Every finding on record at Briarcliff Manor Center For Rehab And Nursing Care

Based on record review and interviews conducted during the survey, the facility failed to ensure that each resident received adequate supervision/assistance to prevent accidents for two (2) of seven (7) residents (Residents #1 and #12) reviewed for abuse. Specifically, 1) Resident #1 required 2-person assistance with bed mobility and toileting, however the facility did not provide 2-person assistance per the care plan and Resident #1 alleged they were turned roughly and pushed against the side rail of their bed, and 2) Resident #12 required 2-person assistance with showers however the facility did not provide 2-person assistance per the care plan and Resident #12 alleged their head jerked backwards when the head of the shower bed slipped from the certified nurse aide's hands. Findings include:The 2/18/2026 facility policy titled Accidents/Incidents Investigation Process documented the process of an incident investigation included: to review previous interventions in the care plan, establish new intervention for this specific incident and write it in the incident report and update the care plan.1) Resident #1 had diagnoses including hemiplegia, malnutrition, and asthma.The 10/16/2025 admission Minimum Data Set assessment documented Resident #1 had upper extremity impairment on one side. The Resident required substantial maximal assistance with bed mobility and was dependent with toileting hygiene.The 10/01/25 Activities of Daily Living care plan documented on 10/20/2025 to provide 2-person substantial/maximal assistance with bed mobility and 2-person dependent assistance with toilet use.The 3/27/2026 quarterly Minimum Data Set assessment documented Resident #1 had impairments to both lower extremities, required substantial/ maximal assistance with rolling in bed and was dependent with toileting hygiene.Registered Nurse #2's progress note dated 06/10/2026 at 1:26 PM, documented Resident #1left the facility at 9:45 AM for a wound care appointment.Registered Nurse #2's progress note dated 06/10/2026 at 6:22 PM, documented the wound care center called and the resident was transferred to the hospital for evaluation due to allegations made toward the nursing staff.The facility Full QA Report (investigation) dated 6/10/2026 documented Resident #1 informed the wound clinic nurse that the staff member who cared for them overnight handled them roughly during incontinent care, and Resident #1 was transferred to the emergency room for further evaluation and was medically cleared. Certified Nurse Aide #1 provided care to Resident #1 and the investigation conclusion documented that Resident #1's care plan was updated to include a 2-person approach during care. The facility finding was that there was insufficient evidence to substantiate that abuse, neglect, or mistreatment occurred. There was no documented evidence that the facility was aware that Resident # 1 required 2-person assistance with bed mobility and toilet use since 10/20/2025.The 6/10/2026 Certified Nurse Aide #1's statement documented that at approximately 1:30 AM, they provided incontinence care and changed the linens for Resident #1. There was no documentation that Certified Nurse Aide #1 provided care to Resident #1 with another staff member's assistance.The 6/10/2026 Nursing Home Investigative Report documented the incident was not a result of a care plan violation and that Resident #1's care was changed to two persons for care. The documentation referred to care provided by Certified Nurse Aide #1 in the singular without another staff member's assistance.On 7/06/26 at 9:11 AM during an interview, Resident #1 stated that the Certified Nurse Aide was rough when they assisted them to roll onto their side and pushed them against the side rail. They stated they were evaluated at the hospital and at the nursing home and had no injuries from the incident.On 7/07/26 at 10:31 AM during an interview, Certified Nurse Aide #1 stated they assisted Resident #1 with bed mobility and toilet use without another staff member's assistance. They stated they thought that Resident #1 required 1-person assistance with toilet use and bed mobility. They stated they rolled Resident #1 onto their side in bed to change their brief.On 7/06/26 at 1:15 PM during an interview, the Director of Nursing stated Resident #1 made the allegation while they were at an outside appointment and were sent to the emergency room for evaluation. They stated Resident #1 was medically cleared at the hospital, and the hospital social worker evaluated Resident #1 and deemed the resident was safe to return to the nursing home. The Director of Nursing stated they implemented a new care plan intervention to provide 2-person assistance with toilet use.On 7/07/26 at 11:48 AM a follow-up interview and record review with the Director of Nursing was conducted and the Resident Nursing Instructions for Resident #1 were reviewed. The 10/20/25 instructions documented to provide 2-person assistance with bed mobility and toilet use. The Director of Nursing stated that when they investigated the allegation, they were not aware that Resident #1 had already required 2-person assistance. The Director of Nursing stated they did not realize that the Certified Nurse Aide #1 did not follow the care plan.2) Resident #12 had diagnoses which included traumatic spinal cord dysfunction, deep vein thrombosis, and gastroesophageal reflux disease.The 2/11/2026 Minimum Data Set admission assessment documented Resident #12 was able to make themselves understood and had intact cognition. Resident #12 had impairments on both sides to their upper and lower extremities and was dependent on staff for showers.The 2/04/2026 ADL Functional Rehab Potential Care Plan documented Resident #12 had a cervical spine cord compression unspecified injury at unspecified level of cervical spine cord, needing extensive assistance in most areas of ADL functioning. The goal was to maintain the current level of functioning. The interventions included to provide two-person substantial/ maximal assist physical assistance with showers.The Resident Nursing Instructions dated 02/01/2026 through 04/03/2026 documented Resident #12 required 2-person physical assist with showers.The 4/03/26 Full QA Report (investigation) documented a behavior problem in the shower. The conclusion documented that Resident #12 stated that during showering, their head jerked backwards when Certified Nurse Aide #21 attempted to lower the head of the shower bed. On assessment, there were no visible injuries consistent with a fall and Resident #12 denied pain or discomfort. Certified Nurse Aide #21 confirmed that Resident #12 requested that the head of the shower bed be lowered. During lowering the head of the shower bed, it slipped from their hand and I quickly guided it to the shower bed. The Assistant Director of Nursing's written statement documented a physical assessment with no injuries noted, Resident #12's neck was non-tender, range of motion was at baseline, and no complaints of pain or discomfort. Certified Nurse Aide #21's written statement documented that during Resident #12's shower, the resident requested that the head of the shower bed be lowered during the shower, and as they were lowering it, the head of the shower bed slipped out of their hand but they caught the resident's head with their hand immediately and gently lowered it to the shower bed. The Resident's head did not jerk back or fall down to the shower bed. The Resident told them they were fine and had no pain or discomfort. Certified Nurse Aide #22's written statement documented they assisted Certified Nurse Aide #21 with transferring Resident #12 to and from the shower bed. The 03/27/26 wheelchair and shower bed management education documented nursing staff received education.On 8/05/26 at 1:42 PM during an interview, Certified Nurse Aide #22 stated they assisted with transferring Resident #12 to and from the shower bed using a mechanical lift, however they did not stay in the shower room to assist with Resident #12's shower. They stated that nobody asked them to assist with Resident #12's shower.On 08/05/26 at 1:45 PM during interview and review of the Activities of Daily Living Care Plan and the Certified Nurse Aide Tasks with the Director of Nursing, they stated Resident #12 required 2-person assistance with showers. They stated that Certified Nurse Aide #21 gave Resident #12 a shower without assistance. The Director of Nursing stated when the investigation was conducted, they had not identified that a care plan breach had occurred.On 08/05/26 at 2:08 PM during an interview with the Assistant Director of Nursing, they stated they conducted the Full QA Report which addressed multiple accusations and displays of extreme behavioral symptoms by Resident #12 and their family members, screaming and shouting at staff using profanities. The Assistant Director of Nursing stated they did not separately investigate the shower incident/allegation in an Accident / Incident Report and did not look into the Care Plan interventions and Certified Nurse Aide Tasks, and therefore had not realized that a care plan breach had occurred when only one (1) staff, Certified Nurse Aide #21 showered Resident #12 without the assistance of another staff. They stated that in hindsight they should have reviewed the care plan interventions and C.N.A. Tasks.On 08/05/26 at 2:43 PM during an interview, Licensed Practical Nurse #23 stated that although Certified Nurse Aide #21 told them they needed assistance with transferring Resident #12 to and from the shower bed via mechanical lift, they were not assigned to Resident #12 and were not aware of Resident #12's care plan requirements for assistance with showers. They stated that Certified Nurse Aide #21 did not tell them that they needed assistance with showering Resident #12. They stated that primary Certified Nurse Aide #21 was responsible to check what level of assistance Resident #12 required. They stated the assigned nurse was responsible to assure the Certified Nurse Aide provided the correct level of assistance to Resident #12.On 08/05/26 at 2:58 PM during an interview and demonstration by Certified Nurse Aide #21, they demonstrated the shower chair incident to the surveyor. Certified Nurse Aide #21 stated Resident #12's head did not jerk backwards or go all the way down to the flat position and Resident #12 did not complain of any pain or discomfort after that happened and told Certified Nurse Aide #21 they were okay. Certified Nurse Aide #21 stated Resident #12 required 2-person assistance in the shower but Certified Nurse Aide #22 had to leave take care of another resident and Certified Nurse Aide #21 stated they did not tell the Licensed Practical Nurse #23 they needed another staff to provide assistance with Resident #12's shower.On 08/05/26 at 4:33 pm during an interview, Registered Nurse #24 stated they were responsible for Resident #12 on 4/03/26. They stated they were aware and Certified Nurse Aide #21 was aware that Resident #12 required 2-person assistance with showers, however they were not aware that Resident #12 was receiving a shower at that time because they were in another area of the unit.On 8/06/26 at 4:05 pm during an interview, the facility Administrator stated that Resident #12's complaint about the shower should have been investigated as an Accident/Incident, and the care plan breach should have been identified.10 New York Codes, Rules and Regulations 415.12(h) (2)

Based on interviews and record reviews it was determined that for one of two residents (Resident #22) reviewed for admissions, the facility did not ensure that a Level II referral for individuals identified with an intellectual disability (ID) was sent to the Office of Persons With Developmental Disabilities prior to admission, in order to receive care and services in the most integrated setting appropriate to their needs. Specifically, the Pre-admission Screen Resident Review (PASRR) for Resident #22 was completed on 2/5/26 and the Office of Persons With Developmental Disabilities was made aware of the resident in the facility on 2/20/26. Findings include: Resident #22 was admitted on [DATE] with a diagnosis of Down's Syndrome and pneumonia. The Minimum Data Set (assessment tool) dated 2/10/2026 documented the resident had impaired cognition and was dependent on staff for all activities of daily living including eating, bed mobility, transfers and personal hygiene.The resident's Preadmission Screening and Resident Review form was reviewed and documented the screen was performed at the hospital on 2/5/2026 and the resident was admitted on [DATE]. The facility did not send a Level II Referral to the Office of Persons With Developmental Disabilities for their staff to determine if a Level II PASRR was needed.The facility policy titled Screen and PASRR, dated 10/17/2017 and reviewed 3/23/2026 documented that all residents must have PASRR screen prior to admission to the facility to identify the importance of screening potential nursing home residents for mental illness, to be familiar with the requirements for Level I and Level II PASRR screening and referral process.During an interview on 8/7/2026 at 1:49 PM Social Worker #2 stated they had been at the facility only a few months and had not had a situation like this but stated it made sense it should have been done prior to the admission to ensure the proper services were available.During an interview on 8/10/2026 at 10:45 AM Social Worker #1 stated the resident's documents and screen documented the resident was at the facility for a brief and finite stay which qualified for 30 days without having to apply for Level II assessment. They stated that was what they were going with and thought they had time to get Level II if needed.During an interview on 8/10/2026 at 3:45 PM the Regional Director of Social Work stated if a resident was coming into the facility for convalescent care/ finite stay then the person did not need to come in with Level II. They stated Level II was used for placement reasons but not convalescent. They stated they were not aware of any changes and as long as they were following directions on the DOH- 695 Screen form they had been doing it the right way.New York Codes, Rules and Regulations 415.11 (e)

Based on record review and interviews conducted during an abbreviated survey, the facility did not ensure that residents received routine medications in a timely manner by maintaining a sufficient supply of medications for one (Resident #11) of six residents reviewed for pharmacy services. Specifically, Resident #11 did not receive the ordered intravenous antibiotic medication meropenem on 12/24/2025 at 2:00PM and 10:00PM and on 12/25/2025 at 6:00AM because the facility did not timely enter the medication order or utilize its process to obtain an expedited medication delivery. The medical provider was not notified that the ordered doses were not administered.The Policy and Procedure titled admission: Nursing dated 1/8/2026, documented it was the policy of this facility to ensure that all needs are identified, medications and treatments ordered based on assessment and transfer documentation and received, including pharmacy contacted if immediate delivery required.Resident #11 was admitted to the facility on [DATE] with diagnoses including pneumonia, multi-drug-resistant organism, and anxiety disorder.The 12/28/2025 five-day scheduled Minimum Data Set (a resident assessment tool) documented Resident #11 had moderate cognitive impairment and received medications including intravenous antibiotics. Review of the hospital Medication Administration Record documented Resident #11 was initiated on intravenous meropenem (antibiotic) 500 milligrams on 12/21/2025, with the last dose administered in the hospital on [DATE] at 6:53 AM.The Nursing admission assessment dated [DATE], documented Resident #11 was admitted to the facility at 2:00 PM, with medications that included intravenous meropenem 500 milligrams/50 milliliters every eight hours for four days.The Physician Orders dated 12/24/2025 documented meropenem 500 milligrams/50 milliliters in 0.9% sodium chloride intravenous piggyback, infuse 100 milliliters intravenously every eight hours for four days for unspecified bacterial pneumonia, with scheduled administration times of 6:00 AM, 2:00 PM and 10:00 PM. The order was entered and completed by Registered Nurse #12 at 8:48 PM.The December 2025 Medication Administration Record documented the first dose of intravenous meropenem was administered on 12/25/2025 at 2:00PM (24 hours after admission). There was no documented evidence the medication was administered on 12/24/2025 at 2:00PM and 10:00PM and on 12/25/2025 at 6:00AM.There was no documented evidence the physician was notified that Resident #11 did not receive three scheduled doses of the ordered intravenous antibiotic.During a telephone interview on 07/20/26 at 10:41 AM, Registered Nurse #12 stated they admitted Resident #11 to the facility on [DATE] at 2:00 PM. Registered Nurse #12 stated the admission process included reviewing the hospital discharge records, contacting the physician to complete medication reconciliation, entering physician-approved orders into the electronic medical record, and notifying the pharmacy of the resident's admission and medication orders. Registered Nurse #12 stated the admission process typically took no longer than two and a half hours. Registered Nurse #12 stated that medication orders entered after 1:00PM were routinely delivered by the pharmacy around midnight or the following morning, however, if a medication was needed sooner, the nurse could designate the order as immediate and contact the pharmacy to request expedited delivery. Registered Nurse #12 did not know why Resident #11's intravenous antibiotic medication order was not entered until 8:48 PM, or why the immediate order process was not used to obtain the medication sooner.During a telephone interview on 07/20/26 at 12:07PM, the Pharmacist stated that the pharmacy received the order for intravenous meropenem from the facility on 12/24/2025 at 9:11PM with status of 'new admission batch'. The Pharmacist stated that medications entered as 'new admission batch' orders were generally shipped the following morning between 3:00AM and 4:00AM. The Pharmacist stated the orders were reviewed by the evening pharmacist on 12/24/2025 at 11:04 PM, verified by another pharmacist on 12/25/2025 at 2:58 AM, shipped between 3:00 AM and 4:00 AM, and delivered to the facility on [DATE] at 6:47 AM. The Pharmacist stated the pharmacy accepted and processed immediate medication orders when requested by the facility. Immediate orders required the nurse to designate the medication as immediate and notify the pharmacy by telephone, allowing delivery within approximately four hours of the request.During an interview on 07/20/2026 at 2:26 PM, the Director of Nursing stated the admission nurse was responsible for reviewing the hospital discharge medications, reconciling them with the physician, and entering approved medication orders into the electronic medical record. The Director of Nursing stated medication reconciliation was a priority during the admission process, and admission generally required only a few hours to complete.The Director of Nursing did not know why Resident #11's intravenous antibiotic and other medication orders were not entered until 8:48 PM. The Director of Nursing stated that all nurses had been educated on the process for requesting expedited medication delivery by entering an immediate order and contacting the pharmacy. The Director of Nursing stated they were not aware that Resident #11 had missed three scheduled doses of intravenous meropenem or that the physician had not been notified. 10 New York Code of Rules and Regulations 415.18(a)

