Every finding on record at A Holly Patterson Extended Care Facility

Based on observations, record review, and interviews, the facility failed to ensure services provided or arranged by the facility met the current professional standards of quality. This was identified for one (Resident #5) of three residents reviewed for Quality of Care. Specifically, on 02/25/2026 Registered Nurse #12 administered the expired intravenous Diflucan (antifungal) medication to Resident #5 without checking the expiration date in its entirety, including the year of expiration. The Diflucan medication expired in November 2025. Additionally, on 02/22/2026, Registered Nurse #13 administered an intravenous dose of Diflucan that was not for Resident #5.Complaint #2798497The findings include:The facility's policy titled, Medication Administration reviewed 03/2024 documented the individual administering medications must check the label three times to verify: right resident, right medication, right dosage, right time, right route of administration, right frequency and the expiration date. Drugs from a bottle, box, or container which are not labeled should not be used. The medication not available is not a valid reason for not giving the medication. If the medication is not in the emergency supplies, the pharmacy must be called. If the pharmacy cannot bring the dose by an acceptable time, the clinician must be notified. A back-up pharmacy, if available, may need to be contacted by the [vendor] pharmacy to deliver the medication.Resident #5 was admitted with diagnoses including acute respiratory failure with hypoxia, and acute kidney injury. Minimum Data Set assessment was not completed due to recent admission.A Physician's Order dated 02/22/2026 documented to administer Diflucan 200 milligrams intravenously for a total of three doses after hemodialysis today (2/22/2026), Wednesday and Friday.A Medication Administration Record for February 2026 documented intravenous Diflucan was administered on 02/22/2026 and 02/25/2026.A Medication Error Sheet dated 2/25/2026 documented on 02/25/2026 at 6:00 PM, Registered Nurse # 12 administered Fluconazole intravenous medication with an expiration date of 11/2025. One dose was administered.During an interview on 06/25/2026 at 9:38 AM, the vendor pharmacy company manager/Pharmacist stated the pharmacy received Resident #5's Diflucan order from the facility on 02/22/2026; however, the medication was not delivered to the facility until 02/26/2026 due to the pharmacy's internal processing error.During an interview on 06/26/2026 at 10:56 AM, Registered Nurse #12 stated that they administered the intravenous Diflucan to Resident #5 in the evening on 02/25/2026. Registered Nurse # 12 stated that Resident #5's Diflucan intravenous medication was not in the medication cart, so they went looking for it and found two bags of Diflucan intravenous medication at the nursing station. Registered Nurse # 12 stated they could not recall if the two bags were labeled with any resident name. Registered Nurse #12 took one of the bags and checked for the expiration date (day); however, they failed to check the year of expiration and administered the Diflucan intravenously to Resident #5. Registered Nurse # 12 stated they should have called the pharmacy or notified the nursing supervisor when they could not find Resident #5's intravenous Diflucan medication.During an interview on 6/26/2026 at 12:36PM, Registered Nurse # 13 stated that they administered the intravenous Diflucan to Resident #5 in the evening on 02/22/2026. Registered Nurse # 13 stated the intravenous Diflucan for Resident #5 was not available in the medication cart. Registered Nurse # 13 found an unlabeled bag of intravenous Diflucan with the right dose and the right route as Resident #5's Diflucan order. Registered Nurse # 13 stated they checked the expiration date of the medication and administered to Resident #5. Registered Nurse # 13 stated that they administered the unlabeled Diflucan medication to Resident #5 because they wanted to make sure Resident #5 received their medication timely, as ordered by the Physician.A review of Registered Nurse # 12's training record dated 11/17/2025 documented Registered Nurse # 12 demonstrated understanding of the six Rights of Medication Administration and verified expiration date during medication pass.A review of Registered Nurse # 13's training record dated 6/26/2025 documented Registered Nurse # 13 demonstrated understanding of the six Rights of Medication Administration and verified expiration date during medication pass.During an interview on 06/26/2026 at 1:03 PM, Registered Nurse Educator #1 and Registered Nurse Educator #2 concurrently stated that the nurses must check for the right drug, right person, right order, right route and right time and the expiration date prior to administering any medication. Registered Nurse Educator #1 and Registered Nurse Educator #2 both stated the nurse should not have administered the intravenous Diflucan that was not labeled with Resident #5's information. Registered Nurse Educator #1 and Registered Nurse Educator #2 both confirmed nurses should call the pharmacy and notify the nursing supervisor and the Physician when the prescribed medications for the resident are not available for administration.During an interview on 6/30/2026 at 11:57AM, the Director of Nursing Services stated prescription medications without the correct resident information label and expired medication should not be administered to any resident. Administration of the expired intravenous Diflucan to Resident #5 was a medication error and Registered Nurse #12 should have contacted the pharmacy when they noticed Resident #5's Diflucan medication was not available. The Director of Nursing Services stated the nursing supervisor, and the Physician should have been notified for any pharmacy concerns including delayed medication administration time or administration of the expired medication.10 New York Code Rules and Regulations 415.11(c)(3)(i)

Based on record review and interviews during the survey, the facility failed to ensure that each resident was free from significant medication errors. This was identified for one (Resident #5) of three residents reviewed for Quality of Care. Specifically, Resident #5 had a physician's order for Diflucan (antifungal medication) 200 milligrams intravenously (through a vein directly into the blood stream) for a total of three doses after the dialysis treatments. On [DATE], Registered Nurse #12 administered the intravenous Diflucan medication that was expired in [DATE] to Resident #5. Complaint #2798497The findings include: The facility's policy titled, Medication Administration reviewed 03/2024 documented the individual administering medications must check the label three times to verify: right resident, right medication, right dosage, right time, right route of administration, right frequency and the expiration date. Drugs from a bottle, box, or container which are not labeled should not be used. The medication not available is not a valid reason for not giving the medication. If the medication is not in the emergency supplies, the pharmacy must be called. If the pharmacy cannot bring the dose by an acceptable time, the clinician must be notified. A back-up pharmacy, if available, may need to be contacted by the [vendor] pharmacy to deliver the medication.Resident #5 was admitted with diagnoses including acute respiratory failure with hypoxia, and acute kidney injury. Minimum Data Set assessment was not completed due to recent admission.A baseline care plan dated [DATE] document Resident #5 was admitted with respiratory failure and cardiac arrest. Resident #5 was in a vegetative state and was on ventilator and Tracheostomy and received hemodialysis (dialysis) on Mondays, Wednesday and Fridays.A Physician's admission History and Physical dated [DATE] documented Resident #5 was admitted to the hospital after a cardiac arrest at home. The resident suffered renal and respiratory complications, urinary tract infection, anemia, and shock liver (an acute liver injury). Resident #5 was treated with broad-spectrum antibiotics. The Physician documented to continue the current medication including intravenous Diflucan.A Physician's Order dated [DATE] documented to administer Diflucan 200 milligrams intravenously for a total of three doses after hemodialysis today ([DATE]), Wednesday and Friday.A Medication Administration Record for February 2026 documented intravenous Diflucan was administered on [DATE].A Medication Error Sheet dated [DATE] documented that on [DATE] at 6:00 PM, Registered Nurse #12 administered intravenous Diflucan medication with an expiration date of 11/2025 to Resident #5. The Physician was notified at 8:00 PM and no medical treatment was ordered. No side effects were observed. At the resident's family member's request Resident #5 was transferred to the hospital. The Medication Error report indicated that Registered Nurse #12 did not check the expiration date [of the medication].During an interview on [DATE] at 9:38 AM, the vendor pharmacy company manager/Pharmacist stated the pharmacy received Resident #5's Diflucan order from the facility on [DATE]; however, the medication was not delivered to the facility until [DATE] due to the pharmacy's internal processing error.During an interview on [DATE] at 10:56 AM, Registered Nurse #12 stated that they administered the intravenous Diflucan to Resident #5 in the evening on [DATE]. Registered Nurse # 12 stated that Resident #5's Diflucan intravenous medication was not in the medication cart, so they went looking for it and found two bags of Diflucan intravenous medication at the nursing station. Registered Nurse # 12 stated they could not recall if the two bags were labeled with any resident name. Registered Nurse #12 took one of the bags and checked for the expiration date (day); however, they failed to check the year of expiration and administered the Diflucan intravenously to Resident #5. Registered Nurse # 12 stated they should have called the pharmacy or notified the nursing supervisor when they could not find Resident #5's intravenous Diflucan medication.During an interview on [DATE] at 9:51 AM, Physician #1 stated that Resident #5 received Diflucan intravenously to treat for positive candida (fungal) infection. Physician #1 stated nursing staff should contact the pharmacy for any missing medications and notify them (Physician #1) of any delay in medication administration. Physician #1 stated prior to administration nurses must ensure the medication is not expired.During an interview on [DATE] at 11:57AM, the Director of Nursing Services stated prescription medications without the correct resident information label and expired medication should not be administered to any resident. Administration of the expired intravenous Diflucan to Resident #5 was a medication error and Registered Nurse #12 should have contacted the pharmacy when they noticed Resident #5's Diflucan medication was not available. The Director of Nursing Services stated the nursing supervisor, and the Physician should have been notified for any pharmacy concerns including delayed medication administration time or administration of the expired medication. 10 New York Code Rules and Regulations 415.12(m)(2)

Based on observations, record review, and staff interviews, the facility failed to provide adequate supervision and a safe environment for each resident. This was identified for one (Resident #3) of five residents reviewed for elopement. Specifically, Resident #3 who had severe cognitive impairment, exit seeking behaviors, and was at high risk for elopement, exited their fourth-floor room through a window and fell to a second-floor patio (awning roof) sustaining multiple fractures (broken bones) on 03/03/2026. Upon the resident's return from the hospital to the facility on [DATE], the resident was placed back onto the fourth floor and continued to have access to the windows in their room. The facility's Elopement Risk Assessment tool failed to evaluate residents for exit-seeking behaviors or the risk of elopement through windows. The Comprehensive Care Plan interventions were not updated to address window safety in Resident #3's room to prevent future elopements through the window. This resulted in the potential for serious injury, serious harm, serious impairment, or death for 82 residents identified as elopement risks, that is Immediate Jeopardy. The findings include: The facility's policy titled Resident Elopement dated 06/2025 documented that the facility will ensure staff has knowledge of resident's whereabouts at all times. The facility will provide measures to ensure the safety and well-being of those residents who are considered at risk to wander from the facility. Resident rounds are conducted by nursing staff for safety every shift. Each resident is assessed initially upon admission, and on an ongoing basis to determine their potential risk for wandering behavior or elopement. Assessment shall be based on factors including but not limited to capacity, judgment, and history of wandering behavior. Care plans shall be revised as indicated, when there is a change in elopement/wandering behavior, or when a particular intervention is no longer effective. Staff should be aware of times of day when behaviors may escalate, and heightened monitoring may be indicated. Resident #3 was admitted with diagnoses including frontoparietal infarct (a type of stroke or tissue death affecting the front and upper side of the brain), aphasia (language and communication disorder caused by brain damage) and altered mental status. The admission Minimum Data Set (a resident assessment tool) dated 12/22/2025 documented a Brief Interview for Mental Status score of three, which indicated Resident #3 had severe cognitive impairment. Resident #3 had behavior of wandering. Resident #3's wandering placed the resident at significant risk of getting to a potentially dangerous place including stairs, or outside of the facility. Resident #3 was independent with mobility and did not use any assistive device.A Comprehensive Care Plan dated 12/24/2025 titled, Secure Placement related to Elopement Risk documented interventions including moving the resident to a locked, secure unit, placement of a wander guard (a wearable bracelet and door sensors to track resident's movement and trigger automated alerts or lock doors if a resident nears an exit) and on-going staff redirection and education.The Risk Assessment Elopement Decision Tree form dated 12/15/2025 documented that Resident #3 was ambulatory (ability to walk and move independently) and was cognitively impaired with poor decision-making skills. The resident displayed behaviors and body language indicating an elopement may be forthcoming. The interventions were to provide a wander detection system (wander guard), staff education, notation on the Certified Nursing Assistant Accountability Record (resident care instructions), and security notification by forwarding the resident's information and photo. A Nursing Progress Note dated 12/16/2025 documented that Resident #3 attempted to exit the unit (on the first floor) multiple times and was unable to be redirected by nursing staff. Resident #3 was observed fully dressed carrying their passport and a bag indicating that elopement was forthcoming. Resident #3 was transferred to a secure unit on the fourth floor. A Social Work Progress Note dated 12/16/2025 documented Resident #3 attempted to leave the facility by opening a door. The resident was moved to the fourth floor (secure locked unit) for safety. A review of the medical record from 12/17/2025 through 03/03/2026 did not document exit seeking behaviors or elopement attempts by Resident #3. A Nursing Progress Note dated 03/03/2026, written by Registered Nurse #10, documented that at approximately 4:15 AM, Resident #3 was standing outside a second-floor room window (Unit 21). Resident #3 was assisted back inside the facility through the window and was taken back to their unit on the fourth floor (Unit 41) for a full body assessment. The physician was notified and Resident #3 was sent to the hospital for evaluation. A review of the facility's Accident and Incident report initiated on 03/03/2026 documented that Resident #3 was observed on the second-floor patio (awning roof) outside a window of room [ROOM NUMBER]. The resident was unable to give account of the occurrence. The facility investigation summary documented the resident was last seen at 3:30 AM, lying in their bed. Resident #3 did not exhibit active exit seeking behaviors such as activating door alarms, lingering near exit doors, or packing belongings. Based on the facility findings, Resident #3 had fully dressed themself, packed their personal belongings, broke the window lock, and exited through the window. Resident #3 intentionally attempted to leave the facility. A review of a form titled, Head Count from 03/02/2026 - 03/03/2026 documented that Resident #3 was observed sleeping in their bed during hourly rounds at 11:00 PM, 12:00 AM, 1:00 AM, 2:00 AM and 3:00 AM. A review of the hospital emergency room progress note dated 03/03/2026 at 7:23 AM documented that Resident #3 was admitted to the emergency department for an unwitnessed fall from an unknown height. The resident sustained multiple fractures including retrosternal hematoma (blood pooled behind the chest bone), sternal (chest bone) fracture, spinal compression fracture (collapse of the bone in the spine), and comminuted (bone shatters into multiple pieces) ankle fracture. The nursing admission progress note dated 03/11/2026 documented the resident was readmitted to the facility on [DATE] on the fourth-floor secure unit. There is no documented evidence that the Elopement Risk Assessment was completed for Resident #3 upon their return from the hospital on [DATE]. The Comprehensive Care Plan titled, Secure Placement related to Elopement Risk dated 12/24/2025 was updated on 03/11/2026 to include a new intervention of every 30 minutes visual checks for three days. There was no documented evidence that interventions related to monitoring the window to prevent future elopements through the window were added to Resident #3's Comprehensive Care Plan. During an observation on 06/25/2026 at 9:18 AM, Resident #3 was sitting on their bed which was closer to the door as opposed to the window. Resident #3 was ambulatory and was unable to communicate. Resident #3's room window was observed with an anti-tilt lock with two additional screws, an L-bracket (an L shaped fastener) on each side of the window, and another lock to prevent the window from opening more than six inches. During an interview on 06/24/2026 at 9:18 AM, Certified Nursing Assistant #5 stated they were regularly assigned to Resident #3 during the 3:00 PM - 11:00 PM shift. Certified Nursing Assistant #5 stated at times they also work during the 11:00 PM - 7:00 AM shift and are responsible for conducting hourly rounds. Certified Nursing Assistant #5 stated when they make the hourly rounds, they check to see if the resident is in the room. Certified Nursing Assistant #5 stated when Resident #3 returned from the hospital on [DATE], they did not receive instructions to check Resident #3's room windows for tampering during the hourly rounds. Certified Nursing Assistant #5 stated they do not check the resident's room windows. During an interview on 06/24/2026 at 9:33 AM, Licensed Practical Nurse #2, the 7:00 AM - 3:00 PM unit charge nurse, stated they were aware of the incident related to Resident #3 jumping out of the window and that the resident was at risk for elopement. Licensed Practical Nurse #2 stated that if they notice broken window glass or broken window locks, they will report to the maintenance staff; however, they do not routinely check for the window integrity in resident rooms. Licensed Practical Nurse #2 stated that after Resident #3 returned from the hospital, there were no instructions for the nursing staff to check Resident #3's room windows for any tampering. During an interview on 06/24/2026 at 9:45 AM, the 11:00 PM - 7:00 AM shift Certified Nursing Assistant #16 stated they were assigned to conduct the hourly resident head count on 03/03/2026 at 3:00 AM. Certified Nursing Assistant #16 stated they saw Resident #3 at 3:00 AM lying in bed. Certified Nursing Assistant #16 stated they did not check the room window. Certified Nursing Assistant #16 stated that after Resident #3 returned from the hospital, no specific instructions were provided to check the room windows for tampering. They continue to conduct the routine hourly headcounts without checking the resident room windows. During an interview on 06/25/2026 at 9:00AM, Certified Nursing Assistant #15 stated that prior to the incident on 03/03/2026, they went to the resident's room at 3:30 AM and the resident was sleeping in their bed. They did not turn on the lights and walked up to the room's window to look outside. They did not notice anything unusual with the window. Certified Nursing Assistant #15 stated when Resident #3 returned from the hospital, there were no specific instructions related to checking the window integrity in Resident #3's room. Certified Nursing Assistant #15 stated they continued to conduct the hourly head count rounds as before without the window safety checks. During an interview on 06/25/2026 at 9:59 AM, Nurse Educator #1 stated that after Resident #3's elopement incident, they provided education to the public safety staff related to identification of all residents who are at risk for elopement and resident safety. Nurse Educator #1 stated that the lesson plan did not include window safety instructions. There was no documented evidence that in-service education was provided to nursing staff related to window safety or window monitoring after Resident #3 jumped out of the window on 03/03/2026. During an interview on 06/25/2026 at 1:19 PM, Registered Nurse #11, the charge nurse, stated that after they sent Resident #3 to the hospital on [DATE], they were not sure if the care plan for Elopement was updated to include interventions for window safety. Registered Nurse #11 stated that Registered Nurse Supervisor #10 was responsible for updating care plans. During an interview on 06/25/2026 at 1:30 PM, the Director of Nursing Services stated since Resident #3 was moved to the fourth floor, they did not have any exit seeking behaviors or attempts of elopement, prior to 03/03/2026. The Director of Nursing Services stated that Resident #3 was wearing a wander guard and resided on a secure unit. There are hall monitors on the secured unit who are responsible for conducting an hourly head count and monitoring the residents' whereabouts. The Director of Nursing Services stated that when Resident #3 returned from the hospital on [DATE], the Comprehensive Care Plan interventions did not include window safety checks by the nursing staff because window safety was a Maintenance process and not Nursing. The Director of Nursing Services stated they did not know the frequency of the window checks conducted by the maintenance staff. The Director of Nursing Services verified that the facility's elopement risk assessment did not evaluate the potential for elopement through windows. Additionally, the elopement risk assessment did not consider residents' history of eloping through a window to determine further elopement from the window and implement appropriate interventions. During an interview on 06/25/2026 at 2:55 PM, Registered Nurse #10, the unit supervisor for the 11:00 PM - 7:00 AM shift, stated they were the nursing supervisor on duty on 03/03/2026 when Resident #3 jumped from the fourth-floor window and was found outside the second-floor window. They assessed Resident #3, notified the physician, and the resident was sent to the hospital. Registered Nurse #10 stated they were responsible for updating the resident's care plan; however, they could not recall why they did not update Resident #3's Comprehensive Care Plan after the resident's return from the hospital on [DATE]. During an interview on 06/26/2026 at 9:15 AM, the Administrator stated that an Ad hoc (meeting for immediate purpose rather than planned or intended for a wider application) meeting was immediately held on 03/03/2026 to discuss the incident and needed interventions. The Administrator stated when Resident #3 returned from the hospital, their room was changed to be closer to the nurse's station and their bed closer to the door. An L-bracket was installed for all windows on the resident's unit. The Administrator stated that the windows were last inspected by the maintenance staff in December 2025. The Administrator stated that there was no documented evidence of the window monitoring as the logs that were being used in the past were discontinued by the previous Administrator. During an interview on 06/26/2026 at 9:30 AM, the Superintendent of Building (Maintenance) stated that prior to the incident on 03/03/2026, all the windows in the facility were checked for integrity of the locks, window glass, security, and functionality on 12/23/2025 and no negative findings were identified; however, the findings and the monitoring were not documented. The Superintendent of Building stated that there were no work orders for the windows prior to 03/03/2026. After the incident, all windows in the facility were checked. All the windows on Resident #3's unit had L brackets and an anti-tilt lock with two additional screws installed, along with a lock to prevent the window from opening more than six inches. The Superintendent of Building stated that after the incident on 03/03/2026, the maintenance department has been conducting window safety checks monthly. 10 New York Code Rules and Regulations 415.12(h)(2)

