On September 27, 2019 a
Exhibit,Appendix
was filed
involving a dispute between
Michelle Perez
As The Proposed Administrator Of The Estate Of Grace Johnson, Deceased,
and
Dr. Caron Beth Rockman M.D.,
Nyu Langone Health System,
Nyu Vascular & Endovascular Surgery Associates,
Villagecare Rehabilitation And Nursing Center,
Village Center For Care D B A Villagecare Rehabilitation And Nursing Center,
Village For Care,
Visiting Nurse Service Of New York Home Care Ii D B A Visiting Nurse Service Of New York Home Care,
Vns Choice,
for Torts - Other (PHL2801-d&2803-c Med Mal)
in the District Court of New York County.
Preview
FILED: NEW YORK COUNTY CLERK 03/12/2024 11:25 AM INDEX NO. 159471/2019
NYSCEF DOC. NO. 114 RECEIVED NYSCEF: 03/12/2024
Controlled Substance Accountability Record
NURSES' NURSES' SIGNATURE
SIGNATURE
AMT OUT DATE SHw1 AMT IN AMT OUT
DATE SHIFT AMT IN
D D
e D D
D D
D D
E E
N N
/,
D D
/
D
E
1 p
) D
E
N N
D D
(O D D
10 I N
D
'
5 i
'
N
D ___
_ _
' __N
N ____ ___________
D D _________ __ _
E E
N N
D D
N N
D D
FILED: NEW YORK COUNTY CLERK 03/12/2024 11:25 AM INDEX NO. 159471/2019
NYSCEF DOC. NO. 114 RECEIVED NYSCEF: 03/12/2024
3OHNSON, GRACE 9
AME VCVN/ÆTH FL/602 P G i°g
onzw
FAd FüCf-E< NON-REr0KNABLE
.M# PHYSICIAN HynROMORPHON TAB 8MG 30 TABS
; DIL AUDID
St
a white , round, 54 425 10/07/16
DRUG DOSAGE 3 GIVE 1 TABLET (8 MG)
ROUTE FREQUENCY BY ORAL ROUTE EVERY
4 HOURS PATIENT MAY CONTROL L ED
AMOUNT RECEIVED REFUSE
RX#
useeuARsornvAReToREORDER
¤F"'" """ "^
RX DATE:
-
?",!¤¤s_2s
NEW ORDER ax #: z312143
RECEIVED BY RN: Refi11 on: 10/10/16 al7dis o
SECOND
NURSE DATE
DATE HOUR DOSAGE AMOUNT ADMINISTERED
BY AMOUNT AMOUNT ADMINISTERED
BY AMOUNT
USED (SIGNATURE) REMAINING DAM HOM WAGE
USED (SIGNATURE) REMAINING
UNUSED PORTIONS OF NARCOTIC PRESCRIPTIONS RETURNED TO (CHECK ONE):
RESIDENT (UPON ADVICE OF PHYSICIAN) ODESTROYED
REIDENT'S SIGNATURE RN SIGNATURE
RETURNED TO NURSING OFFICE DATE
FILED: NEW YORK COUNTY CLERK 03/12/2024 11:25 AM INDEX NO. 159471/2019
NYSCEF DOC. NO. 114 Controlled Substance Record RECEIVED NYSCEF: 03/12/2024
Accountability
DATE SH.IFT AMT N AMT OUT DATE S AMT lÑ AMT OUT
D & D
N N
D D
...
E E
N _ N_
D D
E E
E E
E E
N
D D
E E
.. N
D D
E E
N N
D D
..
N N
D D
N N
D D
E E
D
E E
N N
D D
E E
N N
E E
N N
____ D D ____
N N
D D
FILED: NEW YORK COUNTY CLERK 03/12/2024 11:25 AM INDEX NO. 159471/2019
NYSCEF DOC. NO. 114 RECEIVED NYSCEF: 03/12/2024
NAME
C x fãNYL DIS iÔ6Mt 7H1 T T
RM# PHYSICIAN r sub ror: DURAGESK .
