Every finding on record at Bellhaven Center for Rehab and Nursing Care

Based on record review and interviews during the survey, the facility failed to ensure sufficient nursing staff were available to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was identified for three (3) (unit A1, B2, and C2) of six (6) units during the sufficient and competent nurse staffing review task. Specifically, a review of the Payroll-Based Journal Staffing Data Report, the facility assessment, and the daily staffing revealed that on multiple days the facility did not have adequate staffing to meet the residents' needs as indicated in the Facility Assessment. The findings include: The facility's Nursing Staffing/Minimum Staffing policy revised 03/2026 documented Safe Staffing: Knowing that it may not be always possible to achieve the facility assessment has determined a safe staffing level that is included in the range. Safe staffing is determined to be one (1) Licensed Practical Nurse per unit, per shift and four (4) Certified Nursing Assistant per unit on the day shift, three (3) Certified Nursing Assistant per unit on the evening shift, and two (2) Certified Nursing Assistant per unit on the night shift. It is noted that the Director of Nursing /designee may increase the safe staffing level on any unit, based on the congregate and/or individual needs of residents or in the event of a reduced census. The Facility Assessment policy reviewed 01/2026 documented the purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and during emergencies. This assessment will be created, used, reviewed, and updated in order to make decisions about direct care staff needs as well as the facilities' capabilities to provide services to the residents in the facility. The Facility Assessment reviewed 1/2026 documented the following staffing levels for the Certified Nursing Assistant for each unit with a census of 40 residents: -For Unit A1: three (3) to five (5) during the day shift, two (2) to four (4) during the evenings shift and, one (1) to two (2) during the night shift.-For Unit B1: three (3) to six (6) during the day shift, two (2) to five (5) during the evening shift, and one (1) to three (3) during the night shift.-For Unit C1: three (3) to five (5) during the day shift, two (2) to four (4) during the evenings shift and, one (1) to two (2) during the night shift.-For Unit A2: three (3) to six (6) during the day shift, two (2) to five (5) during the evening shift, and one (1) to three (3) during the night shift.-For Unit B2: three (3) to five (5) during the day shift, two (2) to four (4) during the evenings shift and, one (1) to two (2) during the night shift.-For Unit C2: three (3) to five (5) during the day shift, two (2) to four (4) during the evenings shift and, one (1) to two (2) during the night shift.The Payroll-Based Journal Staffing Data Report for Fiscal Year Quarter one 2026 (October 1-December 31) documented the facility triggered for excessively low weekend staffing. A Review of the facility's actual staffing for October 2025 to December 2025 revealed the following:-On 10/04/2025 (Saturday) during the 07:00 to 03:00 PM shift, Unit B2, with a census of 40 residents, had two (2) Certified Nursing Assistants instead of the three (3) to five (5) Certified Nursing Assistants as indicated in the Facility Assessment. -On 10/18/2025 (Saturday) during the 7:00 AM to 3:00 PM shift, Unit C2, with a census of 40 residents, had two (2) Certified Nursing Assistants instead of the three (3) to five (5) Certified Nursing Assistants; and during the 3:00 PM to 11:00 PM shift, Unit B2, with a census of 40 residents, had only one (1) Certified Nursing Assistant instead of two (2) to four (4) Certified Nursing Assistants as indicated in the Facility Assessment. -On 10/19/2025 (Sunday) during the 7:00 AM to 3:00 PM shift, Unit C2, with a census of 40 residents, had two (2) Certified Nursing Assistants instead of the three (3) to five (5) Certified Nursing Assistants as indicated in the Facility Assessment. -On 11/01/2025 (Saturday) during the 3:00 PM to 11:00 PM shift, Unit B2, with a census of 40 residents, had only one (1) Certified Nursing Assistant instead of two (2) to four (4) Certified Nursing Assistants as indicated in the Facility Assessment. -On 11/02/2025 (Sunday) during the 7:00 to 3:00 PM shift, Unit A1, with a census of 40 residents, had two (2) Certified Nursing Assistants instead of the three (3) to five (5) Certified Nursing Assistants as indicated in the Facility Assessment. During the 3:00 PM to 11:00 PM shift, Unit C2 had only one (1) Certified Nursing Assistant instead of two (2) to four (4) Certified Nursing Assistants as indicated in the Facility Assessment. -On 11/29/2025 (Saturday) and 11/30/2025 (Sunday) during the 3:00 PM to 11:00 PM shift, Unit B2, with a census of 39 residents, had only one (1) Certified Nursing Assistant instead of two (2) to four (4) Certified Nursing Assistants as indicated in the Facility Assessment. -On 12/13/2025 (Saturday) and 12/14/2025 (Sunday) during the 7:00 AM to 3:00 PM shift, Unit A1, with a census of 40 residents, had two (2) Certified Nursing Assistants instead of the three (3) to five (5) Certified Nursing Assistants as indicated in the Facility Assessment -On 12/14/2025 (Sunday) during the 3:00 PM to 11:00 PM shift, Unit B2, with a census of 40 residents, had only one (1) Certified Nursing Assistant instead of two (2) to four (4) Certified Nursing Assistants as indicated in the Facility Assessment. -On 12/21/2025 (Sunday) during the 7:00 AM to 3:00 PM shift, Unit A1, with a census of 40 residents, had two (2) Certified Nursing Assistants instead of the three (3) to five (5) Certified Nursing Assistants as indicated in the Facility Assessment; and Unit C2, with a census of 37 residents, had had two (2) Certified Nursing Assistants instead of the three (3) to five (5) Certified Nursing Assistants as indicated in the Facility Assessment A Review of the facility's actual staffing, during the survey, from 05/12/2026 -05/20/2026 revealed that on 5/17/2026 (Sunday) during the 7:00 AM to 3:00 PM shift, Unit C2 with a census of 40 residents had two (2) Certified Nursing Assistant instead of the three (3) to five (5) Nursing Assistant as indicated in the Facility Assessment. During an interview on 05/19/2026 at 9:51 AM, the Staffing Coordinator stated that there were days when the facility had insufficient number of staff available during the 3:00 PM-11:00 PM shift due to multiple call outs. The Staffing Coordinator stated they attempted to replace the staff but were unable to do so. The Staffing Coordinator stated they were usually able to replace the staff during the 7:00 AM- 3:00 PM shift. During an interview on 05/19/2026 at 02:40 PM, the Human Resources Director stated the facility has staff shortage on the 7:00 AM - 3:00 PM and the 3:00 PM - 11 PM shift. The Human Resources Director stated that they frequently hire Certified Nursing Assistant, but the staff do not stay. The Human Resources Director stated that the new hires would attend orientation, but they leave after the orientation. During an interview on 05/19/2026 at 4:12 PM, the Director of Nursing Services stated that the facility has shortage of nursing staff on all three shifts and a staff retention problem. The Director of Nursing Services stated that when there are multiple call outs, they have to offer incentives for staff to work a double shift or to pick up an extra shift. During an interview on 05/20/2026 at 2:32 PM, the Administer stated they were aware that the facility had insufficient nursing staffing, specifically for the Certified Nursing Assistants. The Administrator stated that they are very liberal about offering overtime; they offer gift cards and bonus pay to staff who pick up extra shifts. The Administrator stated that the facility has a training program for Certified Nursing Assistants, and they offer the certification exam on site. The Administrator stated for the last six (6) months they have been running two Certified Nursing Assistants training classes because staffing has gotten worse and they get the most consistent staff through the program. The Administrator stated getting and retaining staff has been a challenge. 10 New York Code Rules and Regulations 415.13(a)(1)(i-iii)

Based on observation, record review, and interviews during the survey, the facility failed to maintain 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 one (1) (Resident #119) of eight (8) residents reviewed for infection control task. Specifically, Resident #119 had a physician's order for enhanced barrier precautions (transmission-based precautions to prevent the spread of infection) for tube feeding and foley catheter use. On 05/18/2026 Resident #119's foley catheter was dislodged. Registered Nurse #1 entered the resident's room without wearing a gown. Registered Nurse #1 removed and discarded the dislodged foley catheter, the tubing, and the collection bag which contained urine from the resident's bedside without wearing appropriate personal protective equipment. The findings include:The facility Policy and procedure for Enhanced Barrier Precautions dated March 2025 documented Glove and Gown Use: Staff that are required to perform high contact resident care activities will don (put on) and doff (take off) [the personal protective equipment] in the resident's room, followed by hand hygiene. High contact resident care activities include but are not limited to care or use of devices (central lines, urinary catheters, feeding tubes, tracheostomy, ventilator).Resident #119 was admitted with diagnoses that include stroke (a sudden interruption of blood flow to the brain), dementia, and Parkinson's disease. The admission Minimum Data Set assessment dated [DATE] documented that a Brief Interview for Mental Status score could not be completed due to severe cognitive decline. The Minimum Data Set documented the resident had an indwelling catheter and utilized a feeding tube. The physician's order dated 03/31/2026 documented enhanced barrier precautions for percutaneous epigastric tube (feeding tube) and foley catheter. During an observation on 05/18/2026 at 11:30 AM, an enhanced barrier precaution signage was posted outside Resident #119's room. The signage indicated putting on a gown and gloves when providing care for the urinary catheter. Registered Nurse #1 was observed entering Resident #119's room without the use of a gown. Registered Nurse #1 then removed the resident's foley catheter that had been dislodged and was hanging from the side of the resident's bed. The foley catheter tubing and the collection bag contained urine. There was urine observed on the floor next to the resident's bed. The nurse took the dislodged foley catheter with the tubing and the collection bag and discarded them in the resident's garbage bin, removed the gloves and sanitized their hands. During an interview on 05/18/2026 at 11:33 AM, Registered Nurse #1 stated they were unaware that Resident #119 was on enhanced barrier precautions, and they did not notice the sign that was posted outside the resident's room.During an interview on 05/19/2026 at 09:48 AM, the Infection Preventionist, Registered Nurse #1 stated a gown, and gloves are required when staff are providing high contact care activities including handling of the dislodged foley catheter. During an interview 05/19/2026 at 10:25 AM, the Director of Nursing Services stated nurses did not need to put on a gown when handling a dislodged foley catheter even though the resident had a physician's order for enhanced barrier precautions related to the use of a foley catheter. The Director of Nursing Services stated nurses however need to use the gown when emptying the urine from the foley catheter and while performing any wound care dressing changes.10 New York Code Rules and Regulations 415.19 (a)(1-3)