Based on observation, record review, and interviews during the Recertification Survey and Abbreviated Survey (#769417) initiated on 09/23/2025 and completed on 09/30/2025, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents. This was identified for one (1) (Resident #314) of four (4) residents reviewed for accidents. Specifically, Resident #314 required two (2) staff persons for transfers as per the Physician's order and their plan of care. On 01/10/2025, Certified Nursing Assistant #8 transferred Resident #314 from the wheelchair to the bed without a second staff member. During the transfer, Resident #314 hit their left leg on the metal bed frame and sustained a fractured tibia and fibula (lower leg bones). This resulted in actual harm to Resident #314, that was not Immediate Jeopardy.The finding is:The facility's policy titled Activities of Daily Living, dated March 2023, documented to ensure residents receive appropriate assistance with Activities of Daily Living to maintain or improve their quality of life, independence, dignity, and safety, and promote maximum level of function. Trained staff will provide the level of assistance required to maintain or improve residents' quality of life and promote the maximum level of function. Maintain safety at all times.The facility's policy titled Certified Nursing Assistant Accountability Record, dated March 2023, documented the Certified Nursing Assistant Accountability Record is the plan of care utilized by Certified Nursing Assistants to provide direct care for the residents. The Certified Nursing Assistant Accountability Record needs to be checked before providing care to the residents.Resident #314 was admitted with diagnoses including muscle weakness, lack of coordination, and osteoarthritis (a common joint disease that causes pain, stiffness, and loss of mobility). The 12/28/2024 Annual Minimum Data Set (a resident assessment tool) documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. The resident was dependent (helper did all the effort the resident did none of the effort to complete the activity or, the assistance of two (2) or more helpers was required for the resident to complete the activities) on staff members for transfer to and from a bed to a chair or wheelchair.A Physician's order dated 12/18/2024 documented out of bed to wheelchair with the assistance of two (2) people.The 12/18/2024 Physical Therapy Screen documented the resident had left lower extremity contracture (Equinovarus deformity-the foot is turned inward and downward). Resident #314 required the assistance of two (2) persons for out of bed transfers. The resident was placed on skilled rehabilitation therapy due to a decline in functional transfers and balance.The Fall Risk Potential for Injury Accident/Incident Comprehensive Care Plan effective 01/07/2025, documented that Resident #314 required two (2) person assistance for out of bed to wheelchair transfer.The January 2025 Certified Nursing Assistant Accountability Record documented Resident #314 required two (2) people for out of bed transfers and required substantial maximal assistance (helper lifts and holds trunk or limbs and provides more than half the effort) for chair/bed-to-chair transfer. The Accident and Incident Report dated 01/10/2025 documented the resident complained that during transfer to bed, their leg touched the bed frame, and they had big pain on their left shin, and they were unable to move their leg as the pain was very sharp. The Physician was notified after the resident was assessed and pain medication was administered.A written statement from Certified Nursing Assistant #8 dated 01/10/2025, documented that when they were transferring the resident to bed, the resident stated they hit the right leg on the bed.A Post Incident Root Cause Investigation, dated 01/10/2025, documented that all preventive measures were in place, including two (2) [persons] for transfers. The document did not include any contributing factors or corrective preventive actions. The Nurse Manager/Supervisor's summary of investigation, documented by Registered Nurse #7 indicated the resident was assessed for complaints of pain to the left lower leg. No signs of redness or any injury were noted.The Situation, Background, Assessment, and Recommendation (SBAR) form, completed by Licensed Practical Nurse #3, dated 01/10/2025 at 7:10 PM, documented that Resident #314 had left shin pain when transferred to bed. The Physician was notified, and an order for a pain reliever was obtained.A Physician's order (following the incident) dated 01/10/2025 documented Ibuprofen (pain medication) 200 milligram tablet, give two (2) tablets two (2) times a day as needed for unspecified pain and an order for X-ray of the left lower leg.The Situation, Background, Assessment, and Recommendation (SBAR) form dated 01/11/2025 at 8:30 PM documented Resident #314 complained of left leg pain, was unable to move the leg, and was screaming. An X-ray of the left leg was completed, which indicated a fracture of the fibula (lower leg bone). The Physician ordered to transfer the resident to the emergency room for evaluation.The portable X-ray report dated 01/11/2025, documented an acute fracture (sudden break of a bone that occurs as a result of trauma) of the fibula (lower leg bone). The X-ray showed osteopenia (lower than normal bone mineral density) and osteoporosis (a condition that causes bones to become weak and brittle).A Physician's order dated 01/11/2025 documented to transfer the resident to the Emergency Room.The Accident and Incident Investigation summary report, completed on 01/14/2025, documented on 01/10/2025 at around 5:00 PM, Resident #314 complained of left leg pain after being transferred from a wheelchair to the bed. The resident stated their leg contacted the bed frame during the transfer. The portable X-ray of the left lower leg was completed on 01/11/2025 at the facility, which revealed an acute fracture of the left fibula. The Physician was made aware of the X-ray results and ordered the resident to be sent to the emergency room for further evaluation, where the resident was diagnosed with left tibia and fibula (lower leg bones) fractures. The investigation summary documented that Certified Nursing Assistant #8 reported that they were aware the resident required two-person assistance for transfers and lifted Resident #314 by themselves. Certified Nursing Assistant #8 also admitted that they did not check the Certified Nursing Assistant Accountability Record before providing care.The Hospital discharge documents dated 01/12/2025 confirmed additional X-rays of Resident #314's left leg were taken in the Emergency Room. The impression was a minimally displaced fracture of the tibia and fibula (lower leg bones). The hospital recommended non-weight bearing to the left lower extremity; the resident refused surgical intervention, and a knee immobilizer was placed with instructions to follow up with the orthopedic clinic.A Physician's order dated 01/13/2025 documented out of bed to wheelchair via a mechanical lift.During an observation and interview on 09/24/2025 at 9:30 AM, Resident #314 stated on 01/10/2025, only one (1) aide transferred them to the bed, and no other nurse was in the room during the transfer. Resident #314 stated that during the transfer, they hit their leg on the bed and started screaming in pain. Resident #314 stated they had to go to the hospital and got a brace for the leg.During an interview on 09/24/2025 at 11:53 AM, Rehabilitation Department Director #1 stated prior to the incident on 01/10/2025, Resident #314 required two (2) persons for transfer from one surface to another. After the incident, Resident #314's transfer status changed to mechanical lift because the resident was unable to bear weight on the left leg.Multiple attempts were made to call Certified Nursing Assistant #8; however, they were unavailable for the interview. During an interview on 09/24/2025 at 3:05 PM, Licensed Practical Nurse #3 stated on 01/10/2025, Resident #314 called them and stated they wanted to go back to bed; the resident required two (2) staff members for transfers. Licensed Practical Nurse #3 stated they told Certified Nursing Assistant #8 that Resident #314 wanted to go back to bed. Licensed Practical Nurse #3 stated they did not see Certified Nursing Assistant #8 go into Resident #314's room and did not assist with the transfer. Licensed Practical Nurse #3 stated at approximately 5:00 PM, they heard Resident #314 screaming in pain, and they went to the resident's room. The resident was in bed and complained that Certified Nursing Assistant #8 swung the resident into bed, and the resident's leg hit against the bed frame. Licensed Practical Nurse #3 stated they notified Registered Nurse Supervisor #7. During an interview on 09/25/2025 at 9:15 AM, Registered Nurse Supervisor #7 stated after Licensed Practical Nurse #3 notified them regarding Resident #314's complaint of pain to the left leg, Registered Nurse Supervisor #7 assessed the resident. There were no obvious signs of injury, such as swelling, bruising, or skin breaks. The resident reported they had pain after Certified Nursing Assistant #8 transferred the resident to bed. The Physician was notified, and an investigation was initiated.During an interview on 09/25/2025 at 9:25 AM, Registered Nurse Risk Manager #1 stated they conducted the investigation and concluded that the resident required two (2)person assistance for transfer. Certified Nursing Assistant #8 transferred Resident #314 by themselves and did not follow the resident's plan of care, creating an unsafe transfer.During an interview on 09/25/2025 at 11:10 AM, the Director of Nursing Services stated Certified Nursing Assistant #8 did not review the resident's accountability record before providing care. Certified Nursing Assistant #8 did not follow the resident's plan of care and transferred the resident by themselves, therefore, creating an unsafe transfer. Certified Nursing Assistant #8 was terminated from employment at the facility.During an interview on 09/25/2025 at 11:25 AM, the Medical Director (who is Resident #314's primary Physician) stated the resident had an order to utilize two (2) persons for transfers as recommended by the Rehabilitation Department. The Medical Director stated the Certified Nursing Assistants should follow the transfer orders and the resident's plan of care.10 NYCRR 415.12(h)(1)

Based on observation, record review, and staff interviews during the Recertification Survey initiated on 09/23/2025 and completed on 09/30/2025, the facility did not ensure that the interdisciplinary team had determined that self-administration of medications was clinically appropriate for each resident. This was identified for one (1) (Resident #94) of eleven residents reviewed for Accidents. Specifically, Resident #94 was self-administering their inhaler medications. The facility staff was aware of the resident's self-administration of the inhalers; however, there was no documented assessment to determine if the resident could safely self-administer their medication. Additionally, Resident #94 did not have a physician's order to self-administer their medications. :The finding isThe facility's policy titled Medication Administration, last reviewed on 03/2024, documented that Residents may self-administer their own medications only if the attending clinician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. The medications are stored in a locked area in their room.Resident #94 was admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Bronchitis (inflammation of the bronchial tubes, the airways that carry air to and from the lungs), and Colon Cancer. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #94 had intact cognition Resident #94 had an active diagnosis of Chronic Obstructive Pulmonary Disease and did not receive any respiratory treatment. A Physician's Order dated 09/15/2025 documented Advair HFA (medication to treat Asthma and Chronic Obstructive Pulmonary Disease) eight (8) grams 230 per 21 inhaler, two (2) puffs per inhalation by mouth twice a day. A Physician's Order dated 09/15/2025 documented Spiriva (bronchodilator)18 micrograms Handihaler two (2) puffs per inhalation per one capsule by mouth once a day. A review of Resident #94's electronic medical record revealed that Resident #94 did not have a Physician's order to self-administer their own medications. A review of Resident #94's electronic medical record revealed that Resident #94 did not have a self-administration assessment. A Comprehensive Care Plan dated 05/31/2025 titled, Respiratory Distress related to Chronic Obstructive Pulmonary Disorder documented interventions including administering treatments and medications as ordered by the Physician, monitoring for effectiveness, observing adverse drug reactions, and notifying the Physician of any abnormal findings. During an observation on 09/23/2025 at 11:00 AM, Resident #94 was sitting in a wheelchair in their room. An unlabeled box of Spiriva Handihaler was resting on top of Resident #94's nightstand. An unlabeled Advair HFA inhaler was on top of Resident #94's bed. During an interview on 09/23/2025 at 11:02 AM, Resident #94 stated that they administer their own inhalers. Resident #94 stated they know their medications and are aware of when to take them. Resident #94 stated that the Nursing staff were aware that they (Resident #94) had the inhalers in their room. Resident #94 stated that the Nurses administer all their medications except for the inhalers.During an interview on 09/23/2025 at 11:15 AM, Licensed Practical Nurse #2, Medication Nurse, stated that Resident #94 was alert and oriented and was capable of self-medicating their inhalers. Licensed Practical Nurse #2 stated they were not sure if an assessment was completed for Resident #94's self-administration of medication. Licensed Practical Nurse #2 stated they did not know the inhalers were not stored in a locked cabinet in the resident's room. During an interview on 09/24/2025 at 12:20 PM, Registered Nurse #6, Charge Nurse, stated they were not aware that Resident #94 had their inhalers in their room and was administering their own inhalers. Registered Nurse #6 stated that if a resident wanted to self-administer their medications, the Attending Physician should have been notified to assess the resident for the capacity to safely self-administer the medications.During an interview on 09/26/2025 at 8:23 AM, the Director of Nursing Services stated that Nursing staff should have ensured the resident was assessed and had a physician's order to self-administer their medication, and that the medications were stored according to the facility policy. During an interview on 09/30/2025 at 10:24 AM, the Attending Physician #1 stated that Resident #94 was alert and oriented and was capable of administering their inhalers. Attending Physician #1 stated that Resident #94 had a follow-up with a pulmonologist, and an education was provided on how to administer their inhalers. Attending Physician #1 stated that they were not aware that an evaluation was needed for the resident to be able to self-administer their medication; otherwise, they would have completed the evaluation. 10 NYCRR 415.3(f)(1)(vi)

Based on record reviews and interviews during the Recertification Survey and Abbreviated Surveys (Complaint #769423 and Complaint #2580693) initiated on 09/23/2025 and completed on 09/30/2025, the facility did not ensure the residents had the right to be free from abuse. This was identified for four (4) (Resident #183, Resident #26, Resident # 184, and Resident #90) of five (5) residents reviewed for Abuse. Specifically, 1) on 02/24/2025, Resident #183, with intact cognition, while fighting over a privacy curtain, hit Resident #26, with severely impaired cognition, in the face, resulting in Resident #26 having a swollen lip, and 2) Resident #90 had a physical and verbal altercation with Resident #184 on 08/03/2025 at 01:25 PM. Resident #90 accused Resident #184 of stealing their money. Later, the same day at 08:45 PM, Resident #184 was found on the floor and reported that Resident #90 had hit them in the face with the television remote to retrieve their money.The findings are: The facility's policy titled Resident Abuse, dated 07/13/2021 and last revised on 05/20/2025, documented to ensure that every resident is free from abuse and that their rights are respected and dignity maintained. The term abuse shall mean the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The term physical abuse includes, but is not limited to, hitting, slapping, pinching, kicking, and shoving. Abuse can occur between one resident to another resident, between a staff member to a resident, and/or between a family/visitor to a resident. 1) Resident #183 has diagnoses including Hypertension (high blood pressure) and Schizophrenia (a serious mental health condition that affects how people think, feel, and behave). The admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The Minimum Data Set (MDS) assessment also documented that Resident #183 did not exhibit any behaviors. A Comprehensive Care Plan titled High risk for abuse dated 01/23/2025 and last updated 07/19/2025 documented the goal as: Resident will not experience any form of abuse over 90 days. The interventions included, but were not limited to monitor for changes in mood and behavior, observe for signs of abuse, and educate the resident to report issues/concerns. The Resident Accident/Incident Report dated 02/24/2025 for Resident #183 documented the resident's description of the occurrence as: Resident #26 threw a shoe at them over an argument involving the (privacy) curtain (which separates their beds), and they responded by hitting them (Resident #26) in their face. Resident #26 has diagnoses including Diabetes Mellitus and Bipolar Disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognitive skills for daily decision making with long- and short-term memory problems. The Minimum Data Set (MDS) assessment also documented that Resident #26 did not exhibit any behaviors. A Comprehensive Care Plan titled High risk for abuse – Cognitive impairment, easily annoyed, history of touching female staff inappropriately dated 06/10/2024 and last updated 02/24/2025, documented interventions including but not limited to: monitor for changes in mood and behavior, and observe for signs of abuse. The Resident Accident/Incident Report dated 02/24/2025 for Resident #26 documented the resident's description of the occurrence as: Resident #183, their roommate, hit them. Resident #26 was unable to describe what triggered the incident. The Resident Information Follow-Up report dated 02/24/2025 documented there was reasonable cause to believe that abuse, neglect, or mistreatment occurred. The report documented Resident #26 was alert but severely confused. Resident #26 stated in the initial interview that Resident #183 hit them in the face, but was unable to explain any further. The report also documented Resident #183 was alert and oriented and stated that Resident #26 disturbed their sleep by pulling and playing with the (privacy) curtain located at Resident #183's bedpost and one in between their beds. When Resident #183 stopped Resident #26 by taking the curtain away, Resident #26 hit Resident #183 with a shoe, and Resident #183 hit Resident #26 back in the face. During an interview on 09/23/2025 at 2:15, Resident #183 stated they remembered the incident that occurred on 02/24/2025 PM between them and Resident #26. Resident #183 stated that Resident #26 kept bothering them when they were sleeping and kept waking them up by pulling their (privacy) curtain back. Resident #183 stated the noise woke them up, and Resident #26 also kept bumping into their bed. Resident #183 stated they wanted to stop Resident #26 and pulled back the (privacy) curtain, but Resident #26 kept tugging at it. Resident #183 stated Resident #26 then took a swing at them, hitting them in the face, and then they hit Resident #26 back in the face. During an interview on 09/24/2025 at 12:30 PM, Resident #26 stated they did not recall a fight in February 2025 and have not fought with anyone in the facility. Resident #26 stated they had an issue with the (privacy) curtain with a roommate, but that roommate has not returned to their room. Resident #26 denied being punched or hitting their roommate. During an interview on 09/26/2025 at 12:15 PM, Certified Nursing Assistant #3, who was assigned to Resident #26 on 02/24/2025, stated they were informed by the Nurse regarding the resident to resident altercation between Resident #26 and Resident #183. Certified Nursing Assistant #3 stated that after the altercation, Resident #183 was moved to another room. Certified Nursing Assistant #3 stated they had not seen anything because they were caring for another resident at the time During an interview on 09/26/2025 at 2:50 PM, Licensed Practical Nurse #1 stated 02/24/2025, they found Resident #26 with a swollen lip, and they informed Registered Nurse #2. Licensed Practical Nurse #1 stated they went to Resident #183 to ask what happened, and Resident #183 refused to speak with them. During an interview on 09/29/2025 at 10:15 AM, Certified Nursing Assistant #4, who was assigned to Resident #183 on 02/24/2025, stated they were informed by the Nurse that Resident #183 and Resident #26 were fighting over the bed (privacy) curtain and Resident #183 had hit Resident #26, giving them a swollen lip. Certified Nursing Assistant #4 stated they had not seen the fight actually happen. During an interview on 09/29/2025 at 10:35 AM, Registered Nurse #2, the Registered Nurse Nursing Supervisor who had completed the Accident/Incident Reports on 02/24/2025, stated Resident #183 told them they had an argument with Resident #26 over the (privacy) curtain. Resident #26 threw a shoe at them, and Resident #183 then hit Resident #26 in their face. During an interview on 09/29/2025 at 1:50 PM, Registered Nurse Risk Manager #1 stated the incident between Resident #183 and Resident #26 was considered abuse because Resident #183 knew what they were doing when they hit Resident #26. During an interview on 09/30/2025 at 8:50 AM, the Director of Nursing Services stated the incident between Resident #183 and Resident #26 on 02/24/2025 was abuse because Resident #183, with intact cognition, hit Resident #26, who was confused. During an interview on 09/30/2025 at 11:00 AM, the Administrator stated the altercation between Resident #183 and Resident #26 on 02/24/2025 was an incident of abuse because Resident #183 was alert and knew what they were doing. Both residents were separated, and Resident #183 was moved to another room. 2) Resident #90 was admitted with diagnoses of Dementia, Hyperlipidemia, and Hypertension. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of seven (7), which indicated Resident #90 had severe cognitive impairment. The Quarterly Minimum Data Set assessment documented that Resident #90 did not exhibit any behaviors. A Comprehensive Care Plan titled No Behavior Problem/Concerns Exhibited, dated 01/10/2025, documented interventions including monitoring changes in cognition, mood, and behavior, and redirecting the resident as appropriate. The care plan was revised on 04/04/2025, indicating the resident accused the staff at times. On 08/03/2025, the Resident accused peers of holding their money. The resident tapped on the peer's shoulders and arms. Nursing staff educated the resident and advised them to keep calm when discussing a matter with another resident and to report to the nurse in charge. One (1) to one (1) visual rounds every half hour were initiated. Resident #184 was admitted to the facility with diagnoses of Fracture of the Left Femur (leg bone), Diabetes Mellitus, and Hypertension. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #184 had intact cognition. The Minimum Data Set documented that Resident #184 did not exhibit any behaviors. A Comprehensive Care Plan titled High Risk for Abuse, dated 07/03/2025 and updated on 08/03/2025, with interventions including observing changes in mood and behavior, observing for signs of abuse, and educating the resident to report issues/concerns. The Resident Accident/Incident Report dated 08/03/2025 for Resident #90 documented that Resident # 90 and Resident #184 were involved in an argument in the hallway on the unit at 01:25 PM. Resident #90 was tapping Resident #184 on their (Resident #184) shoulders and arms. Resident #90 thought that Resident #184 was trying to keep their (Resident #90) money. Staff separated both residents very quickly and took Resident #90 back to their room. Both residents were placed on half-hour visual rounds for three (3) days. The Accident and Incident report dated 08/03/2025 for Resident #184 documented a statement from Resident #184 indicating Resident #90 thought they (Resident #90) gave them (Resident #184) money ($800) to hold. Resident #184 was assessed and did not sustain any injury. A separate Resident Accident/Incident Report dated 08/03/2025 for Resident #90 documented that at 08:45 PM, Registered Nurse #8 reported observing Resident #184 on the floor in their room. Resident #184 stated that Resident #90 hit them (Resident #184) in the face with a television remote control. Resident #90 was interviewed and was unable to describe the occurrence. Both residents were separated immediately to prevent further escalation. Resident #90 was transferred to the hospital for further evaluation with psychiatry and will be relocated upon returning to the facility. A separate Resident Accident/Incident Report dated 08/03/2025 for Resident #184 documented a statement from Resident #184 indicating that Resident #90 came to their (Resident #184) room and hit them with a television remote control. Resident #184 was found on the floor by Registered Nurse # 8 with nose bleeding. Upon assessment, Resident #184 sustained injury to the head, face, and left pinky fingers. Resident #184 was transferred to the hospital for Computed Tomography (CT) of the head, spine, and face, and an X-ray of the left 5th digit to rule out fracture. The investigation summary of both incidents concluded there was cause to believe abuse related to resident-to-resident had occurred. A review of documents titled Visual Observation Rounds from 08/03/2025 to 08/05/2025 indicated Resident #90 was observed at a 30-minute interval by Certified Nursing Assistant #10 between 08:00 PM-09:00 PM on 08/03/2025, and Resident #90 was seen in the hallway between 08:30 PM to 09:00 PM. A review of documents titled Visual Observation Rounds from 08/03/2025 to 08/05/2025 indicated Resident #184 was observed at a 30-minute interval. Resident #184 was seen in their room between 08:30 PM to 09:00 PM on 08/03/2025. During an interview on 09/23/2025 at 10:54 AM, Resident #90 stated their family members gave them money for their birthday, and they handed the money to another resident for safekeeping when they were going to take a shower. Resident #90 could not recall the name of the resident. Resident #90 stated that after returning from the shower, they asked the other resident (Resident #184) for their money, and the other resident refused to return the money. Resident #90 stated they got very upset and hit the other resident (Resident #184) in the forehead with a television remote. During an interview on 09/24/2025 at 03:08 PM, Resident #184 stated they were hit by another resident (could not recall the name). Resident #184 denied pain or being fearful for their safety at this time. During an interview on 09/29/2025 at 11:00 AM, Certified Nursing Assistant #10 stated they were assigned to care for Resident #184 during the 07:00 AM-03:00 PM shift on 08/03/2025, and there was no prior history of altercation between Resident #184 and Resident #90. On 08/03/2025, Resident #90 was arguing over money with Resident #184 during the morning shift. Resident #90 was observed tapping Resident #184 on the shoulder and was verbally argumentative. Certified Nursing Assistant #10 stated that both residents were placed on half-hourly visual rounds. Certified Nursing Assistant #10 stated they also worked the evening shift (03:00 PM to 11:00 PM) on the same unit on 08/03/2025 and were responsible for checking the residents (Resident #90 and Resident #184) for a visual round between 8:00 PM to 09:00 PM. Certified Nursing Assistant #10 stated both residents were observed during 8:00 PM to 9:00 PM; however, Certified Nursing Assistant #10 could not say what time they last saw both residents. Certified Nursing Assistant #10 stated that at approximately 08:45 PM, they were putting away a mechanical lift when they heard Registered Nurse #8 call for help. Certified Nursing Assistant #10 stated that when they responded to the room, Resident #90 was standing in front of Resident #184's room, and Resident #184 was sitting in their wheelchair inside their room. Certified Nursing Assistant #10 stated Resident #184's forehead was red and the resident was communicating through non-verbal gesture, indicating Resident #90 had hit them (Resident #184) with a television remote control. During an interview on 09/29/2025 at 01:18 PM, Licensed Practical Nurse # 3 stated that they were called earlier in the day to assist in translating for the residents after the altercation had occurred on 08/03/2025, as both residents' primary language was not English. Licensed Practical Nurse #3 stated that Resident #184 reported that Resident #90 had been arguing with them (Resident #184) over money and calling them a thief, and Resident #184 was very upset. Licensed Practical Nurse # 3 stated Resident #90 accused Resident #184 of keeping their (Resident #90) money that they (Resident #90) gave to Resident #184 for safekeeping before going into the shower. Licensed Practical Nurse # 3 stated that they were again called to translate at approximately 08:45 PM on the same day (08/03/2025) when the second incident occurred, and Resident #184 told them (Licensed Practical Nurse # 3) that Resident #90 had hit them in the face with a television remote control. During an interview on 09/30/2025 at 09:15 AM, Certified Nursing Assistant #13 stated they were sitting at the nursing station when they heard noises at approximately 1:25 PM. Certified Nursing Assistant #13 stated they saw Resident #90 and Resident #184 in front of Resident #184's room, exchanging words in a language they did not understand. Resident #90 was tapping Resident #184's shoulders. Resident #184 was sitting in their wheelchair, trying to avoid Resident #90. Certified Nursing Assistant #13 stated they immediately separated the residents, and both residents were placed on half half-hour visual round. During an interview on 09/29/2025 at 03:58 PM, Registered Nurse #10, the evening shift (3:00 PM to 11:00 PM) Nursing Supervisor on 08/03/2025, stated that they were on the unit and responded to Registered Nurse #8's call for help. Upon entering Resident #184's room, Registered Nurse # 10 observed Resident #184 on the floor. The resident was bleeding from a laceration to the left side of the nose. Registered Nurse # 10 stated that Resident #184 was alert and responsive and reported that Resident #90 hit them in the face. Registered Nurse #10 stated Resident #90 was not roommates with Resident #184. There was a clear indication that Resident #90 was again trying to seek out Resident #184 to complete the unfinished argument they both had during the previous shift. Registered Nurse #8 was unavailable for an interview despite multiple attempts. During an interview on 09/30/2025 at 10:23 AM, the Risk Manager stated they concluded that abuse had occurred through review of resident and staff interviews and statements. The Risk Manager stated there was evidence to indicate that Resident #90 acted out against Resident #184 with reason and intent, although the reason was unfounded, as Resident #90 did not have any money on their person. During an interview on 09/30/2025 at 11:01 AM, the Administrator stated there was evidence that abuse had occurred when an altercation between Resident #90 and Resident #184 took place. Resident #90 hit Resident #184 as they (Resident #90) were upset that Resident #184 had refused to return their money. During an interview on 08/30/2025 at 11:31 AM, the Director of Nursing Services stated that there was evidence to indicate abuse had taken place as Resident #90 had intent and targeted Resident #184 twice on the same day for the same reason, even though the reason was unrealistic. The Director of Nursing Services stated Resident #184 sustained a minor injury requiring a transfer to the hospital for evaluation after the second incident, when Resident #90 hit Resident #184 in the face with a television remote control. 10 NYCRR 415.4(b)(1)(i)

