Alice Hyde Medical Center

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Nursing #1 stated Resident #7 is alert, confused at baseline and can be territorial or sometimes argumentative with other residents. Director of Nursing #1 said the Resident #7 was care planned to be toileted every two hours sometimes around the time of the incident due to the resident becoming incontinent. After the incident occurred, Director of Nursing #1 was notified and educated Certified Nurse Aide #5 on toileting residents every two hours. There was no facility wide education at the time. Additionally, Certified Nurse Aide #5 had never had any complaints regarding resident care by residents or colleagues.

Minimum Data Set Coordinator #1 was on call the date of incident who reported to the Department of Health. The facility investigation, dated 4/24/2025, documented that Resident #7 was found to have some bruising that was attributed to a fall that was unwitnessed. Due to Resident #7's incontinence and inability to follow direction, Resident #7 was placed on every 2-hour continence checks. In the investigation of the bruises noted on the resident's arm on 4/19/2025, Certified Nurse Aide #5 admitted that they did not wake Resident #7 up to be toileted as care planned. Resident #105 Resident #105 was admitted to the facility with the diagnoses of vascular dementia, unspecified severity, with agitation (a decline of thinking skills from condition that damage blood vessels), Alzheimer's disease, unspecified (a progressive brain disorder that slowly destroys memory) and ventricular premature depolarization (type of abnormal heart rhythm that originates from the ventricles of the heart). The Minimum Data Set, dated [DATE REDACTED], documented the resident was usually understood, sometimes understand others and was severely cognitively impaired. The comprehensive care plan for Activities of Daily Living dated 8/06/2024, documented that the resident required assistance with activities of daily living. Interventions include: assistance of two (2) persons, do not leave alone, dependent on care for bathing, bed mobility, dressing and toileting. For transfers, Resident #105 was documented as requiring the assistance of two (2) persons, dependent with gait belt and stand aid. The facility investigation dated 7/06/2024 documented that on 5/31/2024, Resident #105 was transferred to the bathroom by Certified Nurse Aide #6. Resident #105 did not follow directions of Certified Nurse Aide #6, and due to improper body mechanics, Certified Nurse Aide #6 had to lower Resident #105 to the floor. The physical therapy note dated 6/03/2024 at 4:37 PM, documented that the resident had no change in function or signs of abuse after the fall. The resident was care planned for two-person assistance for transfers with mechanical lift, and Certified Nurse Aide #6 did not follow the care plan. Resident #119 Resident #119 was admitted to the facility with the diagnoses of Parkinson's disease without dyskinesia, without mention of fluctuations (progressive neurological disorder that primarily affected?movement where

the patient does not experience involuntary movements (dyskinesia), unspecified dementia, unspecified severity, with agitation (a condition characterized by a decline in cognitive function) and Alzheimer's disease. The Minimum Data Set, dated [DATE REDACTED], documented that the resident was usually able to be understood but rarely to never understand others with severe cognitive impairment. The comprehensive care plan for Falls, dated 8/05/2021, documented the resident was at high risk for falls related to confusion, weakness, hypertension, Parkinson's and needed assistance with ambulation. Interventions include: maintaining a safe environment by ensuring the floor was free from clutter and lighting was adequate; documented as of 3/08/2024 the use of a bed alarm. A care plan note dated 8/24/2024 at 5:10 AM, documented the resident was found on the floor next to their bed, and a bed alarm was not present on the bed. Certified Nurse Aide #7 did not follow the care plan after putting Resident #119 back to bed by not putting the bed alarm in place. New York Codes, Rules, and Regulations Title 10 S 415.4 (b)(1)(i)

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Alice Hyde Medical Center

45 Sixth Street Malone, NY 12953

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

tell you their name if asked what it was. During an interview on 12/18/2025 at 11:32 AM, Registered Nurse #2 stated they completed all the accident and incident reports at the facility. They stated Licensed Practical Nurse #2 gave Resident #46 another resident's medications. It was a significant medication error, and the nurse was terminated. They stated, they tried to complete counseling and education for medication errors, but some errors could not be ignored such as giving medication to the incorrect resident. They did not want their residents harmed there. Registered Nurse #2 further stated the facility provided medication administration education upon hire and annually. During an interview on 12/19/2025 at 10:02 PM, Director of Nursing #1 stated on 5/14/2024 at 5:30 PM, Licensed Practical Nurse #2 popped all of the medications, gave the medications outside the window of time they were ordered, and gave them to the wrong resident.

They stated Licensed Practical Nurse #2 was suspended during the investigation and then terminated related to the event on 5/16/2024. Director of Nursing #1 stated once Licensed Practical Nurse #2 realized

they had administered the medications to the wrong resident, they immediately reported it to the Registered Nurse, Resident #46 was assessed, and the Medical Provider and family were notified. The Medical Provider gave new orders and Resident #46 was put on 15- minute checks for additional safety. Director of Nursing #1 stated they believed a house wide education on medication administration was completed. They also completed a root cause analysis and reported the medication error to the Chief Nursing Officer who reported it to New York State Board of Education. They further stated medication audits were completed which included the 5 Rights to Medication Administration and the audits were reviewed at the Quality Assurance Performance Improvement Committee. Director of Nursing #1 stated they were still completing medication audits. Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement at the time of this survey: Upon discovery of the medication error, a Registered Nurse assessment was completed immediately. The medication error was reported to the resident's representative and the physician with new orders obtained. The Licensed Practical Nurse who was responsible for the medication error was suspended during the investigation and later terminated. The Board of Education was notified of the nurse's error. The medication error was reported to the New York State Department of Health Medication Administration education was initiated on 7/09/2024 to all nursing staff including Licensed Practical Nurses and Registered Nurses on the Medication Administration policy and procedure, the 6 (six) rights, and documentation. Education was completed on 12/12/2024. For Quality Assurance, medication administration audits were initiated and reviewed monthly. Medication administration audits were still being conducted at time of survey. 10 New York Codes, Rules, and Regulation 415.12(m)(2)

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