Based on record review and interview conducted during an abbreviated survey, the facility did not ensure services were provided to restore or improve normal bladder function to the extent possible after the removal of an indwelling catheter for one (Resident #10) of one resident reviewed for indwelling urinary catheter. Specifically, Resident #10 had their catheter removed during a urology consultation with a recommendation to follow-up with a renal/bladder ultrasound within one week. The renal/bladder ultrasound was not scheduled until 6 weeks later.Findings include:The Policy and Procedure titled Laboratory and Radiology Policy last reviewed on 1/10/2026, documented it is the policy of this facility to provide or obtain laboratory and radiology services as ordered by a physician, physician assistant, nurse practitioner or clinical nurse specialist in accordance with State law, including scope of practice laws.Resident #10 was admitted to the facility with diagnoses including retention of urine, unspecified, non-Alzheimer's dementia and hip fracture. The 10/10/2025 admission Minimum Data Set Assessment (a resident assessment tool) documented Resident #10 had moderately impaired cognition and an indwelling urinary catheter.Physician Orders dated 10/7/2025 documented a urology follow- up appointment scheduled for 10/20/2025.Licensed Practical Nurse #18's Progress Note dated 10/20/2025 documented Resident #10 attended the urology follow-up appointment. The consult recommendations documented indwelling urinary catheter removed, continue Flomax 0.4 milligrams daily and obtain a renal/bladder ultrasound within one week to measure post-void bladder residual. The progress note documented that a prescription for the renal/bladder ultrasound and the radiology scheduling telephone number accompanied the consult recommendations.Licensed Practical Nurse #18's progress note dated 10/29/2025 documented a telephone call was received from the Urology Physician Assistant requesting that the renal/bladder ultrasound be scheduled. The note documented the Administrative Assistant had been notified to schedule the appointment as soon as possible.Nurse Practitioner #1's order dated 12/10/2025 (six weeks after the urology recommendation) documented an immediate renal/bladder ultrasound per the Urology Physician Assistant due to urinary retention. The Renal/Bladder Ultrasound report documented the study was collected on 12/10/2025 with results dated 12/11/2025.During an interview on 07/16/2026 at 9:59 AM, Licensed Practical Nurse Unit Manager #4 stated that when a resident returned from an outside appointment with written recommendations, the charge nurse was responsible for reviewing the consultation notes, documenting the recommendations, notifying the physician, documenting the physician's response, and entering any necessary physician orders. Licensed Practical Nurse Unit Manager #4 stated that ordering diagnostic testing was the responsibility of the charge nurse and should be completed the same day the recommendations were received. Licensed Practical Nurse Unit Manager #4 stated that Licensed Practical Nurse #18 was the charge nurse on 10/20/2025 and they were familiar with this process.During an interview on 7/17/26 at 12:01 PM, the Administrative Assistant stated that on 10/20/26 Licensed Practical Nurse #18 notified them that Resident #10 had returned from the urology appointment with consultation paperwork, and the Administrative Assistant scanned it into the medical record. The Administrative Assistant stated that nurses were responsible for entering physician orders and scheduling diagnostic testing. The Administrative Assistant stated that after the discussion with Licensed Practical Nurse #18 on 10/20/2025, there were no additional conversations regarding scheduling the renal/bladder ultrasound.During a telephone interview conducted on 07/17/26 at 1:15 PM, the Urology Physician Assistant stated they contacted the facility numerous times between 10/24/25 and 12/2/2025 to determine whether the renal/bladder ultrasound had been completed. The Physician Assistant stated that on 10/20/2025, they spoke with Licensed Practical Nurse #18, who reported Resident #10 was voiding. The Physician Assistant explained that because Resident #10 had a history of urinary retention, the ultrasound remained necessary to determine the amount of urine retained in the bladder and whether reinsertion of the urinary catheter was indicated. The Physician Assistant stated the importance of obtaining the ultrasound was emphasized during the conversation and again requested that the test be completed as soon as possible. The Physician Assistant stated Licensed Practical Nurse #18 acknowledged the request and stated the ultrasound would be completed promptly.Review of Physician Orders, Nursing Progress Notes, Medical Progress Notes, and diagnostic reports revealed no evidence that a physician order for the renal/bladder ultrasound was entered or that the diagnostic test was scheduled until 12/10/2025. 10 New York Code of Rules and Regulations 415.12(d)(1)

Based on record review and interviews during the survey, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for two of seven residents (Residents #3 and #28) reviewed for quality of care. Specifically, Resident #3 called their family loudly wheezing, coughing, breathing fast, and crying, stating they could not breathe and that staff were not helping them and asked their family to call 911. When the Emergency Medical Technician arrived, Resident #3 had an oxygen saturation of 67 percent, was wheezing, and displayed labored breathing. 2) Resident #28 experienced an unwitnessed fall, and there was no documented evidence that a Registered Nurse assessed the resident following the fall. The findings include: The 1/01/2026 facility policy titled Change in Condition documented all staff are encouraged to promptly report any changes in condition to the charge nurse, supervisor, Director of Nursing, Assistant Director of Nursing or designee immediately. 1) Resident #3 had diagnoses including Chronic Obstructive Pulmonary Disorder, hypertension, and non-Alzheimer's dementia. The 5/11/2026 quarterly Minimum Data Set documented Resident #3 had impairments to upper & lower extremity on one side, and required assistance with activities of daily living, was not on oxygen, and was short of breath when lying flat. Nurse Practitioner #1's progress note documented date of service of 5/08/2026, Resident #3 was seen for evaluation of wheezing for the past two days. Resident #3 had a history of respiratory symptoms requiring nebulizer treatment. Nursing reported ongoing wheezing without documented acute distress at the time of evaluation. A one time Lasix 20 milligram (water pill) trial had been ordered. Vitals were reviewed. The assessment and plan documented plan to monitor respiratory status, lung sounds, respiratory rate, oxygen saturation, and response to nebulizer treatments. Notify provider for worsening wheezing, shortness of breath, increased work of breathing, hypoxia, chest pain, or acute decline. Nurse Practitioner #1's progress note documented date of service of 5/11/26, Resident #3 was seen for wheezing with mild shortness of breath noted by nursing staff. No fever, cough, chest pain, or acute respiratory distress reported. Resident with history of chronic obstructive pulmonary disorder. Respirations stable at time of assessment with mild intermittent wheezing on exam. Initiate Duoneb (nebulizer treatment), Lasix (water pill) 20 milligrams one time, Prednisone (steroid) 40 milligrams daily for five (5) days. Will continue close respiratory monitoring. Licensed Practical Nurse #8's progress note dated 5/13/26 at 11:52 AM documented Resident #3 was noted wheezing. Nebulizer treatment given per physician's order with no relief. Nurse Practitioner #1 was notified gave Prednisone (steroid) 40 milligrams. Vital signs documented temperature 97.5, pulse 76, 18, blood pressure 120 / 64. There was no documentation of Resident #3's oxygen saturation. There was no follow-up nurse's note to document Resident #3's response to the administration of Prednisone (steroid). There was no documentation of an assessment by a Registered Nurse. The 5/13/2026 Emergency Medical Service Patient Care Record for Resident #3 recorded by Emergency Medical Technician #1 documented at 11:00 AM they responded for chief complaint of extreme difficulty breathing. Signs and symptoms included acute respiratory distress, chronic obstructive pulmonary disease, dyspnea, shortness of breath, tachypnea (quick, shallow breathing), and wheezing. Oxygen saturation 67%. Dispatched for difficulty breathing. Upon arrival to facility, staff was unaware of the situation, the resident was sitting in wheelchair in common room presenting with rapid breathing, cold and clammy skin, using accessory muscles to breathe, audibly wheezing, and unable to breathe. The resident was in acute distress and unable to communicate. Staff reported that the resident had been like that for a whole day. Staff reported that the resident was worse yesterday and they did not call 911 since they thought the resident was getting better. The nurse reported the resident was seen by the doctor yesterday. The resident's oxygen saturation was 67% upon arrival. Staff did not supply the resident with oxygen or provide any interventions. The resident was immediately placed on non-breather nebulizer treatments. Oxygen saturation increased minimally to high 70's. The resident was moved to stretcher and brought to ambulance. Paramedic continued care, provided a second nebulizer treatment and continuous positive airway pressure treatment. The resident improved, however, was still in emergency situation. The resident was transferred with Emergency Medical Technician and Paramedic, lights and sirens, to closest facility. Arrived at the hospital and was brought into the emergency room where they were taken into respiratory treatment room immediately. The 5/13/2026 Volunteer Ambulance Corps Patient Care Record for Resident #3 recorded by Paramedic #1 documented at 11:17 AM they responded to a call for Resident #3 for shortness of breath. On arrival, the resident was in the care of the basic life support unit on the scene. The resident's family had called 911 after the resident stated they were short of breath. On arrival, basic life support reported the resident was wheezing and had oxygen saturation in the 70 percent range. The resident was given one nebulizer treatment by basic life support team prior to Paramedic's arrival. The resident had audible wheezing. The resident was moved to a stretcher and taken to the ambulance and placed on continuous positive airway pressure. The resident's oxygen saturation improved within normal limits, and they were transported to the hospital. The 5/14/26 at 7:31 AM registered nurse note documented Resident #3 was admitted to the hospital. The 5/17/26 Hospital discharge summary documented the primary diagnosis at the time of discharge was chronic obstructive pulmonary disorder exacerbation, acute respiratory failure, and rhinovirus infection. On 7/07/26 at 4:09 PM during an interview, Emergency Medical Technician #1 stated that when they arrived at the facility, Resident #3 was wheezing and had labored breathing and an oxygen saturation of 67%. They stated they administered two doses of Duoneb (ipratropium and albuterol) (nebulizer) treatments and high flow oxygen via non-rebreather oxygen mask with good effect, and when the Paramedic arrived, the Paramedic applied continuous positive airway pressure, and they took Resident #3 to the emergency room for evaluation. On 7/08/26 at 10:00 AM during an interview, the Director of Nursing stated that a few hours after Resident #3 had received a nebulizer treatment, Resident #3 called their family, their family was worried about the Resident and called 911. They stated that Licensed Practical Nurse #3 had called the Nurse Practitioner and administered Prednisone and Lasix per orders. They stated everything happened very fast and when 911 arrived, Registered Nurse Unit Manager #2 was not aware of Resident #3's change in condition. On 7/08/2026 at 10:27 during an interview, Licensed Practical Nurse #3 stated they were on duty on 5/13/2026 at around 10:30 AM when Resident #3 was wheezing. They stated they called the Nurse Practitioner because Resident #3 was wheezing despite having received a nebulizer treatment at around 6:00 or 7:00 AM that morning. They stated the Nurse Practitioner told them to give Predisone (steroid) 40 milligrams and Lasix (water pill) 20 milligrams, which they gave. They stated they did not notify the Registered Nurse of Resident #3's change in condition and did not document Resident #3's oxygen saturation at that time. Licensed Practical Nurse #3 stated the police came to the facility and when they asked who called them, the police stated the resident's family had called. On 7/08/26 at 11:00 AM during interview, Registered Nurse Unit Manager #2 stated they were not aware of Resident #3's change in condition. Registered Nurse Unit Manager #2 stated the Licensed Practical Nurse should have called them to assess Resident #3 for change in condition. On 7/08/26 at 11:53 AM during an interview, Paramedic #1 stated that Resident #3 had audible wheezing and increased work of breathing, and their oxygen saturation was 74% when they arrived at the facility. They stated Emergency Medical Technician #1 had arrived at the facility before them and had already administered nebulizer treatments and high flow oxygen. They stated that Emergency Medical Technician #1 told them that when they arrived at the facility Resident #3 had labored breathing and an oxygen saturation of 67 percent. On 7/08/2026 at 12:45 PM, the Director of Nursing stated they had not been made aware of Resident #3's change in condition. On 7/09/2026 at 9:35 AM during a follow-up interview, Registered Nurse Unit Manager #2 stated that if they had been made aware of Resident #3's condition, they would have assessed Resident #3 and taken vital signs, called the Nurse Practitioner or physician with the results of their assessment, and would have applied high flow oxygen via non-rebreather if Resident #3 needed it, and called 911 if they could not manage Resident #3's condition at the nursing home. On 7/09/2026 at 8:33 AM during an interview, Resident #3's family member stated that on the phone Resident #3 complained of difficulty breathing and stated they needed to go to hospital and said the staff weren't helping them. They stated they could hear Resident #3 loudly wheezing, coughing, breathing fast, and crying, saying they couldn't breathe. Resident #3's family member stated they spoke with Resident #3 again about 10-15 minutes later and Resident #3 did not sound any better. Resident #3's family member stated they heard Resident #3 wheezing loudly and sounded out of breath, and Resident #3 told them they wanted to go to the hospital, so the family called 911. On 7/09/2026 at 10:55 AM during an interview, the Medical Director stated that the Registered Nurse should have been made aware of Resident #3's change in condition. They stated a Registered Nurse should have assessed Resident #3, taken a reading of Resident #3's oxygen saturation, administered oxygen for wheezing and shortness of breath if needed, and notified the Nurse Practitioner or physician regarding Resident #3's change in condition, and describe their respiratory status including a description of their breath sounds, wheezing, coughing, and oxygen saturation. 2) The policy and procedure titled Accident/Incident Investigation Process, last updated 02-18-2026, documented that the purpose of the policy was to ensure that all residents were properly assessed and that appropriate interventions were implemented to prevent accidents and incidents. The policy directed staff to assess the resident immediately upon discovering an incident, notify the physician and carry out any orders, and notify the resident's family representative. Review of the policy titled Staffing Policy, last reviewed 05-24-2026, documented that when adequate staffing could not be obtained, the Staffing Coordinator was responsible for contacting Nursing Administration to request overtime coverage. The policy further documented that the Nurse Supervisor was responsible for providing appropriate assistance and supervision as needed to ensure the safety and care of residents. Resident #28 diagnoses of obesity, schizophrenia, and diabetes mellitus. Review of the admission Minimum Data Set Resident Assessment tool dated 02-18-2025 documented that Resident #28 had intact cognition and required one-person physical assistance with transfers and activities of daily living. Review of the care plan titled Fall, dated 02-11-2025, directed staff to keep the call bell attached to the resident's pillow, respond promptly when the resident requested assistance, maintain a clutter-free environment, monitor blood glucose levels, and review medications as a possible cause of falls. Review of the incident report dated 03-24-2025 at 6:40 AM documented Resident #28 attempted to ambulate to the bathroom without requesting assistance. A Certified Nurse Aide found the resident on the right side of the bed and immediately notified Licensed Practical Nurse Unit Manager #4, who was serving in a supervisory role. Upon arrival, Licensed Practical Nurse Unit Manager #4 observed the resident lying on the floor on her right side and abrasions to both knees related to the fall. The resident denied striking the head and denied pain. Licensed Practical Nurse Unit Manager #4 directed staff to assist the resident from the floor and return the residents to bed. Staff cleaned the abrasions, and no swelling was observed. The call bell was within reach. Staff educated the residents about the importance of using the call bell when assistance was needed. The incident summary documented that the resident attempted to ambulate independently without requesting assistance. Based on the resident's account, staff observations, and review of the circumstances, the incident report concluded that no evidence of abuse, neglect, or mistreatment was identified. Review of a progress note dated 03-24-2025 at 8:06 AM, written by Licensed Practical Nurse Unit Manager #4, documented that the resident experienced an unwitnessed fall and was found on the floor on the right side of the bed. The resident's range of motion remained within the normal baseline. Bruises were noted on both knees and were cleaned with normal saline. Immediate interventions included an assessment of injuries and pain and assistance back to bed by two staff members. The resident was not wet at the time, and the call bell was within reach. Staff educated the resident about the importance of using the call bell when assistance was needed. The physician and the resident's family representative were notified and updated. Review of the physician's note dated 03-24-2025 documented that the resident was seen following readmission for acute kidney injury. Laboratory results showed a creatinine level had improved. The residents were stable. The treatment plan included continued oral hydration, avoidance of nephrotoxic medications, when possible (medications that could damage the kidneys), continued monitoring, and a nephrology consultation as needed. (There was no documentation regarding the fall.) Review of the medical record revealed no documented evidence that a Registered Nurse assessed the resident following the fall. During an interview on 08-10-2026 at 9:53 AM, the resident's family representative stated that the resident fell and sustained bruises to both knees but was not transferred to the hospital for evaluation. The family representative expressed concern that the residents may have struck their head and was not cognitively intact enough to reliably report whether a head injury occurred. The family representative believed that the resident should have been transferred to the hospital for further evaluation. During an interview on 08-10-2026 at 2:00 PM Certified Nursing Assistant #43 stated that they did not remember the incident. Certified Nursing Assistant #43 explained that when staff found a resident on the floor, staff stayed with the resident and notified the nurse or nursing supervisor. The nurse or nursing supervisor assessed the resident and directed staff either to assist the resident back to bed or keep the resident on the floor. During an interview on 08-10-2026 at 2:10 PM, Licensed Practical Nurse #3 stated they did not remember the incident. Licensed Practical Nurse #3 stated that when staff found a resident on the floor, staff ensured the resident's safety and notified the Registered Nurse Supervisor. The Registered Nurse Supervisor assessed the resident and directed staff either to assist the resident back to bed or keep the resident on the floor. During an interview on 08-10-2026 at 3:00 PM, Licensed Practical Nurse Unit Manager #4 stated that they did not remember the incident that occurred on 03-24-2025. After reviewing the nursing note, Licensed Practical Nurse Unit Manager #4 stated they remembered assessing the resident and directing staff to assist the resident from the floor. Licensed Practical Nurse Unit Manager #4 stated that they served in a supervisory role at the time. The physician and the resident's family representative were notified. Licensed Practical Nurse Unit Manager #4 stated that completing a formal fall assessment was outside the scope of practice of a Licensed Practical Nurse. During an interview on 08-10-2026 at 3:30 PM, the Director of Nursing stated that a Licensed Practical Nurse assessed the resident instead of a Registered Nurse following the fall. The Director of Nursing stated that a Registered Nurse was unavailable at the time and that the Licensed Practical Nurse functioned in a supervisory role. The Director of Nursing stated that staff sometimes contacted the Director of Nursing by telephone or FaceTime for assistance with assessments. No telephone or FaceTime assessment occurred following the incident. The Director of Nursing stated that a physician evaluated the resident the following day and found the resident stable. The Director of Nursing was not aware the physician's documentation did not mention the fall. The Director of Nursing stated that future efforts would include scheduling a Registered Nurse as the supervisor and establishing a plan for staff to obtain assistance by telephone or FaceTime when needed. 10 New York Code Rules Regulations 415.12(h)(2)