Based on interviews and record review, the facility did not coordinate and refer all Level II residents and all residents with newly evident or possible mental disorder, intellectual disability, or a related condition for Level II resident review upon a significant change in status assessment. This was identified for one (1) (Resident #5) of 37 residents reviewed for Pre-admission Screening and Resident Review (PASARR). Specifically, there was no documented evidence that the facility referred Resident #5 for Level II resident review when the resident was newly diagnosed with Schizoaffective Disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder) during the course of their stay in the facility.The finding is:The facility's policy titled Pre-admission Screening and Resident Review, last revised June 2023, documented that in the event a resident is admitted with a level I screen, and further exploration reveals information indicating that there is a serious mental illness, a referral shall be made to the appropriate Pre-admission Screening and Resident Review agency immediately. In the event that a resident is determined prior to admission to require a Level II screen, that resident shall not be admitted without authorization from the appropriate Pre-admission Screening and Resident Review agency. Resident #5 was originally admitted to the facility prior to 2009 with diagnoses including Dementia (a group of conditions characterized by the impairment of at least two brain functions, such as memory and judgment), and Oral Thrush. The Annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of six (6), which indicated the resident had severely impaired cognition. The Minimum Data Set indicated the resident had diagnoses of Depression and Schizophrenia. The Physician admission History and Physical assessment dated [DATE] documented that Resident #5 had periods of confusion. Resident #5 was prescribed medications, including but not limited to Risperdal (an antipsychotic medication) 0.5 milligrams at bedtime. The Assessment did not document that Resident #5 had a diagnosis of schizoaffective disorder. There was no documented evidence of the resident's diagnosis of schizoaffective disorder prior to 06/29/2018. A review of the Psychiatric evaluation dated 06/29/2018 documented that Resident #5 was seen for follow-up. The assessment indicated the resident has a history of schizoaffective disorder and Unspecified Dementia. The evaluation documented a recommendation to continue Cymbalta (a medication to treat depression and anxiety) 30 milligrams at bedtime and Depakote (a medication to treat seizures and bipolar disorder) 25 milligrams at bedtime. A review of the hospital Discharge summary dated [DATE] documented that the resident was sent from the nursing facility with a complaint of Shortness of breath. The history of present illness documented past diagnoses, including but not limited to schizoaffective disorder. The summary documented that the resident was successfully treated for hospital-acquired Pneumonia and Acute Chronic Congestive Heart Failure and was discharged back to the nursing facility in stable condition. The Annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderately impaired cognition. The assessment documented Resident #5 had an active diagnosis of Schizophrenia (schizoaffective and schizophreniform disorders) and did not exhibit any behaviors. The assessment's Pre-admission Screening and Resident Review (PASARR) section documented that Resident #5 was not currently considered by the State level II Pre-admission Screening and Resident Review (PASARR) process to have serious mental illness, intellectual disability, or other related conditions. The Level II screen condition section was not completed. The Significant Change Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of seven (7), which indicated Resident #5 had severely impaired cognition and had an active diagnosis of Schizophrenia (schizoaffective and schizophreniform disorders) and Depression. The resident did not exhibit any behaviors. The Pre-admission Screening and Resident Review (PASARR) section documented that Resident #5 was currently considered by the State level II Pre-admission Screening and Resident Review (PASARR) process to have serious mental illness, intellectual disability, or other related conditions. The Level II screen condition section was completed and indicated the resident has a condition of serious mental illness. The medical record lacked documented evidence that a Level 1 or Level II Pre-admission Screening and Resident Review (PASARR) was completed for the resident. During an interview on 09/25/2025 at 01:54 PM, the Director of admission stated that Resident #5 did not have a completed Level 1 or Level II Pre-admission Screening and Resident Review on file during the entire course of their stay. The Director of admission stated that when Resident #5 was discharged and returned to the facility in October 2023, the facility did not require the resident to have a Level 1 Pre-admission Screening and Resident Review because the resident's discharge was anticipated, and the resident returned to the facility within 30 days. During an interview on 09/26/2025 at 01:53 PM, the Minimum Data Set Assessor stated that Resident #5 had a significant change in condition due to weight loss, activities of daily living function, and presence of a new venous ulcer. The Minimum Data Set Assessor stated that there was no significant change noted in mood or psychiatric behavior in the assessment. During an interview on 09/26/2025 at 02:32 PM, the Social Work Supervisor stated that they were responsible for completing the Minimum Data Set assessment's Pre-admission Screening and Resident Review (PASARR) section dated 10/26/2023. The Social Work Supervisor stated that they were aware of Resident #5's schizoaffective disorder diagnosis, which existed prior to their employment in 2022. The Social Work Supervisor stated that a Level II Pre-admission Screening and Resident Review referral should be done at the time when the resident had a change in psychiatric condition or had a new psychiatric diagnosis. The Social Work Supervisor stated that there was no documented evidence to indicate that a Level 1 or Level II Pre-admission Screening and Resident Review referral was completed for Resident #5 since their admission to the facility. During an interview on 09/29/2025 at 03:05 PM, the Director of Nursing Services stated that Resident #5 did not have any psychiatric diagnosis except Dementia when they were first admitted to the facility in 2002. The Director of Nursing Services stated they were unable to establish the onset date of Resident #5's Schizoaffective Disorder diagnosis due to the resident's long history of stay in the facility, and the resident's medical records were maintained primarily on paper only. During an interview on 09/30/2025 at 02:24 PM, the Administrator stated that residents who received a new diagnosis of a serious mental illness after admission to the facility should be screened to see if they require additional mental health services. The Administrator stated that the Social Worker can refer to an outside agency or utilize an in-house qualified screener to determine if the resident requires a Level II Pre-admission Screening and Resident Review (PASARR) further services. 10 NYCRR 415.11(e)

Based on record review and staff interviews during the Recertification Survey initiated on 09/23/2025 and completed on 09/30/2025, the facility did not ensure that a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical and nursing needs that are identified in the comprehensive assessment was implemented for each resident. This was identified for one (1) (Resident #6) of three (3) residents reviewed for Position/Mobility and for one (1) (Resident #70) of three (3) residents reviewed for Position and Mobility Specifically, 1) Resident #6 was observed on three separate occasions without a right-hand splint as ordered by a Physician. 2) Resident #70 had a physician's orders to apply a gauze roll to the right anterior (in the front) elbow. Resident #70 was observed on multiple occasions without the gauze roll in place as ordered. The findings are: 1) The facility's undated policy titled Splinting/Bracing/Orthotic Devices documented splints/braces/orthotics are types of orthotic devices that support or correct musculoskeletal deformities or abnormalities. The device is applied by nursing staff if the resident requires assistance or applied by the resident when the resident is independent in donning/doffing (putting on/taking off) the device. Resident #6 has diagnoses including Hypertension (high blood pressure) and Diabetes Mellitus. The significant change Minimum Data Set (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated the resident had moderately impaired cognitive skills for daily decision making. The Minimum Data Set (MDS) also documented Resident #6 required substantial/maximal assistance for upper body dressing and was dependent on staff for lower body dressing. The Physician's Order dated 03/17/2025, last renewed 08/27/2025, documented: Right hand splint, apply in the morning and remove at the hour of sleep for the right-sided Hemiparesis (muscle weakness) due to Cerebral Vascular Accident. The Certified Nursing Assistant Assignment/Accountability Record dated September 2025 documented a right-hand splint under Devices. The Comprehensive Care Plan did not include the use of the right-hand splint. On 09/23/2025 at 11:55 AM, the resident was observed sitting upright in their bed, not wearing their right-hand splint. On 09/24/2025 at 10:40 AM, the resident was observed sitting upright in their bed, not wearing their right-hand splint. On 09/24/2025 at 2:50 PM, the resident was observed seated in their wheelchair, not wearing their right-hand splint. During an interview on 09/25/2025 at 10:35 AM, Certified Nursing Assistant #1, who cared for the resident on 09/24/2025 during the 7:00 AM-3:00 PM shift, stated they did not put on the resident's splint yesterday because they did not know where the splint was, and they had notified Registered Nurse #1 that the splint was missing. Certified Nursing Assistant #1 stated they did not remember when they made Registered Nurse #1 aware that the resident's splint was missing. During an interview on 09/25/2025 at 10:55, Registered Nurse #1 stated, sometime after 3:00 PM, they went to look for the resident's splint and found the splint in the top drawer of their dresser. Registered Nurse #1 stated they did not know why Certified Nursing Assistant #1 was not able to find it. Registered Nurse #1 stated the resident's splint should have been applied by Certified Nursing Assistant #1. During an interview on 09/25/2025 at 1:40 PM, Certified Nursing Assistant #2, who cared for the resident on 09/23/2025 during the 7:00 AM-3:00 PM shift, stated they should have applied the splint after they provided morning care to the resident. During an interview on 09/26/2025 at 11:05 AM, the Director of Nursing Services stated the resident's splint should have been applied according to the Physician's Order. The Director of Nursing Services stated the splint should have been applied as soon as the Certified Nursing Assistant was finished providing morning (AM) care to the resident. The Director of Nursing Services also stated if Certified Nursing Assistant #1 could not find the resident's splint, they should have reported that to the Nurse as soon as possible and should have also looked in the resident's drawers themselves. 10 NYCRR 415.11(c)(1) 2) The facility policy titled Care Planning, dated 10/2023, documented that it is the responsibility of the discipline that triggers the Care Area Assessment (CAA) to initiate and update the plan of care. It is the responsibility of the Registered Nurse supervisor/Nurse manager to be familiar with each resident and review the care plan for accuracy, and to reflect the current condition. Resident #70 was admitted with diagnoses of Diffuse Traumatic Brain Injury (damage to the brain from a sudden, external force, like a bump, blow, or jolt to the head), functional Quadriplegia (unable to move their arms and legs), and Dysphagia (difficulty swallowing). An Annual Comprehensive Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 0, indicating severe cognitive impairment. Resident #70 was dependent on caregivers for dressing, bathing, toileting, eating, and all personal care. The Occupational Therapy screen dated 06/19/2025 documented that Resident #70 had impairments on both sides of the upper extremities. The Occupational Therapy screen documented the use of a gauze roll on the right anterior elbow. A physician's order dated 08/11/2025 documented a gauze roll to the right anterior elbow for skin care. The Comprehensive Care Plan did not document the use of a rolled gauze to the right anterior elbow as an intervention. The September 2025 Certified Nursing Assignment Accountability Record documented assistive devices: a gauze roll to the right anterior elbow. The Certified Nursing Assistants documented that the gauze roll was applied to the resident's elbow daily, on all shifts. During an observation on 09/23/2025 at 12:54 PM, Resident #70 was in bed without the gauze roll applied to their right anterior elbow. During an observation on 09/24/2025 at 10:06 AM, Resident #70 was in bed without the gauze roll applied to their right anterior elbow. During an observation on 09/25/2025 at 9:44 AM, Resident #70 was in bed without the gauze roll applied to their right anterior elbow. During an interview on 09/25/2025 at 9:51 AM, Certified Nursing Assistant #5 stated they did not know that the gauze roll was supposed to be applied to the resident's elbow. They would usually put the gauze roll in the resident's hand, never in the elbow. Certified Nursing Assistant #5 stated they did not realize the accountability record instructions included placing the gauze roll in the resident's right elbow. They had mistakenly signed that they applied the gauze roll for Resident #70. During an interview on 09/25/2025 at 10:47 AM, Registered Nurse #2 stated Resident #70 had a physician's order for a gauze roll to be applied to the right elbow. The Certified Nursing Assistants were responsible for reviewing the accountability record and following the instructions, and the nurses on the unit were responsible for ensuring the Certified Nursing Assistnats were following the physician's orders. Resident #70 should have had a gauze roll placed in the right elbow to prevent skin breakdown. During an interview on 09/25/2025 at 11:40 AM, the Director of Occupational Therapy stated they completed the annual Occupational Therapy evaluation of the resident on 06/19/2025, and recommended a gauze roll be applied to the right elbow for skin integrity. The Director of Occupational Therapy stated that nursing staff should apply the gauze roll to prevent skin from rubbing together and reduce moisture buildup. The Director of Occupational Therapy stated that after they complete their recommendations, the Doctor will sign off, and they will notify the unit nurse. The Director of Occupational Therapy stated that they are responsible for initiating the care plan, and the intervention should have been documented in the Skin Integrity care plan. The Comprehensive Care Plan titled 'Skin Problems' dated 07/15/2025 was revised on 09/26/2025 to include the use of a gauze roll on the right anterior elbow as an intervention. During an interview on 09/26/2025 at 8:23 AM, the Director of Nursing Services stated the Certified Nursing Assistant would be responsible for applying the gauze roll as ordered and then signing the Certified Nursing Assistant accountability that it was completed. The Director of Nursing Services stated the Nurse should also check to ensure the task was completed. 10 NYCRR 415.11(c)(1)

Based on observations, record review, and interviews during a Recertification survey initiated on [DATE] and completed on [DATE], the facility did not ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team. This was identified for one (1) (Resident #70) of one (1) resident reviewed for Advanced Directives. Specifically, Resident #70 had a physician's order for Medical Orders for Life Sustaining Treatment (MOLST), which included a Do Not Resuscitate (DNR) order; however, the resident's advance directives care plan documented to provide cardiopulmonary resuscitation (CPR). The finding is: The facility policy titled 'Advance Directives: Ascertaining existence of' last revised 05/2021 documents, Advance Directives are expressions of the patient's wishes as to how future care should be delivered or declined, including decisions that must be made when the patient is not capable of expressing those wishes. When the resident is transferred into the facility, Social Work reviews with the resident/family the Advance Directives. Policies and procedures address the use of such directives in the care of the resident: the face sheet of the comprehensive care plan indicates the advance directives. The facility policy titled 'Care Planning' dated 10/2023 documents, the care plan will be reviewed and revised to reflect the resident's current condition per policy and regulations. It is the responsibility of the discipline that triggers the Care Area Assessment (CAA) and to initiate and update the plan of care. It is the responsibility of the Registered Nurse supervisor/nurse manager to be familiar with each resident and review the care plan for accuracy, and to reflect the current condition. Resident #70 was admitted with diagnoses of Diffuse Traumatic Brain Injury (damage to the brain from a sudden, external force, like a bump, blow, or jolt to the head), functional Quadriplegia (unable to move their arms and legs), and Dysphagia (difficulty swallowing). An Annual Comprehensive Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 0, indicating severe cognitive impairment. Resident #70 was dependent on caregivers for dressing, bathing, toileting, eating, and all personal care. Minimum Data Set documented the resident's advance directive in section S to be Do Not Resuscitate. A Comprehensive Care Plan titled Advance Directives dated [DATE] documented Medical Order For Life Sustaining Treatment (MOLST) and Full Cardiopulmonary Resuscitation (CPR) to be performed. A Medical Order for Life Sustaining Treatment (MOLST) dated [DATE] documented a Do Not Resuscitate (DNR) order (allow natural death). A physician's order dated [DATE] documented Do Not Resuscitate (DNR).During an interview on [DATE] at 1:14 PM, Registered Nurse #5 stated that Resident #70's physician order and Medical Order for Life Sustaining Treatment (MOLST) indicated Do Not Resuscitate. Registered Nurse #5 stated that the nurses can identify the residents who are a Do Not Resuscitate based on a color-coded system on the chart and wrist band. Registered Nurse #5 stated the care plan and the physician's order should match. During an interview on [DATE] at 12:11 PM, Social Worker Supervisor #1 stated they were responsible for the Advance Directive care plans. Social Worker Supervisor #1 stated that Resident #70's care plan documented the resident was a full code (requiring cardiopulmonary resuscitation); however, the Medical Order for Life Sustaining Treatment (MOLST) dated [DATE] indicated Do Not Resuscitate. Social Worker Supervisor #1 stated the care plan should have been revised on [DATE] to accurately identify the resident's advance directive wishes. During an interview on [DATE] at 8:23 AM, the Director of Nursing Services stated that the resident's care plan should reflect the current advance directive orders. They stated the Social Worker is responsible for completing that section of the care plan, and it should have been revised to reflect the current Do Not Resuscitate (DNR) status. 10NYCRR 415.11(c)(2)(i-iii)