ColorleSS "acr=m'ular, FENTANYL SYSTEM, D§0
TRANSDERMA& 1 16
A CH G00
Ruc FENTANYL DOSAGE
r. ;UTE FREQUENCY ys
DAU DOS
AMOUNT RECEIVED
TOREORDER
SOFTWARE
USEEMAR
Ref l on 1 /2 /16 RR L : O
RECEIVED BY RN: ,
SECOND
NURSE DATE
REMOVALNURSE'
S CO"SIGN NURSE's
REMOVAL DATE
AMOUNT ADMINISTERED
BY AMOUNT
DATE HOUR DOSAGE REMAINING SIGNATURE SIGNATURE REMOVED
USED (SIGNATURE)
UNUSED PORTIONS OF NARCOTIC PRESCRIPTIONS RETURNED TO (CHECK ONE):
ORESIDENT (UPON ADVICE OF PHYSICIAN) ODESTROYED
REIDENT'S SIGNATURE RN SIGNATURE
RETURNED TO NURSING OFFICE DATE PAGE#
FILED: NEW YORK COUNTY CLERK 03/12/2024 11:25 AM INDEX NO. 159471/2019
to be witnessed
Control two Charge Nurses at all times.
NYSCEF Inventory
DOC. NO. 114 by RECEIVED NYSCEF: 03/12/2024
NURSES' SIGNATURE ES 5*GNA
SHIFT AMT OUT DATE SHIIT AMT IN AMT OUT
D AMT IN
D D
o W N N
D D
Akiy ').. E
/ (o E
'l/ N 1A N
fo
D u/ A600f D
D D
N N
D D
E E
_
N N
D D
_
E
_
E
N _________
E E
N N
D D
E E
N N
.___._____ D
N N
D D
E E
N N
D D
E E
FILED: NEW YORK COUNTY CLERK 03/12/2024 11:25 AM INDEX NO. 159471/2019
NYSCEF DOC. NO. 114 RECEIVED NYSCEF: 03/12/2024
JB}lNSON, GRACE 5P
VCRE/6TH FL/602 P ome
NAME FACI/FACI-B NON-RETURNABLE
= FENTANYL DIS 100MCG/H 3 PT72
T# PHYSICIAN r sub ror: DURAG E5IC
colorb mgular, FENTANYLTRANSDERMAI SYSTEM, 1020;tRh/16
A
DRUG FENTANYL DOSAGE B
SROUTE
ROUTE FREQUENCY CONTROLLED
RERY
MAXIMUM DAILY DOSE: RECORD
AMOUNT RECEIVED 1 PATCH/72 HOURS
USEEMAR80mVARE70REORDER
" !¤!nbw Name:E. M EAMNA
as
NEW ORDER ax ,: z26ts74
Refill on: 10/08/16 °r : o
RECEIVED BY RN:
SECOND
NURSE PDATF
DATE HOUR AMOUNT ADMINISTERED
BY AMOUNT REMOVALNURSE's CO-SIGN
REMOVAL
NURSE'S DATE
DOSAGE REMAINING SIGNATURE SIGNATURE REMOVED
USED (SIGNATURE)
UNUSED PORTIONS OF NARCOTIC PRESCRIPTIONS RETURNED TO (CHECK ONE):
ORESIDENT (UPON ADVICE OF PHYSICIAN) ODESTE0YED
TIDENT'S SIGNATURE RN SIGNATURE
RETURNED TO NURSING OFFICE DATE PAGE#
FILED: NEW YORK COUNTY CLERK 03/12/2024 11:25 AM INDEX NO. 159471/2019
NYSCEF DOC. NO. 114 RECEIVED NYSCEF: 03/12/2024
NURSES' NURSES' SIGNATURE
SIGNATURE
DATE . SillFT AMT . IN AMT OUT )ATE $ÈIFT -AMT. 7 INd.½ f AMT OUT
E E
N N
D D
E E
N N
D D
E E
N N .
