Based on observation, record review, and interviews during the Recertification Survey initiated on 6/23/2025 and completed on 6/27/2025, the facility did not ensure it provided pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. This was identified for one (Resident #58 of four residents reviewed for Medication Administration. Specifically, on 6/3/2024, Resident #58 had a new Physician's order for Topiramate 100 milligram tablet, give 1.5 tablet (for 150 milligrams) one time a day for a diagnosis of headaches. During the medication pass observation on 6/24/2024, it was revealed that the Topiramate 1.5 tablet (150 milligrams) order was never delivered by the pharmacy, and the resident continued to receive the discontinued dose of 100 milligrams of Topiramate for approximately 20 days. The finding is: The facility policy titled Provider Pharmacy Requirements, dated 8/2020, documented that regular and reliable pharmaceutical service is available to provide residents with prescription and non-prescription medications, services, and related equipment and supplies. The provider pharmacy agrees to perform all of, but not only, the following pharmaceutical services: Accurately dispensing prescriptions based on authorized prescriber orders. Resident #58 was admitted with diagnoses including Migraine Headaches, Anxiety Disorder, and Displaced Bimalleolar Fracture (an ankle injury where both parts of the ankle bone are fractured and shifted out of normal alignment). The 6/6/2025 admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. A Physician's order dated 6/3/2025 at 2:48 PM documented Topiramate Tablet 100 milligram, give one tablet by mouth one time a day for Migraines. This order was discontinued on 6/3/2025 at 3:40 PM. A Physician's order dated 6/3/2025 at 3:40 PM documented Topiramate 100 milligram tablet, give 1.5 tablets (150 mg) by mouth one time a day for headaches. During a Medication Pass observation on 6/24/2025 at 9:16 AM, Licensed Practical Nurse #1 prepared medications to be administered to Resident #58. Licensed Practical Nurse #1 stated they were not regularly assigned to Resident #58's unit and had not administered medications to Resident #58 before today. Licensed Practical Nurse #1 retrieved a medication blister from the medication cart and stated the blister pack label read, Topiramate 100 milligram tablet, give one tablet by mouth one time a day for Migraines. The date on the blister pack was 6/3/2025 [date delivered from the pharmacy]. Licensed Practical Nurse #1 stated the tablets in the blister pack were not scored (which refers to a pill or tablet that has a line or indentation on its surface to facilitate splitting the tablet into smaller doses), and therefore, they could not administer the 1.5 tablets per the current Physician's order. Licensed Practical Nurse #1 stated they were not sure how the previous medication nurses were providing the 1.5 tablets of Topiramate as per the physician's order and would refer this matter to their supervisor. Licensed Practical Nurse #1 was unable to find the blister pack for Topiramate 1.5 tablets (150 milligrams). During an interview on 6/24/2025 at 9:25 AM, Resident #58 stated that at home, they were taking Topiramate 150 milligrams for migraine headaches. Resident #58 stated they did not know how much Topiramate they were getting at the facility. During an interview on 6/24/2025 at 10:57 AM, Pharmacist #1 stated the pharmacy delivered Topiramate 100 milligrams blister pack to the facility on 6/3/2025. Another Topiramate order for Topiramate 150 milligrams, 1.5 tablets was received about an hour after the original order on 6/3/2025; however, the pharmacy did not fill the order for Topiramate 150 milligrams, 1.5 tablets. Review of the June 2025 Medication Administration Record revealed that from 6/4/2024 to 6/23/2024, the medication administration nurses documented that they had administered Topiramate 150 milligrams (1.5 tablets) to the resident. During a re-interview on 6/24/2025 at 3:00 PM, Pharmacist #1 stated the pharmacy should have dispensed the 1.5 tablet Topiramate order (150 milligram); the order was mis-assessed by the pharmacy's billing department. The pharmacy only sent the 100-milligram dose; this was an oversight. Pharmacist #1 further stated that the facility staff did not call to inquire why the Topiramate 1.5 tablet, 150 milligram order was not delivered by the pharmacy. During an interview on 6/25/2025 at 1:15 PM, the Director of Nursing Services stated the pharmacy delivered the original order of Topiramate 100 milligram tablets, but did not deliver the new order for Topiramate 1.5 tablets (150 milligrams) that was also ordered on 6/3/2025. The Director of Nursing Services stated the nurses should have also followed up with the pharmacy to inquire why the Topramate 1.5 tablet (150 milligram) order was not delivered to the facility. 10 NYCRR415.12 (l)(1)

Based on observation, record review, and interviews during the Recertification Survey initiated on 6/23/2025 and completed on 6/27/2025, the facility did not ensure that it maintained all patient care equipment in a safe operating condition. This was identified for one (Resident #161) of two residents reviewed for Pressure Ulcers. Specifically, Resident #161 had a Stage 3 pressure ulcer (full-thickness skin loss, where the damage extends into the subcutaneous tissue) and had a care plan intervention for the use of an air mattress. There were multiple observations of the low-pressure light flashing on the air mattress pump before the facility staff replaced the air mattress. The finding is: The facility's undated policy titled Use of Low Air Loss Systems/Air Mattress documented that low air loss systems are medical devices designed to prevent and manage pressure ulcers by providing air circulation to reduce pressure and moisture on the skin. Low-air-loss systems should be installed according to the manufacturer's guidelines and checked by facility staff for compliance with safety standards. The mattress or overlay must be adjusted for proper pressure distribution, ensuring that the patient's body is adequately supported. Any malfunctions, patient injuries, or adverse events related to the use of low-air-loss systems must be reported immediately to Risk Management/Director of Nursing/Wound Nurse. Resident #161 was admitted with diagnoses including Parkinson's Disease, Malnutrition, and Hypertension. The 6/2/2025 admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact, was at risk for pressure ulcer development, and had one Stage 3 pressure ulcer (full-thickness skin loss, where the wound extends into the subcutaneous tissue, but not to