Based on observations, record review, and interviews during the Recertification survey initiated on 09/23/2025 and completed on 09/30/2025, the facility did not ensure all drugs and biologicals were stored in a locked compartment and accurately labeled. This was identified for one (Unit 22 medication cart) of seven (7) medication carts, one (Unit 22 medication room) of six (6) medication rooms reviewed for the Medication Storage and Labeling task, and one (1) (Resident #94) of eleven residents reviewed for Accidents. Specifically, 1) the Unit 22 medication cart was noted to be unlocked in the hallway without any staff members present, 2) the Unit 22 medication room refrigerator contained an injectable medication (Ozempic-medication for Diabetes Mellitus) that was opened and was not dated. 3) Resident #94 was observed with an unlabeled Spiriva Handihaler (a medication used for relaxing and opening the airway) on their nightstand and an unlabeled Advair (medication to treat Asthma) inhaler on the bed. There was no nursing staff in the vicinity of Resident #94's room. 4) Resident #1 was observed with a physician-ordered pain patch in their room. The resident did not have a physician's order to self-administer their medication. The findings are: The facility's policy titled 'Medication administration' dated 03/2024 documents that, during the administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. The expiration on the medication label must be checked prior to administering. When opening a multi-dose container, the date shall be recorded on the container. 1) During an observation on 09/25/2025 at 9:30 AM, a medication cart was unlocked without a staff member present at the end of the hallway on Unit 22. At 9:32 AM, Registered Nurse #3 exited a resident's room two doors down from the cart and approached the medication cart. During an interview on 09/25/2025 at 9:37 AM, Registered Nurse #3 acknowledged that the medication cart was unlocked and stated they were administering medications to a resident inside a room nearby. Registered Nurse #3 stated they forgot to lock the medication cart before leaving the cart in the hallway. Registered Nurse #3 stated the medication cart should be locked when unattended, as other residents can get into the cart and take a medication from the cart. 2) Resident #399 has diagnoses that include Diabetes Mellitus Type 2 (a chronic condition that affects how the body uses sugar), Hypertension (high blood pressure), and Chronic Ischemic Heart Disease (a condition that restricts blood and oxygen to the heart). The Annual Minimum Data Set, dated [DATE] documented a Brief Interview for Mental Status score of 15, indicating the resident had intact cognition. The physician's order dated 07/15/2025 documented Ozempic 0.25 milligrams per 0.5 milligrams, inject 0.5 milligrams subcutaneously (under the skin) weekly, every Wednesday at 10 AM. A record review of the Medication Administration Record from July 2025 to September 2025 documented that Ozempic was administered to Resident #399 weekly, as ordered. During an observation of the medication room in Unit 22 on 09/25/2025 at 12:21 PM, the medication refrigerator was opened by Registered Nurse #4. An opened Ozempic pen was stored inside the medication refrigerator with no open date. The medication label indicated the Ozempic pen was for Resident #399. The pharmacy label on the box of the medication indicated that the prescription was fulfilled on 06/11/2025. Registered Nurse #4 stated all injectable medications should be dated when opened, and Ozempic should be discarded 28 days after opening. The medication instructions for Ozempic, dated 09/2023 documented the Ozempic pen should be disposed (thrown away) after 56 days, even if it still has Ozempic left in it. Write the disposal date on your calendar. During an interview on 09/26/2025 at 8:23 AM, the Director of Nursing Services stated the medication cart should never be left unlocked without a nurse present. The Director of Nursing Services stated that someone can potentially take and ingest a medication from the cart if the medication cart is left unlocked. The Director of Nursing Services stated that all insulin and insulin pens should be dated when opened and discarded after twenty-eight (28) days. The Director of Nursing Services stated nurses should date all injectable medications when opened to ensure medications are never administered after the discard date. 3) Resident #94 was admitted to the facility with Diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Bronchitis (inflammation of the bronchial tubes, the airways that carry air to and from the lungs), and Colon Cancer. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #94's Brief Interview of Mental Status (BIMS) score of 15, indicating Resident #94 had intact cognition. Resident #94 did not receive any respiratory treatments. A Comprehensive Care Plan dated 05/31/2025 titled, Respiratory Distress related to Chronic Obstructive Pulmonary Disorder documented interventions including administering treatments and medications as ordered by the Physician, monitoring for effectiveness, observing adverse drug reactions, and notifying the Physician of any abnormal findings. A Physician's Order dated 11/15/2024 documented Advair HFA eight (8) grams 230 per 21 inhaler, two (2) puffs per inhalation by mouth twice a day. A Physician's Order dated 09/15/2025 documented Spiriva 18 micrograms Handihaler two (2) puffs per inhalation per one capsule by mouth once a day. A review of Resident #94's electronic medical record revealed that Resident #94 did not have a Physician's order to self-administer their own medications. During an observation on 09/23/2025 at 11:00 AM, Resident #94 was sitting in their wheelchair in their room. An unlabeled box of Spiriva Handihaler was on the nightstand, and an unlabeled Advair inhaler was on Resident #94's bed. During an interview on 09/23/2025 at 11:02 AM, Resident #94 stated that they administer their own inhalers. Resident #94 stated they know their medications and are aware of when to take them. Resident #94 stated that the Nursing staff were aware that they (Resident #94) had the inhalers in their room. Resident #94 stated that the Nurses administer all their medications except for the inhalers. During an interview on 09/23/2025 at 11:15 AM, Licensed Practical Nurse #2, Medication Nurse, stated that Resident #94 was alert and oriented and was capable of self-medicating their inhalers. Licensed Practical Nurse #2 stated they did not know the inhalers were not stored in a locked cabinet in the resident's room. During an interview on 09/24/2025 at 12:20 PM, the Registered Nurse #6, Charge Nurse, stated that they were not aware that Resident #94 kept the inhalers unlocked in their room. During an interview on 09/26/2025 at 8:23 AM, the Director of Nursing Services stated that Resident #94 should have a locked drawer to keep their medications. The Director of Nursing Services stated that Resident #94 should have been assessed by the Physician and Nursing staff for self-administration of medication. 10NYCRR 415.18(e)(1-4)

Based on observation, record review, and staff interviews during the Recertification Survey initiated on 09/23/2025 and completed on 09/30/2025, the facility did not ensure it established and maintained an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for one (1) (Resident #314) of four (4) residents reviewed for Pressure Ulcers. Specifically, during the wound care observation of Resident #314's left heel pressure ulcer, Licensed Practical Nurse #4 allowed the cleansed heel wound to come in contact and rest on a dirty surface.The finding is:The facility's policy titled Wound Dressing, dated 12/2023, documented the nurse to bring a Certified Nursing Assistant for assistance; remove the old dressing, observe the area; wash hands, put on new gloves, and cleanse the wound as ordered, with circular motion, inside to outside.Resident #314 was admitted with diagnoses including Muscle Weakness, Lack of Coordination, and Osteoarthritis (a common joint disease that causes pain, stiffness, and loss of mobility). The 06/30/2025 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of nine (9), indicating the resident had moderate cognitive impairment. The resident had one unstageable (covered by dead tissue or scab and unable to determine true depth) pressure ulcer.A Comprehensive Care Plan, effective 04/07/2025 and last updated 09/29/2025, titled Potential for Further Pressure Injuries, Related to Actual Pressure Ulcer, Unstageable to Left Heel, Fragile Skin, Incontinence, Impaired Mobility. The interventions included administering supplements, treatments, and medications as per the physician's order and monitoring effectiveness. An update on 09/29/2025 documented a new treatment order for the left heel pressure.A physician's order dated 09/29/2025 documented Carrasyn Wound Gel, apply to the left heel two times a day after cleansing with normal saline and cover with a dry protective dressing.During an observation and interview on 09/30/2025 at 8:40 AM, Resident #314's left heel wound care was performed by Licensed Practical Nurse #4. Licensed Practical Nurse #4 stated the wound care order was changed yesterday (09/29/2025) because the dry scab came off the wound, and now the wound was open. Licensed Practical Nurse #4 stated they did not need assistance during wound care and would work alone. Licensed Practical Nurse #4 then instructed the resident to lift their leg and to keep the leg elevated so the wound to the heel could be attended to. Licensed Practical Nurse #4 placed a clean field under the heel. The wound was approximately 1.5 centimeters in width x 1.5 centimeters in length and about 0.1 centimeters in depth. The wound appeared to have mostly granulation tissue (healing tissue) with a small amount of slough (dead tissue). There was serosanguinous (blood-tinged) drainage on the old dressing that the nurse removed. The nurse left the old dressing on the clean field rather than discarding it. After the nurse cleansed the wound with normal saline, the resident appeared to have a grimacing look on their face and brought their leg down to a resting position on the bed. The already cleansed heel wound came in contact and rested on the old dressing, which was folded in half. The nurse was ready to apply the treatment wound gel to the wound bed when the surveyor pointed out that the cleansed wound was now resting on the old dressing. The nurse stated they would have to re-cleanse the wound because it was contaminated by the dirty dressing.During an interview on 09/30/2025 at 12:05 PM, Registered Nurse Educator #1 stated that the nurse should have asked for help from another nurse or the Certified Nursing Assistant to assist them during wound care. If, after the wound was cleansed and came in contact with a dirty surface, the wound would have to be re-cleaned.During an interview on 09/30/2025 at 12:15 PM, Registered Nurse Wound Care #1 stated that it could be painful and uncomfortable for a resident to hold their leg up by themselves for an extended time while wound care is being done. The nurse should have asked the resident if they were comfortable and should have asked for assistance from another staff member to hold the resident's leg to provide treatment to the resident's heel wound. Registered Nurse Wound Care #1 stated that once the heel wound came back in contact with a dirty surface, the nurse would have to re-cleanse the wound.During an interview on 09/30/2025 at 12:22 PM, Registered Nurse Infection Preventionist #1 stated that once the wound comes in contact with the dirty surface, it has to be re-cleansed; there is no point in putting the wound medication on the wound because the wound is still dirty.During an interview on 09/30/2025 at 12:45 PM, the Director of Nursing Services stated the nurse should have asked for assistance from another staff member when performing the heel wound care. Once the wound came in contact with the dirty surface, the nurse should have re-cleansed the wound.10 NYCRR 415.19(a)(1-3)

Based on observations, record review, and staff interviews during an abbreviated survey (NY00380105), the facility failed to prevent and protect an incident of physical abuse for one (1) resident (Resident #1) out of three (3) residents reviewed for abuse. Specifically, on 05/04/2025 at 3:59 PM, Certified Nursing Assistant #1 was observed on facility surveillance video restraining both hands of Resident #1 and hitting them in the head two (2) times. Using the reasonable person concept, this resulted in actual psychosocial harm that was Immediate Jeopardy. The findings are: Resident #1 had a medical diagnosis including dementia, hyperlipidemia, and hypertension. Review of the Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score- 99, Resident #1 is not understood and does not understand, indicating severe impairment for decision making. Review of the facility policy entitled, Abuse with a revision date of 03/2024, documented it is the policy of the facility to ensure that every resident is free from abuse and that their rights, dignity and respect are maintained. The policy further documented all staff are responsible for reporting abuse, intervene immediately to safeguard resident if abuse, neglect, mistreatment or misappropriation of property has been observed. The policy further documents that staff are to report incidents of actual or alleged abuse, neglect or mistreatment to charge Nurse or Supervisor immediately. Review of the facility surveillance video with the Administrator, Director of Nursing, and Risk Manager on 05/19/2025 at 10:28 AM revealed that on 05/04/2025 at 3:59 PM, Resident #1 was in the hallway sitting in a wheelchair outside of a resident room. Certified Nursing Assistant #2 was observed standing at the nursing station and Certified Nursing Assistant #3 was observed in the hallway taking vital signs of another resident. Certified Nursing Assistant #1 was observed pointing their finger in the face of Resident #1. Resident #1 responded by striking the hand of Certified Nursing Assistant #1 two (2) times. Certified Nursing Assistant #1 responded by striking Resident #1 across the head and proceeded to hold both resident's hands down towards the wheelchair. Certified Nursing Assistant #2 and #3 were observed in the hallway facing the direction of the incident. Review of the Resident Accident/Incident Report dated 05/07/2025 at 10:30 AM documented that on 05/06/2025 an anonymous visitor reported to Unit Liaison #1, they had witnessed staff having an inappropriate encounter with Resident #1 on 05/04/2025. On 05/06/2025 between approximately 5:30 PM and 6:00 PM, the visitor notified Unit Liaison #1 that on Sunday 05/04/2025, when the visitor was present on the unit, they heard screaming and observed staff hitting Resident #1 in the head. The Accident Incident Report further documented Unit Liaison #1 did not report this information to Unit Liaison #2 until the morning of 05/07/2025. The Accident/Incident Report further documented while reviewing the camera it was observed two (2) additional staff members were in the hallway at the time of the incident looking towards the incident. The facility investigation documented Certified Nursing Assistants #2 and #3 denied seeing the occurrence. On 05/19/2025 at 10:30 AM during observation and an attempt to interview, Resident #1 was observed sitting in the wheelchair in the hallway, the resident began yelling and waving appearing fearful. During an interview on 05/19/2025 at 12:53 PM with Unit Liaison #1, they stated they received a call on 05/06/2025 at approximately 5:30PM-6:00 PM from an unidentified caller who stated that on Sunday 05/04/2025, when the caller was visiting the facility, they heard screaming and when they came out of the room they were in, they observed staff hitting Resident #1 in the head. Unit Liaison # 1 stated on the morning of 05/07/2025 they reported this to Unit Liaison #2. Unit Liaison #1 further stated that they should have notified the supervisor immediately. Multiple telephone call attempts to reach Certified Nursing Assistant #1 on 05/19/2025 at 1:30 PM and 2:00 PM, as well as on 05/20/2025 between 10:30 AM and 2:00 PM were unsuccessful. Phone call messages were not returned, and a letter was sent, with no response to the letter. Multiple telephone call attempts to reach Certified Nursing Assistant #2 on 05/20/2025 at 2:00 PM and 3:00 PM were unsuccessful. A letter was sent with no response. During an interview with Certified Nursing Assistant #3 on 05/19/2025 at 3:16 PM, they stated that on 05/04/2025 they worked 3:00 PM - 11:00 PM as their regular assignment and they stated Resident #1 was on their assignment. They stated Resident #1 is not combative and does not hit staff during care. They stated on 05/04/2025, they were taking vital signs for another Resident and did not notice Certified Nursing Assistant #1 hit Resident #1. They stated they heard Resident #1 yelling but did not look to see what was going on. When asked about the surveillance video where they were observed looking in the direction of Resident #1, Certified Nursing Assistant #3 stated they did not recall. During a telephone interview with Licensed Practical Nurse #1 on 05/19/2025 at 1:51 PM, they stated that on 05/04/2025 at approximately 4:00 PM, while at the nurse's station they heard screaming in the hallway and saw Certified Nurse Aide #1 removing a resident away from Resident #1. Licensed Practical Nurse #1 stated they did not see anyone hitting Resident #1 and this was not reported by any staff in the hallway. Licensed Practical Nurse #1 stated if the staff saw any abuse going on, such as anyone hitting a resident, they should have informed the Nursing Supervisor immediately. When asked about the video surveillance not showing another resident in the proximity at that time, Licensed Practical Nurse #1 stated they did not see the video and could not recall. During an interview on 05/19/2025 at 3:08 PM with the Director of Nursing, they stated the incident was reported by Unit Liaison #1 on 05/07/2025. The incident should have been reported as soon as the visitor reported what they saw. They stated during the investigation and review of the surveillance video they could see Certified Nursing Assistant #1 strike Resident #1. They further stated during the investigation, Certified Nursing Assistant #2 and Certified Nursing Assistant #3 can be seen facing the direction of Certified Nursing Assistant #1 and Resident #1 however, they denied seeing anything , and did not report any incident to the nurse or the supervisor. The investigation summary documented abuse did occur to Resident #1. During an interview on 05/20/2025 at 2:00 PM with the Medical Director, they stated Resident #1 was assessed with no visible signs of injury. They further stated Resident #1, or any other resident, should not be hit by staff. The Medical Director stated the facility has a zero tolerance for abuse. 10 NYCRR 415.4 (b)(1)(i)

Based on record review, and staff interview during an abbreviated survey (NY00380105), the facility failed to implement Abuse/Neglect policies to prevent, protect and report an incident of physical abuse for one (1) resident (Resident #1) out of three (3) residents reviewed for abuse. Specifically, on 05/04/2025 at 3:59 PM, the facility failed to protect Resident #1 from Certified Nursing Assistant #1 who was observed restraining both hands of Resident #1 and hitting them in the head. This incident was observed by Certified Nursing Assistants #2 and #3 who were in the hallway at the time of the incident and did not identify, correct, intervene or report the occurrence of abuse. Additionally, the incident was reported by a visitor on 05/06/2025 to Unit Liaison #1 who did not report the incident to their supervisor (Unit Liaison #2) until 05/07/2025. This allowed Certified Nursing Assistants #1, #2, and #3 to have continued access to Resident #1 and the other 436 Residents in the facility. Using the reasonable person concept, this resulted in actual psychosocial harm that was Immediate Jeopardy. The findings are: Resident #1 had a medical diagnosis including dementia, hyperlipidemia, and hypertension. Review of the Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score- 99 indicating severe impairment for decision making. The review of the facility policy entitled, Abuse, with a revision date of 03/2024, documented it is the policy of the facility to ensure that every resident is free from abuse and that their rights, dignity and respect are maintained. The policy further documented all staff are responsible for reporting abuse, intervene immediately to safeguard resident if abuse, neglect, mistreatment or misappropriation of property has been observed. Report incident of actual or alleged abuse, neglect or mistreatment to charge Nurse or Supervisor immediately. Review of the facility video surveillance with the Administrator, Director of Nursing and Risk Manager on 05/19/2025 at 10:28 AM, revealed that on 05/04/2025 at 3:59 PM Resident #1was in the hallway sitting in a wheelchair outside of a resident room. Certified Nursing Assistant #2 is observed standing at the nurse's station and Certified Nursing Assistant #3 was observed in the hallway taking vital signs of another resident. Certified Nursing Assistant #1 was observed pointing their finger in the face of Resident #1. Resident #1 responded by striking the hand of Certified Nursing Assistant #1 twice. Certified Nursing Assistant #1 responded by striking Resident #1 across the head and proceeds to hold both of the resident's hands down towards the wheelchair. Review of the Resident Accident/Incident Report dated 05/07/2025 at 10:30 AM documented that on 05/06/2025 an anonymous visitor reported to Unit Liaison #1 that they witnessed Staff had an inappropriate encounter with Resident #1 on 05/04/2025. The Accident Incident Report further documented Unit Liaison #1 did not report this information to Unit Liaison #2 until the morning of 05/07/2025. The Accident/Incident Report further documented while reviewing the camera, it was observed that Certified Nursing Assistant #1 had inappropriate contact with Resident #1. It was also noted that two (2) additional staff members were in the hallway at the time of the incident looking towards the incident. The facility investigation documented that Certified Nursing Assistants #2 and #3 denied seeing the occurrence. During an interview on 05/19/2025 at 12:53 PM with Unit Liaison #1, they stated they received a call on 05/06/2025 at approximately 5:30PM-6:00PM from an unidentified caller who stated that on Sunday 05/04/2025, when the caller was visiting the facility, they heard screaming and when they came out of the room they were in, they observed staff hitting Resident #1 in the head. Unit Liaison #1 stated on the morning of 05/07/2025, they reported this to Unit Liaison #2. They further stated that they should have notified the supervisor immediately about the incident. Multiple telephone call attempts to reach Certified Nursing Assistant #1 on 05/19/2025 at 1:30 PM and 2:00 PM, as well as on 05/20/2025 between 10:30 AM and 2:00 PM were unsuccessful. Phone call messages were not returned, and a letter was sent, with no response to the letter. Multiple telephone call attempts to reach Certified Nursing Assistant #2 on 05/20/2025 at 2:00 PM and 3:00 PM were unsuccessful. A letter was sent with no response. During an interview with Certified Nursing Assistant #3 on 05/19/2025 at 3:16 PM, they stated that on 05/04/2025 they worked 3:00 PM - 11:00 PM as their regular assignment and they stated Resident #1 was on their assignment. They further stated Resident #1 is not combative and does not hit staff during care. They stated on 05/04/2025 they were taking vital signs for another Resident and did not notice Certified Nursing Assistant #1 hit Resident #1. They stated they heard Resident #1 yelling but did not look to see what was going on. When asked about the video surveillance where they were observed looking in the direction of Resident #1, Certified Nursing Assistant #3 stated they did not recall. During a telephone interview with Licensed Practical Nurse #1 on 05/19/2025 at 1:51 PM, they stated that on 05/04/2025 at approximately 4:00 PM, while at the nurse's station, they heard screaming in the hallway and saw Certified Nurse Aide #1 removing a resident away from Resident #1. Licensed Practical Nurse #1 stated they did not see anyone hitting Resident #1 and this was not reported by any staff in the hallway. Licensed Practical Nurse #1 stated if the staff saw any abuse, such as anyone hitting a resident, they should have informed the Nursing Supervisor immediately. When asked about the video surveillance not showing another resident in the proximity at that time, Licensed Practical Nurse #1 stated they did not see the video and could not recall. During an interview conducted on 05/19/2025 at 3:08 PM with the Director of Nursing, they stated the incident was reported by Unit Liaison #1 on 05/07/2025. The incident should have been reported as soon as the visitor reported what they saw. They stated during the investigation and review of the video surveillance they could see Certified Nursing Assistant #1 strike Resident #1. They further stated during the investigation Certified Nursing Assistant #2 and Certified Nursing Assistant # 3 were seen facing the direction of the incident, however both denied seeing anything, and did not report any incident to the floor nurse or the supervisor. The investigation summary documented abuse did occur to Resident #1. During an interview conducted on 05/19/2025 at 4:30 PM with the Facility Administrator they stated the incident should have been reported immediately. They further stated Certified Nursing Assistant #2 and #3 denied seeing abuse however are observed facing the direction of the incident. The Administrator stated the facility has a zero-tolerance policy for abuse. They further stated the staff should have intervened and protected the resident and reported immediately. 10 NYCRR 415.4(b)(2)

