The Certified Nursing Assistant Accountability Report (CNAAR) for [DATE] documented instructions for carrot splint to be worn at all times, remove for skin checks, hygiene and ROM. The CNA shifts 7AM-3PM and 3PM-11PM from 8/23/21-8/29/21 and CNA shift 11PM-7AM on 8/23/21-8/25/21, 8/27/21-8/28/21, and 8/30/21 documented that the carrot splint was placed on the resident. The document does not address the heel boots. The CCP, Therapy Screening Form, Active Orders and CNAAR do not specify whether the carrot splint or splints should be applied to Right, left, or bilateral hands. On 08/30/21 at 12:27 PM, an interview was conducted with the CNA #1 who stated Resident #59 requires total care with Activities of Daily Living (ADLs). The resident is repositioned every 2 hours. The resident uses heel boots, carrot splints and elbow splint. CNA #1 stated the devices should be applied every day and released every 15 minutes, especially the elbow splint. CNA #1 stated the heel boots were put on on today. CNA #1 was informed that the carrot and heel boots were not observed in place on several days during the survey. CNA #1 stated maybe the devices were not there and CNA #1 did not remember to ask where the devices were stored. CNA #1 stated the carrots keep falling out of Resident #59's hands. On 08/30/21 at 01:12 PM, during an interview the Registered Nurse (RN #1) stated RN #1 observes Resident #59 at the beginning of the shift and while dispensing medication. RN #1 stated they monitor to ensure the resident is repositioned, dry, and assistive device heel boots is on. RN #1 stated Resident #59 has muscle [CONDITION(S)] of the hands (cannot open or close the hand) and should be provide exercises and devices (could not specify what device) to prevent muscle stiffness. RN stated on Friday, the resident had an assisted device in the hands and observed the feet being elevated due to dressing on the left calves. On 08/30/21 at 11:49 AM, an interview was conducted with the Director for Rehabilitation (DR). The DR stated Resident #59 is totally dependent for all ADLs. The DR stated the left elbow splint, carrot splints and heel boots should be worn all times and removed during skin check and hygiene. The DR stated the last assessment in March 2021 documented Resident #59 continues to require left elbow splint, carrot splint and heel boots, and therapy ensured that these devices were present. 415.12(e)(2)

Based on record review and staff interviews conducted during the Recertification and Abbreviated survey (NY 772), the facility did not ensure that a resident received medically-related social services to attain or maintain their highest practicable Psysical, mental and psychosocial well-being. Specifically, a resident hospitalized for Psoriasis and discharged with a pre-scheduled follow-up dermatology appointment was not assisted with transportation to attend the appointment. This was evident for 1 of 1 residents reviewed for Quality of Care (Resident #341). The finding is: Resident #341 was admitted to the facility with diagnoses which include Psoriasis, Diabetes Mellitus without complications, and Hypertension. The Admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] and Quarterly MDS dated [DATE] documented the resident was cognitively intact. No skin issues were documented in the MDS. On 08/23/21 at 03:19 PM, the complainant was interviewed and stated being the POA (Power of Attorney and Health Care Proxy). The complainant stated Resident #341 has [CONDITION(S)] and that flared up really bad in February and was hospitalized as a result. The resident was transferred to the nursing home for rehabilitation and would require a specialist visit. The complainant stated the facility was informed by the hospital's physician and the complainant of the scheduled appointment with the specialist. On the day of the appointment the complainant called the facility about the appointment and a charge nurse on the morning shift stated the resident could be seen by the doctor at the facility. On 08/27/21 at 09:12 AM, the complainant stated the facility didn't schedule the appointment or transportation and acted as if they were not aware of appointment. Complainant stated the call was being bounced around to several staff but finally spoke to a charge nurse who stated the facility did this a lot because of the Coronavirus (COVID-19) and would try to get an appointment with facility's physician which occurred two weeks later. On 08/30/21 at 10:22 AM Resident #341 was interviewed but could not recall the appointment or speaking to the physician about the appointment. The Hospital's Patient Review Instrument (PRI) dated 02/12/2021 documented primary diagnosis of Psoriasis. The PRI documented history of present illness: the rash has been present for months and is slowly worsening. It is diffused but worst on her back and legs and associated with itching that keeps her up at night. The patient has not had followup with dermatology. Psoriasis treatment included [MEDICATION(S)] 0.1% ointment twice a day (BID) x 14 days and wound care. The Consult orders documented a skin/wound care referral on 02/12/2021 for Psoriasis with skin breakdown on the back and legs. Per note, the instructions/recommendation are: [MEDICATION(S)] 0.1% ointment (BID) x 14 days. Consider a nursing home for more monitored care. The Hospital Discharge Summary dated 02/12/2021 documented discharge date as 02/23/2021. Psoriasis is documented as the admitting and discharge diagnosis. The resident presented with worsening psoriasis, difficulty with self-care at home and had a good clinical response to initial treatment modalities. The discharge summary documented dermatology had been consulted at the onset, and an outpatient dermatology appointment was scheduled for 03/05/2021 at 1PM. A Comprehensive Care Plan (CCP) initiated 02/24/2021 documented the resident has a rash and the area will show signs of healing. The CCP intervention included to monitor skin rashes for increased spread or signs of infection. For dry and flaky use high quality moisturizers to rehydrate skin and to monitor change in medical/status/condition/risk factors for interference with goal attainment. i.e. change in intake, signs of infection, episodic illness/event. The CCP initiated 02/23/2021 documented potential/actual impairment to skin integrity r/t fragile skin, psoriasis. The CCP goal is to maintain skin integrity and area will show signs of healing. The CCP interventions include avoid scratching and skin hands and body parts from excessive moisture, keep skin dry and clean. Use lotion on dry skin and do not apply on site of injury. Monitor signs and symptoms of infection and wound changes. Notify MD and initiate interventions per MD order. Physician Order documented [MEDICATION(S)] [MEDICATION(S)] Cream 0.1 % apply to affected areas topically every shift for Psoriasis from 02/24/2021- 03/03/2021. [MEDICATION(S)] Powder 100,000 UNIT/GM apply topically one time a day to the back began on 04/19/2021. The progress notes from 02/25/2021 to 03/05/2021 make no reference to the scheduled Dermatology follow-up appointment. The MD Progress Notes dated 02/26/2021, 03/03/2021, and 03/24/2021 do not address the resident's skin or the 03/05/2021 pre-scheduled dermatological appointment. The Dermatology Form (referral) signed 03/05/2021 documented reason for consultation as generalized itchiness. The MD Progress Note dated 04/18/2021 documented chief complaint as a followup visit for fungal rash on back and [MEDICATION(S)] powder ordered, but does not provide details related the examination of the resident's skin. There was no documented evidence the facility attempted to ensure Resident #341 attended the Dermatology appointment on 3/5/2021 or rescheduled the appointment. There was no evidence that the facility discussed canceling the appointment with the resident or complainant, and transportation to the appointment was never arranged. There was no documented evidence the resident was seen by the dermatologist. On 08/27/21 at 03:00 PM, and interview was conducted with a Corporate Nurse (CN). The CN stated if there is an appointment scheduled from the hospital, the physician is notified of the appointment by the nurse who inputs the orders. The Appointment Coordinator schedules appointments and transportation and an escort if needed. The CNA stated there is no evidence the Physician was informed about the Dermatology appointment or that Resident #341 received a Dermatology consult. The CN stated the in-house Dermatology referral