Every finding on record at Allegria Nursing & Rehab Center of Port Jefferson

Based on record review and interviews, the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice to maintain their highest practicable physical wellbeing. This was identified for one resident (Resident #1) of three residents reviewed. Specifically, on 07/24/2026, Resident #1 experienced increased abdominal pain following a cholecystectomy (laparoscopic abdominal surgery to remove the gallbladder). There was no documented evidence that Resident #1 was assessed by a registered nurse or physician after abdominal pain was not resolved after as needed narcotic medications were administered. A STAT (immediate) Kidney Ureter Bladder X-ray (diagnostic imaging procedure that uses X-ray beams to produce images of the abdominal area, focusing on the kidneys, ureters, and bladder) was ordered and there is no documented evidence that the test was completed. This resulted in actual harm to Resident #1 and the likelihood for serious injury, serious harm, serious impairment or death to all 109 residents that was Immediate Jeopardy.The findings are:The facility policy titled Pain Assessment, Reassessment and Management dated 02/16/2026 documented it shall be the responsibility of all clinical staff to observe and screen all residents expeditiously for the presence or absence of pain, and avoid delays related to testing, diagnostic or consultations. If through observation or the formal screening assessment process pain is revealed in a resident, it shall be the responsibility of clinical staff to conduct an in-depth clinical assessment of the pain and periodic and timely reassessments of the resident for determination of pain and relief from pain, Including the intensity and quality and responses to treatment.Resident #1 was admitted with diagnoses that include metabolic encephalopathy (brain dysfunction caused by an underlying systemic illness or a chemical imbalance in the blood that deprives the brain of essential energy or exposes it to toxins), acute cholecystitis (the sudden swelling and irritation of the gallbladder), sepsis (the body's extreme response to an infection, the immune system overreacts and attacks healthy tissues and organs) and acute kidney failure (the rapid loss of the kidneys' ability to remove waste and help balance fluids and electrolytes in the body).The Minimum Data Set (a resident assessment tool) dated 07/26/2026 documented a Brief Interview for Mental Status score of 14, indicating intact cognition.A Comprehensive Care Plan for potential for pain related to post surgery cholecystectomy (surgical removal of the gallbladder) initiated 07/19/2026 documented Resident #1's interventions: administer analgesic as per physician's order, monitor for effectiveness, anticipate the resident's needs for pain relief and respond immediately to any complaint of pain. Notify physicians if interventions are unsuccessful.A Nursing Progress Note dated 07/24/2026 at 11:05 AM by Licensed Practical Nurse #1 documented Resident #1 stating their abdominal pain is 10/10. Tylenol 650 milligrams and Xtampza ER 18 milligrams (an extended-release oral oxycodone opioid medication) are not working. Per Physician Assistant, give one dose of Oxycodone 5 milligrams.A Nursing Progress Note dated 07/24/2026 at 2:56 PM by Licensed Practical Nurse #1 documented Resident #1 stating the pain level is an 8/10 after receiving an additional dose (of Oxycodone).A Nursing Progress Note dated 07/25/2026 at 10:57 AM by Licensed Practical Nurse #1 documented Resident #1 complaints of pain stating the pain level is a 15/10 and shortness of breath. Per Physician Assistant #1, give one-time dose of Oxycodone 5 milligrams and order Kidney Ureter Bladder STAT.A Nursing Progress Note dated 07/26/2026 at 8:07 AM by Registered Nurse Supervisor #1 documented they were called to assess Resident #1 related to abdominal distention and pain. Abdomen grossly distended, void of bowel sounds. Family Member #1 at bedside insisting resident be sent to hospital emergency room for evaluation. Informed Family Member #1 a call would be placed to the physician assistant for further instructions. Prior to response from medical provider; family member called emergency medical services.There was no documented evidence that a medical provider was notified after Resident #1's pain did not subside after receiving two doses of pain medication.There is no documented evidence that the Kidney Ureter Bladder ray was completed.There is no documented evidence of a physical assessment of Resident #1 completed by a registered nurse on 07/24/2026 or 07/25/2026.The hospital medical records dated 07/26/2026 at 9:21 AM documented Resident #1's abdomen is distended with abdominal tenderness in all four quadrants and hypoactive bowel sounds.The hospital records dated 07/26/2026 at 10:55 AM documented Resident #1 with diagnoses of post-op ileus (a temporary slowdown or stoppage of normal intestinal movement after surgery, occurring without any physical blockage), opioid induced constipation, Ogilvie syndrome (a sudden widening of the large intestine without any physical blockage), and bowel obstruction.The hospital records dated 07/26/2026 at 3:40 PM documented Resident #1 vomiting bilious vomit (fluid with a greenish-yellow color that contains bile) with abdominal guarding (the tensing of the stomach wall muscles to protect inflamed organs underneath from the pain of pressure).During an interview with Licensed Practical Nurse #1 on 08/13/2026 at 1:20 PM, they stated that on 07/25/2026, Resident #1 complained of pain on a scale of 15/10. They notified Registered Nurse Supervisor #1 that Resident #1 had pain of 15 out of 10. Licensed Practical Nurse #1 stated Resident #1 was not assessed. Physician Assistant #1 was notified and ordered Kidney Ureter Bladder test STAT. When they came back the next day, 07/26/2026, the test was not completed. Family Member #1 visited and noticed the resident's abdomen was more distended than the day before. Licensed Practical Nurse #1 stated they listened to resident's stomach and there were little to no bowel sounds. Family Member #1 called emergency medical services. The emergency medical services transferred Resident #1 out of the facility to the hospital.During an interview with Registered Nurse Supervisor #1 on 08/12/2026 at 2:02 PM, they stated, Resident #1 was status post cholecystectomy. They stated that on 07/26/2026 they assessed the resident by listening to the bowel sounds and there was an absence of bowel sounds. They stated they called Physician Assistant #1 and they did not answer, then Family Member#1 called 911.During an interview with Unit Charge Registered Nurse #2 on 08/12/2026 at 2:07 PM, they stated they were not working on 07/26/2026. They were aware that Resident #1's abdominal pain was from the surgery. They complained of a pain level of 10 out of 10, which is very bad and warrants an assessment. They stated they did not do an assessment because the resident had bowel sounds. They were aware that Physician Assistant #1 ordered a Kidney Ureter Bladder test STAT on 07/25/2026. Unit Charge Registered Nurse #2 stated that a STAT ordered test should be completed within four hours and that they must enter the order into a stat portal for confirmation. The order was entered, but the lab technician never came. No follow up was completed.During an interview with Family Member #1 on 08/13/2026 at 9:40 AM, they stated they came to visit Resident #1 at 7:10 AM on 07/26/2026. They stated Resident #1's stomach was swollen like they were pregnant and they were crying in pain. They stated Resident #1 had black stuff on their bed because they vomited. They stated Licensed Practical Nurse #1 took Resident #1's blood sugar and it was 323. They stated that at 7:35 AM, they called emergency medical services and Resident #1 was transferred to the hospital at 7:50 AM.During an interview with the Director of Nursing on 08/13/2026 at 12:16 PM, they stated the registered nurses do not routinely assess every complaint of abdominal pain. The Director of Nursing stated Resident #1 should have had an abdominal assessment due to increasing abdominal pain and recent surgery. The Director of Nursing stated if the Kidney Ureter Bladder test was not done within four to six hours, then they should have called the medical doctor, and Resident #1 should have been sent out. The Director of Nursing stated that on 07/25/2026 at approximately 10:53 AM, they assessed Resident #1's incision site, but they did not document their assessment, and Resident #1 was complaining of shortness of breath. The Director of Nursing stated that an increasing pain of 10 out of 10 is urgent, and a huge belly is a medical emergency. The Director of Nursing stated that Resident#1's abdomen did not appear distended, they just looked at the incision site, they did not listen for bowel sounds, but they told Licensed Practical Nurse #1 to ask Physician Assistant #1 for an X-ray.During an interview with Administrator on 08/13/2026 at 3:27 PM, they stated they recall the situation. The Administrator stated that when a patient is in pain, the medical provider should be notified for further instruction. The Administrator stated if a resident who is post operative is complaining of abdominal pain, they expect the staff to complete an assessment of the abdomen. The Administrator stated the expectation of a STAT lab/test is within 24 hours. The Administrator stated when Resident #1 complained of pain 10 out of10 and 15 out of 10 pain, the nursing staff notified the medical provider, which is the appropriate intervention.During an interview with the Medical Director at 08/21/2026 at 4:08 PM, they stated they recall Resident #1. The Medical Director stated they were unaware of Resident #1's increasing abdominal pain while in the facility. The Medical Director stated Resident #1's pain was generalized. The Medical Director stated that the nursing staff is not equipped to assess a post-operative abdomen, so if Resident #1 was complaining of incisional pain they should have been transferred for further evaluation. The Medical Director stated that the expectation of a STAT lab/test is within 24 hours. 10 NYCRR 415.12 The immediacy was removed on 08/16/2026 when: The facility implemented the systemic change by revising their policy for Pain, bowel, change in condition, lab and diagnostic test. Education conducted for all registered nurses on pain management and full comprehensive assessments, change in condition and when to identify the need for further intervention. Inservice was given to the Medical Director and nursing staff on the policy for STAT diagnostic testing and need for escalation. The facility developed a lesson plan to include pain management and timely assessment and STAT diagnostic testing procedures.

Based on observation and staff interviews during the Recertification Survey initiated on 5/04/2025 and completed on 5/08/2025, the facility did not ensure that it established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This was identified for 1) two (Resident #82 and Resident #73) of five residents reviewed for Medication Administration and 2) laundry room observation conducted during the Infection Control Laundry Task. Specifically, 1) Licensed Practical Nurse #1 did not follow the manufacturer's instructions and did not use the appropriate Environmental Protection Agency (EPA) approved disinfectant to clean and disinfect the shared blood glucose meter between the two residents (Resident #82 and Resident #73). 2) Laundry Aid #1 did not use appropriate Personal Protective Equipment when handling soiled and clean laundry. The findings are: 1)The facility's policy titled Blood Glucose Testing/Glucose Control, dated 7/11/2024, documented cleaning the glucometer (blood glucose meter) with isopropyl alcohol or low-level disinfectant and allowing the glucometer to remain wet until dry. The blood glucose meter manufacturer's instruction manual instructed cleaning and disinfecting the device between each patient. The meter is validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. The following products have been approved for cleaning and disinfecting the glucose meter device: Dispatch(R) Hospital Cleaner Disinfectant Towels with Bleach (EPA Registration Number: 56392-8). Clorox Healthcare(R) Bleach Germicidal and Disinfectant Wipes (EPA Registration Number: 67619-12). Medline Micro-KillTM Bleach Germicidal Bleach Wipes (EPA Registration Number: 37549-1). Medline Micro-Kill disinfecting, Deodorizing, Cleaning Wipes with Alcohol. Resident #82 was admitted with diagnoses that included Vascular Dementia, Hypertension, and Type 2 Diabetes Mellitus. The Minimum Data Set assessment, dated March 28, 2025, documented a Brief Interview for Mental Status score of 6, indicating the resident had severely impaired cognition. A physician's order dated 5/01/2025 documented the use of the FreeStyle Libre 3 Reader Device (Continuous Glucose System). Resident #73 was admitted with diagnoses that included Chronic Respiratory Failure, Type 2 Diabetes Mellitus, and Major Depressive Disorder. The Quarterly Minimum Data Set assessment, dated January 31, 2025, documented a Brief Interview for Mental Status score of 15, indicating the resident had intact cognition. A physician's order dated 12/08/2024 documented the use of the FreeStyle Libre 3 Reader Device (Continuous Glucose System). The Facility List identified a total of nine residents (Resident #110, #112, #53, #9, #69, #73, #2, #82, and #114) who had a physician's order for fingerstick blood glucose monitoring. During a medication administration observation on 5/6/2025 at 5:55 AM, Licensed Practical Nurse #1 was observed performing a fingerstick for Resident #82. The glucometer was a multi-use blood glucose meter for the unit. Licensed Practical Nurse #1 was observed using an alcohol wipe (70 % Isopropyl Alcohol) to clean the blood glucose meter. (Federal Drug Administration (FDA) guidance for manufacturers of blood glucose meters indicates that 70% ethanol (alcohol) solutions are not effective against viral bloodborne pathogens.) Licensed Practical Nurse #1 then collected supplies, including the same blood glucose meter, from the medication cart to check Resident #73's blood glucose. On 5/6/2025 at 6:00 AM, Licensed Practical Nurse #1 reached the door of Resident #73's room. Licensed Practical Nurse #1 was stopped before entering the resident's room and immediately interviewed. Licensed Practical Nurse #1 stated both residents had physician orders for continuous blood glucose monitoring systems; however, the continuous blood glucose monitors were not functioning for both residents. Licensed Practical Nurse #1 stated that to administer insulin coverage, they had to perform blood glucose testing via finger stick. Licensed Practical Nurse #1 stated they typically use alcohol wipes to cleanse the blood glucose meter after performing a fingerstick. Licensed Practical Nurse #1 further stated facility policy directs that an alcohol pad could be used in place of a germicidal wipe to clean items like the blood glucose meter. During an interview on 5/6/2025 at 12:21 PM, Licensed Practical Nurse #2 stated they have been employed by the facility for over [AGE] years, and they always cleaned the blood glucose meter with an alcohol wipe. Licensed Practical Nurse #2 stated it was the facility's policy to use alcohol wipes to disinfect the blood glucose meters. During an interview on 5/6/2025 at 2:06 PM, the Assistant Director of Nursing/Nurse Educator stated nurses were educated to clean the blood glucose meter with alcohol prep pads. The Assistant Director of Nursing/Nurse Educator stated that it is the facility's policy to use alcohol wipes to disinfect the glucometer between resident use. The Assistant Director of Nursing/Nurse Educator stated they did not develop the facility policy, but were involved in the Quality Assurance Committee review of the policy. The Assistant Director of Nursing/Nurse Educator stated that nursing staff can use the low-level disinfectants, including germicidal wipes, to disinfect the blood glucose meters. During an interview on 5/6/2025 at 2:43 PM, the Infection Preventionist stated it is the facility's policy to use alcohol and low-level disinfectants to disinfect the blood glucose meters. The Infection Preventionist stated they are not aware who created the facility policy or when the policy was last reviewed. The Infection Preventionist stated that the blood glucose meter's manufacturer's instructions indicated that the use of alcohol wipes would not kill pathogenic organisms. The Infection Preventionist stated they were unaware that germicidal wipes should be used to disinfect the blood glucose meter. The Infection Preventionist stated there were no known residents with bloodborne pathogens who require finger-stick blood glucose monitoring. The Infection Preventionist stated there is one resident in the facility on contact precautions for a Multidrug Resistant Organism; however, the resident did not require fingerstick blood glucose monitoring at the present time. During an interview on 5/6/2025 at 3:20 PM, Registered Nurse #3 stated that they cleaned the blood glucose meter with an alcohol wipe, and it was the facility's policy to use alcohol wipes to disinfect the glucometer machine. During an interview on 5/6/2025 at 4:56 PM, the Director of Nursing Services stated they had no concerns when they reviewed the Blood Glucose Testing/Glucose Control policy. The Director of Nursing Services stated that the policy has been implemented since 1997, and now they see that the policy needs to be updated. The Director of Nursing Services stated they should have considered the manufacturer's guidelines when reviewing the policy. 2) The facility's policy titled Laundry Procedures, dated 8/16/2024, documented that laundry personnel will wear protective gloves and gowns when sorting laundry. During an observation and interview on 5/7/2025 at 10:27 AM, Laundry Aid #1 was in the folding room with another aid folding and hanging up clean laundry. Neither of the aides was wearing a gown or gloves while folding and hanging up the residents' laundry. Laundry Aide #1 brought the surveyor to the laundry room, where they had two washing machines and two dryers. They put on gloves and demonstrated how they pulled a soiled laundry bag and transported the soiled laundry into the washing machine. Laundry Aid #1 stated they use gloves and do not wear a gown when they empty the soiled linen bags into the laundry machine. Laundry Aid #1 stated they only put on a gown when handling laundry for residents on isolation precautions. Laundry Aid #1 stated they put on a new pair of gloves to transfer the clean laundry in and out of the dryer. Laundry Aid #1 stated they do not wear a gown when doing laundry because they do not let the dirty or clean clothes touch their clothing. During an interview on 5/8/2025 at 10:05 AM, the Director of Housekeeping stated that laundry staff should wear a gown when handling soiled laundry as per the facility policy. During an interview on 5/8/2025 at 11:31 AM, the Director of Nursing Services stated that staff should be wearing gowns and gloves when handling dirty laundry as pr the facility policy. 10 NYCRR 415.19(a)(1-3)

