**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during a recertification and abbreviated survey (Case #'s NY00363829, NY00364424, and NY00347964), the facility failed to ensure residents were free of any significant medication errors for five (5) (Resident #s 12, 23, 47, 77, and 327) of 10 residents reviewed for medication administration. Specifically, (a.) Resident #47 was not administered 12 days-worth of psychiatric medication from 11/25/2024 to 12/06/2024. Over the 12 days, the resident decompensated psychiatrically, and on 11/29/2024 at 9:00 AM, the resident requested to be sent to the hospital. (b.) Resident #12 was not administered their antibiotics (medication to treat active infections) 10 of 20 times as prescribed. (c.) Resident #23 was not administered antibiotics as prescribed, receiving only four (4) of eight (8) doses prescribed. (d.) Resident #77 was not administered prescribed medication to lower their high potassium level on 12/21/2024 and did not receive the medication until 12/25/2024, after it was noted that Resident #77's potassium level was further elevated. (e.) Resident #327 was not administered antibiotics until two (2) days after the order was prescribed, causing a delay in treatment for an active infection. This resulted in actual harm for Resident #47 which was Immediate Jeopardy and Substandard Quality of Care with the likelihood of risk for harm to the health and safety of Residents #12, #23, #77, and #327. This is evidenced by: The Policy and Procedure titled, Administering Medications, effective 10/1997 and reviewed on 1/2025, documented that Medications should be administered in a safe and timely manner, and as prescribed. The policy Interpretation and Implementation documented the following: Medications must be administered in accordance with the orders, including any required time frame; medications must be administered within one (1) hour of their prescribed time, unless otherwise specified; if a dosage was believed to be inappropriate or excessive for a resident, or an education had identified consequences, the person preparing or administering the medications should contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns. The following information must be checked/verified for each resident prior to administering medications: allergies to medications; vital signs, if necessary; for residents not in their rooms or otherwise unavailable to receive medication on the pass, the Electronic Medication Administration Record may be flagged. After completing the medication pass, the nurse would return to the missed resident to administer the medication; if a drug was withheld, refused, or given at a time other than the scheduled time, the individual administering the medication should document the same in the Electronic Medication Administration Record for that drug and dose. The person withholding, receiving the refusal, or administering medication at a different time would notify the attending/covering physician. The individual administering the medication must sign the resident's Electronic Medication Administration Record as indicated by the software after giving each medication and before administering the next one. As required or indicated for medication, the individual administering the medication would record in the resident's medical record: (a.) the date and time the medication was administered; (b.) the dosage; (c.) the route of administration; (d.) the injection site (if applicable); (e.) any complaints or symptoms for which the drug was administered; (f.) any results achieved and when those results were observed; and (g.) the signature and title of the person administering the drug; topical medication used in treatment must be recorded on the resident's treatment record; and residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, had determined that they have the decision-making capacity to do so safely. Resident #47 Resident #47 was admitted to the facility with diagnoses of schizophrenia (a mental condition characterized by thoughts or experiences that seem out of touch with reality), chronic obstructive pulmonary disease with acute exacerbation (a chronic lung disease that causes progressive and irreversible damage to the airways in the lungs), and type 2 diabetes mellitus (a chronic condition where the body does not use insulin properly or does not produce enough insulin to regulate blood sugar levels). The Minimum Data Set, dated , 10/01/2024 documented the resident was cognitively intact, could be understood, and understand others. The Care Plan for Resident Displays/Reports the following moods: feeling down, depressed, hopeless, feeling tired or having little interest or pleasure in doing things, revised 12/02/2024, documented the resident had a history of suicidal ideation and their last statement was on 11/25/2024, when they had suicidal ideation, no plan. Interventions included administer psychotropic medications as ordered, assess for suicidal ideation if needed, no cords per statement