Based on interviews and record review conducted during an abbreviated survey (Complaint # NY00340951) the facility failed to protect a resident from physical abuse by nursing home staff. This was evident for one of three residents reviewed for physical abuse (Resident #1). Specifically, on 5/2/24 at 6:30AM Certified Nurse Assistant #1 was observed by Registered Nurse #1 pushing Resident #1 to the floor. The findings were: Resident #1 was admitted to the facility with medical diagnosis including Non-Alzheimer's Dementia, Diabetes Mellitus, and coronary artery disease (heart disease). The Annual Minimum Data Set, dated dated dated [DATE] documented Resident #1 had a Brief Interview for Mental Status score of 9 indicating impaired cognition. The Minimum data set further documented no behaviors exhibited, and Resident #1 uses a manual wheelchair for ambulation. The facility policy and procedure titled Resident Abuse dated February 2024 documented it is the policy of the facility to ensure that every resident is free from abuse and that their rights are respected, and dignity maintained. The comprehensive care plan dated 4/2/2024 titled High risk for abuse related to vulnerable population documented Resident #1 will not experience any form of abuse x 90 days. The interventions include 1:1 room visits to provide emotional support, observe for signs of abuse, and monitor for changes in mood and behavior. The physician order dated 4/30/2024 documented Aspirin (blood thinning effect) 81 milligrams to be administered by mouth daily. The Medication Administration Record dated April 2024 documented resident received Aspirin 81milligrams every day for the month of April. A Nursing progress note dated 5/2/2024 at 1:30PM documented Resident #1 was admitted to the surgical intensive care unit with a diagnosis of non-traumatic intracranial hemorrhage . There is no additional documented evidence in the nursing progress note related to a fall or incident on 5/2/2024. The facility communication transfer form dated 5/2/2024 at 6:30AM documented Resident #1 was pushed by a Certified Nurse Assistant #1 and fell on the floor. The form further documented Resident #1 hit his head and left leg and was transferred to the hospital for further evaluation. The undated and unsigned facility investigation titled Investigation of case NY00340951 documented on 5/2/2024 at around 5:50AM Resident #1 became upset when the Certified Nurse Assistant #1 moved their wheelchair. Resident #1 took the wheelchair back to the room. Certified Nurse assistant #1 and Resident #1 had a verbal disagreement as Certified Nurse Assistant #1 refused to keep the wheelchair in the room. Resident #1 became angry and walked towards Certified Nurse Assistant #1 and was pushed away. Resident #1 fell , hitting his head and left leg onto the floor. As per Nursing Supervisor #1 assessment, Resident #1 pointed to his head and was noted with limited range of motion of the left leg. Resident #1 was transferred and admitted to the hospital for further evaluation. The hospital records dated 5/2/2024 documented Resident #1 was found on the floor by staff and complained of left sided pain and unable to move extremities. The Computed Tomography (scan used to take images) of the head dated 5/2/2024 documented there is a round hyper density likely reflecting acute hemorrhage (bleeding) withing the subcortical region of the high right posterior frontal lobe. The hematoma measures 1.3x1.2 centimeters. During a telephone interview conducted with Certified Nurse Assistant #1 on 5/22/2024 at 3:15PM they stated they moved Resident #1 wheelchair into the hallway to get access to the sink. Resident #1 got up and went to get the wheelchair. Certified Nurse Assistant #1 stated as they were walking out from caring for the roommate, Resident #1 walked towards them and attempted to hit Certified Nurse Assistant #1. Certified Nurse Assistant #1 stated they put up their hands to protect themselves from Resident #1 and inadvertently touched them causing Resident #1 to fall to the floor. Certified Nurse #1 stated the Registered Nurse #1 was in the room and did not redirect Resident #1. During an interview conducted with Registered Nurse #1 on 5/6/2024 at 3:04PM , they stated that at about 5:40AM while in the hallway giving medication, they observed Resident #1 upset because Certified Nurse Assistant #1 removed the wheelchair from the room. Registered Nurse #1 stated the wheelchair prevented access to the sink, so Certified Nurse Assistant #1 moved the chair into the hallway. Resident #1 walked to the hallway to retrieve the wheelchair and was engaged in a verbal exchange with Certified Nurse Assistant #1. Registered Nurse #1 stated Resident #1 is non-English speaking so they could not understand what was said. Registered Nurse #1 stated Certified Nurse's Assistant #1 was arguing back and suddenly pushed Resident #1 to the floor causing him to hit his head on the floor and left leg against the bed. Registered Nurse #1 stated Certified Nurse Assistant #1 was immediately removed from the room and they notified the supervisor. During an interview conducted with Nursing Supervisor #1 on 5/6/2024 at 2:17PM they stated Registered Nurse #1 called them to the to the unit because a resident fell . Nursing Supervisor #1 stated when they arrived in the unit, Registered Nurse #1 reported that Certified Nurse Assistant pushed Resident #1 to the floor. Resident #1 speaks Korean, Nursing Supervisor #1 could not understand, however Resident #1 was gesturing towards Certified Nurse Assistant #1 that Certified Nurse Assistant #1 pushed them. Resident #1 was touching his head and had facial grimace and was unable to move the left leg as usual. The physician was notified and instructed to send Resident #1 to the hospital. Nursing Supervisor #1 stated they interviewed Certified Nurse Assistant #1 who stated Resident #1 was coming towards them and they pushed Resident #1 away. Nursing Supervisor #1 stated Certified Nurse Assistant #1 was sent to the nursing office and they notified the Director of Nursing and the physician immediately. During an interview conducted with the Director of Nursing on 5/6/2024 at 2:30PM who stated they were notified by Nursing supervisor #1 that Resident #1 was pushed by Certified Nurse Assistant #1 and was sent to the hospital. The Director of Nursing states they spoke to the nurse on the unit who reported they witnessed Certified Nurse Assistant #1 push Resident #1, causing a fall. Certified Nurse Assistant #1 was immediately taken off the schedule. The Nurse Supervisor #1 assessed Resident #1 and notified the physician and family. The police were not notified while they completed the investigation, however, they notified the family who stated they did not want the police involved. The Director of Nursing stated there is no tolerance for resident abuse. The facility is reeducating all their staff on the abuse policy. During an interview conducted with the Facility Administrator on 5/6/204 at 2:45pm who stated they were notified by the Director of Nursing reporting an altercation between a resident and an employee. The facility was still investigating and wanted to complete the investigation prior to notifying the police but the family did not want to call the police. The family was informed the employee was terminated and the facility does not tolerate abuse. The staff are educated about abuse on hire, annually and as needed. 10 NYCRR 415.4(b)(1)(i)

Based on record review and staff interviews during the Recertification and Abbreviated Survey (Complaint #NY00314085) initiated on 3/26/2024 and completed on 4/2/2024, the facility did not ensure that each resident's environment remains free of accident hazards as is possible. This was identified for two (Resident #42 and #159) of eight residents reviewed for accidents. Specifically, 1) on 4/4/2023 Resident #42 fell out of the mechanical lift when the mechanical lift sling pad loops got detached from the mechanical lift's sling bar hook. The mechanical lift used for the resident's transfer was missing the safety latches (clips), which were supposed to hold the mechanical lift sling pad loops in place, on the mechanical lift's sling bar hook. Certified Nursing Assistant #14, who was assisting with the resident's transfer, was aware of the missing safety latches and continued with transferring the resident from the bed to the wheelchair. Subsequently, the resident was transferred to the hospital and was diagnosed with a Right Humerus (upper arm bone) Fracture. 2) Additionally, Resident #159 was observed on 3/26/2024 with one medication capsule (Neurontin 100 milligrams) in a medication cup on their overbed table with no staff member in the vicinity. The resident was not assessed to self-administer their medication and did not have a physician's order to self-administer medications. This resulted in actual harm to Resident #42 that is not Immediate Jeopardy. The findings are: 1) Resident #42 was admitted with diagnoses that included Cerebral Vascular Accident with Right Hemiplegia (paralysis of one side of the body), and Osteoarthritis (degenerative joint disease). The annual Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 11 which indicated the resident had moderately impaired cognition. The resident had no behavior problems and required extensive assistance of two staff members for bed mobility and total assistance of two staff members for transfers. The facility policy and procedure dated 10/11/2023 for Management of Essential Equipment Malfunction documented to replace and sequester the malfunctioning equipment without interruption to patient care. In the event of malfunctioning of a medical device and or injuries sustained to a patient caused by equipment, the device must be sequestered, labeled with an appropriate tag describing the malfunction, and sent to the Medical Electronics Department. The facility policy and procedure for Application and Use of Transfer Sling revised 10/2022 documented that at least two staff members are needed to transfer a resident using a mechanical lift, the nursing staff will ensure resident safety during transfer procedures and inspect the (mechanical lift) for functionality prior to use for safety. The undated instruction manual for the mechanical lift, under the safety instruction section, documented that before lifting always make sure that accessories are not damaged, the lifting accessory is correctly attached to the lift; the latches are intact; missing or damaged latches must always be replaced; and that the sling's strap (pad) loops are correctly connected to the sling bar hooks when the sling straps are stretched up but before the patient is lifted from the underlying surface. A Comprehensive Care Plan for activities of daily living dated 2/23/2023 documented interventions that included but were not limited to provide total assistance of two staff members for transfers via a mechanical lift. A Comprehensive Care Plan for falls dated 2/23/2023 documented interventions included but were not limited to transfer the resident out of bed to a wheelchair via a mechanical lift. A review of the Certified Nursing Accountability Record dated 3/2023 documented the resident required the use of a mechanical lift and two staff members for transfers. A nursing progress note dated 4/4/2023 documented the resident was alert, verbally responsive, and able to make needs known. The resident sustained a fall during the transfer and complained of right shoulder pain. The resident's physician was notified and visited the resident. Tylenol (pain medication) 1000 milligrams was administered as per the physician's order. The resident was transferred to the hospital for further evaluation. A medical progress note dated 4/4/2023 documented the resident fell during transfer and complained of right arm and right shoulder pain. There was a decreased passive range of motion causing severe pain. Tylenol Extra Strength was ordered for pain and the resident was sent to the emergency room for further evaluation. A physician's order dated 4/4/2023 documented to administer Tylenol 500 milligram, give 2 tablets by mouth one time only for right shoulder pain. A physician's order dated 4/4/2023 at 12:52 PM documented to transfer the resident to the emergency room , Status Post fall. The Hospital Radiology Report dated 4/4/2023 documented a fracture of the right humerus. The Hospital Orthopedic Consult and Recommendation dated 4/4/2023 documented the Computerized Tomography (CT) scan of the right shoulder showed there was a right humerus fracture. The plan included no weight bearing to the right upper extremity; to place a sling to the right upper extremity; and pain control. The Accident and Incident Report dated 4/4/2023 documented that at 11:15 AM the resident sustained a fall during transfer and the resident was transferred to the emergency room for complaint of pain to the right shoulder and right elbow. The resident was unable to describe the occurrence and stated, I fell . A nursing admission note dated 4/6/2023 at 2:00 PM documented the resident was readmitted to the facility status post fall with diagnoses of humerus fracture and Urinary Tract Infection (UTI). The resident had a right arm sling status post fracture and required extensive assistance for all activities of daily living and three staff members' assistance with the mechanical lift transfers. The Accident and Incident Summary dated 4/10/2023 documented a demonstration of the procedure which was performed with the two involved Certified Nursing Assistants shortly after the occurrence revealed a missing metal closure clip (latch) on the right hook of the mechanical lift. The mechanical lift was removed from the unit for further inspection and repair. The team analyzed the root causes of the event; any equipment with missing parts or malfunctioning should have been removed from the unit and reported immediately for maintenance; there was a need to reinforce with staff to ensure the attachment of mechanical lift pad loops onto the hooks and that the staff is using the right size sling. A Work Order Sheet dated 4/13/2023 documented that a full service was completed for the Unit 24 Electrical Patient Lift (mechanical lift) and both missing safety clips were replaced for the sling bar. Registered Nurse #11, who was on duty on 4/4/2023 and responded to the accident, was interviewed on 3/28/2024 at 9:14 AM. Registered Nurse #11 stated they were outside a resident's room when they heard Certified Nursing Assistant #15 calling for assistance. Registered Nurse #11 stated they ran to the room and observed Resident #42 on the floor between the legs of the mechanical lift. Registered Nurse #11 stated they assessed the resident who complained of right arm pain and was transferred to the hospital. Registered Nurse #11 stated they spoke with Certified Nursing Assistant #14 and Certified Nursing Assistant #15, who reported the right side of the safety latch was missing from the mechanical lift sling bar where the mechanical lift sling pad loops came off. Registered Nurse #11 stated maintenance was called, and the mechanical lift sling bar hook was fixed. Registered Nurse #11 was re-interviewed on 4/1/2024 at 9:17 AM and stated they were not aware the safety latches were missing from the sling bar until after Resident #42 fell from the mechanical lift. Registered Nurse #11 stated Certified Nursing Assistants were responsible for checking the mechanical lift before they used the machine and if a problem was identified they were to report the issue to the unit nurses immediately. Registered Nurse #11 stated a sticker should be placed on the machine indicating the machine is out of order and the mechanical lift is then removed from the unit. Registered Nurse #11 stated when they were examining the mechanical lift, they observed that one of the safety latches were missing. Registered Nurse #11 stated they could not recall if the safety latch was missing on both sides. An attempt to call Certified Nursing Assistant #15 on 3/27/2024 at 3:07 PM was made; however, the staff member was out of the country on vacation and would not be available until 4/3/2024 as reported by the Director of Nursing Services. A re-enactment observed by the surveyor was completed on 3/28/2024 at 8:15 AM with Certified Nursing Assistant #14 who had assisted with Resident #42's transfer on 4/4/2023. Certified Nursing Assistant #14 demonstrated that they were on one side of Resident #42 and the assigned Certified Nursing Assistant #15 was on the other side of Resident #42. Certified Nursing Assistant #14 stated they attached the mechanical lift sling pad loops to the hook of the mechanical lift sling bar on their side and the assigned Certified Nursing Assistant #15 attached the mechanical lift sling pad loops on their side. Certified Nursing Assistant #14 stated that assigned Certified Nursing Assistant #15 was controlling the mechanical lift and lifted the resident off the bed without a problem. Certified Nursing Assistant #14 stated just before Certified Nursing Assistant #15 began to lower the resident onto the wheelchair, they (Certified Nursing Assistant #14) observed that one of the mechanical lift sling pad loops came off the mechanical lift sling bar hook, and the resident slid out of the mechanical lift sling pad onto the floor between the legs of the mechanical lift. Certified Nursing Assistant #14 stated the safety latch was missing from the right side of the mechanical lift sling bar and that the safety latch keeps the mechanical lift sling pad loops in place and prevents the mechanical lift sling pad loops from coming off the hook. Certified Nursing Assistant #14 was interviewed on 3/28/2024 at 8:34 AM and stated during Resident #42's mechanical lift transfer on 4/4/2023, when Certified Nursing Assistant #14 was hooking up the mechanical lift sling pad loops, they noticed the safety latch was missing; however, continued using the mechanical lift. Certified Nursing Assistant #14 stated they did not switch the mechanical lift because the second mechanical lift available on the unit was in use. A subsequent interview was conducted with Certified Nursing Assistant #14 on 4/1/2024 at 9:10 AM. Certified Nursing Assistant #14 stated both safety latches on the mechanical sling bar were missing for a long time and they have been using the mechanical lift without the safety latches. Certified Nursing Assistant #14 could not recall how long the safety latches on the mechanical lift had been missing. Certified Nursing Assistant #15's written statement, dated 4/4/2023, documented that while transferring Resident #42 with the mechanical lift, they noticed one of the loops (right top one) fell off. Certified Nursing Assistant #14 and Certified Nursing Assistant #15 tried their best to lower the patient. An interview was conducted on 3/28/2024 at 10:19 AM with the Medical Electronic Technician (maintenance employee) who was responsible for servicing the mechanical lift and other medical equipment. The Medical Electronic Technician stated the mechanical lift that was used for Resident #42 was last serviced on 7/1/2022. All the mechanical lifts are checked annually and as needed. The Medical Electronic Technician stated after the resident's fall, they were informed by the Director of Environmental Services that the safety clips were missing. The Medical Electronic Technician stated when they checked the mechanical lift sling bar, both safety clips were missing and on 4/13/2023 both safety clips were replaced. The Medical Electronic Technician stated they were not notified of the missing safety latches prior to the resident's fall. The Medical Electronic Technician stated if the nursing staff observed missing parts or that the machine was not functioning properly, nursing staff were supposed to email their department (Medical Electronic) The Medical Electronic Technician stated that the safety latch on the mechanical lift functions to keep the mechanical lift sling pad loops from slipping off of the mechanical lift sling bar hooks. An interview with Resident #42's physician, who was on duty on 4/4/2023, was conducted on 4/1/2024 at 9:52 AM. The physician stated they assessed Resident #42 after the resident fell from the mechanical lift on 4/4/2023. The physician stated that the resident complained of severe pain to the right arm and was sent to the emergency room . The physician stated the pain in the resident's right arm was related to a fracture which was directly related to the fall from the mechanical lift. The Registered Nurse Risk Manager was interviewed on 4/1/2024 at 10:16 AM and stated on 4/4/2023 they were on the resident's unit and when they got to the resident's room the resident was already back in bed; however, the mechanical lift was still in the resident's room. The Registered Nurse Risk Manager stated the safety latch on the right side of the sling bar hook was missing. The Registered Nurse Risk Manager stated that Certified Nursing Assistant #14 and Certified Nursing Assistant #15 informed them the mechanical lift safety latch was missing prior to the use of the mechanical lift for Resident #42. The Registered Nurse Risk Manager stated the staff should not have used the mechanical lift as the safety latch was missing. The Registered Nurse Risk Manager stated the staff should have immediately reported the faulty mechanical lift issue to the charge nurse. The Inservice Coordinator was interviewed on 4/1/2024 at 10:45 AM and stated all Certified Nursing Assistants receive training on the use of the mechanical lift transfer and then a competency is completed at least yearly, and as needed. The Inservice Coordinator stated if the Certified Nursing Assistants observe any malfunction that prevents the machine from functioning as designed, then the Certified Nursing Assistants should report the malfunction to the unit Registered Nurse in charge or the Supervisor. The Inservice Coordinator stated the staff should not have used the mechanical lift to transfer Resident #42 if the safety latch was missing. The Director of Nursing Services was interviewed on 4/1/2024 at 11:36 AM and stated they expected the staff to inspect the equipment before use and if there was something wrong with the equipment, or if the equipment was broken, the staff should have reported the issue to the unit nurses, and the equipment should have been immediately removed from the unit. The Director of Nursing Services stated the staff should not have used the mechanical lift knowing the safety latch was missing. The Director of Nursing Services stated Resident #42 sustained a fracture due to a fall from the mechanical lift. The Director of Nursing Services stated after the Registered Nurse Risk Manager completed the investigation, the mechanical lift was taken out of service on 4/4/2023. 44963 2) Resident #159 was admitted with diagnoses that included Peripheral Autonomic Neuropathy (when there is damage to the nerves that control automatic body functions this can affect the blood pressure or temperature control), End Stage Renal Disease, and Seizures. The Annual Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 3 which indicated severely impaired cognition. The Minimum Data Set assessment documented the resident was usually able to understand others. The facility's policy titled, Medication Administration last reviewed 3/2024 documented that medications are never left at the bedside. The unit nurse must watch the resident take the medications. Directly Observed Therapy is required by the nurse when administering medication. Visualization of the oral cavity by a resident's tongue sweep after the resident has taken a dose of medication is required to verify that it (the medication) has been swallowed. A physician's order dated 10/8/2023 documented to administer Neurontin 100 milligram (mg), 1 capsule by mouth three times a day for Peripheral Autonomic Neuropathy. A Seizure Activity Comprehensive Care Plan dated 2/21/2024 documented the resident has potential for seizure activity related to Seizure disorder. Interventions included but were not limited to administer anticonvulsant(s) as per the physician's order. Resident #159 was interviewed on 3/26/2024 at 2:30 PM. Resident #159 was observed in bed and alert. A medication cup containing one white dry capsule was observed on the resident's overbed table within the resident's reach. Resident #159 was unable to name the medication and did not know how long the medicine had been there on the overbed table. There was no staff member present in the resident's room. The medication was observed in Resident #159's room accompanied by Registered Nurse #7 at 2:35 PM. Registered Nurse #7 stated that the medication in the cup was a Neurontin 100 milligram capsule that they (Registered Nurse #7) had administered to Resident #159 approximately ten minutes ago. Registered Nurse #7 stated they observed Resident #159 put the medicine in their (Resident #159) mouth. Registered Nurse #7 stated they were then called away to see another resident on the unit and left the resident with the empty medication cup and their nutrition supplement. Registered Nurse #7 stated they assumed the resident had swallowed the medicine but did not ask the resident to open their mouth to check. Licensed Practical Nurse #6 was interviewed on 3/28/2024 at 1:39 PM. Licensed Practical Nurse #6 stated that they were the regularly assigned day (7:00 AM-3:00 PM) shift nurse on the unit where Resident #159 resided; however, they did not work on that unit on 3/26/2024. Licensed Practical Nurse #6 stated they regularly administered medications and Resident #159 required a lot of encouragement to take their (Resident #159) medication. Licensed Practical Nurse #6 stated they have never observed Resident #159 with any noncompliant behaviors. Licensed Practical Nurse #6 stated Resident #159 cannot take medications on their own and there was no reason for the medication to be left unattended with the resident. Registered Nurse #8 was interviewed on 3/29/2024 at 1:44 PM and stated that they were the regularly assigned evening (3:00 PM-11:00 PM) shift nurse on the unit where Resident #159 resided. Registered Nurse #8 stated they regularly administered medications to Resident #159 who required verbal prompts to take their medications. Registered Nurse #8 stated they have never observed Resident #159 with any noncompliant behaviors. Registered Nurse #8 stated Resident #159 cannot take medications on their own and the nurses should not leave any medicine with the resident unless the resident was assessed for self-administration. The Director of Nursing Services was interviewed on 3/29/2024 at 3:12 PM and stated that the nurse who administered medications to Resident #159 should have ensured the medications were swallowed by the resident. The Director of Nursing Services stated that Resident #159 was not allowed to self-administer their medication and therefore the medication should not have been left unattended by Resident #159's bedside. 10 NYCRR 415.12(h)(1)(2)

