Every finding on record at Brooklyn Center for Rehabilitation and Residential

Based on observation, record review, and interviews conducted during the Recertification and Complaint (2604985), the facility failed to ensure a resident was free from misappropriation of property. This was evident for one (1) of five (5) residents (Resident #207) reviewed for Abuse out of 38 total sampled residents. Specifically, Certified Nursing Assistant #2 removed Resident #207's dresser key from their arm, opened their dresser, removed $250 from Resident #207's wallet and left the room. The findings are: The facility policy titled 'Abuse' revised 7/18/2025 documented the facility prohibits the misappropriation of resident property by anyone including but not limited to staff, family, friends and residents of the facility. The facility has designed and implemented processed which strive to ensure the prevention and reporting of suspected or alleged resident abuse, neglect, mistreatment and or misappropriation of property. Misappropriation-deliberate misplacement, exploitation or wrongfully temporary or permanent use of a resident belongings or money without the resident's consentThe facility policy titled Personal Property revised 3/1/2024 documented residents are permitted to retain and use personal possessions and clothing as space and safety regulation permit. A locked drawer in the resident room is available as needed if residents wishes to secure personal items or valuables. The facility will promptly investigate any complaints of misappropriate or mistreatment of resident property The facility policy titled Investigation- Theft/ Misappropriation of Resident Property revised 11/2019 documented all reports of theft or misappropriation of resident property shall be promptly and thoroughly investigated. When an incident if theft or misappropriation of resident property is expected/alleged, the Administrator will appoint a staff member to investigate the incident. Examples of misappropriation examples provided, and it does not include theft of resident directly in the form of cash, Shall an alleged or suspected case of misappropriation of resident property be reported the facility Administrator or designee will notify the following agencies within 24 hours of such an incident stated and certification agency. Ombudsman, resident representative local law enforcement official and adult protective services. The Administrator will report the result so the investigation to the local police department, ombudsman and the state survey and certification agency within an identified regulatory timeline. Resident #207 had diagnoses of Chronic Obstructive Pulmonary Disease, Heart Failure, Anxiety and Depression. The Significant Change Minimum Data Set assessment dated [DATE] documented Resident #207 was cognitively intact and required partial to moderate and total assistance with Activity of Daily Living.The General documentation note written by Licensed Practical Nurse #7 on 08/29/2025 at 07:54 AM, documented Resident #207 went to their appointment accompanied by escort. The General documentation note written by Licensed Practical Nurse #8 on 08/29/2025 at 1:08 PM, documented Resident #207 returned to unit in stable condition from clinic appointment via wheelchair accompanied by Certified Nursing Assistant at 1:08 PM. The Comprehensive Care Plan for at risk for misappropriation, neglect, abuse and/or exploitation related to dependence on others for care initiated 3/5/2023 documented interventions ensure resident place with a compatible roommate, monitor resident for signs/symptoms of abuse, neglect, misappropriation and or exploitation and report to facility abuse office and medical director, refer to psychiatric evaluation and follow up as indicated, separate resident from aggressor, refer to psychology evaluate and ongoing services if indicated. On 12/01/2025 at 12:37 PM, Resident #207 was interviewed and stated a Certified Nursing Assistant came into their room, took their key to their bedside dresser, opened the dresser and took $250 given to them by their family for their birthday. Resident #207 also stated they pretended to be asleep as the staff took their money and did not report it until the next day as they were waiting for their family to come to tell them, but they changed their mind and reported it to the nurse after they returned from a medical appointment on 08/29/2025. Review of the medical record revealed there was no documentation in social service or nursing notes regarding Resident #207's allegation regarding stolen money. The Accident/Incident Statement Form completed by Certified Nursing Assistant #2 on 9/2/2025 at 10:15 documented Resident #207 rang the bell, and they answered the bell and Resident #207 asked them to turn off the light. The statement also documented Certified Nursing Assistant #2 turned off the light, washed their hands and left the room and this occurred between 10:45 PM and 10:50 PM. The Accident/Incident Statement Form completed by Licensed Practical Nurse #1 on 8/29/2025 documented Resident #207's child informed them that their parent was missing $250 from their wallet. The statement also documented Licensed Practical Nurse #1 called the supervisor to report the incident, however the resident's child called the police before the supervisor arrived on the unit. The Accident/Incident Statement Form completed by Licensed Practical Nurse #2 on 8/29/2025 at 9:30 PM documented Resident #207 reported money was stolen on 08/28/2025 between 10:00 PM and 11:00 PM and described who took it. The statement also documented that this was immediately reported to the supervisor on duty at 9:30 PM. The Accident/Incident Statement Form completed by the Director of Social Work on 9/3/2025 documented Resident #207 reported that on 08/28/2025 after 11:00 PM, the Certified Nursing Assistant removed their drawer key from their arm, opened the night drawer and took their money from their purse and they did not say anything because they were sleepy. The statement also documented the Director of Social Work confirmed Resident #207's son and spouse visited on 08/14/2025 and gave Resident #200. The statement further documented Resident #207 realized the money was missing before they left for their medical appointment on 08/29/2025 at 7:30 AM and reported the missing money when they returned from their medical appointment later that day. The timecards for Certified Nursing Assistant #2 were reviewed and revealed they worked on 08/28/2025 and 08/29/2025. The staffing sheets for 08/28/2025 documented Certified Nursing Assistant #2 was assigned to Resident #207's unit on the 3:00 PM to 11:00PM shift. The Employee Disciplinary Corrective Action Form which was signed and dated 09/08/2025 documented Resident #207 identified Certified Nursing Assistant #2 as the staff who went into their bag and took their money. The Employee Disciplinary Corrective Action Form also documented Certified Nursing Assistant #2 was suspended and then terminated by the facility.On 12/05/2025 at 3:04 PM, Certified Nursing Assistant #2 was interviewed via telephone and stated they received training on abuse for four (4) days and they were not aware of any abuse situations at the facility. Certified Nursing Assistant #2 also stated they received training on misappropriation of resident funds. Certified Nursing Assistant #2 further stated they last worked at the facility in October 2025, and they were let go when a resident told the facility that they took something from them. During an interview on 12/05/2025 at 12:43 PM, Social Worker #1 was interviewed and stated that they were not aware of any missing property for resident #207. There are not residents with missing money they are aware of. No audits of missing money they are aware of for the unit. They communicate with the resident's representatives about resident rights. If items are missing, ask for report and explain money lost and grievance and give to the director. The Director of Social work covers for them when they are not working.During an interview on 12/05/2025 at 2:40 PM, the Director of Human Resources stated Certified Nursing Assistant #2 was picked out of a staff photo lineup by Resident #207. The Director of Human Resources also stated Certified Nursing Assistant #2 was terminated for stealing Resident #207's money from their drawer. 10 NYCRR 415.4(b)

Based on observations and interviews, the facility did not ensure that drugs and biologicals were stored appropriately. This was evident for the Medication Storage Task on Unit 2 and Unit 1 (out of 7 units). Specifically, 1). Medications were left unattended in the Unit 2 nurses station, and 2). Expired medical supplies, enteral feeds, and protein supplement were located in the medication room on Unit 1. The findings are: The facility policy titled 'Medication- Storage' revised 05/02/2024 documented the facility will store medications safely and securely in a manner that maintains the integrity of that product in accordance with the manufacturer recommendation, current standards 0fpractice and federal and state regulation. Expired, discontinued and/or contaminated medication will be removed from the medication storage areas and disposed of in accordance with state federal regulations. With the exception of Emergency Drug Kits, medication include house stock medication will be stored in a locked cabinet, cart or medication room that is accessible only to licensed nursing staff and authorized personnel.1.During a random observation on 12/01/2025 from 4:34 PM to 05:04 PM on Unit 2, a bag of medication was observed unattended on a desk at the nurse's station. The contents slip attached documented the bag contained 4 vials of antibiotics mixed in a solution. Nursing staff was observed in the dining room away from the nurse's station, Licensed Practical Nurse # 9 was observed leaving the nurses station, and non-nursing staff and visitors were on the unit. During an interview on 12/01/2025 at 5:04 PM, Licensed Practical Nurse #9 stated they were on orientation and the medication on the nurse's station desk was delivered about an hour ago before the evening shift nurse came on duty. Licensed Practical Nurse #9 also stated the medications should have been secured, but the nurses were serving supper and had not gotten a chance to put the medication inside the medication cart. On 12/01/2025 at 5:07 PM, Licensed Practical Nurse #7 was interviewed and stated they came into work at 4:00 PM. Licensed Practical Nurse #7 also stated when medication is delivered, it should be taken and placed in the medication cart because it has confidential resident information, and they do not want anyone to walk off with the medication. Licensed Practical Nurse #7 further started the prior nurse did not get to put away the medication during their shift as the pharmacy delivery usually comes after 2:30 PM. Licensed Practical Nurse #7 stated they did not notice the medication at the nurses station. During an interview on 12/01/2025 at 5:16 PM, Registered Nurse Supervisor #6 stated the pharmacy delivers medications to the nurse's station. Registered Nurse Supervisor #6 also stated if medication is delivered while staff are serving meals, it should be secured in the narcotic box or in the medication cart. 2. On 12/04/2025 at 1:08 PM, the Unit 1 medication room was observed with Licensed Practical Nurse #4 and mineral oil lubricant with an expiry date of 6/21/2025, a box of 50 povidone 10% iodine swab sticks with an expiration date of 11/2025, 3 bottles of 30 fluid ounce bottles of wild cherry Pro Stat Liquid with an expiration date of 07/10/2025, and 2 bags of Isosource 1.5 calorie 1000 ml enteral feeding with a use by date of 09/03/2025 were observed. During an interview on 12/04/2025 at 1:15 PM, Licensed Practical Nurse #4 stated that they had not checked the medication room cabinet recently and another nurse on the evening/night shift should have checked the cabinet. Licensed Practical Nurse #4 also stated that if the enteral feeding was expired, it should have been discarded and any medications and biologicals that are expired should not be in the medication room. Licensed Practical Nurse #4 further stated only licensed nurses and the central supply persons have access to the medication room.During an interview on 12/04/2025 at 3:05 PM, the Central Supply Person was interviewed and stated they drop off medical supplies only. The Central Supply Person also stated they normally check that there is nothing expired on the medication room shelves, and they check the cabinets periodically but have not checked the cabinets since last week. The Central Supply Person further stated most of the time the nurses check the cabinets, but they did not check the lower cabinets as there are no supplies there for them. The Central Supply Person stated they deliver supplies, over the counter medications, and wound care supplies to the unit 2-3 times a week, and they will remove expired medications if they are located in the cabinets they are restocking only. The Central Supply Person also stated the tube feeding and Prostat are delivered from dietary. On 12/08/2025 at 2:26 PM, the Director of Nursing was interviewed and stated all the medication rooms are checked. The Director of Nursing also stated the pharmacy also does inspections of the medication rooms. 10 NYCRR 415.18(e)(1-4)