of suicidal ideation, and psychological services as needed Order Summary Report for order date range 11/01/2024 to 3/07/2025, documented an order dated 11/25/2024 for Clozapine oral tablet, give 375 milligrams by mouth at bedtime for schizophrenia. There was no end date on the order. Record review of manufacturer specification of Clozaril (clozapine), located at https://clozaril.com/important-safety-information/ documented the following: Important Safety Information, Discontinuing Treatment documented to reduce the dose gradually over a period of 1 to 2 weeks if termination of clozapine therapy was planned and there was no evidence of moderate to severe neutropenia (low number of neutrophils (a type of white blood cell) in the bloodstream). For abrupt clozapine discontinuation for a reason unrelated to neutropenia, continuation of the existing ANC (absolute neutrophil count) monitoring was recommended. It documented to monitor all patients carefully for the recurrence of psychotic symptoms. Medication Administration Record dated November 2024 documented, Clozapine 375 milligrams was to start on 11/25/2024 at 9:00 PM and documented: o 11/25/2024 was not given and documented: awaiting pharmacy delivery. o 11/26/2024 was not given and documented: medication was enroute from pharmacy, would administer upon arrival. Physician notified. o 11/27/2024 was documented as given. o 11/28/2024 was not given and documented: the medication was on order and awaiting arrival from the pharmacy. Skilled nursing would follow up. Hospital Discharge summary dated [DATE], Hospital Course documented the resident was found to have a lung infection and was also seen by psychiatry services. The resident was on one-to-one observation for suicidal ideation. Prior to discharge, the resident was cleared by psychiatry services and was taken off one-to-one observation. Discharge diagnosis/plan included schizophrenia and suicidal ideation. Behavioral Health Services Note dated 11/26/2024 documented the resident recently returned for a hospitalization for medical reasons, but then required additional time on the psychiatric unit for suicidal ideation. The resident currently was reporting feeling more stable, with no thoughts of suicidal ideation. The resident reported continued thoughts of mild depression and confusion. Target symptoms that would be the focus of treatment: depression, psychosis. A nursing note dated 11/29/2024 at 8:36 AM by Registered Nurse #5 documented Resident #47 stated, I want to die. I want to go to the hospital. Registered Nurse #5 informed the provider and social work and assigned a staff member to sit with the resident. 911 was called and the resident was sent to the Emergency Department. The resident was sent to the hospital at 9:00 AM. A nursing note dated 11/29/2024 at 4:07 PM, documented the resident returned from the Emergency Department at 4:05 PM. The Medication Administration Record dated November 2024 documented Clozapine 375 milligrams was given on 11/29/2024 and 11/30/2024 at 9:00 PM. Surveyors were unable to determine how/why Clozapine was documented as given on 11/27/2024, 11/29/2024, and 11/30/2024. There was no documented evidence Clozapine was delivered to the facility in November 2024: Pharmacy report for Clozapine for Resident #47, dispense date range 2/01/2024 to 3/03/2025, did not document Clozapine was dispensed in November 2024. The medication was not dispensed until 12/6/2024. Per the report of what was available in the facility PYXIS (automated medication dispensing system), Clozapine was not stocked in the facility. The Medication Administration Record dated December 2024documented Clozapine 375 milligrams was to be given at bedtime and was scheduled for 9:00 PM. It documented: o 12/01/2024 was not given and documented: enroute from pharmacy. Physician notified. o 12/02/2024 was documented as given. o 12/03/2024 was documented as given. o 12/04/2024 was documented as given. o 12/05/2024 was not given and documented: awaiting pharmacy delivery. There was no documented evidence that Clozapine was delivered to the facility from 12/01/2024 to 12/05/2024. A Physician Progress Note dated 12/06/2024 at 3:38 PM by Nurse Practitioner #2, documented Resident #47 was prescribed Clozapine for schizophrenia. Clozapine level was less than 10. (therapeutic range 350-600 nanograms/milliliter) It documented questionable medication adherence. The medication administration report showed 5 times the resident did not receive medication, unclear why. A nursing note dated 12/06/2024 at 4:01 PM documented the nurse was informed by the pharmacy that the resident's clozapine was waiting for approval, and as soon as it was approved, it would be sent on the next delivery. Provider was made aware. The Medication Administration Record dated December 2024 documented Clozapine 375 milligrams was not given on 12/06/2024 at 9:00 PM. A Medication Administration Note dated 12/06/2024 at 8:51 PM, documented: awaiting pharmacy delivery. The Pharmacy Packing Slip Proof of