Based on observations, interviews and record review during survey, the facility failed to ensure that each resident received treatment and care based on their comprehensive assessment and in accordance with professional standards of practice. This was identified for one (1) (Resident #229) of one (1) resident reviewed for activities of daily living. Specifically, on 05/15/2026, Resident #229 was observed with edema (swelling) on both lower extremities and had ace wraps (elastic bandage) applied on both lower legs. The ace wraps were not applied properly as the skin was visible in between the bandaged ace wrap layers. The ace wrap was excessively tight as evidenced by visible bulging/protruding skin between the wrapped layers. Additionally, the resident's physician was not notified of reoccurrence of the bilateral lower extremities' edema.The findings include:The facility policy titled Protocols for Acute Medical Episodic Events effective 12/2024, documented for congestive heart failure (the heart muscle cannot pump blood efficiently), an intervention for bilateral lower leg edema may apply ace wrap if appropriate. The licensed nursing staff will monitor and notify the physician after activating the standing order protocol accordingly.The facility policy titled Resident Assessment effective 01/2026, documented residents shall be assessed as clinically indicated and findings shall be documented in the medical record and any changes in resident condition shall be communicated to the Physician.Resident #229 was admitted with diagnoses that included traumatic brain injury, localized edema (accumulation of fluid in one specific area), and peripheral vascular disease (blood circulation disorder that narrows, blocks blood vessels). The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief interview for Mental Status score of 12, indicating Resident #229 had moderately impaired cognition.A physician's order dated 04/10/2026 and discontinued on 04/24/2026 documented to apply ace wraps to bilateral extremities daily in the morning and remove at bedtime for fourteen (14) days.A comprehensive care plan titled cardiac diseases, hypertension, hyperlipidemia, peripheral vascular disease and fluid restrictions last reviewed 04/14/2026 documented interventions that included monitor for signs and symptoms of fluid overload, such as peripheral edema.During an observation on 05/15/2026 at 11:38 AM, Resident #229 was seated in a wheelchair attending a music activity program. The resident was noted with edema on both lower extremities and had ace wraps applied on both lower legs. The ace wraps were not applied properly as the skin was visible in between the bandaged ace wrap layers. The ace wrap was excessively tight as evidenced by visible bulging/protruding skin between the wrapped layers.During an interview on 05/15/2026 at 11:42 AM, Certified Nursing Assistant #3 stated in the morning, they help Resident #229 with getting dressed and transferring into the wheelchair. Certified Nursing Assistant #3 stated when they start their shift, Resident #229's feet and ankles are already wrapped; they were wrapped today, and on the previous days as well. Certified Nursing Assistant #3 stated they do not remove the ace wraps or apply them. During an observation and interview on 05/15/2026 at 11:47 AM, Registered Nurse #3 (the unit manager) stated the resident had a physician's order on 04/10/2026 for the use of the ace wraps and the order was discontinued on 04/24/2026; currently the resident did not have any order or a care plan for the use of ace wraps. Registered Nurse #3 approached Resident #229, who was seated in a wheelchair in the hallway. Registered Nurse #3 stated the resident's lower extremities were edematous and that they needed to re-apply the currently applied ace wraps as the bandages (ace wraps) were cutting off the circulation to Resident #229's ankles. Registered Nurse #3 stated all the nurses on all shifts should monitor Resident #229's edema and notify the physician of any changes in condition.During an interview on 05/15/2026 at 11:54 AM, Resident #229 stated the ace wraps felt uncomfortable, tight, and annoying. Resident #229 stated they did complain about the ace wraps to the staff, but they did not recall who or when. During an interview on 05/20/2026 at 6:28 AM, the 11:00 PM-07:00 AM shift Licensed Practical Nurse #2 stated Resident #229 usually has edema on their ankles. Licensed Practical Nurse #2 stated they applied the ace wraps to Resident #229's ankle; however, they did not know that the resident did not have a current physician order for the ace wrap use. Licensed Practical Nurse #2 stated they did not call the Physician or document in the medical record regarding the bilateral lower extremity edema because they thought the resident had a physician order for the use of the ace wraps. Licensed Practical Nurse #2 stated they should have verified the physician's order before applying the ace wraps to Resident #229's lower extremities.During an interview on 05/20/2026 at 07:27 AM, the Director of Nursing Services stated the facility has a policy which includes applying ace wraps as an automatic order when the resident experiences the lower extremity edema. The Director of Nursing Services stated nurse should have documented the electronic medical record and called the physician when they noted the resident had lower leg edema. The nursing staff is expected to follow the plan of care and document any changes in the resident's electronic medical record.10 New York Code Rules and Regulations 415.12

Based on observations, record review, and interviews during the survey, the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with the resident rights. This was identified for one (1) (Resident #119) of one (1) resident reviewed for skin conditions and for one (1) (Resident #15) of three (3) residents reviewed for pressure ulcers. Specifically, 1) Resident#119's physician orders and comprehensive care plan indicated use of a Geri sleeves (protective sleeves designed to safeguard fragile skin) on both arms for senile purpura (age related skin thinning and bruising). On two separate occasions, the resident was observed without the use of the Geri sleeves as ordered. 2) Resident #15 had a physician's order for a bed cradle at the foot of the bed every shift while in bed to prevent the sheets from directly touching the resident's feet. On multiple occasions, the resident was observed without the use of the bed cradle, and the bed sheets were directly contacting the resident's feet. The findings include: The facility policy titled Baseline Care Plan/ Comprehensive Care Plan, dated October 2024, documented the facility staff shall establish and implement the care and services for each resident to assist in attaining or maintaining their highest practicable quality of life. The facility policy titled Bed Cradle Use and Monitoring effective 01/2024 documented that the facility shall provide and monitor comfort, safety, and prevention of skin or lower extremity concerns. The bed cradle shall be used in accordance with the plan of care. Nursing staff shall assess the residents for placement, tolerance, effectiveness, and any potential safety concerns related to the bed cradle. 1) Resident #119 was admitted with diagnoses that include stroke (a sudden interruption of blood flow to the brain), dementia, and Parkinson's disease. The admission Minimum Data Set assessment dated [DATE] documented that a Brief Interview for Mental Status score could not be completed due to severe cognitive decline. The Minimum Data Set did not indicate presence of pressure ulcers or skin conditions. The comprehensive care plan for skin integrity-senile purpura dated 05/10/2026 documented interventions including using bilateral Geri sleeves as tolerated. The nursing progress notes dated 05/10/2026 documented the resident was noted with open purpura on the right upper arm; first aid was rendered. The Nurse Practitioner ordered a treatment of normal saline, bacitracin (antibacterial skin ointment), and dry dressing for ten days. During an observation with Registered Nurse #1 on 05/18/2026 at 11:30 AM, the resident's bed sheet was noted with a dark brown stain under the resident's right upper arm. The resident had an open wound on the right arm, approximately one inch above the elbow. There was no dressing present on the wound. A used gauze dressing was observed on the floor. The resident was not wearing the Geri sleeves as per the comprehensive care plan. During an interview on 05/18/2026 at 01:58 PM, Certified Nursing Assistant #1 stated they were the assigned Certified Nursing Assistant for Resident #119, and they did not know that the resident required Geri sleeves. Certified Nursing Assistant #1 stated at the beginning of the shift they review the Certified Nursing Accountability Record for the assigned residents on the computer. Certified Nursing Assistant #1 stated they did not know where to locate the use of Geri sleeve documentation in the Certified Nursing Accountability Record. During an observation with Certified Nursing Assistant #1, Certified Nursing Accountability record was reviewed. The instructions to use the Geri sleeve were documented under the Safety tab. During an interview on 05/18/2026 at 02:18 PM, Registered Nurse #1, the nurse manager, stated Resident #119 was picking on the senile purpura wound on the right elbow and was frequently removing the wound dressing. Registered Nurse #1 stated that the resident's care plan indicated use of the Geri sleeves because of the behavior of picking on the wound. The entire comprehensive care plan was reviewed and there was no documentation of noncompliance related to the resident's behavior of removing their wound dressings or the Geri sleeves. During an interview on 05/19/2026 at 10:25 AM, the Director of Nursing Services stated if the resident's comprehensive care plan required use of the Geri sleeves, the staff should have ensured the intervention was implemented. The certified nursing assistants should check the Certified Nursing Accountability Records to ensure all the safety interventions are implemented according to the resident's plan of care. If the resident refuses any care plan interventions, then the nurses and the physician should be notified. 2) Resident #15 was admitted with diagnoses that included cerebral infarction (blocked or narrowed blood vessel that cuts off blood supply to an area of the brain), peripheral vascular disease (blood circulation disorder that narrows, blocks blood vessels), and dementia (decline in mental ability). The Quarterly Minimum Data Set assessment dated [DATE] documented that a Brief Interview for Mental Status was not completed because the resident was rarely or never understood. Resident #15 had impairment to both upper and lower extremities and was dependent on staff for all activities of daily living. Resident #15 did not have venous or arterial ulcers. The resident had a stage three (3) pressure ulcer on the sacral area that was not present on admission. A comprehensive care plan titled at risk for skin breakdown due to peripheral vascular disease last reviewed 05/04/2026 documented an intervention to apply a bed cradle to the foot of the bed while in bed. A physician's order last reviewed on 05/13/2026 documented to apply a bed cradle to the foot of the bed every shift while in bed. The current certified nursing assistant accountability record documented to apply a bed cradle to the foot of the bed every shift while in bed. The medication administration record for April and May 2026 documented nursing staff confirmed application of the bed cradle to the foot of the bed each shift as indicated by staff signature. During an observation on 05/15/2026 at 9:38 AM, Resident #15 was sleeping in bed. The bed cradle was observed on the floor in the resident's room. During an observation on 05/15/2026 at 9:59 AM, Resident #15 was sleeping in bed under blankets without the bed cradle at the foot of the bed. The bed cradle was on the floor. During an observation on 05/18/2026 at 10:26 AM, Resident #15 was in bed and was unable to be interviewed. The bed cradle was observed on the floor in the resident's room. During an interview on 05/18/2026 at 10:29 AM, Registered Nurse #2 (the unit manager) stated Resident #15 had a history of wounds on their feet which are now healed, and the bed cradle was used to keep the blanket from putting pressure on the resident's feet, preventing pain, and wound development. Registered Nurse #2 stated the bed cradle was not on the bed today (05/18/2026) because the resident just finished receiving wound care. During an interview on 05/18/2026 at 10:38 AM, Certified Nursing Assistant #2 stated the bed cradle was on the floor during wound care and the Wound Care Nurse may have left it off after the treatment. Certified Nursing Assistant #2 stated they have not yet provided morning care to Resident #15. Certified Nursing Assistant #2 stated they would have placed the bed cradle on the bed after morning care. Certified Nursing Assistant #2 stated the bed cradle was used to keep the blankets off the resident's skin. During an interview on 05/18/2026 at 10:46 AM, Licensed Practical Nurse #1 stated the bed cradle was on the bed this morning when they saw Resident #15, so they documented the bed cradle was in place. Licensed Practical Nurse #1 stated the wound care nurse may have removed the bed cradle during wound care. Licensed Practical Nurse #1 stated all nursing staff are responsible to ensure the bed cradle was appropriately placed on the bed. During an interview on 05/20/2026 at 06:34 AM, Wound Care Nurse #1 stated the bed cradle was used to keep blankets off the resident's feet. Wound Care Nurse #1 stated severe arterial and vascular disease can cause pain when anything is resting on the residents' feet; the slightest pressure can hurt. Wound Care Nurse #1 stated that they had removed the bed cradle to provide wound care for Resident #15. Wound Care Nurse #1 stated they could not recall if they put the bed cradle back on the resident's bed after they completed the wound care. During an interview on 05/20/2026 at 07:24 AM, the Director of Nursing Services stated nursing staff should apply the bed cradle when Resident #15 is in bed and to re-apply the bed cradle after providing care. The Director of Nursing Services stated certified nursing assistants were responsible for ensuring that the bed cradle was in place and not on the floor. 10 New York Code Rules and Regulations 415.11(c)(1)

