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

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

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

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

Based on observation, record review, and staff interviews during the Recertification Survey started on 9/28/2022 and completed on 10/5/2022 the facility did not ensure that its medication error rate was not 5 percent or greater. This was identified for 2 of 33 opportunities during the medication pass observation, resulting in a 6 % medication error rate. Specifically, during the medication pass observation 1) Registered Nurse (RN) #1 administered a Sucralfate tablet (a medication used to treat and prevent gastric and intestinal ulcers) to Resident # 91 while the resident was eating breakfast; however, the Physician ordered the medication to be administered on an empty stomach. 2) Licensed practical Nurse (LPN) #1 administered Gabapentin (a medication used to treat nerve pain) to Resident # 302 at the wrong time. The finding is: The facility's policy titled Medication Administration-General, dated February 2016, documented that medications are administered to residents in a timely and accurate manner; the nurse will review the Physician's orders and compare against the medication administration record; compare the medication name, strength, and dosage schedule on the medication administration record against the prescription label; always check three (3) times prior to administration of medication. 1) Resident #91 was admitted with diagnoses including Non-Alzheimer's Dementia, Diabetes Mellitus, and Gastroesophageal Reflux Disease with Esophagitis with Bleed. The 9/1/2022 Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident had severe cognitive impairment. A Physician's order dated 9/20/2022 documented to administer Sucralfate 1 gram tablet, give one tablet by oral route four times per day on an empty stomach, one hour before meals and at bedtime, at 9 AM, 1 PM, 5 PM, and 9 PM, for diagnosis of gastroesophageal reflux disease. Review of the Sucralfate blister packet documented to administer Sucralfate 1 gram tablet, give one tablet by oral route four times per day on an empty stomach, one hour before meals and at bedtime, at 9 AM, 1 PM, 5 PM, and 9 PM. During an observation on 9/29/2022 at 8:30 AM, the medication pass for Resident #91 was performed by Registered Nurse (RN) #1. The nurse crushed the Sucralfate tablet, an iron tablet, and a Vitamin B 12 tablet together. RN #1 then mixed all the crushed medications in apple sauce and administered the medications to Resident #91 while the resident was eating their oatmeal. The resident had already completed eating the food that was on the breakfast plate. RN #1 was interviewed on 9/29/2022 at 10:51 AM and stated they (RN #1) were aware that the Sucralfate tablet was supposed to be administered on an empty stomach. RN #1 stated they administered the medication Sucralfate to the resident because the resident had not eaten that much of their breakfast yet. 2) Resident #302 was admitted with diagnoses including Heart Failure, Bipolar Disorder, and Post Herpetic Polyneuropathy. The 7/4/2022 admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. A Physician's order dated 9/8/2022 documented Gabapentin 100 milligram (mg) capsule by oral route every 8 hours at 5 AM, 1 PM, and 9 PM for diagnosis of Postherpetic Polyneuropathy. A Physician's order dated 9/27/2022 documented strict isolation and contact precautions for a diagnosis of Clostridium Difficile (C-Diff). During an observation on 9/29/2022 at 8:58 AM the medication pass for Resident #302 was performed by Licensed Practical Nurse (LPN) #1. LPN #1 prepared the Gabapentin capsule, as well as an iron tablet, an Eliquis (blood thinner) tablet, and a Bupropion (antidepressant) tablet for administration. After preparing the medications, LPN #1 donned an isolation gown and gloves; entered the resident's room with the medications in a cup, and administered the medications to Resident #302. After administration of the medications, LPN #1 removed the isolation gown and stated the medications were all given and the medications would be signed off in the medication administration record (MAR). A review of the MAR revealed that the Gabapentin capsule that was due at 5 AM on 9/29/2022 had already been administered by another nurse and the next due time to administer Gabapentin was documented to be at 1 PM. LPN #1 was interviewed on 9/29/2022 at 10:55 AM. LPN #1 stated that they (LPN #1) gave the dosage of Gabapentin at 9 AM because they (LPN#1) were so busy thinking about the C-Diff and mistakenly gave the medication that was not due for administration. RN #2, who was the in-service coordinator, was interviewed on 9/30/2022 at 12:56 PM. RN #2 stated both nurses (RN #1 and LPN #1) made medication errors and the residents' families and physicians were notified of the medication errors. RN #2 stated both nurses will have to be re-educated on medication administration. The Director of Nursing Services (DNS) was interviewed on 10/3/2022 at 8:00 AM. The DNS stated RN #1 and LPN #1 both made medication errors and both nurses will have to be re-educated. 415.12(m)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 9/28/2022 and completed on 10/5/2022, the facility did not ensure that all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles. This was identified on one of four medication carts reviewed during the Medication Storage and Labeling Task. Specifically, Resident #80's two Admelog insulin vials were observed opened with no date to indicate when the insulin vials were first opened. The finding is: The Facility's Medication Labeling Policy and Procedure dated 8/2021 documented that upon opening insulin pens/vials, the licensed nurse will write the date opened. Resident #80 was admitted with diagnoses that included Diabetes Mellitus, Hyperlipidemia, and Malnutrition. The admission Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #80 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS further documented that Resident #80 received insulin injections 5 of 7 days during the MDS look-back period. The Physician's order dated 8/30/2022, last renewed on 10/3/2022, documented Admelog U-100 Insulin lispro 100 unit/milliliters subcutaneous solution to be injected by subcutaneous route every day at 7:30 AM, 11:30 AM, 4:30 PM and 9:00 PM for Type 2 Diabetes Mellitus. The Medication Cart on Unit 2 B was observed on 10/3/2022 at 2:50 PM with LPN #2. There were two insulin vials of Admelog that were opened and not dated. LPN #2 stated that the two insulin vials belong to Resident #80 and both vials were opened and not dated. LPN #2 stated that they (LPN #2) did not know when the vials were first opened. The Director of Nursing Services (DNS) was interviewed on 10/5/22 at 11:20 AM. The DNS stated that the insulin vials are expected to be dated when they are first opened. 415.18(d)