Delivery documented Clozapine 375 milligrams was delivered to the facility for Resident #47 on 12/06/2024 at 9:49 PM. There was no documentation on the Medication Administration Record dated 12/06/2024 that the clozapine was administered on 12/06/2024 after it was received in the facility at 9:49 PM. The Medication Administration Record dated 12/7/2024 documented Clozapine 375 milligrams was given at 9:00 PM. A nursing note dated 12/08/2024 at 4:24 PM by Registered Nurse #6 documented at 3:35 PM Registered Nurse #6 and the unit nurse entered the resident's room and found Resident #47 flailing their arms around and flipping their body over continuously and putting themselves onto their knees and attempting to stay on the floor. Resident #47 was not speaking normally, oriented to self , and unable to say the name of the facility. Typically, the resident could say the name of the facility. Resident #47 has also known Registered Nurse #6's name for months but could not recall their name. Resident #47 stated they wanted to go to the hospital. Resident #47 has not received their psychiatric medication in a week and the resident was not functioning safely. A nursing note dated 12/08/2024 at 5:19 PM by Registered Nurse #documented they called 911 and report was given to the Emergency Medical Technicians. Resident #47 appeared to understand they were going to the hospital and wanted to go. The Hospital Emergency Documentation documented the resident was seen on 12/8/2024 at 7:36 PM. Chief complaint: The resident was brought in by ambulance from the nursing home for altered mental status. The resident had a history of schizophrenia and has not been given their clozapine for unknown time/unreason. The Emergency Department Course/Medical Decision Making documented resident presents with altered mental status. Differential diagnosis included but not limited to medication side effect, medication withdrawal, urinary tract infection, or metabolic abnormality. Basic labs, urinalysis, and chest x-ray were obtained. Urinalysis was not suggestive of urinary tract infection. Chest x-ray and computed tomography did not show any significant findings. On reevaluation, the resident was arousable and was able to have a conversation. The resident stated they remembered feeling somewhat confused that afternoon but now felt back to normal. The resident was discharged and transported back to the facility by ambulance. The Emergency Department Clinical Summary, Discharge Information, documented the resident discharged on 12/09/2024 at 2:26 AM with diagnosis of confusion. A Physician Progress Note dated 12/09/2024 at 3:39 AM by Nurse Practitioner #6 documented they received a call from the facility for admission medication reconciliation. The resident returned from the hospital after hallucinating. During an interview on 3/2/2025 at 12:12 PM, Nurse Practitioner #2 stated Resident #47 missed several doses of Clozapine and ended up going to the hospital because they were suicidal. Resident #12 Resident #12 was admitted to the facility with diagnoses of severe intellectual disabilities (a developmental delay that limits a person's ability to function in social and practical ways), chronic kidney disease stage 3 (a moderate level of kidney damage that would make it harder for kidneys to filter waste and fluid from the blood), and type 2 diabetes mellitus. The Minimum Data Set (an assessment tool) dated 12/09/2024 documented the resident had severe cognitive impairments, could be understood, and sometimes understand others. A Physician Progress Note dated 1/02/2025 at 12:28 PM documented Resident #12 was diagnosed with a urinary tract infection on 12/19/2024, with enterococcus faecalis bacteria in critically high amounts. It documented they were prescribed an antibiotic, Amoxicillin 500 milligrams by mouth; however, according to nursing staff, the resident had been spitting out the pills and refusing to take them. Based on the resident's behavior, the oral antibiotic was changed to intravenous antibiotic (administered into a vein). The resident was prescribed the antibiotic Ampicillin, 2 grams intravenously every 6 hours for 7 days. A Physician Order dated 1/02/2025 at 11:56 AM documented Resident #12 was to receive Ampicillin Sodium Solution, reconstituted 2 grams, starting 1/02/2025 at 6:00 PM, administered intravenously every 6 hours at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM for 7 days. Registered Nurse Orders Administration Report dated 1/02/2025 6:00 PM dose was not given. The record was blank. There was no documented evidence why the medication was not given. A Physician Order dated 1/03/2025 at 1:10 PM documented Ampicillin Sodium Solution reconstituted 2 grams, intravenously every 6 hours at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM for 7 days. Start date 1/3/2025 at 6:00 PM. A Registered Nurse Orders Administration Report dated January 2025 documented Ampicillin Sodium Solution Reconstituted 2 grams, use intravenously every 6 hours for urinary tract infection