D D
E E
N N
D D
E E
N N
D D ¡
N N
D D
E E
N N
D D
N N
D D
E E
N N
D D
E E
... N N
D D
E E
D D
E E
N N
. ...D D
E E
N N
D D
E E
N N
D D
FILED: NEW YORK COUNTY CLERK 03/12/2024 11:25 AM INDEX NO. 159471/2019
NYSCEF DOC. NO. 114 RECEIVED NYSCEF: 03/12/2024
NAME . . .
RM# PHYSICIAN
DRUG . DOSAGE
ROUTE w< AFREQUENCY O
AMOUNT RECEIVED 2 44
RX DATE:
RECBVED BY RN
SECÓND
NURSE . DATE
AMOUNT ADMINISTERED
BY AMOUNT- BÇÜR
AMOUNT ADMINISTERED
BY AMOUNT
DATE H UR DOSAE DATE DOSAGE USED .
USED {SIGNATURE) REMAINING {SIGNATURE) REMINING
bNUSED PORTIONS OF NARCOTIC PRESCRIPLONS RETURNED TO [CHECK O E
ORESIDENT (UPON ADVICE OF PHYSICIAN}j ODESTRDYED
______-,------- .---------- - ----.
REIDENT'S SIGNATURE RN SIGNATURE
FILED: NEW YORK COUNTY CLERK 03/12/2024 11:25 AM INDEX NO. 159471/2019
NYSCEF DOC. NO. 114 RECEIVED NYSCEF: 03/12/2024
Controlled Substance Accountability Record
NURSES' NURSES$
SIGNATURE SIGNATURE
D D
D D
N
D / C D
o D D
N N
D D
E
N . N
D D
N N
D D
N . N
D D
E E .
FILED: NEW YORK COUNTY CLERK 03/12/2024 11:25 AM INDEX NO. 159471/2019
NYSCEF DOC. NO. 114 RECEIVED NYSCEF: 03/12/2024
JAMg
OHNSON, GRACE 2P
RM# VCRN/BTH FL/602 P liCWGwAN oarve
PHYSICIAN
FACF/FACI-B NON-RETURNABLE Ï1s o
DRUG
DOSAGE
sHu FO IL DI
ROUTE whito , round, 54 425
FREQUE NCY 09/29/16
GIVE 1 TABLET (8 MG)
I BY ORAL ROUTE EVERY
AMOUNT RECNVED
4 HOURS PATIENT MAY
ax#. REI-USE CONTROL L ED
RX DATE:
USEEMAR SOFTWARE TOREORDER
RECEIVED BY RN' est-w4ao
°°°" °²"*
er.sce L. a..le: E. DELA PENA
NEW ORDER "" ""
Rx #: 7247097
SE Refi 17 on: 10/02/16
o
NURSE
DATE
DATE HOUR DOSAGE
DATE HOUR DOSAGE
USED
O |
SED PORTIONS OF NA COTIC PRESCRIPT ONS RETURNED TO [CHECK 0NE)¼
.SIDENT {UPON ADVICE OF
PHYSICIAN) ODESTROYED
EIDENT's SIGNATURE
RN SIGNATURE
FILED: NEW YORK COUNTY CLERK 03/12/2024 11:25 AM INDEX NO. 159471/2019
NYSCEF DOC. NO. 114 RECEIVED NYSCEF: 03/12/2024
Controlled Substance Accountability Record
NURSES' NURSES'
SIGNATURE SIGNATURE
T 4SMFT AMT NEEE ANTi T$VEBUTS$ /¾b#lM PT$Ull! 9ANT{. NEd¾§ iMM bU
N N
D_...... D
D D
, D D
0 E E
( N N
D D
D CL D -
N N
D D .