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

Based on record review and staff interviews during the Recertification Survey the facility did not ensure that Drug Regimen Reviews were acted upon for each resident. This was identified for one (Resident #62) of seven residents reviewed for Unnecessary Medications. Specifically, Resident #62 had a Drug Regimen Review dated 12/29/19 that recommended a re-evaluation of the medications Atarax (hydroxyzine) tablet and Triamcinolone (ointment), prescribed for Pruritis (itching), because these medications did not have stop dates. The response from the Physician did not address the pharmacist's concern regarding stop dates. The finding is: The facility's policy, dated 12/31/18, titled Drug Regimen Review, documented that the Attending Physician or Extender will address issues and document in the Electronic Medical Record (EMR) or the report within 14 days. Resident #62 has diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Hypertension, and Osteoporosis. The 11/27/19 admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident had moderately impaired cognition. The MDS also documented the resident had no skin problems. A Comprehensive Care Plan (CCP) effective 1/16/2020 titled Chronic Pruritis documented interventions to follow up with Dermatology as needed and to monitor the effectiveness of the treatment plan. A Dermatology consult dated 12/12/2019 documented the resident was seen by the Dermatologist due to a rash to the shoulders, back, abdomen, and left thigh. The medications prescribed were Hydroxyzine 10 milligrams (mg), one tablet at bedtime, for 30 days; and Triamcinolone Acetonide 0.1%, a small amount of ointment twice a day for 30 days. A Physician's order, dated 12/12/19 and renewed 1/8/2020, ordered Hydroxyzine 10 mg tablet, give one tablet by oral route once daily at bedtime for itching. There was no stop date in the order. A Physician's order, dated 12/19/19 and renewed 1/8/2020, ordered Triamcinolone Acetonide 0.1% Topical Ointment, apply by topical route two times per day for itching. There was no stop date in the order. A Pharmacy Consult report, dated 12/29/19, documented that the resident was receiving the following medications without an end date: Atarax (Hydroxyzine) 10 mg every day and Triamcinolone 0.1% twice a day. The Pharmacist Consultant requested to re-evaluate, consider stop date/parameters on medications and evaluate and monitor efficacy and continuation of treatment. Review of the Pharmacy Consultation in the EMR did not reveal a response from the Physician. The Physician was interviewed on 1/16/20 at 1:29 PM. He stated he did have a conversation on 12/29/19 with nursing regarding the Pharmacy consult. He stated he did not put an end date on the medications because he was waiting for the resident to return to the Dermatologist, but he stated there was no date for the Dermatology appointment or an order for a follow up Dermatology consult. The Director of Nursing Services (DNS) was interviewed on 1/16/2020 at 2:35 PM. She stated the Physician electronically signed that he had seen the consult in the EMR on 12/29/2019, but the Physician did not provide a response. She stated that she had to call the doctor because the pharmacy recommendations were not addressed. She stated she hand wrote the discussion she had with the doctor on a printout of the pharmacy report. The DNS's hand-written statement on the 12/29/19 Pharmacy Consult was as follows: Signed off by Physician on 12/29/19. Discussed-disagree, was Dermatology recommendation. Continue with current treatment. The discussion with the Physician did not address stop dates for the medications. Review of the January 2020 Medication Administration Record (MAR) revealed that the resident continued to receive Hydroxyzine 10 mg daily through 1/20/20, and review of the January 2020 Treatment Administration Record (TAR) revealed that the resident continued to be treated with Triamcinolone Acetonide 0.1% topical ointment twice a day through 1/20/20. The Medical Director was interviewed on 1/21/20 at 10:56 AM. He stated that the Primary Physician might have misunderstood the question that was being asked by the pharmacist. He stated the end date for the medications should have been addressed. 