Based on observations, record review, and interviews during the Recertification Survey initiated on 3/26/2024 and completed on 4/2/2024, the facility did not ensure that drug records were in order and accounted for all controlled drugs. This was identified on three (Unit 21, Unit 22, and Unit 31) of 13 nursing units. Specifically, during the medication storage task observations on Unit 21, Unit 22, and Unit 31, the Controlled Substance Administration Record form was not reconciled to reflect the available controlled medications in the medication blister pack for Resident #35 (Unit 21), Resident #221 (Unit 22) and for Resident #7 (Unit 31). The finding is: The facility's policy titled, Medication: Controlled Substances, revised 3/2024, documented that immediately after a medication dose is administered the licensed nurse administering the drug enters all of the following information on the controlled substance administration record: date/time of administration, dose/amount administered, and the signature of the nurse administering the drug. 1) Resident #35 was admitted with diagnoses including Diabetes Mellitus, Anxiety Disorder, and Depression. The 1/8/2024 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. A physician's order effective 3/8/2024 documented to administer Klonopin (Clonazepam-a controlled substance used to treat anxiety) 1-milligram tablet, one tablet by mouth two times a day, for diagnosis of Anxiety Disorder. During an observation of Unit 21's medication cart on 3/26/2024 at 1:16 PM, Resident #35's Controlled Substance Administration Record form for Clonazepam documented that 55 tablets of Clonazepam were remaining; however, the blister pack for Clonazepam only had 24 tablets. Registered Nurse #1 was present during the observation. Registered Nurse #1 was interviewed on 3/26/2024 immediately after the observation and stated that there were 30 additional tablets available, in storage, in the medication room. Registered Nurse #1 stated they gave one tablet of Clonazepam to Resident #35 at 10:00 AM but did not document in the Controlled Substance Administration Record form that the dose was administered because the unit was busy. Registered Nurse #1 stated they should have documented and reconciled the Controlled Substance Administration Record as soon as they removed the controlled substance from the blister pack. 2) Resident #221 was admitted with diagnoses including Diabetes Mellitus, Cerebral Palsy, and Seizure Disorder. The 1/18/2024 Minimum Data Set assessment documented no Brief Interview for Mental Status due to the resident's severely impaired cognitive skills for daily decision-making. A physician's order dated 3/11/2024 documented to administer Vimpat (Lacosamide- controlled substance used to treat seizures) 100 milligrams tablet; give one tablet via gastrostomy tube two times a day, for diagnosis of Seizures. During an observation of Unit 22's medication cart on 3/26/2024 at 1:25 PM Resident #221's Controlled Substance Administration Record form for Lacosamide (Vimpat) documented that 34 tablets were remaining; however, the blister pack for Lacosamide only had three tablets. Licensed Practical Nurse #2 was present during the observation. Licensed Practical Nurse #2 was interviewed on 3/26/2024 immediately after the observation and stated there were 30 additional tablets in storage in the medication room. Licensed Practical Nurse #2 stated they gave one Lacosamide tablet to Resident #221 at 10:00 AM. Licensed Practical Nurse #2 stated normally they document on the Controlled Substance Administration Record form immediately after the medication is administered; however, today the unit was busy and they were not feeling well. 3) Resident #7 was admitted with diagnoses including Diabetes Mellitus, Seizure Disorder, and Schizophrenia. The 2/15/2024 Minimum Data Set assessment documented no Brief Interview for Mental Status score due to the resident's moderately impaired cognitive skills for daily decision-making. A physician's order dated 3/19/2024 documented to administer Xcopri (a controlled substance used to treat seizures) 100 milligrams tablet; give one tablet by mouth per day, for diagnosis of Seizures. During an observation of Unit 31's medication cart on 3/26/2024 at 2:07 PM, Resident #7's Controlled Substance Administration Record form for Xcopri documented that eight tablets were remaining; however, the blister pack for Xcopri only had seven tablets. Registered Nurse #2 was present during the observation. Registered Nurse #2 stated they administered one Xcopri tablet to Resident #7 at 10:00 AM. Registered Nurse #2 stated they have been getting calls from residents and have been busy and that is why they (Registered Nurse #2) did not document on the Controlled Substance Administration Record form when they removed the controlled medication from the blister pack for administration. The Registered Nurse Inservice Coordinator was interviewed on 3/27/2024 at 10:26 AM and stated all medications have to be signed for when they are administered, not just narcotics or controlled substances. The Registered Nurse Inservice Coordinator stated whenever a narcotic or controlled substance is removed from a blister pack, the Controlled Substance Administration Record form has to be updated and the controlled substance count of the blister pack has to be confirmed. The Director of Nursing Services was interviewed on 3/27/2024 at 1:52 PM and stated signing the Controlled Substance Administration Record form has to be done immediately after a medication is administered because reconciliation of the Controlled Substance Administration Record is necessary to keep track of controlled substances. 10 NYCRR 415.18(b)(1)(2)(3)

Based on observations, record review, and interviews during the Recertification Survey initiated on 3/26/2024 and completed on 4/2/2024 the facility did not ensure that each resident was treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of their quality of life. This was identified for two (Resident #134 and Resident#192) of three residents reviewed for dignity. Specifically, during a lunch meal observation on 3/26/2024 two staff members were observed standing over Resident #134 and Resident #192 while they assisted the residents with eating. The findings are: The facility's policy titled, Meal Pass documented to provide dignified care to residents during the meal pass. 1) Resident #134 was admitted with diagnoses that included Cerebral Vascular Accident (stroke), Dementia, and Depression. The Quarterly Minimum Data Set assessment dated [DATE] documented the Brief Interview for Mental Status score was 11, which indicated the resident had moderately impaired cognition. The resident required setup or clean-up assistance for meals. The Comprehensive Care Plan for Activities of Daily Living initiated on 8/18/2023 and updated on 11/9/2023 documented Resident #134 needed setup or clean-up assistance with eating and was able to feed themself. During the Dining Task observation conducted on Unit 14 during the lunch meal on 3/26/2024 from 12:24 PM to 12:56 PM Resident #134 was observed being fed their yogurt by Certified Nursing Assistant #2, who was standing over the resident. Certified Nursing Assistant #2 was interviewed on 3/26/2024 at 2:16 PM and stated Resident #134 needed encouragement to eat and before they (Certified Nursing Assistant #2) removed the tray they wanted to encourage Resident #134 to eat a little more yogurt. Certified Nursing Assistant #2 stated Resident #134 normally eats independently once the tray is set up. Certified Nursing Assistant #2 stated they should have sat down next to Resident #134 while they assisted the resident with completing their meal. Registered Nurse #4 was interviewed on 3/26/2024 at 2:29 PM. Registered Nurse #4 stated a staff person assisting a resident with their meal should be seated next to the resident. Registered Nurse #4 stated a staff person is expected to sit and interact with the resident in order to maintain the resident's dignity and quality of life. The Director of Nursing Services was interviewed on 3/26/2024 at 3:48 PM. The Director of Nursing Services stated a staff person is expected to sit next to and interact with the resident while assisting with a meal in order to maintain the resident's dignity and quality of life. The Director of Nursing Services stated they reviewed the Meal Pass policy, and the policy did not explicitly indicate that staff should sit next to the resident while assisting with meals. Resident #134 was interviewed on 3/28/2024 at 11:31 AM. Resident #134 stated they were able to eat independently; however, they sometimes felt weak and the staff assisted them with eating. Resident #134 could not recall if the staff normally sat next to them during that time. 2) Resident #192 was admitted to the facility with diagnoses that included Cerebral Vascular Accident (stroke), Dementia, and Left Hemiparesis (weakness). The resident required setup or clean-up assistance for meals. The Comprehensive Care Plan for Activities of Daily Living initiated on 8/30/2023 and updated on 11/23/2023 documented Resident #192 needed setup or clean-up assistance with eating and was able to feed themself. During the Dining Task observation conducted on Unit 14 during the lunch meal on 3/26/2024 from 12:24 PM to 12:56 PM Resident #192 was observed being fed their sherbet by Certified Nursing Assistant #3, who was standing over the resident. Certified Nursing Assistant #3 was interviewed on 3/26/2024 at 2:23 PM. Certified Nursing Assistant #3 stated Resident #192 normally did not require assistance with eating once their meal tray was set up. Certified Nursing Assistant #3 stated Resident #192 does not have use of their left hand but was able to use a utensil in their right hand. Certified Nursing Assistant #3 stated they normally sit next to a resident who requires total assistance with eating but during the lunch meal, they (Certified Nursing Assistant #3) wanted to encourage Resident #192 to eat a little bit more before they (Certified Nursing Assistant #3) removed Resident #192's tray. Certified Nursing Assistant #3 stated they should have been seated next to Resident #192 when they assisted the resident with their sherbet. Certified Nursing Assistant #3 understood it was a dignity concern and they would normally sit next to a resident they were assisting with a full meal. Registered Nurse #4 was interviewed on 3/26/2024 at 2:29 PM. Registered Nurse #4 stated a staff person assisting a resident with their meal should be seated next to the resident. Registered Nurse #4 stated a staff person is expected to sit and interact with the resident in order to maintain the resident's dignity and quality of life. The Director of Nursing Services was interviewed on 3/26/2024 at 3:48 PM. The Director of Nursing Services stated a staff person is expected to sit next to and interact with the resident while assisting with a meal in order to maintain the resident's dignity and quality of life. The Director of Nursing Service stated they reviewed the Meal Pass policy, and the policy does not explicitly indicate that staff should sit next to the resident while assisting with meals. Resident #192 was interviewed on 3/28/2024 at 11:38 AM. Resident #192 stated they did not like to be fed because it made them feel worse than they really were. Resident #192 stated their left hand is in a brace due to a stroke and their right hand sometimes shakes. Resident #192 stated on days when their right hand shakes more than normal they required assistance with eating and could not recall if staff sat next to them or stood over them. 10 NYCRR 415.3(d)(1)(i)

Based on observations, record review, and interviews during the Recertification Survey initiated on 3/26/2024 and completed on 4/02/2024, the facility did not ensure that each resident received services in the facility with reasonable accommodation of resident needs including ensuring that the resident has a call system within reach and is able to use it if desired. This was identified for one (Resident #233) of one resident reviewed for the Environmental Task. Specifically, Resident #233 was observed lying in a Geri chair in their room on 3/26/2024 at 10:15 AM, 3/26/2024 at 2:39 PM, and on 3/28/2024 at 9:46 AM. The call bell was observed on the floor on each occasion and was not within the resident's reach. The finding is: The facility's policy titled, Call Bells/Call Bell Audit revised in April 2023, documented the call bell must always be accessible to the resident. Resident #233 was admitted with diagnoses that included Cerebral Infarction, Pulmonary Embolism, and Tachycardia. The Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 00 which indicated the resident had severe cognitive impairment. The Minimum Data Set assessment documented the resident had a range of motion impairment to both upper extremities. The Comprehensive Care Plan for Falls dated 2/28/2024 documented to keep the call bell within the resident's reach. The Comprehensive Care Plan for Potential for Injuries dated 3/07/2024 documented to place the call bell within reach of the resident. During an observation on Unit 21 on 3/26/2024 at 10:15 AM and again on 03/26/2024 at 2:39 PM, Resident #233 was lying in a [NAME] chair in their bedroom with no call bell within their reach. The call bell was observed on the floor on both occasions. Resident #233 was not able to be interviewed. On 03/27/2023 at 11:03 Certified Nursing Assistant #5 was observed finishing their care with Resident #233 and placing the call bell on her blanket within reach. During an observation on 3/28/2024 at 9:46 AM the surveyor walked with Registered Nurse #1, the Charge Nurse, into Resident#233's room. The resident was resting in their bed. The curtain was drawn halfway around the bed and the resident was not visible from the room door. The call bell was on the floor. Registered Nurse #1, the Charge Nurse, cleaned and placed the call bell in the resident's hand. Registered Nurse #1 asked the resident if they could press the call bell. The resident stated Yes but did not press the call bell. On 3/27/2024 at 11:04 AM, Certified Nursing Assistant#5 was interviewed and stated that every resident must always have access to a call bell. Registered Nurse #1 was interviewed on 3/28/2024 at 9:46 AM and stated Resident #233 sometimes uses the call bell. Registered Nurse #1 stated the call bell should be accessible to the resident when the resident is in their room. The Director of Rehabilitation Services was interviewed on 3/29/2024 at 8:47 AM and stated that Resident #233 receives occupational and speech-language pathology services. Resident #233 will be evaluated today for the ability to use the call bell. Licensed Practical Nurse #4 was interviewed on 3/29/2024 at 10:00 AM and stated Resident #233 was evaluated today by an Occupational Therapist and the resident was unable to use a call bell and therefore now will be monitored frequently. Once the physician's order to monitor the resident is obtained the Certified Nursing Aide Accountability record will be updated to reflect the enhanced monitoring schedule. The Director of Nursing Services was interviewed on 4/01/2024 at 8:29 AM and stated if the residents cannot use the call bell, they should be evaluated for an alternate means to alert staff if they need assistance. The use of a tap bell is an alternative to the regular call bell. For those residents who cannot use any call bell, the call bell will still be kept within reach for the resident and any of the resident's visitors. The Director of Nursing Services further stated that staff should monitor those residents who cannot use the call bell system and Resident #233 should have been assessed upon admission for their ability to use the call bell system. 10 NYCRR 415.5 Euro(1)

Based on record review and interviews during the Recertification Survey initiated on 3/26/2024 and completed on 4/2/2024, the facility did not ensure a person-centered comprehensive care plan was reviewed and revised to address each resident's needs. This was identified for one (Resident #252) of one resident reviewed for care planning care area out of 40 total sampled residents. Specifically, there was no documented evidence that the comprehensive care plans for Resident #252 were reviewed and revised upon the quarterly Minimum Data Set assessment dated [DATE]. The finding is: The facility's policy and procedure titled, Care Planning last reviewed 2/2024, documented to ensure the accurate and timely completion of the Minimum Data Set, Care Area Assessment, and Comprehensive Care Plan for all residents. Procedure 1.0.3 documented the care plan will be reviewed and revised to reflect the resident's current condition per policy and regulation. Procedure 1.0.11 documented it is the responsibility of the clinical team to ensure that care plans are updated according to specified time frames and the resident response to goals, interventions, and changes in condition must be updated as well. Resident #252 was admitted diagnosis of Cerebral Infarction. The quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15 indicating the resident was cognitively intact. The resident required setup assistance for eating and bed mobility, and supervision for toileting and transfer. The resident participated in the assessment. The quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15 indicating the resident was cognitively intact. The resident required setup assistance for eating and bed mobility, and supervision for toileting and transfer. The resident participated in the assessment. A record review revealed multiple Comprehensive Care Plans (such as, but not limited to dementia, dental, vision, communication, and pain) with an onset date of 8/4/2023, last revised 10/27/2023, were not reviewed and/or revised in accordance with the Minimum Data Set assessment schedule. There was no documented evidence that the comprehensive care plans were reviewed and/or revised when the quarterly Minimum Data Set assessment was completed on 1/19/2024. Registered Nurse #11 was interviewed on 4/1/2024 at 9:55 AM and stated that all Registered Nurses and Nursing Supervisors, on any shift can initiate, update, and review care plans. Registered Nurse Supervisor #6 was interviewed on 4/1/2024 at 10:04 AM and stated that any Registered Nurse on the unit can update a care plan. The Director of Nursing Services will also assign some nurses familiar with the process to review and revise the care plans. Registered Nurse Supervisor #6 stated that care plans are updated every time there is a change in the resident's condition, such as a medical order; and reviewed and revised quarterly, with the Minimum Data Set schedule. Registered Nurse Supervisor #6 stated nursing supervisors are responsible for ensuring that residents' care plans are initiated and updated timely. Registered Nurse Supervisor #6 stated they were not aware that the care plans for Resident #252 were not updated when the quarterly Minimum Data Set assessment was completed on 1/19/2024. The Registered Nurse Minimum Data Set Coordinator was interviewed on 4/1/2024 at 2:41 PM and stated that they complete the Minimum Data Set assessments but have nothing to do with the care plans. The Registered Nurse Minimum Data Set Coordinator further stated that the Director of Nursing Services assigns the Nursing Supervisors to initiate and update the care plans in accordance with the Minimum Data Set schedule. The Director of Nursing Services was interviewed on 4/1/2024 at 2:46 PM and stated that the Nurse Manager and Nursing Supervisors are responsible to review and update residents' care plans. The care plans are supposed to be updated whenever there is a change in the resident's condition or when a change in the resident's treatment plan occurs such as new physician orders, etc. The Director of Nursing Services stated that if there are no changes in the resident's plan of care then the staff are supposed to review the care plans in accordance with the Minimum Data Set schedule. The Director of Nursing Services stated that the care plans for Resident #252 should have been updated with the 1/19/2024 Minimum Data Set assessment schedule. 10 NYCCR 415.11(c)(2)(i-iii)