underlying bone, tendon, or muscle). A wound care note dated 5/28/2025 documented that the resident had a sacral stage 3 pressure ulcer and recommended continuing to maintain a pressure-relieving mattress with correct settings. A Comprehensive Care Plan titled, Actual Skin Impairment, Sacral Stage 3 pressure ulcer, initiated 5/28/2025, documented an intervention for pressure reducing air mattress. The resident's most recent weight, as of 6/23/2025, was 168.0 pounds. During an observation on 6/23/25 at 10:37 AM, Resident #161 was in bed. The air mattress pump's red low-pressure light was flashing, and the weight setting was set at 600-750 pounds. During an observation on 6/24/2025 at 08:21 AM, Resident #161 was in bed. The air mattress pump's red low-pressure light was still flashing, and the weight setting was set at 220 pounds. The air mattress manufacturer's manual documented when abnormal pressure occurs, the low-pressure indicator will come on. During an interview on 6/24/2025 at 2:08 PM, Licensed Practical Nurse #4 (unit medication/treatment nurse) stated they had observed the flashing low-pressure light on Resident #161's air mattress pump; they were not sure what the flashing low-pressure light meant, and were not sure what the next step should be. During an observation and interview on 6/25/2025 at 8:30 AM, Resident #161 was observed in bed. The resident's bed had a different air mattress in place. Licensed Practical Nurse #4 stated that after the surveyor brought the low-pressure light to the nurses' attention, the Director of the Maintenance Department had changed the air mattress because the Director of the Maintenance Department was not sure if there was an air pressure leak. During an interview on 6/25/2025 at 9:10 AM, Maintenance Director #1 stated they were alerted about the low air pressure light on the air mattress yesterday (6/24/2025). Maintenance Director #1 stated they replaced the mattress because they were not sure what was causing the low-pressure light to flash. Maintenance Director #1 stated yesterday afternoon was the first time they were alerted that Resident #161's mattress was not functioning properly, and that there were no prior maintenance requests. During an interview on 6/26/2025 at 1:25 PM, the Director of Nursing Services stated that nurses or certified nursing assistants should inform the maintenance department when a low-pressure light on the resident's air mattress pump is flashing. 10 NYCRR 415.29

Based on observation, record review, and interviews during the Recertification Survey initiated on 6/23/2025 and completed on 6/27/2025, the facility did not ensure services provided or arranged by the facility, as outlined by the comprehensive care plan, met professional standards of quality. This was identified for one (Resident #58) of four residents observed during Medication Administration. Specifically, Resident #58 had a Physician's order for 150 milligrams of Topiramate (a medication to treat migraine headaches) daily. From 6/4/2024 to 6/25/2024, multiple medication nurses did not ensure the resident received the correct dosage of Topiramate 150 milligrams. Multiple nurses administered 100 milligrams and inaccurately documented that they administered 150 milligrams of Topiramate, 1.5 tablets. The finding is: The facility's policy titled Medication Administration and Documentation-General, dated 1/2024, documented that medication administration and documentation shall occur in a timely and accurate manner. The nurse assesses all medications that are due for administration at the assigned hour according to the electronic medication administration record. The nurse assures the 5 rights: Compares the medication name, strength, route, and dosage schedule on the medication administration record against the prescription label. Resident #58 was admitted with diagnoses including Migraine Headaches, Anxiety Disorder, and Displaced Bimalleolar Fracture (an ankle injury where both parts of the ankle bone are fractured and shifted out of normal alignment). The 6/6/2025 admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. A Physician's order dated 6/3/2025 at 2:48 PM documented Topiramate Tablet 100 milligram, give one tablet by mouth one time a day for Migraines. This order was discontinued on 6/3/2025 at 3:40 PM. A Physician's order dated 6/3/2025 at 3:40 PM documented Topiramate 100 milligram tablet, give 1.5 tablets (150 milligrams) by mouth one time a day for headaches. During a Medication Pass observation on 6/24/2025 at 9:16 AM, Licensed Practical Nurse #1 prepared medications to be administered to Resident #58. Licensed Practical Nurse #1 stated they were not regularly assigned to Resident #58's unit and had not administered medications to Resident #58 before today. Licensed Practical Nurse #1 retrieved a medication blister from the medication cart and stated the blister pack label read, Topiramate 100 milligram tablet, give one tablet by mouth one time a day for Migraines. The date on the blister pack was 6/3/2025 [date delivered from the pharmacy]. Licensed Practical Nurse #1 stated the tablets in the blister pack were not scored (which refers to a pill or tablet that has a line or indentation on its surface to facilitate splitting the tablet into smaller doses), and therefore, they could not administer the 1.5 tablets per the current Physician's order. Licensed Practical Nurse #1 stated they were not sure how the previous medication nurses were providing the 1.5 tablets of Topiramate as per the physician's order and would refer this matter to their supervisor. Licensed Practical Nurse #1 was unable to find the blister pack for Topiramate 1.5 tablets (150 milligrams). During an interview on 6/24/2025 at 9:25 AM, Resident #58 stated that at home, they were taking Topiramate 150 milligrams for migraine headaches. Resident #58 stated they did not know how much Topiramate they were getting at the facility. During an interview on 6/24/2025 at 10:57 AM, Pharmacist #1 stated the pharmacy delivered Topiramate 100 milligrams blister pack to the facility on 6/3/2025. Another Topiramate order for Topiramate 150 milligrams, 1.5 tablets was received about an hour after the original order on 6/3/2025; however, the pharmacy did not fill the order for Topiramate 150 milligrams, 1.5 tablets. Review of the June 2025 Medication Administration Record revealed that from 6/4/2024 until 6/23/2024, the medication administration nurses documented that they had administered Topiramate 150 milligrams (1.5 tablets) to the resident. A new physician order dated 6/24/2024 at 9:37 AM documented Topamax (Topiramate) 100 milligram tablet, give one tablet by