Based on record review and interview, the facility failed to ensure that medications ordered by the physician were administered to a resident by a licensed or registered nurse in accordance with regulations for one (Resident #12) of eleven (11) residents reviewed for medications. Specifically, on 03/11/2026, Certified Nurse Aide #20 administered medications to Resident #12. The findings include:The facility Medication Administration policy last reviewed 2/2026 documented that It is the policy of the facility to administer medication to all residents in accordance with physician or nurse practitioner orders to maintain residence optimal health. Nurses will log into the medications due section of the electronic medical administration record to administer medications as scheduled and nurses will sign the electronic medication administration record at the time of administration.The undated facility Certified Nursing Assistant Job Description documented the primary purpose of their position was to provide each of their assigned residents with routine daily nursing care and services in accordance with the resident assessment and care plan and any other duties that may be directed by their supervisor.The undated facility Licensed Practical Nurse Job Description documented they were responsible to direct the day-to-day functions of the certified nurse aides or other nursing personnel in accordance with current rules regulations and guidelines that govern the long term care facility, ensure that all assigned nursing personnel including certified nurse aides comply with the written policies and procedures established by the facility, prepare and administer medications as ordered by the physician, and ensure that assigned Certified Nurse Aides and other nursing personnel are performing their work assignments in accordance with acceptable nursing standards.The New York State Education Department Career and Technical Education for Nurse Aides (nysed.gov/career-technical-education) documented Nurse Aides were unlicensed New York State certified individuals who play an integral role on the healthcare team in long-term care or skilled nursing facilities (nursing homes). They perform non-medical services and support for residents who need help with activities of daily living.Resident #12 had diagnoses which included traumatic spinal cord dysfunction, deep vein thrombosis, and gastroesophageal reflux disease.The 2/11/2026 Minimum Data Set (resident assessment tool) admission assessment documented Resident #12 was able to make themselves understood, had clear speech and adequate vision, and had intact cognition.The physician orders dated 2/04/2026 documented Tizanidine 2 milligram tablets; administer two (2) tablets by oral route every 8 hours for muscle spasm; Pantoprazole 40 milligram; tablet administer one tablet by oral route once daily for gastro-esophageal reflux disease without esophagitis.The physician order dated 3/10/2026 documented Gabapentin 600 milligram tablet; administer one tablet by oral route three times a day for acute postprocedural pain,The March 2026 Medication Administration Record documented two Tizanidine 2 milligram tablets, one Gabapentin 600 milligram tablet, and one Pantoprazole 40 milligram tablet on 3/11/2026 were administered at 6:00 AM by Licensed Practical Nurse Unit Manager #4.The 3/11/2026 Medication Incident Investigation Report documented the occurrence that Certified Nurse Aide #20 administered two Tizanidine 2 milligram tablets, one Gabapentin 600 milligram tablet, and one Pantoprazole 40 milligram tablet to Resident #12 on 3/11/2026 at 6:00 AM. Statements written by Licensed Practical Nurse Unit Manager #4 and Certified Nurse Aide #20 documented the occurrence. On 8/04/2026 at 8:50 AM during an interview, Licensed Practical Nurse Unit Manager #4 stated that on 03/11/2026 at 5:00 AM, Resident #12 wanted their standing morning medications which included Pantoprazole and Tizanidine and Gabapentin and wanted to spend time with them, but they did not have much time to spend with Resident #12 so they brought Certified Nurse Aide #20 with them to spend time with the resident. Licensed Practical Nurse Unit Manager #4 gave Certified Nurse Aide #20 the resident's medications to give to Resident #12. Licensed Practical Nurse Unit Manager #4 stated they observed Resident #12 from the doorway taking the medications with no difficulty.On 8/04/2026 at 9:37 AM during an interview, the Director of Nursing stated they investigated the Medication Incident when Certified Nurse Aide #20 administered medications to Resident #12 and stated that Licensed Practical Nurse Unit Manager #4 observed that Resident #12 took the medications without difficulty.On 8/04/2026 at 3:29 PM during an interview, Certified Nurse Aide #20 stated they gave three (3) medications to Resident #12 with Licensed Practical Nurse Unit Manager #4 present and observing the administration.On 8/06/2026 at 4:05 PM during an interview with the facility Administrator and review of the facility's Certified Nurse Aide Job description, they stated Certified Nurse Aide #20 should not have administered medications to Resident #12, and Licensed Practical Nurse Unit Manger #4 should not have given Certified Nurse Aide #20 medications to administer to Resident #12.10 New York Code Rules and Regulations 415.11(c)(3)(ii)

Based on observation, interview, and record review conducted during survey, the facility did not ensure the New York State Department of Health was notified when an allegation of abuse was made for one of seven residents (Resident #15) reviewed for abuse. Specifically, Resident #15 reported an allegation of verbal abuse, and the facility did not report the allegation of abuse to the New York State Department of Health.The findings include: The facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Residents Property, last reviewed 02/03/2026, documented the Director of Nursing/Designee will coordinate an investigation of alleged violations and the facility will ensure that all alleged violations involving abuse are reported immediately but not later than 2 hours after the allegation is made to the administrator of the facility and to other officials including the State Survey Agency in accordance with State Law through established procedures.Resident #15 had diagnoses including schizoaffective disorder, hypertension and hyperlipidemia.The Minimum Data Set assessment dated [DATE] documented Resident #15 presented with intact cognition, there were no documented physical or verbal behaviors exhibited toward others during the review.A grievance form dated 06/07/2025 documented the resident verbalized being dissatisfied with a recent interaction with their certified nurse aide. The resident was interviewed, emotional support provided, and investigation conducted into nature of complaints. Certified nurse aide was removed from resident's assignment, inservice and re-education done. Resident made aware and satisfied with resolution.A Facility Soft File Investigation Form initiated 06/19/2025 documented Resident #15's alleged verbal abuse by Certified Nurse Aide #30. Certified Nurse Aide #30's statement dated 06/19/2025 documented they did not hear or know of anything happening on the unit with Resident #15. Certified Nurse Aide #30 completed a Customer Service Posttest and was in-serviced on abuse/neglect and customer service on 06/19/2025.There was no documented evidence that the facility reported the investigation of Resident #15's allegation of abuse to the New York State Department of Health. During an interview on 08/07/2026 at 11:23 AM the Director of Nursing stated on 06/13/2025 the Ombudsman made them, the facility Administrator, and the Director of Social Work aware of a letter Resident #15 had written on 06/11/2025 alleging Certified Nurse Aide #30 had been verbally aggressive and threatened Resident #15 on 06/07/2026. The Director of Nursing stated they were not aware of the letter until notified by the Ombudsman and stated after that the receptionist found the letter addressed to the Director of Nursing in a drawer at the front desk. On 06/19/2026 the Director of Nursing and facility Administrator interviewed Resident #15 regarding the letter Resident #15 wrote. During an interview on 08/07/2026 at 2:11 PM, the ombudsman stated Resident #15 wrote a letter and put copies of it in the mailboxes of the Administrator, Director of Nursing and Social Services (grievance officer) and emailed a copy of the letter to the ombudsman office. The resident felt threatened by Certified Nurse Aide #30. They stated on 06/23/2025, the Administrator showed the ombudsman a letter they had given to the resident that Certified Nurse Aide #30 had been removed from their care. 10 New York Codes, Rules and Regulations 415.4(b)(2)

Based on record review, interviews, and observations conducted during a survey, the facility failed to ensure a resident was provided with the necessary services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 of 5 residents reviewed for behavioral health. Specifically, Resident #5 refused 144 out of 178 doses of antipsychotic medications from March 2026 to June 2026 that contributed to symptoms of catatonia (withdrawal, intermittent mutism and posturing), weight loss, urinary tract infection and admission to hospital on 6/7/26. Findings include:Resident #5 was admitted to facility with the following diagnoses including: Non-Alzheimer's Dementia, Bipolar, and Schizophrenia. The 1/19/2026 Annual Minimum Data Set (resident assessment) documented Resident #5 had moderate impairment in cognition. It documented the resident sometimes felt lonely or isolated from those around them and received antipsychotics on a routine basis. The 11/27/2023 Psychoactive Medication Care Plan documented resident was at risk for side effects related to psychoactive medications. The documented interventions were to: administer medications as ordered by the physician, monitor for behaviors, monitor response to medications, notify physician if medications are refused because medications are ineffective in not taken regularly. The 3/18/24 physician order documented Fluphenazine (antipsychotic medication) 5 milligram/milliliter (liquid) give 2 milligrams by mouth 2 times a day for schizophrenia. The 3/11/26 physician documented Fluphenazine 1 milligram give 2 tablets, 2 times a day for catatonic schizophrenia. The 3/18/26 physician order documented Fluphenazine decanoate 25 milligram injection every 2 weeks for schizophrenia.The 4/07/2026 Psychiatric Consult documented a follow up with Resident #5 for medication nonadherence and features of catatonia including withdrawal, intermittent mutism and posturing. Due to a medication noncompliance Fluphenazine decanoate, an antipsychotic medication was initiated and administered on 4/2/2026. Resident #5 continued to present with catatonic features, including withdrawal, minimal engagement. Per nursing, appetite has improved and sleep remains normal. The plan documented to continue Fluphenazine decanoate for schizoaffective disorder to target symptoms of medication nonadherence, catatonic features, decreased oral intake, impaired functioning from baseline. The 4/20/2026 Medical Note written by Nurse Practitioner #1 documented resident seen for follow up dementia and urinary tract infection. Resident #5 had a history of dementia and selective mutism and was seen for follow up of urinary tract infection and cognitive status. Resident #5 remained minimally interactive at baseline with limited ability to report symptoms. Oral intake remained variable. Neuro consult was reviewed and recommendations included supportive care and delirium precautions. The plan was to initiate Donepezil (memory enhancement medication) 5 milligram at bedtime as recommended by neurology. Resident #5 continued on Ceftriaxone intravenous for a confirmed positive urinary tract infection with E. coli (Escherichia coli, bacteria in the colon). Previously noted medication noncompliance with refusal of oral antibiotics; currently tolerating intravenous therapy. No acute changes reported. Continue plan, neurology recommendations implemented with initiation of Donepezil. Continue close monitoring of infection response, hydration status, and cognitive baseline. The 4/20/26 Medical note written by Physician # 1 documented the resident was seen on 4/17/26 and was stable. The note did not document resident's continued refusal of antipsychotic medications.The 4/21/2026 Psychiatric Consult documented the resident was seen for medication nonadherence and catatonia. If symptoms worsen or new concerning features emerge, please transfer resident to a higher level of care for further evaluation. The 4/23/26 Care Plan meeting note documented interdisciplinary team met with Designated Representative #1 to discuss patient's progress thus far. Per nursing, resident was refusing medication in all routes. There was no documented evidence hospitalization was discussed to psychiatrically stabilize resident if symptoms worsen as recommended by psychiatrist in their notes on 4/21/2026.The 4/25/26 Medical note written by Physician #1 documented resident still refusing fluphenazine despite all attempts. It further documented they spoke to Resident #5 about taking medication and the resident agreed. The plan was to follow up with psychiatry.The March, April and May 2026 Medication Administration Records documented 144 refusals out of 178 doses of antipsychotic medications. Nurse Practitioner #1 documented they were made aware of antipsychotic medication refusals on 3/17/26, 4/7/26, 4/14/26, 4/16/26, 4/20/26 and 4/21/26. The 5/05/2026 Psychiatric Consult documented the resident was seen for medication nonadherence and catatonia. If symptoms worsen or new concerning features emerge, please transfer resident to a higher level of care for further evaluation.The 5/19/26 at 3:02 PM Nursing note documented Resident #5 refused all medications.The 5/13/26 Medical Note written by Nurse Practitioner #1 documented per nursing report Resident #5 refused all medications this tour. Medication review notable for intermittent refusal of oral medications including fluphenazine (antipsychotic) by mouth per medication administration record review. The plan was to continue behavioral redirection and encouragement; Monitor psychiatric status and medication adherence closely.The 5/27/26 at 2:37 PM Nursing note documented Resident #5 refused all medications.The 5/27/26 Medical note written by Nurse Practitioner #5 documented per nursing report Resident #5 refused all medications this tour. The plan was to provide education and reassurance as tolerated, Re-approach later and administer medications if resident agrees, document refusal and notify provider/family.The 6/07/2026 Nursing note documented Next of Kin #1 called 911 when they visited Resident #5 and requested the resident be transferred to the emergency room for further evaluation. The Next of Kin #1 reported the resident experienced a decline in mental health. Emergency Medical Services contacted receiving hospital and proceeded with transfer. The 6/10/26 Hospital Discharge Paperwork documented Resident #5 was admitted to hospital for evaluation of altered mental status, agitation, urinary tract infection, poor oral intake and reported weight loss. During an interview on 7/13/2026 at 12:31 PM, Registered Nurse Unit Manager #2 stated Resident #5 took one (1) or two (2) of the antipsychotic medication injections and stated the physician was informed of the refusal. They further stated the physician was informed and hospitalization was discussed with the physician, however, they were unable to find documented evidence. During a follow up interview on 7/14/2026 at 11:16 AM Designated Representative #1 stated they were not asked about sending Resident #5 to the hospital for psychiatric evaluation to stabilize the resident. They stated they would have agreed to send the resident to the hospital. During an interview on 7/14/2026 at 12:41 PM, the Psychiatrist stated when they held the fluphenazine due to abnormal labs, mild catatonia happened (withdrawal, intermittent mutism and posturing). Psychiatrist stated holding the antipsychotic medication may have contributed to catatonia, but it was very mild. The Psychiatrist stated the resident had some improvement, after medication was restarted, and did not see any concerns. In March, Resident #5 started to refuse any form of oral antipsychotic medication (fluphenazine), so a long-acting injection (fluphenazine) was ordered. They stated the resident was improving in April; the resident was talking more and engaging but they were unaware the resident was not taking the long-acting antipsychotic injection. The Psychiatrist stated there was no discussion with the interdisciplinary team about hospitalization for psychiatric stabilization. If they had been aware the long-acting antipsychotic injectable medication was not being taken regularly they would have sent Resident #5 out to the hospital within a month to stabilize the resident's medication. They further stated when the resident did not take their antipsychotic medication it would cause psychiatric decompensation. The psychiatrist stated they were also not informed that the resident had a urinary tract infection, which could have contributed to altered mental status. During a follow up interview on 7/24/2026 at 12:27 PM, Physician #1 stated they had discussions about hospitalization to psychiatrically stabilize the resident, but Resident #5 and Designated Representative #1 refused. Physician #1 was unable to find documented evidence of these conversations. 10 NYCRR 415.12(f)(1)