Based on interviews and record review during the recertification survey, the facility failed to ensure a resident was from physical or chemical restraints imposed for the purpose of discipline or convenience and are not required to treat the resident's medical symptoms. This was evident for one (1) of five (5) reviewed for unnecessary medications. Specifically Resident #24 with a diagnosis of dementia had a physician's order for quetiapine (Seroquel-a psychotropic/antipsychotic medication) for major depressive disorder. At the resident's family member's request, the quetiapine dosage was increased from 100 milligrams per day to 150 milligrams per day without documented evidence of clinical justification.The findings are: A facility policy and procedure titled Psychotropic Medications documented the facility will make every effort to ensure each resident's drug regimen is appropriate and that only necessary medications are used. The facility will continue to reassess the use of non-pharmacological interventions. In most cases, psychotropic medications should only be used if clinically indicated. Resident #24 was admitted on [DATE], with diagnosis of non-Alzheimer's dementia, major depressive disorder, and bipolar disorder. An admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 12, which indicated the resident had moderate cognitive impairment. The Minimum Data Set documented mood indicators including feeling down, depressed, or hopeless, feeling tired or having little energy, trouble concentrating on things such as reading the newspaper or watching television in the assessment lookback period. The Minimum Data set indicated the resident did not exhibit behaviors and did not receive psychotropic medications. A comprehensive care plan titled Psychotropic Drug Use, effective 03/27/2026, documented the resident is receiving antipsychotic medication (quetiapine-Seroquel), antidepressant medication (trazadone) and a mood stabilizer (Depakote). The care plan did not have goals or interventions documented on the care plan. The physician's orders dated 03/27/2026 included quetiapine (a medication used for mood disorders) 25 milligram tablet four times per day for major depressive disorder, a total of 100 milligrams per day. This order was discontinued on 05/05/2026. A medical progress note dated 05/04/2026 documented the resident did not exhibit any behaviors. A physician's order dated 05/05/2026 documented the quetiapine dose was increased to a 50-milligram tablet three times per day for Major depressive disorder, a total of 150 milligrams per day. A review of the electronic medical record from 04/01/2026 through 05/05/2026 revealed there was no documented evidence of changes in the resident's behaviors or symptoms of depression or any evidence that non-pharmacological interventions to manage the resident's behaviors were implemented prior to increasing the quetiapine dose to 50 milligrams three times a day for a total of 150 milligrams per day. A nursing progress note dated 05/05/2026 at 08:37 AM documented Seroquel (quetiapine) titrated to 50 milligrams three times per day as per the Psychiatric Nurse Practitioner secondary to a family member's request and apparent daily sundowning. During an interview on 05/20/2026 at 10:23 AM, Registered Nurse Unit Manager #3 stated Resident #24 tended to sundown after lunch; the behaviors including Resident #24 repeatedly coming to the nursing station looking for their family members or visitors, who frequently do visit in the afternoon; however, they are easily redirected. Registered Nurse Unit Manager #3 stated that this is not a problematic behavior as there are no agitation or behavioral issues, it is just that the resident seems more confused after lunch. Registered Nurse Unit Manager #3 stated that the resident's family requested a higher dose of quetiapine medication. Registered Nurse Unit Manager #3 stated that the care plans are initiated by a Registered Nurse, and every care plan should have goals and interventions, including non-pharmacological interventions for the psychotropic medication use care plan. Registered Nurse Unit Manager #3 acknowledged that Resident #24's care plan for psychotropic medication use was not complete and did not include goals or interventions. During an interview on 05/20/2026 12:58 PM, the Medical Director stated there should be documentation regarding the resident's behaviors and changes in symptoms of increasing depression. The Medical Director stated that there was lack of documentation to justify the need to increase the psychotropic medication for Resident #24. The Medical Director stated that a family member's request is not sufficient reason to increase a psychotropic medication dosage. The Medical Director further stated that an increase of quetiapine 50 milligrams a day is a large increase. The Medical Director stated that the black box warning should be considered, given Resident #24's diagnosis of dementia. During an interview on 05/20/2026 at 1:25 PM, the Director of Nursing Services stated that Resident #24 was pleasant and easily redirected. The Director of Nursing reviewed and the electronic medical record and verified that the psychotropic medication use care plan was not completed. The Director of Nursing Services stated Resident #24's family members were highly involved in resident care, and the facility tried to consider the family member's input related to resident care. During an interview on 05/20/2026 at 1:36 PM, the Psychiatric Nurse Practitioner stated that they spoke with Registered Nurse Manager #3 regarding Resident #24's family members request to increase the quetiapine medication, and they increased the quetiapine dose. The Psychiatric Nurse Practitioner stated they were not aware that there was no documentation of behaviors to support the increased dosage. The Psychiatric Nurse Practitioner stated that they only evaluated the resident after they increased the medication dosage. The Psychiatric Nurse Practitioner stated they only make a recommendation and do not provide an order for psychotropic medication dosage changes. Registered Nurse Unit Manager #3 should confer with the residents' Primary Care Physician to address the recommendations provided. The Psychiatric Nurse Practitioner stated that they knew Resident #24 had a diagnosis of dementia and there is a black box warning for the use of quetiapine for resident with dementia diagnosis. The Psychiatric Nurse Practitioner stated and that increasing the quetiapine dose for sundowning is not indicated; however, they followed the family member's request. The Psychiatric Nurse Practitioner further stated if they knew that the resident did not exhibit agitation or aggressive behavior, they would not have increased the medication dosage just for sundowning. 10 New York Code Rules and Regulations 415.4

Based on observations, interviews and record review during the survey, the facility failed to ensure that each resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of their quality of life. This was identified for one (1) (Resident #9) of one (1) resident reviewed for dignity. Specifically, Resident #9 had a Foley catheter and was observed in the dining room without a privacy cover on the Foley catheter drainage bag. The Foley catheter drainage bag was filled with yellow colored urine and was visible to other residents and staff. Licensed Practical Nurse #3 subsequently wheeled the resident to the hallway sitting area with other residents present and did not cover the drainage bag with a privacy cover.The findings include: The facility's Catheter Daily Care Policy last reviewed on 01/2025 documented indwelling catheter care will be performed daily with activities of daily living care or as indicated by the physician's order. Licensed nursing staff or certified nursing assistants will be responsible for placing a privacy cover over the drainage bag and thus providing privacy for the residents who require a catheter. Resident #9 was admitted with diagnoses including obstructive and reflux uropathy (blocked or slowed urine flow), benign prostatic hyperplasia, and congestive heart failure. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident had severely impaired cognitive function. The assessment documented the resident was utilizing an indwelling catheter. The physician's orders renewed on 05/15/2026 documented suprapubic catheter, change if plugged, leaking or dislodged. Irrigate the suprapubic catheter with 50 milliliters of normal saline as needed if plugged or leaked. The care plan for urinary incontinence / indwelling catheter initiated on 09/04/2025 last reviewed on 03/16/2026 did not include intervention related to privacy covering for the urinary drainage bag. During an observation on 05/12/2026 at 12:25 PM, Resident #9 was observed in the dining room during the lunch meal. Resident #9's foley catheter drainage bag was not covered with a privacy cover and was filled with yellow colored urine which was visible to other residents and staff. During an observation on 05/12/2026 at 12:40 PM, Licensed Practical Nurse #3 wheeled Resident #9 to a sitting area in the hallway with the other residents. Licensed Practical Nurse #3 did not cover the resident's drainage bag with a privacy cover. The foley catheter drainage bag was half-filled with yellow urine and was visible to other residents, staff and visitors. During an interview on 05/12/2026 at 12:45 PM, Certified Nursing Assistant #1 stated they do not provide privacy covers for the foley catheter drainage bags, and it was the nurse's responsibility. During an interview on 05/12/2026 at 12:50 PM, Licensed Practical Nurse #3 stated providing a privacy cover for the urinary drainage bag is the certified nursing assistant's responsibility. Licensed Practical Nurse #3 stated they did not realize Resident #9 did not have a privacy cover for the urinary drainage bag. Licensed Practical Nurse#3 stated there were no privacy bags to be found on the floor and they had to go to the storage room to retrieve it. Licensed Practical Nurse #3 stated the urinary drainage bags should be covered with a privacy bag to maintain the residents' dignity. During an interview on 05/12/2026 at 01:52 PM, Registered Nurse #4 stated Resident #9 needs a privacy cover for the foley catheter to maintain the resident's dignity. Registered Nurse #4 stated that both the certified nursing assistants and nurses were responsible for providing the privacy cover for the resident's urinary drainage bag. During an interview on 05/20/2026 at 07:31 AM, the Director of Nursing Services stated the foley catheter drainage bags should have a privacy cover to maintain resident dignity. The Director of Nursing Services stated certified nursing assistants and nurses were responsible to provide privacy covers for the urinary drainage bags as part of activities of daily living care. The Director of Nursing Services stated the supply of the privacy bags should be readily available on each unit. 10 New York Code of Rules and Regulations 415.3(d)(1)(i)

Based on observation, record review, and interviews during the survey, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles. This was identified for one (1) (Resident #1) of four (4) residents reviewed for accident hazards. Specifically, an unlabeled medication cup containing topical wound dressing paste was observed in Resident #1's room. There were no staff in the vicinity of the room.The findings include:The facility Medication Storage policy and procedure effective 1/2025 documented the facility shall store all drugs and biological in a safe, secure, and orderly manner. The nursing staff shall be responsible for maintaining medication storage and preparation area in a clean, safe, and sanitary manner.Resident #1 was admitted with diagnoses of anemia, Alzheimer's disease and peripheral vascular disease (circulation disorder). A significant change Minimum Data Set assessment dated [DATE] documented the resident had short and long-term memory problems. Resident #1 was totally dependent on staff for activities of daily living and was always incontinent of bowel and bladder. The Minimum Data Set documented the resident had skin changes including moisture associated skin damage and required application of ointment to areas other than to feet. During an observation on 05/12/2026 at 12:00 PM, an unlabeled medication cup containing topical wound dressing paste was observed on the resident's dresser. There were no staff in the vicinity of the room. The resident was observed lying in bed but was unable to state what was in the medication cup. A Comprehensive Care Plan for Pressure Ulcers dated 08/30/2020 and updated 04/21/2026 documented the resident was at risk for skin breakdown related to peripheral vascular disease, incontinence, impaired mobility, and history of pressure ulcers. Interventions included to apply Triad Paste (local wound care treatment) to the lower back, buttocks, and the posterior thighs twice daily for four (4) weeks for a fungal rash. A Physician's order dated 04/21/2026 and renewed on 05/12/2026 documented to apply Triad wound dressing paste to the lower back, buttocks, and posterior thighs for a fungal two (2) times per day for four (4) weeks. During an interview on 05/12/2026 at 12:15 PM, Registered Nurse #6 stated that usually they wait for the Certified Nursing Assistant to provide care before they apply the topical ointment. Registered Nurse #6 stated when they went into the resident's room with the ointment the Certified Nursing Assistant was not ready to administer care. The Registered Nurse stated that they placed the ointment on the resident's dresser and forgot to take it with them when they left the room. Registered Nurse #6 stated they should not have left the ointment unattended in the resident's room. During an interview on 05/19/2026 at 3:33 PM, the Director of Nursing Service stated that Registered Nurse #6 should not have left the medication unattended in the resident's room. 10 New York Code Rules and Regulations 415.18(e)(1-4)