Based on observations and interviews during the Recertification Survey initiated on 5/4/2025 and completed on 5/8/2025, the facility did not maintain all mechanical, electrical, and patient care equipment in a safe operating condition. This was identified during the laundry observation for the Infection Control Task. Specifically, during a tour of the laundry room, a washing machine was observed overflowing and causing the water to accumulate on the floor around the drain. Additionally, the back of the washing machine and dryers had an accumulation of lint and dust. The finding is: The facility's policy titled Laundry Procedures, dated 8/16/2024, documented at the end of each shift, the walls are washed down using disinfectant, washers are wiped down with disinfectant, and then wiped down with stainless steel cleaner. The floors are swept and mopped daily using all-purpose cleaner. The Porters will clean the room weekly. Infection control policies and procedures will be followed when applicable to this department. During an observation of the laundry room on 5/7/2025 at 10:32 AM, there was pooled, stagnant water on the floor around the drain in the middle of the laundry room. Overflowing water from the drainpipe was observed in the back of a washing machine. Additionally, the back of the washing machine and dryers had an accumulation of lint and dust. During an interview on 5/7/2025 at 10:32 AM, the Director of Housekeeping stated that the washing machine in the laundry room leaks when the machine is overloaded with soap or dirty laundry. The Director of Housekeeping stated that water spills out from the overflow pipe at the back of the machine. The Director of Housekeeping stated that the washing machine has been leaking for about a month. The Director of Housekeeping stated that the facility maintenance department staff inspected the machine and explained that the machine is designed to overflow if it is too full, and the floor drain is intended to catch any excess water. The Director of Housekeeping stated they have not contacted an outside repair company to examine the washing machine. The Director of Housekeeping stated that a porter is supposed to clean behind the machines once a month. The Director of Housekeeping stated that the area behind the machines appeared dirty and had not been cleaned this month. During an interview on 5/8/2025 at 11:30 AM, the Director of Nursing Services stated that the laundry room needs to be kept clean. 10 NYCRR 415.5(e)(1)(2)

Based on observations, record review, and interviews during the Recertification Survey initiated on 5/4/2025 and completed on 5/8/2025, the facility did not ensure each resident was treated with respect and dignity and provided care in a manner and in an environment that promotes maintenance or enhancement of their quality of life. This was identified for one unit (Unit B) of three units observed during the Dining Task. Specifically, 1) during the lunch meal observation on 5/4/2025, twelve residents were seated at a large table in the Unit B main dining room. Four (Resident #15, Resident #95, Resident #44, and Resident #56) of the twelve residents at the table did not receive their lunch meal until 30 minutes after the other eight residents were served. Resident #15 left the dining room and said they felt disrespected when they were not served their lunch meal at the same time as others. 2) Certified Nurse Aide #1 was observed standing over Resident #55 while assisting the resident with their lunch meal in the sencondary dining room on Unit B. The findings are: The facility's policy titled Person Centered Dining Approach, dated 3/24/2025, documented that each person will be treated like a special individual, with a focus on individualizing all interactions and interventions. All individuals will be treated with the utmost courtesy, respect, and dignity. The facility's policy titled Dining Experience Staff Responsibilities, dated 3/24/2025, documented that staff will sit next to a resident when assisting them with eating rather than standing over them. 1) Resident #15 was admitted with diagnoses that included Dementia, Acute Kidney Failure, and Hypokalemia. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 5, indicating the resident had severely impaired cognition. Resident # 95 was admitted with diagnoses that included Dementia, Rhabdomyolysis (muscle breakdown), and Chronic Heart Disease. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Resident Interview for Mental Status score of 99, indicating the resident was unable to complete the interview and had severely impaired cognition. Resident #44 was admitted with diagnoses that included Cerebral Infarction, Dementia, and Acute Respiratory Failure. The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 99, indicating the resident was unable to complete the interview and had severely impaired cognition. Resident #56 was admitted with diagnoses that included Alzheimer's Disease, Schizoaffective Disorder, and Major Depressive Disorder. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 3, indicating the resident had severely impaired cognition. During an observation in the Unit B main dining room on 5/4/2025 at 11:50 AM, twelve residents were seated around a large dining table when the first lunch meal truck arrived in the dining room. Eight of the twelve residents received their meals at 12:00 PM. The other four residents (Resident #15, Resident #95, Resident #44, and Resident #56) did not receive their meal trays and Resident #15 left the dining room. During an interview on 5/4/2025 at 12:05 PM, Resident #15 stated they did not get a meal tray when other residents on their table got their meals and were eating. Resident #15 stated, What did I do to deserve this? Resident #15 stated they often do not get a meal tray when other residents are served meals, and they have to watch the other residents eat. Resident #15 stated, What is wrong that I cannot get a meal tray? Why do they (the staff) put us in a group and not give us meal trays together? I feel disrespected, my stomach is too upset now. Resident #15 went back to their room and sat in the doorway of their room. During an observation on 5/4/2025 at 12:20 PM Resident #95, Resident #44, and Resident #56 were still in the dining room with no meal tray, while other residents on the table were finishing their meals. The second lunch truck arrived at 12:23 PM. Resident #95 received their lunch tray at 12:24 PM, Resident #44 received their lunch tray at 12:28 PM, and Resident #56 received their lunch tray at 12:33 PM. During an observation on 5/4/2025 at 12:34 PM, Resident #15 was offered a lunch tray in their room, and the resident refused. Resident #15 stated they may eat later. During an interview on 5/4/2025 at 12:38 PM, Registered Nurse #1 stated they would speak to Resident #15 and re-approach them to offer them lunch. During an interview on 5/8/2025 at 8:11 AM, the Food Service Director stated they expect restaurant-style dining where each resident at the table eats at the same time. The Food Service Director stated it is not appropriate to send up trays for only some of the residents who sit at the same table and not others. The Food Service Director stated the kitchen did not have a list of residents or seating arrangement information for residents who eat in the dining room. The Food Service Director stated the staff members in the dining should notify the kitchen if the resident's meals were not delivered timely according to the seating arrangement. During an interview on 5/8/2025 at 11:25 AM, the Director of Nursing Services stated that all residents should be served their meals at the same time when seated at a table. The Director of Nursing Services stated that meal trucks should be organized to follow the seating arrangements in the dining room. 28173 2) Resident #55 had diagnoses that included Alzheimer's disease and Dysphagia (difficulty swallowing). The Minimum Data Set assessment dated [DATE] documented that the resident had severely impaired cognition and was dependent on staff for feeding. During an observation on 5/4/2025 at 12:05 PM, Certified Nurse Aide #1 was observed standing while feeding Resident #55 their lunch meal. Three unoccupied chairs were observed in the dining room. Certified Nurse Aide #1 was immediately interviewed and stated they did not sit to assist Resident #55 because it was not comfortable for them (Certified Nurse Aide #1). During an interview on 5/8/2025 at 11:51 AM, the Director of Nursing Services stated that Certified Nursing Assistants are expected to feed residents while seated at eye level with the resident to promote dignity. 10 NYCRR 415.3 (d)(1)(i)

Based on observations, record review, and interviews during the Recertification Survey initiated on [DATE] and completed on [DATE], the facility did not ensure that all medications and biologicals were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. This was identified for two (Unit H and Unit B ) of the four units reviewed during the Medication Storage Task. Specifically, Unit H medication carts were not clean and had items stored other than the medications. The Unit H medication refrigerator had yellowish-brown dried substances on the bottom shelf. Unit B Long Hall medication cart contained unidentifiable medication tablets and loose glucometer strips. The findings are: The facility's Routine Cleaning and Disinfecting Policy dated [DATE] documented routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces and high touch areas to include but not limited to: treatment and medication carts. The Medication Labeling and Storage Policy dated [DATE] documented that each resident's medications are assigned to an individual cubicle, drawer, or other holding area including but not limited to sealed storage bags, and labeled with individual names to prevent the possibility of mixing medications of several residents. Any loose pills found will be discarded in sharps containers. The Medication Cart Usage and Cleanliness policy dated [DATE] documented to ensure that all medication carts are used safely, securely, and hygienically in compliance with state and federal regulations, and to prevent cross-contamination or unauthorized access to medications. Spills must be cleaned immediately using appropriate disinfectants. Medication carts must undergo a thorough cleaning. This includes emptying drawers, removing expired or discontinued medications, and cleaning both internal and external surfaces. During an observation on [DATE] at 11:13 AM, the Unit H Short Hall medication cart was observed in the presence of Licensed Practical Nurse #5. There were three prescribed eye drops stored without an individualized zip lock bag, four loose glucometer strips, and a wander guard accuracy reader device in the first drawer. The Second drawer had two loose unidentifiable medication tablets. The third drawer had seven opened liquid medication bottles with no open date and the bottles were soiled with a dried yellow substance. During an interview on [DATE] at 11:17 AM, Licensed Practical Nurse #5 stated they knew that each eye drop medication should be stored in a separate bag. Licensed Practical Nurse #5 stated the blood glucose meter strips were loose, but they were not used. Licensed Practical Nurse#5 stated if the bottles contain over-the-counter liquid medications, they do not have to be dated when opened. Licensed Practical Nurse #5 stated there should not be any loose medications in the medication carts. All nurses are responsible for cleaning the medication carts. During an observation on [DATE] at 11:25 AM, the Unit H medication storage room was observed in the presence of the Assistant Director of Nursing. The medication storage room refrigerator had yellowish-brown dried substances on the bottom shelf. During an interview on [DATE] at 11:25 AM, the Assistant Director of Nursing stated the refrigerator should be kept clean at all times. During an observation on [DATE] at 11:35 AM, the Unit H High Unit medication cart was observed in the presence of Licensed Practical Nurse #6. There was a thermometer (not in a bag) and five insulin pens (none in a bag) in the first drawer. In the third drawer, there were five opened and undated liquid medication bottles and a blood pressure cuff with a blood pressure machine. During an interview on [DATE] at 11:36 AM, Licensed Practical Nurse #6 stated they did not know why the insulin pens were not stored in individual bags. Licensed Practical Nurse #6 stated all medications like eye drops and insulin pens are supposed to be stored in a separate bag. Licensed Practical Nurse #6 stated the thermometer did not belong in the medication cart drawer and did not know the thermometer was there. During an observation on [DATE] at 1:50 PM, the Unit B Long Hall medication cart was observed in the presence of Licensed Practical Nurse #7. There were six unidentifiable medication tablets and five loose blood glucose meter strips in the first drawer. The second drawer had twelve unidentifiable loose medication tablets. During an interview on [DATE] at 1:50 PM, Licensed Practical Nurse #7 stated there should not be loose pills in the medication carts and that all nurses are responsible for cleaning the medication carts. Licensed Practical Nurse #7 stated there should not be loose glucose strips and they were almost sure the blood glucose strips were not used. During an interview on [DATE] at 1:53 PM, the Director of Nursing Services stated the medication carts should not contain loose pills and loose glucose strips and the wander guard accuracy reader, blood pressure machines, blood pressure cuffs, and thermometers. They stated all eye drops and insulin pens should be stored in individualized bags. The Director of Nursing Services stated all liquid medication bottles should have an open date on them so that they can be discarded after a month from the opening date. 10 NYCRR 415.18(e)(,d+[DATE])

Based on observation, record review, and interviews during the Recertification Survey initiated on 5/4/2025 and completed on 5/8/2025, the facility did not ensure that food was stored in accordance with professional standards for food service safety. This was identified during the Kitchen Task. Specifically, two kitchen refrigerators contained numerous unlabeled and undated food items. The finding is: The facility's policy titled Food Storage with a revised date of 8/4/2024, documented that all food will be dated upon stocking if taken out of its original packaging. If not in the original packaging, all food items must be dated and labeled with the name of the contained food and discarded after three days. During the kitchen tour on 5/4/2025 at 10:21 AM, the refrigerator was observed with 18 egg salad sandwiches that were not labeled and dated. Another refrigerator used to store day-service food items was observed with five apple sauce cups, 30 chocolate pudding cups, six Jello cups, and seven single-serve salads that were not labeled with a use-by date. During an interview on 5/4/2025 at 10:30 AM, the [NAME] stated that the food items were likely prepared the day before, 5/3/2025; however, they were unsure because the food items were not labeled. During an interview on 5/5/2025 at 2:25 PM, the Food Service Director stated the kitchen staff should have dated and labeled all food items. The Food Service Director stated they were unsure which staff member prepared the identified items and when they were prepared. 10 NYCRR 415.14(h)