mouth, one time only, for migraines until 6/24/2025 at 3:59 PM. During an interview on 6/24/2025 at 2:38 PM, Licensed Practical Nurse #2 (who had administered one tablet of the 100 milligram Topiramate but signed the medication administration record 14 times, indicating they administered 150 milligrams, 1.5 tablets) stated, I just gave one tablet of the Topiramate. I do not recall seeing the order for the 1.5 tablets. During a re-interview on 6/24/2025 at 3:00 PM, Pharmacist #1 stated the pharmacy should have dispensed the 1.5 tablet Topiramate order (150 milligram); the order was mis-assessed by the pharmacy's billing department. The pharmacy only sent the 100-milligram dose; this was an oversight. Pharmacist #1 further stated that the facility staff did not call to inquire why the Topiramate 1.5 tablet, 150 milligram order was not delivered by the pharmacy. During an interview on 6/25/2025 at 10:58 AM, Licensed Practical Nurse #3 (who had administered one tablet of the 100 milligram Topiramate but signed the medication administration record two times that they administered 1.5 tablets) stated, I do not recall the medication pass for this resident [#58]. During an interview on 6/25/2025 at 1:15 PM, the Director of Nursing Services stated that the medication nurses made a medication error by giving the wrong dosage of Topiramate to Resident #58. Nurses are supposed to check the Physician's orders against the blister pack to ensure correct medication and dose are being administered to the resident. The Director of Nursing Services stated they initiated a medication error investigation, and the pharmacy would also be checking all facility orders for medication errors. The Director of Nursing Services stated the nurses should have followed up with the pharmacy to inquire why the Topiramate 1.5 tablet (150 milligram) order was not delivered to the facility. [10 NYCRR 415.11 (C)(3)(i)]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification and Abbreviated Survey (Complaint #NY00326729) initiated on 12/19/2023 and completed on 12/22/2023, the facility did not ensure each resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. This was identified for one (Resident #68) of three residents reviewed for Pressure Ulcers. Specifically, Resident #68 was assessed to be at a moderate risk for developing pressure ulcers. On 8/26/2023 the resident's Physician ordered a wheelchair gel cushion as a pressure relieving device. There was no documented evidence that the resident received the gel cushion until 10/19/2023. The resident was identified to have a Stage 2 sacral pressure ulcer on 10/19/2023. The finding is: The facility's policy titled, Pressure Ulcer Prevention and Treatment dated January 2022 and last revised January 2023, documented that new pressure-relieving devices/measures or changes to pressure-relieving devices/measures will be noted in the 24-hour report and the CNA accountability record. Rehabilitation responsibilities include assessment of residents for appropriate pressure relieving devices and measures (to include cushions, splints, booties, mattresses, turning and positioning schedules) and ensuring implementation as needed. Resident #68 was admitted with diagnoses including Cerebral Infarction, Hemiplegia, and Hemiparesis affecting the Left Non-Dominant Side, and Type 2 Diabetes Mellitus. The admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognition. The resident had no pressure ulcers and was at risk for developing pressure ulcers. The MDS documented the resident was dependent on staff for transfers, used a wheelchair, and had limitations in range of motion on one side of the upper and lower extremities. The Nursing admission assessment dated [DATE] documented the resident's Braden Scale score (a scale for predicting pressure ulcer risk) was 13 indicating the resident was at a moderate risk for pressure ulcer development. A Physician's Order dated 8/26/2023 documented to utilize a gel foam cushion in the wheelchair. A Comprehensive Care Plan (CCP) titled, The Resident has Potential for Impairment to Skin Integrity due to Decreased Mobility dated 8/28/2023 documented interventions to provide education, keep skin clean and dry, and to use lotion on dry skin. The interventions did not include the use of a gel foam wheelchair cushion. A Physiatrist's Consultation Note dated 9/19/2023 documented a recommendation for a cushion to be used in the resident's wheelchair for offloading purposes and pressure relief. The Resident Nursing Instructions (care instructions provided to the Certified Nursing Assistants) for August 2023, September 2023, and October 2023 revealed no instructions for the use of a gel cushion until 10/19/2023. A Nursing Progress Note dated 10/19/2023 documented the resident complained of sacral pain. An evaluation by the Nursing Supervisor revealed a Stage 2 sacral ulcer. The resident's Physician was notified and orders for Silvadene (topical antimicrobial cream) and a dry protective dressing were obtained. A Physician's Order dated 10/19/2023 documented instructions to apply Silver Sulfadiazine (Silvadene) Cream 1% to sacrum topically one time a day for wound healing. The wound care assessment dated [DATE] documented the wound site as an in house acquired Stage 2 pressure wound that measured as 0.6 centimeters in length x 0.6 centimeters in width x 0.1 centimeters in depth. A Rehabilitation Therapy Note dated 10/19/2023 documented that an Equagel cushion was provided for the resident's wheelchair on 10/19/2023. A CCP titled, Actual Skin Impairment effective 10/19/2023 documented that the pressure-reducing gel cushion in the wheelchair was first initiated on 10/19/2023. The Director of Rehabilitation was interviewed on 12/22/2023 at 10:19 AM and stated that orders by Physicians for pressure relieving devices, such as gel cushions, are presented at morning meetings and the devices are provided by the Rehabilitation Department. The Director of Rehabilitation was unable to provide any documented evidence of the provision or implementation of the gel cushion that was ordered for Resident #68 on 8/26/2023. Licensed Practical Nurse #2 was interviewed on 12/22/2023 at 1:20 PM and stated that interventions ordered by the Physician are documented on the CCPs and automatically populate in the Resident Nursing Instructions. Licensed Practical Nurse #2 was not able to recall if the resident had a wheelchair cushion in use during their stay on the unit. Licensed Practical Nurse #2 stated they expected that interventions ordered by the Physician should be documented on both the Comprehensive Care Plans and the Resident Nursing Instructions. Licensed Practical Nurse #2 stated that the nursing supervisor would be the person responsible to update the care plans to include new interventions. Primary Physician #3, who is also the facility's Medical Director, was interviewed on 12/22/2023 at 2:30 PM and stated they (Physician #3) expected facility staff to follow the physician orders and expected that Resident #68 was provided with the pressure relieving chair cushion for offloading. Physician #3 stated they rely on Nursing and Rehabilitation Staff to follow their (Physician #3) orders. The Director of Nursing Services (DNS) was interviewed on 12/22/2023 at 3:00 PM and stated that the gel cushion should have been added as an intervention on the Resident Nursing Instructions and the Comprehensive Care Plan for Resident #68. The Director of Nursing Services stated Resident #68's Electronic Medical Record (EMR) did not have any documentation related to implementation of the pressure relieving cushion ordered on 8/26/2023. 