Based on interviews and record review during the survey, the facility failed to review and revise the comprehensive person-centered care plan by the interdisciplinary team after each assessment. This was identified for one (1) (Resident #119) of one (1) resident reviewed for skin conditions. Specifically, Resident #119's comprehensive care plan for behaviors was not updated to include noncompliance behaviors related to removal of wound dressings and Geri repeated pulling of dressing and Geri sleeves (protective sleeves designed to safeguard fragile skin). The findings include: Resident #119 was admitted with diagnoses that include stroke (a sudden interruption of blood flow to the brain), dementia, and Parkinson's disease. The admission Minimum Data Set assessment dated [DATE] documented that a Brief Interview for Mental Status score could not be completed due to severe cognitive decline. The Minimum Data Set did not indicate presence of pressure ulcers or skin conditions.The comprehensive care plan for behavioral symptoms dated 03/31/2026 did not document noncompliance behaviors related to removal of wound dressings and Geri repeated pulling of dressing and Geri sleeves.The comprehensive care plan for skin integrity-senile purpura dated 05/10/2026 documented interventions including using bilateral Geri sleeves as tolerated. The nursing progress notes dated 05/10/2026 documented the resident was noted with open purpura on the right upper arm; first aid was rendered. The Nurse Practitioner ordered a treatment of normal saline, bacitracin (antibacterial skin ointment), and dry dressing for ten days. A review of the electronic medical record from 03/31/2026-05/18/2026 revealed no documentation related to the resident's behavior of removing the wound dressings or the Geri sleeves.During an observation with Registered Nurse #1 on 05/18/2026 at 11:30 AM, the resident's bed sheet was noted with a dark brown stain under the resident's right upper arm. The resident had an open wound on the right arm, approximately one inch above the elbow. There was no dressing present on the wound. A used gauze dressing was observed on the floor. The resident was not wearing Geri sleeves as per the comprehensive care plan.During an interview on 05/18/2026 at 02:18 PM, Registered Nurse #1, the nurse manager, stated Resident #119 was picking on the senile purpura wound on the right elbow and was frequently removing the wound dressing and the Geri sleeve. Registered Nurse #1 stated that the resident's care plan indicated use of the Geri sleeves because of the behavior of picking on the wound.During an interview on 05/19/2026 at 10:25 AM, the Director of Nursing Services stated the comprehensive care plans should be revised to reflect the resident's status, including the behaviors that lead to noncompliance with resident care.10 New York Code Rules and Regulations 415.11(c)(2)(i-iii)

Based on record review and an interview with the facility Administrator during the survey, the facility failed to document the resources that were necessary to care for its residents competently during daily operations and emergencies. Specifically, the facility assessment did not include the use of agency Licensed Practical Nurses and use of Safety Aides to provide resident care.The findings include:The Facility Assessment policy reviewed 01/2026 documented the purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and during emergencies. This assessment will be created, used, reviewed, and updated in order to make decisions about direct care staff needs as well as the facility's capabilities to provide services to the residents in the facility. A review of the facility's list of new hires on 05/20/2026 revealed 20 Licensed Practical Nurses were hired through a nursing agency in the last four months. A review of the staffing sheets for May 2026 indicated the facility utilized Safety Aides (the new graduates of the Certified Nursing Assistant training program who were not yet certified). The Facility Assessment last updated in January 2026 did not include the use of Safety Aides and the nursing staff (Licensed Practical Nurses) that were hired through a staffing agency. During an interview on 05/20/2026 at 2:32 PM, the Administrator stated that the facility utilizes Safety Aides for resident care. The facility also uses nursing agencies to fulfill the need for Licensed Practical Nurses. The Administrator stated the Facility Assessment did not include either the Safety Aides or the agency Licensed Practical Nurses. The Administrator stated they should have updated the Facility Assessment to include the use of the staffing agency and safety Aides to accurately document resources needed to provide resident care. 10 New York Code Rules and Regulations 415.26

Based on observation, record review, and staff interview during the abbreviated survey (NY00375947) the facility did not review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation of bed rails for four (4) of 27 residents (Resident #1, #2 and #3, #4) reviewed. Specifically, the facility failed to assess the residents for risk of entrapment from bed rails prior to installation and failed to ensure the bedrails did not pose a risk of entrapment, asphyxiation, suffocation or injury. The facility failed to protect all four (4) residents from the likelihood of entrapment. This resulted in no actual harm with likelihood of serious harm that is Immediate Jeopardy and Substandard Quality of Care to all residents' using bedrails health and safety. The findings are: The facility policy titled Seizure Precautions and Care dated 06/2018, and revised 01/2023, documented Residents with a seizure diagnosis will have bilateral side rails with padding for protection when in bed. Resident #1 had diagnoses including Seizure disorder, muscle wasting and atrophy, and dementia. The Minimum Data Set (an assessment tool) dated 07/02/2025, documented a brief interview for mental status of 99, indicating severe cognitive impairment. There was no documented evidence of the use of side railsA physicians' order dated 09/03/2024 for Resident #1 documented two quarter side rails. A Comprehensive Care Plan dated 12/02/2023 documented that Resident #1 was at risk for seizures. It documented the following interventions, two quarter added siderails, monitor and report to Medical Doctor the intensity and duration of any seizure activity, protect head during seizure. There was no documented evidence in the medical record that Resident #1 was assessed for the risk of entrapment prior to the side rail installation, or that the resident and representative were educated regarding the risks and benefits and consented to the use of bilateral quarter side rails. Resident# 2 had diagnoses including seizure disorder, cerebral palsy, and muscle wasting and atrophy. The Minimum Data Set, dated [DATE] documented a brief interview for mental status score of 9 indicating moderate cognitive impairment. There was no documented evidence of the use of side railsA physicians' orders dated 12/10/2024 documented seizure precautions two quarter added side rails. A Comprehensive Care Plan dated 12/14/2016 documented Resident #2 had a diagnosis of a seizure disorder. Interventions include pad both upper side rails used as enablers for safety. During seizure, avoid restraining, keep suction equipment available, place pillow under neck, position on side, provide privacy, after monitor level of consciousness. There was no documented evidence in the medical record that Resident #2, was assessed for the risk of entrapment prior to the side rail installation or the resident and representative were educated regarding the risks and benefits and consented to the bilateral quarter side rails. Resident# 3 had diagnoses including seizures, cerebral palsy, and asthma. The Minimum Data Set, dated [DATE] documented Resident #3's brief interview for mental status score of 99 indicating severe cognitive impairment. There was no documented evidence of the use of side railsA physicians' orders dated 08/15/2025 for Resident #3 documented seizure precautions quarter padded side rails. A Comprehensive Care Plan dated 08/15/2025 documented Resident #3 was at risk for seizures. Seizure precautions documented interventions as follows: pad both upper side rails used as enablers for safety, protect head during seizure, monitor and report to Medical Doctor the intensity and duration of any seizure activityThere was no documented evidence in the medical record Resident #3 was assessed for the risk of entrapment prior to the side rail installation or the resident and representative were educated regarding the risks and benefits and consented to the bilateral quarter side rails.During an observation on 08/26/2025 at 11:36 AM, staff were unable to locate padding for Resident #1's side rails. During an observation on 08/27/2025 at 9:36 AM, Resident #1 was in bed with bilateral side rails up, and blankets taped to side rails. During an observation on 08/28/2025 at 8:10 AM Resident #1 was in bed with blankets taped to side rails.During an observation of the unit on 08/27/2025 at 11:48 AM Resident #2's side rails were up with one pad and one blanket noted over side rails. During an observation on 08/28/2025 at 8:10 AM Resident #2 was in bed with one pad and one blanket over side rails.During an observation on 08/27/2025 at 11:42 AM, Resident #3 was in bed with one blanket and one pillow in place over side railsDuring an observation on 08/28/2025 at 8:20 AM Resident #3 was in bed with one blanket and one pillow covering the side rails.During an observation on 08/29/2025 at 9:00 AM Resident #3 was in bed, with quarter bilateral side rails up. One rail had a pad covering, and the other rail was covered with a pillow. During an interview on 08/27/2025 at 10:05 AM, Director of Nursing Services stated they were aware that blankets and pillows were being used instead of pads on the quarter side rails. The Director of Nursing Services stated the nurses are responsible to make sure the pads are in place. The Director of Nursing Services stated that blankets and pillows provided padding, and they (the facility) found it acceptable. During an interview on 08/27/2025 at 12:06 PM Certified Nursing Assistant #4 stated that Resident #2 was missing padding for their side rails. Certified Nursing Assistant #4 stated that the nurse came in, wrapped a blanket around the side rail and secured it with tape this morning. Certified Nursing Assistant #4 did not recall if this was the first occurrence of this type. During an interview on 08/28/2025 at 8:29 AM Certified Nursing Assistant #7, stated they have worked in the facility for many years. They stated that at times, the facility will use blankets or pillows in place of padding on the quarter siderails. They stated, it happens when they are waiting for a shipment of new siderail pads. Certified Nursing Assistant #7 stated that many residents in the facility use pads, and they are hard to locate in the facility. They stated blankets and pillows provide padding. During an interview on 8/28/2025 at 11:46 AM the Administrator, stated they were aware blankets and pillows were being taped to side rails to be used instead of pads. They stated they have always utilized this practice and found it acceptable. The Administrator stated they did not think it caused a suffocation or entrapment risk. During an interview on 08/28/2025 at 2:35 PM the Assistant Director of Nursing Services stated the nursing staff are responsible to ensure there is padding on the side rails. They stated they did not think it should be documented in the medical record that proper padding and side rails are in place. They stated that if a resident has a diagnosis of seizures, the nurse should be ensuring the pads and rails are in place. They stated that if the residents are using the padding in bed, it does not matter if it is blankets, pillows or pads. They stated there was no difference what is used, as long as it is padded. They stated they do not think it causes a suffocation or entrapment risk. During an interview on 08/29/2025 at 10:19 AM Nurse Practitioner #1 stated they were not aware the facility was using blankets and pillows in lieu of pads on side rails. They stated they did not think that was an appropriate form of padding. They stated if the pillows or blankets shift, it could create a risk for entrapment. Nurse Practitioner #1 stated many of the residents have impaired cognition, and they could get their face stuck and suffocate. During a telephone interview with the bed manufacture on 08/29/2025 at 9:37 AM they stated they do not sell specific pads to cover the side rails, and they do not have any specific recommendations for padding. They stated the installation manual states that anything placed on the side of the rails should be tested for entrapment prior to use. They stated that a pillow or blanket could potentially cause a gap and not pass the entrapment test. During an interview on 09/26/2025 at 8:58AM, with medical director they stated the blankets and pillows were used temporarily until the pads came in, they stated it is not customary practice. They stated they do believe an assessment was completed but they are not certain. They stated everyone is now educated.10NYCRR 415.12(h)(1) (2)