Based on observation, record review, and staff interviews during the Recertification Survey initiated on 5/4/2025 and completed on 5/8/2025, the facility did not ensure that each resident's right to personal privacy and confidentiality of his or her medical record was maintained. This was identified for one (Resident #62) of nine residents observed for the Medication Administration Task. Specifically, Licensed Practical Nurse #4 left Resident #62's electronic medical record open in the hallway with the resident's personal and medical information visible to other staff, residents, and visitors. The finding is: Resident #62 was admitted with diagnoses that included Hypertension, Cerebral Infarction, and Hemiplegia. A Quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 14, which indicated intact cognition. The resident received Antiplatelet and Anticoagulant medications. During a medication pass observation on 5/6/2025 at 9:35 AM for Resident #62, Licensed Practical Nurse #4 left the medication cart outside the resident's room, with the electronic medical record open, displaying the resident's personal and medical information accessible to other residents, staff, and family members. During an interview on 5/6/2025 at 9:35 AM, Licensed Practical Nurse #4 stated they should have closed the electronic medical record computer screen prior to walking away from the medication cart. During an interview on 5/6/2025 at 4:19 PM, the Registered Nurse Educator stated that the nurses should ensure the resident's medical record and other personal health information remain secure. The Registered Nurse Educator stated Licensed Practical Nurse #4 should have closed the computer screen prior to walking away from the medication cart. During an interview on 5/8/2025 at 11:59 AM, the Director of Nursing Services stated Licensed Practical Nurse #4 should close the screen to protect the resident's personal health information before leaving the medication cart. 10 NYCRR 415.3(e)(1)

Based on observation, record review, and interviews during the Recertification and abbreviated (Complaint #NY 00377877) Survey, initiated on 5/4/2025 and completed on 5/8/2025, the facility did not ensure that all alleged violations involving abuse, neglect, and mistreatment were reported immediately to the facility administration and not later than 2 hours to the Department of Health after the allegation was made. This was identified for one (Resident #108) of one resident reviewed for Abuse. Specifically, Resident #108 alleged that Certified Nursing Aide #4 pushed them off the bed, resulting in a fall without injury. There is no documented evidence that the facility reported the allegation of abuse to the New York State Department of Health. The finding is: The facility's policy, titled Abuse, Mistreatment, Neglect, and Exploitation, dated 7/14/2024, documents that the facility completes a full investigation when signs of Mistreatment, Neglect, Exploitation, or Abuse are noted by any personnel. The witness of such actions will immediately notify their Supervisor on duty. All reports/allegations of potential abuse, neglect, mistreatment, and or exploitation must be reported promptly to their direct supervisor and to the New York State Department of Health within two hours after the determination of suspicion during the investigation. Resident #108 was admitted with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction affecting the left non-dominant side, Muscle Weakness, and Major Depressive Disorder. The 3/11/2025 Admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 12, indicating the resident had moderate cognitive impairment. The resident was dependent on facility staff for bed mobility and was incontinent of both bowel and bladder. The Comprehensive Care Plan dated 12/8/2023 and last revised on 11/25/2024 titled Resident was at moderate risk for falls related to gait and balance problems documented interventions including bed in the lowest position, floor mats as the bed extenders while in bed and to ensure the resident is placed in the middle of the bed for all care rendered in bed. The care plan was updated on 4/5/2025 to include a two-person approach. A Comprehensive Care Plan titled Resident is Inappropriate to Female Staff Related to Mental/Emotional Illness and Poor Impulse Control, effective 1/18/2024, documented interventions including care provision by a male aide and or two female aides. A Comprehensive Care Plan titled The resident has a behavior problem including non-compliance with transfers, attempts to self-transfer at times, refuses care, has episodes of confabulation, and calls 911 without staff knowledge. Interventions included monitoring behaviors, attempting to determine the underlying cause, and explaining all procedures to the resident. The care plan was updated on 4/5/2025 to include a two-person approach. The Resident Nursing Instructions (care instructions for Certified Nursing Assistant), effective 4/6/ 2025, document under the heading Safety, Male Aides Only, and/or 2-person approach for care. During an interview on 5/8/2025 at 2:15 PM, Resident #108 stated they were provided hygiene care by Certified Nursing Aide #4 on 4/5/2025. The resident alleged that they were pushed off the bed by Certified Nursing Aide #4 on 4/5/2025 and reported the incident to the nurse supervisor (Licensed Practical Nurse #3), but felt that they didn't believe them. The occurrence report dated 4/5/2025 documented resident was observed lying on the floor on their right side on the floor mat. The resident received care from Certified Nursing Assistant #4 when the resident rolled themselves out of bed onto the floor. No injuries were noted. There was no statement obtained from the resident. Certified Nursing Assistant #4's written statement indicated while giving morning care the resident rolled themselves on the floor on the right side of the bed. The facility investigation summary report dated 4/10/2025 documented as per Certified Nursing Assistant #4 on 4/5/2025 at 11:00 AM when they were opening the resident's brief, the resident rolled off the bed so fast and Certified Nursing Assistant #4 was unable to stop the resident from falling out of bed onto the floor mat. At 3:00 PM the resident called Emergency Services (911) and their family member to take them to the Hospital without the staff's knowledge. The resident returned to the facility the next day. All testing was negative for acute fractures. A new nursing intervention was added to the care plan to have two persons during care. The investigation concluded there was no reasonable cause to believe that alleged abuse, neglect, or mistreatment occurred. No statements from the resident were included in the investigation. A review of the medical record revealed a struck-out note, written by Licensed Practical Nurse #3, on 4/5/2025 at 3:26 PM documented they received a message from the resident's family member informing them that the resident told the family member staff threw them out of bed during care. The strike-out reason was documented as incorrect documentation. During an interview on 5/8/2025 at 2:25 PM, Licensed Practical Nurse #3 stated that on 4/25/2025, they heard a thud while in the hallway and heard Resident # 108 yell, She pushed me. Upon entering the room, Licensed Practical Nurse #3 observed Certified Nursing Aide #4 next to the resident's bed, and Resident #108 was on the floor. Licensed Practical Nurse #3 stated that they immediately notified the Director of Nursing Services. During an interview on 5/8/2025 at 4:14 PM, Certified Nursing Assistant #4 stated they were assigned to Resident #108 on 4/5/2025 during the day shift. Certified Nursing Assistant #4 stated they performed hygiene care for Resident #108 alone on that day. Certified Nursing Aide #4 stated they did not know another staff member was supposed to be present during care for Resident #108. Certified Nursing Assistant #4 stated they reviewed the Certified Nursing Assistant Accountability record and only one Certified Nursing Aide was required to care for Resident #108. Certified Nursing Assistant #4 denied pushing resident #108 off the bed and maintained that the allegation was a fabrication by the resident. During an interview on 5/8/2025 at 4:20 PM, the Director of Nursing Services stated that they were unaware of the allegation of abuse made by the resident. They stated that the policy of the facility is to investigate every allegation of abuse and report to the Department of Health and the police within two hours. During an interview on 5/8/2025 at 4:30 PM, the Administrator stated they were aware of the allegation of abuse made by Resident#108. Resident #108 had a history of making false allegations and based on statements provided by the Certified Nursing Assistant, the Administrator believed no abuse investigation was necessary. They stated that the policy of the facility is to investigate every allegation of abuse and report it to the Department of Health and the police within two hours, except for this incident, because of the resident's history of making false allegations. 10 NYCRR 415.4(b)(2)

Based on observation, record review, and interviews during the Recertification and Complaint (NY 00377877) Survey, initiated on 5/4/2025 and completed on 5/8/2025, the facility did not ensure that all alleged violations involving abuse, mistreatment, or neglect were thoroughly investigated. This was identified for one (Resident #108) of one residents reviewed for Abuse. Specifically, Resident #108 alleged that Certified Nursing Assistant #4 pushed them off the bed, resulting in a fall without injury. The facility did obtain a statement from the resident and an investigation related to the allegation of being pushed out of bed was not completed. The finding is: The facility's policy, titled Abuse, Mistreatment, Neglect, and Exploitation, dated 7/14/2024, documents that the facility completes a full investigation when signs of Mistreatment, Neglect, Exploitation, or Abuse are noted by any personnel. The witness of such actions will immediately notify their Supervisor on duty. All reports/allegations of potential abuse, neglect, mistreatment, and or exploitation must be reported promptly to their direct supervisor and to the New York State Department of Health within two hours after the determination of suspicion during the investigation. Resident #108 was admitted with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction affecting the left non-dominant side, Muscle Weakness, and Major Depressive Disorder. The 3/11/2025 Admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 12, indicating the resident had moderate cognitive impairment. The resident was dependent on facility staff for bed mobility and was incontinent of both bowel and bladder. The Comprehensive Care Plan dated 12/8/2023 and last revised on 11/25/2024 titled Resident was at moderate risk for falls related to gait and balance problems documented interventions including bed in the lowest position, floor mats as the bed extenders while in bed and to ensure the resident is placed in the middle of the bed for all care rendered in bed. The care plan was updated on 4/5/2025 to include a two-person approach. A Comprehensive Care Plan titled The resident has a behavior problem including non-compliance with transfers, attempts to self-transfer at times, refuses care, has episodes of confabulation, and calls 911 without staff knowledge. Interventions included monitoring behaviors, attempting to determine the underlying cause, and explaining all procedures to the resident. The care plan was updated on 4/5/2025 to include a two-person approach. During an interview on 5/8/2025 at 2:15 PM, Resident #108 stated they were provided hygiene care by Certified Nursing Aide #4 on 4/5/2025. The resident alleged that they were pushed off the bed by Certified Nursing Aide #4 on 4/5/2025 and reported the incident to the nurse supervisor (Licensed Practical Nurse #3), but felt that they didn't believe them. The occurrence report dated 4/5/2025 documented resident was observed lying on the floor on their right side on the floor mat. The resident received care from Certified Nursing Assistant #4 when the resident rolled themselves out of bed onto the floor. No injuries were noted. There was no statement obtained from the resident. Certified Nursing Assistant #4's written statement indicated while giving morning care the resident rolled themselves on the floor on the right side of the bed. The facility investigation summary report dated 4/10/2025 documented as per Certified Nursing Assistant #4 on 4/5/2025 at 11:00 AM when they were opening the resident's brief, the resident rolled off the bed so fast and Certified Nursing Assistant #4 was unable to stop the resident from falling out of bed onto the floor mat. At 3:00 PM the resident called Emergency Services (911) and their family member to take them to the Hospital without the staff's knowledge. The resident returned to the facility the next day. All testing was negative for acute fractures. A new nursing intervention was added to the care plan to have two persons during care. The investigation concluded there was no reasonable cause to believe that alleged abuse, neglect, or mistreatment occurred. The facility investigation lacked documented evidence of a statement from the resident to identify the root cause of the fall and to rule out abuse, neglect, and mistreatment. A review of the medical record revealed a struck-out note, written by Licensed Practical Nurse #3, on 4/5/2025 at 3:26 PM documented they received a message from the resident's family member informing them that the resident told the family member staff threw them out of bed during care. The strike-out reason was documented as incorrect documentation. During an interview on 5/8/2025 at 2:25 PM, Licensed Practical Nurse #3 stated that on 4/25/2025, they heard a thud while in the hallway and heard Resident # 108 yell, She pushed me. Upon entering the room, Licensed Practical Nurse #3 observed Certified Nursing Aide #4 next to the resident's bed, and Resident #108 was on the floor. Licensed Practical Nurse #3 stated that they immediately notified the Director of Nursing Services. During an interview on 5/8/2025 at 4:14 PM, Certified Nursing Assistant #4 stated they were assigned to Resident #108 on 4/5/2025 during the day shift. Certified Nursing Assistant #4 stated they performed hygiene care for Resident #108 alone on that day. Certified Nursing Aide #4 stated they did not know another staff member was supposed to be present during care for Resident #108. Certified Nursing Assistant #4 stated they reviewed the Certified Nursing Assistant Accountability record and only one Certified Nursing Aide was required to care for Resident #108. Certified Nursing Assistant #4 denied pushing resident #108 off the bed and maintained that the allegation was a fabrication by the resident. During an interview on 5/8/2025 at 4:20 PM, the Director of Nursing Services stated that they were unaware of the allegation of abuse by the resident. They state that the policy of the facility is to thoroughly investigate every allegation of abuse and report the incident to the Department of Health and the police within two hours. During an interview on 5/8/2025 at 4:30 PM, the Administrator stated they were aware of the allegation of abuse made by Resident#108. Resident #108 had a history of making false allegations and based on statements provided by the Certified Nursing Assistant, the Administrator believed no abuse investigation was necessary. They stated that the policy of the facility is to investigate every allegation of abuse and report it to the Department of Health and the police within two hours, except for this incident, because of the resident's history of making false allegations. 10 NYCRR 415.4(b)(3)