was generated by mistake because it is only used by in-house doctors. The CN could not state why the consult was not followed through. The CN stated the physician also reviews resident's discharge documents. On 08/30/21 at 01:25 PM, an interview was conducted with the Physician. The Physician stated the resident's psoriasis had no exacerbation during their stay at the facility. The Physician was not aware of the Dermatology appointment scheduled per the Discharge Summary, and it was clearly missed. The Physician stated they can follow-up with the resident about the Dermatology appointment. The Physician stated follow-up appointments are scheduled by nursing and administration. The Physician stated the administration team will inform the resident/family that the appointment is being scheduled. On 08/27/21 at 03:54 PM, an interview was conducted with the Medical Director (MD). The MD stated the hospital generates multiple appointments. If the patient is stable, the MD frequently disagrees with the appointments, feeling it is not good practice. The MD reviewed the resident's chart and stated it does not mention wounds or infection. There was a fungal rash in April, and the treatment was positive. If patients come in with an appointment from the hospital, the need for the appointment is assessed. The MD stated the MD will put the appointment into the system when they feel there is a need. The decision is discussed with the resident. The MD stated every conversation that is had with residents cannot be documented. The Medical Director asked if there was a need for a follow-up appointment two weeks after discharge. 415.5(g)(1)(i-xv)

Based on observation, record review, and staff interview conducted during the Recertification survey, the facility did not ensure expired medications were removed from the current medication supply. Specifically, 2 bags of [MEDICATION(S)] solution, a vial of [MEDICATION(S)], and a vial of Tazobactam were observed in the medication storage past the expiration date. This was evident on 1 of 7 units reviewed for Medication Storage (Unit 4). The findings are: The form titled Environmental Rounds Audits- Medication Storage/Handling dated 8/30/21 documented no that expired or discontinued medications are present in the Medication Room/Carts section of the form. On 08/30/21 at 11:24 AM, an observation of the medication storage room on the 4th floor was conducted with the Registered Nurse (RN #1). [MEDICATION(S)] Ringer's and 5% [MEDICATION(S)] Injection USP 1000 ml (milliliter) bags (2 bags) was observed with the manufacturer's expiration date of 6/21. A vial of [MEDICATION(S)] and Tazobactam 3.375 gram per vial was observed with the manufacturer's expiration date of 4/2021. On 8/30/21 at 11:58 AM an interview was conducted with RN #1. RN #1 stated the night shift nurse looks at the medication and determines what is expired and needs to be thrown out. On 08/30/21 at 03:21 PM, during a follow-up interview, RN #1 stated the [MEDICATION(S)] ringer's, [MEDICATION(S)], and Tazobactam were not assigned to a specific resident. On 08/30/21 at 01:00 PM, an interview was conducted with RN #2 who worked the 7 PM-7 AM shift on 8/29/21 on the 4th floor. RN #2 stated during the audit of the medication storage room, RN #2 ensures the narcotic box is locked, everything is in order, ensures the emergency box is sealed, and reviews expiration dates on medications to ensure expired medication is removed and given to pharmacy. RN #2 stated RN #2 did not notice the expired medications. On 08/30/21 at 12:18 PM, an interview was conducted with the Assistant Director of Nursing (ADNS). The ADNS stated the pharmacy consultant conducts monthly audits of the medication storage rooms and provides a list deficiency when expired medication, duplicate medication, and discontinued medication is found. The ADNS stated the facility will correct the deficiencies by disposing any discontinued and expired medication. The ADNS also stated that the overnight nurse conducts audits to ensure that medications that are expired or discontinued are removed. 415.18 (b)(1)(2)(3)

Based on observations, record reviews and interviews during the re-certification survey, the facility did not maintain infection control practices to help prevent the development and transmission of communicable diseases and infections. Specifically, one resident with a Foley Catheter drainage bag and tubing were observed touching the floor and the floor mat in the resident's room. This was observed on two separate occasions on the same day. (Resident #76) The findings are: The facility policy titled, Urinary Catheter Care dated 3/2016 documents It is the policy of the facility that following the insertion of a urinary catheter, a closed drainage system is maintained. Catheter Care shall be provided daily for residents with Indwelling catheters and documented in the medical record. Purpose, to reduce risk of infection. Procedure- #8- A non-obstructed downhill flow must be maintained at all times. Keep the collection bag below the level of the bladder at all times. Do not rest the bag on the floor. Resident #76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) 3.0 dated 7/18 documents- Hearing- adequate, no hearing aid, Clear speech, understood, understands, Vision- adequate, wears corrective lenses. Cognitive patterns- Brief Interview for Mental Status(BIMS) score = 13. No [MEDICAL CONDITION]. Mood - Total Severity Score = 01. Behaviors- none. The resident requires total dependence for bed mobility, transfer, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. Activity did not Occur- walk in room, walk in corridor. The resident has Functional Limitation in Range of Motion with impairment on both sides- upper and lower extremity, and uses a wheelchair for mobility. The residents urinary continence is not rated and the bladder appliances are an indwelling catheter. The Resident's Care Plan for Alteration in Urinary Elimination related to infection documented the following interventions to prevent infection including, but not limited to: - assess urinary history, treatable causes and contributing factors (i.e. medication side effects, medical condition, infection, elevated temperature, decrease fluids, pain/discomfort). Assess/monitor for urinary leakage. Observe for wetness, stains, urine odor. Pericare per plan. preventative skin care per plan. Provide hygiene after elimination, daily and prn. Reinforce clean, rinse, dry and barrier procedures. Practice techniques to reduce infection risk. i.e. handwashing, teach peri-hygiene measures to resident/family/staff. Catheter. Check ostomy/suprapubic site for any redness, irritation or skin breakdown during care. Check tubing for kinks, occlusion/obstruction each shift. Cover drainage bag when out of bed, promoting privacy and dignity. Educate staff/resident/family re-catheter maintenance and hygiene and anchoring, bag positioning. Replace drainage/collection bag as per facility protocol and as needed. 8) Secure catheter to leg. 8) Resident has a F16 Foley catheter with 30 ml balloon. Position catheter bag and tubing below the level of the bladder and off the floor. On 2/26/19 at 10:35 AM during the initial pool process the resident was observed lying in bed asleep. Bed mats were observed on the floor on both sides of the resident's bed. The Foley Catheter urinary drainage bag was observed hanging off the side rail of the right side of the bed and resting on the floor and the floor mat. The attached catheter drainage tubing was observed resting on the floor mat on the right side of the bed. On 2/26/19 at 10:45 AM Certified Nurse Assistant (CNA) #1 was interviewed and stated, I started my shift today at 7AM. I came in and made my rounds and he was okay. This resident is a feeder. I came in about 8:35AM to feed him. I fed him his breakfast. He is a good eater and ate all the breakfast. I see that the catheter drainage bag is touching the floor and the bed mat that is on the floor. I see that the catheter drainage tubing is also touching the floor mat. This is not how it is supposed to be. The drainage bag and the tubing should be hooked higher on the bed so it does not touch the floor. On 2/26/19 10:50 AM Registered Nurse (RN) #1 was interviewed and stated, I see the Foley catheter drainage bag is touching the floor mat and the floor. I see the drainage tubing is also touching the floor mat. This is not supposed to be like this. This is a risk for infection. The drainage bag should be hanging off the frame of the bed and not