Based on observations, record review, and interviews during the abbreviated survey complaint # (NY00375947) the facility did not ensure the Quality Assurance Performance Improvement committee developed and implemented appropriate plans of action to correct identified issues with the facility's side rail padding concern identified for four (4) of twenty-seven (27) residents (Resident #1, #2, #3 and #4) reviewed. Specifically, the facility failed to assess the residents for risk of entrapment from bed rails prior to installation and failed to ensure that the bedrails did not pose a risk of entrapment, asphyxiation, suffocation or injury. Additionally, the facility had blankets and pillows attached with tape to the siderails of four (4) of four (4) residents siderails in place of side rail pads further adding to the likelihood of entrapment. The Quality Assurance Performance Improvement Committee did not address, review, analyze, and act on available data on the identified issue to make improvements and to ensure improvements are sustained.Cross Reference:F 700 F 609The finding is:During an observation on 08/26/2025 at 11:36 AM, Certified Nursing Assistant #4 could not locate siderail padding for Resident #1's bilateral quarter side rails. During an observation on 08/27/2025 at 11:42 AM, Resident #3 was observed in bed with one blanket and one pillow in place over both quarter side rails.During an observation of the unit on 08/27/2025 at 11:48 AM Resident #2's side rails were up with one pad and one blanket over both quarter side rails. During an observation on 08/28/2025 at 8:10AM Resident #2 was in bed with one pad and one blanket over both quarter side rails.During an observation on 08/28/2025 at 8:20 AM Resident #3 observed in bed with one blanket and one pillow covering both quarter side rails.During an observation on 08/29/2025 at 9:00 AM Resident #3 observed in bed, with both quarter side rails up. One rail had a pad covering, and the other rail was covered with a pillow. During an interview on 8/27/25 at 10:05AM with Director of Nursing Services, they stated they were aware that blankets and pillows were being used in lieu of siderail pads on the bilateral quarter side rails. The Director of Nursing Services stated the nurses are responsible to make sure the siderail pads are in place. Director of Nursing Services stated that blankets and pillows provided padding, and they (the facility) found it acceptable. During an interview on 8/28/2025 at 11:46 AM, with the Administrator, they stated they were aware the staff were utilizing blankets and pillows taped to the resident's quarter side rails to be used in lieu of pads. They stated they have always utilized this practice and found it acceptable. The Administrator stated they did not think it caused a suffocation or entrapment risk, and the topic has not been discussed at any of our Quality Assurance Performance Improvement (QAPI) committee meetings. 10 NYCRR 483.75 (a)(2)(h)(i)

Based on observations, record review and interviews during the abbreviated Survey (complaint # NY00375947) the facility did not ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was identified for four (4) (Resident #1, #2, #3 and #4) of twenty-seven (27) residents with the potential to affect all 27 residents. Specifically, the facility failed to assess the residents for risk of entrapment from bed rails prior to installation and failed to ensure that the bedrails did not pose a risk of entrapment, asphyxiation, suffocation or injury. Additionally, the facility had blankets and pillows attached with tape to the siderails of four (4) of four (4) residents siderails in place of side rail pads further adding to the likelihood of entrapment. The facility failed to protect all four (4) residents from the likelihood of injury caused by entrapment. Refer to F700 siderails: Scope and Severity of K.The findings are: The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern long-term care facilities to assure that the highest degree of quality care can be provided to our residents.The facility policy titled Seizure Precautions and Care dated 06/2018, and revised 01/2023 documented Residents with a seizure diagnosis will have bilateral side rails with padding for protection when in bed. Resident's #1 had diagnoses including Seizure disorder, Muscle Wasting and Atrophy, and Dementia. The minimum data set assessment dated [DATE] documented a brief interview for mental status score of 99 indicating severe cognitive impairment. A physicians' order dated 09/03/2024 documented bilateral (both sides), quarter padded side rails. During an observation on 08/27/25 at 9:36 AM Resident #1 was in bed with bilateral quarter side rails up, with blankets taped to each quarter side rail. During an observation on 08/28/25 at 8:10 AM Resident #1 was observed in their bed with blankets taped to each quarter side rail.There was no documented evidence in the medical record that Resident #1, was assessed for the risk of entrapment prior to the bilateral (both sides) quarter side rail installation, or the resident and representative were educated regarding the risks and benefits and consented to the bilateral quarter side rails. During an interview on 8/28/2025 at 11:46 AM, with the Administrator, they stated they were aware that resident #2 had blankets and pillows taped to their side rails to be used in lieu of pads. They stated they have always utilized this practice and found it acceptable. The Administrator stated they did not think it caused a suffocation or entrapment risk. Resident's # 2 had diagnoses including seizure disorder, Cerebral Palsy, and Muscle Wasting and Atrophy. The minimum data set assessment dated [DATE] documented Resident#2's brief interview for mental status score of 9 (nine) indicating moderate cognitive impairment. A physicians' orders dated 12/10/2024 documented seizure precautions utilize 2 bilateral quarter padded side rails. During an observation of the unit on 08/27/2025 at 11:48 AM Resident #2's side rails were up with one pad and one blanket noted over both quarter side rails. During an observation on 08/28/2025 at 8:10 AM Resident #2 was in bed with one pad one of the siderails and a blanket over the other side rail.There was no documented evidence in the medical record that Resident #2, was assessed for the risk of entrapment prior to the side rail installation, the resident and representative were educated regarding the risks and benefits and consented to the bilateral quarter side rails. During an interview on 8/28/2025 at 11:46 AM, with the Administrator, they stated they were aware that resident #2 had blankets and pillows taped to their side rails to be used in lieu of pads. They stated they have always utilized this practice and found it acceptable. The Administrator stated they did not think it caused a suffocation or entrapment risk. Resident's # 3 had diagnoses including Seizures, Cerebral Palsy, and Asthma. The minimum data set assessment dated [DATE] documented Resident#3's brief interview for mental status score of 99 indicating severe cognitive impairment. It did not document the use of side rails. A physicians' orders dated 08/15/2025 documented seizure precautions, utilize bilateral padded quarter side rails. During an observation on 08/27/2025 at 11:42 AM, Resident #3 was observed in bed with one blanket and one pillow in place over the residents one (1) quarter side rail.During an observation on 08/28/2025 at 8:20 AM, Resident #3 observed in bed with one blanket and one pillow covering one (1) quarter side rail.During an observation on 08/29/2025 at 9:00 AM, Resident #3 was observed in their bed, with bilateral quarter side rails up. One quarter side rail had a pad covering, and the other quarter side rail was covered with a pillow. There was no documented evidence in the medical record that Resident #3, was assessed for the risk of entrapment prior to the side rail installation or the resident and representative were educated regarding the risks and benefits and consented to the bilateral quarter side rails. During an interview on 8/28/2025 at 11:46 AM, with the Administrator, they stated they were aware resident #3 had blankets and pillows taped to their quarter side rails to be used in lieu of pads. They stated they have always utilized this practice and found it acceptable. The Administrator stated they did not think it caused a suffocation or entrapment risk. 10NYCRR 415.26

Based on record review and interviews conducted during the recertification survey initiated on 8/14/2024 and completed on 8/21/2024 the facility did not ensure that all residents were provided with medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was identified for one of two residents reviewed for Advanced Directives. Specifically, Resident #132's Medical Orders for Life-Sustaining Treatment dated 7/20/2023 indicated the resident was to be intubated (when a tube is inserted through a person's mouth or nose to open an airway) and provided with long-term mechanical ventilation (to use a ventilator for breathing), including tracheostomy (an opening into the trachea from outside of the neck). The facility did not review/revise Resident #132's Medical Orders for Life-Sustaining Treatment form since the form was first completed on 7/20/2023. Additionally, Resident #132's Comprehensive Care Plan and the advance directive physician's order did not match the Medical Orders for Life-Sustaining Treatment form. The finding is: The facility's Medical Orders for Life-Sustaining Treatment policy last revised in March 2024 documented the Medical Orders for Life-Sustaining Treatment form is a medical order that converts an individual's wishes regarding life-sustaining treatment into medical orders. The purpose of the Medical Orders for Life-Sustaining Treatment form is to help the Physician/Nurse Practitioner/Physician's Assistant and other health care providers to discuss and convey a resident's wishes regarding cardiopulmonary resuscitation and other life-sustaining treatment. The Physician/Physician Assistant/Nurse Practitioner will review the Medical Orders for Life-Sustaining Treatment form with each 90-day resident review (assessment). When a resident is admitted or readmitted to the facility, the Social Worker, or the Unit Nurse in the absence of the Social Worker, will copy the Medical Orders for Life-Sustaining Treatment form on bright pink paper and file the form in the Resident's Medical record along with the Resident's advance directive. As the resident moves from one healthcare setting to another, the bright pink Medical Orders for Life-Sustaining Treatment form is to accompany the resident. Resident #132 was admitted with the diagnoses of Dementia, Hyperlipidemia (high cholesterol), and Hypertension. The Annual 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. The Admission Minimum Data Set Assessment documented Resident #132's Advanced Directives as Do Not Intubate. Resident #132's Medical Orders for Life-Sustaining Treatment form dated 7/20/2023 documented to provide intubation and long-term mechanical ventilation, including a tracheostomy, if the resident required respiratory support. The Review and Renewal section of the Medical Orders for Life-Sustaining Treatment form was blank indicating the Medical Orders for Life-Sustaining Treatment form had not been reviewed since 7/20/2023. A physician's order dated 8/10/2024 documented not to intubate Resident #132. Resident #132's Advanced Directives care plan effective 7/19/2023 and last reviewed on 7/24/2024 documented Do Not Intubate. This care plan was updated on 10/25/2023, 1/18/2024, 4/20/2024, and 7/24/2024 and documented Quarterly - Advanced directives reviewed with resident's sponsor. No changes at this time. Education ongoing. On 8/20/2024 the Care Plan was revised to include that advanced directives were reviewed with the resident's family member and a new Medical Orders for Life-Sustaining Treatment (MOLST) form was completed with the following orders: Do Not Resuscitate, Do Not Intubate, no feeding tube, and to send the resident to the hospital when medically necessary. The Social Worker assigned to Resident #132 was unavailable for an interview. Social Worker #1 was interviewed on 8/20/2024 at 4:13 PM and stated the Medical Orders for Life-Sustaining Treatment form should be reviewed quarterly with the designated representative, nursing, and social worker during the care plan meeting. The Director of Social Work was interviewed on 8/21/2024 at 9:32 AM and stated the Medical Orders for Life-Sustaining Treatment form is reviewed at the quarterly care plan meetings; if there is a change in condition; or when the designated representative requested a change. The Director of Social Work stated the Medical Orders for Life-Sustaining Treatment form should have matched the physician's orders and the resident's care plan. The discrepancy between the physician's orders and the Medical Orders for Life-Sustaining Treatment form was an oversight. The Director of Social Work was interviewed on 8/21/2024 at 3:38 PM and stated the Social Worker is responsible for ensuring that the Medical Orders for Life-Sustaining Treatment form, Comprehensive Care Plan, and physician's orders match and are accurate. The Director of Nursing Services was interviewed on 8/21/2024 at 3:45 PM and stated the resident's Social Worker should review the Medical Orders for Life-Sustaining Treatment form at the quarterly Comprehensive Care Plan Meeting and ensure the physician's orders and Care Plan are consistent with the Medical Orders for Life-Sustaining Treatment form. 10 NYCRR 415.5(g)(1)(i-xv)