Based on observation, record review and interviews conducted during the abbreviated surveys (#2652750, and #2610252) the facility failed to ensure that each resident received adequate supervision to prevent accidents. This was evident for two (2) of five (5) residents (Resident #1 and Resident #2) sampled. Specifically, 1). On 10/23/2025, Resident #1 who required a two (2) person mechanical lift transfer out of bed was transferred with one (1) staff only and sustained a fracture of the left hand, and 2). On 09/05/2025, Resident #2 who required a two (2) person mechanical lift transfer out of bed was transferred with one (1) staff only and sustained a fracture of the hip. This resulted in actual harm to Resident #1 and Resident #2 that was not Immediate Jeopardy. The findings are: The facility policy titled 'Accident Incidents' last reviewed 01/01/2024, documents it is the policy of the facility to monitor and evaluate all occurrences of accidents and incidents or adverse events occurring on the facility premises which is not consistent with the routine operation of the facility or care of a particular resident. The policy also documented if assistance is needed, summon help and if the employee cannot leave the victim, ask someone to report to the nurse's station that help is needed, or if possible, use the call bell system located in the resident room to summon help. The policy further documented should an employee witness an accident, or find it necessary to aid an accident victim, the employee should render immediate assistance, do not move the victim until resident has been examined by a nurse for possible injuries. 1.Resident #1 was admitted to the facility with diagnoses including heart failure and anxiety. A review of the Minimum Data Set (a resident assessment tool) dated 10/08/2025 documented Resident #1 had intact cognition, and they required dependent assistance for toileting, showers, and transfers. On 10/31/2025 at 1:25 PM, the State Surveyor observed Resident #1 sitting in a wheelchair in their room. Resident #1 was wearing a blue sling on their left arm and swelling the size of quarter was observed over the left eyebrow area. Resident #1 denied pain and stated the injury occurred when they fell from the Hoyer lift when one (1) staff transferred them without assistance of another staff person. Resident #1 also stated they felt helpless at the time of the incident and is shaking more than before when they talk about the incident. The Kardex report as of 10/23/2025 documented Resident #1 required dependent care of two (2) or more staff (at least two provide hands-on care), for toileting, hygiene, and transfers, and resident does not use own strength for any part of the activity. The Kardex report also documented two (2) or more use own strength to lift or hold the resident's body, arms, and legs during the entire activity, and the resident does not use own strength for any part of the activity. The nursing progress note written by Licensed Practical Nurse #5, dated 10/24/2025 at 9:36 PM, documented resident returned from the Emergency Room, where they transferred for post-fall evaluation. The resident was diagnosed with a humerus fracture (a break in the long bone in the upper arm), which is being treated with immobilization. The medical progress note written by the Medical Director dated 10/24/2025 documented Chief Complaint/Nature of Presenting Problem: Evaluation post fall Resident is seen today for evaluation on post fall. Resident present in acute distress and pain due to fall. Resident reported pain of right temple, left upper eyelid, and swelling and left forearm pain. No shortness of breath or chest pain. Plan of care discussed with resident. Neuro check within normal limits at baseline. The Radiology Results Report for left wrist dated 10/24/2025 at 4:24 PM documented no acute fracture/dislocation. The Hospital Discharge summary dated [DATE] documented Discharge Diagnosis: fall fracture of the humerus (disorder). Humerus fracture treated with immobilization follow up with orthopedics in two (2) to three (3) days. Return for any complication. The facility Quality Assurance Report dated 10/24/2025 documented fall was lift related and a witnessed fall and incident occurred on 10/23/2025 at 12:30 PM. The Quality Assurance Report documented Resident #1 reported they fell from the mechanical lift while Certified Nursing Assistant #1 was transferring Resident #1 alone, and Certified Nursing Assistant #1 placed Resident #1 back in bed and then transferred Resident #1 with Recreation Aide in the room. The Quality Assurance Report documented Recreation Aide admitted they were in the room during the second transfer but did not assist with the transfer and observed Resident #1 with ice on their face and Resident #1 reported they fell from the mechanical lift when Certified Nursing Assistant #1 was transferring Resident #1 out of bed alone. Resident #1 was evaluated with neuro checks, facility x-rays and then transferred to the emergency room for computer tomography scan (an advanced x-ray that takes detailed pictures inside the body) and returned to the facility on [DATE] with a left humerus fracture. The Quality Assurance report also documented review of the resident's bed exit device revealed Resident #1 had bed exit between 12:00 PM to 1:00 PM and 1:00 PM to 2:00 PM, and documented based on Resident #1's report, Recreation Aide statement and review of the bed exit report for 10/23/2025, the facility concluded Certified Nursing Assistant #1 ignored facility polity and independently transferred Resident #1 without the assistance of a second certified nursing assistant and was terminated from the facility. The Bed Exit Alarm Report dated 10/23/25 documented Resident #1 exited the bed twice on 10/23/2025, once exit between 12:00 PM and 1:00 PM and the other exit between 1:00 PM and 2:00 PM. On 10/31/2025 at 9:50 AM, Certified Nursing Assistant #4, regularly assigned to Resident #1 on the night shift, stated Resident #1 is dependent on staff for care and always requires two (2) staff to give care including being taken out of bed with a Hoyer lift. Certified Nursing Assistant #4 stated they observed the swelling and bruising on Resident #1's face on 10/24/2025 around 7:00 AM when they entered Resident #1's room with Licensed Practical Nurse #3. On 10/31/2025 at 9:55 AM, Licensed Practical Nurse #2 stated they worked on the day shift on 10/23/2025 and was not aware Resident #1 fell on [DATE]. Licensed Practical Nurse #2 stated they were in the dining area until 4:00 PM, and neither Resident #1 nor staff reported Resident #1 fell. Licensed Practical Nurse #2 further stated Certified Nursing Assistant #1 did not ask for assistance and did not tell Licensed Practical Nurse #2 that Resident #1 fell. On 10/31/2025 at 11:18 AM, Licensed Practical Nurse #1 was interviewed and stated they worked on the unit the date of the incident (10/23/2025) but they were not aware of what occurred. Licensed Practical Nurse #1 stated they saw Resident #1 in the dining area and also saw Certified Nursing Assistant #1 on the unit, but no one reported a fall, or any incident to Licensed Practical Nurse #1. Licensed Practical Nurse #1 further stated when they saw Resident #1 in the dining area, Resident #1 did not have an ice pack, there was no swelling, and Resident #1 did not appear to be in pain. On 10/31/2025 at 12:40 PM, Recreation Aide #1 was interviewed and stated at approximately 1:40 PM, they came to the unit to pick up Resident #1 to attend bingo. Recreation Aide #1 stated when they entered Resident #1's room, they observed Resident #1 holding an ice pack on their face and Resident #1 stated Certified Nursing Assistant #1 dropped Resident #1 from the Hoyer lift to the floor when trying to take Resident #1 out of bed. Recreation Aide #1 stated Resident #1 stated they were scared and wanted the Recreation Aide to stay in the room with them, and Resident #1 was shaking while holding the ice pack to their face. Recreation Aide #1 stated a few minutes later, Certified Nursing Assistant #1 came into the room and proceeded to use the mechanical lift to transfer Resident #1 alone. Recreation Aide #1 stated they thought the incident had been reported to the nurse because Resident #1 was holding the ice pack when Recreation Aide #1 entered their room. On 10/31/2025 at 1:25 PM, Resident #1 was interviewed and stated their arm hurts, but they get medication which helps. Resident #1 also stated on the day of the incident, Certified Nursing Assistant #1 tried to transfer Resident #1 with the mechanical lift, but the lift turned as Certified Nursing Assistant #1 was transferring them alone, and the resident fell between the chair and the bed hitting their head and arm. Resident #1 stated Certified Nursing Assistant #1 pulled them up by their arms and placed them back into the bed. Resident #1 stated Certified Nursing Assistant #1 then gave them ice in a glove to put on the left side of their face, and they were very scared, nervous, felt helpless, and were shaking much more than before the fall. Resident #1 stated Recreation Aide #1 came to their room, and they asked Recreation Aide #1 to stay with them because they were scared. Resident #1 also stated Recreation Aide #1 did not assist in any transfer and left the room when Certified Nursing Assistant #1 returned. Resident #1 stated they did not report this incident to the nurse or any staff. On 10/31/2025 at 2:40 PM, Certified Nursing Assistant #1 was interviewed via telephone and stated they did not transfer Resident #1 alone and transferred Resident #1 with Recreation Aide #1 who was in the room at the time. Certified Nursing Assistant #1 stated Recreation Aide #1 assisted in placing the sling under Resident #1, helped placed the hooks on the sling, and put Resident #1 in the chair just as a certified nursing assistant does. Certified Nursing Assistant #1 further stated they did not give Resident #1 an ice pack and only gave Resident #1 a cup of ice because they are new to the facility and did not know where to find anything. Certified Nursing Assistant #1 stated the Recreation Aide #1 offered to help and there was no reason for them to refuse the help. Certified Nursing Assistant #1 stated they were inserviced on the mechanical lift and knew two (2) persons are needed to transfer residents from the bed to the chair. Certified Nursing Assistant #1 also stated they did not transfer Resident #1 alone, and that Resident #1 did not fall on 10/23/2025 when they were assigned to them. On 11/3/2025 at 12:52 PM, the Director of Recreation was interviewed and stated Recreation Aide #1 reported to them they saw Resident #1 with an ice pack, and they spoke to Resident #1 who informed them they fell and were picked up by the nurse. The Director of Recreation stated they just assumed if the nurse picked up Resident #1, then it was reported to Nursing. The Director of Recreation further stated Recreation Aides are not allowed to assist in transfers especially with mechanical lifts and Recreation Aide #1 denied they assisted in transferring Resident #1. On 11/04/2025 at 11:02 AM, Licensed Practical Nurse #3, who reported the incident, was interviewed by telephone and stated they worked the 4:00 PM-12:00 AM shift on 10/23/2025, and the 12:00 AM – 8:00 AM shift on 10/24/2025. Licensed Practical Nurse #3 stated the evening shift was uneventful, they gave Resident #1 medications and Resident #1 did not complain about anything and they did not notice any injury to Resident #1's face on 10/23/2025. Licensed Practical Nurse #3 stated that 10/24/2025 around 7:00 AM, they went into Resident #1's room to administer medications and observed a large swollen area and a long scratch mark above Resident #1's left eye. Licensed Practical Nurse #3 stated Resident #1 told them they fell from the mechanical lift the day before and Certified Nursing Assistant #1 was aware. 2. Resident #2 was admitted to the facility with diagnoses that included coronary artery disease (when the heart's blood supply is blocked or interrupted), cerebrovascular accident (interruption in the flow of blood to cells in the brain), and seizure disorder. The Minimum Data Set, dated [DATE] documented Resident #2 had severe impairment in cognition and impairment on one side of upper extremity and lower extremity (hip, knee, ankle, foot). The Minimum Data Set also documented Resident #2 was dependent on staff (resident does none of the effort to complete the activity, staff does all the effort or requires the assistance of two (2) or more staff to complete the activity) for all Activities of Daily Living. The Kardex Report as of 11/03/2025 documented Resident #2 was dependent on two (2) or more staff (at least two (2) provide hands-on care) for Bed-to-Chair Transfer. The Kardex Report also documented two (2) or more helpers complete all of the activity. The Care Plan Progress note dated 09/05/2025 at 3:12 PM written by Registered Nurse Manager #1, documented Writer notified by the Certified Nursing Assistant that Resident #2 sustained a fall during transfer. Facility fall protocol in place. Vital signs measured. Monitoring continues. The Physician's order dated 09/05/2025 written by the Medical Director documented x-ray of hips, bilateral with pelvis when performed, two (2) views. The Radiology Results Report dated 09/05/2025 documented Resident #2 sustained acute fracture in the right femur (bone of the upper leg between the hip and the knee). The Facility Investigation Report dated 09/10/2025 documented at approximately 2:30 PM, Registered Nurse Manager #1 was made aware Resident #2 fell during a mechanical transfer. The investigation revealed Certified Nursing Assistant #6 did not follow Resident #2's plan of care and attempted to transfer Resident #2 via mechanical lift without a second certified nursing assistant despite the facility direction that mechanical lift transfers require two (2) staff for safety. Resident was assessed, Medical Director and family were notified, x-ray ordered which determined Resident #2 sustained a right trochanter (hip) fracture that required surgical intervention. The facility investigation concluded that there is reasonable cause to believe that resident abuse, neglect or mistreatment may have occurred. The Hospital Discharge summary dated [DATE] documented Resident #2 was admitted to the hospital 09/06/2025 after fall incident. The imaging hip x-ray indicated acute right displaced femoral spiral fracture and was admitted for intertrochanteric spiral hip fracture. On 10/31/2025 at 11:11 AM, Certified Nursing Assistant #7 was interviewed, and stated they were looking for a shower chair and went into Resident #2's room to check for the chair and observed Resident #2 on the floor and Certified Nursing Assistant #6 standing by the resident's side. Certified Nursing Assistant #6 told them they were trying to transfer Resident #2 from bed to chair with the mechanical lift when Resident #2 fell and asked Certified Nursing Assistant #7 to help them pick up Resident #2 from the floor. Certified Nursing Assistant #7 stated they helped Certified Nursing Assistant #6 pick Resident #2 up from the floor and put them back to bed, and then they immediately went to notify the charge nurse. Certified Nursing Assistant #7 also stated Certified Nursing Assistant #6 did not call them to help assist in use of the mechanical lift for the transfer. Certified Nursing Assistant #7 further stated they were suspended for helping to pick up Resident #2. On 10/31/2025 at 12:15 PM, Certified Nursing Assistant #6 was interviewed and stated they were transferring Resident #2 from the bed to the recliner chair alone when the Hoyer lift canvas loosened, and Resident #2 fell out to the floor. Certified Nursing Assistant #7 walked in and assisted them in putting Resident #2 back into the bed. Certified Nursing Assistant #6 stated they decided to transfer Resident #2 alone after trying to find someone to help without any success as the other four (4) Certified Nursing Assistants on the unit were busy with their assigned residents and the two (2) nurses were busy giving medications to the residents. Certified Nursing Assistant #6 stated they knew they should call for another staff to help and they tried to look for someone but could not readily get anyone, and they thought Resident #2 had been in bed too long, so they just went ahead and did it alone to ensure Resident #2 was taken out of bed on time. On 10/31/2025 at 11:26 AM, Licensed Practical Nurse #1 was interviewed and stated they were waiting to assist Certified Nursing Assistant #7 with a resident's shower when Certified Nursing Assistant #7 came to inform them Resident #2 fell when Certified Nursing Assistant #6 was trying to transfer resident from bed by themself with the mechanical lift. Registered Nurse Manager #1 was immediately notified and assessed Resident #2, the doctor was notified and an order for stat x-ray was obtained. Licensed Practical Nurse #1 also stated Certified Nursing Assistant #6 did not call for help before using the mechanical lift to transfer Resident #2 by themself. On 10/31/2025 at 11:52 AM, Registered Nurse Manager #1 was interviewed and stated they were on the unit on the day of the incident, and they were called to Resident #2's room to assess Resident #2 who reportedly fell during transfer with the mechanical lift. Registered Nurse Manager #1 also stated Resident #2 was already placed back in bed when they got to the resident's room. During assessment, Resident #2 was observed with decreased passive range of motion on the right lower extremity with facial grimacing when gentle passive range of motion was attempted. Registered Nurse Manager #1 stated a stat x-ray was done as per the physician's order and facility protocol. Registered Nurse Manager #1 stated the x-ray results revealed a right hip fracture, and Resident #2 was transferred to the hospital for further evaluation/orthopedic surgery as per the physician's order.On 11/03/2025 at 2:20 PM, the Associate Administrator was interviewed and stated they do not know why these injuries are happening and they should not be happening. On 11/03/2025 at 3:08 PM, the Medical Doctor, who is also the Medical Director, was interviewed and stated they had a discussion with the Director of Nursing and the Administrator about the incidents of staff not following the plan of care causing accidents. The Medical Director stated the staff was educated, and the interdisciplinary team has weekly meetings to discuss hospitalizations, and situations that occurred leading to the hospitalization to determine if the Medical Director can assist in any way. The Medical Director further stated the Team meets weekly and discusses falls, weight loss or any high-risk issues. 10 NYCRR 415.12(h)(2)