touching the floor or the G mat. The tubing should not be touching the floor mat. The drainage tubing is in a horizontal position and appears to not drain. It is against the gravity and the urine is not draining. On 2/26/19 at 10:55 AM Registered Nurse (RN) #2 was interviewed and stated, I see the Foley catheter drainage bag is touching the floor mat. I see the drainage tubing is touching the floor mat. This is not supposed to be like this. The Foley catheter drainage bag and the tubing should not be touching the ground. The resident is prone to infection. The drainage tubing is kinked and the urine is not going into the drainage bag. The bed should be higher. The drainage bag should be attached higher up on the bed. The tubing should be made straight and not touch the floor mat or floor. On 2/26/19 at 3:52 PM during a return observation to the resident's room it was observed that the resident had a Foley catheter drainage bag inside a blue dignity bag. hanging off the side rail on the right side of the bed. The blue dignity bag was resting on the floor mat on the right side of the residents bed. 02/26/19 at 3:54 PM Certified Nursing Assistant #2 was interviewed and stated, I started my shift at 3PM. I made rounds and stopped by to see this resident at 3:05PM. Everything was okay. This resident has a catheter. I see the blue bag that holds the drainage bag is touching the floor mat. The drainage bag is not supposed to be touching the floor mat. The drainage bag should not be touching the floor mat. It should be hanging from the bed rail and not touching the floor. On 2/26/19 at 4:02 PM Registered Nurse #2 was interviewed and stated, The drainage bag is inside a blue dignity bag which is resting on the floor mat. It is not supposed to be like this touching the floor mat. After you showed me this morning that the drainage bag was touching the floor and the floor mat the orderly put the drainage bag inside a blue dignity bag and attached it to the side of the bed frame. I checked after he put it up and the dignity bag was hanging off the floor. After this I honestly did not go back and check. The problem is that there is a possibility of an infection and the flow of urine wound not flow correctly. I will fix this this. 415.19(b)(1)

Based on interviews and record review during an abbreviated survey (NY 539), the facility did not ensure a resident was free from significant medication error. This was evidenced in 1 of 4 sampled residents (Resident #1). Specifically, Resident #1's Primary Medical Doctor (PMD) stated that he gave a telephone order for [MEDICATION NAME] 80 mg. Instead, Resident #1 was administered [MEDICATION NAME] 80 mg. Resident #1 was found unresponsive approximately six hours later. 911 was called, transferred to hospital Emergency Department (ED), and admitted to the hospital with [REDACTED]. Resident # 1 was admitted to the facility from the hospital on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 dated 8/3/2017 documented impaired short and long-term memory impairment & modified independence in cognitive skill for daily decision making. The policy and procedure on Telephone Order with effective date 6/2017, states: #1. Any licensed nurse is authorized to obtain a telephone order from a physician/nurse practitioner. When entering a telephone order into the Electronic Medical Record (EMR), the information must be entered as required by the EMR. After entering the order, the nurse MUST read the order back as well as the allergies [REDACTED]. The order may not be implemented until the ordering clinician has verified that the order is accurate and complete. The Primary Medical Doctor (PMD) order dated 8/10/2017 documented [MEDICATION NAME] capsule 125 mg, 1 capsule orally 3 times a day for Bloating; it was discontinued on 8/11/2017. The PMD telephone order created 8/10/2017 at 20:54 and electronically signed by the PMD 8/10/2017 at 23:19 documented [MEDICATION NAME] HCL tablet soluble 40 mg give 2 tablets by mouth every 6 hours for pain. The PMD telephone order created 8/11/2017 at 00:04 and e-Signed by the PMD on 8/11/2017 at 00:09 discontinued [MEDICATION NAME] HCL 80 mg (40 mg two tablets). The PMD order created 8/11/2017 at 00:06 and signed (via Web Application) by the PMD 8/11/2017 at 00:09 documented [MEDICATION NAME] HCL tablet 10mg give 8 tablets by mouth every 6 hours for pain, total 80 mg. The Medication Administration Record [REDACTED]. On 8/11/2017 MAR indicated [REDACTED]. Accident Report dated 8/11/2017 at 11:30 AM, documented the resident was seen by staff at 11:30 AM, lying in bed unresponsive. Vital signs: blood pressure (BP) = 80/50, pulse = 80, respiration = 13 and blood sugar = 199mg/dl. The resident was seen and examined by the Medical Director, he ordered [MEDICATION NAME], intravenous fluid (IVF) and hospital transfer via 911. Nurse's notes dated 8/11/2017 at 11:45 AM documented Registered Nurse #4 (RN #4) received a report from the staff that Resident #1 was unresponsive around 11:30 AM. RN #4 assessed the resident and noted unresponsive even after verbal and tactile stimulation. The blood sugar = 199, Oxygen saturation = 84%, and Resident #1 was placed on non-rebreather mask. The Medical Director (MD) ordered [MEDICATION NAME] 0.2ml and Intravenous Fluid (IVF); both were administered as per MD order. The paramedics arrived. On 8/11/2017 at 10:43 PM it is documented the resident was admitted in the hospital. Review of the hospital Emergency Department Adult Nurse Initial Triage/Intake assessment dated [DATE] at 4:37 PM documented: Chief Complaint Quote: Patient is unable to speak at this time. Emergency Medical Service (EMS) states He is here for Altered Mental Status (AMS) from the Nursing Home (NH). As per EMS, [MEDICATION NAME] 80 mg, which was a new prescription for the patient was given at 3:00 AM this morning and the patient was found AMS and hypotensive later (at ED). Patient received two (2) mg [MEDICATION NAME] with one-liter (1L) normal saline (NS) at the NH and an additional four (4) mg [MEDICATION NAME] with 1L NS given by EMS. Blood pressure = 50/30 was noted on EMS arrival, after one Liter NS was given; BP = 76/41 prior to ED arrival. Finger stick = 190 was done by the EMS. Patient was awake on ED arrival. The oxygen saturation was 80% (Normal 95-100%) when the resident arrived in the ED. Hypotensive on arrival (60s/40s) presenting for overdose of [MEDICATION NAME]. Review of the hospital Emergency Department Provider Note by the attending physician dated 8/11/2017 at 3:48 PM documented Impression: Principal Discharge Diagnosis: [REDACTED]. Review of the Patient Discharge Instructions documented the resident was admitted on [DATE] at 3:05 PM after he was accidentally given 80 mg of [MEDICATION NAME]. The resident was treated for [REDACTED]. On 9/7/2017 at 10:10 AM, telephone interview was conducted with RN #4/Medication Nurse, on the 7-3 shift. He stated that during medication pass on 8/11/2017 around 11:30 AM, Resident #1 was observed lying in bed; breathing, but unresponsive. He stated that he tried to wake him up and took the vital signs: BP = 80/50, Pulse = 80, Respiration = 13, Temperature = 98.3 and oxygen saturation was low at 80% (Normal 95-100%). RN #4 stated that he immediately grabbed and applied the non-rebreather face mask. He immediately notified the RN Charge Nurse; who immediately called STAT. He stated RNS #2 was notified. RNS #2 notified the Medical Director, who was on the unit. The Medical Director ordered [MEDICATION NAME]; which was administered by RNS #2. RN #4 stated the 911 responders arrived on the unit. On 9/7/2017 at 11:30 AM, the assigned Certified Nurse's Aide (CNA) on the 7-3 shift was interviewed. She stated that on 8/11/2017 at 8:30 AM, she offered to provide the morning care to Resident #1. The resident refused, stated wait and raised his hand with eyes closed. She stated she left the room and she provided care to other residents. CNA stated that when she returned in the resident's room at 11:25 AM, she called his name four to five times, with no response. She stated that when she touched the resident's right hand, it was cold, his chest was rising up and down; he was breathing. She stated that she immediately called the medication nurse/RN #4, who was outside the resident's door. The RN #4 called Resident #1 by his name, but the Resident #1 did not respond; STAT was paged. On 9/7/2017 at 12:00 PM, the RN #3 on the 11-7 shift was interviewed. She stated that on 8/11/2017, the RN #1 on the 3-11 shift reported that the [MEDICATION NAME] 