for seven (7) days. The medication was scheduled to be given at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. The resident did not receive 10 out of 20 scheduled doses as follows: o 1/03/2025 12:00 AM, 6:00 AM, and 12:00 PM doses were not given and there were no progress notes. Physician Progress Note dated 1/03/2025, documented the resident missed three (3) doses due to a delay in delivery by the pharmacy and a staff shortage. o 1/04/2025 12:00 AM, 6:00 AM, and 6:00 PM doses were not given and there was no documented evidence why the medication was not given. o 1/05/2025 6:00 PM dose was not given and there was no documented evidence why the medication was not given. o 1/06/2025 6:00 PM dose was not given and there was no documented evidence why the medication was not given. o 1/07/2025 12:00 PM dose was not given and there was no documented evidence why the medication was not given. A Physician Progress Note dated 1/07/2025 at 4:50 PM by Nurse Practitioner #2 documented they were notified that several doses of intravenous Ampicillin had been missed. Ampicillin was ordered to treat enterococcus faecalis urinary tract infection. The intravenous medication was specifically ordered as the resident had been refusing all medications by mouth. This was brought to the physician's attention on 1/02/2025 and as a result, was started on Ampicillin 2 grams intravenously every six (6) hours. Order changed to Levaquin 250 milligrams intravenously once a day at 2:00 PM, for better medication compliance. The Medication Administration Record dated January 2025 documented Levofloxacin (Levaquin) intravenous solution, use 250 milligrams intravenously in the afternoon for urinary tract infection for three (3) days, to start on 1/07/2025 at 2:00 PM. A record review of the Medication Administration Record revealed the resident did not receive the Levaquin on 1/09/2025. There was no documented evidence why the medication was not given. A Physician Progress Note dated 1/10/2025 at 11:50 AM by Nurse Practitioner #2 documented the resident was prescribed intravenous Levaquin for urinary tract infection. The resident did not receive the last dose yesterday afternoon (1/09/2025). Plan: would give the last dose of intravenous Levaquin 250 milligrams now. The provider would follow up to ensure the dose was received. A record review of the Medication Administration Record revealed the resident received the intravenous Levaquin on 1/10/2025. During an interview on 3/02/2025 at 12:12 PM, Nurse Practitioner #2 stated they had to alter orders to account for no staffing. It had been something they had to do since about October 2024. They could not recall other resident names, but they knew missed medication doses for other residents had happened in the past. They stated nurses were documenting medications were not available but were not notifying providers. Providers had to double cover infections with more than one (1) antibiotic because they were unsure if residents had received all the doses. They stated Resident #12 was ordered to have Ampicillin intravenously every six (6) hours to treat urinary tract infection. They did not have enough nurses on the unit to administer the medication as ordered and the resident missed doses of Ampicillin. They had to think of a way to provide medication to the resident and ordered Levaquin intravenously once daily for three (3) days for better medication compliance by nursing staff. They stated that even with the Levaquin being a once daily medication, the resident did not get it for three (3) consecutive days as ordered. They stated the resident missed the third dose and they had to order a one-time dose of Levaquin intravenously. Resident #23 Resident #23 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (a chronic lung disease that causes progressive and irreversible damage to the airways in the lungs), acute on chronic systolic congestive heart failure (a sudden worsening of symptoms of a pre-existing condition of weakened heart muscles), and type 2 diabetes mellitus. The Minimum Data Set, dated [DATE] documented the resident was cognitively intact, could be understood, and understand others. A Physician Progress Note dated 2/22/2025 at 6:00 PM by Nurse Practitioner #3 documented they received a call from nursing staff reporting the resident's urinalysis and culture results returned positive for urinary tract infection and was sensitive to Augmentin (antibiotic). The resident was prescribed Augmentin 875 milligrams twice daily. A Physician Order dated 2/22/2025 documented Amoxicillin-potassium clavulanate (Augmentin) tablet 875-125 milligrams, give 1 tablet by mouth every 12 hours for urinary tract infection for seven (7) days. Start date 2/22/2025. The Medication Administration Record dated February 2025 documented Amoxicillin-potassium clavulanate tablet 875-125 milligrams, give one (1) tablet every 12 hours for urinary tract infection for seven (7) days, to start on 2/22/2025 at 6:00 PM. It was scheduled to be given at 6:00 