h E E
N N
D D
N N
N N
D D
E E
N N
D D
E E
N N
D . D
D D d
N . N
D D
E . E
N
D D
E
n D
FILED: NEW YORK COUNTY CLERK 03/12/2024 11:25 AM INDEX NO. 159471/2019
NYSCEF DOC. NO. 114 RECEIVED NYSCEF: 03/12/2024
H FLfbut P ause
NAME ETURNABLE o
RM# PHYSICIAN . . .. OXYCODONE TAB 10MG ER 30 T12 A
5ub FOr: OXYCONT TN 10MG
dite· rou"d· ". 10 09/24/16
RUG DOSAGE
GIVE 1 TABLET (10 MG)
- ROUTE BY ORAL ROUTE EVERY
FREQUENCY MAXIMUM
12 HOURS CONTROL L ED
" DAILY DOSE: 2 TABLETS
AMOUNT RECNVED RECORD
RX#. USEEMARSOFTWARETOREORDER
us, .scrio.r no.. ,,. cna .,.rs,
RX DATE:
Ref 1 on 1 /O /16 o
SECOND
NURSE
DA H /R DOEAGE AMOUNT ADMINISŠTREDBY AMOUNT AMOUNT ADMINISTEREDBY
USED [SIGNATURE) REMAUMG DATE HOUR DOSAGE
USED . (SIGNA*IURE)
AMOUNT
. REMAINING
UNUSED PORTIONS OF NARCOTIC PRESCRIPT ONS RETURNED TO (CHECK ONE)i
ESIDENT (UPON ADVICE OF PHYSICIAN) ODESTROYED
REIDENT'S SIGNATURE PJi SIGNATUPJ3
FILED: NEW YORK COUNTY CLERK 03/12/2024 11:25 AM INDEX NO. 159471/2019
NYSCEF DOC. NO. 114 RECEIVED NYSCEF: 03/12/2024
Controlled Substance Accountability Record
NURSES' NURSES'
SIGNATURE SIGNATURE
D D
Z O 10 Nr \ y$
f
fLUdb . _ .
N )- (JA /At A t | LAA.t 2A N
d f
D ((9 p p / D
N A5 c N
D '.) D
E
N \ 'f ;;4-t 7 N
D 2 7 1 D .
D D .
E E
b )
D . D
E E
D
lL(
| N
D
O ) ;(A-t ( N N
D
·
{ i
E '? ] E
N N
D D
E E
N N
D D
E E
N N
D D
FILED: NEW YORK COUNTY CLERK 03/12/2024 11:25 AM INDEX NO. 159471/2019
NYSCEF DOC. NO. 114 RECEIVED NYSCEF: 03/12/2024
30NNSÛk,-!E
NAME
xdT BTH FL/602 P e s arve
FACT/FACI-B NON-RETURNASLE I'sÎ,
RM# PHYSICIAN ..
DR
DRUG DOSAGE ORPA D
10/04/16
white, round, 54 425
ROUTE GIVE 1 TABLET (8 MG)
FREQUENCY
BY ORAL ROUTE EVERY
RMOUNT RECMVED 4 HOURS MAXIMUM CONTROLLED
DAILY DOSE = 6TABS/
CAPS PATIENT MAY RECORD
RX#s
REFUSE
usEEmansomVARE
TOREORDER
RX DATE:
RECUVED BY RN: . NEW ORDER a ,: 72 3 7
' 16 0
Refi 71 on :
SEC
NURSE DATE
·-
DATE H0 DOSAGE AMOUNT ADMINISTERED
BY AMOUNT
DATE BOUR DOSAGE AMOUNT ADMINISTERED
BY AMOUNT
USED . (SGNA g
UNUSED PORTIONS OF NARCOTIC PRESCRIPT ONS RETURNED TO (CHECKONE)i
ORESIDENT [UPON ADVICE OF PHYSICIAN) ¡DESTROYED
REIDENT'S SIGNATURE RNSIGNATURE
FILED: NEW YORK COUNTY CLERK 03/12/2024 11:25 AM INDEX NO. 159471/2019
NYSCEF DOC. NO. 114 RECEIVED NYSCEF: 03/12/2024
Controlled Substance AccountabilityRecord
NURSES' NURSES'
SIGNATURE SIGNATURE
TEü4SMFT . IV[T M EdN%%iiOWlMTT ETEDUTS Dat 5 B inMT T2@MNMM MMGM 4M$i% ÚTM
N N
D D
o !(a 84
D /f) D
E 00 . E
o N 8 N
p
D .