Based on observation, record review, and interviews conducted during an Abbreviated Survey (#2652750 and #2610252), the facility failed to ensure that all alleged violations involving abuse, exploitation, or mistreatment, including injuries of unknown source are reported immediately but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This was evident for two (2) out of five (5) residents (Resident #1, Resident #2) reviewed. Specifically, 1). On 10/23/2025, Resident #1 fell to the floor during a transfer with a mechanical lift and sustained a fracture in left humerus (a break in the long bone in the upper arm) which was not reported to the New York State Department of Health until 10/26/2025, and 2). On 09/05/2025, Resident #2 fell to the floor during a transfer with a mechanical lift and sustained a fracture in the right femur (a break in the long bone between the hip and knee) which was not reported to the New York State Department of Health until 09/06/2025. The findings are: The facility's policy titled Abuse Policy revised 07/18/2025 documented the Administrator and The Director of Nursing are responsible for investigation and reporting. The policy also documented notification to the local law enforcement and appropriate State Agency(s) immediately no later than two (2) hours after allegation/identification of allegation by Agency designated process after the identification of alleged/suspected incident, and initiate process according to the Elder Justice Act and State specific regulations. 1.Resident #1 was admitted to the facility with diagnoses including heart failure and anxiety. A review of the Minimum Data Set (a resident assessment tool) dated 10/08/2025 documented Resident #1 had intact cognition, and they required dependent assistance for toileting, showers, and transfers. The nursing progress note written by Licensed Practical Nurse #5, dated 10/24/2025 at 9:36 PM, documented resident returned from the Emergency Room, where they transferred for post-fall evaluation. The resident was diagnosed with a humerus fracture (a break in the long bone in the upper arm), which is being treated with immobilization. The medical progress note written by the Medical Director dated 10/24/2025 documented Chief Complaint/Nature of Presenting Problem: Evaluation post fall Resident is seen today for evaluation on post fall. Resident present in acute distress and pain due to fall. Resident reported pain of right temple, left upper eyelid, and swelling and left forearm pain. No shortness of breath or chest pain. Plan of care discussed with resident. Neuro check within normal limits at baseline. The Hospital Discharge summary dated [DATE] documented Discharge Diagnosis: fall fracture of the humerus (disorder). Humerus fracture treated with immobilization follow up with orthopedics in two (2) to three (3) days. Return for any complication. The Department of Health Nursing Home Facility Incident Report Submission Report documented submitted on 10/26/2025 at 1:45 AM, and the incident occurred on 10/23/2025 at 1:00 PM. On 10/31/205 at 10:21 AM, the Regional Director of Nursing was interviewed and stated they were responsible for the facility at the time of the incident because the Director of Nursing was not available. The Regional Director of Nursing also stated on 10/26/2025 they read the hospital discharge summary and realized Resident #1 had been diagnosed with a fracture, so they reported it to the New York Department of Health then. The Regional Director of Nursing further stated they are aware this incident needed to be reported within two hours and gave no reason why it was reported late. On 11/03/2025 at 2:50 PM, the Associate Administrator was interviewed and stated they became made aware of the incidents after they occurred and is aware these incidents need to be reported within two (2) hours after they occurred. The Associate Administrator also stated they did not know the incidents had been reported late as these incidents should be reported within two hours, and they did not know why they were not reported within two hours. 2.Resident #2 was admitted to the facility with diagnoses that included Coronary artery disease, Cerebrovascular accident, and Seizure disorder. The Minimum Data Set (an assessment tool) dated 07/16/2025 documented Resident #2 had severe cognitive impairment, had impairment on one side of the upper extremity and lower extremity (hip, knee, ankle, foot) and was totally dependent on staff for activities of daily living. The Facility Investigation Report dated 09/10/25 documented date/time of event when Nursing became aware of event of Resident #2's fall during a mechanical lift transfer was 09/05/2025 at 01:59 PM. The Radiology Results Report dated 09/05/2025 at 10:55 PM, documented Resident #2 had an acute fracture in the right femur. The Facility Submission Report documented a report was submitted to the New York State Department of Health on 09/06/2025 at 07:13 AM. The report was submitted more than 17 hours after the incident occurred and more than 8 hours after x-ray results confirmed Resident #2 had sustained a fracture as a result of the incident. On 11/03/2025 at 11:03 AM, Registered Nurse Unit Manager #1 was interviewed and stated when they were notified of Resident #2's fall on 09/05/2025, the facility fall protocol was observed by assessing the resident and reported to the Assistant Director of Nursing and calling for stat X-ray as per doctor's order. Registered Unit Manager #1 also stated they were not sure if they should report the incident to the Department of Health. On 11/03/2025 at 12:36 PM, the Director of Nursing was interviewed and stated they were not in the facility when the incident with Resident #2 occurred. The Director of Nursing also stated a stat x-ray was ordered on 09/05/2025 at 1:58 PM, and the facility received the results on 09/05/2025 at 10:55 PM, and it was reviewed by the supervisor on duty at that time. Attempts to contact the physician were unsuccessful until the morning of 09/06/2025 when the physician ordered to send the resident to the hospital on [DATE]. The Director of Nursing further stated the incident was reported to the Department of Health on 09/06/2025 because that was when the x-ray results were received. On 11/03/2025 at 12:48 PM, the Regional Director of Nursing was interviewed and stated the incident occurred on 09/05/2025 and stat x-ray was ordered, and they thought the x-ray result was reported on the same day. The Regional Director of Nursing also stated they were not aware Resident #2 had a fractured hip until the morning of 09/06/2025. The Regional Director of Nursing further stated they submitted the report to Department of Health on 09/06/2025 after Resident #2 was sent to the hospital. On 11/03/2025 at 2:01 PM, the Medical Director was interviewed and stated they did not receive the call about Resident #2's fracture until the morning of 09/06/2025. The Medical Director also stated the nursing staff did not need their approval and should have notified the Department of Health when the result was received. On 11/03/2025 at 2:30 PM, Associate Administrator was interviewed and stated they Resident #2's injury should be reported within two hours, and it is the nursing department's responsibility to submit the online report. The Associate Administrator also stated they were not aware the reports had not been submitted on time. 10 NYCRR 415.4(b)(2)

