Every finding on record at Bethel Nursing Home Company Inc

Based on observation and interview the facility failed to ensure that food was stored in accordance with professional standards for safe food handling and storage practice. Specifically, food items stored in the walk-in refrigerator and dry storage room were expired, lacked required date labeling, were left open to air, and an employee's personal lunch bag was stored in a food storage area. The findings include:During an initial kitchen tour observation on 6/15/2026 at 9:26 AM, the dairy walk-in refrigerator had a blue lunch bag stored on a shelf of a food storage rack. There was one open 46- ounce bottle of 100 percent Tomato Juice with a 4/25/2026 received date/ no date indicating when the product was opened, and one opened eight-ounce carton of milk with an expiration date of 5/18/2026. Observation of the dry storage room on 6/15/2026 at 9:57 AM, revealed an opened box of Maypo Cream Farina that was not labeled with the date the package had been opened. During an interview on 6/15/2026 at 10:07 AM, the Food Service Director stated the lunch bag belonged to an employee and should not have been stored in any food service area, but rather in the designated employee break area. The Food Service Director stated that all food and beverage products must be discarded upon reaching the manufacturer's expiration date. The Food Service Director stated that open canned or bottled juice products had a shelf life of five to seven days after opening and must be discarded thereafter. The Food Service Director stated that they were responsible for monitoring food storage, checking expiration dates, and ensuring proper labeling of food products. The Food Service Director stated that all food items must be labeled upon opening with the date the product was opened. 10 New York Code Rules Regulations 415.14 (h)

Based on interview and record review the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and/or that each resident receives adequate supervision to prevent accidents for one of two residents (Resident #1) reviewed for accidents. Specifically, the comprehensive Care Plan did not include interventions to address supervision for Resident #1 who was assessed as at risk for elopement, was able to remove their wander guard and exit the building unsupervised on the morning of 06/22/2025. Additionally, there was no consistent documented evidence that every 15-minute monitoring x 48 hours was implemented as per the comprehensive Care Plan after Resident #1eloped on 06/22/2025. The Findings are:The Policy and Procedure for elopement prevention and follow up procedures last revised 11/22/2022 documented in the staff responsibilities: Staff who are assigned the responsibility of resident care must maintain constant awareness of the whereabouts of the resident(s) assigned to them. All facility staff must be alert to wandering residents and aware of which residents are potential elopement risks at all times.Resident #1 had diagnoses including but not limited to Schizophrenia, mild cognitive impairment, and adult failure to thrive.The Physician Order dated 08/20/2024 documented use wander guard -on right wrist. Check every shift for placement.The Care Plan for risk for elopement dated 08/20/2024 documented new wander-guard system installed. Use wander-guard/location monitor daily. Wander-guard placed on left wrist. Avoid possible triggering events, elopement assessment, provide emotional support and refer to psychologist. There was no documented evidence in the risk for elopement Care Plan to address supervision of Resident #1. The quarterly Minimum Data Set, dated [DATE] documented Resident #1 had moderately impaired cognition, no behaviors, received antipsychotic medications, and had a daily wander/elopement alarm.The 05/13/2025 Elopement Assessment documented Resident #1 was an elopement risk.The Incident and Accident Report dated 06/22/2025 at 07:25 AM signed by Registered Nurse Supervisor # 3 documented during rounds Resident #1 was not in their room, a search was conducted and Resident # 1 was found outside the building. Resident #1 was brought back to the unit, upon assessment no injuries found and resident denies pain. Resident removed the wander guard.The Incident and Accident Statement dated 06/22/2025 written by the Minimum Data Set Nurse documented that during an interview Resident #1 revealed to them that they removed the wander guard and placed it inside the drawer. The resident stated they can't get in the elevator to go down. It further documented that the clip to the wander guard was missing.The Incident and Accident Summary dated 06/22/2025 documented the resident's care plan was reviewed with new interventions implemented when appropriate. It documented the Certified Nurse Aide Accountability Record was revised. The recommendation of Interdisciplinary team concluded the probability that a medical device contributed to this occurrence is due to resident's removal of the wander guard bracelet. It further documented to monitor the care plan schedule and keep the resident in view of staff as much as practicable. The Investigative Summary documented that they ruled out abuse, mistreatment or neglect regarding this incident. It documented the staff should monitor every 15 minutes, advancing to every 30 minutes to 1 hour for 48 hours.The Care Plan for elopement was updated on 06/22/2025 to include Resident #1 was placed on every 15-minute monitoring for 48 hours for safety.The Progress Note documented on 06/22/2025 at 9:37 PM Resident continued every 15-minute safety check, observed both in bed and chair. The Progress Note documented on 06/23/2025 at 3:55 AM continued 15-minute safety check, resident stayed most of the night in their room sleeping in bed. Wander guard in place on their left wrist.The Progress Note documented on 06/24/25 at 6:01 slept quietly all night, easily arousable, cheerful, pleasant, took medication, guard in place, comfortable.During interview on 06/17/2026 at 12:40 PM, Resident #1 Health Care Proxy stated the wander guard was put on shortly after Resident #1 was admitted to facility. They stated the resident was forgetful and would walk out of their own residence. They stated the resident wandered out of facility, last year. They further stated they told Resident #1 they were going to stop by on that day and that may have triggered the resident to look for them outside. They were called by facility to inform them Resident #1 was found in parking lot in the morning a little after 8 AM. The Health Care Proxy stated Resident #1 had a wander guard and somehow, they removed it. The Health Care Proxy stated the wander guard has not been off again since the incident, and it functions properly.During interview on 06/17/2026 at 2:00 PM, the Minimum Data Set Nurse stated they joined in the search after they were alerted by Certified Nurse Aide #6 that Resident #1 was missing. They stated Resident #1 was discovered in the parking lot. They stated that it was the first time Resident #1 eloped. They stated they interviewed Resident #1 and was told they removed the wander guard and placed it in the drawer. They stated when located in the drawer the clip was observed to be broken. They further stated the elevator prevented elopement by not opening when a Resident with a wander guard attempted to enter the elevator. During interview on 06/18/2026 at 11:58 AM, Registered Nurse Supervisor #3 stated on 06/22/2026 they arrived late (07:20 AM) for their shift. They stated as they conducted rounds, they discovered Resident #1 was not in their room. Registered Nurse Supervisor #3 stated they called Registered Nurse Supervisor #13 who worked the night shift and was told Resident #1 was in front of the nursing station at the end of their shift. Registered Nurse #3 stated certified nurse aides performed a building search and Certified Nursing Assistant #6 later reported Resident #1 was discovered in the parking lot, in front of the facility. Registered Nurse Supervisor #3 stated the Health Care Proxy told them Resident #1 may have been triggered to go downstairs to look for them since they told Resident #1, they would be picking them up to take them to the store on that day. During a follow-up interview on 06/18/2026 at 12:45 PM, Registered Nurse Supervisor #3 stated after the elopement Resident #1 was observed frequently during the shift, about every fifteen minutes. During an interview on 6/18/2026 at 1:42 PM the Administrator stated they understood when Resident #1 was found the wander guard was off their wrist because Resident #1 took it off. The Administrator stated they found the wander guard in the drawer, and it was put back on Resident #1. During an interview on 6/18/2026 at 3:40 PM, the Minimum Data Set Nurse stated 15-minute monitoring was put in place right away and may have been ongoing for 2-3 days. They stated the physician was made aware, but they did not feel they needed a physician's order for monitoring They stated they were unsure of the policy. They stated the monitoring was put in place to ensure Resident #1 was in the building and safe. The Minimum Data Set Nurse stated they could not tell if consistent monitoring was done because they did not have the monitoring sheets.10 New York Code Rules and Regulations 415.12(h)(2)

Based on observation, interview, and record review, the facility failed to ensure the resident had the right to a dignified experience for two of two residents (Residents # 26 and # 7) reviewed for dignity. Specifically, 1. Residents #30, and Resident #25 received and were eating their lunch, while Resident # 26 who was seated at the same table waited 20 minutes for their lunch to be served and 2. Certified Nurse Aide #1 stood and was not at eye level while feeding Resident # 7. The findings include: The policy titled Assistance with Meals, dated 05/2026, documented that residents shall receive assistance with meals in a manner that meets the individual needs of each resident in a dignified manner. Residents who cannot feed themselves will be assisted to eat with attention to safety, comfort, and dignity; for example, staff should not stand over residents while assisting them with meals. All residents at the same table will be served at the same time. The food services department will deliver food carts to appropriate areas or serve them from steam tables in the dining room when available. 1.Resident #26 had diagnoses including diabetes mellitus, hypertension, and cerebral infarction (brain injury). The 05/15/2026 quarterly Minimum Data Set (an assessment tool) documented that Resident #26 had severe cognitive impairment and required set-up or clean-up assistance with eating. During an observation on 06/15/2026 at 12:27 PM, Resident #30 received a lunch tray at 12:28 PM and completed their lunch at 12:43 PM. Resident #25 received a lunch tray at 12:31 PM and completed their lunch at 12:41 PM. Resident #26 who was seated at the same table did not receive a lunch tray until 12:49 PM. During an interview on 06/15/2026 at 12:45 PM, Certified Nurse Aide #4 Resident #26 did not receive their lunch tray because their hamburger was not on the food truck. Certified Nurse Aide #4 stated when they told the dietitian, the dietitian called the kitchen to have staff bring up Resident 26's hamburger. During an interview on 06/15/2026 at 12:51 PM, [NAME] #1 stated they received a call from the dining room regarding Resident #26, who had not received their lunch. [NAME] #1 stated they then prepared a hamburger and sent it to the dining room for Resident #26 During an interview on 06/15/2026 at 1:05 PM, the Registered Dietitian stated that all residents at a table were supposed to be served their meals at the same time. The Registered Dietitian stated it was not acceptable for Resident #26 to wait for their tray and believed the aide had told Resident #26 they were waiting for the kitchen staff to bring the hamburger. The Registered Dietician stated they called the kitchen to request Resident #26's hamburger. During an interview on 06/18/2026 at 8:35 AM, the Dining Services Director stated that Resident #26's hamburger should have been placed on the steam table and ready for Resident #26 at lunchtime. The Dining Services Director stated they missed sending the hamburger up on the steam table, so the staff had to call the kitchen. They stated after receiving the call, the kitchen staff prepared the hamburger for Resident #26. 2. Resident #7 was admitted with diagnoses that included unspecified dementia, adult failure to thrive, and anxiety disorder. The 03/24/2026 Minimum Data Set documented Resident #7 had severely impaired cognitive skills for daily decision making and required substantial/maximal assistance with eating. During an observation and interview on 06/16/2026 between 8:33 AM Certified Nurse Aide #1 was standing while feeding Resident #7. Certified Nurse Aide #1 was not at eye level with Resident #7. Certified Nurse Aide #1 stated they received in-service on feeding residents. Certified Nurse Aide #1 stated they were aware they should have sat down when feeding Resident #7. During an interview on 06/16/2026 at 8:38 AM Registered Nurse Supervisor #2 stated certified nurse aides should not be standing when they were feeding residents. 10 New York Codes Regulations and Rules 415.3(d)(1)(i)