AM and 6:00 PM. The order was discontinued on 2/26/2025 at 8:29 AM, for a total of eight (8) doses to be given. The facility printed a report from the automated medication dispensing system on 2/27/2025 for Resident #23, for date range 2/21/2025 to 2/25/2025, documented Augmentin (four (4) doses) were removed from the automated medication dispensing system on: o 2/22/2025 at 5:43 PM o 2/23/2025 at 7:12 AM o 2/24/2025 at 4:02 PM o 2/25/2025 at 3:34 PM Review of the Medication Administration Record dated February 2025 for Amoxicillin-potassium administration revealed the resident did not receive four (4) doses as follows: o 2/23/2025 6:00 PM documented Augmentin was given. There was no record that it was removed from the automated medication dispensing system. o 2/24/2025 6:00 AM was not given and there was no documented evidence why the medication was not given. o 2/25/2025 6:00 AM documented Augmentin was not given. The medication administration notes documented: did not come from pharmacy and not available in automated medication dispensing system. Supervisor aware. o 2/26/2025 6:00 AM was not given. The medication administration notes documented: not available from pharmacy and none in automated medication dispensing system. Supervisor notified. During an interview on 2/26/2025 at 12:40 PM, Resident #23 stated they missed two or three doses of antibiotics because they were not available. During an interview on 3/02/2025 at 12:12 PM, Nurse Practitioner #2 stated Resident #23 developed pneumonia while being treated for urinary tract infection. They stated the Augmentin that was ordered would have taken care of the urinary tract infection and pneumonia if the nurses had given the medication as ordered. They stated they had to order intravenous antibiotic for Resident # 23's pneumonia because of the missed doses of Augmentin. They stated Resident #47 missed several doses of Clozapine and ended up going to the hospital because they were suicidal. Resident #77 Resident #77 was admitted to the facility with diagnoses of chronic kidney disease (chronic kidney damage that makes it harder for kidneys to filter waste and fluid from the blood), cerebral infarction (a medical condition where the blood flow to the brain is interrupted, leading to the death of brain cells), and chronic obstructive pulmonary disease. The Minimum Data Set, dated [DATE] documented the resident was cognitively intact. The resident made themselves understood and was able to understand others. A Laboratory Report dated 12/21/2024 documented the results of a basic metabolic panel (helps doctors check the body's fluid balance and levels of electrolytes) that was collected on 12/20/2024. The potassium result was 5.2 (reference range 3.5 - 5.1) and was flagged as being high. An Order Summary Report for 11/01/2024 to 3/31/2025 documented an order dated 12/21/2024 for sodium zirconium cyclosilicate, give one (1) packet by mouth for hyperkalemia (high level of potassium in the blood often caused by kidney disease) for one (1) day. A nursing note dated 12/21/2024 at 10:54 PM by the Registered Nurse #3 documented they received a call from the provider regarding Resident #77 having a potassium level of 5.2. The provider placed a new order for sodium zirconium cyclosilicate. Registered Nurse #3 contacted the pharmacy, and they reported they were not able to get the medication to the facility until the following afternoon. The provider was made aware and confirmed it was okay that the medication was not available until the following afternoon. The Medication Administration Record dated December 2024 did not document sodium zirconium cyclosilicate was given on 12/22/2024, and there was no documented evidence in a Nursing Progress Note that the provider was notified. A Laboratory Report dated 12/24/2024 documented the results of a basic metabolic panel that was collected on 12/23/2024. The potassium result was 5.4 (reference range 3.5 - 5.1) and was flagged as being high. A Physician Progress Note dated 12/24/2024 at 3:45 PM by Physician #2 documented the resident was seen for routine lab review related to chronic illness. It documented resident received one (1) dose of the sodium zirconium cyclosilicate for potassium of 5.2 on 12/21/2024, and on that day the potassium level was 5.4. There was no documented evidence Resident #77 received sodium zirconium cyclosilicate on 12/21/2024, 12/22/2024, or 12/23/2024. An Order Summary Report for order date range 11/01/2024 to 3/31/2025, documented an order dated 12/24/2024 for sodium zirconium cyclosilicate oral packet 10 grams (sodium zirconium cyclosilicate), give one (1) packet by mouth two (2) times a day for hyperkalemia for one (1) day. An Order Note dated 12/25/2024 at 2:16 AM by Registered Nurse documented the order for sodium zirconium cyclosilicate oral packet 10 grams, give one (1) packet two (2) times a day for hyperkalemia was outside of the recommended dose or frequency. The frequency of two (2) times a day exceeded the usual frequency of every