Based on record review and interview during the abbreviated survey (#2265750), the facility did not ensure a comprehensive person-centered care plan for each resident was reviewed and revised based on changing goals, preferences and needs of the resident and in response to current interventions. This was evident for one (1) out of five (5) residents (Resident #1) reviewed. Specifically, the comprehensive care plan for Resident #1 was not reviewed or revised after Resident #1 fell from a mechanical lift during transfer and sustained injury. The finding is: The facility policy titled 'Care Plan Comprehensive' reviewed 8/2/2024 documented assessments of residents are ongoing, and care plans are revised as information about the residents and the resident's conditions change. Resident #1 had diagnoses which included Heart failure and Anxiety. A review of the Minimum Data Set (a resident assessment tool) dated 10/08/2025 documented Resident #1 had intact cognition, and they required dependent assistance for toileting, showers, and transfers. The Minimum Data Set also documented Resident #1 had no history of falls. On 10/31/2025 at 1:25 PM, the State Surveyor observed Resident #1 sitting in a wheelchair in their room. Resident #1 was wearing a blue sling on their left arm and swelling the size of quarter was observed over the left eyebrow area. Resident #1 denied pain and stated the injury occurred when they fell from the hoyer lift when one (1) staff transferred them without assistance of another staff person. The Hospital Discharge summary dated [DATE] documented Discharge Diagnosis: fall fracture of the humerus (disorder). Humerus fracture treated with immobilization follow up with orthopedics in two (2) to three (3) days. Return for any complication. The nursing progress note written by Licensed Practical Nurse #5, dated 10/24/2025 at 9:36 PM, documented resident returned from the Emergency Room, where they transferred for post-fall evaluation. The resident was diagnosed with a humerus fracture (a break in the long bone in the upper arm), which is being treated with immobilization.The care plan titled had an actual fall related to history of falls reviewed on 11/5/2024 with had interventions which included anticipate and meet the resident needs, be sure the resident's call light is within reach and encourage to use it for assistance as needed and provide well-lit environment.There was no documented evidence that the comprehensive care plan was reviewed or revised to include interventions after the fall that occurred on 10/23/2025. On 10/31/2025 at 1:40 PM, Registered Nurse #1 Unit Manger was interviewed and stated they did not know about the incident with Resident #1 until they returned to work on 10/24/2025. Registered Nurse #1 also stated they are responsible for completing and updating all care plans on the unit and that the care plans was updated at the time of the incident, however they were unable to provide a copy of the updated care plan. On 11/03/2025 at 11: 15 AM, the Director of Nursing was interviewed and stated the Registered Nurses are responsible for initiating, and updating care plans and the Licensed Practical Nurses can update if they discuss this with the Registered Nurses. The Director of Nursing logged into the computer and stated the care plan was not updated. The Director of Nursing further stated the fall Care Plan was last updated on 10/16/2025 prior to the fall and could not explain why the fall care plan had not been updated after the fall incident. 10 NYCRR 415.11(c)(2)(i-iii)

Based on observation, record review and interviews conducted during the abbreviated survey (#2610252) the facility did ensure residents were provided with treatment and care in accordance with professional standards of practice. This was evident for one (1) of five (5) residents (Resident #2) sampled. Specifically, Resident #2, who fell and sustained a fracture of the hip during a mechanical lift transfer from bed, was not assessed and evaluated by a registered nurse before being transferred from the floor back to bed.The findings are: The facility policy titled 'Accident Incidents' last reviewed 01/01/2024, documents it is the policy of the facility to monitor and evaluate all occurrences of accidents and incidents or adverse events occurring on the facility premises which is not consistent with the routine operation of the facility or care of a particular resident. The policy also documented if assistance is needed, summon help and if the employee cannot leave the victim, ask someone to report to the nurse's station that help is needed, or if possible, use the call bell system located in the resident room to summon help. The policy further documented should an employee witness an accident, or find it necessary to aid an accident victim, the employee should render immediate assistance, do not move the victim until resident has been examined by a nurse for possible injuries. Resident #2 was admitted to the facility with diagnoses that included coronary artery disease (when the heart's blood supply is blocked or interrupted), cerebrovascular accident (interruption in the flow of blood to cells in the brain), and seizure disorder. The Minimum Data Set, dated [DATE] documented Resident #2 had severe impairment in cognition and impairment on one side of upper extremity and lower extremity (hip, knee, ankle, foot). The Minimum Data Set also documented Resident #2 was dependent on staff (resident does none of the effort to complete the activity, staff does all the effort or requires the assistance of two (2) or more staff to complete the activity) for all Activities of Daily Living. The Kardex Report as of 11/03/2025 documented Resident #2 was dependent on two (2) or more staff (at least two (2) provide hands-on care) for Bed-to-Chair Transfer. The Kardex Report also documented two (2) or more helpers complete all of the activity. The Care Plan Progress note dated 09/05/2025 at 3: 12 PM written by Registered Nurse Manager #1, documented Writer notified by the Certified Nursing Assistant that Resident #2 sustained a fall during transfer. Facility fall protocol in place. Vital signs measured. Monitoring continues. The Facility Investigation Report dated 09/10/2025 documented at approximately 2:30 PM, Registered Nurse Manager #1 was made aware Resident #3 fell during a mechanical transfer. The investigation revealed Certified Nursing Assistant #6 did not follow Resident #3's plan of care and attempted to transfer Resident #3 via mechanical lift without a second certified nursing assistant despite the facility direction that mechanical lift transfers require two (2) staff for safety. Resident was assessed, Medical Director and family were notified, x-ray ordered which determined Resident #3 sustained a right trochanter (hip) fracture that required surgical intervention. The facility investigation concluded that there is reasonable cause to believe that resident abuse, neglect or mistreatment may have occurred.There was no documented evidence Resident #2 was assessed and evaluated by a nurse before being placed back to bed following a fall. On 10/31/2025 at 11:11 AM, Certified Nursing Assistant #7 was interviewed, and stated they were looking for a shower chair and went into Resident #3's room to check for the chair and observed Resident #3 on the floor and Certified Nursing Assistant #6 standing by the resident's side. Certified Nursing Assistant #6 told them they were trying to transfer Resident #3 from bed to chair with the mechanical lift when Resident #3 fell and asked Certified Nursing Assistant #7 to help them pick up Resident #2 from the floor. Certified Nursing Assistant #7 stated they helped Certified Nursing Assistant #6 pick Resident #3 up from the floor and put them back to bed, and then they immediately went to notify the charge nurse. Certified Nursing Assistant #7 also stated Certified Nursing Assistant #6 did not call them to help assist in use of the mechanical lift for the transfer. Certified Nursing Assistant #7 further stated they were suspended for helping to pick up Resident #3. On 10/31/2025 at 12:15 PM, Certified Nursing Assistant #6 was interviewed and stated they were transferring Resident #3 from the bed to the recliner chair alone when the hoyer lift canvas loosened, and Resident #3 fell out to the floor. Certified Nursing Assistant #7 walked in and assisted them in putting Resident #3 back into the bed. Certified Nursing Assistant #6 stated they decided to transfer Resident #3 alone after trying to find someone to help without any success as the other four (4) Certified Nursing Assistants on the unit were busy with their assigned residents and the two (2) nurses were busy giving medications to the residents. Certified Nursing Assistant #6 stated they knew they should call for another staff to help and they tried to look for someone but could not readily get anyone, and they thought Resident #3 had been in bed too long, so they just went ahead and did it alone to ensure Resident #3 was taken out of bed on time.On 10/31/2025 at 11:26 AM, Licensed Practical Nurse #1 was interviewed and stated they were waiting to assist Certified Nursing Assistant #7 with a resident's shower when Certified Nursing Assistant #7 came to inform them Resident #2 fell when Certified Nursing Assistant #6 was trying to transfer resident from bed by themself with the mechanical lift. The Nurse Manager was immediately notified and assessed Resident #2 after the resident was placed back in bed by the Certified Nursing Assistants. Licensed Practical Nurse #1 stated Certified Nursing Assistant #6 did not call for help before using the mechanical lift to transfer Resident #2 by themselves and failed to notify them before Resident #2 was placed back to bed after the incident. On 10/31/2025 at 11:52 AM, Registered Nurse Manager #1 was interviewed and stated they were on the unit on the day of the incident, and they were called to Resident #2's room around 2:00 PM on 09/05/2025 to assess Resident #2 who reportedly fell during transfer with the mechanical lift. Registered Nurse Manager #1 also stated Resident #2 was already placed back in bed when they got to the resident's room. During assessment, Resident #2 was observed with decreased passive range of motion on the right lower extremity with facial grimacing when gentle passive range of motion was attempted. Registered Nurse Manager #1 further stated they were not informed of the incident before Resident #2 was placed back to bed. On 11/03/2025 at 12:36 PM, the Director of Nursing was interviewed and stated Certified Nursing Assistant #6 was terminated for not following Resident #2's plan of care, and Certified Nursing Assistant #7 was suspended for not following the facility protocol to notify the supervisor if they observed a resident on the floor.10 NYCRR 415.12