Based on record review and interviews conducted during the Recertification Survey initiated on 8/14/2024 and completed on 8/21/2024 the facility did not ensure that a Physician reviewed each resident's total program of care, including treatments and medications. Specifically, Resident #132's Medical Orders for Life-Sustaining Treatment form documented the resident is to be intubated (when a tube is inserted through a person's mouth or nose to open an airway) and provided with long-term mechanical ventilation (to use a ventilator for breathing), including tracheostomy (an opening into the trachea from outside of the neck). Resident #132's Medical Orders for Life-Sustaining Treatment form was not reviewed since the form was first completed on 7/20/2023. Resident #132's physician orders documented the resident was not to be intubated, which did not match the Medical Orders for Life-Sustaining Treatment form. The finding is: The facility's Medical Orders for Life-Sustaining Treatment policy last revised in March 2024 documented the Medical Orders for Life-Sustaining Treatment form is a medical order that converts an individual's wishes regarding life-sustaining treatment into medical orders. The purpose of the Medical Orders for Life-Sustaining Treatment form is to help the Physician/Nurse Practitioner/Physician's Assistant and other health care providers to discuss and convey a resident's wishes regarding cardiopulmonary resuscitation and other life-sustaining treatment. The Physician/Physician Assistant/Nurse Practitioner will review the Medical Orders for Life-Sustaining Treatment form with each 90-day resident review (assessment). When a resident is admitted or readmitted to the facility, the Social Worker, or the Unit Nurse in the absence of the Social Worker, will copy the Medical Orders for Life-Sustaining Treatment form on bright pink paper and file the form in the Resident's Medical record along with the Resident's advance directive. As the resident moves from one healthcare setting to another, the bright pink Medical Orders for Life-Sustaining Treatment form is to accompany the resident. Resident #132 was admitted with the diagnoses of Dementia, Hyperlipidemia (high cholesterol), and Hypertension. The Annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status of 99, indicating the resident was unable to complete the interview. The Minimum Data Set assessment documented Resident #132's Advanced Directives as Do Not Intubate. Resident #132's Medical Orders for Life-Sustaining Treatment form dated 7/20/2023 documented providing intubation and long-term mechanical ventilation, including a tracheostomy if the resident required respiratory support. The Review and Renewal section of the Medical Orders for Life-Sustaining Treatment form was blank indicating the Medical Orders for Life-Sustaining Treatment form had not been reviewed since 7/20/2023. A physician's order dated 8/10/2024 documented not to intubate Resident #132. The Adult-Gerontology Nurse Practitioner was interviewed on 8/21/2024 at 11:28 AM and stated they reviewed the Medical Orders for Life-Sustaining Treatment form for Resident #132 on 7/20/2023. The Adult Gerontology Nurse Practitioner stated the Medical Orders for Life-Sustaining Treatment form should be reviewed to ensure that the form matched the physician's order for advance directives including wishes regarding intubation. The Medical Director was interviewed on 8/21/2024 at 11:38 AM and stated the Medical Orders for Life-Sustaining Treatment form is completed with the Resident's Representative and the facility's nursing and social work staff. The Medical Director stated the instructions documented on the Medical Orders for Life-Sustaining Treatment form are the standard of care and the Medical Orders for Life-Sustaining Treatment form and physician's order should match. 415.15(b)(2)(iii)

Based on record review and interviews conducted during the Recertification Survey and Abbreviated Survey (NY 00336468) initiated on 8/14/2024 and completed on 8/21/2024, the facility did not ensure that all incidents including an injury of unknown origin were thoroughly investigated. This was identified for one resident (Resident #430) of six residents reviewed for Accidents. Specifically, on 3/19/2024 Resident #430 sustained a fracture of their left leg, an injury of unknown origin. The facility did not thoroughly investigate the incident to identify the root cause of the injury to rule out abuse, neglect, and mistreatment. The finding is: The facility's policy titled Accidents/Incidents Involving Residents revised in July 2021 documented the facility's aim is to protect all the residents from accidents and incidents. If a resident has an accident, incident, or fall, including but not limited to an injury of unknown origin, appropriate treatment is provided, applicable persons are notified, and there is a thorough investigation and follow-up to ensure that the resident is safe from harm. The purpose of the policy is to monitor for abuse, mistreatment, exploitation, or neglect; identify the facts of the accident, incident, or fall; and ensure appropriate follow-up and preventative measures. Resident #430 had diagnoses that included Dementia, Type 2 Diabetes, and Major Depressive Disorder. The Significant Change Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 9, indicating the resident had moderate cognitive impairment. Resident #430 used a walker and wheelchair for mobility. Resident #430 required partial/moderate assistance for bed mobility and transfer. The Nursing Home Investigation Report dated 3/22/2024 documented the staff did not witness falls or trauma involving the resident since 3/7/2024. An undated Accident and Incident Summary documented on 3/18/2024 Resident #430 complained of left leg pain; the resident was medicated with Oxycodone (narcotic pain medication) and extra strength Acetaminophen (Tylenol-pain medication). Resident #430 continued to report discomfort and could not move their left leg. The Nurse Practitioner was notified and ordered an x-ray of the left leg. The x-ray results of the left knee were received on 3/19/2024 and revealed a recent femoral (leg bone) fracture. The Medical Doctor was notified, and Resident #430 was sent to the hospital. The summary concluded there was no evidence of abuse, mistreatment, exploitation, or neglect. The written statements from staff only had information regarding the resident's complaint of pain. The written statements did not include whether the staff witnessed falls or trauma before the resident complained of pain on 3/18/2024 and before the discovery of the fracture. The summary did not identify the possible root cause of the injury. The summary did not include a statement from Resident #430. The Registered Nurse Risk Manager was interviewed on 8/20/2024 at 3:04 PM and stated they completed the Accident and Incident Report for Resident #430 on 3/18/2024. The Registered Nurse Risk Manager stated they interviewed and took statements from the staff who took care of the resident 48 hours prior to the incident. The Registered Nurse Risk Manager stated they asked each staff member about any unusual events regarding the resident's care, such as falls or mistreatment. The Risk Manager stated the staff responses were not documented on the statement forms. Registered Nurse Risk Manager stated they concluded that there were no signs of abuse, mistreatment, or neglect based on their assessment of the resident which noted no bruising or swelling to the affected area and based on the resident's clinical history. The Director of Nursing Services was interviewed on 8/21/2024 at 10:37 AM and stated the staff statements should have reflected any instances of falls or trauma to rule out abuse, neglect, or mistreatment. The Director of Nursing Services stated the facility's policy was to investigate concerns related to an injury of unknown origin and based on the documented statements regarding Resident #430's injury abuse, neglect, and mistreatment could not be ruled out. 10 NYCRR 415.4 (b)

Based on observation, record review, and interviews conducted during the Recertification Survey initiated on 8/14/2024 and completed on 8/21/2024 the facility did not ensure that a comprehensive person-centered care plan was developed for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs. This was identified for one (Resident #132) of two residents reviewed for hearing and vision. Specifically, Resident #132 did not speak English as their primary language. The Comprehensive Care Plan did not identify that Resident #132 had a language barrier. The finding is: The facility's policy titled Language Services dated July 2023, documented that in the event a resident is admitted who does not speak English as their preferred language, the facility will attempt to locate staff that speak the language to communicate with the resident; however, the facility also makes use of a phone service that provides a translator in the language of choice. The facility did not have a policy on Comprehensive Care Planning. Resident #132 was admitted with the diagnoses of Dementia, Hyperlipidemia (high cholesterol), and Hypertension. The Annual 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. The Minimum Data Set documented Resident #132's hearing was adequate, their speech was clear, they made themselves understood, and they usually understood others. Resident #132's admission nursing assessment dated [DATE] documented that Resident #132's primary language was French Creole. Resident #132 was observed sitting in a chair in their room on 8/14/2024 at 10:13 AM. Resident #132 responded to the surveyor in French-Creole. Resident #132's Comprehensive Care Plan for Communication effective 7/19/2023 last updated on 7/23/2024, documented that Resident #132 was at risk for decline due to an impaired ability to make themselves understood. Interventions included but were not limited to expand nonverbal communication skills and to provide auditory stimuli by speaking to the resident during care. The Comprehensive Care Plan did not include the resident's language barrier. The Comprehensive Care Plan was updated on 8/21/2024 to include an intervention for the use of a communication board. Certified Nursing Assistant #5, Resident #132 regularly assigned Certified Nursing Assistant, was interviewed on 8/20/2024 at 11:53 AM. Certified Nursing Assistant #5 stated Resident #132 spoke French Creole and did not speak any English. Certified Nursing Assistant #5 stated they were able to communicate with Resident #132 because they also spoke French Creole. Registered Nurse #2 was interviewed on 8/21/2024 at 12:46 PM and stated they were aware that Resident #132 did not speak English. Registered Nurse #2 stated they did not know that the resident's Comprehensive Care Plan did not include the resident's language barrier status because they were not regularly assigned to the unit and were the covering Unit Manager. Registered Nurse #2 stated the communication care plan should have included that Resident #132 did not speak English along with the interventions to meet the resident's communication needs related to the language barrier. Registered Nurse #2 stated the regularly assigned unit Registered Nurse was responsible for updating the care plans. The Administrator was interviewed on 8/21/2024 at 2:02 PM and stated a resident who does not speak English as a primary language, should have a Comprehensive Care plan related to their preferred language with interventions in place such as the use of family members, employees, and translation services to effectively communicate with the resident. 10 NYCRR 415.11(c)(1)