Based on record review, interviews, and observations conducted during survey the facility failed to ensure residents receive services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain for 1 of 5 residents reviewed for antibiotics. Specifically, Resident #5 was determined to have a urinary tract infection on 4/13/26, refused antibiotics in all forms and there was no documented follow up. Resident was admitted to hospital on [DATE] with a urinary tract infection. The findings include: Resident #5 was admitted to facility with the following diagnoses including: Non-Alzheimer's Dementia, Bipolar, and Schizophrenia. The 1/19/2026 Annual Minimum Data Set (resident assessment) documented Resident #5 had moderate impairment in cognition. It documented Resident #5 was always continent of bowel and bladder and needed supervision for toileting. The 4/13/2026 urine test documented Resident #5 had a urinary tract infection. The 4/14/26 Physician Order documented Cipro (antibiotic) 500 milligram by mouth every 12 hours for 7 days for urinary tract infection. The April 2026 Medication Administration Record documented the 4/14/26 Physician Order Cipro 500 milligram by mouth every 12 hours for 7 days for urinary tract infection, 4 out of 5 doses refused. The April 2026 Medication Administration Record documented dextrose 5% and 0.45% sodium chloride intravenous solution: infuse 70 cc per hour by intravenous route every shift was documented refused on 4/16/2026. The 4/16/26 Nursing Note written by Registered Nurse Unit Manager #2 at 10:18 PM documented resident continues to refuse all medications. Resident #5 was previously on Cipro 500 mg by mouth twice daily for 7 days for urinary tract infection; however resident remains non compliant with all medications by mouth. Nurse Practitioner #1 was made aware. New orders received for ceftriaxone 1 gram daily for 7 days. Designated Representative #1 was made aware. The 4/16/26 Medical Note written by Nurse Practitioner #1 documented Resident #5 seen for follow up for urinary tract infection. It further documented Resident #5 has been refusing oral medications including antibiotics.The 4/17/26 Physician Order documented Ceftriaxone (antibitotic) 1 gram solution for injection intramuscular 1 time daily for 7 days for urinary tract infection. The April 2026 Medication Administration Record documented the 4/17/26 Physician Order Ceftriaxone 1 gram solution for injection intramuscular 1 time daily for 7 days for urinary tract infection, 6 out of 6 doses refused. Resident #5 refused 10 out of 11 doses of antibiotic medications via intravenous, intramuscular and oral forms. The 4/20/2026 Medical Note written by Nurse Practitioner #1 documented resident seen for follow up dementia and urinary tract infection. Resident #5 had a history of dementia and selective mutism and was seen for follow up of urinary tract infection and cognitive status. Resident #5 remained minimally interactive at baseline with limited ability to report symptoms. Resident #5 continued on Ceftriaxone intravenous for a confirmed positive urinary tract infection with E. coli (Escherichia coli, bacteria in the colon). Previously noted medication noncompliance with refusal of oral antibiotics; currently tolerating intravenous therapy. The documented plan was to continue close monitoring of infection response, hydration status, and cognitive baseline. The 4/20/26 Medical Note written by Nurse Practitioner #1 documented Resident #5 seen for follow up for urinary tract infection. It documented resident refused Ceftriaxone. Previously noted for medication non compliance with refusal of oral antibiotics, currently tolerating intravenous therapy. It documented to continue to use intravenous route for antibiotics The 4/22/26 at 2:24 PM Nursing note and 4/23/26 at 2:34 PM Nursing note written by Licensed Practical Nurse #44 documented Resident #5 refused all medications during this tour. It documented Nurse Practitioner #1 was notified of medication refusals. The 4/23/26 Care Plan meeting note documented interdisciplinary team met with Designated Representative #1 to discuss patient's progress thus far. Per nursing, Resident #5 refused medication in all routes. The 4/26/2026 Nursing note documented despite encouragment and reapproach 3 times, resident refused for IV line to be inserted. Physician #1 was made aware and placed an order for intravenous fluids and intravenous antibiotics to be discontinued. Resident to start on intamuscular ceftriaxone. There was no documented evidence of follow up related to Resident #5 refusals to take any form of antibiotics for their urinary tract infection. The 6/07/2026 Nursing note documented Next of Kin #1 called 911 when they visited Resident #5 and requested the resident be transferred to the emergency room for further evaluation. The Next of Kin #1 reported the resident experienced a decline in mental health. Emergency Medical Services contacted receiving hospital and proceeded with transfer. The 6/10/26 Hospital Discharge Paperwork documented Resident #5 was admitted to hospital for evaluation of altered mental status, agitation, poor oral intake and reported weight loss. Initial evaluation was notable for findings consistent with a urinary tract infection. During an interview on 7/13/2026 at 12:31 PM, Registered Nurse Unit Manager #2 Registered Nurse Unit Manager #2 stated the 4/13/2026 urinalysis documented the resident was positive for a urinary tract infection. They stated the resident was prescribed antibiotics and refused to take them. They further stated the physician was informed and hospitalization was discussed with the physician, however, they were unable to find documented evidence. Registered Nurse Unit Manager #2 reviewed the hospital records and acknowledged that Resident #5 had diagnosis of urinary tract infection. During an interview on 7/14/2026 at 9:54 AM, Physician #1 stated they were not informed by the nursing staff that the resident did not take the injectable antibiotic. They stated Nurse Practitioner #1 may have been informed but it was not communicated to them and they relied on the nursing staff to inform them. They stated they found out after the resident was hospitalized that they still had a urinary tract infection. Physician #1 acknowledged they did not follow up on antibiotic refusals and stated if they would have been aware of the refusals they would have repeated the urine sample. During an interview on 7/14/2026 at 12:41 PM, the Psychiatrist stated they were also never informed that the resident had a urinary tract infection, which could contribute to the resident's altered mental status. 10 NYCRR 415.12(d)(1)

Based on observation, interview, and record review conducted during the abbreviated survey (NY00383393), the facility did not ensure a resident remained free from physical abuse. This was evident for one (1) (Resident #1) of four (4) total sampled residents. Specifically, Resident #1 reported they were hit in their groin by Certified Nurse Aide #3 on 6/11/2025 at approximately 1:30 AM. This resulted in psychosocial harm that did not rise to level of Immediate Jeopardy. The findings are: The facility policy titled Abuse Prevention & Reporting, dated 1/3/2025, documented any employee involved in abuse will be disciplined appropriately. Resident #1 had diagnoses of hydrocephalus (fluid on the brain) and major depressive disorder. The Minimum Data Set 3.0 assessment (an assessment tool) dated 5/16/2025 documented Resident #1 presented with mild cognitive impairment with a Brief Interview for Mental Status score of 14 out of 15. The Comprehensive Care Plan related to victimization, initiated 5/10/2025 and last reviewed on 6/16/2025, documented Resident #1 would verbalize feeling safe. Documented interventions included encouraging Resident #1 to verbalize their feelings and report to staff if feeling threatened. The Social Work Note dated 6/11/2025 documented Resident #1 reported a Certified Nurse Aide (later identified as Certified Nurse Aide #3) on the night shift struck them in the groin. Resident #1's roommate, Resident #3, was present and witnessed the incident. The Nurse Practitioner note dated 6/11/2025 documented Resident #1 reported being hit in the groin by a Certified Nurse Aide. There were no visible injuries to Resident #1's groin area and an incident investigation was initiated. The Physician Orders documented Resident #1 was ordered to receive psychiatry and psychology consults on 6/11/2025. A Psychology Consult dated 6/12/2025 documented Resident #1 was previously evaluated for psychological services upon admission to the facility and declined ongoing services because they were adequately coping. Resident #1 was evaluated by the psychologist on 6/12/2025 after reporting they were punched in the groin by a Certified Nurse Aide on 6/11/2025. Resident #1 endorsed sadness/frustration when describing the incident, became teary at times, and stated everything was going well, and then this had to happen. The Social Work Note dated 6/13/2025 documented the Director of Social Work followed up with Resident #1 regarding their abuse complaint and the resident did not express any negative concerns; however, they continued to request discharge home. The facility Investigation Form, initiated 6/11/2025 and completed 6/18/2025, documented Resident #1 and Resident #3 provided consistent and detailed statements that Resident #1 was by their bed in their room on 6/11/2025 at 1:30 AM when Certified Nurse Aide #3 pushed Resident #1 onto the bed and punched them in the groin. Resident #1 and Resident #3 picked Certified Nurse Aide #3 out of a photo lineup of facility staff. The facility investigation documented there was reasonable cause to believe that resident abuse occurred. Certified Nurse Aide #3 was suspended pending investigation and terminated as of 6/17/2025. On 6/16/2025 at 1:38 PM, Resident #1 was interviewed and stated they recalled being hit in the groin by Certified Nurse Aide #3. They reported the incident to the Director of Social Work and wanted to be discharged from the facility. Resident #1 stated their physical pain subsided, but they were emotionally affected and distraught by the experience. Resident #1 became tearful and wept during the interview. On 6/17/2025 at 11:45 AM, the Director of Social Work was interviewed and stated they arrived at work on 6/11/2025 and were informed by the unit manager that Resident #1 requested to speak with them. The Director of Social Work stated Resident #1 reported the Certified Nurse Aide from the night shift pushed them onto their bed and struck them in the groin. The Director of Social Work corroborated Resident #1's allegation by interviewing Resident #3 and immediately informed the Administrator, who was responsible for reporting the allegation to the New York State Department of Health. On 6/17/2025 at 1:56 PM, in a phone interview Certified Nurse Aide #3 stated they recalled working with Resident #1 on 6/11/2025 but denied hitting the resident in the groin. On 6/17/2025 at 2:46 PM the Administrator was interviewed and stated the facility determined abuse occurred and Certified Nurse Aide #3 will be terminated. In-services regarding abuse prevention were ongoing. On 6/17/2025 at 1:21 PM, the Director of Nursing was interviewed and stated they were made aware of Resident #1's abuse allegation on 6/11/2025 and determined Certified Nurse Aide #3's involvement through staffing sheets and a photo lineup presented to Resident #1 and Resident #3. The Director of Nursing stated the facility determined that abuse did occur and would terminate the Certified Nursing Aide #3. On 6/16/2025 at 12:26 PM and 6/17/2025 at 2:46 PM, the Administrator was interviewed and stated the Director of Social Work informed them Resident #1 alleged a Certified Nurse Aide hit them on 6/11/2025. It was determined through investigation that Certified Nurse Aide #3 was the alleged perpetrator. The police were notified, came to the facility, and met with Resident #1. The Nurse Practitioner and Resident #1's family were made aware of Resident #1's allegation and facility's pending investigation. All staff, including Certified Nurse Aide #3, had been in serviced on abuse prevention in 5/2025 and 6/2025, and abuse prevention in-services were ongoing in relation to Resident #1's allegation. The facility had until 6/18/2025 to complete their investigation and the summary of investigative findings will be sent to the New York State Department of Health once completed. The Administrator stated Certified Nurse Aide #3 would be terminated from facility employment because the abuse did occur. During a telephone interview on 6/17/2025 at 2:32 PM, the Medical Director stated they were aware of the incident that occurred on 6/11/2025 between Resident #1 and Certified Nurse Aide #3. The Medical Director stated Resident #1 was assessed and did not present with ongoing pain or injury to the groin area. The Medical Director stated they agreed with the facility's decision to report the incident, was informed by the facility Certified Nurse Aide #3 was removed from direct patient care, and believed the facility decided to terminate Certified Nurse Aide #3. 10 NYCRR 415.4(b)(1)(i)

Based on observation, record review, and interview conducted during the recertification and abbreviated survey (NY00365646) from 3/5/24 to 3/12/24, it was determined the facility did not ensure residents received adequate supervision to prevent accidents for 1 of 6 residents (Resident #165) reviewed for accidents. Specifically, a two (2) person assist was not provided as per care plan resulting in Resident #165 rolling to the floor from the bed and sustaining a laceration/abrasion to their forehead, bridge of nose, and left hip. The findings include: Resident #165 was admitted to the facility with diagnoses including hypotension, pneumonia, and malnutrition. The November 2024 Certified Nurse Aide Instructions documented resident required one- person physical assistance for bed mobility and bathing. The Activities of Daily Living Care Plan with a revision date of 11/28/24 documented dependent for bathing and required 2-person physical assist for bathing and bed mobility, half side rails to be used as enablers for bed mobility. The December 2024 Certified Nurse Aide Instructions documented the resident was changed (undated) from a one-person physical assist to a 2-person physical assist for bathing and bed mobility. The 12/5/24 Admission 5-day Minimum Data Set Resident #165 was cognitively intact was dependent for bed mobility and transfers, used a wheelchair and was dependent for propelling wheelchair and further documented the resident was on the rehabilitation program and received occupational therapy and physical therapy for 120 minutes each. The 12/18/24 Accident/Incident Report documented in the conclusion, Resident #165 was receiving care by Certified Nurse Aide #8 at bedside, when they turned to get a fresh wash cloth from the bedside table to clean the body, the resident was rolling off the bed. Certified Nurse Aide #8 attempted to hold the resident, but the resident was already on the floor. The fall was witnessed, caused by resident intent or behavior. The resident was sent to hospital for Cat Scan and returned in stable condition. No treatment necessary to areas. Will observe for signs and symptoms of infection. Referred to rehabilitation. Resident's care was changed to 2 -person assistance with care. No evidence of abuse, neglect or mistreatment. The 12/19/24 Fall Assessment documented resident was unable to recall details of the incident. Resident was extensive assist of 1 person and uses a wheelchair for mobility, unable to lock and unlock wheelchair. Resident was alert but confused and able to follow simple directions. Recommend close supervision. Resident screened status post fall on 12/18/24. Resident noted with small laceration to anterior forehead on the bridge of nose; small, closed abrasion to left hip/pelvic and left trochanter. Resident hospitalized and returned on the same day. CAT scan of the brain is negative for any acute bleeding. The CAT of the bones does not show any fractures. Resident will be reassessed for possible side rails. Resident recommended to have low bed and floor mats for fall prevention. Resident requires frequent supervision due to fall decreased safety awareness. Resident will continue occupational therapy program in order to facilitate participation in functional activities and decrease caregiver burden. During interview on 3/11/25 at 1:37 PM Certified Nurse Aide #8 stated when they were providing care, they turned to get the towel to wash the resident, and the resident rolled onto floor. Certified Nurse Aide #8 stated the resident was able to move around in bed and was able to move onto their side when asked. Certified Nurse Aide #8 stated Resident #165 was a 1- person assist for bed mobility and bathing and stated they never saw any Certified Nurse Aides providing a 2- person assist for care of Resident #165 before or after the falls. Certified Nurse Aide #8 stated the only time they asked for assistance from another aide was to help move the resident up toward the head of the bed. Certified Nurse Aide #8 stated the nursing staff are not good with communication, and they don't tell the Certified Nurse Aides of changes with the resident's care. During interview on 3/12/25 at 5:54 PM during an interview, Physical Therapist #9 stated Resident #165 required 2-person extensive assist on 11/26/24 status post hospitalization . Resident was not making any more progress, so they discharged the resident on 12/6/24 and the resident continued to require extensive assist of 2 person for transfers and bed mobility. 10 NYCRR 415.12(h)(2) 51874