Based on observation, record review and interview conducted during the abbreviated survey (2610252), the facility did not ensure residents with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. This was evident for one (1) of five (5) residents (Resident #2) reviewed. Specifically, Resident #2 was observed not wearing a right knee or elbow brace as per the plan of care. The findings are:The facility policy titled 'Appliances/Devices - Splints, braces, slings' last updated 09/08/2025 documented the facility will maintain the safe application, monitoring, and maintenance of resident appliances (such as splints, braces, and slings) in accordance with current standards of practice, manufacturer's instruction for use and state and federal regulations.Resident #2 was admitted to the facility with diagnoses that included Coronary artery disease, Cerebrovascular accident, Hemiplegia (weakness on one side of the body).The Minimum Data Set, dated [DATE] documented Resident #2 had severe impairment in cognition and impairment on one side of upper extremity and lower extremity (hip, knee, ankle, foot). The Minimum Data Set also documented Resident #2 was dependent on staff (resident does none of the effort to complete the activity, staff does all the effort or requires the assistance of two (2) or more staff to complete the activity) for all Activities of Daily Living.The Comprehensive Care Plan titled 'Contracture' revised 09/10/2025 documented Resident #3 has limited physical mobility related to cerebral infarction, had a goal of resident will remain free of complications related to immobility, including contractures and interventions which included Right knee brace to be worn at all times as tolerated except skin check and hygiene care, Right elbow brace to be worn at all times as tolerated remove for skin checks and hygiene care. On 10/31/2025, between 09:55 AM and 02:30 PM, Resident #2 was observed in bed, noted with contractures on both upper and lower extremities. There was no device applied to Resident #2's elbow or knee. On 11/03/2025, between 09:00 AM and 12:00 PM, Resident #2 was observed in bed, there is no device applied on Resident #2's elbow or knee. The Resident Nursing Instruction Form 'Kardex Reports as of 11/3/2025' (contains instructions for Certified Nursing Assistants) documented Resident Care: Adaptive Device: Right knee brace to be always worn as tolerated except skin check and hygiene care. The Kardex Report did not include instructions for the elbow brace.There was no documented evidence in the Certified Nursing Assistant Task reviewed from September 2025 to November 2025 that an elbow or knee brace was being applied for Resident #2. On 10/31/2025 at 10:06 AM, Certified Nursing Assistant #8 stated they have been assigned to Resident #2 when floated to the unit, and they were not aware Resident #2 was supposed to have a device for the knee or elbow. Certified Nursing Assistant #8 also stated they had never seen or applied any device to Resident #2's elbow or knee. On 10/31/2025 at 10:16 AM, Certified Nursing Assistant #9 was interviewed, stated that they have been assigned to Resident #2 in the past. Certified Nursing Assistant #9 also stated they were not aware Resident #2 had any device to be applied on the elbow or knee, and they had not seen or placed any device on Resident #2's knee or elbow during care. On 10/31/2025 at 10:22 AM, Licensed Practical #3 was interviewed and stated they occasionally floated to Resident #2's unit, and they had not observed Resident #2 with any hand brace or knee brace, and they were not aware Resident #2 was to be provided with such devices.On 11/03/2025 at 10:35 AM, Certified Nursing Assistant #10 was interviewed and stated they have been taking care of Resident #2 since re-admission to the unit in September 2025. Certified Nursing Assistant #10 also stated they did not know Resident #2 had a device and had not seen any device in their daily tasks in the electronic medical records. Certified Nursing Assistant #10 further stated that such devices used to be visible to them when signing off tasks performed for the residents, but they are no longer seeing those devices in the electronic medical record, and they do not know how to check the instructions when documenting tasks performed in the electronic medical record. On 11/03/2025 at 10:46 AM, Licensed Practical Nurse #4, who was the charge nurse on the unit, was interviewed and stated the instructions on the resident's splint devices are supposed to be visible to the Certified Nursing Assistant in the Kardex so they know what needs to be done for the residents. Licensed Practical Nurse #4 also stated they were not aware the Certified Nursing Assistants are not able to view and implement instructions as per the residents' plan of care. Licensed Practical Nurse #4 further stated they have not seen Resident #2 with any devices because the Certified Nursing Assistant had not been applying it. On 11/03/2025 at 11:49 AM, the Rehabilitation Director was interviewed and stated that Resident #2 was issued both hand and knee braces to be applied at all times, and to be removed during care for skin check and hygiene care only, and they were not aware nursing staff had not been applying the devices as recommended. The Rehabilitation Director also stated when they were informed on 11/03/2025 that the devices were not placed on Resident #2, they went to the unit to check and found the two devices were located in Resident #2's closet. The Rehabilitation Director further stated when a device is recommended for a resident, it is given to the nursing staff, documented in the resident care plan and in the electronic medical record Kardex Task for the staff to view the instructions for the device. The Rehabilitation Director stated they usually do audits randomly to see if the device is still in use, and the last audit conducted around 2 years ago indicated Resident #2 had the devices in place. The Rehabilitation Director also stated it is the responsibility of the nursing staff to ensure the devices are being applied, and if they are missing, to contact Rehabilitation department for replacement. On 11/03/2025 at 11:55 AM, the Director of Nursing was interviewed and stated the task is documented in the Kardex located in the electronic medical record and the Certified Nursing Assistants are supposed to be checking the instructions to know what is to be done for their residents. The Director of Nursing also stated there was no physician's order for the braces because it is a nursing intervention that the staff need to implement to prevent residents from further contractures. The Director of Nursing further stated the charge nurses and managers on the unit should be monitoring the Certified Nursing Assistants to ensure they are carrying out all tasks as per the residents' plan of care. On 11/03/2025 at 12:05 PM, the Assistant Director of Nursing, who supervised the Licensed Practical Nurses, was interviewed and stated staff are educated and are expected to be monitored and supervised by the charge nurse to ensure devices are applied on the resident as per plan of care. The Assistant Director also stated they were not aware devices were not being applied. On 11/03/2025 at 2:01 PM, the Medical Director was interviewed and stated they place an order for 'curative devices' recommended for residents, and other devices are at the discretion of the therapist and nurses. The Medical Director also stated it is usually dependent on the Rehabilitation department who makes the recommendation, nursing staff implements the recommendations and documents it in the resident's plan of care to ensure the interventions are carried out. The Medical Director further stated no physician orders is needed for knee and elbow braces as they are just to prevent further contractures and not to cure the contractures. 10 NYCRR 415.12 (e)(2)

Based on observations, record review, and interviews conducted during the Recertification and Complaint survey from 10/26/23 to 11/2/23, the facility did not ensure safe food storage was practiced to prevent food-borne illness. This was evident during the initial tour of the Kitchen. Specifically, milk past their use by date were located in the kitchen refrigerator. The findings are: The facility policy titled Receiving reviewed 01/2023 documented all items will be checked for appropriate quality and quantity upon receipt. Refrigerated foods date sensitive foods are within sell by or use by date (at a minimum, this date must be after the next delivery date for the product). The facility policy titled Food Storage reviewed 07/19/2023 documented all stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and high quality of all foods. Old stock is always used first (first in-first out method). Supervise the person designated to put stock away to make sure it is rotated properly. Refrigerated food storage: all foods should be labeled and dated. All foods will be checked to assure that foods including leftovers will be consumed by their sage use by date or frozen where applicable or discarded. On 10/26/2023 at 10:02 AM, the kitchen tour was done with the Food Service Director (FSD) and the following was noted in the refrigerator 3 quart size bottles of fat free milk with use by dates of 10/15/23 WL 04:52 21, 2 quart size bottles stamped 10/6/23 WL 08:11 11, 1 quart size bottle 09/29/23 WL 09:47 04, 2 quart size bottles 10/15/23 WL 04:51 21, 1 quart size bottle 10/15/23 WL 04:50 21, 1 quart size bottle 1-/6/23 WL 08:11 11. On 10/26/2023 at 10:07 AM, the Food Service Director was interviewed and stated that they did not know where the milk came from, as the facility usually receives half gallon sized bottles. The FSD also stated that they will talk to the milk company. The store room person does not receive a copy of the receipt from the delivery company that it does to the corporate office. On 11/02/2023 at 1:54 PM, the Dairy Plant Manager was interviewed and stated that the date stamped on milk is the expiration date of the milk. Stores may use it as the last date they can sell milk to a customer. In a nursing home the milk should be discarded after this stamped date. On 11/02/23 at 12:24 PM, an additional interview was done with the Food Service Manager (FSM) who stated they check the refrigerator items daily to make sure they are dated. They check the expiration date for the milk and the staff should also be checking the milk. The FSM also stated that the date on the container of milk is the date the milk expires and they try to avoid using milk on the expiry date of that milk. 415.14 (h)