10 NYCRR 415.12(c)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews during the Recertification Survey initiated on 12/19/2023 and completed on 12/22/2023, the facility did not ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice. This was identified for one (Resident # 317) of four residents reviewed for Respiratory Care. Specifically, Resident #317 was administered oxygen therapy without a Physician's order since the resident's admission to the facility on 9/28/2023 until 12/19/2023. The finding is: The facility's policy and procedure titled, Oxygen Administration, last revised on 10/20/2023 documented that oxygen use must be documented in the medical record. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and /or nasal catheter. Before administering oxygen. While the resident is receiving oxygen therapy, an assessment must be documented for signs or symptoms of hypoxia and cyanosis. Resident#317 was admitted with Diagnoses of Atrial Fibrillation, Chronic Obstructive Pulmonary Disease (COPD), and Congestive Heart Failure (CHF). The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 7 which indicated severely impaired cognition. The MDS documented the resident utilized oxygen therapy. The hospital History and Physical dated 9/21/2023 documented that the resident was making sounds during breathing and was put on oxygen at 2 Liters via nasal cannula. The Patient Review Instrument (PRI, a tool used in the healthcare field to assess the functional status and needs of individuals who are receiving long-term care services) dated 9/28/203 documented that Resident #317 needed oxygen therapy as a medical treatment. The admission Physician's Order dated 9/28/2023 did not include an order for oxygen therapy. A Comprehensive Care Plan (CCP) titled Pt [patient] referred to respiratory rehab [rehabilitation] skilled services for experiencing SOD [shortness of breath] while lying flat and diagnosis of COPD dated 10/31/2023 documented interventions including to keep the Head of bed (HOB) elevated, administer Oxygen, Positioning, Pulmonary Rehabilitation, and Respiratory Muscle Training. Resident #317 was observed on 12/19/2023 at 11:00 AM in bed receiving oxygen from an oxygen concentrator 1.5 liters per minute via a nasal cannula. An oxygen tank was attached to the resident's wheelchair. A Physician's order dated 12/19/2023 entered at 11:00 PM documented to administer oxygen at 2 Liters per minute via nasal cannula as needed. During a subsequent observation on 12/20/2023 at 8:34 AM, Resident #317 was observed in bed receiving oxygen from the oxygen concentrator at 2 Liters per minute via a nasal cannula. Certified Nursing Assistant (CNA) #2 was interviewed on 12/20/2023 at 1:45 PM and stated that Resident # 317 needed oxygen because Resident #317 gets short of breath without it. Certified Nursing Assistant #2 stated that the staff, both nurses and nurses aides, always put the oxygen on for Resident #317 when the resident is in bed or in a wheelchair. Licensed Practical Nurse (LPN) #1 was interviewed on 12/20/2023 at 2:00 PM and stated that Resident # 317 has been using oxygen therapy on an as-needed basis since September 28, 2023 when they (Resident #317) were admitted to the facility. Licensed Practical Nurse #1 stated a physician order is required when a resident is receiving oxygen therapy. Licensed Practical Nurse #1 stated they did not know why there was not a Physician's order for the use of oxygen for Resident # 317. An interview was conducted with Registered Nurse #2, who was the Unit Supervisor, on 12/20/2023 at 2:30 PM. Registered Nurse #2 stated that a physician order must be in the Electronic Medical Records (EMR) system before the start of a treatment or medication. Registered Nurse #2 further stated that Resident # 317 should have a physician's order for oxygen therapy. Registered Nurse #I was interviewed on 12/20/2023 at 2:45 PM and acknowledged that the oxygen orders were obtained for the oxygen therapy for Resident #317 on 12/19/2023 at 11:00 PM after the resident was observed receiving supplemental oxygen by the surveyor on 12/19/2023. The Director of Nursing Services was interviewed on 12/21/2023 at 2:23 PM and stated that there should have been an order for the use of oxygen for Resident #317. The Director of Nursing Services stated it was an oversight that no one picked up that the oxygen therapy was part of the resident's respiratory treatment regimen and that no one obtained the physician's orders for the use of the oxygen. Medical Doctor #1 was interviewed on 12/21/2023 at 8:40 AM and stated that it was an oversight that an order for oxygen use was not documented in the Physician's Orders. Oxygen is a part of the resident's management of symptoms and should have been included as an order. Medical Doctor #1 further stated that they added the order for oxygen for Resident #317 on 12/19/2023 at 11:00 PM. NYCRR 415.12(k)(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the Recertification Survey initiated on 12/19/2023 and completed on 12/22/2023, the facility did not ensure that a physician, physician's assistant, nurse practitioner or clinical nurse specialist provide orders for each resident's immediate care and needs. This was identified for one (Resident #318) of seven residents reviewed during the Medication Administration task. Specifically, Resident #318 had a Physician's Order to administer Midodrine (medication used to treat low blood pressure); however, the order did not include blood pressure parameters regarding when to hold the medication and when to call a Physician. The finding is: The facility's policy and procedure titled, Medication Administration/Physician Orders, last