N N.
D D .
E E
N N
D D
D D
N N
E
N N
D . . D
E
E E
N . . N
D D
E E . .
FILED: NEW YORK COUNTY CLERK 03/12/2024 11:25 AM INDEX NO. 159471/2019
NYSCEF DOC. NO. 114 RECEIVED NYSCEF: 03/12/2024
VILLAGECARE REHABILITATION AND NURSING CENTER
214 West Houston Street, New York, ... 10014
Tel. 212-337-9400 Fax 212-645-9209
Notice of Medicare Non-Coverage
Patient name: GRACE JOHNSON Patient number:
Of
The Effective Date Coverage of Your Current Skilled Nursing Facility (SNF)
Services Will
Document Filed Date
March 12, 2024
Case Filing Date
September 27, 2019
Category
Torts - Other (PHL2801-d&2803-c Med Mal)
For full print and download access, please subscribe at https://www.trellis.law/.
Preview
FILED: NEW YORK COUNTY CLERK 03/12/2024 11:25 AM INDEX NO. 159471/2019 NYSCEF DOC. NO. 114 RECEIVED NYSCEF: 03/12/2024 Controlled Substance Accountability Record NURSES' NURSES' SIGNATURE SIGNATURE AMT OUT DATE SHw1 AMT IN AMT OUT DATE SHIFT AMT IN D D e D D D D D D E E N N /, D D / D E 1 p ) D E N N D D (O D D 10 I N D ' 5 i ' N D ___ _ _ ' __N N ____ ___________ D D _________ __ _ E E N N D D N N D D FILED: NEW YORK COUNTY CLERK 03/12/2024 11:25 AM INDEX NO. 159471/2019 NYSCEF DOC. NO. 114 RECEIVED NYSCEF: 03/12/2024 3OHNSON, GRACE 9 AME VCVN/ÆTH FL/602 P G i°g onzw FAd FüCf-E< NON-REr0KNABLE .M# PHYSICIAN HynROMORPHON TAB 8MG 30 TABS ; DIL AUDID St a white , round, 54 425 10/07/16 DRUG DOSAGE 3 GIVE 1 TABLET (8 MG) ROUTE FREQUENCY BY ORAL ROUTE EVERY 4 HOURS PATIENT MAY CONTROL L ED AMOUNT RECEIVED REFUSE RX# useeuARsornvAReToREORDER ¤F"'" """ "^ RX DATE: - ?",!¤¤s_2s NEW ORDER ax #: z312143 RECEIVED BY RN: Refi11 on: 10/10/16 al7dis o SECOND NURSE DATE DATE HOUR DOSAGE AMOUNT ADMINISTERED BY AMOUNT AMOUNT ADMINISTERED BY AMOUNT USED (SIGNATURE) REMAINING DAM HOM WAGE USED (SIGNATURE) REMAINING UNUSED PORTIONS OF NARCOTIC PRESCRIPTIONS RETURNED TO (CHECK ONE): RESIDENT (UPON ADVICE OF PHYSICIAN) ODESTROYED REIDENT'S SIGNATURE RN SIGNATURE RETURNED TO NURSING OFFICE DATE FILED: NEW YORK COUNTY CLERK 03/12/2024 11:25 AM INDEX NO. 159471/2019 NYSCEF DOC. NO. 114 Controlled Substance Record RECEIVED NYSCEF: 03/12/2024 Accountability DATE SH.IFT AMT N AMT OUT DATE S AMT lÑ AMT OUT D & D N N D D ... E E N _ N_ D D E E E E E E N D D E E .. N D D E E N N D D .. N N D D N N D D E E D E E N N D D E E N N E E N N ____ D D ____ N N D D FILED: NEW YORK COUNTY CLERK 03/12/2024 11:25 AM INDEX NO. 