Based on record review and interviews conducted during the Recertification & Complaint (NY00321990) survey from 10/26/2023 to 11/2/2023, the facility did not ensure the resident's right to a dignified existence. This was evident for 1 (Resident #59) out of 40 total sampled residents. Specifically, Resident # 59 was not provided their own personal clothes to wear for an entire weekend after their re-admission to the facility. The findings are: There was no facility policy that documented when the facility provides the personal items including the personal clothes back to a resident upon their re-admission to the facility to ensure the resident shall be cared for in a manner promoting and enhancing quality of life, dignity, respect, and individuality. Resident #59 had diagnoses which included Cerebral Infarction, Depression, and Unspecified Dementia. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #59 had severely impaired cognition, did not reject care, and required extensive assistance with of one staff for dressing. The Annual MDS dated [DATE] documented it was somewhat important for Resident #59 to choose clothes to wear. The complainant Intake Information form with a received date of 8/14/23 documented that the concern occurred on 8/11/23. The complainant reported the hospital called and informed them that Resident #59 was transported back to the facility at 12:30 PM on Friday. The complainant further reported their family member visited Resident #59 on 8/11/23 and observed Resident #59 was in bed with no clothes and no clothes were in the closet. The complainant reported the family member spoke to RN #1 and was informed Resident #59 could not have clothes until Monday as only the housekeeping staff had keys to storage room. The Admission or Incoming Personal Property Lists dated 11/25/20 to 7/13/22 documented Resident #59 had 2 sweaters, 5 sweatshirts, 6 sweatpants, 4 T-shirts, 5 under wear, 7 socks, 2 blankets, 1 pajama, and 1 pair of shoes. A black marble notebook labeled storage located in the lower level storage room area of the facility documented that Resident #59 had 1 bag of personal items stored in the room on 8/10/23 (Thursday) and the bag was returned to Resident #59 on 8/14/23 (Monday). The Environmental Services Department duty sheet dated 8/12/23 and 8/13/23 documented Housekeeping Aide #1 and Housekeeping Aide #2 were working on Saturday 8/12/23 and Sunday 8/13/23 respectively and covered the B2 level where the storage room was located. The nursing note dated 8/11/23 at 3:17 PM (Friday) documented that Resident #59 was readmitted to the facility from the hospital. There was no documented evidence that Resident #59's personal clothing was returned on re-admission day 8/11/23 (Friday) or over the weekend, which would have allowed Resident #59 to dress in personal clothes as was their preference and ensure a dignified existence for the resident. On 10/27/23 at 05:19 PM, Registered Nurse (RN) #1 who was also the nurse supervisor for evening shift working on Wed, Fri, Sat, and Sun; was interviewed and stated the assigned Certified Nursing Assistant (CNA) packed the resident's personal belongings, labeled them, and gave them to the housekeeping staff for storage when the resident was admitted to the hospital. RN #1 also stated the process was the opposite when a resident was readmitted to the facility. The housekeeping staff picked up the packed resident's belongings from the storage room and the CNA gave them back to the resident. RN #1 stated the Director of Housekeeping had the keys for the 2 storage rooms and they worked from 9 AM to 5 PM during the weekdays. RN #1 also stated they had master key to open the 2 storage rooms if needed, and housekeeping staff was able to pick up the resident's belongings when the Director of Housekeeping was not in the facility. RN #1 stated they remembered Resident #59 as the resident had been at the facility for years. RN #1 also stated they did not remember a representative of Resident # 59 speaking to them regarding Resident #59's clothing in August 2023 after Resident #59 was readmitted . The RN #1 further stated Resident #59 was not left in bed without wearing clothes since their re-admission to the facility on [DATE]. The RN #1 had no explanation where Resident #59's clothes were which the storage book documented were returned to Resident #59 on 8/14/23. On 10/30/23 at 10:29 AM, the Director of Housekeeping (DH) was interviewed and stated the housekeeping staff put the resident's name, room number, and number of bags in the book in the storage room located at level B2 after the CNA packed the resident's personal belongings for resident's hospitalization . The DH also stated they brought the resident's personal items back to the unit after the unit charge nurse notified them the resident was readmitted . The DH stated one housekeeping staff is on duty and had the keys to the storage room for the day shift and the security had the key for the evening shift after 5 PM for the weekdays and the whole day for the weekends and holiday. The housekeeping staff for the evening (3 PM to 11 PM) and night shift (11 PM to 7 AM) go to the security for the key to storage room if needed. The DH stated they had a book in the storage room documented the resident's name, room number, number of bags and when the bags were stored and returned back to the resident. On 10/30/23 at 12:46 PM, the Housekeeping Aide (HA) #1 was interviewed and stated they work from 7 AM to 3 PM every Sat and Sun. HA #1 also stated they had the key to the storage room and left with the security staff when they left the facility. HA #1 further stated they worked on Sat 8/12/23, covered the B2 level where the storage room was, and no one called them to pick up Resident #59's person items from the storage room On 10/30/23 at 12:52 PM, Housekeeping Aide (HA) #2 was interviewed and stated they work every other Sunday from 7 AM to 3 PM. HA #2 also stated they were assigned to cover B2 level where the storage room located and had a key to it on 8/13/23. HA #2 further stated they did not recall any staff calling them to get Resident # 59's personal items from the storage room on 8/13/23 On 10/30/23 at 02:21 PM, the Director of Nursing (DNS) was interviewed and stated the unit charge nurse is supposed to notify the housekeeping staff to bring the resident's personal items back to the unit when the resident was readmitted to the facility. The DNS also stated the unit charge nurses were all in-serviced for this procedure and should know the housekeeping staff were available 7 days a week and had access to the storage room. The DNS was not able to explain why Resident # 59 did not have their personal clothes back upon readmission on Friday 8/11/23 and had to wait until Monday on 8/14/23. 415.5(a)

Based on record review and interviews conducted during the Recertification survey completed from 10/26/23 through 11/2/23, the facility did not ensure that each resident was offered the opportunity to participate in the review of their Comprehensive Care Plans (CCP). This was evident for 2 out of 3 residents reviewed for Care Planning out of a sample of 40 residents. Specifically, Resident #89 and Resident #269 were not invited to participate in their care plan meeting. The findings are: The facility policy and procedure titled Care Plan last revised 10/2019, documented as follows: The Interdisciplinary Team (IDT:), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 1.Resident #89 was admitted with diagnoses that included Dementia, Hypertension, and Coronary Artery Disease. The Admission Minimum Data Set (MDS) dated [DATE] documented that Resident #89 was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 12, required extensive assistance with most Activities of Daily Living. The MDS also documented resident independently participated in the assessment and goal setting process. On 10/26/23 at 10:39 AM, an interview was conducted with the Resident #89 who stated that they had not been invited to participate in care planning meetings and to discuss discharge to the community. The progress notes, the care plan invitation binder, and the meeting schedule contained no documented evidence that Resident #89 had been invited to or participated in care plan meetings. 2.Resident #269 is diagnosed with Major Depressive Disorder and Anxiety Disorder. The Admission MDS dated [DATE] documented that Resident # 269 was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 12. On 10/26/23 at 02:09 PM, an interview was conducted with the Resident #269 who stated that they had been at the facility for almost 7 weeks and had not been invited to care planning meetings even after expressing an interest in discussing discharge to the community. The progress notes, the care plan invitation binder, and the meeting schedule contained no documented evidence that Resident #269 had been invited to or participated in any care plan meetings. On 10/31/23 at 11:01 AM, an interview was conducted with the Director of Social Work (DSW) who stated that at this time they are responsible for completing the Minimum Data Set (MDS) and Comprehensive Care Plans for all residents. Residents are invited to care plan meetings by written invitation, phone calls are made to the family members. This information is documented in progress notes and the signed invitations are kept in the invitation binder. State Surveyor reviewed the medical record with the DSW who acknowledged that there was no invitation for meetings in the record and no documentation that the care plan meeting was done and either resident was in attendance. On 11/01/23 at 03:22 PM, an interview was conducted with the Facility Administrator who stated that the facility ensures that there is resident and family involvement. Family gets written invitation notice in the mail and at minimum a phone call. Residents capable of attending are notified in-person and may get a written notice. A sign in sheet is created at the meeting and care plan notes are documented in the progress notes. Care planning has been a constant discussion, the Social Worker (SW) conducts audits and will determine which residents are due to be scheduled. The Facility Administrator also stated that they were not aware that there were residents who had not been invited to participate in care planning meetings. 415.5

Based on record reviews and interviews during the Recertification and abbreviated survey (NY00310538 from 10/26/23 to 11/2/23, the facility did not ensure that a resident's representative was immediately notified of the presence of a Stage 3 sacrum ulcer. In addition, the resident's representative was not notified when a Stage 3 sacrum pressure ulcer reopened on June 29, 2023. This was evident for 1 of 1 resident reviewed for Notification of Change (Resident #105). The findings are: The facility's policy titled Change in Resident's Condition last revised 05/2019 documented the nurse will notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status. Notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. Resident #105 was initially admitted to the facility with diagnoses that included Alzheimer's disease, Diabetes Mellitus, and Malnutrition. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #105 was severely cognitively impaired, required extensive assist for bed mobility, was totally dependent on two staff for transfer, and had one Stage 3 pressure ulcer. The Nursing Readmission assessment dated [DATE] documented the resident had a Stage 3 sacrum ulcer with Pressure: Length of 4 cm, Width of 3.5 cm and Depth of 0.1 cm. The Nursing note dated 06/29/23 documented the previously healed sacral pressure wound reopened. On 10/13/23 the complainant reported to the DOH complaint hotline that it was discovered that Resident #105 had a Stage 4 sacrum ulcer. The complainant further stated that the facility never informed the resident's representative that the resident had developed a sacrum ulcer. There was no documented evidence that the resident representatives were informed about the Stage 3 sacrum ulcer upon re-admission or when the wound reopened in June 2023. On 10/31/23 at 11:38 AM, Registered Nurse (RN) #2 stated that the resident was readmitted on [DATE] with a Stage 3 sacrum ulcer. The sacrum ulcer healed in May 2023 and reopened again in June 2023. RN #2 also stated that they notify families of any change in a resident's condition immediately. The Wound Doctor would notify the family of new wounds or if the wounds get worsen. RN #2 further stated that they are not sure if the facility notified the residents' family in June 2023 when the sacrum ulcer re-opened. There was no notification to family upon admission and when the sacral wound re-opened. Notification of change is done immediately and upon readmission. RN #2 stated that there was no documentation that the family was informed of the sacrum ulcer. On 10/31/23 at11:59 AM, the Wound Care Nurse (WCN) stated that the family was contacted about the sacrum ulcer upon admission and when the wound re-opened. The sacrum ulcer closed on 5/31/23. The wound re-opened on 6/29/23. The WCN also stated that the Wound Care Doctor would usually contact the resident's family member. The WCN further stated that they usually tell the family upon admission if a resident has a wound and when they saw the wound in June 2023, the wound was not closed internally. The WCN stated that the Wound Care Doctor saw the resident on 6/30/23 due to the re-opening of the sacral ulcer. On 11/02/23 at 11:16 AM, the Assistant Director of Nursing (ADNS) stated if there any changes in condition, we have to notify the resident's family and inform them of all changes immediately. If the resident's representative is not available, we leave a message and ask the family to call back. The Attending Doctor would also notify the family. The ADNS also stated that if the Doctor did not notify the family, the Nurse Manager on duty would notify the family. On 11/02/23 at 11:40 AM, the Director of Nursing (DON) stated that the policy is that they are to notify the family of any changes in condition immediately. If a resident was admitted with a wound, the admission nurse or the Nurse Manager must inform the resident's representative immediately. If there are any changes in medications, the Doctor and the Nurse are responsible for notifying the family. The DNS also stated that they have a wound notification protocol and all families are supposed to be notified of any wounds upon discovery. The DNS further stated that the admission nurse or the wound care nurse should notify the family right away. 415.3(e)(2)(ii)(c)