415.18(c)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey the facility did not ensure that the Antibiotic Stewardship program included antibiotic use protocols and a system to monitor antibiotic use for 1 (Resident #22) of 2 residents reviewed for Urinary Tract Infection (UTI)/Catheter Use. Specifically, Resident #22 was prescribed Macrobid 100 milligrams (mg) from 6/14/19, and the antibiotic stewardship program did not have a prophylactic antibiotic use protocol in place. The finding is: The facility antibiotic stewardship program dated February 2018 documented that the Infection Preventionist was the committee chairman. The antibiotic surveillance form communicates the affected resident, location in facility, date symptoms first noted, signs and symptoms, antibiotic ordered, and days of treatment. The stewardship program further documented that when placing orders, include microbiology cultures, and when cultures come back, take an antibiotic time out to determine if the antibiotic is still warranted and if it is effective against the organism. Resident #22 was admitted to the facility with the diagnosis of Alzheimer's Dementia, Parkinson's Disease, and Peripheral Vascular Disease. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #22 had a Brief Interview for Mental Status (BIMS) Score of 3, indicating severely impaired cognition. The MDS documented that Resident #22 received an antibiotic 7 out of 7 days but did not have a diagnosis of a UTI in the 30 past days. The Urology consultation dated 6/14/19 documented that Resident #22 presented with a chief complaint of recurrent UTI. The Urologist recommendations included to attempt Macrobid 100 milligrams (mg) daily. The Urologist documented that the use of Macrobid may select Macrobid Resistant Bacteria. If Resident #22 has a symptomatic UTI during therapy, treat with prophylactic Ceftin 250 mg for 5 days. The Physician's orders dated 6/14/19 documented: Macrobid 100 milligram (mg), give 1 capsule (100 mg) by oral route once daily with food for prophylaxis, no stop date. The order was renewed on 7/12/19, 8/4/19, 9/23/19, 10/16/19, 11/8/19, 12/1/19 and 1/16/20. A nursing progress note dated 10/3/19 documented the Licensed Practical Nurse (LPN) spoke with the Physician (MD) at the family's request, the MD ordered Cipro 250 mg twice a day for 5 days for prophylactic measures. Urine Specimen ordered for Urinalysis, Culture and Sensitivity (UA, C&S). Th Physician's order dated 10/3/19 documented Cipro 250 mg tablet by oral route every 12 hours for 5 days. The RN Unit Manager was interviewed on 1/21/20 at 9:30 AM. The RN stated that Resident #22 has a history of frequent UTIs. The RN stated the resident was diagnosed with a UTI on 3/18/19, 5/8/19, 5/20/19 and was referred for a Urology consultation in June 2019. The RN stated the Urologist recommended daily prophylactic use of the antibiotic, Macrobid, to reduce the recurrence of UTIs and to follow up in 1 year. The RN stated Resident #22 became symptomatic of a UTI on 10/3/19 and was prescribed Cipro for treatment. The RN stated Resident #22 was continuously given Macrobid 100 mg from 6/14/19 to present. The RN further stated Resident #22 did not have a time out period throughout the trial of antibiotic therapy. The Physician was interviewed at 1/21/20 at 10:30 AM. The physician stated that Resident #22 was prescribed Macrobid 100 mg to help reduce the frequency of UTIs. The Physician stated that Resident #22 presented with symptoms of a UTI in October 2019, and the resident's family member advocated for continuing the Macrobid. The Physician stated that he felt that the Macrobid was effective in reducing the recurrence and decided to continue the therapy to the present day. The Infection Preventionist (IP) was interviewed on 1/21/20 at 11:13 AM. The IP stated that Resident #22 was not included in his antibiotic usage statistics because there is no facility-wide surveillance of prophylactic use of antibiotics. The IP stated the residents who were prescribed antibiotics for prophylactic reasons are only care planned for the use of antibiotics and monitored for signs and symptoms of active UTI at the nursing level. The IP stated that microbiology cultures are only obtained in the presence of symptoms of a UTI and time-out periods do not apply to residents who use antibiotics prophylacticlly. The IP stated only residents who have an active infection and use antibiotics are included in the facility-wide antibiotic surveillance. The IP stated that information about the residents who have an active infection is collected and presented during Quality Assurance (QA) meetings for review. The IP stated that Resident #22 was not included in the most recent Infection Surveillance Report presented to QA on 1/10/20. The antibiotic stewardship program plan does not specify a separate protocol for prophylactic antibiotic use. 415.19(a)(1-3)