Ellicott Center for Rehabilitation and Nursing
February 7, 2025 Complaint Survey

Standard Health Citations

FF15 483.45(a)(b)(1)-(3):PHARMACY SRVCS/PROCEDURES/PHARMACIST/RECORDS

REGULATION: 483. 45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483. 70(f). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. 483. 45(a) Procedures. A facility must provide 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. 483. 45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who- 483. 45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. 483. 45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and 483. 45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2025
Corrected date: N/A

Citation Details

Based on interview and record review conducted during an Onsite Post Survey Revisit #1 completed on 4/24/2025, the facility did not ensure that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for three (Harbor View, River View, and City View) of four resident units. Specifically, the controlled substance records for the unit shift to shift counts were not consistently signed off as completed. This is a continuing deficiency. The finding is: The policy and procedure titled Controlled Substance Management dated 8/2022 documented that separate records shall be maintained on all controlled substances in the form of a declining inventory record. Such records shall be accurately maintained and shall be reconciled by the incoming and outgoing nurse. Review of the controlled substance book for Harbor View Unit Cart A, there were missing signatures from the incoming and outgoing nurses on 4/19/ 2025. Review of the controlled substance book for River View Unit Cart A, revealed there were missing signatures from the incoming and outgoing nurses on 4/5/2025, 4/17/2025, and 4/22/ 2025. Review of the controlled substance book for River View Unit Cart B, there were missing signatures from the incoming and outgoing nurses on 4/11/2025 and 4/14/ 2025. Review of the controlled substance book for City View Unit Cart B, there were missing signatures from the incoming and outgoing nurses on 4/7/2025, 4/11/2025, and 4/19/ 2025. During an interview on 4/23/2025 at 9:40 AM with Licensed Practical Nurse Nursing Supervisor #1, they stated that the nurses were supposed to sign the controlled substance book after they completed the narcotic count between the incoming and the outgoing nurse. They stated the book should have been signed on those days. During an interview on 4/23/2025 at 10:00 AM with Licensed Practical Nurse Unit Manager #2, they stated that nurses were supposed to sign the controlled substance book when they completed a narcotic drug count for the residents. They said it should have been signed by the nurses. During an interview on 4/23/2025 at 10:10 AM with Licensed Practical Nurse Unit Manager #3, they stated that nurses should count the narcotics and then sign the controlled substance book. They stated that the unit managers were responsible for making sure there were signatures in the book. During an interview on 4/23/2025 at 10:39 AM with the Director of Nursing, they stated that they expected the nurses on the unit to sign the controlled substance book after the narcotics were counted. They stated that they reviewed the controlled substance book every Friday and the controlled substance book should have been corrected. During an interview on 4/24/2025 at 1:36 PM with the Administrator, they stated that they and the Director of Nursing were ultimately responsible for ensuring that the controlled substance books were signed by the nurses. They stated that the unit managers were to monitor the controlled substance books to ensure they were signed by the incoming and outgoing nurses after the narcotic drug count. During an interview on 4/24/25 at 2:40 PM, the Director of Nursing stated that the facility had been cited previously for F755 in the past and that the unit managers need to be auditing the narcotic books on the unit on a daily basis. The Director of Clinical Services was present during the interview and stated that they have noted scattered missing signatures but there was about 60% noted improvement in compliance of staff signatures. The Director of Clinical Services stated that they felt their plan of correction for the F755 effective because there was tremendous improvement but not as fast as they expected. 10 NYCRR 415. 18 (b)(3)

Plan of Correction: ApprovedMay 9, 2025

Step 1: Licensed nurses that failed to sign Narcotic shift to shift counts received written disciplinary memos. DON and Unit Managers with units less than 100% compliance for Narcotics shift to shift counts were counseled by the Director Of Clinical Operations regarding daily follow up of Narcotic ledgers and shift to shift count. No residents were affected by the lack of compliance. All narcotics were reconciled on 4/28/25 with no discrepancies noted. Step 2: A QAPI meeting was held on 4/28/25 to discuss ongoing non-compliance related to Narcotics shift to shift count. All Narcotic ledgers were reviewed for omissions and disciplinary actions issued as indicated. Step 3: Unit Narcotic ledgers will be brought to morning meeting for IDT team review x 4 weeks. Licensed nurses who failed to sign shift to shift count will receive progressive disciplinary action. All licensed nurses will be re-educated regarding Narcotic Management including necessity of shift to shift count. Education will include progressive disciplinary action for nurses failing to follow protocol. Education will include a post test to ensure understanding of information. The policy for Narcotic Management was reviewed by the Director Of Clinical Operations with no revisions required. Step 4: The DON or designee will complete Weekly Narcotics Reconciliation audit of all Unit Narcotics ledgers x 8 weeks. Audits will ensure that all shift to shift counts are completed and will include random observations to verify that shift to shift counts are being completed. Any issues identified will result in disciplinary action. The Pharmacy Consultant was made aware of the facilities plan for compliance and will review audits monthly x 3 months. The results of reviews and audits will be forwarded to the QAPI Committee for review and input.