Based on interview and record review conducted during a Recertification and Complaint (NY00318699) survey from 10/26/2023 to 11/2/2023, the facility did not ensure an incident involving a confused resident being unsupervised for about 2 hours in the community was reported to the State Survey Agency. This was evident for 1 (Resident # 18) out of 5 residents reviewed for Accidents out of a sample of 40 residents. Specifically, the facility did not report to the New York State Department of Health (NYSDOH) that Resident #18 was picked up by transportation, left the facility without staff escort, and was dropped off by the transportation on the hospital campus without any staff supervision. The findings include: The facility policy titled Accident - Incident with creation date 11/2013 and last date revised 7/2023 documented an incident is any occurrence not consistent with the routine operation of the center, normal care of the resident a happening involving visitors, malfunctioning equipment, or observation of a condition which might be a safety hazard. It also documented these occurrences must be evaluated and investigated. It further documented the Director of Nursing and Admin are responsible to review incident, investigation, and conclusion to determine if incident requires reporting to outside agencies such as DOH, OIG, CMS etc. Resident #18 had diagnoses which included Cerebral infarction, Altered Mental Status, and Unspecified speech disturbances. The Admission Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #18 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 10, did not walk, and required total care for locomotion. The complainant reported on 6/20/23 they were working at the Emergency Department (ED) of [NAME] County Hospital. Resident #18 was found sitting in a wheelchair and unsupervised on the hospital campus by a hospital Security Officer. The hospital Security Officer took Resident #18 to the ED for safety. Resident #18 was not able to communicate. The ED staff contacted Resident #18's family member by looking up the name on Resident #18's wrist band and then called the facility to pick up Resident #18. The Residents Clinical Appointments sheet located at the security station dated June 20, 2023, documented Resident #18 was to be picked up by the transportation for a dental appointment at 6:30 AM for an appointment at 7:30 AM. It also documented Resident #18 left the facility at 6:33 AM and returned at 9:45 AM. The facility's incident list from [DATE] - [DATE], documented Resident #18 had an incident happened during the 7AM-3PM shift at 12:00 PM on 6/21/23. The incident type was Other and the detail type was New Type. The Accident/Incident Statement Form completed by the Home Health Aide (HHA) dated 6/21/23 documented they were assigned to escort Resident #18 to a dental appointment on 6/20/23. The pickup time was 6:30 AM. The HHA documented they clocked in at 6:28 AM. The HHA also documented Resident #18 was not in the room upon their arrival. The HHA further documented they were instructed to take a taxi to the hospital to look for Resident #18. The HHA documented they met Resident #18 at the ED of the hospital, missed the dental appointment, and escorted Resident #18 back to the facility. The Accident/Incident Statement Form completed by Security Officer #2 dated 6/21/23 documented they were on duty when Resident #18 came down with a staff member for transportation to a community clinical appointment. The statement also documented that the transportation driver placed Resident #18 inside the van, the staff member came back into the facility, and the van left with Resident #18 unescorted. The document titled Full QA Report by the facility dated 6/21/23 documented the incident happened on 6/21/23. Resident #18 had an appointment at the hospital, was placed in the transportation vehicle, and the driver left without waiting for the escort. The assigned escort HHA went to the hospital campus, found Resident #18 and escorted Resident #18 back to the facility. The report also documented that the Administrator, Director of Nursing, and Assistant Director of Nursing were notified of the incident on 6/21/23 at 12:00 PM. On 10/30/23 at 11:56 AM, Registered Nurse (RN) #6, also the Unit Manager, was interviewed and stated they reported this incident to the Director of Nursing immediately after they were made aware of it. On 10/31/23 at 12:42 PM, the Director of Nursing (DNS) was interviewed and stated they did not know exactly what happened on 6/20/23 and that Resident #18 left the facility with transportation and without a staff to escort them. The DNS also stated Resident #18 was confused and it was not safe for the resident to be left alone in the community. The DNS further stated Resident #18 was not supervised by any facility staff for about 2 hours after Resident #18 left the facility. The DNS stated the Unit Manager notified them of the incident, and they did not report this incident to DOH as they did not know they had to report it. The DNS further stated it would primarily be their responsibility to report the incident to DOH. On 10/31/23 at 12:56 PM, the Administrator was interviewed and stated the DNS and themselves have access to the Health Commerce System for reporting incidents to DOH. The Administrator also stated that the DNS was the staff to report an incident to the DOH. The Administrator further stated they did not report this incident to DOH as they thought they did not have to report this incident as Resident #18 was not injured. 415.4 (b)(2)

Based on interview and record review conducted during a Recertification and Complaint (NY00318699) survey from 10/26/2023 to 11/2/2023, the facility did not ensure an incident involving a confused resident being unsupervised for about 2 hours in the community was thoroughly investigated. This was evident for 1 (Resident #18) out of 5 residents reviewed for Accidents. Specifically, the facility did not obtain the statement from the LPN #1 who took Resident #18 down to the transportation and left the resident unattended by facility staff and complete an incident report thoroughly. The findings include: The facility policy titled Accident - Incident with creation date 11/2013 and last date revised 7/2023 documented an incident is any occurrence not consistent with the routine operation of the center, normal care of the resident a happening involving visitors, malfunctioning equipment, or observation of a condition which might be a safety hazard. It also documented these occurrences must be evaluated and investigated. Resident #18 had diagnoses which included Cerebral infarction, Altered Mental Status, and Unspecified speech disturbances. The Admission Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #18 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 10, did not walk, and required total care for locomotion. The complainant reported on 6/20/23 they were working at the Emergency Department (ED) of [NAME] County Hospital. Resident #18 was found sitting in a wheelchair and unsupervised on the hospital campus by a hospital Security Officer. The hospital Security Officer took Resident #18 to the ED for safety. Resident #18 was not able to communicate. The ED staff contacted Resident #18's family member by looking up the name on Resident #18's wrist band and then called the facility to pick up Resident #18. The Residents Clinical Appointments sheet located at the security station dated June 20, 2023, documented Resident #18 was to be picked up by the transportation for a dental appointment at 6:30 AM for an appointment at 7:30 AM. It also documented Resident #18 left the facility at 6:33 AM and returned at 9:45 AM. The facility's incident list from [DATE] - [DATE], documented Resident #18 had an incident happened during the 7AM-3PM shift at 12:00 PM on 6/21/23. The incident type was Other and the detail type was New Type. The Accident/Incident Statement Form completed by the Home Health Aide (HHA) dated 6/21/23 documented they were assigned to escort Resident #18 to a dental appointment on 6/20/23. The pickup time was 6:30 AM. The HHA documented they clocked in at 6:28 AM. The HHA also documented Resident #18 was not in the room upon their arrival. The HHA further documented they were instructed to take a taxi to the hospital to look for Resident #18. The HHA documented they met Resident #18 at the ED of the hospital, missed the dental appointment, and escorted Resident #18 back to the facility. The Accident/Incident Statement Form completed by Security Guard #2 dated 6/21/23 documented they were on duty when Resident #18 came down with a staff member for transportation to a community clinic appointment. The statement also documented that the transportation driver placed Resident #18 inside the van, the staff member came back into the facility, and the van left with Resident #18 unescorted. The document titled Full QA Report by the facility dated 6/21/23 documented the incident happened on 6/21/23. Resident #18 had an appointment at the hospital, was placed in the transportation vehicle, and the driver left without waiting for the escort to arrive. The HHA assigned to escort the resident went to the hospital campus, found Resident #18 and escorted Resident #18 back to the facility. The report also documented that the Administrator, Director of Nursing, and Assistant Director of Nursing were notified of the incident on 6/21/23 at 12:00 PM. There was no documented evidence that a statement was obtained from the Licensed Practical Nurse (LPN) who took Resident #18 from the unit to the transportation pickup area on 6/20/23. There was also no documented evidence that an investigation report had been completed. A Quality Assurance report was completed which contained no investigation, documentation of whether abuse or neglect occurred and identification of interventions to prevent a similar incident from re-occurring. On 10/31/23 at 08:22 AM, Licensed Practical Nurse (LPN) #1 was interviewed and stated they usually work on the night shift. LPN #1 also stated that on 6/20/23 they took Resident #18 down to the lobby when they did not see the HHA on the unit when it was time for the resident's clinic appointment. LPN #1 further stated they were supposed to meet the escorting HHA in the lobby and there was some miscommunication because they did not see the HHA in the lobby. LPN #1 stated they left Resident #18 with another staff to wait for the HHA and returned to the unit. LPN #1 also stated they could not recall which staff they left Resident #18 with at that time. LPN #1 stated that Resident #18 was confused and had to be escorted by a staff all the time for safety. LPN #1 further stated they were not aware the driver left the facility with Resident #18 without escort. LPN #1 stated they did not provide and had not been asked to provide a statement regarding the incident. On 10/30/23 at 11:56 AM, the Registered Nurse (RN) # 6, also the Unit Manager, was interviewed and stated they reported this incident to the Director of Nursing immediately after they were aware of it. On 10/31/23 at 12:42 PM, the Director of Nursing (DNS) was interviewed and stated they did not know exactly what happened on 6/20/23 except that Resident #18 left the facility with transportation without a staff to escort them. The DNS also stated Resident #18 was confused and was not safe to be alone in the community. The DNS further stated Resident #18 was not supervised by any facility staff for about 2 hours after Resident #18 left the facility. The DNS stated the facility investigation only had the employee statements from the CNA assigned to the Resident #18, the HHA assigned to escort Resident #18, and the security officer on duty at the time the incident happened. The DNS also stated they did not obtain statements from LPN # 1 or the driver who picked up Resident #18. The DNS further stated the incident was not thoroughly investigated and there was no intervention to prevent similar incident from happening again. 415.4(b)(3)