80 mg ordered for Resident #1 was not yet delivered. She stated that she asked RN #1 if the dosage was too much; RN #1 told her that it was the PMD order. RN #3 stated the PMD telephone order documented [MEDICATION NAME] 80 mg every six hours for pain was electronically signed by the PMD. RN #3 stated she called the pharmacy around 2:00 AM; as per pharmacist, the medication would be coming shortly. She stated that RNS #1 also called the pharmacist. The RNS #1 told her to give the [MEDICATION NAME] upon delivery. She stated the PMD was not notified about the late delivery of the [MEDICATION NAME]. RN #3 stated that on 8/11/2017 at 5:45 AM, she administered [MEDICATION NAME] 10 mg, eight tablets (80mg) orally as per PMD order. However, on the MAR, it was documented the medication was administered at 1:00 AM; there was no further explanation noted on the screen or entry in the nurse's notes. She reported to the incoming 7-3 shift RN #4 that she administered [MEDICATION NAME] 80mg at 5:45 AM. On 9/7/2017 at 1:03 PM, telephone interview was conducted with the PMD. He stated that on 8/10/2017 between 8:00 PM - 9:00PM he gave a telephone order for [MEDICATION NAME] 80 mg orally every six hours as standing order for Resident #1. PMD stated he did not order the [MEDICATION NAME] 80 mg before; he thought it was a renewal. He stated that he signed the telephone order late that night around 12:01 AM on the night shift. He stated that the [MEDICATION NAME] is used for resident on opioid; the side effects included respiratory distress and loss of consciousness. On 2/2/2018 at 2:27 PM, follow-up telephone interview was conducted with the PMD. He stated that when he gave a telephone order on 8/10/2017 for [MEDICATION NAME] 80 mg orally every 6 hours, the nurse taking the telephone order did not repeat his order as per protocol. The PMD stated that the nurse only stated Okay. On 9/7/2017 at 1:55 PM, the Medical Director (MD) was interviewed. He stated that on 8/11/2017, a STAT was paged overhead for the 13th floor. MD stated that he and the Director of Nursing (DON) went in the room of Resident #1. He observed the resident lying in bed, unresponsive, breathing heavy and pupils were constricted. An RN (MD did not recall name) told him that the Resident #1 was started on [MEDICATION NAME] 80mg. The MD stated that the 80mg of [MEDICATION NAME] is not an ideal initial dose. Intravenous Fluid (IVF) and one dose of [MEDICATION NAME]/[MEDICATION NAME] was administered STAT. He stated when EMS arrived on the unit, they agreed the resident's unresponsiveness was related to the narcotic medication. EMS administered another dose of [MEDICATION NAME]. MD stated that despite the additional dose of [MEDICATION NAME] administered by EMS on the unit; the resident remained unresponsive. He stated that when he asked the PMD, the PMD admitted that he signed the telephone order for [MEDICATION NAME] 80 mg. The PMD told him that he expected the order to be signed for Resident #1 was for [MEDICATION NAME], not [MEDICATION NAME]. On 2/2/2018 at 3:00 PM, follow-up interview was conducted with the MD. He stated that the STAT [MEDICATION NAME] was administered by RNS #2 to Resident #1 via IV push. On 9/7/2017 at 4:25 PM the Director of Nursing (DON) was interviewed. The DON stated that during investigation it was confirmed that the 80mg [MEDICATION NAME] telephone order was signed/approved by the PMD; that the administration of the 80mg [MEDICATION NAME] was signed off on the MAR indicated [REDACTED]. The DON stated that the RN #1 told her that while she was taking the telephone order from the PMD, she heard [MEDICATION NAME] and repeated it back to the PMD. The DON stated that the PMD told her I ordered [MEDICATION NAME]. 415.12(m)(2)

Based on interviews and record review during an abbreviated survey, the facility did not ensure that the Primary Medical Doctor (PMD) reviewed and confirmed telephone medication orders before signing the orders. This was evidenced in 1 of 4 sampled residents (Resident #1). Specifically, on 8/10/2017 the PMD anticipated that there was a telephone order for [MEDICATION NAME] 80 mg awaiting his review and sign off/approval. On 08/10/2017 at 11:19 PM the PMD, without reviewing the order, signed off/approved a telephone order for [MEDICATION NAME] 40 mg two 2 tablets by mouth every 6 hours for pain. On 8/11/2017 at 12:09 AM the PMD, without reviewing the order, signed off/approved to discontinue a telephone order for [MEDICATION NAME] 40 mg two tablets every 6 hours. On 8/11/2017 at 12:09 AM the PMD without reviewing the order, signed off/approved a telephone order for Metadone 10 mg eight tablets every 6 hours. On 8/11/2017 at 11:30 AM, Resident #1 was found unresponsive; STAT [MEDICATION NAME] was administered; Emergency Medical Services (EMS)/911 was called; and Resident #1 was transferred to hospital. Resident #1 was first admitted to the facility from the hospital on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 dated 8/3/2017 documented short and long-term memory impairment & modified independence in cognitive skill for daily decision making. The policy and procedure on Telephone Order with effective date 6/2017, states: #1. Any licensed nurse is authorized to obtain a telephone order from a physician/nurse practitioner. When entering a telephone order into the Electronic Medical Record (EMR), the information must be entered as required by the EMR. After entering the order, the nurse MUST read the order back as well as the allergies [REDACTED]. The order may not be implemented until the ordering clinician has verified that the order is accurate and complete. The PMD order dated 8/10/2017 at 10:06 AM documented [MEDICATION NAME] capsule 125 mg, 1 capsule orally 3 times a day for Bloating; it was discontinued on 8/11/2017. The PMD telephone order created 8/10/2017 at 8:54 PM and electronically signed by the PMD 8/10/2017 at 11:19 PM documented [MEDICATION NAME] HCL tablet soluble 40 mg give 2 tablets by mouth every 6 hours for pain. The PMD telephone order created 8/11/2017 at 12:04 AM and e-Signed by the PMD on 8/11/2017 at 12:09 AM discontinued [MEDICATION NAME] HCL tablet soluble 40 mg give 2 tablets by mouth every 6 hours for pain. The PMD order created 8/11/2017 at 12:06 AM and signed (via Web Application) by the PMD 8/11/2017 at 12:09 AM documented [MEDICATION NAME] HCL tablet 10mg give 8 tablets by mouth every 6 hours for pain, total 80 mg. The Medication Administration Record [REDACTED]. It also documented on 8/11/2017 at 11:57 AM, [MEDICATION NAME] HCL solution 0.4mg/ml (inject 0.2ml) was administered intramuscularly STAT for unresponsiveness. The nurse's notes dated 8/10/2017 at 2:11 PM documented the Resident #1 was seen by the PMD, there was no complain of pain. The resident was noted with distended abdomen. The MD ordered [MEDICATION NAME] 125 mg three times daily until 8/12/2017 for bloating gas. On 8/11/2017 at 11:45 AM documented the Resident #1 was unresponsive around 11:30 AM. The RN #4 assessed the resident and noted unresponsive even after verbal and tactile stimulation. The blood sugar = 199, Oxygen saturation = 84%, and was placed on non-rebreather mask. The physician on the unit (not the primary MD) was made aware, responded and evaluated the resident. The resident had Do Not Resuscitate (DNR) order. The sister/emergency contact was in the resident's room and stated she changed her mind about DNR. The sister wanted the resident on full code. The Medical Director changed the order from DNR to Full Code. The Medical Director ordered [MEDICATION NAME] 0.2ml and Intravenous Fluid (IVF); both were administered as per MD order. EMS/911 was called and arrived shortly thereafter. The physician progress (Medical Director) notes dated 8/11/2017 at 12:06 PM documented he was notified by a nurse (MD did not remember name) that a resident was found unresponsive at about 11:30 AM. The resident was seen and evaluated; unresponsive to stimuli. The family revoked the DNR order. [MEDICATION NAME] 0.2ml was ordered, the EMS came, took over further care and the resident was taken to the hospital. Review of the hospital Emergency Department (ED) Adult Nurse Initial Triage/Intake assessment dated [DATE] at 4:37 PM documented: Chief Complaint Quote: Patient is unable to speak at this time. Emergency Medical Service (EMS) states He is here for Altered Mental Status (AMS) from the Nursing Home (NH). As per EMS, [MEDICATION NAME] 80 mg, which was a new prescription for the patient was given at 3:00 AM this morning and the patient