Based on record review and interview, the facility failed to ensure certified nurse aide performance reviews were completed at least once every 12 months. Specifically, two of six certified nurse aides (Certified Nurse Aide #4 and #10) reviewed for staffing did not have an annual performance review documented. Subsequently, there was no documented evidence of tailored outcomes based on performance review. The findings include:The policy titled Performance Review, dated 07/01/2025, documented that employees were evaluated on their job performance annually on or about their anniversary date of employment. The department head had to forward the original performance review to Human Resources.There was no documented evidence of an annual performance review for Certified Nurse Aide #4 who had been hired on 06/01/2005, and Certified Nurse Aide #10 who had been hired on 04/22/1998.There was no documented evidence that each certified nurse aide received in-service education based on an individual performance review. During an interview on 06/17/2026 at 2:08 PM, Certified Nurse Aide #4 stated they had completed their yearly mandatory in-services. They stated the last time they had a performance evaluation done was about a year ago. They stated they did not sign the evaluation.During an interview on 06/18/2026 at 8:18 AM, Registered Nurse Supervisor #2 stated they were not responsible for certified nurse aide annual performance evaluations. They stated in the past; the regular staff supervisor was responsible for completing the certified nurse aide performance evaluations. They stated they were due.During an interview on 06/18/2026 at 9:35 AM, the interim Director of Nursing stated that the certified nurse aide performance improvement reviews were to be conducted on their anniversary or hire date. They stated they could not locate 2026 performance reviews. 10 New York Codes Regulations Rules 415.26 (c) (2) (iii)

Based on observation, interview, and record review the facility failed to ensure that an injury of unknown origin was reported to the State Agency immediately, but not later than two hours for one of two residents (Resident #6) reviewed for injury of unknown origin. Specifically, on 08-30-2025 Resident #6 was transferred to the hospital after they complained of right hip pain with right leg swelling and abduction of the right knee. On 08-31-2025 at 2:26 AM the facility was made aware that Resident #6 was diagnosed with a right hip fracture. The State Agency was not notified until 09-01-2025 at 1:19 PM. The findings include: Resident #6 had diagnoses including dementia, osteoporosis, and anxiety. The quarterly Minimum Data Set (assessment tool) dated 06-27-2025 documented Resident #6 had severe cognitive impairment and was dependent on staff for daily living activities. The Incident Report dated 08-30-2025 at 9:30 PM documented Resident #6 complained of right hip pain while being repositioned in a wheelchair and continued to complain of pain. The report documented that the resident was guarding the right hip, and the physician was notified. An order was obtained for radiographic imaging of the right hip to rule out a fracture. The resident was later observed with swelling of the right thigh and the right knee adducted (turned inward toward the body). The physician was notified and ordered transfer to the hospital for further evaluation. The investigation revealed no evidence to support abuse. The Nursing Progress Note dated 08-31-2025 at 2:26 AM documented that the resident was admitted to the hospital with a right hip fracture. The Incident Report submitted to the State Agency on 09-01-2025 at 1:19 PM documented that the allegation type was injury of unknown source. The report documented. Resident #6 complained of pain during the day shift. Acetaminophen was administered, and the physician was notified. The report documented radiographic imaging was ordered. During the evening shift, the resident continued to complain of pain. The physician was notified again and ordered transfer to the hospital for further evaluation. The report documented follow-up communication with the hospital, which confirmed the resident sustained a right distal femur fracture. During an interview on 06-18-2026 at 9:37 AM, the Administrator stated that the facility received notification from the hospital on [DATE] at 2:26 AM that Resident #6 had sustained a fracture. The Administrator stated they were responsible for reporting incidents to the State Agency. The Administrator stated the incident was not reported within the required two-hour timeframe. They stated the report submitted on 09-01-2025 at 1:19 PM was late. 10 New York Code Rules Regulations 415.4(b)(2)

Based on observation, interview, and record review, the facility failed to ensure the comprehensive Care Plan was revised for one of three residents (Resident #48) reviewed for closed records. Specifically, the comprehensive Care Plan was not updated on 04-27-2026 to reflect a change in Resident #48's advanced directive status from Full Code to Do Not Resuscitate and Do Not Intubate. The findings included: The policy and procedure titled Do Not Resuscitate and Advance Directives, last reviewed 11-2025, documented the Social Worker, Director of Social Services, or designee would periodically audit residents' medical records for accuracy of Do Not Resuscitate orders and supporting documentation. The policy and procedure titled Resident Assessment and Comprehensive Care Planning, last reviewed 02-17-2021, documented the comprehensive care plan was subject to periodic review and revision as necessary. Resident #48 had diagnoses including malignant neoplasm of the lower lobe of the left bronchus or lung, chronic pain, and anxiety disorder. The comprehensive Care Plan dated 04-14-2026 documented that the residents' healthcare wishes were to be respected and identified as Full Code. Interventions included assisting with completing required forms in accordance with facility policy and procedure, educating the resident representative on advanced directives, and providing support with healthcare decision-making. The admission Minimum Data Set (assessment tool) dated 04-22-2026 documented Resident #48 had intact cognition. The Medical Orders for Life-Sustaining Treatment form dated 04-27-2026 documented Resident #48 elected Do Not Resuscitate and Do Not Intubate status. The resident signed the Medical Orders for Life-Sustaining Treatment form. The Physician Order dated 04-27-2026 documented Do Not Resuscitate, Do Not Intubate, and comfort measures. There was no documented evidence that the comprehensive Care Plan was revised to reflect that Resident #48 was Do Not Resuscitate, Do Not Intubate, and comfort measures only. During an interview with the Acting Director of Nursing on 06-17-2026 at 11:00 AM, they stated the comprehensive Care Plan was not updated following the change in the resident's advance directive status. They stated the Social Worker was responsible for updating the comprehensive Care Plan following changes in advance directives. During an interview with the Director of Social Worker on 06-18-2026 at 11:01 AM, they stated residents were asked about resuscitation preferences upon admission. They stated Resident #48 elected Full Code status upon admission. The Social Worker stated on 04-27-2026, the day before the resident's death, the resident and family elected to change the resident's status to Do Not Resuscitate and Do Not Intubate. They stated a Medical Order for Life-Sustaining Treatment form was completed, signed by the resident, witnessed by the Social Worker and Administrator, and implemented. The Social Worker stated the comprehensive Care Plan was not revised to reflect the resident's change in resuscitation preferences and stated it should have been updated to reflect Do Not Resuscitate/Do Not Intubate status. 10 New York Code Rules Regulations 415.11(c)(2)

Based on record review and interview the facility failed to ensure that a thorough and/or accurate investigation was conducted for one of one resident (Resident #51) reviewed for abuse. Specifically, the Investigative Summary statement from Registered Nurse Supervisor #11 documented the wrong incident date and incorrect initials for Certified Nurse Aide #4 after Resident #51 called 911 on 05/01/2026 and accused staff of abuse.The findings include:The policy titled Abuse Prevention and Reporting last reviewed 3/2026 documented that any employee or volunteer that suspects hears about or witness's resident abuse, neglect or misappropriation of resident's property must complete an Accident/Incident Report.Resident #51 was admitted to facility with diagnoses of vascular dementia, anxiety and depression. The 4/29/2026 Baseline Care Plan for behavior documented that the resident had a history of trauma. Assist of one for bowel and bladder care, assist of one for transfer.The 5-day Minimum Data Set (an assessment tool) dated 5/01/2026, documented that Resident #51 had intact cognition, and required substantial to maximal assist for toileting and transfer. The undated and unsigned Investigative Summary documented incident occurred 04/30/2026. On 04/30/2026 at approximately 4 PM the assigned Certified Nurse Aide #4 saw Resident #51 inside another resident room wheeling towards the bed. A resident in that room was also assigned to the same aide as Resident #51. The aide explained that this was not Resident #51's room and the resident became upset when the aide attempted to help Resident #51 to return to their room. On 05/01/2026 at 9:30 AM it was reported to the Administrator and Minimum Data Set Coordinator that the resident called 911 (police) accusing staff of abuse. Two police officers arrived at approximately 9:30 AM and talked to the resident. According to the Registered Nurse Supervisor, police stated that the resident was not able to state as to when, who and how abuse occurred so the two police officers left. The Administrator called the Registered Nurse Supervisor at approximately 7:15 AM and asked they not assign the same aide that the resident had on 04/30/2026 due to allegations and until an investigation was completed. The Conclusion documented Resident #51 was noted to have intermittent confusion and noted to have emotional lability thus showing on and off agitation and refusal of care which is most likely secondary to her diagnosis of Alzheimer's and vascular dementia. Resident somehow wheeled themself to room thinking it was their room which is in the exact same placement of their room but in a different hallway. The resident became upset when the aide explained about the room to them. The resident may have interpreted it as the aide not wanting to care for resident. The smell of feces was only evident when the occupational therapist was talking to Resident #51, and they agreed to be toileted Allegation of abuse was not substantiated. Registered Nurse Supervisor #11 statement documented the wrong incident date (04/03/2026) and incorrect initials for Certified Nurse Aide #4.During an interview on 06/17/2026 at 11:31 AM, The Interim Director of Nursing stated that it was the responsibility of the Administrator and Director of Nursing to review Accident/Incident Summaries and ensure they were accurate. They further stated when the Administrator and Interim Director of Nursing reviewed Registered Nurse Supervisor #11's statement, they must have overlooked the errors.During an interview on 6/18/2026 at 11:27 AM, The Administrator stated it was the responsibility of the Director of Nursing and Administrator to review the Investigative Summary for accuracy. 10 New [NAME] Code Rules and Regulations 415.3(b)(1-8)