159471/2019 NYSCEF DOC. NO. 114 RECEIVED NYSCEF: 03/12/2024 NAME C x fãNYL DIS iÔ6Mt 7H1 T T RM# PHYSICIAN r sub ror: DURAGESK . ColorleSS "acr=m'ular, FENTANYL SYSTEM, D§0 TRANSDERMA& 1 16 A CH G00 Ruc FENTANYL DOSAGE r. ;UTE FREQUENCY ys DAU DOS AMOUNT RECEIVED TOREORDER SOFTWARE USEEMAR Ref l on 1 /2 /16 RR L : O RECEIVED BY RN: , SECOND NURSE DATE REMOVALNURSE' S CO"SIGN NURSE's REMOVAL DATE AMOUNT ADMINISTERED BY AMOUNT DATE HOUR DOSAGE REMAINING SIGNATURE SIGNATURE REMOVED USED (SIGNATURE) UNUSED PORTIONS OF NARCOTIC PRESCRIPTIONS RETURNED TO (CHECK ONE): ORESIDENT (UPON ADVICE OF PHYSICIAN) ODESTROYED REIDENT'S SIGNATURE RN SIGNATURE RETURNED TO NURSING OFFICE DATE PAGE# FILED: NEW YORK COUNTY CLERK 03/12/2024 11:25 AM INDEX NO. 159471/2019 to be witnessed Control two Charge Nurses at all times. NYSCEF Inventory DOC. NO. 114 by RECEIVED NYSCEF: 03/12/2024 NURSES' SIGNATURE ES 5*GNA SHIFT AMT OUT DATE SHIIT AMT IN AMT OUT D AMT IN D D o W N N D D Akiy ').. E / (o E 'l/ N 1A N fo D u/ A600f D D D N N D D E E _ N N D D _ E _ E N _________ E E N N D D E E N N .___._____ D N N D D E E N N D D E E FILED: NEW YORK COUNTY CLERK 03/12/2024 11:25 AM INDEX NO. 159471/2019 NYSCEF DOC. NO. 114 RECEIVED NYSCEF: 03/12/2024 JB}lNSON, GRACE 5P VCRE/6TH FL/602 P ome NAME FACI/FACI-B NON-RETURNABLE = FENTANYL DIS 100MCG/H 3 PT72 T# PHYSICIAN r sub ror: DURAG E5IC colorb mgular, FENTANYLTRANSDERMAI SYSTEM, 1020;tRh/16 A DRUG FENTANYL DOSAGE B SROUTE ROUTE FREQUENCY CONTROLLED RERY MAXIMUM DAILY DOSE: RECORD AMOUNT RECEIVED 1 PATCH/72 HOURS USEEMAR80mVARE70REORDER " !¤!nbw Name:E. M EAMNA as NEW ORDER ax ,: z26ts74 Refill on: 10/08/16 °r : o RECEIVED BY RN: SECOND NURSE PDATF DATE HOUR AMOUNT ADMINISTERED BY AMOUNT REMOVALNURSE's CO-SIGN REMOVAL NURSE'S DATE DOSAGE REMAINING SIGNATURE SIGNATURE REMOVED USED (SIGNATURE) UNUSED PORTIONS OF NARCOTIC PRESCRIPTIONS RETURNED TO (CHECK ONE): ORESIDENT (UPON ADVICE OF PHYSICIAN) ODESTE0YED TIDENT'S SIGNATURE RN SIGNATURE RETURNED TO NURSING OFFICE DATE PAGE# FILED: NEW YORK COUNTY CLERK 03/12/2024 11:25 AM INDEX NO. 159471/2019 NYSCEF DOC. NO. 114 RECEIVED NYSCEF: 03/12/2024 NURSES' NURSES' SIGNATURE SIGNATURE DATE . SillFT AMT . IN AMT OUT )ATE $ÈIFT -AMT. 7 INd.