revised on 7/24/2023 documented that vital signs are recorded in the Electronic Medication Administration Record (eMAR). The eMAR shall serve as the source from which all medications are documented and to use prudent professional judgment by informing the Physician in a timely manner when medications are held, refused, or otherwise unavailable for administration. Resident #318 was admitted on [DATE] with diagnoses including Orthostatic Hypotension ( a form of low blood pressure that occurs when standing up after sitting or lying down that can cause dizziness, lightheadedness, fainting or confusion), Essential Hypertension, and Personal History of Traumatic Brain Injury. The Minimum Data Set (MDS) assessment was not available as the resident was newly admitted to the facility. A Physician's Order dated 12/18/2023 documented to administer Midodrine Hydrochloride (HCL) tablets 2.5 milligrams (mg), one tablet by mouth three times a day for Hypotension, and to monitor vital signs every shift. The order did not include blood pressure parameters and guidance regarding when to hold the medication and or when to call the resident's Physician. The Baseline Care Plan dated 12/19/2023 documented the resident was alert and oriented to time, place, and person; was cognitively intact, and could communicate with staff. A Medication Administration Observation task was conducted on 12/20/2023 at 8:16 AM with Licensed Practical Nurse #1. Licensed Practical Nurse #1 obtained Resident #318's blood pressure and heart rate. The resident's blood pressure reading was 124/62 millimeters of mercury (mmHg), and their heart rate was 73 beats per minute. Licensed Practical Nurse #1 then administered Midodrine medication as per the Physician's Order. Licensed Practical Nurse #1 was interviewed on 12/20/2023 at 8:22 AM and stated that they (Licensed Practical Nurse #1) do not call the Physician with any vital sign results because the Physician's Order did not indicate when to call a Physician. A review of the Medication Administration Record (MAR) from 12/18/2023 to 12/20/2023 documented the following vital signs: -On 12/18/2023 the resident's blood pressure was 145/63 millimeters of mercury (mmHg) (normal range 120/80) and their heart rate was 85 beats per minute (normal range 72-80 beats per minute). The resident was administered Midodrine as per the Physician's Order. -On 12/19/2023 the resident's blood pressure was 132/68 mmHg, and their heart rate was 80 beats per minute. The resident was administered Midodrine as per the Physician's Order. -On 12/20/2023 the resident's blood pressure was 130/74 mmHg, and their heart rate was 74 beats per minute. The resident was administered Midodrine as per the Physician's Order. A Physician's Order dated 12/21/2023 documented to hold Midodrine HCL 2.5 milligrams if the systolic blood pressure (BP) is above 110 millimeters of mercury (mmHg) as per the MD every shift for Midodrine Protocol. The Director of Nursing Services was interviewed on 12/21/2023 at 1:57 PM and stated the resident's Physician has a team that enters all orders for a new admission. The facility has the ultimate responsibility of checking those orders for accuracy. It was an oversight on the facility's part that they did not check for those parameters or to clarify the vitals sign orders. The Director of Nursing Services further stated the unit supervisors should have checked the accuracy of the orders and the nurses who administer the medication should have brought up that there were no parameters for such significant medication to the attention of the nursing Supervisors. Physician #2, who is the primary care physician for Resident #318 and who signed the medication orders, was interviewed on 12/21/2023 at 4:00 PM. Physician #2 stated that they (Physician #2) would only document an order for parameters if the resident was on Dialysis. When asked why the Midodrine medication had an indicated parameter as of 12/21/2023, after the medication administration observation of 12/20/2023 and not at the time of admission, Physician #2 stated the Medical Director ordered the parameters on 12/21/2023. The Medical Director was interviewed on 12/22/2023 at 3:06 PM and stated that the standard of practice for the medication Midodrine would be to monitor the resident's Blood Pressure (BP) for a week and to hold the medication if the resident's Blood Pressure was above 110 millimeters of mercury (mmHg) because a high blood pressure can cause dizziness or blurred vision that can lead to a fall. The Medical Director stated that the Physician would then decide if the medication should be discontinued, or the order should be changed to a lower dose or frequency. According to Drugs.com, last reviewed 2/6/2023, Midodrine is used to treat low blood pressure that causes severe dizziness or a light-headed feeling. Blood pressure will need to be checked before and during treatment with Midodrine. NYCRR 415.15(b)(1)(i)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey and the Abbreviated Survey (Complaint # NY 00261362) completed on 12/9/2021 the facility did not consult with the resident's Physician when there was a significant change in the resident's physical or mental status for one (Resident #205) of one resident reviewed for Choices. Specifically, Resident #205 had a Physician's Order to monitor Blood Pressure (BP) weekly, and to call the Physician for a Systolic BP less than 90 millimeter of mercury (mmHg) or greater than 140 mmHg. On 7/23/2020 the resident's BP was documented as 83/46 mmHg and there was no documentation in the resident's medical record that the resident's Physician was made aware of the resident's low BP. The finding is: Resident #205 has diagnoses which include Moderate Protein-Calorie Malnutrition and Malignant Neoplasm of the Colon. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 6 which indicated that the resident had severely impaired cognitive skills. The Physician's Order dated 6/17/2020 documented to obtain the resident's Pulse and Blood Pressure (BP) weekly. The order included to call the Physician for Systolic BP less than 90 mmHg or greater than 140 mmHg. The July 2020 Medication Administration Record (MAR) documented that on 7/23/2020 the resident's BP was 83/46 mmHg (normal value 120/80 mmHg). Review of the resident's Electronic Medical Record (EMR) revealed no documented evidence that the resident was assessed or that the resident's Physician was notified of the resident's low BP. The Director of Nursing Services (DNS) was interviewed on 12/9/2021 at 1:10 PM and stated that the Physician's Order should have been followed and the Physician should have been called when the resident's BP was greater or less than the parameters documented in the Physician's Orders. The DNS stated that they (DNS) also expected the nurses to document the resident's condition and notification to the Physician in the EMR. The resident's Physician, who is also the facility's Medical Director, was interviewed on 12/9/2021 at 1:25 PM and stated that they (Physician) would definitely expect the nurse to call them when the resident had an abnormal blood pressure. The Physician stated that the nurse would usually call them, and they (Physician) would ask the nurse to recheck the BP because it could be an error. The Physician stated that they would also ask the nurse if the resident was symptomatic for Hypotension such as dizziness, weakness, lightheadedness, nauseous, or had a change in mental status from baseline. The Physician stated that if the resident was symptomatic, they would start intravenous (IV) fluids and hold the BP medications if the resident was receiving any. 415.3(e)(2)(ii)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) The facility's policy, titled Pressure Ulcer-Prevention and Care, effective 5/1/2021, documented that aseptic technique is used for all dressing changes unless otherwise ordered. Resident #158 was admitted with diagnoses including left heel unstageable Pressure Ulcer and Metabolic Encephalopathy. The admission Nursing assessment dated [DATE] documented that the resident had an unstageable left heel ulcer and a Stage 3 ulcer to the left lateral lower leg. A physician's order dated 12/3/2021 documented to apply Betadine Topical Solution, one applicator full by topical route once daily to the left heel after cleaning with Normal Saline and pat dry for diagnosis of Pressure Ulcer of left heel. During an observation of Resident #158's left heel wound care, performed by LPN #1, on 12/6/2021 at 10:08 AM LPN #1 placed a barrier under the left leg, removed the existing dressing from the left heel, and allowed the heel to rest directly on the barrier. The left heel was observed with an eschar (dead skin tissue). LPN #1 lifted the left leg and applied Betadine solution to the left heel without first cleansing the heel ulcer with normal saline. LPN #1 was interviewed immediately after the observation and stated cleansing the wound with Normal Saline was not necessary. The Director of Nursing Services (DNS) was interviewed on 12/6/2021 at 11:14 AM and stated that LPN #1 should have cleaned the heel ulcer with Normal Saline as per the physician's order. 415.11(c)(1) Based on observation, record review and interviews during the Recertification Survey and the Abbreviated Survey (Complaint # NY 00255243) completed on 12/9/2021, the facility did not implement a comprehensive person-centered care plan for each resident to meet a resident's medical and nursing needs that are identified in the comprehensive assessment for one (Resident #105) of one resident reviewed for Pain and one (Resident #158) of two residents reviewed for Pressure Ulcers. Specifically, 1) Resident #105 was admitted to the facility on [DATE] and had Physician's Orders to receive Dolophine (Methadone - Opioid Analgesic) for Abdominal Pain. Resident #105 did not receive Methadone until 8/22/2019 (7 days after being ordered). Additionally, Resident #105 did not receive Methadone on 8/27/2019 and 8/28/2019 when the Methadone supply for Resident #105 ran out. 2) On 12/6/2021, during the observation of Resident #158 wound care, Licensed Practical Nurse (LPN) #1 did not cleanse the left heel Pressure Ulcer with Normal Saline (NS) as ordered by the Physician. The findings are: 1) The facility's policy titled Controlled Substances - Ordering dated August 2017 documented that a Physician's Order is obtained for a controlled substance medication after an assessment is completed by a Registered Nurse (RN)/Medical Doctor (MD)/ Nurse Practitioner (NP)/Physician's Assistant (PA). A Physician's Order is entered into the Electronic Medication Administration Record (EMAR) and a written prescription (Rx) is obtained. The prescription is faxed to the pharmacy and the medication is then delivered to the facility. While the medication is in route, the facility may utilize the emergency narcotic medication supply. The facility's policy titled Medication Administration and Documentation-General, last reviewed 8/1/2021, documented that medications are to be administered within a two-hour time frame (i.e. one hour before or after the medication order time). It is the responsibility of the Licensed Nurse to immediately notify the nursing supervisor if medication is unavailable for administration. Resident #105 was admitted to the facility on [DATE] with diagnoses including Malignant Neoplasm of the Bladder and Major Depressive Disorder. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14 which indicated that the resident was cognitively intact. The MDS documented Resident #105 had occasional pain in the last 5 days and rated the worst pain level as a 4 on a scale of 1-10. The Pain Management/Pain Risk Comprehensive Care Plan (CCP) dated 8/16/2019 documented to administer pain medications as ordered by the MD. The Physician's Order dated 8/15/2019 documented to administer Dolophine (Methadone) 10 milligrams (mg) tablet, give 2 tablets (20 mg) by oral route once daily for Unspecified Abdominal Pain. This order was discontinued on 8/17/2019 and a clarification order was requested. The Physician's Order dated 8/17/2019 documented to administer Dolophine (Methadone) 10 mg tablet, give 2 tablets (20 mg) by oral route once daily for Unspecified Abdominal Pain. This order was discontinued on 8/19/2019 and another clarification order was requested. The Physician's Order dated 8/19/2019 documented to administer Dolophine (Methadone) 10 mg tablet, give 2 tablets (20 mg) by oral route once daily for Unspecified Abdominal Pain. This order was discontinued on 9/2/2019 when the resident was discharged to the hospital. The August 2019 EMAR documented the following for Dolophine (Methadone) 10 mg tablet - give 2 tablets (20 mg) by oral route once daily: 8/16/2019 9:00 AM - Awaiting delivery (from the Pharmacy). 8/18/2019 9:00 AM - Awaiting delivery (from the Pharmacy). 8/20/2019 9:00 AM - Awaiting Rx. MD notified. Will administer when available. 8/21/2019 9:00 AM - Awaiting delivery (from the Pharmacy). 8/27/2019 9:00 AM - Awaiting delivery (from the Pharmacy). MD made aware. 