Based on observation, record review, and interviews during the Recertification and Abbreviated (NY 00377877) Survey initiated on 5/4/2025 and completed on 5/8/2025, the facility did not ensure that a comprehensive person-centered care plan was implemented for each resident to meet the resident's nursing, mental, and psychosocial needs. This was identified for one (Resident #108) of one resident reviewed for Abuse. Specifically, Resident #108 had a comprehensive care plan intervention to provide care by a male certified nursing aide and/or two aides due to verbally inappropriate behavior towards female staff. An accident/incident report dated 4/5/2025 revealed the resident received care from one female Certified Nursing Aide, Certified Nursing Assistant #4. The finding is: The facility's policy titled Care Plans, dated 6/2024, documented that care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. Resident #108 was admitted with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction affecting the left non-dominant side, Muscle Weakness, and Major Depressive Disorder. The 3/11/2025 Admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 12, indicating the resident had moderate cognitive impairment. The resident was dependent on facility staff for bed mobility and was incontinent of both bowel and bladder. The Comprehensive Care Plan dated 12/8/2023 and last revised on 11/25/2024 titled Resident was at moderate risk for falls related to gait and balance problems documented interventions including bed in the lowest position, floor mats as the bed extenders while in bed and to ensure the resident is placed in the middle of the bed for all care rendered in bed. The care plan was updated on 4/5/2025 to include a two-person approach. A Comprehensive Care Plan titled Resident is Inappropriate to Female Staff Related to Mental/Emotional Illness and Poor Impulse Control, effective 1/18/2024, documented interventions including care provision by a male aide and or two female aides. A Comprehensive Care Plan titled The resident has a behavior problem including non-compliance with transfers, attempts to self-transfer at times, refuses care, has episodes of confabulation, and calls 911 without staff knowledge. Interventions included monitoring behaviors, attempting to determine the underlying cause, and explaining all procedures to the resident. The care plan was updated on 4/5/2025 to include a two-person approach. The Resident Nursing Instructions (care instructions for Certified Nursing Assistant), effective 4/6/ 2025, document under the heading Safety, Male Aides Only, and/or 2-person approach for care. The occurrence report dated 4/5/2025 documented resident was observed lying on the floor on their right side on the floor mat. The resident received care from Certified Nursing Assistant #4 when the resident rolled themselves out of bed onto the floor. No injuries were noted. There was no statement obtained from the resident. Certified Nursing Assistant #4's written statement indicated while giving morning care the resident rolled themselves on the floor on the right side of the bed. The facility investigation summary report dated 4/10/2025 documented as per Certified Nursing Assistant #4 on 4/5/2025 at 11:00 AM when they were opening the resident's brief, the resident rolled off the bed so fast and Certified Nursing Assistant #4 was unable to stop the resident from falling out of bed onto the floor mat. At 3:00 PM the resident called Emergency Services (911) and their family member to take them to the Hospital without the staff's knowledge. The resident returned to the facility the next day. All testing was negative for acute fractures. A new nursing intervention was added to the care plan to have two persons during care. During an interview on 5/8/2025 at 2:15 PM, Resident #108 stated that at the time of their fall on 4/5/2025, they received hygiene care from Certified Nursing Aide #4. Resident #108 stated there were no other certified nursing aides present when they fell . During an interview on 5/8/2025 at 4:14 PM, Certified Nursing Assistant #4 stated they were assigned to Resident #108 on 4/5/2025 during the day shift. Certified Nursing Assistant #4 stated they performed hygiene care for Resident #108 alone that day. Certified Nursing Aide #4 stated they were unaware that a male aide or two aides were required for care at that time. Certified Nursing Aide #4 stated they referred to the Resident Nursing Instructions and recalled only one Certified Nursing Aide was required to care for the resident. During an interview on 5/8/2025 at 4:20 PM, the Director of Nursing Services stated that the Certified Nursing Aide instructions should match the care plan related to the assistance needs of the resident. 10 NYCRR 415.11(c)(1)

Based on observation, Record review, and staff interviews during the Recertification Survey initiated on 5/4/2025 and completed on 5/8/2025, the facility did not ensure that each resident's Comprehensive Care Plan was revised by the interdisciplinary team after each assessment to reflect the resident's current status. This was identified for one (Resident #97) of one resident reviewed for Bladder and Bowel Incontinence. Specifically, Resident #97's minimum data set assessments indicated the resident was frequently incontinent of bladder; however, the comprehensive care plan inaccurately documented the resident was occasionally incontinent of bladder. The finding is: The facility's Care Plan policy and procedure, effective 6/20/2024, documented assessment of the resident is ongoing, and care plans are revised as information about the resident and the resident's condition changes. The care planning/interdisciplinary team is responsible for the review and updating of the care plan when: there has been a significant change in the resident's condition; the desired outcome is not met; the resident has been readmitted to the facility from a hospital stay; and at least quarterly. Resident #97 was admitted with diagnoses that included Seizure Disorder, Depression, and Schizophrenia. The Annual Minimum Data Set, dated dated dated [DATE] documented the resident's Brief Interview Mental Status score was 14, which indicated the resident's cognition was intact. The Minimum Data Set assessment documented the resident was frequently incontinent of bladder and required partial/moderate assistance for toileting and personal hygiene. A Quarterly Minimum Data Set assessment dated [DATE] documented the resident was frequently incontinent of bladder and required moderate assistance for toileting and supervision with set up help for personal hygiene. A Comprehensive Care Plan dated 10/18/2022 and last revised on 3/12/2025 documented the resident had occasional bladder incontinence. Interventions included to clean he peri-area with each incontinence episode and to monitor and document the signs and symptoms of Urinary Tract Infection. A Review of the Bladder Elimination Record (Certified Nursing Assistant Accountability Record) dated 4/25/2025 to 5/8/2025 documented that the resident was incontinent 1 to 3 times per shift (frequently incontinent). During an interview on 5/8/25 at 10:22 AM, the Minimum Data Set Coordinator stated usually, the Registered Nurse Managers are responsible for updating the Care Plan, and the Care Plan Nurse is responsible for initiating the Care Plans on admission. The Minimum Data Set Coordinator stated that the Care Plans are updated Quarterly, annually, and as needed. The Minimum Data Set Coordinator stated that the resident's Care Plan should have been updated to reflect the resident's current urinary status of frequently incontinent. During an interview on 5/8/25 at 11:51 AM, the Director of Nursing Services stated that the Nurse Manager, or the Care Plan Nurse, is responsible for updating the Care Plan during the review period prior to the Care Plan meeting. The Director of Nursing Services stated the Care Plans should have been updated at the time of the Quarterly assessment to ensure the Care Plans reflect the resident's current urinary status. 10 NYCRR 415.11(c)(2)(i-iii)

Based on observation, record review, and interviews, during the Recertification Survey initiated on 5/4/2025 and completed on 5/8/2025, the facility did not ensure the resident's environment remained free of accident hazards as possible. This was identified for one (Resident #62) of nine residents observed for the Medication Administration Task. Specifically, during a medication administration pass for Resident #62, Licensed Practical Nurse #4 left the medication cart unattended and went into the resident's room without ensuring the medication cart was securely locked and was clearly visible to the nurse administering medication. The finding is: The facility's Administrating Medication policy and procedure dated 12/3/2024, documented during administration of medication, the medication cart is kept closed and locked when out of sight of the medication nurse. Additionally, the cart must be clearly visible to the personnel administering medication. Resident #62 was admitted with diagnoses that included Hypertension, Cerebral Infarction, and Hemiplegia. A Quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 14, which indicated intact cognition. The resident received Antiplatelet and Anticoagulant medications. During a medication pass observation on 5/6/2025 at 9:35 AM for Resident #62, Licensed Practical Nurse #4 walked away from the medication cart and entered Resident #62's room without locking the medication cart. The resident's privacy curtain was drawn around the bed. Licensed Practical Nurse #4 went behind the privacy curtain to administer the medications, and the medication cart was not visible to Licensed Practical Nurse #4. During an interview on 5/6/2025 at 9:35 AM, Licensed Practical Nurse #4 stated they should have ensured the medication cart was securely locked when they walked away from the cart. During an interview on 5/8/2025 at 11:59 AM, the Director of Nursing Service stated Licensed Practical Nurse #4 should have ensured the medication cart was securely locked before stepping away from the cart. The Director of Nursing Services stated when the medication cart is left unlocked and unattended, anyone can open the cart, including staff and or residents, causing a potential accident hazard. 10 NYCRR 415.12(h)(1)

Based on record review and interviews during the Recertification Survey initiated on 5/4/2025 and completed on 5/8/2025, the facility did not ensure its Facility Assessment considered daily staffing needs for each resident unit and for each shift, such as day, evening, and night. This was identified during the Sufficient and Competent Nurse Staffing Review Task. Specifically, the Facility Assessment, last updated on 2/3/2025, only reflected emergency staffing levels and did not consider the daily Nursing staffing needs for each nursing unit. The finding is: The Facility assessment dated [DATE] documented the facility was licensed for 143 residents with an average daily census of 120. The facility assessment identified a total of three units including Unit A, Unit B, and Unit H. The facility assessment did not document the bed capacity for each unit. The facility assessment documented the following staffing plan per 24 hours (for the entire facility): Three (3) Registered nurses, nine (9) Registered Nurses/Licensed Practical Nurses providing direct care, and 15 Certified Nursing Assistants. The facility assessment documented daily staffing needs for the resident population and during emergencies. Unit A, Unit B, and Unit H were each assessed to need: -One (1) Licensed Practical Nurse and two (2) Certified Nursing Assistants during the 7:00 AM to 3:00 PM shift -One (1) Licensed Practical Nurse and two (2) Certified Nursing Assistants during the 3:00 PM to 11:00 PM shift -One (1) Licensed Practical Nurse and one (1) Certified Nursing Assistant during the 11:00 PM to 7:00 AM shift. The staffing plan documented that the entire facility needed one (1) Registered Nurse supervisor for all three units on each shift. The facility provided a staffing par level (minimum number of staff needed) sheet that documented the following staffing ratios: -Units A and B should have one (1) Certified Nursing Assistant to care for 11 residents during the 7:00 AM to 3:00 PM shift and 3:00 PM to 11:00 PM shift. -Unit H should have one (1) Certified Nursing Assistant to care to care for 13 residents during the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shift. -Units A and B should have one (1) Certified Nursing Assistant to care for 22 residents during the 11:00 PM to 7:00 AM shift. -Unit H should have one (1) Certified Nursing Assistant to care for 26 residents during the 11:00 PM to 7:00 AM shift. During an interview on 5/8/2025 at 12:00 PM, Staffing Coordinator #1 stated that the Administrator and the Director of Nursing Services provided them (the Staffing Coordinator) with the required nursing staffing levels for each unit and per shift based on daily census. Unit A and Unit B, with a capacity of 44 beds are staffed with no less than three (3) Certified Nursing Assistants per unit. Staffing Coordinator #1 stated Unit H is a bigger unit and has a capacity of 52 beds. Staffing Coordinator #1 stated Unit H should be staffed with no less than four (4) Certified Nursing Assistants for the day and evening shifts. During an interview on 5/8/2025 at 11:41 AM, the Director of Nursing Services stated that the facility assessment only documented the emergency staffing levels. The Director of Nursing Services stated the nursing staffing numbers in the facility assessment staffing plan were the bare bottom numbers. The Director of Nursing Services stated that they had par levels based on the resident census and maintained a higher number of nursing staff on the units than what was documented on the facility assessment. The Director of Nursing Services stated Unit H had a census of 52 residents and four Certified Nursing Assistants on the unit would be acceptable to care for the residents. The Director of Nursing Services stated staffing needs are analyzed daily, and they notify the Staffing Coordinator of what the minimum staffing should be on all units. The Director of Nursing Services further stated they were not sure what was documented in the facility assessment. During an interview on 5/4/2025 at 10:38 AM, the Administrator stated the facility assessment only reflected emergency nursing staffing levels and should have documented the accurate number of staff needed on a daily basis per unit per shift. The Administrator stated that the nursing staffing should be based on the resident census and acuity of the resident population. The Administrator stated they provide the Staffing Coordinator with unit par levels to guide the actual staffing needs. 10 NYCRR 415.26

Based on observations, record review, and staff interviews during the Recertification Survey initiated on 1/28/2024 and completed on 2/1/2024, the facility did not ensure sufficient nursing staff were available to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. This was identified during a review of the Payroll Based Journal (PBJ) Staffing Data Report, and review of the Facility Assessment; concerns raised during the Resident Council meeting; and during the medication administration observation on Sunday (1/28/2024) on one of three nursing units. Specifically, review of the Payroll Based Journal (PBJ) Staffing Data Report and the Facility Assessment (FA) identified that the facility did not ensure adequate staffing was available to meet the residents' needs on multiple days; two of ten residents present at the Resident Council meeting held on 1/29/2024 voiced concerns regarding staffing shortage and receiving their medications late; an off-hour survey was conducted on 1/28/2024 and one Licensed Practical Nurse did not administer medications to six (Resident #72, Resident #12, Resident # 51, Resident# 82, Resident# 22, and Resident #92) of nine residents in the prescribed time frame due to staffing shortage. The findings are: The Facility's undated Policy for Administering Medications documented medications are administered in a safe and timely manner, and as prescribed. The Policy documented medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal). Medication administration times are determined by resident need and benefit, not staff convenience. The Facility's Policy Interpretation and Implementation on staffing dated March 2023 documented the facility provides adequate staffing to meet needed care and services for the resident population. Facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. Licensed Registered Nursing and Licensed Nursing staff are available to provide and monitor the delivery of resident care services. The facility furnishes information from payroll records setting forth the average numbers and types of personnel (in full-time equivalents) on each shift during at least one (1) week of each quarter to appropriate state agencies. The Facility Assessment for 2024 determined that on the 7:00 AM to 3:00 PM shift and the 3:00 PM to the 11:00 PM shift there should be 7 licensed nurses per shift. The facility has three nursing units. Two Licensed nurses are assigned to each unit and there is one Registered Nurse Supervisor assigned to each shift. The Night shift (11:00 PM to 7:00 AM) has one Licensed staff on each unit (total of three licensed nurses) and one Registered Nurse Supervisor for the entire facility. The Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year (FY) Quarter four 2023 (July 1-September 30) documented the facility triggered for the Metric of excessively low weekend staffing. A review of the weekend staffing from 7/1/2023 to 9/30/2023 revealed there was less licensed staffing than was documented as required on the facility assessment. Examples include but are not limited to: -On July 1 2023, the facility had 5.5 licensed staff for the evening shift instead of 7 licensed nurses. -On July 16, 2023, the facility had 3 licensed staff for the night shift instead of 4 licensed nurses. -On August 20, 2023, the facility had a total of 5 nurses for the evening shift instead of 7 licensed nurses. Additionally, a review of the actual staffing records during the survey from 1/28/2024 to 2/1/2024 revealed that on 1/28/2024, there was 5 licensed nurses on duty during the day shift instead of 7 licensed nurses as determined on the Facility Assessment. A Resident Council meeting was held on 1/29/2024 at 11 AM with 10 residents in attendance. Two residents stated that the nurses are overburdened on the weekends and on some days, they receive their medications late. A resident who attended the Resident Council meeting on 1/29/2024 was interviewed on 1/31/2024 at 3:26 PM and stated there were problems with staffing over the summer. There were less nurses and Certified Nurses' Aides to provide care. A Medication Administration was observed on a Sunday morning 1/28/2024 from 10:30 AM to 11:20 AM. Licensed Practical Nurse # 3 was observed administering 9:00 AM medications to six residents (Resident# 82, Resident # 51, Resident #12, Resident #72, Resident# 22, and Resident #92) from 10:38 AM to 11:20 AM. Licensed Practical Nurse #3 was interviewed on 1/28/2024 at 11:20 AM and stated that the medications they were administering for Resident# 82, Resident # 51, Resident #12, Resident #72, Resident# 22, and Resident #92 were due to be administered at 9:00 AM. Licensed Practical Nurse #3 stated that they were administering the medications late because there was a call out and they had to administer medications to 41 residents on the unit. Licensed Practical Nurse #3 further stated on weekends they have to cover the medication pass due to staff call outs on Unit B. During the weekday there is more staffing; two Licensed Practical Nurse giving medications and one charge nurse that is behind the desk. Licensed Practical Nurse #3 stated the 9:00 AM medications should have been administered no later than one hour after the due time of 9:00 AM. The Staffing Coordinator #1 was interviewed on 1/31/2024 at 12:14 PM and stated that there are difficulties staffing licensed nurses on the weekends. When nurses call out on the weekend, they try to get other nurses to volunteer. If it is critically low staffing, then the facility has to mandate nurses to stay over to the next shift. To mandate the facility has to have four or less nurses on the day shift and or the evening shift and two or less nurses on the night shift. Sometimes even with mandates the nursing levels are still below the ideal level of seven licensed nurses per day and evening shift. The facility does not contract out with staffing agencies for Nurses. Registered Nurse Supervisor #1 was interviewed on 2/1/2024 at 12:15 PM and stated they assist nurses that require assistance, intervene when there are emergencies, speak to families and Physicians, and perform other Nursing supervision tasks. Registered Nurse Supervisor #1 further stated they were not made aware that Licensed Practical Nurse (LPN) #3 was not able to complete the 9:00 AM medication pass timely. The Director of Nursing Services (DNS) was interviewed on 1/30/2024 at 3:30 PM and stated that the medications were administered late on 1/28/2024 and it was not acceptable to administer medications late. The Director of Nursing Services stated that the regularly assigned second nurse for the unit called out and another nurse was not found to substitute. The Director of Nursing Services stated Licensed Practical Nurse #3 should have asked for assistance and the Registered Nurse Supervisor could have assisted; however, the Registered Nurse supervisor could have been busy and may not have been able to assist. The Director of Nursing Services was re-interviewed on 1/31/2024 at 3:52 PM. The weekend staffing sheets from July 1 - September 30 were reviewed with the Director of Nursing Services. The Director of Nursing Services acknowledged that there were less than seven licensed nurses working on July 1st and July 2nd, 16th, and August 20th. There should have been a minimum of six nurses to ensure two nurses are assigned to each unit. On 1/28/2024 during the 7:00 AM- 3:00 PM shift, five nurses were assigned, and one Registered Nurse supervisor should have been helping out on unit B. If Licensed Practical Nurse #3 was having difficulties giving medications in a timely manner, the Registered Nurse Supervisor should have been notified. The Administrator was interviewed on 1/31/2024 at 2:29 PM and stated there is a nationwide nursing staffing shortage. The facility has had difficulties recruiting nurses. The shortage affects weekends the most. The Administrator stated the facility does not have an agency to recruit Licensed Practical Nurses and that the facility is having a difficult time finding nurses. Incentives are provided to Licensed Practical Nurses and increased salaries were provided to the Registered Nurse Supervisor. 10 NYCRR 415.13(a)(1)(i-iii)