was found AMS and hypotensive later (at ED). Patient received two (2) mg [MEDICATION NAME] with one-liter (L) normal saline (NS) at a NH and additional four mg [MEDICATION NAME] with liter NS given by EMS. Blood pressure = 50/30 was noted on EMS arrival, after one Liter NS was given; BP = 76/41 prior to ED arrival. Finger stick = 190 was done by the EMS. Patient was awake on ED arrival. The oxygen saturation was 80% when the resident arrived in the ED. Hypotensive on arrival (60s/40s) presenting for overdose of [MEDICATION NAME]. Patient presents with Right Upper Extremity (RUE) Peripherally Inserted Central Catheter (PICC) line, Peripheral Intravenous (PIV) line was placed, labs were drawn and sent, Electrocardiogram (EKG) was done and the patient was placed on cardiac monitor. Review of the ED Provider Note by the attending physician dated 8/11/2017 at 3:48 PM documented Impression: Principal Discharge Diagnosis: [REDACTED]. Review of the Patient Discharge Instructions documented the resident was admitted on [DATE] at 3:05 PM after he was accidentally given 80 mg of [MEDICATION NAME]. The resident was treated for [REDACTED]. On 9/7/2017 at 10:10 AM, telephone interview was conducted with RN #4/Medication Nurse, on the 7-3 shift. He stated that during medication pass on 8/11/2017 around 11:30 AM, Resident #1 was observed lying in bed; breathing but unresponsive. He stated that he tried to wake him up and took the vital signs: BP = 80/50, Pulse = 80, Respiration = 13, Temperature = 98.3 and oxygen saturation was low at 80% (Normal 95-100%). RN #4 stated that he immediately grabbed and applied the non-rebreather face mask. He immediately notified the RN Charge Nurse; who called STAT. He stated the RNS #2 was notified. The RNS #2 notified the Medical Director, who was on the unit. The Medical Director ordered [MEDICATION NAME]; which was administered by RNS #2. On 9/7/2017 at 12:00 PM, the RN #3 on the 11-7 shift was interviewed. She stated that on 8/11/2017, the RN #1 on the 3-11 shift endorsed that the [MEDICATION NAME] 80 mg ordered for Resident #1 was not yet delivered. She stated that she asked RN #1 if the dosage was too much; RN #1 told her that it was the PMD order. RNS #3 stated the PMD telephone order documented [MEDICATION NAME] 40 mg give 2 tablets orally every six hours for pain was electronically signed by the PMD. RN #3 stated she called the pharmacy around 2:00 AM; as per pharmacist, the medication would be coming shortly. She stated RNS #1 also called the pharmacist. RNS #1 told her to give the [MEDICATION NAME] upon delivery. She stated the PMD was not notified about the late delivery of the [MEDICATION NAME]. RN #3 stated on 8/11/2017 at 5:45 AM, she administered [MEDICATION NAME] 10 mg, eight tablets (80 mg) orally as per PMD order. However, on the EMAR, it was documented the medication was administered at 1:00 AM; there was no further explanation noted on the screen or entry in the nurse's notes. On 9/7/2017 at 12:11 PM, telephone interview was conducted with the RN #1 on the 3-11 shift. She stated that on 8/10/2017 at approximately 7:00 PM, the primary medical doctor (PMD) called the unit and gave a telephone order of [MEDICATION NAME] 80mg orally every six hours for pain for Resident #1. She stated she is aware that the [MEDICATION NAME] is a narcotic. When she was placing the telephone order on the computer; the computer displayed that the [MEDICATION NAME] is not dispensed at 80 mg. The RN #1 stated that she told the RN #2 on the unit that the telephone order for [MEDICATION NAME] 80 mg did not go through. The RN #2 told her to still click the computer; the PMD will sign it anyway. RN #1 stated that she changed the strength of [MEDICATION NAME] 80 mg to [MEDICATION NAME] 40 mg, 2 tablets orally every six hour for pain and it went through. RN #1 stated that she did not notify PMD and the RNS about the problem with the strength of the [MEDICATION NAME]. She stated the PMD did not come to sign the telephone order during the 3 -11 shift. RN #1 stated that as per policy and procedure on Telephone Order; the nurse taking the order should repeat the order twice for clarification. She stated that she repeated the telephone order once; the PMD did not correct her when she repeated the telephone order for [MEDICATION NAME] 80mg. The PMD hung up, before she could repeat the telephone order one more time as per policy and procedure. On 9/7/2017 at 1:03 PM, telephone interview was conducted with the PMD. He stated that on 8/10/2017 between 8:00 PM - 9:00PM he gave a telephone order for [MEDICATION NAME] 80 mg orally every six hours as standing order for Resident #1. PMD stated he did not order the [MEDICATION NAME] 80 mg before; he thought it was a renewal. He stated that he signed the telephone order late that night around 12:01 AM on the night shift. He stated that the [MEDICATION NAME] is used for residents on opioids; the side effects included respiratory distress and loss of consciousness. On 2/2/2018 at 2:27 PM, follow-up telephone interview was conducted with the PMD. He stated that when he gave a telephone order on 8/10/2017 for [MEDICATION NAME] 80 mg orally every 6 hours, the nurse taking the telephone order did not repeat his order as per protocol. The PMD stated that the nurse only stated Okay. On 9/7/2017 at 1:55 PM, the Medical Director was interviewed. He stated that when he asked the PMD, the PMD admitted that he signed the telephone order for [MEDICATION NAME] 80 mg. The PMD told him that he expected the order to be signed for Resident #1 was for [MEDICATION NAME], not [MEDICATION NAME]. 415.15(b)(2)(iii)

Based on interviews and record review during an abbreviated survey (NY 539), the facility did not ensure that services were provided in accordance with the professional standards of quality. This was evidenced by 1 out of 4 sampled residents (Resident #1). Specifically, on 8/10/2017, Resident #1's Primary Medical Doctor (PMD) gave telephone order for [MEDICATION NAME] every six hours to the RN #1 on the 3-11 shift. However, the RN #1 heard [MEDICATION NAME] 80 mg every six hours for pain. Subsequently, the resident was hospitalized due to unresponsiveness and opioid overdose. The findings include: Resident # 1 was admitted to the facility from the hospital on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 dated 8/3/2017 documented short and long-term memory impairment & modified independence in cognitive skill for daily decision making. Comprehensive Care Plan (CCP) dated 7/27/17 documented [MEDICAL CONDITION] Reflux Disease (GERD) related to hyperacidity. Interventions included administer medication as per medical doctor (MD) order and monitor for effectiveness and side effects. Review of the MD order dated 7/27/2017 documented [MEDICATION NAME] capsule 40 mg orally daily. MD order dated 8/10/2017 documented [MEDICATION NAME] capsule 125 mg, one capsule orally three times daily for bloating. It was discontinued on 8/11/2017. MD order dated 8/10/2017 documented [MEDICATION NAME] HCL tablet soluble 40 mg give two tablets by mouth every six hours for pain. It was discontinued on 08/11/2017. MD order dated 8/11/2017 documented [MEDICATION NAME] HCL tablet 10 mg, give eight tablets by mouth every six hours for pain. MD order dated 08/11/2017 documented [MEDICATION NAME] HCL solution 0.4mg/ml inject 0.2ml intramuscularly (IM) STAT for unresponsiveness. Accident Report dated 8/11/2017 at 11:30 AM, documented the resident was seen by staff at 11:30 AM, lying in bed unresponsive. Vital signs: blood pressure (BP) = 80/50, pulse = 80, respiration = 13 and blood sugar = 199mg/dl. The resident was seen and examined by the Medical Director, he ordered [MEDICATION NAME], intravenous fluid (IVF) and hospital transfer via 911. Review of the nurse's notes dated 8/9/2017 at 9:43 PM documented the Resident complained of stomach pain, the sister requested for stronger pain medication. The nurse's note was documented on the primary Medical Doctor (PMD) communication book. On 8/10/2017 at 10:46 AM the PMD ordered [MEDICATION NAME] 125 mg three times daily until 8/12/2017 for bloating gas. On 8/10/2017 at 2:11 PM, the resident was seen by the PMD, there was no complaint of pain. The resident was noted with distended abdomen. On 8/10/2017 at 7:29 PM, Registered Nurse #1 (RN #1) on the 3-11 shift documented medication order carried out with confirmation number of 18. On 8/11/2017 at 11:45 AM, RN #4 on the 7-3 shift received a report from the staff that Resident #1 was unresponsive around 11:30 AM. RN #4 