Based on observation, interview, and record review during the recertification survey from 3/5/25 to 3/12/25, the facility did not ensure residents had the right to a dignified experience for 1 of 4 residents (Resident #24) reviewed for dignity. Specifically, Resident #24 was observed multiple times after meals with food/crumbs on their chin and their gown. The findings include: Resident #24 had diagnoses including cerebral infarction (stroke), hemiplegia affecting left non dominant side, and dementia. A Resident Care Plan dated 3/30/21 titled Activities of Daily Living documented the resident required a one person assist with bathing, partial/moderate assistance for upper body dressing, and supervision or touching assistance for eating and personal /general hygiene. The Quarterly Minimum Data Set (an assessment tool) dated 12/26/24 documented Resident #24 had moderate cognitive impairment, upper and lower extremity impairment on one side and required supervision/touching assistance with eating and hygiene. During an observation on 3/05/25 at 10:35 AM, Resident #24 was observed in bed with dried food/crumbs on their chin and on their gown. During an observation on 03/05/25 at 11:48 AM , Resident #24 was observed in bed with dried food /crumbs on chin and on their gown. During an observation on 3/07/25 at 10:04 AM, Resident #24 was observed in bed with food/cereal on their gown. During an observation on 03/07/25 at 01:30 PM, Resident #24 was observed in the day room after lunch with food residue on their face. During an interview on 03/11/25 at 10:51 AM, Certified Nurse Aide #3 stated Resident #24 was independent when eating but. They stated when their meal was finished, the tray would be removed and activities of daily living, including bathing and change of clothes was usually done a little later. They stated the expectation was the residents face and hands were to be cleaned after meals if needed. They stated when working with Resident #24, they cleaned the resident's face, hands, clothing as needed after meals. During an interview on 03/11/25 at 11:27 AM, the Director of Nursing stated when resident meals were completed, tray/food and clothing protector/napkins should be removed and the resident should have their hands and face cleaned as needed. The Director of Nursing stated residents should not have food remains on their clothing or face/hands after meals. 10 NYCRR 415.3 (d)(i)(i)

Based on record review, observations, and interviews conducted during a recertification survey from 03/05/2025 to 03/12/2025, the facility did not ensure that the residents' advance directives were accurate for 1 (Resident # 82) of 24 residents reviewed. Specifically, Resident #82's Medical Orders for Life Sustaining Treatment form was changed from Do Not Resuscitate (allow a natural death if the heart stops beating or resident stops breathing) to Full Code (perform Cardio-Pulmonary Resuscitation) and the physician orders and facility identifiers (system used to alert staff the resident's code status) were not updated to reflect the resident's wishes. The findings include: The facility policy, Advanced Directives, with a 12/13/2024 review date, documented the individual's wishes on advance directives will be identified and honored by the facility. All Do Not Resuscitate orders must align with the corresponding Medical Orders for Life Sustaining Treatment documentation to maintain accuracy in the resident's care preferences. A Do Not Resuscitate alert will be placed in the resident's Electronic Medical Record for immediate visibility to all relevant staff. A red sticker will be placed as a visual indicator on the resident's armband or next to the resident's name on the door. Resident's Advance Directives will reviewed upon admission, and re-admission from the hospital, quarterly, and annually. Resident # 82 had diagnoses including Chronic Obstructive Pulmonary Disease, Asthma and Major Depressive disorder. The Medical Orders for Life Sustaining Treatment form dated 9/05/2023 documented a Do Not Resuscitate Order (allow natural death). The quarterly Minimum Data Set (an assessment tool) dated 12/05/2024 documented the resident was cognitively intact. The social services note dated 12/19/2024 documented that during the 12/19/2024 quarterly care plan meeting, Resident #82 was present and updated the Medical Orders for Life Sustaining Treatment form to a Cardio-Pulmonary Resuscitation order (full code). The 12/19/2024 Medical Order for Life Sustaining Treatment was signed by the physician on 12/26/2024. The physician orders for Advance Directives, last renewed on 2/19/25, documented Do Not Resuscitate, Do Not Intubate, no feeding tube, a trial period of IV fluids, use antibiotics to treat infections if medically indicated. During a review of Resident #82's electronic medical record on 3/6/2025 at 11:20 AM, a Do Not Resuscitate alert was visible. During an observation on 3/06/2025 at 3:26 PM, a red sticker was seen on Resident #82's door name plate. During an observation on 3/06/2025 at 3:29 PM, a facility binder, containing Medical Orders Life Sustaining Treatment forms for all the residents on the unit, had the 09/05/2023 Medical Order for Life Sustaining Treatment for Resident #82. During an interview on 03/06/2025 at 3:36 PM, the facility Social Work Director stated when an advanced directive change was known, a new Medical Orders for Life Sustaining Treatment form was started and given to the Nurse Practitioner or Physician to sign. Then it was updated in the electronic medical record and the updated copy was placed in the binder in the unit. They stated usually the Nurse Practitioner or Physician put the orders in or would ask the nurses to put the changed orders in. During the quarterly care meeting on 12/19/2024, Resident #82 changed their Medical Orders for Life Sustaining Treatment from Do Not Resuscitate to Full Code. The Social Worker Director stated they did not know why Residents #82's physician orders or electronic medical record were not updated. During an interview on 03/10/2025 at 11:25 AM, Licensed Practical Nurse #1 stated staff identified residents who had advanced directives by the red dot on the door, red dot in computer and red dot on the wrist band. When a resident had to leave the facility to go to the hospital, the nurse made a copy of Medical Orders for Life Sustaining Treatment, resident's face sheet, and medication list to send with the emergency medical system team. They stated nurses checked for new orders in the computer when coming on duty. Licensed Practical Nurse #1 stated there was no formal reporting if advance directives changed unless a new order was put in place. Licensed Practical Nurse #1 stated they thought Resident #82's Medical Orders for Life Sustaining Treatment was Do Not Resuscitate and was not aware of the change from Do Not Resuscitate to Full Code. During an interview on 03/10/2025 at 4:10 PM, the Director of Nursing stated social workers made changes to the advance directives after being told by resident or family. The social worker was supposed to notify nursing after a new Medical Orders for Life Sustaining Treatment form was signed by the physician. The nurse was responsible for updating orders in the computer. The Director of Nursing did not know why Residents #82's orders were not updated. 10 NYCRR 415.3(e)(1)(ii)

Based on observation and interview conducted during the recertification survey conducted from 3/5/25 to 3/12/25, the facility did not ensure that a clean, comfortable, and homelike environment was provided. Specifically, room C-19-B had broken window clips, room C-9-B had a broken radiator cover, a window shade that was stained, and black scuff marks on the wall between the window and resident dresser, room A-17 had a faulty window unit and faulty sealed Packaged Terminal Air Conditioner unit which allowed cold outside air to enter the room. The findings include: The facility policy titled Maintenance/Engineering policy dated 7/24/24 documented provide a safe, functional and effective environment for residents, staff and all individuals who provide care to residents and all individuals who visit the facility. During an observation on 03/06/25 at 12:08 PM of room C-19-B, a hand-written sign was observed on the lower left side of the window stating Do not open this window. A piece of the broken window opening latch was observed on the windowsill. During an observation on 03/06/25 at 12:12 PM of room C-9-B, the radiator cover was observed hanging/broken on the right side below the vents. The window shade was observed stained on the left and right lower sides. The wall between the resident's dresser and radiator/window area was observed with black scuff marks. During an interview on 03/12/25 at 12:23 PM the Director of Maintenance stated they were not aware of the sign posted on room C-19-B window and was not aware who wrote the sign. They stated the broken latches on the top of the window allowed for windows to be opened for cleaning purposes. They stated they have not received a work order request for repairs. The Director of Maintenance stated radiator cover bases frequently fall out if hit with a wheelchair or mechanical lift and can be snapped or drilled back in place. They stated window shades that are dirty or broken will need to be replaced. They stated they were not aware of concerns in room C-9-B and had not received a work order for repairs. They stated the facility currently has an order pending (document observed) for replacement shades for building. The Director of Maintenance stated staff members should report all environment concerns to their unit manager who should enter a work order into facility maintenance software program for repairs to be completed or call/page/e-mail environmental staff with concerns. During an interview on 03/11/25 at 11:35 AM, the Director of Maintenance stated the facility had three windows that were installed incorrectly which allows outside air to enter rooms and room A-17 was one of the three rooms with the faulty windows. They stated it is known that the Packaged Terminal Air Conditioner unit requires a correct seal to not allow outside air into the room. They stated the facility did receive a complaint on 12/10/25 from the resident in room A-17 that cold air was coming in through the Packaged Terminal Air Conditioner unit. The Director of Maintenance stated the facility was working with the window manufacture to determine if the repairs will be covered by the warranty. In addition, the facility is waiting for warmer weather to complete the repairs to the Packaged Terminal Air Conditioner unit. During an observation on 03/11/25 at 11:50 AM, room A-17 window panes could be moved back and forth allowing outside air to enter the room. 10 NYCRR 415.5(h)(2) 51874

Based on observations, interviews and record reviews conducted during a recertification survey from 3/5/25 to 3/12/25 it was determined that for 1 of 1 residents (Resident #10) reviewed for skin conditions the facility did not ensure that injuries of unknown origin were reported to the state agency. Specifically, the state department was not notified after the 3/4/25 Accident/Incident Report documented Resident #10 was observed with discoloration that suddenly appeared on the right side of the resident's face. The findings include: Resident #10 was admitted with diagnoses including Congestive Heart Failure, Non-Alzheimer's Dementia, and Seizure Disorder. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #10 had severely impaired cognition, required partial to moderate assist for bed mobility and transfer; it further documented and had no falls. The 2/18/25 Accident/Incident report documented the resident was being given care by the certified nurse aide when the resident was playing/fidgeting with bed controls, and it suddenly swung into the resident's face. It further documented a nurse was notified and no injury noted. Abuse ruled out. There was no documented evidence of right eye/face bruising in the electronic medical record between 2/18/25 and 3/4/25. The 3/4/25 Accident/Incident documented Resident #10 was observed with discoloration that suddenly appeared on the right side of the resident's face. Resident alert and at baseline. Statements were taken from of all the staff on the unit. There were no recent falls or seizure activity. Resident was noted with movements that are somewhat erratic with control. Resident noted with recent incident with the bed controls swung towards their face per review of records causing injury at the time however it's reasonable to presume that this is the cause of the old nature of the bruise. Certified Nurse Aide #7 stated they were providing care, and resident was fidgeting with bed controls and the remote accidentally hit the resident in the face. The physician was made aware and had no new orders. The documented recommendation was for the bed remote cord to be stretched out as needed. The 3/4/25 medical progress note documented the resident was seen for what appeared to be an old right eye bruise.The area is showing signs of healing different stages of bruising. There were no signs of vision impairment. No further injury observed. Continue to monitor. On 3/05/25 at 2:15 PM, Resident #10 was observed with a yellowish bruise on the right cheek. During interview on 3/12/25 at 12:16 PM the Director of Nursing stated they were not aware Resident #10 had bruising until the 3/4/25 incident report was initiated. They stated they did not feel it was an injury of unknown origin as they attributed the bruising to the incident on 2/18/24. The Director of Nursing stated time had passed from the previous incident and should have considered the 3/4/25 reported bruising to be an injury of unknown origin. During interview on 3/12/25 at 12:25 PM, Licensed Practical Nurse #5 stated they were surprised when they received a call from the facility on 3/4/25 inquiring about the bruise on Resident #10's face. They stated they told the caller they did not see a bruise on the residents face from 2/18/25-3/4/25 and were not sure the bruise on Resident #10 right cheek was from the 2/18/25 incident. During interview on 3/12/25 at 12:46 PM, the Nurse Practitioner stated on 3/4/25 when they assessed the resident and wrote their note, it was the first time bruising was reported to them. They further stated prior to that date they had no knowledge of Resident #10 having a bruise. The Nurse Practitioner stated the bruise on Resident #10's right cheek was of unknown origin. The Nurse Practitioner stated staff were unable to explain what happened to Resident #10. During interview on 3/12/25 at 12:47 PM, the Director of Nursing stated prior to the nurse practitioner conducting an assessment of Resident #10, they did not know where the bruising came from. The Director of Nursing stated when they started collecting statements for the 3/4/25 incident report staff told them the bruise was already there. The Director of Nursing stated an injury of unknown origin should have been reported within 2 hours and further stated Incident Reporting In-Service had not been done. NYCRR 415.4(b)(2) .

Based on record review and interview conducted during recertification and abbreviated survey (NY00365960) from 03/05/2025 to 03/12/2025, the facility did not ensure that the resident's care plan was reviewed and revised timely for 1 of 2 residents (Resident #164) reviewed for falls. Specifically, Resident #164's care plan was not reviewed or updated to reflect new interventions after a medical assessment on 11/29/24 and a fall on 12/2/24. The findings include: Resident #164 was admitted to the facility with diagnoses including intracranial injury, benign prostatic hyperplasia, and weakness. The Admission assessment dated [DATE] documented Resident #164 had three or more falls in the last three months and had balance problem while standing, balance problem while walking, decreased muscular coordination, change in gait pattern when walking through doorway, and jerking or unstable when making turns resulting in a Fall Risk Assessment score of 21 (High Risk for falls). The 11/26/24 Care Plan Report documented risk for falls, orient to surroundings and routine on unit, introduce to roommate and staff. The Medical Progress Note dated 11/29/2024 documented deficits in mobility and activities of daily living due to weakness, balance impairment and debility. Continue with physical therapy/occupational therapy focusing on improving balance, increasing endurance and tolerance to exercise. Continue reviewing blood pressures and discuss with therapy to monitor of orthostatic hypotension limiting functional therapy progress and falls. High risk of falls if hypotension develops. This could result in injuries requiring readmission to the hospital and possible surgical intervention. The Incident Report dated 12/02/2024 documented that the resident had an unwitnessed fall in their room with complaints of pelvic pain. The resident was sent to a hospital emergency room for examination. The facility physician ordered x-rays of bilateral hips and pelvis. The x-rays were negative for fractures. There was no documented evidence in the electronic medical record that care plan interventions were updated after the 12/2/24 fall. The Incident Report dated 12/08/2024 documented the resident had an unwitnessed fall in their room resulting in injuries. The resident had a laceration to their head and bruises on both knees. The resident was sent to a hospital emergency room for examination. The facility physician ordered x-rays of the residents' knees. The x-rays were negative for fractures. During an interview on 03/12/25 at 11:25 AM, the Director of Nursing stated the Care Plan Report had two fall interventions dated 11/26/2024. The Director of Nursing stated the Care Plan Report should have been reviewed and updated with new interventions after the 12/2/24 fall but, that had not been done. During an interview on 03/12/2025 at 1:43 PM, Licensed Practical Nurse #1 stated care plan interventions are added over the course of a residents stay. All care plans are supposed to be reviewed after a fall or change of condition and new interventions are added if necessary. 10 NYCRR 415.11 (c)(2)(i-iii)