Based on observations, record review, and interviews conducted during the Recertification Survey initiated on 1/28/2024 and completed on 2/1/2024, the facility did not ensure that the facility's medication error rates are not five percent or greater. This was identified for 42 of 53 opportunities for six (Resident #82, Resident #51, Resident #12, Resident #72, Resident #22, and Resident #92) of nine residents observed during a medication pass observation. This resulted in a 79.25% medication error rate. Specifically, 1) Resident #82 did not receive eleven of the 9:00 AM Physician ordered medications until 10:56 AM. 2) Resident #51 did not receive three of the 9:00 AM Physician ordered medications until 11:10 AM. 3) Resident #12 did not receive seven of the 9:00 AM Physician ordered medications until 10:38 AM. 4) Resident #72 did not receive seven of the 9:00 AM Physician ordered medications until 11:00 AM. 5) Resident #22 did not receive five of the 9:00 AM Physician ordered medications until 11:05 AM; and 6) Resident #92 did not receive nine of the 9:00 AM Physician ordered medications until 10:49 AM. The findings include but are not limited to: The Facility's undated Policy for Administering Medications documented medications are administered in a safe and timely manner, and as prescribed. The Policy documented medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal). Medication administration times are determined by resident need and benefit, not staff convenience. A medication administration was observed on a Sunday morning, 1/28/2023. Licensed Practical Nurse #3 was observed administering medications to six residents from 10:38 AM to 11:10 AM. 1) Resident #82 was admitted with diagnoses that include Dementia and Hypertension (HTN). The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 4 indicating the resident had severe cognitive impairment. During the medication administration observation task on 1/28/2024 at 10:56 AM, Licensed Practical Nurse #3 was observed administering the following Physician ordered 9:00 AM medications to Resident #82: -Razadyne Tablet 8 milligrams, Give 1 tablet by mouth two times a day for Dementia; -Memantine HCl Tablet 5 milligrams, Give 1 tablet by mouth one time a day for Dementia; -Metoprolol Tartrate Tablet 25 milligrams, Give 1 tablet by mouth every 12 hours for Hypertension, hold for Systolic Blood Pressure greater than 100 millimeters of Mercury; -Potassium Chloride Extended Release tablet 10 milliequivalent, Give 1 tablet by mouth one time a day for supplement; -Sennosides tablet 8.6 milligrams, Give 2 tablets by mouth two times a day for Constipation; -Seroquel Oral Tablet 50 milligrams, Give 1 tablet by mouth two times a day for Bipolar Disorder; -Sertraline HCl Tablet 25 milligrams, Give 1 tablet by mouth one time a day for Depression; -Amlodipine Besylate tablet 5 milligrams, Give 1 tablet by mouth one time a day for Hypertension, hold for Systolic Blood Pressure greater than 100 millimeters of Mercury; -GlycoLax Powder, Give 17 gram by mouth one time a day for Constipation. Dissolve 1 capful in 4-6 ounce fluids; -Hydrochlorothiazide Capsule 12.5 milligrams, Give 1 capsule by mouth one time a day for Hypertension; -Folic Acid Tablet 1 milligram, Give 1 tablet by mouth one time a day for Anemia. A total of eleven 9:00 AM Physician prescribed medications were administered late. 2) Resident # 51 was admitted with diagnoses that include Type 2 Diabetes Mellitus and Chronic Obstructive Pulmonary Disease. The Minimum Data Set (MDS) assessment dated [DATE] documented that a Brief Interview for Mental Status (BIMS) was not completed due to severe cognitive impairment. During the medication administration observation task conducted on 1/28/2024 at 10:38 AM, Licensed Practical Nurse #3 was observed administering the following Physician ordered 9:00 AM medications to Resident #51: -Trintellix Tablet 10 milligram, Give 1 tablet by mouth one time a day for Depression; -Nuedexta Capsule 20-10 milligrams, Give 1 capsule by mouth every 12 hours for Pseudobulbar Affect; -Levetiracetam Solution 100 milligrams/milliliter, Give 5 milliliters by mouth two times a day for Seizure Disorder. A total of three 9:00 AM Physician prescribed medications were administered late. 3) Resident #12 was admitted with diagnoses that included Anxiety Disorder, Major Depressive Disorder, and Dementia. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderately impaired cognition. During a medication administration observation task on 1/28/2024 at 11:10 AM, Licensed Practical Nurse #3 was observed administering the following Physician ordered 9:00 AM medication to Resident #12: -Norvasc Oral Tablet 5 milligrams, Give 1 tablet by mouth one time a day for Hypertension; -Paroxetine HCl Oral Tablet 40 milligrams, Give 40 milligrams by mouth one time a day for Major Depressive Disorder; -Os-Cal Extra D3 Oral Tablet 500 -15 milligrams-micrograms, Give 1 tablet by mouth in the morning for supplementation; -Multivitamin Oral Tablet Give 1 tablet by mouth one time a day for supplementation; -Seroquel Oral Tablet 50 milligrams, Give 50 milligrams by mouth one time a day for Anxiety; -Gabapentin Oral Capsule 100 milligrams, Give 1 capsule by mouth two times daily for Pain; -Metformin HCl Oral Tablet 500 milligrams, Give 1 tablet by mouth two times a day for Diabetes management. A total of seven 9:00 AM Physician prescribed medications were administered late. Licensed Practical Nurse #3 was interviewed on 1/28/2024 at 11:20 AM and stated that the medications they were administering for Resident# 82, Resident #51, Resident #12, Resident #72, Resident# 22, and Resident #92 were due to be administered at 9:00 AM. Licensed Practical Nurse #3 stated that they were administering the medications late because there was a call out and they were to administer medications to 41 residents on the unit. Licensed Practical Nurse #3 stated on the weekends, this is the norm on Unit B. During the weekdays there is more staffing; there is usually another nurse. During the weekdays, Licensed Practical Nurse #3 administers medications and there is one charge nurse behind the desk. Licensed Practical Nurse #3 stated the 9:00 AM medications should have been administered one hour prior or one hour after the due time of 9:00 AM. Registered Nurse (RN) #1 was interviewed on 2/01/2024 at 12:15 PM and stated they were supervising the whole facility and were never made aware about any medications not being given in a timely manner on 1/28/2024. Registered Nurse #1 stated if they were made aware, they would have assisted in the administration of medications to the residents. The Director of Nursing Services (DNS) was interviewed on 1/30/2024 at 3:30 PM and stated that the medications were administered late on 1/28/2024 which is not acceptable. The Director of Nursing Services stated that the regularly assigned second nurse for the unit called out and another nurse was not found to substitute. The Director of Nursing Services stated the nurse should have asked for assistance and the Registered Nurse (RN) Supervisor could have assisted. The Director of Nursing Services further stated that the Registered Nurse Supervisor could have been busy and may not have been able to assist. The Physician Assistant was interviewed on 2/01/2024 at 11:07 AM and stated that nurses sometimes administer medications late due to staffing issues. All six sampled resident's medications were reviewed with the Physician Assistant and none of their medications being given late were considered significant; however, some medications, if not given timely can cause complications. 10 NYCRR 415.12(m)(1)

Based on observation, record review, and interviews conducted during the Recertification Survey initiated on 1/28/2024 and completed on 2/1/2024 the facility did not ensure that each resident had a call bell accessible to alert staff of the residents' needs. This was identified for one (Resident #29) of five residents reviewed for the Environmental Task. Specifically, Resident #29 was observed in their room on 1/28/2024 and 1/31/2024 with the call bell out of their reach. The finding is: The facility's policy for the Call System dated 9/18/2023 documented that residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized station. Resident #29 was admitted with diagnoses that included Cerebral infarction, Type 2 Diabetes Mellitus, and Osteoarthritis. Resident #29's Admission Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 13 which indicated the resident had intact cognition. The Minimum Data Set documented the resident required the assistance of staff for all activities of daily living, used a manual wheelchair for mobility, and was dependent on staff to propel their wheelchair. During an initial tour on 1/28/2024 at 10:21 AM Resident #29 was observed in their room sitting in their wheelchair next to their bed and in front of their nightstand. Resident #29's call bell was observed lying across the top of their nightstand. Resident #29 was not able to reach their call bell. A second observation was conducted on 1/31/2024 at 10:20 AM. Resident #29 was observed sitting in their wheelchair towards the lower half of their bed. Resident #29's call bell was observed lying across the upper section of their mattress. Resident #29 was asked if they could reach their call bell. Resident #29 turned their body to the left while seated in the wheelchair and reached out their arm toward the call bell, but they were not able to reach the call bell. Resident #29 did not attempt to propel their wheelchair in order to position themselves closer to the call bell. Certified Nursing Assistant #2 was interviewed on 1/31/2024 at 10:31 AM. Certified Nursing Assistant #2 stated they last saw Resident #29 between 7:30 AM and 8:00 AM. At that time Resident #29 was dressed and sitting in their wheelchair. Certified Nursing Assistant #2 could not recall where Resident #29's call bell was located when they (Certified Nursing Assistant #2) observed Resident #29 this morning. Certified Nursing Assistant #2 stated the call bell should always be within reach of the resident. Licensed Practical Nurse #2 was interviewed on 1/31/2024 at 10:42 AM. Licensed Practical Nurse #2 stated they expected that the call bell would be placed where the resident could reach it. Registered Nurse #4 was interviewed on 1/31/2024 at 11:36 AM. Registered Nurse #4 stated the call bell should be placed within reach of the resident. The Director of Nursing Services was interviewed on 2/1/2024 at 1:12 PM. The Director of Nursing Services stated they expected the call bell to be placed within the reach of the resident. 10 NYCRR 415.5(e)(1)