Based on record review and interview, the facility failed to ensure quarterly Minimum Data Set assessments were completed within the required 14 calendar days following the Assessment Reference Date and electronically encoded and transmitted to the Centers for Medicare and Medicaid Services within the required time frames for five of five residents (Residents #5, #15, #27, #32, and #42) reviewed for Minimum Data Set assessments. Specifically, quarterly Minimum Data Set assessments for Residents #5, #15, #27, #32, and #42 were not completed and submitted within 14 calendar days following the Assessment Reference Date. The findings included: The policy and procedure titled MDS 3.0 last revised 11-18-2013, documented the Interdisciplinary Team completed Minimum Data Set assessments for residents on admission, quarterly, annually, and following a significant change in condition. The policy further documented that the Minimum Data Set Coordinator was responsible for scheduling and oversight of the completion of the Minimum Data Set process. The policy also documented that designated sections of the Minimum Data Set were completed according to the time frames established by the Minimum Data Set Coordinator. Resident #27's quarterly Minimum Data Set assessment had an Assessment Reference Date of 05-01-2026.The assessment was completed on 06-15-2026. There was no documented evidence that the assessment was submitted to the Centers for Medicare and Medicaid Services before 06-17-2026. Resident #32's quarterly Minimum Data Set assessment had an Assessment Reference Date of 05-01-2026.The assessment was completed on 06-15-2026. There was no documented evidence that the assessment was submitted to the Centers for Medicare and Medicaid Services before 06-17-2026. Resident #5's quarterly Minimum Data Set assessment had an Assessment Reference Date of 05-08-2026. The assessment was completed on 06-15-2026. There was no documented evidence that the assessment was submitted to the Centers for Medicare and Medicaid Services before 06-17-2026. Resident #15's quarterly Minimum Data Set assessment had an Assessment Reference Date of 05-08-2026. The assessment was completed on 06-15-2026. There was no documented evidence that the assessment was submitted to the Centers for Medicare and Medicaid Services before 06-17-2026. Resident #42's quarterly Minimum Data Set assessment had an Assessment Reference Date of 05-08-2026. The assessment was completed on 06-15-2026. There was no documented evidence that the assessment was submitted to the Centers for Medicare and Medicaid Services before 06-17-2026. During an interview on 06-17-2026 at 12:30 PM, the Acting Director of Nursing and Corporate Minimum Data Set Coordinator stated that the five quarterly Minimum Data Set assessments had not been submitted promptly. They stated they are responsible for ensuring timely electronic encoding and submission of Minimum Data Set assessments. They further stated the assessments would be submitted immediately. During an interview on 06-18-2026 at 1:53 PM, the Minimum Data Set Nurse stated the five quarterly Minimum Data Set assessments were completed late on 06-15-2026. They further stated the Corporate Minimum Data Set Coordinator was responsible for electronically encoding and transmitting the assessments to the Centers for Medicare and Medicaid Services. 10 New York Codes, Rules and Regulations 415.11

Based on staff interview and review of facility documents, it was determined that, the facility did not ensure each certified nurse aide received twelve hours in-service education per year based on their individual performance review. Specifically, (1) 4 out of 5 certified nurse aides did not have their mandatory annual 12 hour in services and (2) 5 out of 5 certified nurse aides (#2,6, 7, 8, 9) did not receive performance evaluations. Finding Include: Review of facility training records revealed: Certified Nurse Aide # 2 was hired on 2/28/2011 and received 10.25 hours of in-services in the last 12 months and had no documented evidence of an annual performance review. Certified Nurse Aide # 6 was hired on 12/17/2007and received 0 hours of in-services in the last 12 months and had no documented evidence of an annual performance review. Certified Nurse Aide # 7 was hired 8/23/1995, received 16 hours of in-services in the last 12 months, and had no documented evidence of an annual performance review. Certified Nurse Aide # 8 was hired 4/22/1998, received 10.5 hours of in-services in the last 12 months, and had no documented evidence of an annual performance review. Certified Nurse Aide # 9 was hired 7/20/2009, received 3 hours of in-services in the last 12 months, and had no documented evidence of an annual performance review. On 3/20/25 at 11:38 AM, the Certified Nurse Aide Mandatory 12 hours In-service and the Certified Nurse Aide performance evaluations were requested from the Director of Nursing. The Director of Nursing stated when they started working, they were just working on hiring Certified Nurse Aides and Licensed Practical Nurses and had not done any performance evaluations. On 3/20/25 at 12:07 PM, during an interview with the Director of Nursing, they stated they did not have any performance evaluations completed for the sampled selection of certified nurse aides. On 3/21/25 at 12:09 PM, during an interview with the Administrator, they stated they were not aware the certified nurse aide performance evaluations were not being done. 03/21/25 at 2:21 PM, during an interview with the Director of Nursing, they stated when they were gathering the in-services and calculating the hours for the 5 certified nurse aides, they realized 4 out of 5 certified nurse aides did not meet the mandatory 12 hours of annual in-servicing. 10NYCRR 415.26 (d) (7) .

Based on observations and interviews conducted during the recertification survey from [DATE] to [DATE], the facility did not store, distribute and serve food in accordance with professional standards for food service safety and did not maintain dishwasher heat for sanitation. Specifically, 1) expired foods were stored in dry pantry, walk in refrigerator and freezer; 2) unsealed, unlabeled and undated food were stored in dry pantry and walk in refrigerator; 3) the dishwasher wash and rinse did not maintain proper temperature standards; and 4) three (3) staff were observed not performing proper hand hygiene while serving the lunch meal. Findings include: The facility policy last revised ,d+[DATE], Labeling and Dating stated any unopened food item will be discarded by the manufacturer labeled expiration date and all prepared menu items will be dated in compliance of a 3 day use by date. The facility policy last reviewed ,d+[DATE], Food Storage stated contents of opened food packages will be stored in tightly sealed containers and all containers will be properly labeled as to contents. The facility policy reviewed ,d+[DATE], Dish Machine Temperature Log included documentation of acceptable wash temperature should not fall below 150 degrees F and rinse temperatures not below 180 degrees F. The facility policy reviewed,d+[DATE], Proper Hand Sanitation stated employees must also thoroughly wash their hands after touching their body and after coming in contact with residents. Employees must always change gloves before beginning a different task and as soon as they become soiled. 1) During the initial tour of the kitchen on [DATE] at 9:24 AM with Dietary Staff #1 and Food Service Director it was observed in the pantry five bags of marshmallows with expiration date of [DATE], in the refrigerator an opened jar of clam base with expiration of ,d+[DATE], a case of individual frozen chicken pot pies in the freezer with expiration date of ,d+[DATE], and in the basement panty a jar of Maraschino cherries with expiration date of ,d+[DATE]. The Food Service Director stated they did not use the maraschino cherries; they had been left by previous Food Service Director. Dietary Staff #1 disposed of all expired items. 2) On the same tour an unlabeled, undated plastic container of chunks of chicken was found inside a box on the top shelf of the pantry. Dietary Staff #1 stated it was chicken from last evenings dinner and a diet aide probably placed it there to eat later and left it by mistake. Opened bags of cornbread stuffing (spilling out of bag and onto crate), biscuit mix, and dried pasta were observed in the pantry not sealed and not labeled. Individual cups of applesauce, pudding and salads were stored in the refrigerator with no date. The Food Service Director stated the items were to be used at lunch or by the end of day and stated they knew they needed to label the items. 3) During an observation on [DATE] at 10:18 AM, wash temperature on the dish machine was 148 degrees F and the rinse temperature was 150 degrees F. When interviewed at the time of observation, the Food Service Director stated the dishwasher was working fine earlier. Temperature logs were reviewed with the Food Service Director, and documented temperatures within the normal range. They stated if dish machine continued to not work properly, they would call the service company to repair if needed. During an observation on [DATE] at 10:14 AM the dish machine wash temperature was not at temperature (148 degrees) and the rinse temperature was (154 degrees), not at temperature guidelines. When interviewed at the time of observation, the Regional Food Service Director stated they would switch to chemical sanitizer until it could be fixed. During an interview on [DATE] at 12:35 PM, the Regional Food Service Manager stated the heat booster in dish machine had been condemned by the service company and dish machine was switched to chemical sanitizer. 4) During a lunch meal observation in the dining room on [DATE] at 12:39 PM, the Food Service Director served multiple residents' plates of food while wearing disposable gloves. While wearing the disposable gloves they touched Resident #11 shoulder, scratched their own neck, held food cart handle to move cart, and loaded Resident #9 meal to cart to take to their room. At 12:51 PM Food Service Director removed disposable gloves to make a phone call and continued to serve residents' plates of food and did not use hand sanitizer. During an interview on [DATE] at 2:45 PM the Food Service Director stated she thought she was supposed to wear the disposable gloves when passing plates of food at meals. During an observation on [DATE] at 12:25 PM, Certified Nurse Aide #1 touched Resident #33's legs multiple times to adjust them in their recliner chair. Certified Nurse Aide #1 then went into kitchenette to pour cups of hot beverages, touched the handles of cups, and loaded a cart with meal trays to take to the residents eating in their rooms. They did not use hand sanitizer between touching Resident #33 legs and completing the other tasks. During an interview on [DATE] at 12:27 PM Certified Nurse Aide #1 stated she was in a hurry to assemble the trays and forgot to use hand sanitizer. During an observation on [DATE] at 12:28 PM, Certified Nurse Aide #2 used their thumb and fore finger to pull up their face mask to cover their nose and then held Resident #5's hand and placed a fork in the resident's hand. Certified Nurse Aide #2 continued to deliver lunch meals to three other residents and then assist Resident #15 with feeding. Certified Nurse Aide #2 did not use hand sanitizer during these tasks. On [DATE] at 1:43 PM the Director of Nursing was interviewed and stated staff was to sanitize their hands whenever they switch tasks. 10 NYCRR 415.14(h)