Based on observation, record review and interviews during the Recertification and Abbreviated Survey (NY00303374) initiated on [DATE] and completed on [DATE] the facility did not ensure that each resident receive adequate supervision and assistance to prevent accidents. This was identified for one (Resident #82) of two residents reviewed for falls. Specifically, Resident #82 required total assistance of two staff members for all areas of Activities of Daily Living (ADLs) including bed mobility as per the Comprehensive Care Plan (CCP). During morning care on [DATE] Resident #82 fell in their room, when the Temporary Nursing Assistant (TNA) #1 turned the resident on their right side away from them (TNA #1) without the assistance of another staff member. Subsequently, Resident #82 fell from their bed and sustained Bilateral Femur (upper leg) Fractures. This resulted in actual harm to Resident #82 that is not Immediate Jeopardy. The finding is: The facility Policy on Fall Prevention was revised in [DATE], documented under the Procedure section (#5) to document care plan directives on the Certified Nursing Assistant (CNA) Accountability Sheet. Under procedure section #7 the policy documented at the time of a fall incident the Registered Nurse (RN) Supervisor is to review the resident's plan of directives to ensure that appropriate interventions were followed, and to revise the care plan to include interventions to prevent reoccurrence of fall incidents. Resident #82 was admitted with diagnoses of Dementia and Cerebral Vascular Accident with Hemiparesis (one side body weakness). Resident #82 was readmitted on [DATE] from the hospital Status Post falls and had diagnoses that included Fracture of Right and Left Femur, Hypertension, and Atrial Fibrillation. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short and long term memory problems. The resident required total assistance of two staff members for bed mobility, transfers, toileting, and bathing. The resident has impairment of both upper extremities and on one side of their lower extremity. The resident utilized a wheelchair and had no falls prior to this assessment. The Significant Change MDS dated [DATE] documented the resident had short and long term memory problems and was severely impaired for daily decision making. The resident required total assistance of two staff members for bed mobility, transfers, toileting, and bathing. The resident was always incontinent of both bowel and bladder. The resident has limitations on both sides of the upper and lower extremities. The Nursing Fall Risk assessment dated [DATE] documented the resident's fall risk score was 11 which indicated the resident was at risk for falls and required a Falls/Safety/Injury care plan. The Activities of Daily Living (ADL) Functional/Rehabilitation potential care plan dated [DATE], last updated [DATE] documented the resident required total assistance of two staff members for bed mobility. The At Risk for Falls- Potential/Injury care plan dated [DATE] and was last reviewed on [DATE] documented the resident was at risk for falls with potential for injury related to Dementia, Cerebral Vascular Accident related to Hemiparesis. The interventions included to provide assistance of two staff members for all care including bed mobility. The Resident Nursing Instructions Form (guidance provided to CNAs for resident care needs) dated [DATE]-[DATE] documented Resident #82 required total dependence of two staff members for bed mobility. A Nursing note dated [DATE] at 7:15 AM written by Registered Nurse (RN) #2 documented that at 6:30 AM Resident #82 was turned towards the door by TNA #1 during care. Resident #82 began to roll out of the bed and TNA #1 guided the resident to the floor. Resident #82 was found on the floor in their room lying on their back. The resident complained of right knee discomfort with a pain score of four out of 10 (zero indicating no pain and 10 indicating most severe pain). A Facility Accident and Incident (A/I) Report dated [DATE] at 6:30 AM documented that while TNA #1 was rendering care to Resident #82, TNA #1 turned the resident towards the door and the resident began to roll out of the bed. TNA #1 stated that they guided the resident to the floor. The A/I report documented the resident was found on the floor in their room lying on their back and complaining of right knee discomfort. The Facility A/I Summary dated [DATE] concluded that TNA #1 performed toileting and bed mobility on Resident #82 by themselves without seeking assistance from a Certified Nursing Assistant (CNA) or a nurse. This break in the plan of care resulted in a major injury to the resident. Due to these circumstances, TNA #1 has been relieved from their position. Based on the information provided, there has been evidence of abuse, mistreatment, exploitation, or neglect. The Resident CNA Documentation History Form (documentation of care that was rendered) dated [DATE]-[DATE] revealed at 11:35 PM TNA #1 provided care for Resident #82 utilizing two persons for bed mobility. After 11:35 PM TNA #1 did not document care provision to Resident #82 on [DATE]-[DATE] during the 11:00 PM-7:00AM nursing shift. The Computerized Tomography (CT) scan of the Right Hip, Femur, and Knee dated [DATE] documented there was a right Femur Fracture. The hospital Radiology Report of the Left Knee dated [DATE] documented there was a left Femoral Fracture A Nursing note written by RN #6 dated [DATE] at 2:03 PM documented the x-ray result revealed an Acute Femur Fracture. The Hospital Discharge Instructions dated [DATE] documented that the right Femur fracture was non-operative and the left Femur fracture required surgical intervention on [DATE]. A Medical progress note written by Nurse Practitioner (NP) #1 dated [DATE] documented the resident was evaluated on [DATE] at the bedside. The note documented the resident had a recent hospitalization status post fall resulting in right and left Femur Fractures. TNA #1 was not available for interviews after several attempts were made to contact them on [DATE]. TNA #1's written statement dated [DATE] documented when they (TNA #1) were providing care for Resident #82 they rolled Resident #82 on their right side to apply the cream to the resident's buttocks. TNA #1 wrote they noticed the resident was rolling more to the right and they tried to intervene, but they were only able to catch the upper part of the resident's body. When the resident's legs fell off the bed, TNA #1 gently placed the resident onto the floor and called for the nurse. Resident #82 told TNA #1 that their right knee hurts. An observation of Resident #82 was conducted on [DATE] at 10:15 AM. Resident #82 was observed sitting in their room in a reclining wheelchair. RN #2, the 11:00 PM - 7:00 AM shift Supervisor on [DATE]-[DATE], was interviewed on [DATE] at 6:36 AM. RN #2 stated they were informed by Licensed Practical Nurse (LPN) #4 that the resident was on the floor. RN #2 stated when they arrived at the unit, they observed Resident #82 on the floor laying on their back between the wall and the right side of the bed. RN #2 stated the resident was complaining of severe pain in the right knee and leg. RN #2 stated that they tried to perform Range of Motion (ROM) to the resident's extremities, however, could not continue due to the resident's complaint of pain. RN #2 stated after they assessed the resident, they transferred the resident back to bed using a Hoyer (mechanical) lift. RN #2 stated the resident required two staff members' assistance for bed mobility and turning and positioning. TNA #1 told RN #2 that they did not request assistance from another staff member when providing care to Resident #82. RN #2 stated that TNA #1 informed them they were unaware that Resident #82 required two-person assistance for bed mobility. CNA #3, who was the 11:00 PM - 7:00 AM CNA on duty on [DATE]-[DATE], was interviewed on [DATE] at 3:12 PM. CNA #3 stated TNA #1 was assigned to Resident #82. CNA #3 stated after providing care to one of the residents on their assignment they were walking in the hallway when they heard TNA #1 calling for help. CNA #3 stated when they got to the resident's room, they saw Resident #82 laying on their stomach on the floor. CNA #3 stated that TNA #1 told them when they rolled Resident #82, the resident was too close to the edge of the bed and the resident continued to roll out of bed. CNA #3 further stated that the resident required two staff members for all ADLs and that TNA #1 did not ask for their assistance to turn Resident #82. LPN #2, who was the medication nurse on duty on [DATE]-[DATE] on the 11 PM-7:00 AM shift, was interviewed on [DATE] at 3:30 PM. LPN #2 stated that they were made aware of the incident by TNA #1 who came to the nurse's station and reported that Resident #82 fell out of bed. LPN #2 stated they called RN #2 then went to Resident #82's room and saw the resident lying face down on the floor. LPN #2 stated TNA #1 reported they rolled the Resident too close to the edge of the bed and the resident rolled off the bed. A subsequent interview with LPN #2 was conducted on [DATE] at 5:16 PM. LPN #2 stated that TNA #1 did not request help from them at any time during the [DATE] - [DATE] 11 PM - 7AM nursing shift. The RN Inservice Coordinator was interviewed on [DATE] at 11:52 AM. The RN Inservice Coordinator stated that all new hires receive training on mandatory policies and procedures upon hire and annually. The RN Inservice Coordinator stated that the TNAs receive the same training and in-services as the CNAs. The RN Inservice Coordinator stated after a one-day classroom training that the TNA is buddied with an experienced CNA and that during this period they receive extensive training on the use of the Electronic Medical Record (EMR) including reviewing the ADL Tasks which includes bed mobility prior to providing care. The Medical Director (MD) was interviewed on [DATE] at 4:43 PM. The MD stated when they were made aware of the resident's fall, they ordered an x-ray of the right leg. The MD stated on [DATE] they were made aware the x-ray results revealed a right Femur Fracture they ordered to send the resident to the hospital for evaluation. The MD stated at the time of transfer that they were not aware of the resident's Left Hip Fracture. The MD stated that based on the fall and x-ray results the resident's fractures were directly related to the fall. The Physician further stated that if the resident's plan of care specified two persons for bed mobility, the expectation would be for the care of the resident to be rendered by two staff members. The Director of Nursing Service (DNS) was interviewed on [DATE] at 9:58 AM. The DNS stated that the resident required two staff members for all aspects of ADLs, especially bed mobility. The DNS stated that there was a break in Resident #82's plan of care because TNA #1 did not follow the resident's plan of care. The DNS stated that TNA #1 did not have a second staff member to assist them with care while the resident was in bed. The DNS stated TNA #1 should have asked for assistance from CNA #3 and if CNA #3 was not available TNA #1 should have asked LPN #2 for assistance. Additionally, the DNS stated that the X-Ray revealed an Acute Fracture of the Right Distal Femur and at the time of the incident they were not aware that the resident had fractured their Left Hip because the resident did not complain of left leg pain. The DNS stated it was upon the resident's return from the hospital that they discovered the resident had fractured the Left Femur (upper leg) as well. The DNS stated the bilateral fractures were directly related to the resident's fall from bed on [DATE]. The Administrator was interviewed on [DATE] at 12:31 PM and stated that TNA #1 did not follow the plan of care when administering care to Resident #82. The Administrator stated they expected the staff to follow each resident's plan of care. If a resident's plan of care requires two-person assistance, then the staff must utilize two staff members to provide care. 10 NYCRR-414.12(h)(2)

Based on record reviews and interviews conducted during a Recertification Survey and Abbreviated Survey (NY00308707) initiated on 7/19/2023 and completed on 7/28/2023, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source are reported immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury are reported to the New_York State Department of Health (NYSDOH) within the required timeframe. This was identified for one of four sampled residents reviewed for Accidents. Specifically, Resident #230 was first identified on 1/14/2023 with a right hip fracture and the facility did not report the injury to the NYSDOH until 1/16/2023. The finding is: The Facility Abuse Mistreatment and Neglect Policy dated 1/2023 documented that the facility will report all instances where there is reasonable cause to believe abuse has occurred as required to the Department of Health and take necessary corrective action depending on the result of the investigation. The policy documented under #10- - The DOH will be notified by the DNS or designee of any suspicion or findings of abuse, neglect, mistreatment of resident as per regulation. Resident # 230 was initially admitted to the facility on [DATE]. Resident # 230 was discharged to the hospital on 1/6/2023 due to altered mental status and was readmitted on [DATE]. The residents' diagnoses included Metabolic Encephalopathy, Muscle Wasting and Atrophy, and Peripheral Vascular Disease. The medical record documented a new diagnoses of Age-related Osteoporosis without current pathological fracture on 1/16/2023. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief interview of Mental Status score of 99 which indicated the resident was cognitively impaired. The resident required limited assistance with one person for bed mobility, eating, toilet use, transfer, walk in room, walk in corridor. The resident required extensive assist with one person assist for locomotion on/off unit, dressing and personal hygiene. The MDS documented the resident was not steady and was only able to stabilize with staff assistance for walking, moving from seated to standing position, turning around. The Radiology result dated 1/14/2023 at 10:53 AM documented the resident had a right hip fracture. The Nursing progress note dated 01/14/2023 at 2:06 PM documented the resident's X-Ray of Right(R) hip revealed an Acute fracture of the right femur. The Physician (MD)#1 was notified, and no new orders were given. The resident remains on comfort care measures, pain management was in place with positive effect. The Nursing Progress Note dated 01/14/2023 at 8:06 PM documented the resident's family was contacted regarding the X-Ray result revealing a right hip fracture. The resident had no reported fall since re-admission. X-ray order was old, dated 12/9/22, and got carried over during the readmission and was done 1/14/23. The physician reviewed the result - spontaneous fracture can sometimes happen, make sure family is updated. The Physician's Progress note dated on 01/15/2023 at 8:48 AM documented they (Physician) spoke to the nursing supervisor in reference to the X-ray of the acute fracture femur. The resident did not have any recent fall in the nursing home. The Nursing supervisor spoke to the family regarding the x-ray report and the family wants the patient to be comfortable. The resident was on comfort care and was receiving lorazepam (ant-anxiety medication) as well as morphine (pain medication). The Incident/Accident investigation initiated on 1/16/2023 and completed on 1/20/2023 documented that based on the information provided, there has been no evidence of abuse, mistreatment, exploitation or neglect. The Incident was not reported to the NYSDOH until 1/16/2023. Registered Nurse Supervisor (RNS) #3 was interviewed on 7/25/2023 at 2:00 PM and stated they worked on 1/14/2023 from 7:00 PM to 7:00 AM. RNS #3 stated they were notified by the day supervisor that the resident's X-ray for the right hip was positive for fracture. RNS #3 stated they notified the resident's family, and they did not start an accident/incident report. RNS #3 stated they did not discuss the resident's fracture with the Director of Nursing Services (DNS) because they forgot to do so. RNS#3 stated they worked on 1/12/2023, the day the resident was readmitted , and they observed the resident did not have any bruising or swelling on the resident's bilateral hips. RNS#3 stated the resident did not have any signs and symptoms of pain or discomfort on 1/12/2023, 1/14/2023, 1/15/2023. RNS#3 stated they reinitiated the resident's old orders when the resident was readmitted on [DATE] and one of the orders was a hip X-ray. Accurate?? Licensed Practical Nurse (LPN) #4 who worked on 1/12/2023, 1/14/2023 and 1/15/2023 was interviewed on 7/26/2023 at 11:44 AM. LPN #4 stated that Resident #230 was confused and was able to verbalize their needs at times. LPN#4 stated they do not remember if the resident had symptoms of pain on or after their re-admission on 1/12/2023. LPN#4 stated they received a call from the X-ray company on 1/14/2023 that Resident #230 had a right hip fracture. LPN#4 stated they reported this to RNS #4 and the Physician on 1/14/2023. LPN#4 stated RNS #4 should have reported the fracture to the Director of Nursing (DNS) and initiated an incident and accident report after they received the phone call from the X-ray company. LPN#4 stated the residents X-ray result was on the 24 hours report when they received the call from the X-ray on 1/14/2023. RNS #4 was interviewed on 7/26/2023 at 1:05 PM and stated they worked on 1/14/2023 on the 7:00 AM to 7:00 PM shift and they were informed by the night RNS and read on the 24 hour report that the resident had a right hip fracture. RNS#4 did not start an incident/accident report and did not notify the DNS because they thought the night nurse had initiated the A/I report. RN#5, the Admission Nurse, was interviewed on 7/26/2023 at 1:35 PM and stated they completed the readmission with RNS#3 and the resident did not have any signs and symptoms of a fractured hip such as, swelling, bruising or pain. Physician #1, the resident's primary care physician, was interviewed on 7/27/2023 at 9:46 AM and stated the resident has a lot of comorbidities and this fracture was a pathological fracture. The Director of Nursing Services (DNS) was interviewed on 7/28/2023 at 11:31 AM and stated the X-ray was done for right hip on January 13 th,2023 and the facility was notified of the results on 1/14/2023 which revealed the resident had a acute (new) right fracture. The DNS stated LPN #3 received the report from the X-ray company 1/14/2023 but did not notify the supervisor or the DNS. The DNS stated they (DNS) should have been made aware of any injury, even if on the weekends or during the night, so the facility could notify and report the injury to the NYSDOH. The DNS stated in the morning on Monday, 1/16/2023, they (DNS) read the 24 hour report and noticed that the resident had a fracture reported on 1/14/2023. The DNS stated they started the accident and incident report on 1/16/2023 and reported the incident to the DOH within two hours after reading the 24 hour report; however, they should have been notified once the fracture was identified. 483.12(c)(1)(4)