Based on observation, record review, and interviews during the Recertification Survey initiated on 1/28/2024 and completed on 2/1/2024, the facility did not develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet the resident's medical and nursing needs. This was identified for one (Resident #120) of five residents reviewed for Respiratory Care. Specifically, Resident #120 did not have documented evidence that a care plan was initiated for the use of Oxygen at 2 Liters per minute via nasal cannula continuously every shift for Hypoxia (absence of enough oxygen in the tissues to sustain bodily function). The finding is: The facility's policy titled, Care Plans last revised on 4/20/2023 documented the facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his or her representative, develops and maintains a comprehensive care plan that is based on a thorough assessment. Each resident's comprehensive care plan is designed to identify problems, reflect treatment goals, timetables, and objectives, identify the professional services that are responsible for each element of care, and reflect currently recognized standards of practice for problem areas and conditions. Resident #120 was admitted with diagnoses of Acute Respiratory Failure, Congestive Heart Failure, and Atrial Fibrillation. The Minimum Data Set (MDS) assessment was not completed for the resident's Brief Interview for Mental Status (BIMS) score. A Physician's admission order dated 1/2/2024 documented to administer Oxygen at 2 Liters per minute via nasal cannula continuously every shift for Hypoxia. There was no Comprehensive Care Plan (CCP) for continuous use of Oxygen prior to 1/28/2024. Resident #120 was observed on 1/28/2024 at 10:00 AM sitting in the wheelchair in front of the nurses' station. An oxygen tank was attached behind the resident's wheelchair. The oxygen tubing and the nasal cannula were wrapped around the oxygen tank. The oxygen tank regulator needle was in the green zone which indicated that there was enough oxygen for use. The oxygen tank flow setting was set at zero. A subsequent observation was completed on 1/28/2024 at 10:18 AM. The resident was sitting in the wheelchair in front of the nurses' station. An oxygen tank was attached behind the resident's wheelchair. The oxygen tubing and the nasal cannula were wrapped around the oxygen tank. The oxygen tank regulator needle was in the green zone which indicated that there was enough oxygen for use. The oxygen tank flow setting was set at zero. There were no staff members present at the nurse's station. A third observation was completed on 1/28/2024 at 11:40 AM. Resident # 120 was sitting in the wheelchair in front of the nurses' station. An oxygen tank was attached behind the resident's wheelchair. The oxygen tubing and the nasal cannula were wrapped around the oxygen tank. The oxygen tank regulator needle was in the green zone which indicated that there was enough oxygen for use. The oxygen tank flow setting was set at zero. There were no staff members present at the nurse's station. Licensed Practical Nurse #1 was approached to verify the resident's oxygen order. Licensed Practical Nurse #1 unwrapped the nasal cannula from around the tank. Licensed Practical Nurse #1 then applied the Oxygen cannula to Resident # 120 and turned the oxygen tank regulator to 2 Liters per minute. A new Physician's Order dated 1/28/2024 at 2:46 PM documented to administer Oxygen at 2 Liters per minute via nasal cannula as needed (PRN) for an Oxygen saturation level of less than 92 percent for a diagnosis of Hypoxia. The order for continuous oxygen use was discontinued. A Comprehensive Care Plan (CCP) initiated on 1/28/2024 documented that Resident #120 receives oxygen therapy related to Congestive Heart Failure and ineffective gas exchange. Interventions included to administer oxygen at 2 liters per minute via nasal cannula as needed for oxygen saturation level of less than 92 percent; Monitor for signs and symptoms of respiratory distress and report to the Physician; Promote lung expansion and improve air exchange by positioning with proper body alignment. Registered Nurse #2 was interviewed on 1/30/2024 at 10:30 AM and stated that the care plan was initiated after the Physician changed the oxygen order from continuous to as needed (PRN). Registered Nurse #2 could not provide any documented evidence that a comprehensive care plan for oxygen use was in place prior to 1/28/2024, which was 26 days after the resident's admission. The Director of Nursing Services was interviewed on 2/1/2024 at 8:45 AM and stated they did not know that Resident #120 had no comprehensive care plan developed for the use of oxygen therapy until the physician's order was changed from continuous oxygen use to as needed (PRN). Although a baseline care plan was developed for the use of oxygen therapy when the resident was first admitted , there should have been a comprehensive care plan developed for the resident's status and the use of oxygen therapy. 10 NYCRR 415.11(c)(1)

Based on observations, record review, and staff interviews during the Recertification Survey initiated on 1/28/2024 and completed on 2/1/2024, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan. This was identified for one (Resident #114) of two residents reviewed for Skin Conditions. Specifically, Resident #114 was seen for a Vascular Consult on 1/22/2024 and returned with a dressing on their right lower leg. The resident's right lower extremity was observed on 1/28/2024 and 1/29/2024 with a dressing in place; however, there was no indication when the dressing was last changed. Additionally, there was no documentation regarding the assessment of the right lower extremity wound nor a physician's order for treatment and care of the right lower extremity until 1/29/2024, seven days after the resident was seen by the Vascular Consultant. The finding is: The facility's policy titled, Wound Care, last revised on 10/16/2023, documented guidelines for the care of wounds to promote healing. The policy included reporting type of wounds, the time wound care was given, obtaining a Physician's order, and developing a care plan to assess any special needs of the resident. Resident #114 was admitted with diagnoses that include Atrial Fibrillation, Type II Diabetes, and Acute Respiratory Distress. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated that Resident #114 was cognitively intact. Resident #114 was at risk for pressure ulcers and injuries and had pressure-reducing devices for the bed and wheelchair. A Vascular consult dated 1/22/2024 documented a history of bilateral lower extremity swelling and a calf (back of the lower leg) wound. The consult form documented multiple shallow wounds throughout both calves at various stages of healing consistent with minor trauma and tears from edema. Approximately three wounds were identified on each calf that were small and shallow. The recommendation was to apply an ace wrap from the mid-foot to the upper calf in the morning and remove at night. A review of the Physician's orders from 1/22/2024 through 1/29/2024 lacked documented evidence of an order to use the ace wrap to the lower extremities as recommended by the Vascular Consultant. Resident #114 was observed on 1/28/2024 at 12:48 PM. Resident #114 was sitting in a wheelchair with their legs elevated on the bed. There was edema (swelling) observed on both legs with two Band-Aid dressings on the right lower leg shin area (front of the lower leg). Resident #114 was observed on 1/29/2024 at 12:14 PM. Resident # 114 was sitting in a wheelchair with their legs elevated on the bed. There was edema (swelling) observed on both legs with two Band-Aid dressings on the right lower leg shin area (front of the lower leg). The resident stated that the Band Aids have not been changed for a week. Resident # 114 took off the Band Aids. An open wound measuring approximately half a centimeter was observed on the right shin area. The wound bed was observed with whitish macerated (the softening and breaking down of skin resulting from prolonged exposure to moisture) skin tissue. The area surrounding the wound was moist and a mild discharge was observed coming out of the wound. Resident # 114 asked the surveyor if someone could change the dressing. Licensed Practical Nurse #1 then came in to change the dressing. Resident # 114 was interviewed on 1/29/2024 at 12:29 PM. Resident #114 stated that they went to the Vascular Doctor a week ago. The Vascular Doctor put the Band-Aids on their (Resident #114) right lower leg because there were small open areas. Resident #114 stated no one had changed the dressing since they returned from the Vascular Doctor's office. Certified Nursing Assistant # 1 was interviewed on 1/29/2024 at 2:39 PM and stated they did not notice any dressing on the right lower leg when Resident #114 returned from the consult. Resident # 114 refused the shower the week before on both Monday and Friday. The nurses do a skin check during shower days. Certified Nursing Assistant # 1 stated that they should have checked the resident's skin every shift and reported any changes. Licensed Practical Nurse #1 was interviewed on 1/29/2024 at 12:15 PM and stated they (Licensed Practical Nurse #1) did not know anything about a wound on Resident # 114's right lower leg. Licensed Practical Nurse #1 stated that usually the Certified Nursing Assistants report any skin changes to them and they did not get any report for Resident # 114. Licensed Practical Nurse #1 was aware that Resident #114 went for a Vascular Consult a week ago; however, they did not review the consult note when Resident # 114 returned to the facility. A Physician Order dated 1/29/2024 at 12:24 PM documented to apply Xeroform oil emulsion 2 inch x 2 inch external pad to the right shin every day-shift (7 AM-3 PM) for edema-related skin tear. Registered Nurse #1, the Unit Manager, was interviewed on 1/29/2024 at 12:45 PM and stated that they were not aware of any wounds on Resident #114's right leg. Registered Nurse #1 stated they wrote a note when Resident #114 returned from the Vascular Consult; however, they did not assess Resident #114 for any skin issues. There was no treatment order recommended on the consult note. Registered Nurse #1 did not recall the recommendation for the use of an ace wrap. Registered Nurse #1 stated there were no physician's orders nor a care plan initiated to address the resident's lower extremities because they (Registered Nurse #1) did not see any skin issues at that time. The Director of Nursing Services was interviewed on 2/1/2024 at 11:54 AM and stated that the nurses should have reviewed the Vascular Consult and should have called the resident's Physician for any new orders. If the nursing staff reviewed the consult, they would have seen that Resident #114 had wounds on the lower extremities and addressed the treatment and the need for the ace wrap with the Physician. 10 NYCRR 415.12

Based on observations, record review and interviews conducted during the Recertification Survey initiated on 1/28/2024 and completed on 2/1/2024 the facility did not ensure that each resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This was identified for one (Resident #8) of one resident reviewed for Limited Range of Motion. Specially, Resident #8 was observed on three occasions without the Physician ordered gauze handrolls in place to prevent decline in range of motion. The finding is: The facility's policy titled, Small Adaptive Devices for Activities of Daily Living Skills dated 9/10/2023 documented proper, safe, and consistent use of small adaptive devices can maximize the resident's level of independence. The policy also documented that gauze rolls are used to help protect and preserve the small joints in the hands and fingers. Resident #8 was admitted with diagnoses that included Cerebral Infarction, Hemiplegia (paralysis) and Hemiparesis (weakness). Resident #8's Admission Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was not completed because the resident was rarely/never understood. The Admission Minimum Data Set documented Resident #8 was dependent on a helper for all self-care and mobility needs. The Minimum Data Set documented Resident #8 had functional limitation in range of motion to both upper and lower extremities. A Physician's order dated 5/2/2023 documented to apply bilateral handrolls (to both hands) at all times, and remove once a shift for hygiene and skin checks. Resident #8's Comprehensive Care Plan for Activities of Daily Living Skills related to hand contractures initiated on 2/1/2022 and revised on 7/11/2023 documented bilateral hand palm guard or gauze roll for contracture management to be worn at all times and may be removed for feeding, dressing, bathing, and care. Check every shift for skin tears and skin redness. During an initial tour on 1/28/2024 at 11:19 AM Resident #8 was observed lying in bed with no handrolls in place. A second observation was conducted on 1/29/2024 at 8:50 AM. Resident #8 was observed lying in bed and the handrolls were not in place. A third observation was made with Certified Nursing Assistant #7 on 1/29/2024 at 5:12 PM. Resident #8 was observed lying in bed and the handrolls were not in place. Certified Nursing Assistant #7 was interviewed on 1/29/2024 at 5:12 PM. Certified Nursing Assistant #7 stated Resident #8 wears bilateral handrolls. Certified Nursing Assistant #7 stated they do not place the handrolls because the Licensed Practical Nurses are responsible for placing the hand rolls in the resident's hands. Certified Nursing Assistant #7 stated they remove the handrolls for care and if they (Certified Nursing Assistant #7) noticed the handrolls were not in place they would report it to the Licensed Practical Nurse on the unit. Licensed Practical Nurse #3 was interviewed on 1/30/2024 at 11:12 AM and stated they provided medications and treatments during the morning shift on 1/28/2024; however, they had not yet provided treatments when the observation was made at 11:19 AM. Licensed Practical Nurse #3 stated it was their responsibility to check that the handrolls were in place and to place them if they were not. Registered Nurse #6 was interviewed on 1/30/2024 at 11:29 AM and stated it was the Licensed Practical Nurse's responsibility to check that the handrolls were in place and to document on the Treatment Administration Record. Occupational Therapist #1 was interviewed on 2/1/2024 at 11:58 AM. Occupational Therapist #1 stated Resident #8 has hand contractures of both hands and the handrolls would help prevent further contracture development and pain. Occupational Therapist stated that the resident was not able to remove the handrolls on their own. The Director of Nursing Services was interviewed on 2/1/2024 at 1:12 PM and stated the treatment nurse, normally the Licensed Practical Nurse, is responsible for placing handrolls in the resident's hands. The Certified Nursing Assistants are responsible to inform the treatment nurse or the Registered Nurse on the unit if the handrolls were not in place. The Director of Nursing Services stated orders for assistive devices should be carried out as ordered. 10 NYCRR 415.12(e)(2)

Based on observations, record review, and staff interviews during the Recertification Survey initiated on 1/28/2024 and completed on 2/1/2024, the facility did not ensure that residents who need respiratory care are provided such care consistent with professional standards of practice. This was identified for one (Resident # 120) of five residents reviewed for Respiratory Care. Specifically, Resident #120 had an order for continuous oxygen therapy via a nasal cannula at 2 Liters per minute every shift for Hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). The resident was observed on three occasions without the use of the supplemental oxygen as ordered by the Physician. The finding is: The facility's policy and procedure titled, Oxygen Administration, last revised on 5/16/2023 documented to perform an assessment before and while the resident is receiving oxygen and to administer oxygen as ordered by the Physician. No smoking /Oxygen in Use sign to be placed as per the facility protocol for oxygen administration. Resident #120 was admitted with diagnoses of Acute Respiratory Failure, Congestive Heart Failure, and Atrial Fibrillation. The Minimum Data Set (MDS) assessment was not completed including the resident's Brief Interview for Mental Status (BIMS) score and oxygen use. A Physician's admission order dated 1/2/2024 documented to administer oxygen at 2 Liters per minute via nasal cannula, continuously, every shift for Hypoxia. Resident #120 was observed on 1/28/2024 at 10:00 AM sitting in the wheelchair in front of the nurses' station. An oxygen tank was attached behind the resident's wheelchair. The oxygen tubing and the nasal cannula were wrapped around the oxygen tank. The oxygen tank regulator needle was in the green zone which indicated that there was enough oxygen for use. The oxygen tank flow setting was set at zero. A subsequent observation was completed on 1/28/2024 at 10:18 AM. The resident sitting in the wheelchair in front of the nurses' station. An oxygen tank was attached behind the resident's wheelchair. The oxygen tubing and the nasal cannula were wrapped around the oxygen tank. The oxygen tank regulator needle was in the green zone which indicated that there was enough oxygen for use. The oxygen tank flow setting was set at zero. There were no staff members present at the nurse's station. A third observation was completed on 1/28/2024 at 11:40 AM. Resident # 120 was sitting in the wheelchair in front of the nurses' station. An oxygen tank was attached behind the resident's wheelchair. The oxygen tubing and the nasal cannula were wrapped around the oxygen tank. The oxygen tank regulator needle was in the green zone which indicated that there was enough oxygen for use. The oxygen tank flow setting was set at zero. There were no staff members present at the nurse's station. Licensed Practical Nurse #1 was approached to verify the resident's oxygen order. Licensed Practical Nurse #1 unwrapped the nasal cannula from around the tank. Licensed Practical Nurse #1 then applied the oxygen cannula to Resident # 120 and turned the regulator to 2 Liters per minute. Additionally, there was not a Oxygen in Use sign outside Resident #120's room on 1/28/2024, 1/29/2024 and 1/30/2024. A new Physician's order dated 1/28/2024 at 2:46 PM documented to administer oxygen at 2 Liters per minute via nasal cannula as needed (PRN) for an oxygen saturation level of less than 92 percent for a diagnosis of Hypoxia. The order for continuous oxygen use was discontinued. Certified Nursing Assistant #1 was interviewed on 1/29/2024 at 8:34 AM and stated they provide care to Resident #120 five days a week. Certified Nursing Assistant #1 stated that Resident #120 constantly takes off their oxygen cannula. Certified Nursing Assistant #1 stated that both the Nurses and the Certified Nursing Assistants are responsible for making sure that the residents receive oxygen therapy as needed. Licensed Practical Nurse #1 was interviewed on 1/30/2024 at 10:35 AM and stated that it is the responsibility of all Nursing staff to make sure that Resident #120 has the oxygen on as ordered by the Physician. Licensed Practical Nurse #1 stated that the resident was supposed to receive oxygen every shift continuously as per the Physician's orders. Licensed Practical Nurse #1 did not know why the oxygen was not on while the resident was sitting in front of the nurse's station. The Director of Nursing Services was interviewed on 2/1/2024 at 8:45 AM and stated that the continuous oxygen order by the Physician must always be followed. The Director of Nursing Services did not know why Resident #120 was sitting in front of the nurse's station without oxygen as per the Physician's order. The Director of Nursing Services stated that Resident #120 now has an order for oxygen at 2 Liters per minute via nasal cannula as needed and that an oxygen sign is now placed outside Resident #120's room. 10 NYCRR 415.12(k)(6)