Based on observation, record review and interview conducted during a Recertification survey from 3/18/25 to 3/21/25, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infection for all residents. Specifically, the facility did not provide documentation of screening, administration or declination and education provided for 10 of 10 staff (Certified Nurse Aide #1, #2, #4, Licensed Practical Nurse #1, Registered Nurse Supervisor #1, Dietary Aide #3, Director of Environmental Services, Director of Housekeeping, Physical Therapist #1 and Housekeeping Aide #1), reviewed for COVID vaccination. The findings are: The facility COVID policy dated 12/24/20 documents newly hired staff will be asked to provide COVID vaccination information as part of their Human Resources medical record as they do with other vaccines. If they are unvaccinated, or not up to date, they will be provided education on COVID19 and offered the COVID vaccine. During the recertification survey the facility was asked to provide documentation that COVID vaccination was offered, education was provided, and staff had the opportunity to consent or decline the vaccine for Certified Nurse Aide #1, #2, #4, Licensed Practical Nurse #1, Registered Nurse Supervisor #1, Dietary Aide #3, Director of Environmental Services, Director of Housekeeping, Physical Therapist #1 and Housekeeping Aide #1 but none was provided. During an interview with the Infection Preventionist on 03/20/25 at 01:36 PM they stated the facility had not been offering the COVID vaccination to staff and did not give a reason as to why it had not been done. During an interview with the Director of Nursing on 03/20/25 at 01:53 PM they stated they had been at the facility for a few months and COVID vaccinations had not been offered to staff to her knowledge. The Director of Nursing stated they did not know why it was not being offered to staff but it was important and should have been done. 10NYCRR 415.19 (a)(1-3)

Based on observation, record review and interview conducted during a recertification survey from 3/18/25 to 3/21/25, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infection for all residents. Specifically, the facility did not provide documentation of screening, administration, or declination and education provided for 5 of 10 staff (Certified Nurse Aide #1 and #4, Licensed Practical Nurse #1, Registered Nurse Supervisor #1, Dietary Aide #3) reviewed for influenza and 10 of 10 staff (Certified Nurse Aide #1, #2, #4, Licensed Practical Nurse #1, Registered Nurse Supervisor #1, Dietary Aide #3, Director of Environmental Services, Director of Housekeeping, Physical Therapist #1 and Housekeeping Aide #1) reviewed for pneumococcal vaccination. The findings are: The facility policy titled Prevention, Early Detection and Control of Influenza dated 6/2023 documents the purpose is to control the spread of respiratory infections which includes a preventative vaccination program. All staff members will be offered the influenza vaccine on an annual basis. A master line listing of all residents and staff is to be maintained for all influenza vaccinations administered. The facility did not provide a Pneumococcal Vaccination Policy. During the recertification survey the facility was asked to provide documentation that influenza vaccination was offered, education was provided, and staff had the opportunity to consent or decline the vaccine for Certified Nurse Aide #1 and #4, Licensed Practical Nurse #1, Registered Nurse Supervisor #1, Dietary Aide #3 but none was provided. In addition, the facility was asked to provide documentation that pneumococcal vaccination was offered, education was provided, and staff had the opportunity to consent or decline the vaccine for (Certified Nurse Aide #1, #2, #4, Licensed Practical Nurse #1, Registered Nurse Supervisor #1, Dietary Aide #3, Director of Environmental Services, Director of Housekeeping, Physical Therapist #1 and Housekeeping Aide #1 but none was provided. During an interview on 03/20/25 at 01:36 PM with the Infection Preventionist they stated they are the Preventionist for a few facilities and forwards consents and declinations to Human Resources when they obtain them from staff. The Infection Preventionist stated they have not been keeping a list of which staff has consented and received the influenza vaccination and who has declined. In addition, they stated they have not been offering or keeping track of pneumococcal vaccination for staff. If staff had the vaccine, then fine but not offering it or educating staff. During an interview with the Director of Nursing on 03/20/25 at 01:18 PM they stated vaccine information is sent to the Human Resources offsite for the new hires. They do not get pneumococcal status and has not been keeping track of vaccines since they started at the facility two months ago but stated it was important and was aware it should be done. 10NYCRR 415.19 (a)(1-3) 51902

Based on observation, record review, and interview during the recertification survey the facility did not maintain drugs and biologicals, labeled in accordance with currently accepted professional standards, and include the appropriate accessory and cautionary standards, and expiration dates for 1 of 1 medication storage room (located on the second floor) reviewed. Specifically, the medication storage room (located on second floor) had expired drugs and biologicals that were available and ready for use. The findings include: The facility policy on Storage of Medications last revised 12/2023 documented discontinued, contaminated or deteriorated medications are removed from the medication/treatment storage area and disposed of per facility policy. On 03/19/25 at 10:03 AM, the Second-Floor Short term and Long term Medication Storage Room was observed with expired medicine and products including the following: -2 boxes omeprazole, one box had 3 bottles in it with a total 42 pills and the second box had 2 bottles in it with a total of 28 pills and both boxes expired 2/2024. -3 boxes Assure Platinum (50 ct) strips expired 5/4/2024. -2 boxes Assure Prism Control Solution Blood Glucose Monitoring Expired 10/2023. -1 box curos needless connectors (270 caps) expired 8/2024. -1 box bisacodyl (box of 100) suppositories expired 6/2024. -BD Insyte Autoguard needle lot6253728 exp 8/31/2019. -BD Insyte Autoguard winged needle lot1133998 expired 4/30/2024. -BD Insyte Autoguard needle lot 6169783 exp 5/31/2019. -BD Insyte Autoguard needle lot 9305162 exp 10/31/2022. -BD Insyte Autoguard needle lot 1090022 exp 3/31/2024. -Foley 2 way stabilization lot JUCXF054 expired 9/28/2021. -Kangaroo e pump ENplus Spike Set Lot 200480120 expired 1/31/2023. On 3/19/25 at 10:05 AM during an interview, Registered Nurse Unit Manager #1 stated they must have only checked the carts and not the med storage room. On 3/19/25 at 12:34 PM during an interview, Licensed Practical Nurse #1 stated they gave out medication to the residents and also checked the medication storage room for expired medications and other products. Licensed Practical Nurse #1 stated they checked for expired medications on the top shelf and did not check the 2 storage bins with drawers where the expired items were located. On 3/21/25 at 10:00 AM during an interview, Registered Nurse Unit Manager #1 stated the med storage room was audited on Mondays on the night shift. Registered Nurse Unit Manager #1 stated Licensed Practical Nurse #1 may check their cart and the room as a standard, but it was the night shift's role to check the medication room and carts for expired medications and products. 10 NYCRR 415.18(e)(1-4)

Based on observations, record review, and interviews during the recertification survey from 03/18/25 to 03/21/25, the facility did not ensure a medication error rate of no more than 5%, during a medication administration observation, when 3 of 35 opportunities (8.57%) resulted in error for 1 of 3 residents (Resident #19). Specifically, Resident #19 1) was administered a crushed form of Carbodopa50mg-Levodopa 200mg-entacapone, a crushed form of Acidophilus Probiotic 35 million cell tablet, and 2) an inaccurate dose of Metamucil powder. The findings are: Resident #19 was admitted to the facility with diagnoses including but not limited to Parkinson's disease, heart failure and hypertension. The Minimum Data Set (an assessment tool) dated 3/1/25 documented the resident had severe cognitive impairment, was dependent on staff for all activities of daily living and was prescribed a mechanical diet. 1)The current physician orders as of 3/18/25 documented Carbodopa50mg-Levodopa-entacapone oral tablet, give one tablet by mouth two times a day for Parkinson's disease and Acidophilus 35million cell tablet 1 tablet by mouth one time daily. There were no orders to crush to crush any medications prior to administering medications. The current physician order as of 3/18/25 documented puree diet with thickened liquids-nectar thick. During a medication administration observation on 03/18/25 at 10:05 AM, Licensed Practical Nurse #1 was observed crushing Resident #19 Carbodopa50mg-Levodopa-entacapone oral tablet, and Acidophilus 35million cell tablet prior to mixing the medication with applesauce and was about to administer to Resident #19. The blister pack for the Carbidopa-Levodopa-entacapone and the Acidophilus contained a yellow, white and orange sticker which documented, swallow tablet whole. Do not chew, break or crush. During an interview on 03/18/25 at 11:59 AM, Licensed Practical Nurse #1 stated the resident always took their medicine crushed because it was the only way they could get the resident to take their medications, as they could not swallow pills. They stated the saw the label noted do not crushed but crushed anyway and did not inquire if another form was available. During an interview on 03/19/25 at 3:56 PM, Registered Nurse Unit Manager #1 stated the resident did not have an order for crushed medications. They stated if a resident had their extended-release medications crushed the resident would get a larger dose of the medication all at once. During an interview on 03/19/25 at 10:41 AM, Physician #1 stated nurses should always follow and give medications according to the manufacturer guidelines. If the direction said do not crush, then a question should have been asked. 2) Resident #19's current physician orders as of 3/18/25 documented Metamucil 3.4gm/5.4gm oral powder, administer 1 tablespoon daily. During the medication administration observation on 3/18/25 at 10:05 AM Licensed Practical Nurse #1 used an eating utensil spoon to remove the Metamucil from the container and put it in a cup. A tool that measured a tablespoon was not used by the nurse to measure before putting it in the cup. During an interview with Licensed Practical Nurse #1 on 3/18/25 at 10:35 AM they were asked how they ensure the resident was getting the correct dose of Metamucil if they were not using a measuring spoon. They stated they looked in the canister, and it appeared there was none, so they used a regular spoon. During an interview with the Registered Nurse Unit Manager #1 on 03/19/25 at 10:52 AM they stated nurses always needed to measure accurately to make sure the resident was getting the right dose. They stated a new canister of Metamucil should have been ordered and measuring with a regular teaspoon was not accurate. 10NYCRR 415.12(m)(1)