two (2) days to daily. It documented the provider was aware. The Medication Administration Record dated December 2024 documented sodium zirconium cyclosilicate oral packet 10 grams was given on 12/25/2024 at 9:00 AM. Resident #327 Resident #327 was admitted to the facility with fracture of upper and lower end of the right fibula (when the smaller bone in the lower leg is broken at both the knee and the ankle regions), atrial fibrillation (a common heart rhythm disorder where the upper chambers of the heartbeat irregularly and rapidly), and dementia (a chronic generative condition characterized by progressive or persistent memory impairment). The Minimum Data Set, dated [DATE] documented the resident was able to understand and be understood by others. A Physician's Order dated 4/16/2024 documented the resident was to receive Azithromycin (an antibiotic) 500 milligrams intravenously one time a day for pneumonia for two (2) administrations. The Medication Administration Record documented the resident did not receive either dose of the antibiotic. The progress note dated 4/16/2024 documented the nurse was unable to establish intravenous access, the provider was called and did not give any new orders. There was no documentation on the Medication Administration Record or in the progress notes for the missed dose on 4/17/2024. On 4/18/2024, Resident #327 was transferred to the hospital by family request and admitted overnight. The resident was treated for pneumonia and received intravenous antibiotics. During an interview on 3/02/2025 at 1:48 PM, Director of Nursing #1 stated that they were aware there were medications missing from the pharmacy. They had been looking into it. They stated they had not run into any reports of missing medications or medication errors but had just been informed by staff that pharmacy did not send medications. Director of Nursing #1 stated they would expect staff who discovered medications were not in-house to check the automated medication dispensing system to see if there were any available, contact the Medical Doctor to tell them what was available for substitution, document in the Electronic Medical Record that the medication was not available and that the dose was missed, and call the pharmacy to make sure the medication would come on the next run. Missed medications should be reported to the supervisor. Director of Nursing #1 stated they were unaware that there was a medication error form, and that documentation of missed medications should be in the shift-to-shift 24-hour report that was reviewed every day. Director of Nursing #1 stated Nurse Managers were also supposed to check the 24-hour shift to shift report for discrepancies on their units. The Quality Assurance Plan Initiative meeting had occurred one time since they have been a Director of Nursing, and they were having night nurses review carts and medications to ensure that everything was where it needed to be. The pharmacy made three (3) deliveries a day, early in the morning on the overnight shift, in the afternoon on day shift, and on the evening shift around 8:00 PM or 9:00 PM. During an interview on 3/02/2025 2:00 PM, Administrator #1 stated in the past they had reached out to the providers to help figure out issues. They stated they would expect staff to call the pharmacy for missing medication doses and to find out when they could be delivered. Administrator #1 stated they would expect staff to call the Medical Director to see if something else could be given. They stated they would expect staff to monitor the resident and document whatever direction was given by provider. They stated the medication issues in the building just came to light over the last week. The facility completed medication error/missed dose sheets when there was an error or missed medication. Administrator #1 stated they had not received any sheets in January or February 2025 unless they were on the Director of Nursing's desk, and they did not know it. They stated they did not run reports specific to medication issues, but they would expect the nurses would write a progress note that would be on the 24-hour report that gets reviewed daily. They stated they had never heard that there were not enough staff at the facility to get medications passed or resident care done. During an additional interview on 3/02/2025 at 3:11 PM, Administrator #1 stated they had started a house-wide education regarding what was available in the automated medication dispensing system and what to do when something was not available. Supervisors and unit managers had been reeducated on the policy of checking their reports, checking the clinical dashboard for late and/or missing medications. Daily reports would be run regarding medication errors and missed doses and if the providers were notified. Administrator #1 stated they will be checking reports for yellow and red colors (indicated late or missed doses) daily and trying to correct inconsistencies in real time. 10 New York Codes Rules and Regulations 415.12(m)(2)