Based on observation, record review, and interview conducted during the recertification survey from 3/5/25-3/12/25, the facility did not ensure each Resident who was unable to carry out activities of daily living received the necessary care and services to maintain good personal hygiene for 2 (Residents #52 and #57) of 3 Residents reviewed for Activities of a Daily Living. Specifically, Resident #52 and #57 who required dependent assistance with Activities of Daily Living, were observed during multiple observations with fingernails that were long and ungroomed. The findings include: The facility policy titled Activities of Daily Living, reviewed 7/28/24, documented: It is the policy of this center to provide activity of daily living care to all Residents based on assessment of needs. 1) Resident #52 was admitted [DATE]. Diagnoses included quadriplegia, abnormalities of gait and mobility, and major depressive disorder. The Annual Minimum Data Set (a resident assessment tool) dated 1/2/25 documented Resident #52 was cognitively intact, was dependent on staff for toileting, bathing and lower body dressing, and required substantial/maximal assistance for personal hygiene. A Resident care plan dated 10/20/20 titled Activities of Daily Living Functional/Rehabilitation Potential documented they required a one-person physical assist for hygiene. A physician order dated 12/18/24 documented for the nurse to check the condition of skin on shower days. During an observation and interview on 3/5/25 at 11:05 AM, Resident #52 was in bed with bilateral hand contractures and fingernails that were long and ungroomed. Resident #52 stated their fingernails were rarely cut and the last time was a while ago. During an observation on 03/06/25 at 08:43 AM, bilateral fingernails were observed long and ungroomed. During an observation on 03/10/25 at 01:25 PM, Resident was observed in wheelchair. Bilateral fingernails were long and ungroomed. During a follow-up interview on 3/12/25 at 12:26 PM, Resident #52 stated they had reported long nails to Certified Nurse Aides in the past. Resident #52 stated sometimes they would be cut but they frequently had to wait. 2) Resident #57 was admitted on [DATE]. Diagnoses include: metabolic encephalopathy, sepsis, iron deficiency anemia. The Admission Minimum Data Set (a Resident assessment tool) dated 1/27/25 documented Resident #57 had moderately impaired cognition. The resident's care plan dated 1/14/25 titled Nursing Activities of Daily Living documented the resident required one person assistance for bathing and partial/moderate assistance for hygiene. A physician order dated 2/19/25 documented for the nurse to check the condition of skin on shower days. During an observation on 03/07/25 at 10:20 AM, Resident #57 was resting in bed with bilateral long, ungroomed fingernails. During an observation on 03/10/25 at 11:55 AM, Resident #57 was in main dining room with bilateral long, ungroomed fingernails. During an observation on 03/11/25 at 9:06 AM, Resident #57 was in bed with bilateral long, ungroomed fingernails. During an interview on 03/10/25 at 11:37 AM, Certified Nurse Aide #10 stated they provided activities of daily living cares to residents on the unit. They stated personal hygiene was provided daily. They stated Certified Nurse Aides were responsible for cutting and grooming nails for non-diabetic residents. During an interview on 03/11/25 at 11:06 AM, Registered Nurse Unit Manager #11 stated that the expectation was that Certified Nurse Aides provided nail care (cutting and grooming) for all non-diabetic residents. They stated that Nurses and Nurse Managers on the unit were responsible for supervision to ensure tasks were completed. They stated residents should not have long and ungroomed nails. During an interview on 03/11/25 at 11:24 AM, the Director of Nursing stated that residents' nails should be kept short and well-groomed with no sharp edges. Nail care should be completed as needed during cares. On shower days, a full skin assessment including nail care should be conducted. They stated Certified Nurse Aides were responsible for resident hand nail care except for diabetics. 10 NYCRR 415.12(a)(2)

Based on observation, interview, and record review during the recertification survey from 3/5/25 to 3/12/25, the facility did not ensure appropriate care was provided in accordance with professional standards of practice for 1 of 1 residents (Resident #10) reviewed for Skin Conditions. Specifically, on 2/18/25 the registered nurse was not made aware, and there was no documented evidence that a registered nurse assessment was conducted after Resident #10 was hit in the face with the bed control while cares were being provided by Certified Nurse Aide #7. The findings include: Resident #10 was admitted to the facility with diagnoses including Congestive Heart Failure, Non-Alzheimer's Dementia, and Seizure Disorder. The 2/18/25 Accident/Incident Report documented Resident #10 was being given care by the Certified Nurse Aide when the resident was playing/fidgeting with the bed controls, and it suddenly swung into the resident's face. It further documented a nurse was notified and no injury was noted. Resident #10 received blood thinners. The documented plan was to detangle the bed control cord as needed. Abuse was ruled out. There was no documented evidence in the 2/18/25 progress notes after Resident #10 was hit in the face with the bed control while receiving cares. There was no documented evidence that Resident #10 was assessed by a Registered Nurse after they were hit in the face with the bed control on 2/18/25. The Quarterly Minimum Data Set, dated dated dated [DATE] documented Resident #10 had severely impaired cognition, and required partial to moderate assistance with bed mobility and transfers. During interview on 3/12/25 at 12:16 PM during an interview, the Director of Nursing stated on 2/18/25 Certified Nurse Aide #7 told Licensed Practical Nurse #5 that while they were providing care the bed remote swung and hit Resident #10 in the face. Licensed Practical Nurse # 5 went to see the resident and stated they did not see anything and endorsed it to oncoming Licensed Practical Nurse #6. The Director of Nursing stated both Licensed Practical Nurse #5 and Licensed Practical Nurse #6 did not report the incident to the nursing supervisor and did not document the incident in the electronic medical record. The Director of Nursing stated a Registered Nurse should have assessed Resident #10. During interview on 3/12/25 at 12:25 PM Licensed Practical Nurse #5 stated on 2/18/25 Certified Nurse Aide #7 was taking care of resident and while providing care, they stated the bed remote hit the resident in the face. Licensed Practical Nurse #5 stated they looked at Resident #10 and did not see any bruising. Licensed Practical Nurse #5 stated they should have reported it to the nursing supervisor but did not and instead told the oncoming nurse (Licensed Practical Nurse #6) at change of shift. Licensed Practical Nurse #5 stated they usually documented in progress notes regarding resident incident/s but did not write a note. On 3/12/25 at 12:37 PM during an interview, Licensed Practical Nurse #6 stated they were informed by Licensed Practical Nurse #5 that Certified Nurse Aide #7 was providing care and the bed remote hit the resident in the face. Licensed Practical Nurse #6 stated when they went to see Resident #10, they did not have any marks on their face. They further stated at some time during the next couple of weeks, there was some bruising showing. Licensed Practical Nurse #6 stated they did not document anything in the progress notes about the bruise on the resident's face. Licensed Practical Nurse #6 stated they normally would have documented but the bruising did not appear right away. Licensed Practical Nurse #6 stated they did not report it to anybody. Licensed Practical Nurse #6 stated they should have reported it to nursing supervisor so the resident could be assessed. On 3/12/25 at 2:42 PM, Certified Nurse Aide #7 stated while they were providing care, Resident #10 had the bed control in their hand and was struggling to unravel the cord and pulled it and it snapped back and accidentally hit the resident in the face. Certified Nurse Aide #7 stated they notified Licensed Practical Nurse #5 and stated that nobody asked them about the incident until now. Certified Nurse Aide #7 stated after the incident there was no redness or bruising on Resident #10's face. 10NYCRR 415.4(b)(3)

Based on observations, record review and interviews conducted during the Recertification survey from 3/5/2025 to 3/12/25, the facility did not ensure that 1 of 2 residents (Resident #34) reviewed for Respiratory Care was provided with such care, consistent with the professional standards of practice. Specifically, Resident #34, had a physician's order for oxygen to be administered via nasal cannula at 3 liters per minute, and was observed multiple times with the oxygen rate not consistent with the physicians' order. Additionally, there was no signage present indicating oxygen was being utilized in Resident #34's room. The findings include: The facility policy titled Oxygen Administration last revised on 10/29/24 documented to verify that there is a physician's order; place an oxygen in use sign on the outside of the room entrance door; and turn on the oxygen on at the prescribed rate. Resident #34 had diagnoses including shortness of breath, depression, acute and chronic respiratory infarction. The Quarterly Minimum Data Set (a resident assessment tool) dated 12/19/24 documented Resident #34 had moderately impaired cognition, required supervision for toileting, dressing and transfers and set up assistance for eating. A physician order dated 9/27/24, documented oxygen at 3 liters/minute continuous via nasal cannula. A resident care plan, updated 12/2/24, documented to administer of oxygen per physician order. During observations on 3/05/25 at 12:03 PM, 3/06/25 at 8:51 AM, and 3/07/25 at 1:34 PM, Resident #34 was receiving oxygen via nasal cannula and the concentrator was observed running at 2.5 liters/minute. There was no oxygen use signage observed on door/entrance to the resident's room. During an interview and observation on 3/07/25 at 2:10 PM, the oxygen concentrator was at 2.5 liters/minute. Licensed Practical Nurse #1, observed the concentrator and stated the oxygen concentrator was running between 2.5 and 3 Liters. They stated that Resident #34's oxygen administration rate could fluctuate between 2 and 3 liters and that they were aware the physician order was for the resident to receive 3 Liters continuously. They also stated that the facility did not require a physician order for oxygen running at 2 liters. During an interview and observation on 03/07/25 at 2:18 PM, Registered Nurse Supervisor #2, stated that oxygen use signage should have been posted on / near the doorway of Resident #34's room. They also stated that all residents in the building needed an order for oxygen use and that the oxygen should have been administered at prescribed rate. During an interview on 3/10/25 at 2:21 PM, the Director of Nursing stated physician orders were required for all oxygen use except in an emergency and then the order would be obtained. Signage should be in place by door of a resident's room when using oxygen. Physician orders for liter administration rate were expected to be followed as written. Correct oxygen level settings should be monitored by the Nursing Supervisor on the unit and/or the Director of Nursing. 10 NYCRR 415.12

Based on interview, and record review conducted during a recertification survey from 3/5/25 to 3/12/25, the facility did not ensure that sufficient staff was available to meet the needs of all residents on 30 days reviewed. Specifically, actual staffing levels were below minimum levels on the following dates (2/2/2/25, 2/3/25, 2/4/25, 2/8/25, 2/9/25, 2/10/25, 2/12/25, 2/16/25, 2/17/25, 2/24/25, 2/25/25, 3/1/25, and 3/3/25). The findings include: The Minimum Par Levels for Nursing Sheets documented the 7AM -3PM shift for unit A should have at least 4 Certified Nurse Aides, Unit B should have at least 3 Certified Nurse Aides, and unit C should have at least 3 Certified Nurse Aides, the 3PM-11PM shift for unit A should have at least 3 Certified Nurse Aides, unit B should have at 3 Certified Nurse Aides, and unit C should have at least 2 Certified Nurse Aides, and the 11PM-7AM shift for unit A, unit B and unit C should have at least 2 Certified Nurse Aides. The February 2025 daily staffing sheets documented 2/2/25 11AM - 7PM 1 Certified Nurse Aides on Unit B when the minimum requirement for the night shift was 2 Certified Nurse Aides. 2/3/25 7AM-3 PM 2 Certified Nurse Aides for Unit B and 2 Certified Nurse Aides for Unit C, when the minimum requirement for Unit B and Unit C was 3 Certified Nurse Aides.2/4/25 7 AM -3PM 3 Certified Nurse Aides on Unit A when the minimum requirement was 4 Certified Nurse Aides. 2/8/25 3 PM-11PM 1 Certified Nurse Aide on Unit A when the minimum requirement was 3 Certified Nurse Aides. 2/9/25 11PM-7AM 1 Certified Nurse Aide for Unit C when the minimum requirement was 2 Certified Nurse Aides. 2/10/25 11PM -7AM 1 Certified Nurse Aide for unit B when the minimum requirement was 2 Certified Nurse Aides. 2/12/25 11PM-7AM 1 Certified Nurse Aide for unit B when the minimum requirement was 2 Certified Nurse Aides. 2/16/25 11PM -7AM 1 Certified Nurse Aide for unit B and 1 Certified Nurse Aide for unit C when the minimum requirement was 2 Certified Nurse Aides. 2/17/25 11PM-7AM 1 Certified Nurse Aide for unit B and 1 Certified Nurse Aide for unit C when the minimum requirement was 2 Certified Nurse Aides. 2/24/25 7AM- 3PM 2 Certified Nurse Aides on unit B and when the minimum requirement was 3 Certified Nurse Aides. 2/24/25 11PM- 7AM 1 Certified Nurse Aides for Unit B when the minimum requirement was 2 Certified Nurse Aides. 2/25/25 11PM-7AM 1 Certified Nurse Aide for Unit C when the minimum requirement was 2 Certified Nurse Aides. The March 2025 daily staffing documented 3/1/25 11PM-7AM 1 Certified Nurse Aide for Unit C when the minimum requirement was 2 Certified Nurse Aides. 3/3/25 11PM-7AM 1 Certified Nurse Aide for Unit B when the minimum requirement was 2 Certified Nurse Aides. During an interview on 3/12/25 at 5:12 PM, the Director of Human Resources and Staffing stated they received the minimum staffing requirement from the regional administration. The Director of Human Resources and Staffing stated sometimes they do not have enough Certified Nurse Aides. The Director of Human Resources and Staffing stated the weekends can be tougher to fill, they have a pool or contact list for the call outs, or they ask night shift to stay on for the next shift. The Director of Human Resources and Staffing stated overtime is offered and they do have incentives and bonuses to encourage new hires and stated that the overall staffing is getting better. The Director of Human Resources and Staffing stated they had a high turnover rate for the Certified Nurse Aides but feels it has improved. The Director of Human Resources and Staffing stated when they are short staffed, they will take a Certified Nurse Aide from another unit with a lower census to replace if they cannot get a Certified Nurse Aides to come in. The Director of Human Resources and Staffing stated the staffing was short on the following dates (2/2/25, 2/3/25, 2/4/25, 2/8/25, 2/9/25, 2/10/25, 2/12/25, 2/16/25, 2/17/25, 2/24/25, 2/25/25 3/1/25, and 3/3/25) but could not say if staffing shortages directly affected resident care. NYCRR 415.13(a)(1)(i-iii)