assessed the resident and noted unresponsive even after verbal and tactile stimulation. The physician on the unit was notified and evaluated the resident. On 8/11/2017, the resident was admitted to the hospital. Review of the Policy and procedure on Telephone Orders effective date 6/2017 documented: Physician/Nurse Practitioner (NP): After communicating the order, must verify order by having the nurse read back the order. The ordering clinician or designee must review and sign the telephone order within 48 hours. Any licensed nurse is authorized to obtain a telephone order from a physician/NP. When receiving a telephone order, the order must contain the name of the medication, dose, frequency and route. When entering a telephone order into the Electronic Medical Record (EMR) the information must be entered as required by the EMR. After entering the order, the nurse MUST read the order back as well as the allergies [REDACTED]. The order may not be implemented until the ordering clinician has verified that the order is accurate and complete. Review of the policy and procedure on Medication Administration Guidelines effective 6/2017 documented: Medications are given only with a physician 's order. All physician's orders [REDACTED]. The Physician is to be contacted if the nurse cannot understand an order to his/her complete satisfaction. If there is any doubt about a medication, the nurse should not administer the medication and should contact the Supervisor for clarification. The nurse who carries out the order is responsible for assuring that the order is correct. She/he is required to question/clarify any order which she/he suspects is not correct. On 9/7/2017 at 12:11 PM, telephone interview was conducted with RN #1 on the 3-11 shift. She stated that on 8/10/2017 at approximately 7:00 PM, the PMD called the unit and gave a telephone order for Resident #1. The PMD ordered [MEDICATION NAME] 80mg orally every six hours for pain for Resident #1. She stated that when she was transcribing the telephone order on the computer; the computer displayed that the [MEDICATION NAME] is not dispensed at 80 mg. RN #1 stated that she told RN #2 that the telephone order for [MEDICATION NAME] 80 mg did not go through. She stated that RN #2 told her to still click the computer; the PMD will sign it anyway. RN #1 stated that she changed PMD order from [MEDICATION NAME] 80 mg to [MEDICATION NAME] 40 mg, 2 tablets orally every six hour for pain and it went through. RN #1 stated that she did not notify PMD or the RNS that she changed the MD order. She stated the PMD did not come to sign the telephone order during the 3 -11 shift. RN #1 stated that as per policy and procedure on Telephone Order; the nurse taking the order should repeat the order twice to the physician for clarification. She stated that she repeated the telephone order once; the PMD did not correct her when she stated [MEDICATION NAME] 80mg. The PMD hung up, before she could repeat the telephone order one more time as is required per policy and procedure. She stated that she endorsed the telephone order to the 11-7 shift RN. On 9/7/2017 at 1:03 PM, telephone interview was conducted with the PMD. He stated that on 8/10/2017 between 8:00 PM - 9:00 PM he gave a telephone order for [MEDICATION NAME] 80 mg orally every six hours as standing order for Resident #1. PMD stated he did not order the [MEDICATION NAME] 80 mg before; he thought it was a renewal. He stated that he signed the telephone order late that night around 12:01 AM on the night shift. He stated that the [MEDICATION NAME] is used for residents on opioids; the side effects included respiratory distress and loss of consciousness. On 2/2/2018 at 2:27 PM, follow-up telephone interview was conducted with the PMD. He stated that when he gave a telephone order on 8/10/2017 for [MEDICATION NAME] 80 mg orally every 6 hours, the nurse taking the telephone order did not repeat his order as per protocol. The PMD stated that the nurse only stated Okay. On 9/7/2017 at 1:55 PM, the Medical Director (MD) was interviewed. The MD stated that the ordering physician must read the order and assure it is correct before signing off. He stated that when he asked the PMD, the PMD admitted that he signed the telephone order for [MEDICATION NAME] 80 mg. The PMD told him that he expected the order to be signed for Resident #1 was for [MEDICATION NAME], not [MEDICATION NAME]. On 9/7/2017 at 2:45 PM, the RN #2/Medication Nurse on the 3-11 shift was interviewed. He stated on 8/11/2017 at 12:00 AM he received a telephone call from the pharmacy regarding [MEDICATION NAME] order for Resident #1. He stated the pharmacist told him that they do not carry [MEDICATION NAME] 40 mg and to change the [MEDICATION NAME] to 10 mg, give eight tablets every six hours. He stated that he changed the PMD telephone order to [MEDICATION NAME] 10 mg, give 8 tablets (80 mg) without calling the prescribing PMD for clarification. On 9/7/2017 at 4:25 PM the Director of Nursing (DON) was interviewed. The DON stated that during investigation, it was confirmed that the 80 mg [MEDICATION NAME] telephone order was signed /approved by the PMD; that the administration of the 80 mg [MEDICATION NAME] was signed off on the MAR indicated [REDACTED]. The DON stated that during the investigation, RN #1 told her that while she was taking the telephone order from the PMD, she heard [MEDICATION NAME] and repeated it back to the PMD. The DON stated that when she asked the PMD he told her I ordered [MEDICATION NAME]. 415.11(c)(3)(i)

Based on observations, record reviews, and staff interviews, the facility did not ensure that food was palatable and served at the proper temperature to ensure residents satisfaction. This was evident on the steam table service where cold food holding temperatures did not meet the standards. This was evident during an observation of the temperatures performed on the 3rd floor main dining room. The finding is: An observation was conducted on 4/13/16 at 12:15 PM of the steam table temperatures in 3rd floor main dining room. The following cold food temperatures were taken: Skim milk - 68 degrees F, Orange juice - 67 degrees F, Jello - 69 degrees F and Ice cream 48.8 degrees F. The ice cream was melted and in a liquid state. All cold food items were on a truck, prepared ahead of time in the kitchen and brought to the floors. There was no observed provision to keep the food items cold. On 4/13/16 at 12:25 PM the Food Service Director (FSD) was interviewed and stated that he uses the tray set up system for cold foods prior to service on the floors. He has checked the cold food temperatures in the kitchen, but not on the floors. The facility policy dated 4/2016 for Temperature Monitoring of Meal Service documents, All cold drinks (milk, juice ) should be 40 degrees F or below. 415.14(d)(1)(2)

Based on observation and interview, the facility did not ensure that infection control practices were maintained during wound care. This was evident for 1 of 3 residents reviewed for Pressure Ulcers. (Resident # 317). The finding is: Resident # 317 is a [AGE] year-old with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had severely impaired cognition. The MDS further documented the resident had no pressure ulcers or vascular ulcers. On 4/14/16 at 9:58 AM, a wound care observation was conducted. The following was observed: 1) The Registered Nurse (RN) washed her hands, donned gloves, and removed the old dressing on the resident's left heel and then paced the heel directly on the bed without a barrier underneath; 1) After cleansing the wounds to the (left heel and right great toe) the RN did not wash her hands and don new gloves before applying the treatments and new dressings. On 4/14/16 at 11:02 AM, the RN was interviewed and stated that when doing a dressing change, she should wash her hands, don gloves, remove the old dressing and then wash her hands and don clean gloves and repeat this procedure after cleansing the wound. She stated that she had an inservice on dressing changes about 2 weeks ago and yesterday. The RN stated that once she removed the old dressing from the left foot, she should not have placed the wound on the bed without a barrier between the wound and the bed. On 4/14/16 at 3:57 PM, the Assistant Director of Nursing (ADON) was interviewed and stated the nurse should wash her hands, don gloves and remove the soiled dressing. She further stated the nurse should wash her hands, don new gloves, and clean the site. The ADON stated that after cleaning the wound, the nurse should wash hands, don gloves, and apply the treatment and dressing. On 4/15/16 at 10:57 AM, the Director of Nursing (DON) was interviewed and stated the clean dressing change policy was changed and that is the technique used at all the facilities. She stated that she obtained the technique from a wound resource, but she does not have the books to show at this time. She further stated she did not see an issue with cleaning the wound and then applying the treatment because each gauze used for cleaning is only used once. The DON stated that she would review her resources, update the policy, and have the staff in-serviced. The facility Policy and Procedure for Clean Dressing Change dated 12/2015 documented Remove old dressing .Remove gloves .Perform hand hygiene. Don new clean gloves .Applies ordered treatment .Applies clean dressing .Removes gloves/discards and washed hands. 415.19(a)(1-3)