Based on observations, record review, and interviews during the Recertification Survey initiated on 3/26/2024 and completed on 4/2/2024, the facility did not ensure that a resident who is fed by enteral means receives the appropriate treatment, care, and services to prevent complications of enteral feeding. This was identified for one (Resident #184) of three residents reviewed for Tube Feeding. Specifically, on 3/26/2024 at 10:30 AM and 3/27/2024 at 8:00 AM Resident #184's tube feeding bottle was observed hanging on a feeding tube stand without a label including the resident's name, and the time the tube feeding was initiated. The finding is: The facility's Policy and Procedure titled; Enteral Tube Feeding last revised 10/2023 documented that the tube feeding preparation will be administered as per the physician's order to meet the nutritional needs of the resident. The feeding bottle must be labeled with the resident's name and the administrating nurse's initial, date, and time of administration. Resident #184 was admitted with diagnoses that included Respiratory Failure, Osteomyelitis (bone infection), and Type II Diabetes. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident's Brief Interview for Mental Status (BIMS) score was 99 which indicated the resident had severely impaired cognition. Resident #184 required one-person assistance with all Activities of Daily Living (ADL). The Minimum Data Set documented the resident required a feeding tube to meet the total calories per day. The Comprehensive Care Plan (CCP) for tube feeding dated 1/9/2024 documented interventions to assess for patency and proper placement of the tube, and ensure the head of the bed is elevated at 45 degrees during feeding and one-hour post feeding. The Physician's order dated 2/20/2024 documented to administer Jevity 1.5 Cal (a fiber-fortified, high-nitrogen liquid tube feeding formula, suitable for supplemental or sole source of nutrition) at 95 milliliters per hour continuously. Water flush of 120 milliliters before and after each feeding. During an observation on 3/26/2024 at 10:30 AM, Resident #184 had an enteral feeding bottle hanging from the feeding tube stand. The enteral bottle did not have a label that indicated the resident's name, the time feeding was started, and the feeding directions as prescribed by the physician. In a subsequent observation on 3/27/2024 at 8:00 AM, Resident #184 had an enteral feeding bottle hanging from the feeding tube stand. The enteral bottle did not have a label that indicated the resident's name, the time feeding was started, and the feeding directions as prescribed by the physician. Licensed Practical Nurse #1 was interviewed on 3/27/2024 at 8:00 AM and stated they did not notice that Resident #184 did not have a label on their enteral feeding bottle. Licensed Practical Nurse #1 stated they should have checked the bottle to ensure a label was in place. Resident #184 receives continuous feeding and they (Licensed Practical Nurse #1) were concentrating on the medication administration and forgot to check the enteral feeding label. Licensed Practical Nurse #5 was interviewed on 3/28/2024 at 2:03 PM and stated that they always check the label on the enteral bottle before administering the enteral feeding. All enteral feeding bottles are received from the kitchen. The nurses are responsible for ensuring that labels on the enteral feeding bottles are in place with the correct name of the resident and the amount to be administered as per the Physician's order. The Director of Nutrition and Food Services was interviewed on 4/1/2024 at 8:00 AM and stated that the process of labeling for all enteral bottles starts from the kitchen. Once they receive the order for enteral feeding, one of the nutritionists will provide a label with the resident's name, room number, direction for enteral feeding, date, and the name of the Physician who ordered the enteral feeding. All enteral feeding bottles are supplied to each resident unit with the correct label. The kitchen staff delivers the enteral bottles early in the morning. The Director of Nutrition and Food Services stated they did not know why Resident #184's enteral feeding bottle was not labeled. The Director of Nursing Services was interviewed on 4/1/2024 at 8:19 AM and stated that all nurses must follow the protocol for Tube Feeding which includes labeling the tube feeding bottle with the resident's name, and the direction for enteral feeding administration as per the physician's orders. The Director of Nursing services stated they expected the nurses to ensure that the enteral bottle had a proper label before starting the enteral feeding. 10 NYCRR 415.12(g)(2)

Based on record reviews and staff interviews during the Recertification Survey initiated on 3/1/2022 and completed on 3/9/2022 the facility failed to ensure that the resident's environment was free of accident hazards for one (Resident #220) of 4 residents reviewed for accidents. Specifically, Resident #220 with a known history of Polysubstance abuse, was not supervised to prevent the availability of non-prescribed illicit drug usage within the facility. Resident #220 was readmitted to the facility on [DATE]. A Psychosocial assessment dated [DATE] documented the resident was utilizing and selling illicit drugs in the previous nursing facility. The current facility did not develop care plan interventions to monitor and supervise the resident for substance abuse. On 12/13/2021 Resident #220 was found unresponsive and transferred to hospital for opioid drug overdose. The facility did not initiate an investigation after the 12/13/2021 incident. The hospital discharge recommendations were to provide supervised visits. The facility did not address and re-assess the interventions to monitor and prevent the resident from obtaining illicit drugs. Subsequently, on 3/2/2022 the resident was found unresponsive and sent to hospital with diagnosis of drug overdose. The resident reported to the emergency room Physician that they (Resident #220) snorted heroin and passed out. Additionally, the facility did not have a system in place to identify and monitor residents with history of drug abuse. This resulted in actual harm to Resident #220 with potential for serious harm for 64 residents with history of drug abuse that is Immediate Jeopardy and Substandard Quality of Care. The finding is: The facility Contraband policy and procedure dated 11/2021 documented in order to ensure a safe environment, all residents presenting to the facility will be subject to a search directed towards identifying contraband and preventing its entrance into the facility. The policy defined contraband as items of danger including illegal substances. The procedure documented that all residents who enter the facility will be subjected to search if any suspected, or any evidence of having contraband. If a resident is found to have controlled substances during their stay, the staff member who finds the controlled substances will bring this to the attention of the attending in charge and the nurse in charge. Visitors who bring contraband into the facility may be asked to leave and may be denied visiting privileges in the future. The resident involved may become subject to a repeat search with confiscation or checking of objects as described above. The facility did not have a documented Policy and Procedure for management of residents with diagnosis of Substance Abuse. Resident #220 was admitted with diagnoses of Polysubstance Abuse, Anxiety Disorder, Depression and status post Laminectomy. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented Resident #220 required limited assistance of one-person with locomotion in the resident's room. The locomotion off the unit did not occur in seven days of the MDS look back period. The MDS documented the resident was feeling depressed, or hopeless, and had disturbed sleep. The Quarterly MDS assessment dated [DATE] documented Resident #220 had a BIMS score of 15, indicating intact cognition. The MDS further documented Resident #220 required supervision without physical help from staff for locomotion on and off the unit. The resident was feeling depressed, or hopeless, and had disturbed sleep. The resident exhibited behavioral symptoms that were not directed towards others in four to six days in the last 7 day look back period of the MDS. The psychosocial assessment dated [DATE] documented Resident #220 was at another skilled nursing facility for 2 years for their back issues and was kicked out of previous facility for using and selling heroin, [MEDICATION(S)] and cocaine. The psychosocial assessment documented that Resident #220's judgement was poor. Resident #220 was noted to be anxious, impulsive, easily agitated, and disregarded rules. The history of polysubstance abuse care plan dated 9/28/2021 documented that Resident #220 was kicked out of a previous skilled nursing facility for using and selling heroin, [MEDICATION(S)] and cocaine. Resident #220 knew what was done was wrong and will not do that in the current facility. The goal included that Resident #220 will not use or sell illegal substances. The interventions included to encourage participation in activities of interest, social work one to one visits for emotional support and counselling as needed, psychiatric consultation, and psychological services follow up as needed. The Nursing Progress Note from 9/23/2021 through 12/12/2021 were reviewed and indicated no documented behaviors related to consuming or selling illicit drugs. The Situation Background Assessment Recommendation (SBAR) Communication Form dated 12/13/2021 documented Resident #220 had a change in condition with symptoms of altered mental status. The SBAR documented Resident #220 presented with altered level of consciousness, weakness, and shortness of breath. Around 9:00 PM, Resident #220 was observed sitting in the chair very lethargic with alteration in consciousness and was transferred to the hospital. The hospital record dated 12/13/2021 documented that Resident #220 was admitted to the hospital for altered mental status with Acute Hypoxic [CONDITION(S)] secondary to drug overdose (cocaine, opiate and benzodiazepine) with moderate improvement after [MEDICATION(S)] 2 milligram (mg) injection. As per Emergency Medical Service (EMS) the oxygen saturation rate for Resident #220 was 82% (normal 95% or above) on room air at the Skilled Nursing Facility and was Hypotensive (low blood pressure). The hospital discharge summary dated 12/15/2021 documented a note to the Skilled Nursing Facility: supervised visiting only. Resident #220 has been receiving drugs from outside visitors and subsequently overdosed. There was no documented evidence of an investigation to determine the root cause of Resident #220's opiate overdose nor where and how the resident received the drugs. The Nursing Admission/Readmission note dated 12/16/2021 documented that Resident #220 was admitted from the hospital at 7:40 PM. The resident was to only have supervised visitation. The Social Work note dated 12/16/2021 documented Resident #220 stated that a visitor brought the drugs to the building. Resident #220 stated that they took the visitor's phone number out of their phone and will not do it again. The Social Worker re-educated Resident #220 about not to smoke or vape in the facility. The history of polysubstance abuse care plan dated 9/28/2021 was not updated after the resident had returned from the hospital on 12/16/2021 with a diagnosis of drug overdose. A document titled Resident Delivery Searches dated 12/2021 documented that when a delivery comes to the facility for any of the following residents, the deliveries are to be searched for contraband. The list of names included Resident #220. The Physician readmission note dated 12/17/2021 documented Resident #220 had a past medical history of Polysubstance Abuse. Resident #220 was admitted on [DATE] [to the hospital] for altered mental status with Acute Hypoxic [CONDITION(S)] secondary to drug overdose (cocaine, opiate and benzodiazepine) with moderate improvement after [MEDICATION(S)] 2mg injection. The assessment and plan included to continue current medications, provide safe environment, adequate nutrition, and supportive care. Monitor fingerstick, GI follow up for hepatic mass and psychiatry follow up. The Physician did not acknowledge the recommendation from the hospital related to supervised visitation for Resident #220. The Social Work note dated 1/4/2022 documented Resident #220 was moving from Unit 22 to Unit 46. Resident #220 was educated about not smoking or vaping in the facility. The Physician's note dated 1/12/2022 documented that Resident #220 has not had any acute events. The assessment and plan included to provide current medications, provide safe environment, adequate nutrition, and supportive care. The Physician did not acknowledge the recommendation from the hospital related to supervised visitation for Resident #220. The physician's note dated 2/9/22 documented that Resident #220 has not had any acute events and Resident #220 was able to transfer out of bed to ambulate by pushing the wheelchair independently. The physician documented that Resident #220 has a history of Anxiety that is controlled with [MEDICATION(S)]. Psychiatry recommended to decrease [MEDICATION(S)] and Resident #220 gets very agitated and violent when you try to discuss tapering of the [MEDICATION(S)]. Resident #220 is on [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] for chronic back pain. Will decrease [MEDICATION(S)] and discontinue [MEDICATION(S)] and follow up with Psychiatry regularly. The assessment and plan included to provide current medications, provide safe environment, adequate nutrition, and supportive care. Continue 2 liters of oxygen via nasal cannula. Nursing progress notes from 2/1/2022 to 3/2/2022 were reviewed. There was no documented evidence that the resident was being monitored or supervised for drug seeking behavior, attempts to sell illicit drugs, or consumption of illicit drugs prior to 3/2/2022. The December 2021 to March 2022 Certified Nursing Assistant (CNA) Accountability Records documented Resident #220 had a diagnosis of Polysubstance abuse. The CNA Accountability Records documented that Resident #220 could push the wheelchair independently. There was no documented evidence that the resident was to have supervision or monitoring related to Polysubstance abuse. The SBAR Communication Form dated 3/2/2022 documented Resident #220 had a change in condition. At 6:00 PM, Resident #220 was unresponsive to verbal and tactile stimuli. The SBAR documented oxygen saturation level of 66% when on oxygen at 3 liters per minute. Resident #220 was transferred to the hospital. The hospital record dated 3/2/2022 documented Resident #220 was transferred from the Skilled Nursing Facility for altered mental status. Resident #220 was brought in by EMS from the Skilled Nursing Facility for possible overdose. [MEDICATION(S)] 2mg was administered intramuscularly by EMS. Resident #220 stated that they (Resident #220) snorted some Heroin and passed out. Resident #220 had an admission three months ago in December [2021] for a similar overdose. Resident #220 was admitted to the hospital for altered mental status secondary to opioid intoxication. The urine toxicology report was positive for opiates and benzodiazepines. The attending physician at the hospital diagnosed Resident #220 with toxic [CONDITION(S)] secondary to opioid intoxication and Substance abuse. Certified Nursing Assistant (CNA) #8 was interviewed on 3/03/2022 at 2:17 PM and stated they (CNA #8) were the regularly assigned CNA for the 7AM to 3PM shift for Resident #220 for the past two months. CNA #8 stated Resident #220 propelled their wheelchair throughout the facility and sometimes went downstairs to the vending machine. Resident #220 did not have any specific instructions to be monitored. CNA #8 stated that Resident #220 was independent in self-care and mobility and did not require any oversight. CNA #8 stated that they have not received any instructions to look through Resident #220's belongings to check for substance abuse related materials. CNA #8 was not aware if Resident #220 had any visitors on 3/2/2022 or even in the past month. CNA #8 further stated that there were no special instructions to monitor Resident #220 for substance abuse behaviors and there was no direction provided to supervise the resident throughout the facility. Registered Nurse (RN #7) was interviewed on 3/3/2022 at 2:20 PM. RN #7 stated that they (RN #7) were the regular 7AM to 3PM shift Unit Nurse for Resident #220's unit and has known Resident #220 since the resident was transferred to the unit two months ago. RN #7 stated that the staff did not have any specific instructions for monitoring Resident #220's whereabouts in the facility or for supervised visits. RN #7 was not aware if Resident #220 had any visits on 3/2/2022. RN #7 stated that they were aware of Resident #220's history of Substance abuse but thought it was a long time ago. RN #7 was not aware of Resident #220's overdose in the facility in December 2021. RN #7 further stated they (RN #7) did not receive any instructions to look through Resident #220's belongings to check for substance abuse related materials. CNA #9 was interviewed on 3/3/2022 at 3:15 PM and stated that they (CNA #9) were the assigned CNA for Resident #220 on the 3 PM -11 PM nursing shift on 3/2/2022. CNA #9 stated that the regularly assigned CNA was on vacation as of 3/2/2022. Resident #220 was able to independently propel their wheelchair throughout the facility without supervision. CNA #9 stated that they last saw Resident #220 at 4:30 PM in their room on 3/2/2022. Resident #220 was in the room and was talking. CNA #9 was called over by RN #8 who discovered Resident #220 unresponsive in their room at 5:00 PM. CNA #9 stated that they did not have any instructions for monitoring the resident for substance abuse behaviors and was not aware of Resident #220's history of drug overdose at the facility. CNA #10 was interviewed on 3/3/2022 at 3:20 PM and stated that they (CNA #10) were the regularly assigned CNA on the 11:00 PM to 7:00 AM nursing shift for the past two months for Resident #220. CNA #10 stated that Resident #220 was usually in bed sleeping or watching television when they (CNA #10) started the 11:00 PM to 7:00 AM shift. CNA #10 stated they rarely went into Resident #220's room because Resident #220 was able to care for themself. CNA #10 stated that there was nothing on the CNA accountability record that instructed the CNAs to monitor the resident for drug abuse behavior. CNA #10 further stated they (CNA #10) were not aware of Resident #220's overdose and illicit drug use in the facility. RN #10 was interviewed on 3/3/2022 at 3:26 PM and stated that they (RN #10) were the RN Supervisor on 3/2/2022 on the 11 PM-7AM nursing shift and was covering the 3 PM-11 PM nursing shift on Resident #220's unit. RN #10 stated that they were called by RN #8 to Resident #220's room because Resident #220 presented with an altered mental status and was not waking up. Resident #220's oxygen saturation level was 66% and oxygen was being administered. The oxygen saturation level went up to 90-92%. RN #10 was aware of Resident #220's overdose in December 2021 but did not suspect that the resident had a drug overdose in this case. RN #10 did not tell the EMS anything about Resident #220's drug abuse behavior. RN #8 was interviewed on 3/3/2022 at 3:52 PM and stated that they (RN #8) were covering the 3PM-11PM nursing shift on 3/2/2022. RN #8 stated they were not the regularly assigned nurse for the resident's unit. RN #8 stated they (RN #8) were not aware that Resident #220 had substance abuse behaviors and had overdosed in December 2021 in the facility. RN #8 stated that there were no Physician's orders or instructions related to substance abuse monitoring for Resident #220. At the beginning of the shift Resident #220 was talking and seemed to be their usual self. RN #8 stated that they (RN #8) were not sure if Resident #220 left their bedroom at all during the shift. RN #8 stated that they (RN #8) did not see any visitors for Resident #220 during that shift nor did the Resident Care Associate (RCA) come to escort Resident #220 for a visit. At 5:00 PM, RN #8 went to Resident #220's room and Resident #220 seemed out of it. RN #8 stated they knew Resident #220 had a diagnosis of Diabetes and thought Resident #220 was in Diabetic shock. RN #8 did a fingerstick to check the blood sugar level which was 258 which did not indicate Diabetic shock. RN #8 stated they called RN #10 and continued to try to get Resident #220 to respond. When RN #10 arrived on the unit, RN #8 reported the resident's condition to RN #10. Resident #220 was transferred to hospital due to the unresponsiveness. Social Worker (SW) #2 was interviewed on 3/3/2022 at 5:11 PM and stated that they (SW #2) were the assigned SW for Resident #220 when the resident was admitted in September 2021. SW #2 stated they were aware that Resident #220 had a history of Substance abuse. SW #2 stated that residents with a known history of Substance abuse problems are referred to psychology and their incoming packages are to be checked for illicit drugs. SW #2 stated that searching packages is a standard protocol in the facility and did not have to be in a care plan. The nursing staff are expected to look through food items brought in from outside as per facility wide protocol. SW #2 stated that they (SW #2) believed that Resident #220 was not actively having Substance abuse disorder so a care plan to prevent and monitor substance abuse behavior was not developed. SW #2 stated that the facility cannot always search Resident #220's belongings and there's only so much they can do. SW #2 stated that Resident #220 was placed on SW #1's caseload when the resident was readmitted from the hospital on 12/16/2021 and that it was SW #1's responsibility to develop a care plan to address Resident #220's substance abuse behavior. SW #1 was interviewed on 3/3/2022 at 5:51 PM. SW #1 stated that they were assigned to Resident #220 upon their readmission in December 2021 after the resident returned from the hospital from the opiate overdose. SW #1 stated that they did not complete a psychosocial assessment and did not develop a revised plan of care to address Resident #220's Substance abuse behavior. SW #1 could not recall reviewing the hospital discharge paperwork with the instruction for supervised visitation to reduce Substance abuse behavior. SW #1 stated that an interdisciplinary team approach was not used to address Resident #220's Substance abuse behavior. Resident #220 was reassigned to SW #2 on 1/4/2022. The Medical Director and Director of Nursing were interviewed concurrently on 3/3/2022 at 6:30 PM. The Medical Director stated that Resident #220's diagnosis of Poly Substance Abuse is noted on the medical record and the staff are aware of Resident #220's history. The Director of Nursing stated that there is a system in place to monitor Resident #220 and it is the facility wide protocol to check packages and to supervise visits for all residents in the auditorium. The Director of Nursing stated that everyone on the interdisciplinary team is aware of Resident #220's smoking behavior and the substance abuse history is noted in the medical record. The Medical Director stated that Resident #220's name is on the list at the entrance way for security to search any packages that came from the outside. The facility wide protocol is that the Social Worker, Recreation Aide, and Security are to look through incoming food and packages for any hazardous materials. The Director of Nursing stated that room searches are only done if a staff member suspected that a resident was smoking and that the facility cannot do more than that. The Medical Director and the Director of Nursing stated that Resident #220 has not had any visitors. The Director of Nursing stated that the facility did not initiate an Incident Report to investigate how Resident #220 obtained drugs in the facility on 12/13/2021 because SW #2 had written a note that Resident #220 received the drugs from a visitor. The Director of Nursing stated that Resident #220 did not require increased supervision. The Director of Nursing further stated that the protocols were facility wide and did not need to be documented in a care plan. Attending Physician #2 was interviewed on 3/4/2022 at 3:42 PM and stated that they (Attending Physician #2) provided care for Resident #220 since Resident #220 was moved to Unit 46 on 1/4/2022. Attending Physician #2 stated that Resident #220 required monitoring and supervision and they (Attending Physician #2) had verbally informed CNA #10 and RN #7 to monitor Resident #220 for Substance abuse behavior. Attending Physician #2 stated that they did not recall documenting the need for increased monitoring for Substance abuse behaviors or placing an order instructing nurses to do so. SW #2 was re-interviewed on 3/4/2022 at 5:15 PM. SW #2 stated that the facility staff located Resident #220's care plan entitled history of substance abuse which was dated 9/28/2021. The interventions did not include to monitor and supervise Resident #220's whereabouts in the facility for substance abuse behavior. SW #2 stated that they had developed the care plan but did not revise the care plan after the resident returned from the hospital on 12/16/2021 since that was the responsibility of SW #1. Resident #220 should have had a revised care plan after the 12/13/2021 hospitalization . The care plan did not include any updates in December 2021. Resident #220 was not on the radar for active use of drugs at the time of the 9/28/2021 care plan. The search of packages is a standard practice for any resident in the facility so that intervention would not be in the care plan. 415.12(h)(1) The facility was notified of the Immediate Jeopardy on 3/3/2022. The Immediate Jeopardy was removed on 3/7/2022 prior to the completion of the survey. -The facility created policies and procedures to address needs of the residents with Alcohol and Drug abuse problems and Management of Residents with a History of Substance abuse. -The facility Educated 95% of the facility staff on the newly developed policies and procedures and on identification of care for residents' with a history of using Polysubstance/Polydrug abuse and identifying signs and symptoms of drug abuse. The facility also educated staff on narcotic overdose and use of [MEDICATION(S)]. The staff that did not receive in-service education were either on vacation, on medical leave, or not were been scheduled for duty and will be in-serviced as they report to work. - The facility assessed and formulated care plans for all residents identified as having a history of Polysubstance abuse. -The facility created Resident contracts/agreements to educate residents on the facility's zero tolerance drug policy along with consequences. -The facility developed audit tools to monitor residents with a history of Substance abuse for signs and symptoms of drug abuse and updated the room search audit tool to include legal and illegal substances.