Based on observation, record review and interviews during a recertification survey conducted from 3/18/25 to 3/21/25, the facility did not ensure the provision of nutrition and hydration care and services for 1 of 3 residents reviewed for Nutrition (Resident #5). Specifically, Resident #5 had a 6.3% weight loss over 1 month, and meal intake was not consistently monitored, and the resident was not encouraged with meal and fluid intake as planned. Findings include: The policy and procedure titled L.T.C. Evaluation of Changes Intake revised on January 2004 documented all staff members observe resident intake on a regular basis to evaluate change in resident food intake. Meal consumption is recorded by the Certified Nurse Aides daily for all residents in the Certified Nurse Aide Accountability Book. Nursing staff notifies the Food and Nutrition Services Department if a resident has consumed less than 75% of meals over a two-day period. The Resident #5 had diagnoses including diabetes mellitus, depression, and hemiplegia/hemiparesis following a cerebral infarction (stroke). The 2/11/25 Quarterly Nutritional Assessment documented Resident #5's appetite varied and average intake percent of meals was 25-75%. The resident triggered for a unplanned significant weight loss of 6.3% for 1 month. Recommendations included to add Glucerna twice a day for nutrition support, provide necessary assistance at mealtime and between meals, encourage oral meal and fluid intake, monitor oral intake of foods and fluids. The Minimum Data Set Quarterly assessment dated [DATE] documented the resident had severely impaired cognition and needed set-up assistance with eating. The 2/17/25 nutrition alteration care plan documented interventions included to monitor resident's daily intake, provide assistance during meals, encourage good meal and fluid intake, and offer specific food choices. During observation on 03/18/25 at 10:21 AM Resident #5 was in bed and stated that they did not eat breakfast, and they were hungry. During observation on 03/18/25 at 12:21 PM, the staff brought Resident #5 to the dining room for lunch and set up the meal tray in front of them. The resident ate a few bites of the main course and a small piece of desert with a cup of coffee. The staff did not provide assistance with the meal or encouraged the resident to eat. During observation on 03/21/25 at 12:35 PM the staff brought the Resident #5 to the dining room for lunch and set up the meal tray. The resident slowly started to eat, taking long pauses between bites. The resident ate about 50 % of the lunch. The staff did not provide assistance with the meal or encouraged the resident to eat. The review of Activities of Daily Living Verification Worksheet revealed documentation of the resident's food intake: on 3/18/25 the breakfast intake 100% and lunch 100%; on 3/19/25 the breakfast intake 50% and lunch 25%; on 3/20/25 the breakfast intake 50% and lunch 0%; on 3/21/25 the breakfast intake 50% and lunch 50%. During an interview on 03/21/25 at 1:20 PM, Certified Nurse Aide #2 stated that sometimes they assisted the resident with their meal. Certified Nurse Aide #2 stated that they did not know how the resident's appetite was or if the resident had a recent weight loss. They said when a resident did not eat at all, they reported it to the nurse. Certified Nurse Aide #2 stated on 3/18/25 the resident did not eat breakfast, and they told the nurse. They said the resident ate less than 50% during lunch time on the same day, and they were not aware of care plan interventions to encourage the resident with meal and fluid intake. The Certified Nurse Aide #2 could not explain why they documented 100% food intake for breakfast and lunch on 3/18/25. During an interview on 03/21/25 at 01:29 PM, Licensed Practical Nurse #1 stated Resident #5 always ate well, and they were not aware of any recent weight loss. They stated when the resident did not eat well or at all, the Certified Nurse Aide would report it to the nurse and nurse would contact the physician. Licensed Practical Nurse #1 stated that they encouraged the residents to eat during mealtime if they saw a resident not eating well. Licensed Practical Nurse #1 stated that they were not aware the resident ate 50% of breakfast and 25% of lunch meal on 3/19/25. During an interview on 03/21/25 at 1:37 PM, Registered Nurse #1 stated the Certified Nurse Aides document the amount of food residents consumed during a mealtime in Certified Nurse Aide Accountability Record. Certified Nurse Aides did not have specific assignment to assist specific residents during meals. 10NYCRR 415.12(i)(1)

Based on observation, interview, and record review conducted during the recertification survey from 3/18/25 to 3/21/25, the facility did not ensure residents were provided supervision to prevent accidents for 1 (Resident #33) of 2 residents reviewed for accidents. Specifically, Resident #33 was at risk for aspiration and was not provided supervision or assistance by facility staff during meals. The resident was observed being fed by an unqualified companion aide. The findings are: The facility policy titled Routine Resident Care, dated October 3, 2001, documented residents are given routine daily care by a Certified Nurse Assistant under the supervision of a Licensed Nurse. Routine care by a nursing assistant includes the following: assisting resident in personal care, bathing, dressing, eating and encouraging participation in physical, social, and recreational activities. Observing and recording all aspects of personal care including bathing, food intake, ambulation activities, elimination and vital signs on the Certified Nurse Assistant Accountability Sheet. The facility policy titled, Companion Policy, revised 10/24, documented the facility was to permit the use of Companions hired by a resident's family member or designated representative for specific needs of a resident for companionship or support. Companions are not permitted to give care to any resident within the Home's property. If a Companion does not comply or violates facility policies and procedures, the family or designated representative will be contacted and informed that the companion cannot return. The Companion responsibility included to socialize and converse with the resident, offer reality orientation, offer assurance, assist with hair grooming and applying makeup. Report any changes in resident's condition or any concerns regarding resident's condition to nurse. Push the resident's wheelchair or Geri chair. Resident #33 had diagnoses including metabolic encephalopathy, altered mental status and failure to thrive. The Quarterly Minimum Data Set (a Resident assessment tool) dated 1/17/25 documented Resident #33 was severely cognitively impaired, required partial/moderate assistance with eating and substantial / maximal assistance with bathing and dressing. A Physician's order dated 9/9/24 documented a mechanical soft diet and aspiration precautions as needed. The nutrition care plan, updated 9/30/24, documented the resident had poor intake and spits out food. The goals included the resident would tolerate the diet without signs and/or symptoms of aspiration. Interventions included a mechanical soft diet, to monitor for chewing and swallowing difficulty, and to provide assistance during meals. During an observation and brief interview on 03/18/25 at 12:58 PM, private family hired companion aide was observed feeding Resident #33 lunch. The companion aide stated Resident #33 often refused to eat and shakes their mouth away. The companion aide stated they were not licensed and did not work for the facility. During an observation on 03/20/25 at 12:23 PM, Resident #33 was being fed a peanut butter and jelly sandwich and drinking fluids by the companion aide. During an interview on 03/20/25 at 09:03 AM, Certified Nurse Assistant #3 stated that Resident #33 had a private companion aide who assisted the resident from 11:00 AM until 4:00 PM. They stated that the companion aide did not provide cares to Resident #33, just sits with the resident, feeds the resident lunch and provides encouragement to eat. During an interview on 03/20/25 at 1:24 PM, Unit Manager Registered Nurse #1 stated Resident #33 required full assistance with eating. They stated facility Certified Nurse Aide staff provided feeding assistance for breakfast and dinner, and a private companion aide provided feeding assistance with lunch. They stated they thought the companion aide received training from the present or past Director of Nursing. They stated they did not supervise companion aides. During an interview on 03/21/25 at 8:35 AM, the Director of Nursing stated the facility had one privately hired companion aide in building at the current time. They stated that companion aides did not provide any cares, and only duties such as re-orientation and monitoring for safety. They stated they had not observed and were unaware the companion aide was feeding Resident #33. 10 NYCRR 415.12(h)(2)

Based on record review and interview during a recertification survey from 3/18/25 to 3/21/25, the facility did not ensure resident received treatment and care consistent with professional standards of practice for 1 of 2 Residents (Resident #13) reviewed for skin conditions. Specifically, Licensed Practical Nurse #1 failed to report a change in Resident #13's skin condition. Findings included: The facility policy titled Body Audits, reviewed 6/2017, documented body audits (skin checks) will be done on admission, re-admission and weekly thereafter per treatment order. The purpose is early identification for all potential and actual skin problems. Residents with additional factors such as bed mobility issues, paraplegia and cerebral vascular accident will be closely monitored. Resident #13 had diagnoses including cerebral infarction, flaccid hemiplegia right dominant side, and vascular dementia. The Quarterly Minimum Data Set (a Resident assessment tool) dated 1/24/25 documented Resident #13 had moderately impaired cognition and was dependent on staff for all activities of daily living, bed mobility and transfers. Physician order dated 5/1/23 documented a body audit every week with nurses notes one time weekly. The Skin Integrity care plan documented the resident was at risk for skin breakdown related to a history of previous skin breakdown. Interventions included monitoring for any skin breakdown and reporting to the physician/nurse practitioner. During an interview and observation on 03/18/25 at 01:21 PM, Resident #13's representative stated they observed an area of reddened skin behind the left ankle of Resident #13 earlier in the day and reported it to the Licensed Practical Nurse who also observed skin change. Resident #13's ankle was observed with the resident's representative and had a reddened area approximately 2-3-centimeter x .5 centimeters behind the left ankle area. During an interview on 03/20/25 at 9:08 AM, Certified Nurse Aide #5 stated Resident #13 was showered twice a week, and the nurse provided a skin check weekly. They stated Resident #13 was last showered Tuesday 3/18/25 and a skin check was completed by a nurse. During an interview and observation on 3/20/25 at 11:21 AM, Licensed Practical Nurse #1 stated a 2-3-centimeter blanchable reddened areas was observed behind Resident #13's left ankle. Licensed Practical Nurse#1 stated that Resident #13's representative did inform and show them the area of concern on the resident's left ankle. Licensed Practical Nurse #1 stated they applied bacitracin to the area and wrote their concern on a sheet of paper and planned to inform Unit Manager Registered Nurse #1 and forgot. They stated they had not applied bacitracin, followed up on skin change status or reported the change in skin condition to the Unit Manager Registered Nurse or physician since observing it on 3/18/25. During an interview and observation on 03/20/25 at 11:26 AM, Unit Manager Registered Nurse #1 stated they were not informed by Licensed Practical Nurse #1 of a skin change for Resident #13. Unit Manager Registered Nurse #1 observed Resident #13's skin and stated there was a blanchable reddened area, approximately 3 centimeter x 0.5-centimeter area behind left ankle area. They stated Licensed Practical Nurse #1 should have reported the skin concern immediately to them. They stated that they would have contacted the physician, informed them of the change in skin status and obtained orders. They stated that Licensed Practical Nurse #1 should not have applied bacitracin without a physician order. During an interview on 03/21/25 at 2:39 PM, the Director of Nursing stated reported or observed changes in a resident's skin status should be escalated to nursing staff/ Unit Manager Registered Nurse immediately and an assessment of concern completed by Registered Nurse. The physician should be notified of the change and orders for care received and implemented. They stated that Bacitracin should not be applied without a physician order. 10 NYCRR 415.12