Based on staff interviews and record review during an abbreviated and partial extended survey the facility failed to develop and implement policies and procedures for the supervision and monitoring of residents on therapeutic diets with aspiration precautions. Additionally, key staff were not knowledgeable or informed of residents' therapeutic diet needs, aspiration precautions or need for supervision. Specifically, one (Resident #1) of nine residents reviewed for aspiration precautions was not provided the correct consistency of food and supervision during all meals and snacks. On [DATE] during the night shift, the resident was given a sandwich to eat unsupervised by staff and began choking. The resident did not respond to staff efforts and subsequently was pronounced dead. This resulted in actual harm to Resident #1 and the potential for a pattern of serious harm that is Immediate Jeopardy and Substandard Quality of Care for 11 residents identified by the facility on aspiration precautions. Complaint Number: NY 750 The findings are: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (an assessment tool) dated [DATE] documented that Resident #1 had moderately impaired cognition. The resident required extensive assistance of one person for eating and a mechanically altered diet. The Policy and Procedure on Aspiration, Choking and Asphyxiation (PPACA) dated [DATE] documented that an assessment should include a resident's frequency of coughing or choking while eating, eating/drinking too rapidly or having chronic congestion. The PPACA documented that interventions should include a written plan for feeding a resident, appropriate food texture, swallow evaluation, proper positioning and to stop eating if a resident coughs, chokes or gags. The Policy and Procedure on Patient Abuse dated ,[DATE] documented that no food that could cause choking should be given to residents. There was no documented evidence of a policy and procedure for the monitoring and supervision of residents on Aspiration Precautions. The Feeding and Swallowing Instructions Form (FSIF) dated [DATE] documented that Resident #1 required a diet consistency of puree solids and honey thickened liquids. The FSIF documented that the feeding guidelines as constant supervision for the resident. The Nurse's Notes (NN) dated [DATE] documented that Resident #1 was transferred and admitted to the hospital due to an episode of sluggishness and unresponsiveness. The Hospital Modified Barium Swallow Study/Evaluation dated [DATE] documented recommendations that Resident #1 be assisted with all meals to completion with a slow rate of food and fluid presentation; monitor for signs of aspiration. The NN dated [DATE] documented that Resident #1 was readmitted to the facility from the hospital with a [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The Comprehensive Care Plan (CCP) for the risk of altered nutritional status dated [DATE] and updated [DATE] documented interventions for honey thick liquids and puree texture. The resident should be at the feeders table for lunch and dinner for encouragement and assistance; if left to feed self resident will not eat adequate portions. The CCP for self-care deficits dated [DATE] and updated [DATE] documented interventions for extensive assistance with feeding. The CCP for the risk for aspiration dated [DATE] and updated [DATE] documented interventions for encouragement to chew thoroughly & eat slowly, lunch & dinner at the feeders assist table and a blue placemat for aspiration precautions. The Social Work Services Progress Note dated [DATE] documented that Resident #1 had confusion, was restless at night at times and was able to feed himself with assistance. The Quarterly Care Plan Review Form dated [DATE] documented "honey thickened liquids" in the summary section. There was no other documentation regarding Resident #1's diet. The Neurology Consultation dated [DATE] documented that Resident #1 remained dysarthric (difficulty with speech & pronouncing words) with all lack of dentition (teeth). The Physician's Monthly Notes dated [DATE] documented a concern of weight loss. The nutritional change section was blank. The Nursing Assessment/Care Plan and Accountability Record dated ,[DATE] documented instructions for aspiration precautions and diet order for NSOT (no salt on table), puree, honey thick. The 24 Hour Report dated [DATE] documented that Resident #1 expired on the night shift. There was no other documentation regarding the resident. The NN dated [DATE] (written by the 11:00 PM to 7:00 AM nursing supervisor) documented that, at 12:15 AM, the writer was called to the unit due to patient choking while eating a sandwich. Heimlich maneuver and suctioning being done by LPN (Licensed Practical Nurse). Patient unresponsive; able to suction some of the sandwich that patient was eating but remained unresponsive. Color became cyanotic (bluish) and pupils pinpoint. No pulse, no blood pressure noted as well as no respiration. Patient pronounced at 12:23 am. Doctor made aware and called the family. The NN dated [DATE] at 5:00 AM (written by the LPN #1) documented that Resident #1 was sitting in the wheelchair at the nurse's station in the beginning of the shift. At approximately 12:00 AM resident motioned to mouth with his hand. Resident given a soft sandwich. Resident was eating sandwich fast and staff recommended resident to slow down. Shortly after, staff noticed resident appeared to be choking. Heimlich maneuver performed; O2 (oxygen) applied at 10 LPM (liters per minute) via mask. Suction applied to resident. Food contents suctioned from resident. Resident lost consciousness. Suctioning, Heimlich and O2 continued with no effect. Resident's extremities became cyanotic. Resident remained unresponsive. The Accident/Incident Investigation Report (AIIR) dated [DATE] at 12:15 AM documented that Resident #1 was alert and confused; began to choke on ? sandwich he was eating. Heimlich maneuver, suctioning and O2 at 10 LPM. Resident unresponsive; cyanotic; no blood pressure; no pulse; no respirations. The AIIR documented that, prior to giving out food to a resident, an employee is to check MD (medical doctor) orders and wristband. Wristband to be placed on all residents that are on puree and will state resident is on puree diet; will be of a bright, flashing and designated color. The AIIR documented that there is no cause to believe any alleged abuse, mistreatment or neglect has occurred. An interview was conducted with the 11:00 PM to 7:00 AM charge LPN #1 on [DATE] at 10:15 AM. LPN #1 stated that, on the night of [DATE] around Midnight, Resident #1 had been restless and was sitting at the nursing station; he was hungry. LPN #1 stated that he knew the resident was on a puree diet and took a sandwich out of the refrigerator in back of the nursing station; the sandwich was not marked but looked like puree ham on bread. LPN #1 stated that he went to another resident and left the sandwich on top of the nursing station, directing the resident ' s aide (CNA #3) to give the sandwich to the resident. Another aide (CNA #5) called to LPN #1, who observed the resident not responding verbally and in some sort of distress. LPN #1 started the Heimlich and suctioning but the resident was not responding. The nursing supervisor arrived and saw that interventions were not working; Resident #1 was pronounced by the nursing supervisor and 911 was later called; "I don't know if I was supposed to call 911 or not." LPN #1 further stated that Resident #1 had times of being up at night and would be given a sandwich or snack unsupervised so long as the resident held it in his good (right) hand. An interview was conducted with an 11:00 PM to 7:00 AM LPN #2 on [DATE] at 10:38 AM. LPN #2 stated that, on the night of [DATE], she was the charge nurse on an adjoining unit and an aide came looking for the nursing supervisor. LPN #2 paged the nursing supervisor and went down the hall, observing LPN #1 doing the Heimlich on Resident #1. LPN #2 helped suction the resident. When the nursing supervisor arrived, the resident was pronounced and taken back to his room to be cleaned up. At an unrecalled time thereafter, the police and EMS (emergency medical services) arrived. LPN #2 stated that, up until [DATE], she was assigned to Resident #1's unit during the 7:00 AM to 3:00 PM nursing shift; LPN #2 knew the resident. LPN #2 stated that the resident usually fed himself but needed encouragement because he would eat fast. LPN #2 stated that she remembered the resident being at a feeders table in the dining room during lunch and dinner but would have breakfast and snacks in his room. LPN #2 further stated, "He (Resident #1) was never supervised to eat in his room." An interview was conducted with a 7:00 AM to 3:00 PM Certified Nursing Assistant (CNA #1) on [DATE] at 12:06 PM. CNA #1 stated that she had cared for Resident #1 for a long time up until [DATE]. CNA #1 stated that the resident "sometimes would need assistance (to eat). Other times, he managed by himself. He'd have breakfast by himself in his room." CNA #1 further stated, "I never heard I had to watch him (while eating)." An interview was conducted with the 7:00 AM to 3:00 PM Registered Nurse Supervisor (RNS #1) on [DATE] at 12:11 PM. RNS #1 stated that, although he was not on duty on [DATE], he knew Resident #1 well. RNS #1 stated, "I always though he (Resident #1) was independent with eating by using his special spoon." RNS #1 did not know of any specific supervision needs for Resident #1. An interview was conducted with a 7:00 AM to 3:00 PM CNA #2 on [DATE] at 12:18 PM. CNA #2 stated that she knew Resident #1 but was never assigned to take care of him. CNA #2 stated that she has seen residents with instructions for aspiration precautions and will bring them to the feeders table for lunch and dinner. She stated, "Other than that, they'd (residents) eat in their rooms. If they need a little help, you'd stay with them for a little bit but not the whole time." An interview was conducted with the Registered Dietician (RD) on [DATE] at 12:54 PM. The RD stated that Resident #1 required a puree diet with honey thick liquids and could not have a sandwich. The resident ate lunch and dinner at a feeders table in the dining room. The RD stated that all residents eat alone in their rooms for breakfast including residents on aspiration precautions unless these residents require total feeding. Breakfast and snacks are not supervised like lunch and dinner. The RD then stated that Resident #1 "should have been on aspiration precautions. He should have had close supervision - someone with him (while eating)." An interview was conducted with the assigned 11:00 PM to 7:00 AM CNA #3 on [DATE] at 1:10 PM. CNA #3 stated that he has been Resident #1's assigned aide for a long time. On [DATE] just before Midnight, Resident #1 was sitting at the nursing station because he had been restless. CNA #3 stated that LPN #1 had to do something, so CNA #3 gave the resident a sandwich which LPN #1 had left on top of the nursing station. CNA #3 then went away to do something else and, a few minutes later, heard commotion at the nursing station; Resident #1 was choking and LPN #1 was doing the Heimlich on the resident. CNA #3 stated that he didn't know what happened because he had given Resident #1 a snack in the past; "I never stayed with him." CNA #3 was not sure if Resident #1 was on aspiration precautions or what this meant. An interview was conducted with the 7:00 AM to 3:00 PM charge LPN #3 on [DATE] at 1:36 PM. LPN #3 stated that she had known Resident #1 and been the resident's charge nurse for a very long time. All residents eat breakfast alone in their rooms. LPN #3 stated that Resident #1 didn't eat as well lately but declined to elaborate any further. LPN #3 stated that there were times when the resident could have been a "full feeder" but "residents eat by themselves for breakfast." She then stated, "I'd have to check the chart. I'm not actually sure if he (Resident #1) had aspiration precautions." An interview was conducted with the assigned 7:00 AM to 3:00 PM CNA #4 on [DATE] at 1:47 PM. CNA #4 stated that he had cared for Resident #1 on different nursing shifts for the past couple of years but, most recently, was assigned to the resident on the day shift. CNA #4 stated that he would seat the resident at the feeders table for lunch "but he (Resident #1) had no problems eating." CNA #4 then stated, "He'd have breakfast in bed sitting up; I just set him up and came back a little while later. He'd get a lot of the food all over the bed rather than his mouth but he did okay." CNA #4 did not know what aspiration precautions meant and further stated, "Some residents have a blue mat on their tray but there are so many colors for things around here. I'm not sure what it is exactly." An interview was conducted with the Speech Therapist (ST) on [DATE] at 1:42 PM. The ST stated that she last performed a swallowing evaluation on Resident #1 early in 2013. The ST stated that she recommended a puree diet and constant supervision while eating. The ST stated, "He (Resident #1) definitely required supervision for eating and drinking. This wouldn't have changed. Someone should have been with him while he ate." An interview was conducted with an 11:00 PM to 7:00 AM CNA #5 on [DATE] at 2:19 PM. CNA #5 stated that, shortly after Midnight on [DATE], she was walking towards the nursing station and saw Resident #1. The resident was waving his hand and making a funny sound. CNA #5 called to LPN #1, who came and started the Heimlich. CNA #5 ran down the hall to the next nursing station and asked LPN #2 to call the nursing supervisor, who came to the unit. CNA #5 stated that Resident #1 would sometimes be up at the nursing station at night but she never saw the resident eat. CNA #5 stated that aspiration precautions refer "to lunch and dinner. But, there are no meals served on the night shift, so we don't have to worry about it." CNA #5 stated that aspiration precautions are sometimes written on the accountability. She further stated, "Snacks aren't part of that (aspiration precautions)." An interview was conducted with the assigned 3:00 PM to 11:00 PM CNA #6 on [DATE] at 2:34 PM. CNA #6 stated that Resident #1 "ate fine with one hand." CNA #6 stated that the resident ate dinner at the feeders table but she did not know why. She further stated, "After dinner, he (Resident #1) was always looking for a snack. I just gave it to him and he was fine. I didn't have to watch him." An interview was conducted with the 3:00 PM to 11:00 PM RNS #2 on [DATE] at 3:00 PM. RNS #2 stated that Resident #1 usually sat at the end of the feeders table in the dining room for dinner. The resident "had a blue placemat at times but I'm not sure why." RNS #2 stated that she does not remember anything ever being reported to her regarding eating restrictions for the resident. With regard to supervision and monitoring of Resident #1 while eating, RNS #2 stated, "I would doubt it." An interview was conducted with the 11:00 PM to 7:00 AM RNS #3 on [DATE] at 10:08 AM. RNS #3 stated that, a few minutes after Midnight on [DATE], she was paged to the unit by an unrecalled staff member. RNS #3 observed LPN #1 performing the Heimlich on Resident #1, who she assessed to already be expired; "there was no gag reflex, not responding and pupils were pinpoint." RNS #3 supported LPN #1 in continuing the Heimlich a little longer and, then, pronounced the resident dead at 12:23 PM. RNS #3 stated that she called the Assistant Director of Nursing and the Director of Nursing called back instructing RNS #3 to call 911 around 12:50 AM. RNS #3 stated that Resident #1 was up at night at times for a snack. She stated, "He (Resident #1) was puree but I don ' t know whether he actually needed to be supervised to eat." An interview was conducted with the Attending Physician on [DATE] at 12:39 PM. The AP stated that he has provided monthly orders for aspiration precautions for Resident #1. The resident has had difficulty swallowing for years. The AP stated that he "expected (Resident #1) to be on a puree diet and, like anyone on aspiration precautions, have had continual observance and supervision no matter what or when he ate." An interview was conducted with the Medical Director (MD) on [DATE] at 1:35 PM. The MD stated that he cannot recall ever reviewing a policy on aspiration precautions and is not aware of a system for aspiration precautions; "that's up to nursing." The MD stated that, "for aspiration precautions, it's understood that, when being fed, a patient should be in a certain position. In general, all patients should be supervised at all times if on aspiration precautions." An interview was conducted with the Assistant Director of Nursing (ADON) on [DATE] at 1:50 PM. The ADON stated that she is also the In-Service Director for the facility. The ADON stated that she does not know of a policy on aspiration precautions and in-servicing on aspiration precautions is "done more on a case by case basis if something happens or changes with a resident." The ADON stated that, "unless they (residents) actually need to be fed by staff, all residents eat breakfast in their rooms alone." The ADON stated that she investigated the choking incident of Resident #1 but does not believe "it was abuse or neglect because nothing was done maliciously." She further stated, "We haven't done anything yet, but we're thinking about instituting some type of wrist band that's brightly colored, because, right now, it would be hard to tell immediately if someone (a resident) is on aspiration precautions." An interview was conducted with the Director of Recreation (DR) on [DATE] at 2:19 PM. The DR stated that he is not aware of a policy on aspiration precautions but the recreation department has their own daily routine of calling each nursing unit in the morning to confirm each resident's diet and restrictions so that they know which residents can be offered food at an activity. An interview was conducted with the Director of Nursing (DON) on [DATE] at 3:08 PM. The DON stated that RNS #3 called her on [DATE] after pronouncing Resident #1 dead and she told RNS #3 to call 911 in order to cover all bases. She reviewed the investigation of Resident #1's choking incident and does not believe that any neglect of the resident occurred "because staff did not intentionally force food down his mouth." The DON stated that, as a precautionary measure for the future, all staff is being trained in the Heimlich maneuver. The DON stated that any resident who needs to be totally fed is always supervised. She further stated, "There's no resident on aspiration precautions who eats alone in the room to my knowledge." An interview was conducted with the Administrator on [DATE] at 10:07 AM. The Administrator stated that he was notified of Resident #1's death at approximately 12:45 AM and came to the facility immediately. The Administrator stated that he spoke with LPN #1 regarding the events leading up to Resident #1's choking and advised LPN #1 to be truthful and forthright with authorities who were on the scene. The Administrator stated that he was not aware of any larger concerns other than the incident itself. 415.12 (h)(1)(2)