Based on interviews, and record review during an abbreviated survey (NY00324542), the facility failed to ensure that residents were free of significant medication errors for 2 of 5 residents (Resident #1 and Resident #2) reviewed for anti-seizure medications. Specifically, Resident #1 had a physician's order for Vimpat (controlled antiseizure medication) 200 milligrams (mg) 1 tab every 12 hours at 9AM and 9PM daily, and over three days in 08/2023 and four days in 09/2023. A total of 12 doses of Vimpat were not administered to Resident #1. Resident #2 had a physician's order for Keppra (anti-seizure medication) 1000 mg 1 tab every 12 hours at 9AM and 9PM daily, and over six dates a total of 7 doses of Keppra were not administered to Resident #2. Subsequently, Resident #1 suffered a seizure on 9/17/23 at 3:45 PM and was transferred to the hospital. This resulted in actual harm for Resident #1 which was Immediate Jeopardy and Substandard Quality of care with the likelihood of risk for harm to the health and safety of Resident # 2. The findings are: The Facility Policy and Procedures titled Medication Reordering effective 4/1/2017 and last reviewed on 3/22/2023 documented that the facility is to reorder medications when supply is running low (2 days prior). The physician/Nurse Practitioner (NP) orders medications in the electronic medical record (EMAR). The pharmacy delivers a 28-day supply of all medications unless ordered for a specific amount of time. The licensed nurse receives the medication and verifies the appropriate medication. If a medication is not received in a timely manner, licensed nurse calls the pharmacy to obtain estimated delivery time and notifies the Nursing Supervisor, Manager, Director of Nursing Services (DNS) and Assistant Director of Nursing Service (ADNS). Resident #1 Resident #1 had diagnoses that included diabetes, seizure disorder, and quadriplegia (a form of paralysis that affects all four limbs and the torso). The admission Minimum Data Set (MDS, an assessment tool) dated 7/20/2023 documented Resident #1 had severely impaired cognitive function and was totally dependent on 2 staff for transfer and dressing, total dependence on 1 staff for bed mobility, eating and personal hygiene: and extensive assist of 1 staff for toileting. Resident #1's Seizure Care Plan dated 7/16/2023 documented the goal was that Resident #1 would maintain therapeutic levels of seizure medication. Interventions included notifying the physician if drug levels were out of range, administering medications as ordered and monitoring response, and monitoring for seizures. The Physician order dated 7/14/2023, documented Resident #1 had an order for Vimpat 200mg 1 tab every 12 hours at 9AM and 9PM daily. A review of the EMAR revealed that Resident #1 did not receive a total of 12 doses of Vimpat 200mg as follows: On 8/27/2023-9PM-dose administered on EMAR-(Narcotic sheet final dose was signed out on 8/27/2023 9AM). There was no more medications to administer 8/28/2023-9AM -dose not administered-pending pharmacy (Narcotic sheet final dose was signed out on 8/27/2023 9AM) 8/28/2023-9PM-dose not administered-pending pharmacy 8/29/2023-9AM- dose not administered-pending pharmacy 9/13/2023-9PM-dose administered-(Narcotic sheet final dose was signed out on 9/13/2023 at 9AM, no doses available) 9/14/2023-9AM-dose administered-LPN #1 stated they did not have any doses to administer but clicked administered on the EMAR) 9/14/2023-9PM-dose administered on EMAR-(There were no doses in the facility to administer) 9/15/2023-9AM-dose administered on EMAR-(No doses available but documented as administered in error per LPN #4) 9/15/2023-9PM dose administered; borrowed from Resident #4-per LPN #2 9/16/2023 at 9AM-documented not administered pharmacy pending-LPN #1 9/16/2023-9PM-documented not administered pharmacy pending-LPN #2 9/17/2023 at 9AM-documented not administered pharmacy pending-LPN #1 Review of the Narcotic sheets from 8/27/2023 9PM to 8/30/2023 9AM and from 9/13/2023 9PM to 9/17/2023 9PM revealed Vimpat 200mg tablet for Resident #1 was not in stock. Review of Resident #1's nursing notes from 7/13/2023 to 9/17/2023 revealed no documented evidence of the missing medication and no documented evidence that the physician the, NP or the DNS were notified that the Vimpat was not administered. Resident #1's nursing notes were reviewed from 7/13/23 to 9/17/23. There was no documented evidence that the physician or NP #1 were notified about the missed Vimpat doses or that the delivery of Vimpat was not received. Review of the 24-hour Report (shift to shift communication) from 9/16/2023 to 9/17/2023 revealed no documented evidence that Resident #1 did not receive Vimpat 200mg as ordered or that the medication was not available for administration. Review of Resident #1's nursing progress notes dated 9/17/2023 at 5:36PM documented writer was notified at 3:40PM by a Certified Nursing Assistant (CNA) that Resident #1 was observed having a seizure activity. Resident #1 was observed with facial tics, tremors, and scant blood in their mouth. Resident #1 was placed on their side and oxygen was administered. The Physician (Physician #1) was notified, and an order was received to give an injection of Ativan 1mg and repeat in 5 minutes if seizure activity continued. The first dose of Ativan 1mg was administered at 3:45PM, the next dose was administered at 3:50PM. Physician #1 was notified at 3:56PM that seizure activity continued. Physician #1 ordered Resident #1 to be transferred to the Emergency Room. Emergency Medical Service (EMS) arrived at 4:16PM and administered Ativan 5mg x 2 doses then transported Resident #1 to the hospital at 4:30PM. Resident #2 Resident # 2 had diagnoses that included stroke, non-traumatic brain injury, traumatic brain dysfunction and progressive neurological condition. The Quarterly MDS dated [DATE] documented Resident #2 had intact cognitive function. Resident #2 required extensive assist of 1 staff for personal hygiene, limited assist of 1 staff for toileting, and dressing. Supervision set-up help only for bed mobility, eating and locomotion on and off the unit. Resident #2's Seizure Care Plan dated 11/28/2023 documented Resident #2 would be free from seizures, would have medications administered as ordered and the resident's response to medications would be monitored. A review of the EMAR revealed that on 5/8/2023, 7/26/2023, 7/28/2023, 8/24/2023 and 9/10/2023, Resident #2 did not receive Keppra 1000mg dose at 9:00 AM as ordered. The EMAR further revealed that on 9/10/2023 and 9/11/2023 the resident did not receive Keppra 1000mg at 9:00 PM as ordered. Resident #2's nursing notes from 5/8/2023, 7/26/2023, 7/28/2023, 8/24/2023, 9/10/2023, and 9/11/2023 were reviewed and revealed no documented evidence documentation of that Resident #2 was not administered their medication. There was no documented evidence that the physician, NP or DON were notified the resident was not administered their prescribed medication. Interviews During an interview on 9/21/2023 at 10:45AM, Licensed Practical Nurse (LPN) #1 stated they worked on 9/13/2023, 9/14/2023, 9/16/2023, and 9/17/2023 and was assigned to administer medications to Resident #1. LPN #1 stated on 9/13/2023 they submitted an order for renewal of the Vimpat to the NP to sign after the last dose was administered at 9AM. LPN #1 stated on 9/14/2023 when their shift began, and they found that the Vimpat 200mg supply did not arrive from the pharmacy. LPN #1 submitted another request to the NP, and they texted the NP to sign the request. LPN #1 stated they called the pharmacy on 9/14/2023 and were told the medication would be delivered. LPN #1 stated on 9/16/2023 at 8AM they tried to contact the Physician #1 by phone because there was no Vimpat 200mg available for Resident #1, but there was no response. LPN #1 called the pharmacy again on the 9/17/2023 around 1PM during their shift with Resident #1's representative present. LPN #1 stated they were informed by the pharmacist that Resident #1's insurance would not approve the medication order. The pharmacist rechecked and said the Vimpat would be delivered by the evening. During a subsequent interview on 9/22/2023 at 2:33PM, LPN #1 stated that they never gave Vimpat 200mg to Resident #1 on 9/16/2023 at 9AM and 9/17/2023 at 9AM. LPN #1 stated they were coached to say that they received an emergency delivery of 4 Vimpat tablets on 9/16/2023 and 9/17/2023, but there was no emergency Vimpat 200mg delivered by the pharmacy for Resident #1 on those dates. During a follow-up interview on 9/26/2023 at 3:25PM, LPN #1 stated there was no Vimpat available for Resident #1 on 9/14/2023 at 9AM, and they did not administer Vimpat 200mg to Resident # 1. LPN #1 stated they reported to the oncoming nurse that there was no Vimpat 200mg available for Resident #1. LPN #1 also stated they did not administer Vimpat 200mg on 8/28/2023 and 8/29/2023, but they could not recall why it was not administered. During an interview on 9/21/2023 at 5:35PM, LPN #3 stated they worked the 3PM-11PM shift on 9/13/2023 and 9/14/2023 and was assigned to Resident #1. LPN #3 stated they did not place an order for a refill of the Vimpat 200mg for Resident#1, did not call the pharmacy and did not notify the Physician or NP. LPN #3 was asked, but they did not provide a reason why. During an interview on 9/21/2023 at 6:10PM, LPN #4 stated they worked the day shift on 9/15/2023 and there was no Vimpat for Resident #1's 9AM dose so they notified the LPN Supervisor (LPNS) #2. LPN #4 stated they submitted the prescriptions for the physician to sign but could not verify whether the order was signed by the physician or NP or whether the signed order was received by the pharmacy as they did not have access to view information sent to the pharmacy. LPN #4 stated LPNS #2 never followed-up with them and no medication was delivered during their shift. During an interview on 9/22/2023 at 10:31AM, Physician #1 stated when the nurses queued a medication for refill it appeared electronically on their screen that displays communication from staff and dashboard of the EMAR for signature. Nurses were to submit electronic refills for needed medications when the resident's supply had a 2-3-day supply left. The physician stated that NP #1 shared the dashboard and signed off on refills when requested. The physician was unable to indicate when the Vimpat order for Resident #1 was signed. The physician did not recall if they received any calls about missing medications on 9/16/2023 and 9/17/2023 or any of the other days when medications were not administered. The physician stated they expected nurses to call when there were issues with medications. During an interview on 9/22/2023 at 11:45AM, the Pharmacy Supervisor (PS) stated they received a new prescription for Vimpat from the facility on 9/8/2023 but it was too soon to be filled and dispensed to the facility. The PS stated they waited for the facility to request the medication, The date of the request by the facility was 9/16/2023 at 11:44AM. The PS stated the refill was rejected because there was a Medicaid billing issue and the calls to Medicaid to resolve it were unanswered so the representative could not resolve the issue. The PS stated Medicaid had the scheduled refill date as 9/18/2023 but on 9/17/2023 they received the approval from Medicaid to override and they dispensed 28 Vimpat tablets one day early on 9/17/2023. During an interview on 9/26/2023 at 6:40PM, LPN #2 stated on 9/15/2023 they notified LPNS #1 that there was no 9PM dose of Vimpat to be administered to Resident #1. LPN #2 stated LPNS #1 directed them to borrow the medication from another resident on a different unit. LPN #2 stated they borrowed the Vimpat from Resident #4 and administered it to Resident #1. LPN #2 did not call the pharmacy, did not notify the Physician or NP, and did not request an electronic refill. On 9/16/2023, LPN #2 stated at approximately 8PM, they notified LPNS #1 that Resident #1 still had no Vimpat available to be administered at 9PM. LPNS #1 checked the EMAR and told LPN #2 there was nothing they could do so Resident #1 missed the 9PM dose on 9/16/2023. During an interview on 9/26/2023 at 10:02AM, the Medical Director (MD) stated their role is to oversee the medical providers' activities and ensure there was medical coverage in the facility. The medical providers had the responsibility to order medications, and to sign off electronic refill requests for the residents. The MD stated electronic refills are submitted by the nurses through the EMAR, and nurses are responsible for notifying the medical providers when medications are not available. The MD stated that when the medical providers are notified by the nurses that medications are not available, the medical providers would order a substitute or in extreme cases send the resident to the emergency room (ER). The MD stated if Vimpat was not available for Resident #1, the medical providers should have been made aware to discuss other options such including administering a substitute medication. The MD stated Vimpat was not kept in the emergency supply stock (E-Box). During a subsequent interview on 9/26/2023 at 11:35AM, LPN #4 stated on 9/15/2023 they were assigned to Resident #1 and there was no blister pack for the Vimpat, so they submitted an electronic request for refill and notified LPNS #2 that there was no Vimpat for Resident #1. LPNS #2 instructed LPN #4 to borrow from another resident. LPN #4 stated they were told by LPNS #2 that there was nothing they could do. LPN #4 stated they did not contact the DNS regarding the Vimpat being unavailable. During an interview on 9/26/2023 at 12:01PM, the Registered Nurse Supervisor (RNS #1) stated they spoke to LPN #1 on 9/16/2023 and LPN #1 did not notify them that Vimpat for Resident #1 was out of stock and was not delivered. RNS #1 stated on 9/16/2023, they left the facility at 6:30PM, while LPN #2 was on duty, and LPN #2 did not notify them that the Vimpat was not available or delivered. RNS #1 stated they were not notified that the 9AM dose of Vimpat was not administered or available. RNS #1 stated they did not run an EMAR medication administration shift report on 9/16/2023 or 9/17/2023. RNS #1 added that the report is not run every shift because sometimes they don't get the chance to do so. During an interview on 9/22/2023 at 1:03PM, the DNS stated nurses complete medication competencies upon hire and periodically. The last medication competencies for all nurses were completed May 2023. The DNS stated they were not notified by the nurses or the RNS that there was no Vimpat available for Resident #1. The DNS stated the report given by RNS #1 from the weekend only indicated that Resident #1 was transferred to the hospital. The DNS stated the report did not include any information about Resident #1's unavailable anti-seizure medication. The DNS stated they expect the supervisors to ensure that the nurses complete their assignments and sign off their administered medications/treatments. The DNS stated they/supervisors are responsible to run the EMAR medication administration report which will indicate which medications were not administered. The DNS could not provide any medication administration reports when they were requested and could not provide a date when this report was last run. Surveyor requested a medication error investigation report for the Vimpat omissions, but none was provided by the DNS. During an interview on 9/26/2023 at 8:35AM, LPNS #1 stated they worked 9/15/2023 during the 3pm-11pm shift. LPNS #1 stated they received report from LPNS #2 and was not informed that Resident #1's Vimpat was out of stock and unavailable. LPNS #1 stated they were informed by LPN #2 that Resident #1 had no Vimpat for the 9PM dose. LPNS #1 stated they instructed LPN #2 to borrow from another resident. LPNS #1 stated that on 9/16/2023 they checked the EMAR refill request and saw that the Vimpat was already requested and told LPN #2 there was nothing they could do. The unavailable Vimpat was not documented on the 24hr report. LPNS #1 stated that on 9/17/2023 at 10:04 AM, they texted the physician to sign for the Vimpat refill request. LPNS #1 stated there is not enough supervisory coverage to check the administration report every shift. LPNS #1 stated they did not run the report that weekend. During another interview on 9/26/2023 at 3:25PM, LPN #1 stated they were assigned to Resident #2 on 7/13/2023, 7/28/2023, and 8/24/2023. LPN #1 could not recall administering Keppra 1000mg to Resident #2 on these dates. LPN #1 did not provide a reason for the absence of documentation in the EMAR. LPN #1 did not recall any issues regarding delivery of Resident #2's anti-seizure medication. LPN #1 stated they did not know why they did not sign out the medication as administered on the EMAR. 10 NYCRR 415.12(m)(2)