Based on record reviews and interviews during a recertification survey from 3/18/25-3/21/25 the facility did not ensure a resident's right to be free from misappropriation of resident property for 1 out of 1 resident (Resident #12) reviewed for personal property. Specifically, Resident #12 was missing shirts which was reported to facility staff and the facility did not complete a timely and thorough investigation of the missing property. Findings include: The facility policy titled Missing Items, dated March 2012, documented the facility shall respond to all reports of resident missing property. Once a resident or their representative reports an item missing to any facility staff member immediate action will be taken. Procedure: Clinical staff member asks for details regarding the missing item and completes Missing Item Report form. The form is given to the unit Social Worker. The Social Worker reviews missing item report, interviews the resident and family as appropriate, summarizes steps taken to locate item and documents results of the search. Social Worker notifies resident/designated representative if item has been located or not and documents the conversation on the form. Resident #12 had diagnoses including Polyneuropathy, peripheral vascular disease, and anxiety disorder. The annual Minimum Data Set (a Resident assessment tool) dated 1/3/25 documented Resident #12 was cognitively intact. During an interview on 03/19/25 at 9:21 AM, Resident #12 stated that some clothing had not come back from laundry or was missing (golf shirts with short sleeves). Resident #12 stated their spouse reported the missing items to facility staff about two weeks ago. They stated they were not aware of any follow-up regarding missing items. During an interview on 03/20/25 at 1:39 PM, Resident #12's spouse stated that approximately 1.5-2 weeks ago, they noticed that approximately 8 golf style short sleeved shirts were missing from Resident #12's closet. They stated they reported the missing items to the Unit Manager Registered Nurse the same day. They followed up with the Unit Manager Registered Nurse a couple of days later and were told that they reported missing items to Director of Housekeeping who was investigating. Resident #12's spouse stated they had not received any further follow-up on missing items and had not been reimbursed. They stated all the missing items were labeled when bought into facility. During interviews on 03/20/25 at 1:53 PM and on 3/21/25 at 10:32 AM, Unit Manager Registered Nurse #1 stated that Resident #12's spouse reported missing golf shirts to them, and they reported the missing items to the Direct of Housekeeping the same day and Housekeeping was investigating. They could not recall if they spoke directly to Director of Housekeeping or left a message. They stated they did not fill out a Resident Missing Property report for the missing items. They stated they were not aware of a report that needed to be completed. Unit Manager Registered Nurse #1 stated resident missing items were verbally discussed during morning staff meetings and that the facility Social Worker was present at the meetings. They stated they could not recall if they discussed missing shirts during morning meetings after receiving report from the resident's spouse. During an observation of files during interview, the Unit Manager Nurse Manager found blank Missing Items forms. They stated that the form should have been completed and given to Social Worker, the Director of Nursing or the Director of Housekeeping. During an interview on 03/20/25 at 3:23 PM, the Director of Housekeeping stated they did not receive a phone call, email, or Missing Item report from Unit Manager Registered Nurse regarding missing items for Resident #12 and had not investigated. During an interview on 03/20/25 at 3:40 PM, the Director of Social Work stated that a Missing Item Report form was used in the facility to report missing items. They stated any staff member could complete the forms, which were located at nurse station, and that the Unit Manager Registered Nurse usually completed and distributed the form. They stated were unaware Resident #12 had missing items. During an interview on 03/20/25 at 3:57 PM, the Director of Nursing stated residents/ advocates usually reported missing items to the nursing staff on the unit. The Certified Nurse Aide would search the resident's room for missing items. They will also confirm that the items came into facility on the Resident inventory listing. If Nursing was unable to locate missing items, they would contact the Director of Housekeeping to start investigation. If the missing items were not found by the Director of Housekeeping, the entire unit would be searched by nursing staff and the housekeeping department. If items were not found, a grievance form would be initiated by the Unit Manager and provided to the Social Worker. The Social Worker would discuss the missing items with the interdisciplinary team and contact the resident/advocate. The Administrator would make the final decision on reimbursement if necessary. They stated they were not aware Resident #12 was missing items. 10 NYCRR 415.4(b)

Based on observation, interview, and record review, during the recertification survey from 3/18/25 to 3/21/25 the facility did not ensured that the call bell system was accessible for 1 (Resident #16) of 35 residents reviewed for Environment. Specifically, the facility did not ensure that Resident's #16 call bell was within reach. Findings include: The Policy and Procedure titled Call Bells dated 6/16/03 documented it is the policy of the facility that each resident has a call bell at bedside within reach. The cord should be clipped to the bed. The Nursing Assistant assigned to the resident must check for malfunction of call bells on each shift and report such to the nurse in charge. Resident #16 had diagnoses including depression, diabetes mellitus, and chronic obstructive pulmonary disease. The Minimum Data Set Quarterly assessment dated [DATE] documented the resident was cognitively intact. The resident required substantial assistance with roll left to right, and lying to sitting on side of bed; and was dependent on staff for toileting hygiene, and chair to bed and toilet transfers. The Comprehensive Care Plan for Fall-resident at risk for fall, last updated on 8/2/24, documented to ensure that call bell is within reach at all times and encourage the resident to call for assistance as needed. During observations on 3/18/25 at 9:54 AM, on 3/19/25 at 9:46 AM and on 3/20/25 at 9:27 AM Resident #16 was lying in bed on their back. The call bell was on the floor next to the wall and out of the resident's reach. The resident stated that they used the call bell to call for assistance but could not find it. The resident stated that they would like to have it next to them. During observation on 3/21/25 at 9:23 AM the Resident #16 was lying in bed on their back. The call bell was on the floor behind the folded floor mattress and out of the resident's reach. The resident stated that they could not find the call bell today again. The resident stated that when they needed assistance and could not find the call bell they screamed to call the staff. During an interview and observation on 3/21/25 at 9:31 AM Certified Nurse Aide #3 stated that when they started their shift, they checked all assigned residents and a call bell for every resident during their shift. Certified Nurse Aide #3 entered Resident #16's room to observe the call bell and stated they could not find it. They asked the resident about their call bell. Resident #16 stated that they could not see it. Certified Nurse Aide #3 reached over the folded floor mattress, which was next to the wall and found the call bell. They stated that the call bell must have been moved by staff when serving the breakfast. They stated they had not checked the resident's call bell since the beginning of the shift. 10 NYCRR 415.5(e)(1)