Based on staff interviews and record review during an abbreviated and partial extended survey it was determined that the administration failed to ensure that there was a system in place to identify, monitor and supervise each resident on a therapeutic diet and aspiration precautions in order to maintain each resident's highest practicable physical, mental and psychosocial well-being. Specifically, the Administration failed to develop and implement policies and procedures for the monitoring and supervision of residents at risk for aspiration; failed to ensure staff were knowledgeable of residents' therapeutic diets and/or aspiration precautions; and failed to identify system failures related to the supervision of residents at risk for aspiration. In addition, the Administration failed to conduct a thorough investigation to determine the root cause of a choking incident. This resulted in actual harm to Resident #1 and the potential for a pattern of serious harm that is Immediate Jeopardy for 11 residents with aspiration precautions. Complaint Number: NY 750 Cross References: F 323 - Accidents & Supervision F501 - Medical Director F520 - Quality Assessment & Assurance The findings are: The Policy and Procedure on Aspiration, Choking and Asphyxiation (PPACA) dated 12/16/13 documented that an assessment should include a resident's frequency of coughing or choking while eating, eating/drinking too rapidly or having chronic congestion. The PPACA documented that interventions should include a written plan for feeding a resident, appropriate food texture, swallow evaluation, proper positioning and to stop eating if a resident coughs, chokes or gags. The Policy and Procedure on Patient Abuse dated 1/95 documented that no food that could cause choking should be given to residents. There was no documented evidence of a policy and procedure for the monitoring and supervision of residents on Aspiration Precautions. An interview was conducted with the Attending Physician on 12/17/13 at 12:39 PM. The AP stated that he has provided monthly orders for aspiration precautions for Resident #1. The resident has had difficulty swallowing for years. The AP stated that he "expected (Resident #1) to be on a puree diet and, like anyone on aspiration precautions, have had continual observance and supervision no matter what or when he ate." An interview was conducted with the Medical Director (MD) on 12/17/13 at 1:35 PM. The MD stated that he cannot recall ever reviewing a policy on aspiration precautions and is not aware of a system for aspiration precautions; "that's up to nursing." The MD stated that, "for aspiration precautions, it's understood that, when being fed, a patient should be in a certain position. In general, all patients should be supervised at all times if on aspiration precautions." An interview was conducted with the Assistant Director of Nursing (ADON) on 12/17/13 at 1:50 PM. The ADON stated that she is also the In-Service Director for the facility. The ADON stated that she does not know of a policy on aspiration precautions and in-servicing on aspiration precautions is "done more on a case by case basis if something happens or changes with a resident." The ADON stated that, "unless they (residents) actually need to be fed by staff, all residents eat breakfast in their rooms alone." The ADON stated that she investigated the choking incident of Resident #1 but does not believe "it was abuse or neglect because nothing was done maliciously." She further stated, "We haven't done anything yet, but we're thinking about instituting some type of wrist band that's brightly colored, because, right now, it would be hard to tell immediately if someone (a resident) is on aspiration precautions." An interview was conducted with the Director of Nursing (DON) on 12/17/13 at 3:08 PM. The DON stated that RNS #3 called her on 12/12/13 after pronouncing Resident #1 dead and she told RNS #3 to call 911 in order to cover all bases. She reviewed the investigation of Resident #1's choking incident and does not believe that any neglect of the resident occurred "because staff did not intentionally force food down his mouth." The DON stated that, as a precautionary measure for the future, all staff is being trained in the [MEDICATION NAME] maneuver. The DON stated that any resident who needs to be totally fed is always supervised. She further stated, "There's no resident on aspiration precautions who eats alone in the room to my knowledge." An interview was conducted with the Administrator on 12/18/13 at 10:07 AM. The Administrator stated that he was notified of Resident #1's death at approximately 12:45 AM and came to the facility immediately. The Administrator stated that he spoke with LPN #1 regarding the events leading up to Resident #1's choking and advised LPN #1 to be truthful and forthright with authorities who were on the scene. The Administrator stated that he was not aware of any larger concerns other than the incident itself. 415.26

Based on staff interviews and record review during an abbreviated and partial extended survey the Medical Director failed to ensure that the facility provided care to meet the monitoring and supervision needs of residents on therapeutic diets and/or aspiration precautions. Specifically, the Medical Director failed to ensure that policies and procedures were developed and implemented to supervise residents with aspiration precautions and to ensure residents are provided prescribed diet consistencies. This failure resulted in actual harm to Resident #1 and the potential for a pattern of serious harm that is Immediate Jeopardy. Complaint Number: NY 750 Cross References: F 323 - Accidents & Supervision F 490 - Administration F 520 - Quality Assessment & Assurance The findings are: The Policy and Procedure on Aspiration, Choking and Asphyxiation (PPACA) dated 12/16/13 documented that an assessment should include a resident's frequency of coughing or choking while eating, eating/drinking too rapidly or having chronic congestion. The PPACA documented that interventions should include a written plan for feeding a resident, appropriate food texture, swallow evaluation, proper positioning and to stop eating if a resident coughs, chokes or gags. The Policy and Procedure on Patient Abuse dated 1/95 documented that no food that could cause choking should be given to residents. There was no documented evidence of a policy and procedure for the monitoring and supervision of residents on Aspiration Precautions. An interview was conducted with the Attending Physician on 12/17/13 at 12:39 PM. The AP stated that he has provided monthly orders for aspiration precautions for Resident #1. The resident has had difficulty swallowing for years. The AP stated that he "expected (Resident #1) to be on a puree diet and, like anyone on aspiration precautions, have had continual observance and supervision no matter what or when he ate." An interview was conducted with the Medical Director (MD) on 12/17/13 at 1:35 PM. The MD stated that he cannot recall ever reviewing a policy on aspiration precautions and is not aware of a system for aspiration precautions; "that's up to nursing." The MD stated that, "for aspiration precautions, it's understood that, when being fed, a patient should be in a certain position. In general, all patients should be supervised at all times if on aspiration precautions." An interview was conducted with the Assistant Director of Nursing (ADON) on 12/17/13 at 1:50 PM. The ADON stated that she is also the In-Service Director for the facility. The ADON stated that she does not know of a policy on aspiration precautions and in-servicing on aspiration precautions is "done more on a case by case basis if something happens or changes with a resident." The ADON stated that, "unless they (residents) actually need to be fed by staff, all residents eat breakfast in their rooms alone." The ADON stated that she investigated the choking incident of Resident #1 but does not believe "it was abuse or neglect because nothing was done maliciously." She further stated, "We haven't done anything yet, but we're thinking about instituting some type of wrist band that's brightly colored, because, right now, it would be hard to tell immediately if someone (a resident) is on aspiration precautions." An interview was conducted with the Director of Nursing (DON) on 12/17/13 at 3:08 PM. The DON stated that RNS #3 called her on 12/12/13 after pronouncing Resident #1 dead and she told RNS #3 to call 911 in order to cover all bases. She reviewed the investigation of Resident #1's choking incident and does not believe that any neglect of the resident occurred "because staff did not intentionally force food down his mouth." The DON stated that, as a precautionary measure for the future, all staff is being trained in the [MEDICATION NAME] maneuver. The DON stated that any resident who needs to be totally fed is always supervised. She further stated, "There's no resident on aspiration precautions who eats alone in the room to my knowledge." 415.15 (a)

Based on record review and staff interviews conducted during an abbreviated and partial extended survey the facility failed to provide a quality assessment and assurance program that readily identified resident monitoring and supervision deficiencies. Specifically, the Quality Assessment and Assurance (QAA) Committee failed to review and evaluate the sequence of events preceding Resident #1's death on [DATE] in order to identify system failures and determine the root cause. The QAA Committee failed to ensure the development and implementation of policies and procedures to identify, monitor and supervise residents on therapeutic diets and/or at risk for aspiration. This resulted in no actual harm with the potential for a pattern of serious harm that is Immediate Jeopardy. Complaint Number: NY 750 Cross References: F 323 - Accidents & Supervision F 490 - Administration F 501 - Medical Director The findings are: The Policy and Procedure on Aspiration, Choking and Asphyxiation (PPACA) dated [DATE] documented that an assessment should include a resident's frequency of coughing or choking while eating, eating/drinking too rapidly or having chronic congestion. The PPACA documented that interventions should include a written plan for feeding a resident, appropriate food texture, swallow evaluation, proper positioning and to stop eating if a resident coughs, chokes or gags. The Policy and Procedure on Patient Abuse dated ,[DATE] documented that no food that could cause choking should be given to residents. There was no documented evidence of a policy and procedure for the monitoring and supervision of residents on Aspiration Precautions. The 24 Hour Report dated [DATE] documented that Resident #1 expired on the night shift. There was no other documentation regarding the resident. The Accident/Incident Investigation Report (AIIR) dated [DATE] at 12:15 AM documented that Resident #1 was alert and confused; began to choke on ? sandwich he was eating. [MEDICATION NAME] maneuver, suctioning and O2 at 10 LPM. Resident unresponsive; cyanotic; no blood pressure; no pulse; no respirations. The AIIR documented that, prior to giving out food to a resident, an employee is to check MD (medical doctor) orders and wristband. Wristband to be placed on all residents that are on puree and will state resident is on puree diet; will be of a bright, flashing and designated color. The AIIR documented that there is no cause to believe any alleged abuse, mistreatment or neglect has occurred. An interview was conducted with the Medical Director (MD) on [DATE] at 1:35 PM. The MD stated that he cannot recall ever reviewing a policy on aspiration precautions and is not aware of a system for aspiration precautions; "that's up to nursing." The MD stated that, "for aspiration precautions, it's understood that, when being fed, a patient should be in a certain position. In general, all patients should be supervised at all times if on aspiration precautions." An interview was conducted with the Assistant Director of Nursing (ADON) on [DATE] at 1:50 PM. The ADON stated that she is also the In-Service Director for the facility. The ADON stated that she does not know of a policy on aspiration precautions and in-servicing on aspiration precautions is "done more on a case by case basis if something happens or changes with a resident." The ADON stated that, "unless they (residents) actually need to be fed by staff, all residents eat breakfast in their rooms alone." The ADON stated that she investigated the choking incident of Resident #1 but does not believe "it was abuse or neglect because nothing was done maliciously." She further stated, "We haven't done anything yet, but we're thinking about instituting some type of wrist band that's brightly colored, because, right now, it would be hard to tell immediately if someone (a resident) is on aspiration precautions." An interview was conducted with the Director of Nursing (DON) on [DATE] at 3:08 PM. The DON stated that RNS #3 called her on [DATE] after pronouncing Resident #1 dead and she told RNS #3 to call 911 in order to cover all bases. She reviewed the investigation of Resident #1's choking incident and does not believe that any neglect of the resident occurred "because staff did not intentionally force food down his mouth." The DON stated that, as a precautionary measure for the future, all staff is being trained in the [MEDICATION NAME] maneuver. The DON stated that any resident who needs to be totally fed is always supervised. She further stated, "There's no resident on aspiration precautions who eats alone in the room to my knowledge." An interview was conducted with the Administrator on [DATE] at 10:07 AM. The Administrator stated that he was notified of Resident #1's death at approximately 12:45 AM and came to the facility immediately. The Administrator stated that he spoke with LPN #1 regarding the events leading up to Resident #1's choking and advised LPN #1 to be truthful and forthright with authorities who were on the scene. The Administrator stated that he was not aware of any larger concerns other than the incident itself. The Administrator further stated that there is a daily morning meeting with department heads to discuss issues from the previous day; he is not aware of any other QA in place for aspiration precautions. 415.27 (a-c)