Based on observation, staff and resident interviews, and record review during an abbreviated survey, the facility did not a policies and procedures in place for extreme heat conditions. Specifically, the facility failed to monitor a resident who was found unresponsive after being left unattended on the outside patio for approximately 5 hours and required hospitalization . The resident was diagnosed with [REDACTED]. This resulted in actual harm with potential for serious harm that is immediate jeopardy to resident ' s health and safety and substandard quality of care. Immediate jeopardy was removed at exit on 8/5/2015 as facility was able to employ corrective measures to remove the immediacy to the health and safety of residents. Findings are: Complaint #: NY 645 Resident #1 is an [AGE] year-old resident with [DIAGNOSES REDACTED]. Review of the Minimum Data Set Assessment (MDS) (a resident assessment tool) dated 6/26/2015 documented residents Brief Interview for Mental Status (BIMS) score of 5 which indicates resident's cognitive skills for daily decision making is severely impaired. The MDS further documented resident required supervision with locomotion on and off the unit, eating, and extensive assistance with toilet use and personnel hygiene. Review of the summary facility incident and accident report, not dated but received during onsite visit of 8/4/2015, a Certified Nursing Assistant (CNA) reported seeing the resident on his unit before noon and directed him to go down to the main dining room for lunch on 7/31/2015. Two staff recreation aides reported they saw the resident at approximately 1:30 -2:00PM on the patio awake but somewhat sleepy but in no distress then at 3:40 - 3:45 p.m. The recreation assistant notified the nursing supervisor that resident appeared sleepy. The Registered Nurse (RN) assessed resident at 3:45 p.m. as being unresponsive immediate cooling measures were initiated and 911 was called. Review of the hospital history and physical report dated 8/1/2015 documented, patient was admitted with heat stroke after being left outside for about 3 hours. Once resident was brought back indoors he was noted to have a temperature of 105.6, heart rate of 119, and blood pressure of 116/92. Resident was initially confused and was cooled with ice packs and damp sheets. He was then moved to the shower, he obtained a left shoulder abrasion. Emergency medical service (EMS) was called and patient was brought to the emergency department. Skin inspection found confluent [DIAGNOSES REDACTED]tous (large areas of redness or inflammation of the skin), covering entire scalp, with peeling skin left shoulder, and across abdomen. Review of the Comprehensive Care Plan (CCP) dated 7/13/2015 for urinary incontinence documented that Resident #1 was incontinent of bowel and bladder. Interventions included that resident was to have extensive assistance of 1 person to toilet every 2 hours. Resident #1 also had a CCP in place to address his [DIAGNOSES REDACTED]. Review of facilities head count sheet dated 7/31/2015 documented resident as A , meaning awake at 8 a.m., 10 a.m., 12 p.m., and 2p.m. Review of the Nurses note dated 7/31/2015 documented, Resident was noted on outdoor patio at 4 p.m., resident was unresponsive, he was taken to his room. Vital Signs temperature 105, blood pressure 162/91. Physician and 911 were called. Resident was placed in bed, staff attempted to cool resident down. Cool compress was placed on forehead, under arms, and at groin. Nurse ' s note dated 8/1/2015 documented, Resident was admitted to hospital at 12:00 a.m. on 8/1/2015, [MEDICAL CONDITION] and [MEDICAL CONDITION]. Interview on 8/4/2015 at 11:15 a.m. the Director of Nursing (DON) stated she was aware that resident would take himself to the patio area frequently. She stated that recreation is right there inside and can look out on people on the patio, and are responsible to supervise that area. She stated there was no written policy, procedures, or plan in place for the monitoring and supervision of residents who go to the patio area ad libitum (at one's pleasure). Interview with the Administrator on 8/4/15 at 11:32a.m. he stated that he did not know who was responsible to monitor the patio area, he had no written plan, policy, or procedures specifically for the monitoring and supervision of residents on the patio area. He stated that it is the responsibility of all staff to be checking on resident throughout the day no matter where they are. Interview with the 7 AM-3 PM Registered Nurse (RN) Supervisor on 8/4/2015 at 2:45 p.m. she stated that she was not sure how many residents use the patio on her unit, possibly 2-4. Before the event they went out ad libitum now under supervision. She stated that they have an accountability log and I thought nursing was checking it. Interview on 8/4/2015 at 2:45 p.m. LPN #1 who is the Unit Manager of Unit B and C where Resident #1 resided, stated that the last time she saw the resident was in the morning but was not sure of the time and did not see him again before she went home that day. She has 14 residents who go to the patio ad libitum (at one's pleasure)but was not aware that the resident goes out that much. The staff assigned should be getting residents for lunch and there is a two hour head count accountability log that is completed by an assigned aide daily. Interview on 8/4/2015 at 3:00 p.m. Resident #2 stated that he was good friends with Resident # 1. He told staff at about noon to bring Resident #1 into eat because he had been outside for over an hour. Resident #2 then stated that Resident# 1 never ate lunch. He told staff but he does not recall who he told. At 1:30p.m. he saw a recreation aide go to Resident #1 but she left him there. I went upstairs after that, I thought they would have brought him inside at 1:30 p.m. because it was very hot that day, probably around 88 to 90 degrees. Interview on 8/4/2015 at 4:25 p.m. CNA #1 who was assigned to care for resident stated he got resident up at 10:00 a.m. and the last time he saw resident was about 10:30 a.m. when he went with his walker to the patio, and did not see him for the rest of the day. He stated that he is not responsible for checking resident every two hours and is not responsible if resident leaves for recreation, and that recreation is responsible because we are working on the 2nd floor and recreation is downstairs. CNA #1 stated he did not give any care to resident since 10:30 a.m. on 7/31/2015, and did not know if he ate lunch, or if anyone changed or checked resident all day. Interview on 8/4/2015 at 4:25 p.m. CNA #2 who was responsible for doing the head count sheet stated that she signed the sheet on 7/31/2015 but never saw the resident. She stated she only checks resident ' s rooms and if residents are not in their bed she writes an A. an A means they are awake because they are not in their beds sleeping. Interview on 8/5/2015 at 4:00 p.m. with the Medical Director stated that the DON emailed him on Monday 8/3/2015 and I had to do clinical somewhere else. I didn't get an email until yesterday 8/4/2015, then stated, I get a lot of e-mail and if it ' s urgent I get a phone call, the facility has my contact numbers. I am not the administrator I am the medical director but the residents should have been supervised outside. 415.4(b)

Based on observation, review of the facility security camera log, staff interviews, and record reviews conducted during an abbreviated Survey, it was determined that for one (Resident #1) of nine residents reviewed for accidents, the facility failed to provide adequate supervision and a safe environment for residents to prevent accidents. Specifically, a resident was allowed to go outside to the unsupervised patio area at the facility ad libitum. Subsequently, the resident was found unresponsive after being left unattended for approximately 5 hours and required hospitalization . Resident was diagnosed with [REDACTED]. This resulted in actual harm with potential for serious harm that is immediate jeopardy to resident ' s health and safety and substandard quality of care. Immediate jeopardy was removed at exit on 8/5/2015 as facility was able to employ corrective measures to remove the immediacy to the health and safety of residents. Finding are: Complaint #: NY 645 Resident #1 is an [AGE] year-old resident with [DIAGNOSES REDACTED]. Review of the Minimum Data Set Assessment (MDS) (a resident assessment tool) dated 6/26/2015 documented residents Brief Interview for Mental Status (BIMS) score of 5 which indicates resident's cognitive skills for daily decision making is severely impaired. The MDS further documented resident requires supervision with locomotion on and off the unit, eating, and extensive assistance with toilet use and personnel hygiene. Review of the summary facility incident and accident report, not dated but received during onsite visit of 8/4/2015, a Certified Nursing Assistant (CNA) reported seeing the resident on his unit before noon and directed him to go down to the main dining room for lunch on 7/31/2015. Two staff recreation aides reported they saw the resident at approximately 1:30 -2:00PM on the patio awake but somewhat sleepy but in no distress then at 3:40 - 3:45 p.m. The recreation assistant notified the nursing supervisor that resident appeared sleepy. The Registered Nurse (RN) assessed resident at 3:45 p.m. as being unresponsive immediate cooling measures were initiated and 911 was called. Review of the hospital history and physical report dated 8/1/2015 documented, patient was admitted with heat stroke after being left outside for about 3 hours. Once resident was brought back indoors he was noted to have a temperature of 105.6, heart rate of 119, and blood pressure of 116/92. Resident was initially confused and was cooled with ice packs and damp sheets. He was then moved to the shower, he obtained a left shoulder abrasion. Emergency medical service (EMS) was called and patient was brought to the emergency department. Skin inspection found confluent [DIAGNOSES REDACTED]tous, covering entire scalp, with peeling skin left shoulder, and across abdomen. Review of Physician orders [REDACTED]. Review of facilities head count sheet dated 7/31/2015 documented resident as A, meaning awake at 8 a.m., 10 a.m., 12 p.m., and 2p.m. Review of the Nurses note dated 7/31/2015 documented, Resident was noted on outdoor patio at 4 p.m., resident was unresponsive, he was taken to his room. Vital Signs temperature 105, blood pressure 162/91. Physician and 911 were called. Resident was placed in bed and staff attempted to cool resident down. Cool compress was placed on resident's forehead, under arms, and at groin. Nurse ' s note dated 8/1/2015 documented, Resident was admitted to hospital at 12:00 a.m. on 8/1/2015, with sepsis and[DIAGNOSES REDACTED]. Interview on 8/4/2015 at 11:15 a.m. the Director of Nursing (DON) stated she had originally thought that resident was admitted to hospital with sepsis. On 8/3/2015 the hospital called her and wanted the resident ' s [DIAGNOSES REDACTED]. DON states that recreation is right there inside and can look out on people on the patio and they are responsible to supervise that area, and there is no written policy, procedures, or plan in place for the monitoring and supervision of residents who go to the patio area ad libitum (at one's pleasure). She further stated that she has started in servicing the staff with Dear Administrator Letter 15-12, warm weather advisory after she was notified by the 3-11 p.m. supervisor because she had concerns that resident's condition was caused by the heat. Interview on 8/4/2015 at 11:32 a.m. the Administrator stated he was made aware of the situation on Saturday 8/1/2015, 24 hours after the incident due to Sabbath. Yesterday on 8/3/2015 the hospital called and told him that the resident had heat stroke. He was not aware of who is responsible to monitor the patio area and stated the facility has no written plan, policy, or procedures specifically for the monitoring and supervision of residents on the patio area for environmental and other hazards. He states that it is the responsibility of all staff to be checking on residents throughout the day no matter where they are, and recreation can see residents from their room. He further states that all staff are being in serviced regarding heat precautions, and today they instituted closing patio during severe weather conditions. This was the first concern he has experienced with heat on the patio, and did not think this had been reviewed by quality assurance because there had never been a problem before. Interview on 8/4/2015 at 2:10 p.m. the RN Unit Manager stated that she was not sure how many residents use the patio on her unit, possibly 2-4 maybe. Before the event they went out ad libitum now under supervision. She stated that they have an accountability log and I thought nursing was checking it. The MDS RN Coordinator called me and the Licensed Practical Nurse #2 (LPN) brought resident back from the patio at about 4 p.m. We checked his temperature which was 105.6 and the LPN told me she did not know how long he had been sitting outside. She further stated that she last observed the resident at 9 a.m., he was in his bed and I gave him medications. Interview on 8/4/2015 at 2:25 p.m. the RN MDS Coordinator stated, LPN brought the resident in a wheelchair from the patio. I found the resident unresponsive but breathing, his face was red, had a rash on abdomen and chest, the LPN told me she thought resident had been sitting outside for a long time. We attempted cooling measures and I called 911 . She further stated she did not know who is responsible for monitoring and supervising residents on the patio. Interview on 8/4/2015 at 2:45 p.m. LPN #1 who is the Unit Manager of Unit B and C where Resident #1 resided, stated that the last time she saw the resident was in the morning but was not sure of the time and did not see him again before she went home that day. She has 14 residents who go to the patio ad libitum but was not aware that the resident goes out that much. The staff assigned should be getting residents for lunch and there is a two hour head count accountability log that is completed by an assigned aide daily. Interview on 8/4/2015 at 4:20 p.m. the Recreation Assistant stated I saw the resident at around 3:30 p.m. sitting in his chair with eyes closed and I went and told the nurse at 3:30 p.m. I approached him because he looked sleepy but he refused to come in. She did not recall how long he had been outside and did not report this to nursing. Interview on 8/4/2015 at 3:00 p.m. Resident #2 stated that he was good friends with Resident # 1. He stated that he told staff at about noon to bring Resident #1 into eat and because he had been outside for over an hour. Resident #2 stated that the Resident #1 never ate lunch. He stated he told staff but did not recall who but once at 1:30p.m. it was a recreation aide who went to Resident #1 but left him there. I went upstairs after that, I thought they would have brought him inside at 1:30 p.m. because it was very hot that day, probably around 88 to 90 degrees. Interview on 8/4/2015 at 4:25 p.m. CNA #1 who was assigned to care for resident stated he got resident up at 10:00 a.m. and the last time he saw resident was about 10:30 a.m. when he went with his walker to the patio, and did not see him for the rest of the day. He stated that he is not responsible for checking resident every two hours and is not responsible if resident leaves for recreation, and that recreation is responsible because we are working on the 2nd floor and recreation is downstairs. CNA #1 stated he did not give any care to resident since 10:30 a.m. on 7/31/2015, and did not know if he ate lunch, or if anyone changed or checked resident all day. Interview on 8/4/2015 at 4:25 p.m. CNA #2 who was responsible for doing the head count sheet stated that she signed the sheet on 7/31/2015 but never saw the resident. She stated she only checks resident ' s rooms and if residents are not in their bed she writes an A. an A means they are awake because they are not in their beds sleeping . Interview on 8/5/2015 at 4:00 p.m. the Medical Director stated that the DON emailed him on Monday 8/3/2015 and I had to do clinical somewhere else. I never got an email until yesterday 8/4/2015, then stated, I get a lot of e-mail and if it ' s urgent I get a phone call, the facility has my contact numbers. I am not the administrator I am the medical director but the residents should have been supervised outside. The facility immediately started inservicing staff on heat protocols. The patio remained locked until all staff were inservied with the new policy and procedure for extreme heat. this included complete supervision of the patio when it is open to the residents. The patio will remain closed during extreme heat which is defined by the facility as over 87 degrees. 415.12(h)(1)

Based on record review and staff interviews the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident during an abbreviated Survey. Specifically, the Administration failed to develop and implement policy and procedures to protect residents that go to the outside patio area of the facility, failed to provide a safe environment for residents to prevent accidents, and failed to protect residents from neglect. This resulted in actual harm with potential for serious harm that is immediate jeopardy to resident ' s health and safety and substandard quality of care. Immediate jeopardy was able to be removed at exit on 8/5/2015 as facility was able to employ corrective measures that removed the immediacy to the health and safety of residents. Findings are: Complaint #: NY 645 Refer to Quality of Care F 224 scope and severity - L Refer to Quality of Care F 323 scope and severity - L Refer to Administration F 520 scope and severity - L Interview on 8/4/2015 at 11:15 a.m. the Director of Nursing (DON) stated she had originally thought that resident was admitted to hospital [MEDICAL CONDITION]. On 8/3/2015 the hospital called her and wanted the resident ' s [DIAGNOSES REDACTED]. DON states that recreation is right there inside and can look out on people on the patio and they are responsible to supervise that area, and there is no written policy, procedures, or plan in place for the monitoring and supervision of residents who go to the patio area ad libitum. She further stated that she has started in servicing the staff with Dear Administrator Letter 15-12, warm weather advisory after she was notified by the 3-11 p.m. supervisor because she had concerns that resident's condition was caused by the heat. Interview on 8/4/2015 at 11:32 a.m. the Administrator stated he was made aware of the situation on Saturday 8/1/2015, 24 hours after the incident due to Sabbath. Yesterday on 8/3/2015 the hospital called and told him that the resident had heat stroke. He was not aware of who is responsible to monitor the patio area and stated the facility has no written plan, policy, or procedures specifically for the monitoring and supervision of residents on the patio area for environmental and other hazards. He states that it is the responsibility of all staff to be checking on residents throughout the day no matter where they are, and recreation can see residents from their room. He further states that all staff are being in serviced regarding heat precautions, and today they instituted closing patio during severe weather conditions. This was the first concern he has experienced with heat on the patio, and did not think this had been reviewed by quality assurance because there had never been a problem before. 415.26

Based on record review and staff interviews the facility failed to have a Quality Assurance (QA) program that readily identified issues that had the potential to cause serious harm to residents during an abbreviated Survey . Specifically, The QA program failed to have a policy, procedure, or plan in place to ensure adequate supervision and monitoring was provided to protect residents from potential environmental hazards who go ad libitum (at one's pleasure) to the outdoor facility patio area. This resulted in actual harm with potential for serious harm that is immediate jeopardy to resident ' s health and safety and substandard quality of care. Immediate jeopardy was able to be removed at exit on 8/5/2015 as facility was able to employ corrective measures that removed the immediacy to the health and safety of residents. Findings are: Complaint #: NY 645 Refer to Quality of Care F 224 scope and severity - L Refer to Quality of Care F 323 scope and severity - L Refer to Facility Administration F 490 scope and severity - L Interview on 8/4/2015 at 11:15 a.m. the Director of Nursing (DON) stated she had originally thought that resident was admitted to hospital [MEDICAL CONDITION]. On 8/3/2015 the hospital called her and wanted the resident ' s [DIAGNOSES REDACTED]. DON states that recreation is right there inside and can look out on people on the patio and they are responsible to supervise that area, and there is no written policy, procedures, or plan in place for the monitoring and supervision of residents who go to the patio area ad libitum. She further stated that she has started in servicing the staff with Dear Administrator Letter 15-12, warm weather advisory after she was notified by the 3-11 p.m. supervisor because she had concerns that resident's condition was caused by the heat. Interview on 8/4/2015 at 11:32 a.m. the Administrator stated he was made aware of the situation on Saturday 8/1/2015, 24 hours after the incident due to Sabbath. Yesterday on 8/3/2015 the hospital called and told him that the resident had heat stroke. He was not aware of who is responsible to monitor the patio area and stated the facility has no written plan, policy, or procedures specifically for the monitoring and supervision of residents on the patio area for environmental and other hazards. He states that it is the responsibility of all staff to be checking on residents throughout the day no matter where they are, and recreation can see residents from their room. He further states that all staff are being in serviced regarding heat precautions, and today they instituted closing patio during severe weather conditions. This was the first concern he has experienced with heat on the patio, and did not think this had been reviewed by quality assurance because there had never been a problem before. 415.27(a-c)