Based on record review and interview conducted during an abbreviated survey (NY00310549, NY00313330) the facility did not ensure that each resident received adequate supervision and assistive devices to prevent accidents for 2 resident's (Resident #1 and Resident#2) of 3 residents reviewed for accidents. Specifically, (1) Resident #1 was left in the room unsupervised without prothesis (for right leg) and attempted to self-toilet and fell ; (2) Resident #2 fell out of the bed and sustained a hematoma on the left side of the head. The facility did not ensure that the mats that were supposed to be on both side of Resident #2's bed was in place in accordance with the care plan. The findings are: The Policy and Procedure titled Fall Risk Assessment and Fall Prevention Revised 8/11/2022 documented that all residents will be free from falls and free of injuries associated with falls; and assess all residents for falls. Resident #1 had diagnoses that included Diabetes Mellitus without complications, Acquired absence of right leg below knee and Cellulitis of the left toe. The Admission Minimum Data Set (MDS - a resident assessment tool) dated 2/06/2023 documented resident had severe cognitive impairment. The resident required extensive one-person physical assistance for bed mobility and transfer. The resident was frequently incontinent of bladder and bowel functions. The Fall Comprehensive Care Plan dated 1/13/2023 documented that the resident was at risk for falls related to Weakness with gait instability related to Right Below the Knee Amputation and Left 2nd toe amputation on 2/02/2023 observed sitting on the toilet floor with wheelchair behind no injury. Keep bed in the lowest position, Call bell within reach, mats on the floor. Ensure room is well lit as appropriate. Review of the accident summary dated 2/02/2023 documented that the resident care plan was followed. There were no changes in their medication. A medical device did not contribute to the fall. Recommendations to remind resident to ask for assist with Activity of Daily Living. Review of the fall risk assessment dated [DATE] documented that the resident was at risk for falls. Review of the Certified Nursing Assistant (CNA) Care guides dated 1/13/2023 documented to encourage resident to call for help as needed; to place the resident in visible area when out of bed to wheelchair; for the right below the knee amputation encourage resident to wear the prothesis when out of bed to wheelchair; nonskid socks to left foot when in bed. During an interview conducted with CNA #1 on 7/25/2023 at 11:27AM, the CNA stated, I was next door taking care of another resident heard resident call for help, the therapist was with me we both entered the room found resident on the floor in the bathroom feet (resident not wearing her prothesis) Infront of her and the wheelchair back of her. We called the nurse who assessed her, and we got her up. Resident stated I was trying to go to the bathroom. During an interview conducted with CNA #2 on 7/25/2023 at 2:21PM, the CNA stated, the aide did not put her leg on, and she rolled herself to the bathroom and attempted to toilet herself. You do not leave resident in her room unsupervised she was supposed to be in the dining room having breakfast. During an interview conducted with the Certified Occupational Therapist Assistant (COTA) on 7/25/2023 at 2:00PM, the COTA stated, I was doing my rounds and I heard resident calling for help I got my supervisor, and we went into the room found resident on the floor. Resident was not wearing her prothesis. The nurse came assessed the resident we got her up resident was not hurt. Resident was not on COVID precaution I remember her coming downstairs for therapy. During an interview conducted with the Director of Nursing (DON) on 7/25/2023 at 2:30pm, the DON stated, she came to us when there was an outbreak of COVID I think that why she was in the room. The staff are to follow the resident Care Plan and the Care Cards. I will continue to educate the staff. Resident #2 had diagnoses that included Dementia, Nutritional Deficiency and Major Depressive Disorder. The MDS dated [DATE] documented that the resident had severe cognitive impairment. The resident required total dependence with two people physical assistance for bed mobility and transfer. The resident was frequently incontinent of bladder and bowel functions. The Fall Comprehensive Care Plan Titled Risk for Falls initiated 6/12/2022 and updated 12/10/2022 documented interventions that included Floor bed with Bilateral floor mats, place resident in view of staff when awake, keep areas free of obstruction to reduce the risk of falls or injury. Review of the Accident Incident investigation dated 12/10/2022 at 7pm documented that staff reported resident was on the floor Resident was found lying on their right side on the floor next to their bed, noted with bruise and hematoma to their right temporal area and open skin purpura on their right elbow. Ice Pack applied to right temporal area and bacitracin to right elbow. Review of the CNA Care Card dated 12/12/2022 documented floor mats on both side of the bed turning and positioning every 2 hours. Review of x-ray report dated 12/12/2022 documented facial bones findings with no evidence of fracture no visualized fracture. During an interview conducted with CNA #7 on 7/26/2023 at 12:00pm, CNA stated, I am his regular aide I was not on the night resident fell but he usually has two protective mats on the floor. During a telephone interview conducted with CNA #6 on 7/31/2023 at 9:00pm, the CNA stated the Resident always had a mat on both side and a low bed but when he was found on the floor the mats were not there. It was given to another resident. The following day the mats were in his room. During a telephone interview conducted with RN#3 on 7/27/2023 at 2:00pm, the RN stated resident was found on the floor bleeding from right temporal area physician and family was notified resident also had an x-ray of the face which was negative for facture. There were no mats when they fell , and they were supposed to have mats. During an interview conducted with the DON on 7/27/2023 at 1:30pm, the DON stated CNA #4 was disciplined for removing the mats. During a second interview with the DON on 9/01/2023 at 12:20PM, the DON stated that the resident was care planed for Mats on both side of the bed. During the investigation CNA #4 stated someone removed the mats. CNA #4 was suspended for not following instructions on the Care Card and the Care Plan. To prevent reoccurrence, the DON stated that they educated the staff on the importance of following the Resident Care Card and the Care Plan. 415.12

Based on observation, interview and record review, the facility failed to ensure that the comprehensive care plan interventions to prevent injuries related to falls were evaluated for their effectiveness and revised to prevent repeated injuries for a resident who is cognitively impaired, has difficulty following simple directions and has demonstrated non-compliant behavior (Resident #28). Additionally, based on interview and record review, the care plan for a resident who experienced an eight percent weight loss in one month was not reviewed and revised to include interventions to address the significant change in weight and to prevent further weight loss (Resident #52). This was evident for two residents reviewed in a sample of 34 and resulted in actual harm for Resident #28 that is not immediate jeopardy and for Resident #52, no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are: 1. Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS 2.0 (an assessment tool) dated 8/25/10 and the MDS 3.0 dated 12/3/10 revealed the resident has short and long term memory problem, severe impairment for decision making, difficulty focusing attention and is wheelchair bound. Review of the Fall Risk Assessment revealed the following: Fall risk assessment: 12/10/09 =15 (score of 7 or higher = high risk) Fall risk assessment: 2/13/10 = 20 Fall risk assessment: 12/1/10 = 24 The increase in the score for the 2/13/10 fall risk assessment was related to an actual fall and the use of [MEDICAL CONDITION] medications. The other increase on the fall risk assessment of 12/1/10 was related to neuromuscular dysfunction that was not a new diagnosis. Review of the Comprehensive Care Plan for falls dated 12/10/09 revealed that the resident is at high risk for falls due to dementia, being uncooperative, forgetful and non-compliant with following simple directions such as toileting self. The interventions to prevent falls included: a bed alarm, tab alarm (a device used to alert staff of movement) and the Falling Star Program. According to the facility ' s policy on the falling Star Program, this program utilizes a visual cue to alert all facility staff about residents who had previous falls and are at risk for future falls and that all facility staff will be in-serviced on this program annually. Subsequent to the development of the falls care plan on 12/10/09, the resident had 3 falls with no injuries noted on this plan as follows: 2/13/10, 7/23/10, and 10/24/10. The resident's mental status and [DIAGNOSES REDACTED]. These interventions were not revised after each of the 3 falls. Interview with the Unit Manager/Registered Nurse on 12/17/10 at approximately 5:00PM revealed she was unaware that these interventions were not appropriate for this resident. Review of the Nursing Care Progress Notes dated 11/8/10 revealed that at 1:30 AM when a Certified Nurse Aide (CNA) responded to the sounding of the resident ' s tab and bed alarms she found the resident in the bathroom bleeding from her nose. The resident had fallen hitting her nose on the toilet seat. The Nursing Supervisor was made aware and assessed the resident. The resident was transferred to the hospital for evaluation at 2:00 AM. A nursing note written at 1:40 PM on 11/8/10 following the resident ' s return from the hospital revealed that the resident had bruising around both eyes and a raised area on the lower back left of her head that was tender to the touch. The care plan for falls revealed that it was reviewed on 11/8/10. This review revealed that the resident was high risk for falls due to dementia, being uncooperative, forgetful and non-compliant with following simple directions such as toileting self. This review did not reflect an evaluation of the effectiveness of planned interventions such as: the timeliness of staff member ' s response to the sounding of both alarms; supervision of the resident as defined by the Falling Star Program and the resident ' s ability to follow or comply with the instruction to use the call bell to obtain staff assistance. The response to the 11/8/10 fall with injury continued to be " Resident re-educated to use call bell when she needs help. " No other interventions were added. Further review of the Nursing Care Progress Notes revealed that on 12/3/10 at 6:00AM the resident was restless and requested to be out of bed. The resident was transferred to the day room. While the nurse was attending to other residents she heard the alarm and found Resident #28 on the floor. There was no apparent injury from this fall. According to the 12/3/10 Nursing Care Progress Notes at 9:00AM the same morning, Resident #28 was in the dining room for breakfast. She stood up from her wheelchair, fell to the floor, hit the left side of her head and sustained a 2 cm (centimeter) gash above her left eye. The resident was transferred to the hospital for evaluation and was hospitalized for [REDACTED]. The 12/9/10 nursing care progress notes state "stitches to left brow intact." On 12/15/10 at 12:45PM the Unit Manager/Registered Nurse was interviewed regarding the Falling Star Program. She stated the CNAs are in-serviced regarding keeping residents on this program in sight and frequently checking on them (every half hour to an hour). When asked how she knows if the CNAs are frequently checking on their residents and keeping their resident's in sight, she stated, "They tell me." When asked if they document, she stated there is no documentation completed. Three other nursing staff members (two CNAs on the resident's unit and the Director of Nursing) were interviewed on their understanding of the frequency of monitoring residents on the Falling Star Program. These interviews provided different frequencies of monitoring as follows: - A CNA assigned to the 7-3 shift stated on 12/15/10 at 2:50 PM that she checks every two hours or all the time. - A CNA from the 3-11 shift on 12/15/10 at 4:30 PM stated that he checks his Falling Star Residents every 15 minutes. - In an interview with the Director of Nursing on 12/16/10 at 8:15AM she stated that there is no specific time frame for supervision of residents in the Falling Star Program. She further stated that everyone knows who is in the program and "we all keep an eye on them." She said that during the day they should be checked every hour and at night every two hours. The CNA, who was caring for the resident when she fell in the dining room on 12/3/10, was interviewed on 12/16/10 at 9:30AM. She stated that on that morning when the resident fell and hit her head, she (the CNA) was feeding another resident and had her back to Resident #28. She said that by the time she heard the chair alarm the resident was already on the floor. She offered no explanation as to why the resident was not in her view. No new interventions were added to the resident's plan of care to prevent additional falls upon the resident's return to the facility. The Comprehensive Care Plan dated 12/8/10 revealed that the resident returned from the hospital that day (time not indicated) and was found on the floor in her room between the beds with both alarms going off. "Staff unable to respond to resident before fall." On 12/10/10 the resident was observed seated in reclining chair in the dining room at 12:15PM. She had a bruise and dried blood over her left eye with some bruising on the left side of her face. She did not respond when spoken to. The resident's plan of care was revised on 12/11/10 to reflect the use of the recliner chair to prevent falls. 2. Resident #52 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of the unit's monthly weight record indicated the following weights for the resident: -09/13/10: 97 lbs (Admission weight) -10/29/10: 97 lbs -12/1/10: 89 lbs This reflected an 8 percent weight loss in a month's time from 10/29/10 - 12/10/10. The resident's clinical record was reviewed and revealed no evidence that the resident's weight loss was addressed by the Interdisciplinary Treatment Team or that the Comprehensive Care Plan had been revised to address the significant weight loss. An interview with the Unit Manager, Registered Nurse on 12/15/10 at 5:00PM revealed that she was made aware on 12/1/10 of the resident's 8 percent weight loss. The RN stated that the resident was re-weighed and the weight loss was verified. An interview with the Dietician, on 12/16/10 at 3:00PM revealed that she had not been made aware that the resident had an 8 percent weight loss in one month. She stated that she reviews the unit's communication book every day but there was no information regarding the resident's weight loss. 415.11(c)(2)(i-iii)