½ f AMT OUT E E N N D D E E N N D D E E N N . D D E E N N D D E E N N D D ¡ N N D D E E N N D D N N D D E E N N D D E E ... N N D D E E D D E E N N . ...D D E E N N D D E E N N D D FILED: NEW YORK COUNTY CLERK 03/12/2024 11:25 AM INDEX NO. 159471/2019 NYSCEF DOC. NO. 114 RECEIVED NYSCEF: 03/12/2024 NAME . . . RM# PHYSICIAN DRUG . DOSAGE ROUTE w< AFREQUENCY O AMOUNT RECEIVED 2 44 RX DATE: RECBVED BY RN SECÓND NURSE . DATE AMOUNT ADMINISTERED BY AMOUNT- BÇÜR AMOUNT ADMINISTERED BY AMOUNT DATE H UR DOSAE DATE DOSAGE USED . USED {SIGNATURE) REMAINING {SIGNATURE) REMINING bNUSED PORTIONS OF NARCOTIC PRESCRIPLONS RETURNED TO [CHECK O E ORESIDENT (UPON ADVICE OF PHYSICIAN}j ODESTRDYED ______-,------- .---------- - ----. REIDENT'S SIGNATURE RN SIGNATURE FILED: NEW YORK COUNTY CLERK 03/12/2024 11:25 AM INDEX NO. 159471/2019 NYSCEF DOC. NO. 114 RECEIVED NYSCEF: 03/12/2024 Controlled Substance Accountability Record NURSES' NURSES$ SIGNATURE SIGNATURE D D D D N D / C D o D D N N D D E N . N D D N N D D N . N D D E E . FILED: NEW YORK COUNTY CLERK 03/12/2024 11:25 AM INDEX NO. 159471/2019 NYSCEF DOC. NO. 114 RECEIVED NYSCEF: 03/12/2024 JAMg OHNSON, GRACE 2P RM# VCRN/BTH FL/602 P liCWGwAN oarve PHYSICIAN FACF/FACI-B NON-RETURNABLE Ï1s o DRUG DOSAGE sHu FO IL DI ROUTE whito , round, 54 425 FREQUE NCY 09/29/16 GIVE 1 TABLET (8 MG) I BY ORAL ROUTE EVERY AMOUNT RECNVED 4 HOURS PATIENT MAY ax#. REI-USE CONTROL L ED RX DATE: USEEMAR SOFTWARE TOREORDER RECEIVED BY RN' est-w4ao °°°" °²"* er.sce L. a..le: E. DELA PENA NEW ORDER "" "" Rx #: 7247097 SE Refi 17 on: 10/02/16 o NURSE DATE DATE HOUR DOSAGE DATE HOUR DOSAGE USED O | SED PORTIONS OF NA COTIC PRESCRIPT ONS RETURNED TO [CHECK 0NE)¼ .SIDENT {UPON ADVICE OF PHYSICIAN) ODESTROYED EIDENT's SIGNATURE RN SIGNATURE FILED: NEW YORK COUNTY CLERK 03/12/2024 11:25 AM INDEX NO. 159471/2019 NYSCEF DOC. NO. 114 RECEIVED NYSCEF: 03/12/2024 Controlled Substance Accountability Record NURSES' NURSES' SIGNATURE SIGNATURE T 4SMFT AMT NEEE ANTi T$VEBUTS$ /¾b#lM PT$Ull! 9ANT{. NEd¾§ iMM bU N N D_...... D D D , D D 0 E E ( N N D D D CL D - N N D D . h E E N N D D N N N N D D E E N N D D E E N N D . D D D d N . N D D E . E N D D E n D FILED: NEW YORK COUNTY CLERK 03/12/2024 11:25 AM INDEX NO. 159471/2019 NYSCEF DOC. NO. 114 RECEIVED NYSCEF: 03/12/2024 H FLfbut P ause NAME ETURNABLE o RM# PHYSICIAN . . .. OXYCODONE TAB 10MG ER 30 T12 A 5ub FOr: OXYCONT TN 10MG dite· rou"d· ". 