Based on record review and staff interviews, the facility did not ensure that services provided met professional standards of quality. Specifically, the Licensed and Registered nurses did not monitor the residents pulse and blood pressure prior to administering anti-hypertensive and anti-psychotic medication. This was evident for 1 of 5 residents reviewed for Unnecessary Medication Use. (Resident #622). This resulted in no actual harm with potential for more than minimal harm. Resident # 622 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS dated [DATE] documented: moderately impaired cognition with disorganized thinking, altered level of consciousness and extensive assistance of one person for transfers, dressing and personal hygiene. The MDS further documented [MEDICAL CONDITION] and Hypertension. The Significant change MDS dated [DATE] documented the resident received antidepressant and antipsychotic medications for 7 days. The Care Area Assessment (CAA) Summary documented the [MEDICAL CONDITION] Drug Use care area triggered. The CCP's (Comprehensive Care Plans) for Hypertension and [MEDICAL CONDITION]- dated 12/4/14 documented: Problem- Excessive lowering of BP by antihypertensive medication. Short/Long Term Goals- Will have B/P within a safe therapeutic range. Plan-assess and monitor B/P daily or as ordered; Assess for and report any further increase of B/P, failure of B/P to decline in response to antihypertensive agents or excessive decline in B/P to MD or NP (Nurse Practitioner). [MEDICATION NAME] for CAD and [MEDICATION NAME] for HTN. The CCP for [MEDICAL CONDITION] Drug Use potential for side effects dated 10/4/14 and revised 3/1/15 documented: List [MEDICAL CONDITION] Drug: [MEDICATION NAME] 2.5 mg (milligram) and [MEDICATION NAME] 45 mg. The initial Physician order [REDACTED]. [MEDICATION NAME] 6.25 mg tablet- one tablet by mouth twice daily (10:00 am- 6:00 PM) hold for pulse < 60 ([MEDICAL CONDITION])- pulse daily for 30 days then weekly on Wednesday (wed) ; BP (blood pressure) weekly on Wednesday. Review of the Medication Administration Record [REDACTED]. There was also no documented evidence that the residents pulse and blood pressure was monitored weekly (wed) in January on 1/7, 1/14, 1/21 or 1/28/14 per the physician's orders [REDACTED]. There was no documented evidence that the residents pulse and blood pressure was monitored weekly (wed) in February on 2/4 or that the blood pressure was monitored on 2/10/15. There was no documented evidence that the residents pulse and blood pressure was monitored weekly (wed) in March on 3/4, 3/9 or 3/18/15. The initial Physician order [REDACTED]. [MEDICATION NAME] 2.5 mg tablet ([MEDICATION NAME] 2.5 mg tablet) initial order 2/24/15- one tablet by mouth 1 time a day (10:00 am) agitation secondary to dementia- orthostatic BP monthly on 14th: lying, sitting and standing (if possible). Review of the Medication Administration Record [REDACTED]. The RN (Registered Nurse) /charge nurse was interviewed on 3/18/15 at 2:44pm. The RN stated that the medication nurses are responsible for taking the residents vital signs (BP and pulse) as per the doctors order and also in accordance with their own nursing judgement and clinical standards of practice. This is important for the administration of medications which can lower the blood pressure and cause [MEDICAL CONDITION] (low pulse rate). We will now check every resident record to ensure that the ordered pulse and blood pressure monitoring and parameters are being followed. The unit RN/NM (Nurse Manager) was interviewed on 3/18/15 at 3:06pm. The RN/NM stated that the nurses have to pay closer attention to the medication orders prior to administering the residents medication. I will provide inservice for the all of the nurses. The RN (who administered the [MEDICATION NAME]) to the resident on multiple occasions in February was interviewed on 3/19/15 at 11/25/15. The RN stated that she remembers taking the residents pulse but did not document it. The Director of Nursing was interviewed on 3/19/15 at 12;45pm. The DNS stated the facility had identified (after the SA (State Agency) identified the deficient practice) that the nurses need to take an extra step in the electronic medical record when transcribing orders, by selecting "schedule" which will prompt them to enter the residents ordered vital sign. The DNS further stated that despite an entered prompt in the electronic medical record or not, the nurses are responsible for administering medications in accordance with accepted standards which includes taking a residents pulse and/or blood pressure when indicated. 415.11(c)(3)(i)

Based on record review and staff interviews, the facility did not ensure that services provide were in accordance with the residents written plan of care. Specifically, the unit medication nurses did not monitor the residents pulse and blood pressure consistently per the Physicians order.This was evident for 1 of 5 residents reviewed for Unnecessary Medication Use. (Resident #622). This resulted in no actual harm with potential for more than minimal harm. Resident # 622 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS dated [DATE] documented: moderately impaired cognition with disorganized thinking, altered level of consciousness and extensive assistance of one person for transfers, dressing and personal hygiene. The MDS further documented [MEDICAL CONDITION] and Hypertension. The Significant change MDS dated [DATE] documented the resident received antidepressant and antipsychotic medications for 7 days. The Care Area Assessment (CAA) Summary documented the [MEDICAL CONDITION] Drug Use care area triggered. The CCP's (Comprehensive Care Plans) for Hypertension and [MEDICAL CONDITION]- dated 12/4/14 documented: Problem- Excessive lowering of BP by antihypertensive medication. Short/Long Term Goals- Will have B/P within a safe therapeutic range. Plan-assess and monitor B/P daily or as ordered; Assess for and report any further increase of B/P, failure of B/P to decline in response to antihypertensive agents or excessive decline in B/P to MD or NP (Nurse Practitioner). [MEDICATION NAME] for CAD and [MEDICATION NAME] for HTN. The CCP for [MEDICAL CONDITION] Drug Use potential for side effects dated 10/4/14 and revised 3/1/15 documented: List [MEDICAL CONDITION] Drug: [MEDICATION NAME] 2.5 mg (milligram) and [MEDICATION NAME] 45 mg. The initial Physician order [REDACTED]. [MEDICATION NAME] 6.25 mg tablet- one tablet by mouth twice daily (10:00 am- 6:00 PM) hold for pulse < 60 ([MEDICAL CONDITION])- pulse daily for 30 days then weekly on Wednesday (wed) ; BP (blood pressure) weekly on Wednesday. Review of the Medication Administration Record [REDACTED]. There was also no documented evidence that the residents pulse and blood pressure was monitored weekly (wed) in January on 1/7, 1/14, 1/21 or 1/28/14 per the physician's orders [REDACTED]. There was no documented evidence that the residents pulse and blood pressure was monitored weekly (wed) in February on 2/4 or that the blood pressure was monitored on 2/10/15. There was no documented evidence that the residents pulse and blood pressure was monitored weekly (wed) in March on 3/4, 3/9 or 3/18/15. The initial Physician order [REDACTED]. [MEDICATION NAME] 2.5 mg tablet ([MEDICATION NAME] 2.5 mg tablet) initial order 2/24/15- one tablet by mouth 1 time a day (10:00 am) agitation secondary to dementia- orthostatic BP monthly on 14th: lying, sitting and standing (if possible). Review of the Medication Administration Record [REDACTED]. The RN (Registered Nurse) /charge nurse was interviewed on 3/18/15 at 2:44pm. The RN