FF15 483.45(a)(b)(1)-(3):PHARMACY SRVCS/PROCEDURES/PHARMACIST/RECORDS

REGULATION: 483. 45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483. 70(f). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. 483. 45(a) Procedures. A facility must provide 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. 483. 45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who- 483. 45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. 483. 45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and 483. 45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2025
Corrected date: N/A

Citation Details

Based on interview and record review conducted during an Onsite Post Survey Revisit #1 completed on 4/24/2025, the facility did not ensure that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for three (Harbor View, River View, and City View) of four resident units. Specifically, the controlled substance records for the unit shift to shift counts were not consistently signed off as completed. This is a continuing deficiency. The finding is: The policy and procedure titled Controlled Substance Management dated 8/2022 documented that separate records shall be maintained on all controlled substances in the form of a declining inventory record. Such records shall be accurately maintained and shall be reconciled by the incoming and outgoing nurse. Review of the controlled substance book for Harbor View Unit Cart A, there were missing signatures from the incoming and outgoing nurses on 4/19/ 2025. Review of the controlled substance book for River View Unit Cart A, revealed there were missing signatures from the incoming and outgoing nurses on 4/5/2025, 4/17/2025, and 4/22/ 2025. Review of the controlled substance book for River View Unit Cart B, there were missing signatures from the incoming and outgoing nurses on 4/11/2025 and 4/14/ 2025. Review of the controlled substance book for City View Unit Cart B, there were missing signatures from the incoming and outgoing nurses on 4/7/2025, 4/11/2025, and 4/19/ 2025. During an interview on 4/23/2025 at 9:40 AM with Licensed Practical Nurse Nursing Supervisor #1, they stated that the nurses were supposed to sign the controlled substance book after they completed the narcotic count between the incoming and the outgoing nurse. They stated the book should have been signed on those days. During an interview on 4/23/2025 at 10:00 AM with Licensed Practical Nurse Unit Manager #2, they stated that nurses were supposed to sign the controlled substance book when they completed a narcotic drug count for the residents. They said it should have been signed by the nurses. During an interview on 4/23/2025 at 10:10 AM with Licensed Practical Nurse Unit Manager #3, they stated that nurses should count the narcotics and then sign the controlled substance book. They stated that the unit managers were responsible for making sure there were signatures in the book. During an interview on 4/23/2025 at 10:39 AM with the Director of Nursing, they stated that they expected the nurses on the unit to sign the controlled substance book after the narcotics were counted. They stated that they reviewed the controlled substance book every Friday and the controlled substance book should have been corrected. During an interview on 4/24/2025 at 1:36 PM with the Administrator, they stated that they and the Director of Nursing were ultimately responsible for ensuring that the controlled substance books were signed by the nurses. They stated that the unit managers were to monitor the controlled substance books to ensure they were signed by the incoming and outgoing nurses after the narcotic drug count. During an interview on 4/24/25 at 2:40 PM, the Director of Nursing stated that the facility had been cited previously for F755 in the past and that the unit managers need to be auditing the narcotic books on the unit on a daily basis. The Director of Clinical Services was present during the interview and stated that they have noted scattered missing signatures but there was about 60% noted improvement in compliance of staff signatures. The Director of Clinical Services stated that they felt their plan of correction for the F755 effective because there was tremendous improvement but not as fast as they expected. 10 NYCRR 415. 18 (b)(3)

Plan of Correction: ApprovedMay 9, 2025

Step 1: Licensed nurses that failed to sign Narcotic shift to shift counts received written disciplinary memos. DON and Unit Managers with units less than 100% compliance for Narcotics shift to shift counts were counseled by the Director Of Clinical Operations regarding daily follow up of Narcotic ledgers and shift to shift count. No residents were affected by the lack of compliance. All narcotics were reconciled on 4/28/25 with no discrepancies noted. Step 2: A QAPI meeting was held on 4/28/25 to discuss ongoing non-compliance related to Narcotics shift to shift count. All Narcotic ledgers were reviewed for omissions and disciplinary actions issued as indicated. Step 3: Unit Narcotic ledgers will be brought to morning meeting for IDT team review x 4 weeks. Licensed nurses who failed to sign shift to shift count will receive progressive disciplinary action. All licensed nurses will be re-educated regarding Narcotic Management including necessity of shift to shift count. Education will include progressive disciplinary action for nurses failing to follow protocol. Education will include a post test to ensure understanding of information. The policy for Narcotic Management was reviewed by the Director Of Clinical Operations with no revisions required. Step 4: The DON or designee will complete Weekly Narcotics Reconciliation audit of all Unit Narcotics ledgers x 8 weeks. Audits will ensure that all shift to shift counts are completed and will include random observations to verify that shift to shift counts are being completed. Any issues identified will result in disciplinary action. The Pharmacy Consultant was made aware of the facilities plan for compliance and will review audits monthly x 3 months. The results of reviews and audits will be forwarded to the QAPI Committee for review and input.