8/28/2019 9:00 AM - Awaiting delivery (from the Pharmacy). MD made aware. The Director of Quality from the facility's Pharmacy was interviewed on 12/7/2021 at 9:45 AM and stated that Methadone was not sent to the facility when first ordered because the pharmacy did not receive the required prescription from the ordering Physician. The initial order for Methadone was received by the pharmacy on 8/15/2019. The Pharmacy delivered 10 tablets, a five-day supply, to the facility on 8/22/2019. The Director of Quality from the facility's Pharmacy further stated that a valid eRx was received from the Physician on 8/28/2019 however, the prescription did not include a diagnosis for the medication use. After clarification of the diagnosis on 8/28/2019 60 tablets of Methadone were delivered to the facility on 8/29/2019. The Director of Nursing Services (DNS) was interviewed on 12/7/2021 at 1:45 PM and stated that once an order for a narcotic is put into the facility's EMAR system the Physician is supposed to write the prescription, then the prescription is faxed to the pharmacy, and then the medication is delivered to the facility. The DNS stated the Resident did not receive the pain medication Methadone because the Physician did not sign the required prescription. The facility's Medical Director was interviewed on 12/7/2021 at 3:00 PM and stated that the resident's Physician only worked at the facility for a short period of time The Physician did not come to the facility often, only came at night, and many times you could not get in touch with the Physician. The Medical Director stated that if the facility was unable to reach the resident's Physician, the facility staff could have called them (Medical Director) or called the Pharmacy. The Medical Director then could have called the pharmacy to approve an emergency supply of the medication for a maximum of 5 days. The facility does not carry Methadone in the facility's emergency medication box. The Administrator was interviewed on 12/8/2021 at 11:00 AM and stated that the resident should not have been without Methadone medication for a week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey completed on 12/9/2021 the facility did not ensure that each resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for one (Resident #158) of two residents reviewed for pressure ulcers. Specifically, Resident #158 had an unstageable pressure ulcer to the left heel and had a physician's order to offload the heels. On two separate observations, the heels were not offloaded. Additionally, a wound consult recommended bilateral heel boots on 12/2/2021; however, the care plan and Certified Nursing Assistant (CNA) accountability record were not updated to include the heel boots until 12/6/2021. The finding is: The facility's policy titled Pressure Ulcer-Prevention and Care, effective 5/1/2021, documented that nursing interventions are added as needed to prevent pressure ulcers and to manage treatment; and that nursing interventions include discussing/evaluating, and initiating/implementing interventions with the health care team. Resident #158 was admitted with diagnoses including left heel unstageable Pressure Ulcer and Metabolic Encephalopathy. The admission Nursing assessment dated [DATE] documented that the resident had an unstageable left heel ulcer and a Stage 3 ulcer to the left lateral lower leg. The Braden Scale (a scale to predict pressure sore risk), dated 11/30/2021 documented a score of 9, which equates to very high risk for pressure ulcer development. A physician's order dated 12/1/2021 documented to offload the heels on a pillow when in bed. A Comprehensive Care Plan (CCP) dated 12/1/2021 titled At Risk for Skin Breakdown/Pressure Ulcer included an intervention to offload the heels when in bed by using pillows. Resident #158 was observed in bed on 12/2/2021 at 2:55 PM. CNA #1 pulled back the sheet covering the resident's feet, revealing that the resident's heels were resting on a pillow and not offloaded. The left heel was observed with a dressing in place. On 12/2/2021 at 2:57 PM Licensed Practical Nurse (LPN) #1 observed Resident #158's feet, with the surveyor and CNA #1 present, and stated the resident's heels should be offloaded and not resting on the pillow. LPN #1 then adjusted the pillow under the resident's calves so that the heels were offloaded and not in contact with the pillow. Resident #158 was seen by the wound Physician on 12/2/2021. The wound consult documented an unstageable left heel pressure ulcer measuring 4 centimeters (cm) x 6 cm, with recommendations to apply Betadine, pad, protect, offload wound sites, and use bilateral heel booties. On 12/6/2021 at 8:22 AM Resident #158 was observed in bed having breakfast. CNA #1 was present. The resident's left heel had a heel bootie in place; however, there was no heel bootie on the right foot and the right heel was resting directly on the mattress. There was a pillow under the resident's right calf, but the pillow was not offloading the heel. Resident #158's left heel wound care, performed by LPN #1, was observed on 12/6/2021 at 10:08 AM. The resident had heel boots on both feet. LPN #1 stated they (LPN #1) got a boot for the right foot because the pillows did not seem to be working. The Director of Nursing Services (DNS) was interviewed on 12/6/2021 at 11:14 AM. The DNS stated that offloading means that the heel(s) should not be in direct contact with any surface to prevent friction. The wound care Physician was interviewed on 12/6/2021 at 12:19 PM and stated that offloading means removing all pressure from the heels through the use of pillows or heel boots. The wound care Physician stated if pillows are being used, the heels should be levitating off the pillow. The wound care Physician stated residents often move, so the pillows may have to be repositioned to maintain offloading of the heels. A CCP dated 12/1/2021 titled Presence of Pressure Ulcer: Left Heel, was updated on 12/6/2021 to include a new intervention to use bilateral heel boots when in bed. The primary physician was interviewed on 12/6/2021 at 12:47 PM and stated that the wound care Physician is the expert regarding wound care. If the recommendation is for padding, offloading, heel boots, etc the nursing staff should just do it. CNA #1 was interviewed on 12/6/2021 at 2:14 PM and stated they (CNA #1) were not sure if the heel boots were on the CNA accountability record. CNA #1 stated that they (CNA #1) did not put the heel boots on Resident #158 today. The DNS was re-interviewed on 12/7/2021 at 2:14 PM and stated that when the wound consult was completed on 12/2/2021, the nurses were supposed to read it and ensure the nursing interventions, such as heel boots, were placed on the care plans, CNA accountability record, and on the resident. 