stated that the medication nurses are responsible for taking the residents vital signs (BP and pulse) as per the doctors order and also in accordance with their own nursing judgement and clinical standards of practice. This is important for the administration of medications which can lower the blood pressure and cause [MEDICAL CONDITION] (low pulse rate). We will now check every resident record to ensure that the ordered pulse and blood pressure monitoring and parameters are being followed. The unit RN/NM (Nurse Manager) was interviewed on 3/18/15 at 3:06pm. The RN/NM stated that the nurses have to pay closer attention to the medication orders prior to administering the residents medication. I will provide inservice for the all of the nurses. The RN (who administered the [MEDICATION NAME]) to the resident on multiple occasions in February was interviewed on 3/19/15 at 11/25/15. The RN stated that she remembers taking the residents pulse but did not document it. The Director of Nursing was interviewed on 3/19/15 at 12;45pm. The DNS stated the facility had identified (after the SA (State Agency) identified the deficient practice) that the nurses need to take an extra step in the electronic medical record when transcribing orders, by selecting "schedule" which will prompt them to enter the residents ordered vital sign. The DNS further stated that despite an entered prompt in the electronic medical record or not, the nurses are responsible for administering medications in accordance with accepted standards which includes taking a residents pulse and/or blood pressure when indicated. 415.11(c)(3)(ii)

Based on record review and interviews during an abbreviated survey, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being of a resident. This was evident in 1 of 4 sampled residents (Resident is #1). Resident #1 was noted with a critical value [MEDICATION NAME] Time/International Normalized Ratio (PT/INR), which was not reported to the doctor. The nurses continued to administer [MEDICATION NAME] (anticoagulant) for 4 days. Subsequently, the resident presented with 3 episodes of hemoptysis (expectoration of blood) and was admitted to the hospital with [REDACTED]. This resulted in actual harm that is not Immediate Jeopardy. Complaint # NY 957 The findings include: Resident #1 is an [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 (a resident assessment tool) dated 8/23/11 identified that the resident had moderate impairment in mental status. The Comprehensive Care Plan titled Anticoagulant/Antiplatelet Therapy, Potential for Complications, dated 12/16/10 indicated that the resident receives [MEDICATION NAME]. The facility ' s interventions included monitoring PT/INR as prescribed by the medical doctor (MD), assessing for signs of prolonged bleeding and administering the medication at the same time daily. The physician's order [REDACTED]. The laboratory report dated 9/1/11 revealed that the resident ' s PT was greater than 100 (normal range: 9.8-11.9) and INR was greater than 10 (normal range: 1.0 - 2.0). These are considered " panic values. " The laboratory report documented that the resident ' s PT/INR value was reported to Registered Nurse (RN) #5 at the facility on 9/1/11 at 5:03 PM. A review of the nurses ' notes and MD notes from 9/1/11 to 9/4/11 revealed that there was no documentation regarding the high PT/INR level that was reported to the facility on [DATE]. On 9/8/11 The Resident #1 ' s PT/INR Flow Sheet for Residents on [MEDICATION NAME] was reviewed. The flow sheet revealed that the PT/INR result for 9/1/11 was not documented. The last documented lab result for PT/INR was on 8/25/11. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Nurse Practitioner ' s (NP) progress note dated 9/4/11 documented that the resident was seen with bluish and purplish areas on the bilateral upper extremities without any breakdown or swelling. The NP ordered to put on bilateral skin sleeves to the upper extremities daily. A nurse ' s note dated 9/4/11 11:30AM documented that the resident was observed with blood in the sputum and stool. The MD was notified and ordered PT/INR for 9/5/11. A nurse ' s note dated 9/5/11 7:30PM documented that the laboratory result for PT/INR was noted as " cancelled. " The MD ordered to hold [MEDICATION NAME] on 9/5/11 and get PT/INR on 9/6/11. The resident continued to have blood in sputum. A nurse ' s note dated 9/6/11 at 12:00 AM documented that the resident had discoloration on the arms and episodes of hemoptysis. The nursing note identified that the the MD was notified. The nursing note stated to continue monitoring for signs and symptoms of bleeding. At 5:15 AM, the resident was observed with severe blood flow with 3 episodes of hemoptysis. The MD ordered to transfer the resident to the emergency room . The physician's order [REDACTED]. The Hospital Medical Transfer Summary, dated 9/15/11 identified that the resident was treated at the hospital for [DIAGNOSES REDACTED]. " The resident was treated with Vitamin K in the emergency department. The facility ' s investigation report documented that the nurses who administered [MEDICATION NAME] to the resident from 9/1/11 to 9/4/11 did not follow the facility ' s policy on checking the PT/INR result on the flow sheet prior to administering [MEDICATION NAME]. The report documented that the nurses ' failure to follow the policy " may have resulted in the resident ' s hospitalization . " The facility ' s policy and procedure titled PT/INR Flow Sheet Guidelines dated 4/2010 indicated that prior to administering [MEDICATION NAME], the nurses should " verify an order for [REDACTED]. On 9/8/11 at 2:05PM an interview was conducted with RN #5, who was on duty from 8:00 AM to 8:00 PM on 9/1/11. RN#5 was identified by the laboratory as receiving the laboratory results on 9/1/11. RN #5 stated that she did not receive any critical value laboratory result from the laboratory on 9/1/11. RN #5 stated that the laboratory might have spoken to someone else even if her name was documented on the report. On 9/13/11 at 4:28PM an interview was conducted with RN #1, who was on duty from 8:00 PM to 8:00 AM on 9/1/11 and 9/4/11. RN #1 stated that she was aware that the resident ' s PT/INR was due on 9/1/11. RN #1 stated that she was supposed to check the flow sheet or laboratory report for the result prior to administering [MEDICATION NAME]. RN #1 stated that she administered [MEDICATION NAME] on 9/1/11 without checking the PT/INR result because she " assumed the morning shift took care of it " and did not receive any report regarding the resident. RN #1 stated that on 9/4/11, the resident was observed with blood in stool, but she administered [MEDICATION NAME] to the resident because there was no order to hold [MEDICATION NAME]. On 9/8/11 at 12:15PM RN #2, who was on duty from 8:00 PM to 8:00 AM on 9/2/11, was interviewed. RN #2 stated that she administered [MEDICATION NAME] to Resident #1 on 9/2/11 because she did not receive any report or new orders related to the resident ' s PT/INR level. RN #2 stated that she did not review the PT/INR flow sheet to check the result prior to administering [MEDICATION NAME]. On 9/9/11 at 3:15PM an interview with RN #3, who was on duty from 8:00 PM to 8:00 AM on 9/3/11. RN 3# stated that the PT/INR result was supposed to be checked on 9/1/11 when it was last due. On 9/3/11, she administered [MEDICATION NAME] to the resident because she did not get any reports or new orders related to the resident ' s PT/INR level. She stated that she needed to check the PT/INR flow sheet prior to administering [MEDICATION NAME], but she did not check because it was very busy on the unit that evening. On 9/8/11 at 1:10PM an interview with RN #4, who was on duty from 8:00 AM to 8:00 PM on 9/1/11 and 9/5/11. RN #4 stated that she did not receive any laboratory results for the resident on 9/1/11. RN # 4 stated that on 9/5/11, she found the lab result dated 9/1/11 on top of the MD communication book. She notified the MD right away and was instructed to hold [MEDICATION NAME]. An interview with the Director of Nursing (DON) was conducted on 9/8/11 at 3:10 PM. The DON stated that the nurses administered [MEDICATION NAME] to the resident when they should not have. The DON stated that the nurses failed to check the lab result on the PT/INR flow sheet prior to administering [MEDICATION NAME]. The DON stated that it is unclear what happened to the laboratory report when it was faxed to the nursing office on 9/1/11 and why it was not seen until 9/5/11 on the unit. 415.12