10 09/24/16 RUG DOSAGE GIVE 1 TABLET (10 MG) - ROUTE BY ORAL ROUTE EVERY FREQUENCY MAXIMUM 12 HOURS CONTROL L ED " DAILY DOSE: 2 TABLETS AMOUNT RECNVED RECORD RX#. USEEMARSOFTWARETOREORDER us, .scrio.r no.. ,,. cna .,.rs, RX DATE: Ref 1 on 1 /O /16 o SECOND NURSE DA H /R DOEAGE AMOUNT ADMINISŠTREDBY AMOUNT AMOUNT ADMINISTEREDBY USED [SIGNATURE) REMAUMG DATE HOUR DOSAGE USED . (SIGNA*IURE) AMOUNT . REMAINING UNUSED PORTIONS OF NARCOTIC PRESCRIPT ONS RETURNED TO (CHECK ONE)i ESIDENT (UPON ADVICE OF PHYSICIAN) ODESTROYED REIDENT'S SIGNATURE PJi SIGNATUPJ3 FILED: NEW YORK COUNTY CLERK 03/12/2024 11:25 AM INDEX NO. 159471/2019 NYSCEF DOC. NO. 114 RECEIVED NYSCEF: 03/12/2024 Controlled Substance Accountability Record NURSES' NURSES' SIGNATURE SIGNATURE D D Z O 10 Nr \ y$ f fLUdb . _ . N )- (JA /At A t | LAA.t 2A N d f D ((9 p p / D N A5 c N D '.) D E N \ 'f ;;4-t 7 N D 2 7 1 D . D D . E E b ) D . D E E D lL( | N D O ) ;(A-t ( N N D · { i E '? ] E N N D D E E N N D D E E N N D D FILED: NEW YORK COUNTY CLERK 03/12/2024 11:25 AM INDEX NO. 159471/2019 NYSCEF DOC. NO. 114 RECEIVED NYSCEF: 03/12/2024 30NNSÛk,-!E NAME xdT BTH FL/602 P e s arve FACT/FACI-B NON-RETURNASLE I'sÎ, RM# PHYSICIAN .. DR DRUG DOSAGE ORPA D 10/04/16 white, round, 54 425 ROUTE GIVE 1 TABLET (8 MG) FREQUENCY BY ORAL ROUTE EVERY RMOUNT RECMVED 4 HOURS MAXIMUM CONTROLLED DAILY DOSE = 6TABS/ CAPS PATIENT MAY RECORD RX#s REFUSE usEEmansomVARE TOREORDER RX DATE: RECUVED BY RN: . NEW ORDER a ,: 72 3 7 ' 16 0 Refi 71 on : SEC NURSE DATE ·- DATE H0 DOSAGE AMOUNT ADMINISTERED BY AMOUNT DATE BOUR DOSAGE AMOUNT ADMINISTERED BY AMOUNT USED . (SGNA g UNUSED PORTIONS OF NARCOTIC PRESCRIPT ONS RETURNED TO (CHECKONE)i ORESIDENT [UPON ADVICE OF PHYSICIAN) ¡DESTROYED REIDENT'S SIGNATURE RNSIGNATURE FILED: NEW YORK COUNTY CLERK 03/12/2024 11:25 AM INDEX NO. 159471/2019 NYSCEF DOC. NO. 114 RECEIVED NYSCEF: 03/12/2024 Controlled Substance AccountabilityRecord NURSES' NURSES' SIGNATURE SIGNATURE TEü4SMFT . IV[T M EdN%%iiOWlMTT ETEDUTS Dat 5 B inMT T2@MNMM MMGM 4M$i% ÚTM N N D D o !(a 84 D /f) D E 00 . E o N 8 N p D . N N. D D . E E N N D D D D N N E N N D . . D E E E N . . N D D E E . . FILED: NEW YORK COUNTY CLERK 03/12/2024 11:25 AM INDEX NO. 159471/2019 NYSCEF DOC. NO. 114 RECEIVED NYSCEF: 03/12/2024 VILLAGECARE REHABILITATION AND NURSING CENTER 214 West Houston Street, New York, ... 10014 Tel. 212-337-9400 Fax 212-645-9209 Notice of Medicare Non-Coverage Patient name: GRACE JOHNSON Patient number: Of The Effective Date Coverage of Your Current Skilled Nursing Facility (SNF) Services Will