Based on record review and interviews during the Recertification Survey initiated on 7/19/2023 and completed on 7/28/2023, the facility did not ensure that accurate preadmission screening for individuals with a mental disorder and individuals with intellectual disability was conducted. This was identified for one of 35 residents reviewed for Pre-admission Screening and Resident Review (PASARR). Specifically, Resident # 143 had a Level I (one) PASARR screening partially completed; therefore, the necessity of a Level II screen could not be determined. The finding is: The facility's policy and procedure titled Pre-Admission Screening and Resident Review (PASARR) last revised June 2021 documented to obtain a pre-admission screen for all new admissions and to review the PASARR screen for every new admission. Upon acceptance of a new admission from the hospital or community, the admissions staff will be responsible to obtain a PASARR screen prior to admission. The PASARR screen dated 6/9/2023, completed at the hospital prior to admission to the nursing home, was reviewed. A Level I screen was not fully completed. Questions 26 were left blank. Question 26 asks does this person presents with evidence of cognitive deficit and/or adaptive skill deficit that may indicate the presence of mental retardation or developmental disability? The guideline indicates if item 23 or any or item 24-26 were marked YES, proceed to Categorical Determination (items 27-30). If item 23 and all of the items 24-26 are marked NO, proceed to patient/resident/person disposition (item 36). The PASARR form was not completed to determine if a Level II was required. Resident #143 was admitted to the facility on [DATE] with diagnoses of Bipolar Disorder, Major Depressive Disorder and Metabolic Encephalopathy. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had intact cognition. The assessment's PASARR section documented that Resident #143 was not currently considered by the state level II PASARR process to have serious mental illness, intellectual disability nor other related conditions. The Admission Coordinator was interviewed on 7/27/2023 at 9:40 AM. The Admission Coordinator stated that they received all pre-admission documents from the admission nurse Licensed Practical Nurse (LPN) #3 and they (Admission Coordinator) are responsible to ensure all documents required for admission were present. The Admission Coordinator stated that they do not review documents for completion and accuracy. LPN #3, who was the onsite liaison, was interviewed on 7/27/2023 at 9:54 AM. LPN #3 stated that they were responsible for reviewing admission referrals and thoroughly checking all the resident's pre-admission documents including but not limited to the PASARR screen to determine if the facility would be able to provide the level of care that the resident needed. LPN #3 reviewed Resident #143's PASARR screen dated 6/9/2023 and confirmed that Question 26 was not completed. LPN #3 stated that without answering all the questions (Question 23 through 26), the necessity for a Level 2 screening cannot be determined. LPN #3 stated that the response No should have been checked for Question 26 because Resident #143 did not have evidence of cognitive deficit and/or adaptive skill deficits that may indicate the presence of mental retardation or developmental disability. LPN #3 stated that interdisciplinary members such as social worker should also review the screen and notify them (LPN #3) if there was any issue. LPN #3 stated that Resident #143's social worker did not notify them (LPN #3) of any issue related to the PASARR screen. Social Worker (SW) #1 was interviewed on 7/27/2023 at 10:20 AM and stated they were Resident #143's assigned social worker. SW #1 stated that they (SW #1) reviewed Resident #143's PASARR screening after the resident was admitted . SW #1 stated they did not notice that Question 26 was not answered and should have been. SW #1 stated that they were a certified PASARR screener and that the consideration of level 2 PASARR review cannot be determined without the question answered appropriately. SW #1 stated that Resident #143 would not have required a level 2 review because they (Resident #143) did not fit the criteria. SW #1 stated that if they had discovered the missing response during admission, they would have asked the admission nurse to reach out to the sending facility and have the screen redone. The Director of Social Work (DSW) was interviewed on 7/27/2023 at 11:55 AM and stated that they (DSW) expected the admission office to review and scan all the resident's pre-admission documents to the resident's electronic medical chart. The DSW stated the assigned social worker should make sure that a current PASARR screen was in the chart and notified them (DSW) or the admission coordinator if there were any issues with the screen. The DSW stated that Question 26 should have been answered and that the sending hospital should have been notified to obtain a corrected PASARR screen. The Administrator was interviewed on 7/28/2023 at 11:51 AM and stated that the admission office should ensure all resident's pre-admission documents including the PASARR screen were thoroughly reviewed, and all resident information was completed accurately and appropriately. The Administrator stated that if an issue was identified with the screen, the admission office should request the sending facility to redo the screen. The Administrator stated that both the admission nurse and Resident #143's social worker overlooked the incomplete question which was an error. 10 NYCRR 415.11(e)

Based on observation, record review, and interviews during the Recertification Survey, initiated on 7/19/2023 and completed on 7/28/2023 the facility did not ensure that each resident who needs respiratory care is provided such care consistent with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (Resident #60) of two residents reviewed for Respiratory care. Specifically, Resident #60, with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), had a Physician's Order to administer continuous oxygen at 3 liters per minute via a nasal cannula (tubing used to deliver supplemental oxygen). The resident was observed in the dining room with an empty oxygen tank. The finding is: The Oxygen Concentrator/Oxygen Policy last revised on 1/2023 documented that the facility will utilize oxygen concentrators for residents who require long-term oxygen use unless the use for liquefied oxygen is indicated. The use of concentrators will follow general oxygen use guidelines regarding physician's orders, safety, and infection control. The Oxygen Administration and Maintenance Policy last revised on 1/2023 documented that the Licensed Nursing Staff turns on the [oxygen tank] gauge and adjusts the oxygen flow to the prescribed rate. Resident # 60 was admitted with diagnoses of Dysphagia, Chronic Obstructive Pulmonary Disease (COPD), and Alzheimer's disease. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (MDS) score of 99 which indicated the resident had severely impaired cognition. The resident required extensive assistance of one person for bed mobility and walking in the room and corridor. The resident required limited assistance of one person for transfer, dressing, and personal hygiene. The MDS indicated the resident did not use oxygen. The current Physician's Order dated 3/7/2023 and last renewed on 7/1/2023 documented to administer oxygen via nasal cannula at 3 liters per minute continuously to promote optional lung expansion. The Comprehensive Care Plan (CCP) for Respiratory Disorders: COPD and oxygen use initiated on 1/26/2021 documented interventions to monitor oxygen saturations as ordered and as needed; monitor respiratory status-oxygen saturation, lung sounds, cyanosis (bluish discoloration of the skin due to inadequate oxygen), use of accessory muscles, shortness of breath, and to provide inhalation or nebulizer treatments per physician order. Resident #60 was observed on 7/19/2023 at 12:44 PM in the dining room sitting in the wheelchair at a table. An oxygen tank was observed attached to the back of the resident's wheelchair. The resident was not receiving oxygen. The oxygen tubing was coiled and tucked in between the wheelchair and the oxygen tank. The resident appeared to have difficulty breathing. Licensed Practical Nurse (LPN) #5 was alerted by the surveyor of the resident's condition. LPN #5 checked the resident's oxygen tank and acknowledged that the oxygen tank was empty. The resident's oxygen saturation level was checked by LPN #5 and was measured at 69 percent (%) (normal range 92% and above). The resident was provided a new oxygen tank and oxygen was administered at 3 liters per minute. The resident's oxygen level was 94 % after the supplemental oxygen administration. LPN #5 stated that the resident's oxygen tank was checked in the morning by the resident's CNA. Licensed Practical Nurse (LPN) #5, who was the medication/treatment nurse, was interviewed on 7/25/2023 at 12:50 PM and stated that the Certified Nursing Assistants (CNAs) are responsible to place the oxygen tank and turn on the oxygen for residents who are receiving oxygen via oxygen tanks or concentrators. LPN #5 stated that on 07/19/2023 at 12:44 PM, the resident's oxygen tank was empty and the resident requires continuous oxygen supply. Certified Nursing Assistant (CNA) #2 was interviewed on 7/25/2023 at 2:29 PM and stated they got the resident out of bed around 9:00 AM on 7/19/22023 and turned the resident's oxygen tank on. CNA #2 stated that the oxygen tank was half empty when they first applied the oxygen to Resident #60. CNA #2 stated, Everyone knows turning the oxygen tanks on was the CNAs' responsibility. CNA #2 stated they were not taught how to administer oxygen. They stated they did not put the oxygen tube behind the wheelchair. Registered Nurse (RN) #1, the Nurse Manager, was interviewed on 7/27/2023 at 1:50 PM and stated that it was the Licensed Practical Nurses and RNs' responsibility to turn the oxygen tank on. RN #1 stated everyone is responsible for making sure the oxygen tank is full. The resident's Physician (MD) #2 was interviewed on 7/27/2023 at 2:05 PM and stated that Resident #60 needs continuous oxygen therapy because of the COPD diagnosis. MD #2 further stated it was unsafe for the resident to not receive oxygen therapy continuously. The Director of Nursing Services (DNS) was interviewed on 7/28/2023 at 11:32 AM and stated that Resident #60 needs continuous oxygen as per their physician's orders. The resident could have respiratory distress if adequate oxygen supply is not administered. The DNS stated all staff members were responsible to monitor the oxygen tanks. The DNS further stated the CNAs were allowed to place the oxygen tanks on the wheelchairs but were not allowed to adjust the oxygen because oxygen administration and adjusting the oxygen is the nurses' responsibility. 10 NYCRR 415.12(k)(6)