Based on observation, interview and record review the facility failed to provide: 1) supervision and interventions to prevent falls with injuries. Specifically, the facility did not: provide the necessary supervision and appropriate interventions to prevent falls with injuries for a resident with a history of falls and did not thoroughly investigate accidents to identify the root cause and address the effectiveness of interventions that were in place to prevent falls with injuries (Resident #28) and 2)did not supervise the provision of the correct consistency diet to a resident. Specifically, during a dining observation a resident who was supposed to receive a mechanical soft diet was observed to eat a regular consistency diet (Resident #41). This created a potential choking hazard. This was evident for 2 of 3 residents reviewed for accidents and resulted in actual harm that is not immediate jeopardy for Resident #28 for falls with injuries and no actual harm with potential for more than minimal harm that is not immediate jeopardy for Resident #41 regarding inappropriate consistency diet. The findings are: 1. Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS 2.0 (an assessment tool) dated 8/25/10 for locomotion on the unit was coded as 2/1 - minimal assistance with supervision. Review of the MDS 3.0 dated 12/3/10 revealed that the resident has a short and long term memory problem, severely impaired decision making skills and difficulty in focusing attention. Locomotion on the unit was coded as a 4/2 - total dependence with 1 person assisting. This reflects a decline in locomotion since the 8/25/10 MDS. Review of the Fall Risk Assessment revealed the following: Fall risk assessment (upon admission):12/10/09 =15 (a score of 7 or higher = high risk) Fall risk assessment: 2/13/10 = 20 Fall risk assessment: 12/1/10 = 24 The increase in the fall risk from 12/10/09 to 2/13/10 was related to an actual fall of 2/13/10 and the addition of psychotropic medications according to the fall risk assessment. The increase in fall risk from 2/13/10 to 12/1/10 was related to neuromuscular dysfunction that was not a new diagnosis, also according to the fall risk assessment. The resident had 2 falls with no injuries and 1 fall with an injury between 2/13/10 and 12/1/10; however there were no new fall risk assessments completed during that period. Review of the Non-Compliant Comprehensive Care Plan dated 10/24/10, revealed the following: Resident uncooperative, increased agitation, yells and screams, forgetful, does not follow simple commands such as using the call bell for help, refuses to use the call bell to get out of bed and toilet self via wheel chair, poor safety awareness. The Comprehensive Care Plan for falls dated 12/10/09 included a bed alarm, tab alarm and the Falling Star Program. According to the policy and procedure "The Falling Star Program utilizes a visual cue to alert all facility staff about residents who had previous falls and are at risk for future falls..." Neither the policy and procedure nor the Comprehensive Care Plan define the type or the frequency of the supervision. In addition, the person responsible was not identified. Review of the Nursing Care Progress Notes dated 11/8/10 revealed that at 1:30AM the resident's tab and bed alarm were sounding. When a Certified Nurse Aide (CNA) reached the room the resident was found in the bathroom bleeding from the nose. The resident had fallen hitting her nose on the toilet seat. The Nursing Supervisor was made aware and assessed the resident. The resident was transferred to the hospital for evaluation at 2:00AM. The resident returned from the hospital at 5:50AM. A note written at 1:40PM on 11/8/10 following the resident's return from the hospital, revealed that the resident was very sleepy most of the " tour " (shift) she had bruising around both eyes and a raised area on the lower back left side of her head that was tender to the touch. The Comprehensive Care Plan for falls was reviewed on 11/8/10 and revealed that the resident was at high risk for falls due to dementia, being uncooperative, forgetful and non-compliant with following simple directions such as toileting self. The intervention instituted following the 11/8/10 fall was " Resident re-educated to use call bell when she needs help. " Review of the Accident / Incident Investigation dated 11/8/10 revealed that "the resident's bed alarm went off. Upon going to investigate CNA found that resident had fallen hitting nose on toilet seat. Resident denies hitting head. Tab alarm was also going off at time of incident." The CNA's statement revealed that she and another CNA went to the room immediately upon hearing the alarm. (Observation of the location of the resident's room revealed that it is close to the nursing station. The resident's bed is by the window, some distance from the bathroom). The investigation did not address the length of time it took for the CNAs to respond to the alarms nor did it take into consideration the resident's history of repeated non compliance to use the call bell to ask for help. The Follow-up Action indicated on the report: " Resident to use call bell to call for assistance to the bathroom." In an interview with unit manager Registered Nurse on 12/15/10 at 12:45PM regarding the Falling Star Program, she stated that there is no actual policy or protocol for the Falling Star Program (as noted above, the facility does have a policy). She further stated that the Falling Star symbol is noted on the Certified Nurse Aide (CNA) Accountability Sheet. The CNAs are in-serviced regarding keeping the resident in sight and frequently checking on him/her. She said there is a list of people in the Falling Star Program at the nursing station and there is a star by the name plate next to the resident's room and a star on their walker or wheelchair. She did not provide any evidence of documentation to indicate the level of supervision provided to these residents. The RN stated that she knows that supervision is being provided because "they (the CNAs) tell me." The RN unit manager further stated that the in-service related to the Falling Star Program recommended that the CNAs check their Falling Star residents every half hour to an hour. The CNA Accountability Sheet for Resident #28 for November and December 2010 did not have any indication that the resident was in the Falling Star Program. Review of the Falling Star list revealed that the list hadn't been updated since 10/18/10 and did not include the resident's name. Observation of the resident's room on 12/15/10 at 12:50PM revealed no star by the name plate. Two CNAs and the Director of Nursing were interviewed regarding what it means if a resident is in the Falling Star program. A CNA on the 7-3 shift was interviewed at 2:50PM on 12/15/10 and she stated that she checks her Falling Star residents every two hours or all the time. In an interview with a CNA from the 3-11 shift at 4:30PM on 12/15/10, he stated that he checks his Falling Star Residents every 15 minutes In an interview with the Director of Nursing on 12/16/10 at 8:15AM she stated that there is no specific time frame for supervision of residents in the Falling Star Program. She further stated that everyone knows who is in the program and "we all keep an eye on them." She said that during the day they should be checked every hour and at night every two hours. Review of the Nursing Care Progress Notes dated 12/3/10 revealed that at 6:00AM the resident was restless and requested to be out of bed. The resident was transferred to the day room. While the nurse was attending to other residents she heard the alarm and found the resident on the floor. There was no apparent injury from this fall. According to the Nursing Care Progress Notes at 9:00AM the same morning, the resident was in the dining room for breakfast. She stood up from her wheel chair and fell to the floor hitting the left side of her head sustaining a 2 cm (centimeter) gash above the left eye. The resident was transferred to the hospital for evaluation and admitted for 5 days with [DIAGNOSES REDACTED]. The 12/9/10 Nursing note indicated "stitches to Left brow intact" The CNA who was caring for the resident when she fell in the dining room on 12/3/10, was interviewed on 12/16/10 at 9:30AM. She stated that on that morning when the resident fell and hit her head, she (the CNA) was feeding another resident and had her back to Resident #28. She said that by the time she heard the chair alarm the resident was already on the floor. Review of the Accident / Incident Investigation dated 12/3/10 revealed that the resident was sitting at the table in the dining room for breakfast, stood up and fell to the floor sustaining a laceration to the left side of the forehead. The report did not include any Follow-up Actions nor did it identify a root cause for the fall. There was no evidence in the investigation to determine the effectiveness of the alarm devices and planned supervision to protect the resident from falls. Review of the Comprehensive Care Plan dated 12/8/10 revealed that the resident returned from the hospital that day (time not indicated) and was found on the floor in her room between the beds with both alarms going off. " Staff unable to respond to resident before fall." There was no evidence that the effectiveness of planned interventions was evaluated and no new interventions were added until a recliner chair was instituted on 12/10/10. During a dining observation on 12/10/10 at 12:15PM the first day of the survey, the resident was observed in the dining room with dried blood over her left eye and some bruising on the left side of her face. She did not respond when spoken to. A review of the in-service records regarding The Colors of Safety dated 10/8/10 revealed limited information regarding what it means to be in the Falling Star Program. The in-service addressed that the star indicates high risk for falls. No other information was included about the Falling Star Program. Following the fall on 11/8/10 an in-service regarding the Prevention of Falls was conducted by the RN nurse manager for all the CNAs on the resident's unit. This in-service described where the stars are supposed to be located for residents in the Falling Star Program and included some information regarding anticipating needs, offering hydration, encourage activities etc. The level of supervision these residents require or how frequently they need to be checked was not addressed. In summary, the Accident / Incident Investigations for the 11/8/10 and the 12/3/10 falls did not include information regarding the root cause for the falls nor did the investigations determine the effectiveness of the interventions in place at the time of the falls. The Follow-up Action for the 11/8/10 investigation, for a resident with dementia, difficulty following simple directions and is non-compliant, was to " use the call bell when in need of assistance to use the bathroom." Additionally there was no documentation of Follow-up Action for the 12/3/10 fall. For the 11/8/10 fall, it was unclear what the protocol for the Falling Star Program was. The CNA's were not instructed on a defined time frame for the supervision. The 11/8/10 in-service addressed answering bed and tab alarms promptly (however, the in-service occurred after this fall). Based on the investigation of this fall, the bed and tab alarms were sounding long enough for the resident to get out of bed, into her wheel chair, over to the bathroom, get out of her wheel chair, into the bathroom and fall before anyone was able to reach her. The lack of timeliness of the CNA response was not addressed. For the 12/3/10 fall where the resident needed to be hospitalized for [REDACTED].#28. 2. Resident #41 was admitted to the the facility with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. During a dining observation on 12/16/10 at 6:30PM, Resident #41 was observed eating a regular diet to include chicken fingers. The resident's meal ticket indicated that he required a mechanical soft diet. In an interview with the dietary staff regarding serving the wrong diet at 6:45PM on 12/16/10 she gave no explanation. At that time the RN unit manager was notified that the resident had the wrong diet. She returned the plate to the dietary staff to get the right consistency food. She stated that when she returned to the resident with the new plate of food, he was still chewing the bite of chicken he had taken (from the regular consistency diet) before his plate was taken away, and was having difficulty. The lack of supervison of this resident during this meal put the resident at risk of a potential choking hazard. 415.12(h)(1)(2)