Based on observation, interviews and record review during the Recertification Survey initiated on 3/1/2022 and completed on 3/9/2022, the facility failed to ensure each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Specifically, Resident #220 was admitted to the facility with a known history of illicit drug abuse. The admission psychosocial assessment dated [DATE] documented the resident was utilizing and selling illicit drugs in the previous nursing facility. The facility failed to develop and implement an effective comprehensive person-centered plan of care to address the substance abuse disorder. On 12/13/2021, Resident #220 was found unresponsive, was transferred to the hospital, and was diagnosed with an overdose from opiate use. No assessments or changes to the resident's plan of care were made upon their return from the hospital on 12/16/2021. Subsequently, Resident #220 was again found unresponsive on 3/2/2022, was transferred to the hospital for an overdose of Heroin and was diagnosed with Acute Hypercapnic [CONDITION(S)] secondary to unintentional overdose. This resulted in actual harm to Resident #220 with potential for serious harm for 64 residents with a history of drug abuse that is Immediate Jeopardy. The finding is: The facility policy on assessment process dated 12/2021 documented that all residents receive timely, accurate, and appropriate interdisciplinary assessment and care planning. The assessment and review should be completed upon return from the hospital, when there is a significant change that appears to be permanent, based on a comparison of the resident's pre and post hospital status. The facility Behavior Documentation Policy and Procedure dated 4/4/2008 and last revised in 3/2022 documented to monitor residents' behavior and document on a daily basis. Behavior documentation is done on a daily basis on the Certified Nursing Assistant (CNA) Accountability Record by the CNA. It is the responsibility of the caregiver to document the resident's behavior, the intervention utilized for that behavior, and the efficacy of the intervention used every shift. The facility Contraband policy and procedure dated 11/2021 documented in order to ensure a safe environment, all residents presenting to the facility will be subject to a search directed towards identifying contraband and preventing its entrance into the facility. The policy defined contraband as items of danger including illegal substances. The procedure documented that all residents who enter the facility will be subjected to search if any suspected, or any evidence of having contraband. If a resident is found to have controlled substances during their stay, the staff member who finds the controlled substances will bring this to the attention of the attending in charge and the nurse in charge. Visitors who bring contraband into the facility may be asked to leave and may be denied visiting privileges in the future. The resident involved may become subject to a repeat search with confiscation or checking of objects as described above. The facility did not have a documented Policy and Procedure for management of residents with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #220 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented Resident #220 required limited assistance of one-person with locomotion in the resident's room. The locomotion off the unit did not occur in seven days of the MDS look back period. The MDS documented the resident was feeling depressed, or hopeless, and had disturbed sleep. The Quarterly MDS assessment dated [DATE] documented Resident #220 had a BIMS score of 15, indicating intact cognition. The MDS further documented Resident #220 required supervision without physical help from staff for locomotion on and off the unit. The resident was feeling depressed, or hopeless, and had disturbed sleep. The resident exhibited behavioral symptoms that were not directed towards others in four to six days in the last 7 day look back period of the MDS. Resident #220 was observed on 3/1/2022 at 10:29 AM seated in their wheelchair in the hallway and conversing with another resident. Resident #220 stated that there are no activities that meet their interests. Resident #220 stated that it was very boring at the facility, and they (Resident #220) had complained to the recreation staff. Resident #220 stated that nothing was done and they did not find the current activities appropriate for them (Resident #220). The psychosocial assessment dated [DATE] documented Resident #220 was at another skilled nursing facility for 2 years for back issues. Resident was discharged in August 2021 from the other facility. Resident #220 was admitted to the current facility on 8/24/2021 for subacute rehabilitation and was discharged on [DATE]. Resident #220 decided they (Resident #220) could not stay where they were discharged to and had several hospitalization s until admitted as a second admission to the facility on [DATE]. The psychosocial assessment documented Resident #220 was kicked out of previous facility for using and selling heroin, [MEDICATION(S)], and cocaine. The psychosocial assessment documented that Resident #220's judgement was poor. Resident #220 was noted to be anxious, impulsive, easily agitated, and disregarded rules. The history of polysubstance abuse care plan dated 9/28/2021 documented that Resident #220 was kicked out of a previous skilled nursing facility for using and selling heroin, [MEDICATION(S)] and cocaine. Resident #220 knew what was done was wrong and will not do that in the current facility. The goal included that Resident #220 will not use or sell illegal substances. The interventions included to encourage participation in activities of interest, social work one to one visits for emotional support and counselling as needed, psychiatric consultation, and psychological services follow up as needed. There were no care plan updates from 9/21/2021 to 3/2/2022. The psychology consultation dated 10/14/2021 documented that Resident #220 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #220 reported that they (Resident #220) were living with a friend but were unhappy with the arrangement because their friend was using drugs. The Psychologist documented the Resident #220 presents with a history of drug abuse and was homeless with limited social supports and significant health issues. Resident #220 agreed to speak with the Psychologist today but declined psychotherapy and was coping adequately. No psychotherapy was recommended at this time. The Physician's Order dated 12/2/2021 documented to obtain a psychological evaluation for Anger Management due to Resident #220 having a peer-to-peer altercation. There was no documented evidence that a psychological evaluation was completed after the 12/2/2021 referral. The Situation Background Assessment Recommendation (SBAR) Communication Form dated 12/13/2021 documented Resident #220 had a change in condition with symptoms of altered mental status. The SBAR documented Resident #220 presented with altered level of consciousness, weakness, and shortness of breath. Around 9:00 PM, Resident #220 was observed sitting in the chair very lethargic with alteration in consciousness and was transferred to the hospital. The hospital record dated 12/13/2021 documented that Resident #220 was admitted to the hospital for altered mental status with Acute Hypoxic [CONDITION(S)] secondary to drug overdose (cocaine, opiate and benzodiazepine) with moderate improvement after [MEDICATION(S)] 2 milligram (mg) injection. As per Emergency Medical Service (EMS) the oxygen saturation rate for Resident #220 was 82% (normal 95% or above) on room air at the Skilled Nursing Facility and was Hypotensive (low blood pressure). The hospital discharge summary dated 12/15/2021 documented a note to the Skilled Nursing Facility: supervised visiting only. Resident #220 has been receiving drugs from outside visitors and subsequently overdosed. There was no documented evidence of an investigation to determine the root cause of Resident #220's opiate overdose nor where and how the resident received the drugs. The Nursing Admission/Readmission note dated 12/16/21 documented that Resident #220 was admitted from the hospital at 7:40PM. Resident to only have supervised visitation. The Social Work note dated 12/16/2021 documented Resident #220 stated that a visitor brought the drugs to the building. Resident #220 stated that they took the visitor's phone number out of their phone and will not do it again. The Social Worker re-educated Resident #220 about not to smoke or vape in the facility. A document titled Resident Delivery Searches dated 12/2021 documented that when a delivery comes to the facility for any of the following residents, the deliveries are to be searched for contraband. The list of names included Resident #220. The Physician readmission note dated 12/17/2021 documented Resident #220 had a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment and plan included to continue current medications, provide safe environment, adequate nutrition, and supportive care. Monitor fingerstick, GI follow up for hepatic mass and psychiatry follow up. The Physician did not acknowledge the recommendation from the hospital related to supervised visitation for Resident #220. The Physician's Order dated 12/28/2021, 11 days after the Physician's readmission note, documented to obtain a Psychiatric consultation for adjustment disorder. The Social Work note dated 1/4/2022 documented Resident #220 was moving from Unit 22 to Unit 46. Resident #220 was educated about not smoking or vaping in the facility. The Physician's note dated 1/12/2022 documented that Resident #220 has not had any acute events. The assessment and plan included to provide current medications, provide safe environment, adequate nutrition, and supportive care. The Physician did not acknowledge the recommendation from the hospital related to supervised visitation for Resident #220. The Psychiatric Evaluation dated 1/28/2022, one month after requested by the Physician, documented Resident #220 had the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The social history included a history of polysubstance abuse. The recommendation included to decrease [MEDICATION(S)] to 0.5 mg from 1mg and individual therapy 2-5 times monthly. There was no documented evidence that the individual therapy 2-5 times monthly was offered or provided to Resident #220. The physician's note dated 2/9/2022 documented that Resident #220 has not had any acute events and Resident #220 was able to transfer out of bed to ambulate by pushing the wheelchair independently. The physician documented that Resident #220 has a history of anxiety that is controlled with [MEDICATION(S)]. Psychiatry recommended to decrease [MEDICATION(S)] and Resident #220 gets very agitated and violent when you try to discuss tapering the [MEDICATION(S)]. Resident #220 is on [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] for chronic back pain. Will decrease [MEDICATION(S)] and discontinue [MEDICATION(S)] and follow up Psychiatry regularly. The assessment and plan included to provide current medications, provide safe environment, adequate nutrition, and supportive care. The facility did not provide evidence of a Psychiatric follow up after 1/28/2022. Nursing progress notes from 2/1/2022 to 3/2/2022 were reviewed. There was no documented evidence that the resident was being monitored or supervised for drug seeking behavior, attempts to sell illicit drugs, or consumption of illicit drugs prior to 3/2/2022. The December 2021 to March 2022 Certified Nursing Assistant (CNA) Accountability Records documented Resident #220 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence that the resident was to have supervision or monitoring related to Polysubstance abuse. The SBAR Communication Form dated 3/2/2022 documented Resident #220 had a change in condition. At 6:00 PM, Resident #220 was unresponsive to verbal and tactile stimuli. The SBAR documented oxygen saturation level of 66% when on oxygen at 3 liters per minute. Resident #220 was transferred to the hospital. The hospital record dated 3/2/2022 documented Resident #220 was transferred from the Skilled Nursing Facility for altered mental status. Resident #220 was brought in by EMS from the Skilled Nursing Facility for possible overdose. [MEDICATION(S)] 2mg was administered intramuscularly by EMS. Resident #220 stated that they (Resident #220) snorted some Heroin and passed out. Resident #220 had an admission three months ago in December [2021] for a similar overdose. Resident #220 was admitted to the hospital for altered mental status secondary to opioid intoxication. The urine toxicology report was positive for opiates and benzodiazepines. The attending physician at the hospital diagnosed Resident #220 with toxic [CONDITION(S)] secondary to opioid intoxication and Substance abuse. Certified Nursing Assistant (CNA) #8 was interviewed on 3/03/2022 at 2:17 PM and stated they (CNA #8) were the regularly assigned CNA for the 7AM to 3PM shift for Resident #220 for the past 2 months. Resident #220 did not have any specific instructions to be monitored. CNA #8 stated that Resident #220 was independent in mobility and did not require any oversight. CNA #8 stated that they have not received any instructions to look through Resident #220's belongings to check for substance abuse related materials. CNA #8 was not aware if Resident #220 had any visitors on 3/2/2022 or even in the past month. CNA #8 further stated that there were no special instructions to monitor Resident #220 for substance abuse behaviors and there was no direction provided to supervise the resident throughout the facility. Registered Nurse (RN #7) was interviewed on 3/3/2022 at 2:20 PM. RN #7 stated that they (RN #7) were the regular 7AM to 3PM shift Unit Nurse for Resident #220's unit and has known Resident #220 since the resident was transferred to the unit two months ago. RN #7 stated that the staff did not have any specific instructions for monitoring Resident #220's whereabouts in the facility or for supervised visits. RN #7 was not aware if Resident #220 had any visits on 3/2/2022. RN #7 stated that they were aware of Resident #220's history of substance abuse but thought it was a long time ago. RN #7 was not aware of Resident #220's overdose in the facility in December 2021. RN #7 did not receive any instructions to look through Resident #220's belongings to check for substance abuse related materials. CNA #9 was interviewed on 3/3/2022 at 3:15 PM and stated that they (CNA #9) were the assigned CNA for Resident #220 on the 3PM -11PM nursing shift on 3/2/2022. CNA #9 stated that they did not have any instructions for monitoring the resident for substance abuse behaviors and were not aware of Resident #220's history of drug overdose at the facility. CNA #10 was interviewed on 3/3/22 at 3:20 PM and stated that they (CNA #10) were the regularly assigned CNA on the 11:00 PM to 7:00 AM nursing shift for the past 2 months for Resident #220. CNA #10 stated they rarely went into Resident #220's room because Resident #220 was able to care for themself. CNA #10 stated that there was nothing on the CNA accountability record that instructed the CNAs to monitor the resident for drug abuse behavior. CNA #10 further stated they (CNA #10) were not aware of Resident #220's overdose and illicit drug use in the facility. RN #10 was interviewed on 3/3/2022 at 3:26 PM and stated that they (RN #10) were the RN Supervisor on 3/2/2022 on the 11 PM-7AM nursing shift and was covering the 3 PM-11 PM nursing shift on Resident #220's unit. RN #10 stated that they were called by RN #8 to Resident #220's room because Resident #220 presented with an altered mental status and was not waking up. Resident #220's oxygen saturation level was 66%. RN #10 was aware of Resident #220's overdose in December 2021 but did not suspect that the resident had a drug overdose in this case. RN #10 did not tell the EMS anything about Resident #220's drug abuse behavior. RN #8 was interviewed on 3/3/2022 at 3:52 PM and stated that they (RN #8) were covering the 3PM-11PM nursing shift on 3/2/2022. RN #8 stated they were not the regularly assigned nurse for the resident's unit. At 5:00PM, RN #8 went to Resident #220's room and Resident #220 seemed out of it. Resident #220 was transferred to the hospital due to the unresponsiveness. RN #8 stated they (RN #8) were not aware that Resident #220 had substance abuse behaviors and had overdosed in December 2021 in the facility. RN #8 further stated that there were no Physician's orders or instructions related to substance abuse monitoring for Resident #220. Social Worker (SW) #2 was interviewed on 3/3/2022 at 5:11 PM and stated Resident #220 had a short stay at the facility from 8/24/2021 to 9/3/2021 and was readmitted on [DATE] which was considered a new stay. SW#2 stated that Resident #220 informed them (SW #2) that Resident #220 was kicked out of another skilled nursing facility two years ago because of selling and using illicit drugs. Resident #220 informed SW #2 that they (Resident #220) were clean and were not using illicit drugs when they were admitted on [DATE]. Resident #220 was referred to psychology for therapy and only had one psychotherapy session in October 2021. SW #2 stated that the plan of care for history of substance abuse was to refer Resident #220 to psychology and to check any incoming packages for illicit drugs. SW #2 stated that searching packages is a standard protocol in the facility and did not have to be in a care plan. The nursing staff are expected to look through food items brought in from outside as per the facility-wide protocol. SW #2 stated that Resident #220 was not actively having substance abuse disorder so a care plan to prevent and monitor substance abuse behavior was not developed. SW #2 stated that Resident #220 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . SW #2 stated that the facility cannot always search Resident #220's belongings and there is only so much we can do. On 12/13/21, Resident #220 was found in their room unresponsive and was hospitalized . SW #2 stated that they (SW #2) followed up with Resident #220 on 12/16/21 and educated Resident #220 on the facility rules. SW #2 stated that Resident #220 was placed on SW #1's caseload when readmitted on [DATE]. SW #2 stated that it was SW #1's responsibility to develop and update the care plan to address Resident #220's substance abuse behavior when Resident #220 was readmitted on [DATE]. SW #1 was interviewed on 3/3/22 at 5:51 PM. SW #1 stated that they were assigned to Resident #220 upon their readmission in December 2021 after the resident returned from the hospital from the opiate overdose. SW #1 stated that they did not complete a psychosocial assessment and did not develop a revised plan of care to address Resident #220's substance abuse behavior. SW #1 stated that they could not recall reviewing the hospital discharge paperwork with the instruction for supervised visitation to reduce substance abuse behavior. SW #1 stated that an interdisciplinary team approach was not used to address Resident #220's substance abuse behavior. SW #1 stated that they did not initiate any additional interventions for Resident #220 after the resident's return from the hospital on 12/16/2021. Resident #220 was reassigned to SW #2 on 1/4/2022. The Medical Director and Director of Nursing was interviewed concurrently on 3/3/22 at 6:30 PM. The Medical Director stated that Resident #220's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Nursing stated that everyone on the team is aware of Resident #220's substance abuse history is noted in the medical record. The Director of Nursing stated that the facility did not initiate an Incident Report to investigate how Resident #220 obtained drugs in the facility on 12/13/2021 because SW #2 had written a note that Resident #220 received the drugs from a visitor. The Director of Nursing stated that the facility was in COVID-19 quarantine and Resident #220 did not require increased supervision. The Director of Nursing stated that the visitation protocols were facility wide and did not need to be documented in a care plan. The Director of Nursing stated that Resident #220 refused psychotherapy in the past. The Medical Director stated that they were not aware if the psychotherapist had seen Resident #220 after 12/16/2021. The Medical Director was not aware if the substance abuse behaviors were addressed in psychotherapy or psychiatry and if substance abuse treatment was offered. The Director of Nursing stated that it was the hospital's responsibility to refer Resident #220 to a drug rehabilitation programs and that the facility can only offer psychiatric and psychological care. The Director of Recreation was interviewed on 3/4/22 at 2:40 PM. The Director of Recreation stated that Resident #220 preferred extra newspapers and enjoyed watching television. The Director of Recreation stated that during the outbreak in December 2021 and January 2022, activities were provided one to one or in the room. When Resident #220's unit was cleared in February 2022, Resident #220 would go out to the courtyard when weather permitted and self-propelled throughout the facility, to other units to talk to other residents and to go to the vending machines. Attending Physician #2 was interviewed on 3/4/22 at 3:42 PM and stated that they (Attending Physician #2) provided care for Resident #220 since Resident #220 was moved to Unit 46 on 1/4/2022. Resident #220 has a history of high blood pressure, chronic lower back pain, and anxiety disorder. Attending Physician #2 stated that Resident #220 was known to have agitated and aggressive behaviors and was followed by a psychiatrist. Resident #220 refused psychotherapy on several occasions. Attending Physician #2 stated that they (Attending Physician #2) believed that Resident #220 was very agitated when the suggestion to decrease the [MEDICATION(S)] was recommended by the psychiatrist and Attending Physician #2 reduced [MEDICATION(S)] instead. Attending Physician #2 stated that Resident #220 required monitoring and supervision and they (Attending Physician #2) had verbally informed CNA #10 and RN #7 to monitor Resident #220 for Substance abuse behavior. Attending Physician #2 stated that they did not recall documenting the need for increased monitoring for substance abuse behaviors or placing an order instructing nurses to do so. SW #2 was re-interviewed on 3/4/2022 at 5:15 PM. SW #2 stated that the facility staff located Resident #220's care plan entitled history of substance abuse which was dated 9/28/2021. The interventions did not include to monitor and supervise Resident #220's whereabouts in the facility for substance abuse behavior. SW #2 stated that they had developed the care plan but did not revise the care plan after the resident returned from the hospital on 12/16/2021 since that was the responsibility of SW #1. Resident #220 should have had a revised care plan after the 12/13/2021 hospitalization . The care plan did not include any updates in December 2021. Resident #220 was not on the radar for active use of drugs at the time of the 9/28/2021 care plan. The search of packages is a standard practice for any resident in the facility so that intervention would not be in the care plan. The facility was notified of the Immediate Jeopardy on 3/3/2022. The Immediate Jeopardy was removed on 3/7/2022 prior to the completion of the survey. -The facility created policies and procedures to address needs of the residents with Alcohol and Drug problems and Management of Residents with History of Substance abuse. -The facility Educated 95% of the facility staff on the newly developed policies and procedures and on identification of care for resident history of using Polysubstance/Polydrug abuse and identifying signs and symptoms of drug abuse. The facility also educated staff on narcotic overdose and use of [MEDICATION(S)]. Those not in-serviced are either on vacation, on medical leave, or have not been scheduled for duty and will be in-serviced as they report to work. - The facility assessed and formulated care plans for all residents identified as having history of Polysubstance abuse. -The facility created Resident contracts/agreements to educate residents on facility's zero tolerance drug policy along with consequences. -The facility developed audit tools to monitor residents with history of Substance abuse history for signs and symptoms of drug abuse and updated the room search audit tool to include legal and illegal substances.