415.12(c)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey and the Abbreviated Survey (Complaint # NY 00255243) completed on 12/9/2021, the facility did not ensure that each physician provided orders to meet the resident's care needs timely. This was identified for one (Resident #105) of one resident reviewed for Pain. Specifically, Resident #105 was admitted to the facility on [DATE] and had orders to receive Dolophine (Methadone - Opioid Analgesic) for Abdominal Pain. The medication Methadone was not available in the facility until 8/22/2019 (6 days after the Physician's order) due to a delay in the Pharmacy not receiving a narcotic prescription from the resident's Physician until 8/21/2019. Additionally, Resident #105 was not administered Methadone on 8/27/2019 and 8/28/2019 when the emergency supply of Methadone delivered to the facility on 8/22/2019 ran out and a standing narcotic prescription was needed from the Physician. The finding is: The facility's policy titled Controlled Substances - Ordering dated August 2017 documented that a Physician's Order is obtained for a controlled substance medication after an assessment is completed by a Registered Nurse (RN)/Medical Doctor (MD)/ Nurse Practitioner (NP)/Physician's Assistant (PA). A Physician's Order is entered into the Electronic Medication Administration Record (EMAR) and a written prescription (Rx) is obtained. The prescription is faxed to the pharmacy and the medication is then delivered to the facility. While the medication is in route, the facility may utilize the emergency narcotic medication supply. The facility's policy titled Medication Administration and Documentation - General, last reviewed 8/1/2021, documented that medications are to be administered within a two-hour time frame (i.e. one hour before or after the medication order time). It is the responsibility of the Licensed Nurse to immediately notify the nursing supervisor if medication is unavailable for administration. Resident #105 has diagnoses which include Malignant Neoplasm of the Bladder and Major Depressive Disorder and was admitted to the facility on [DATE]. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14 which indicated that the resident was cognitively intact. The MDS documented the resident had occasional pain in the last 5 days and rated the worst pain level as a 4 on a scale of 1-10. The Pain Management/Pain Risk Comprehensive Care Plan dated 8/16/2019 documented to administer pain medications as ordered by the Medical Doctor (MD). The Physician's Order dated 8/15/2019 documented to administer Dolophine (Methadone) 10 milligrams (mg) tablet, give 2 tablets (20 mg) by oral route once daily for Unspecified Abdominal Pain. This order was discontinued on 8/17/2019 and a clarification order was requested. The Physician's Order dated 8/17/2019 documented to administer Dolophine (Methadone) 10 mg tablet, give 2 tablets (20 mg) by oral route once daily for Unspecified Abdominal Pain. This order was discontinued on 8/19/2019 and another clarification order was requested. The Physician's Order dated 8/19/2019 documented to administer Dolophine (Methadone) 10 mg tablet - give 2 tablets (20 mg) by oral route once daily for Unspecified Abdominal Pain. This order was discontinued on 9/2/2019 when the resident was discharged to the hospital. The August 2019 EMAR documented the following for Dolophine (Methadone) 10 mg tablet - give 2 tablets (20 mg) by oral route once daily: 8/16/2019 9:00 AM - Awaiting delivery (from the Pharmacy). 8/18/2019 9:00 AM - Awaiting delivery (from the Pharmacy). 8/20/2019 9:00 AM - Awaiting Rx. MD notified. Will administer when available. 8/21/2019 9:00 AM - Awaiting delivery (from the Pharmacy). 8/27/2019 9:00 AM - Awaiting delivery (from the Pharmacy). MD made aware. 8/28/2019 9:00 AM - Awaiting delivery (from the Pharmacy). MD made aware. The Director of Quality from the facility's Pharmacy was interviewed on 12/7/2021 at 9:45 AM and provided the following information: On 8/15/2019 at 4:31 PM - A medication order, not a valid prescription, was received by the Pharmacy for Dolophine 10 mg tablet (2 tablets by mouth once daily) with a diagnosis of Abdominal Pain. On 8/17/2019 at 7:07 AM - A facility nurse called and asked the Pharmacy to contact the Prescriber (Physician) for a prescription. On 8/17/2019 at 7:52 AM - The Pharmacist is unable to reach the Physician and left a voicemail. On 8/19/2019 at 9:11 AM and on 8/21/2019 at 9:46 AM - A facility nurse calls and asks the Pharmacy to contact the Physician for a prescription. On 8/21/2019 at 11:11 AM - The Pharmacist reached the Physician and obtained a verbal emergency approval for 10 tablets (a 5-day supply). On 8/22/2019 at 12:27 AM - 10 tablets of Dolophine were delivered to the facility. On 8/28/2019 at 11:51 AM - A valid electronic prescription (eRx) was received from the Physician for 60 tablets of Dolophine, however, the eRx did not include a diagnosis. On 8/28/2019 at 2:26 PM - The Pharmacist clarified the diagnosis as Pain with the Physician. On 8/29/2019 at 12:14 AM - 60 tablets of Dolophine were delivered to the facility. The Director of Quality from the facility's Pharmacy also stated that Dolophine is not a medication that is available from the facility's emergency narcotic medication supply. The Director of Nursing Services (DNS) was interviewed on 12/7/2021 at 1:45 PM and stated that once an order for a narcotic is put into the facility's EMAR system the Physician is supposed to write the prescription, the prescription is faxed to the pharmacy, and then the medication is delivered to the facility. The DNS stated the resident did not receive the pain medication Methadone because the Physician did not sign the required prescription. The facility's Medical Director was interviewed on 12/7/2021 at 3:00 PM and stated that the resident's Physician only worked at the facility for a short period of time. The Physician did not come to the facility often, only came at night, and many times you could not get in touch with the Physician. The Medical Director stated that if the facility was unable to reach the resident's Physician, the facility staff could have called them (Medical Director) or called the Pharmacy. The Medical Director then could have called the pharmacy to approve an emergency supply of the medication for a maximum of 5 days. The facility does not carry Methadone in the facility's emergency medication box. The Medical Director stated that if they (Medical Director) were unable to leave a prescription at the facility, they (Medical Director) could fax the prescription to the pharmacy. The Administrator was interviewed on 12/8/2021 at 11:00 AM and stated that the resident should not have been without the medication for a week. 415.15(b)(1)(i)(ii)