Based on observation, record review and staff interview conducted during the Recertification and complaints survey (# NY00317301), the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This was evident for 1 of 2 residents reviewed for Insulin out of 40 sampled 40 residents. Specifically, Resident #236 admitted with a diagnosis of Diabetes Mellitus had no documented evidence of receiving medication management after 5/18/2023. There was no documented evidence fingerstick were monitored after 8/3/2023, or that insulin coverage was administered for finger sticks over 200mg/dL on multiple occasions, while multiple medical progress notes documented the resident was prescribed insulin and was receiving medication for diabetes. The finding is: The facility Policy titled Diabetes Mellitus Guidelines dated last reviewed 1/2023 documented to assist the resident establish a balance between Diet, exercise, and insulin. The policy further stated recognize, treat, or prevent complications related to Diabetes. Resident #236 admitted with diagnosis including Heart Failure, Chronic Kidney Disease and Diabetes mellitus (DM). The Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented resident as cognitively intact, and required limited to extensive assistance of one person for all Activity of Daily Living (ADL) tasks. The MDS also documented the resident had a diagnosis of Diabetes Mellitus. On 10/31/23 at 12:09 PM, during the Initial Pool interview, Resident #236 stated that when they came back from the hospital on 08/26/2023 no fingerstick was done and no insulin was given, as the staff kept saying there were no orders for that. Resident #236 also stated they have been diagnosed with diabetes since 1998 and staff was not helping to keep track of her condition. Resident #236 further stated they have always received medications for diabetes. The Comprehensive Care Plan titled Resident has Diabetes Mellitus created 01/26/2023 with last evaluation note dated 9/18/2023 had interventions which included monitor for signs/symptoms of hyperglycemia (increased blood sugar), administer medications per Medical Doctor (MD) orders, monitor blood glucose finger stick per MD orders, monitor for effectiveness of medications given, and monitor for signs/symptoms of hypoglycemia (decreased blood sugar). The Medical progress notes dated 05/23/2023, 06/08/2023, 07/07/2023 and 10/13/2023 documented a medication list which included Levemir Flex Pen Solution Pen-injector 100 UNIT/ML, Inject 5 unit subcutaneously at bedtime for DM, 100UNIT/ML effective 01/27/2023, Insulin Aspart, NovoLog Flex Pen Subcutaneous Solution Pen-injector 100 UNIT/ML, with a sliding scale for administration effective 01/27/2023 and Glipizide Tablet 5 MG, Give 1 tablet by mouth two times a day for diabetes which were active 3/30/2023. There were no stop dates documented for any of the medications. The Medical progress notes dated 07/4/2023, 08/18/2023, 08/16/2023, 08/10/2023, 09/26/2023 and 10/11/2023 documented a medication list which included Insulin Detemir, Levemir Flex Pen inject 5 unit subcutaneously at bedtime for DM which was active from 1/27/2023, Glipizide Tablet 5 MG, Give 1 tablet by mouth two times a day for diabetes, 5MG, Active 3/30/2023, Insulin Aspart, NovoLog Flex Pen Subcutaneous Solution Pen-injector 100 UNIT/ML with a sliding scale which was active from 01/27/2023. There was no end date documented for any of the medications listed. Medication Administration Record (MAR) dated April 2023 documented order for Levemir 5 mg which was changed to Lantus 5 mg at bedtime on 2/6/2023 and Novolog as per sliding scale which was changed to Humalog was discontinued on 04/03/2023. The MAR dated May 2023 documented order for Glipizide 5 mg tablets twice daily which was last administered on 5/17/2023 and discontinued on 5/18/2023. The MAR further documented the resident's fingerstick was over 200mg/dL seven (7) times from 5/18/2023 with range 207 mg/dl to 289 mg/dL MAR dated June 2023 documented resident fingerstick was over 200mg/dL over 23 times with ranges 202 mg/dl to 298 mg/dL. MAR dated July 2023 documented the resident fingerstick was 200 mg/dl over 11 times with range 201 mg/dl to 288 mg/dL. MAR dated August 2023 documented resident had order for fingerstick four times daily and at bedtime which was discontinued on 8/10/2023 and changed to three times a week on starting 8/11/2023 before being discontinued completely on 8/21/2023. Resident fingerstick was over 200 mg/dL on one time occasion. The MAR dated September 2023 and October had no documented evidence that Resident #236 had a physician order for insulin, no documented order for hypoglycemics, and no documented order for fingerstick. The MARs dated May 18th, 2023, through October 2023 had no documented evidence resident was receiving any diabetic medications. There was also no documented evidence that Resident #236 received insulin coverage and or oral hypoglycemics for a finger stick over 200mg/dL. Review of MAR documented all insulin was discontinued on 4/3/2023 and Glipizide 5 mg tablets was last administered on 5/17/2023 and discontinued on 5/18/2023. Physician orders last reviewed 10/26/2023 contained no orders for diabetes medication or blood glucose monitoring by fingerstick. The Lab Results Report with a collection date of 03/15/23 documented a Hemoglobin A1c (a blood test that shows blood sugar level over the past three months) result of 5.6%. The Lab Results Report with a collection date of 10/27/2023, completed during the survey, documented a Hemoglobin A1c result of 6.3%. There was no documented evidence that the Hemoglobin A1c had been monitored every three months. There was no documented evidence that Resident # 236 received oral hypoglycemics or insulin coverage for blood glucose levels above 200mg/dL after 5/18/2023. On 10/31/23 at 08:37 AM, an interview was conducted with the Assistant Director of Nursing (ADON) who stated that Resident #236 was admitted in January and can be very difficult at times. The ADON also stated that the resident has a diagnosis of Diabetes and the blood glucose is well controlled staying under 200 most of the time. Resident #236 was admitted on Levemir, but this was discontinued in January. The ADON further stated the resident's blood sugar levels are within normal and not over 200mg/dL and based on the hemoglobin A1c result finger sticks was discontinued. The ADON stated that the resident was being monitored by fingerstick and did not need medications as their diabetes was controlled. The ADON also stated that they were not aware of the physician's notes documenting that the resident was receiving medications for diabetes and they were also not aware that the resident had multiple fingerstick readings over 200mg/dL. On 10/31/23 at 02:53 PM, an interview was conducted with Nurse Practitioner (NP) #2 who stated that they had been covering care for Resident #236 for the past two weeks as the Attending Doctor was on vacation. NP #2 stated the protocol for a resident with diabetes is to check the hemoglobin A1c, order finger sticks to see the trends, and if medications are needed will order after looking at the finger stick trends. NP #2 also stated finger sticks as well as medications depends on the Hemoglobin A1c result however every provider and every case is different. The NP #2 further stated they did see Resident #236 on 10/27/2023 but had not had a chance to review the lab results yet. The NP #2 stated that they were not sure when the medications mentioned in the medical notes were discontinued. On 11/01/23 at 10:04 AM, an interview was conducted with Physician Assistant (PA) #2 working under the Medical Director for the facility, and who is also the resident's Medical Doctor. PA #2 stated that Resident #236 was admitted on Levemir 5 units at bedtime and Novolog Insulin for coverage in January 2023. Levemir 5 mg was changed to Lantus 5 mg at bedtime and the Novolog was changed to Humalog at some point because of insurance coverage. PA #2 also stated the resident's hypoglycemic medication was discontinued by another provider who is no longer in the facility. PA #2 further stated that they last saw Resident #236 on 10/13/2023 and did document the resident was currently receiving Levemir at bedtime, insulin on a sliding scale and oral hypoglycemics, however this documentation is not reflective of what the resident is currently receiving but is prepopulated in the software. PA #2 had no response when asked if they check the resident's orders before writing progress notes and they stated that the resident had not verbalized any concerns to them regarding their diabetes management. PA #2 stated for the resident's age group and comorbidities, a Hemoglobin A1c of 7% will be a concern, and if given medications at this time the resident will be at risk for hypoglycemia. On 11/02/23 at 12:36 PM, an attempt to reach the Medical Director who is also Resident #236's Medical Doctor was unsuccessful. 415.12

Based on observations, interviews, and record review during the recertification and abbreviated survey conducted from 10/26/23 to 11/2/2023, the facility did not ensure that a resident with limited mobility received appropriate services and assistance to prevent further contractures. This was evident for 1 of 3 resident reviewed for Position/Mobility out of a sample of 40 residents. (Resident #66). Specifically, Resident #66, who had bilateral hand contractures, was observed without bilateral hand rolls in place as ordered. The findings are: Resident #66 was admitted with diagnoses that included Non-Alzheimer's Dementia, Cerebrovascular Accident, and Muscle Weakness. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #66 had severely impaired cognition, required dependent assistance of staff with most Activities of Daily Living (ADL) and . The MDS further documented the resident required total assistance of two plus persons for bed mobility, transfers, and toilet use, total assistance of one person for eating, and extensive assistance of one person for personal hygiene. The MDS further documented the resident had no limitation in range of motion in the upper extremities. A Comprehensive Care Plan (CCP) last updated 8/2/2023 documented Resident #66 has Adaptive Devices (Right and left handroll to be worn at all times. Remove for ROM hygiene and skin care. Goals included resident will wear adaptive device as scheduled through the next review date and resident skin will remain intact through the next review date. Interventions included assure proper placement and remove as scheduled, and check for any skin impairment and notify NP/MD. On 10/27/23 at 12:25 PM, Resident #66 was observed out of bed in a wheelchair in the dining area. Resident had bilateral hand contracture and bilateral hand rolls were not in place. On 10/30/23 at 08:32 AM, On 10/31/23 at 08:26 AM and at 10:30 AM, Resident #66 was observed lying in bed in no distress. There were no bilateral hand rolls observed in both hands. The Physician order dated 10/30/2023 documented Bilateral Hand roll to be worn at all times except skin checks, ROM, and hygiene. Monitor skin integrity. On 10/31/23 at 11:09 AM, Licensed Practical Nurse (LPN) #4 looked in the three-drawer bedside table, in the closet and closets drawers and wheelchair and was not able to locate hand rolls for the resident. LPN #4 stated if the hand rolls are not found they are in the laundry. On 10/31/23 at 10:58 AM, an interview was conducted with Certified Nursing Assistant (CNA) #6 who stated they had been assigned to Resident #66 for the past month. CNA #6 stated the resident needs total care with all ADLs, and they had not seen the resident with a hand roll, and was not sure if the resident had a hand roll. CNA #6 also stated they took care of the resident but had not ever placed a handroll for the resident. On 10/31/23 at 11:03 AM, an interview was conducted with Licensed Practical Nurse (LPN)#4 who stated that the resident has contractures to both hand and is supposed to have hand rolls in their hands. LPN #4 also stated that the hand rolls should be applied by the CNA after ADL care is given. LPN #4 further stated the resident has had hand rolls in place for a long time and they were not sure how the CNA missed applying the hand rolls. LPN #4 stated at times the hand roll gets dirty and staff will send to the laundry. LPN #4 also stated they were not told the roll went to wash, but if it is not in the room they assume it was sent down to the laundry. On 10/31/23 at 11:10 AM, CNA #5 approached LPN #4 and surveyor in resident room and stated that they took care of the resident yesterday and sent the hand roll to the laundry to wash because the hand rolls were dirty. CNA #5 stated they did not report to anyone the hand roll was dirty, saw the handroll needed washing and usually just sends to laundry to wash when dirty. On 10/31/23 at 11:28 AM, an interview was conducted with Registered Nurse Supervisor (RNS) #4 who stated the resident is supposed to have bilateral hand rolls and they are put in place by the CNA. RNS #4 also stated the resident hand roll is in the laundry now and they will request a new hand roll from Physical Therapy (PT). RNS #4 further stated the CNA should have informed the nurse or RNS #4 that the handrolls went to the laundry and RNS #4 would have gotten a replacement from PT. RNS #4 stated therapy usually will recommend the hand roll, bring up the hand roll, and show the staff how to use the hand rolls. RNS #4 was unable to stated why hand rolls were not in place on multiple occasions. On 11/01/23 at 11:50 AM, an interview was conducted with the Assistant Director of Rehabilitation (ADR) who stated when hand rolls, splint or any assistive device is needed the Occupational Therapist will do an evaluation and make a recommendation after the evaluation is made. The ADR also stated once the recommendation is made Occupational Therapy will communicate with nursing through documentation and will do a documented in-service to the staff on the unit especially the assigned CNA. The ADR further stated the hand rolls are always available in Rehab and if dirty, torn, or misplaced nursing can inform Rehab and the hand roll can be replaced immediately. The ADR stated as pre recommendations splint/hand rolls must be worn at all times and removed for care. 415.12(e)(2)

Based on interview and record review conducted during a Recertification and Complaint (NY00318699) survey from 10/26/2023 to 11/2/2023, the facility did not ensure a resident received adequate supervision and assistance to prevent accidents. This was evident for 1 out of 5 residents reviewed for Accidents out of a sample of 40 residents. Specifically, Resident #18 who was moderately cognitively impaired was picked up unaccompanied at the facility by a transportation company for a clinic appointment at a hospital and was dropped off at the hospital campus unsupervised by the facility staff for approximately 2 hours. The findings include: The facility policy titled Accident - Incident with creation date 11/2013 and last date revised 7/2023 documented an incident is any occurrence not consistent with the routine operation of the center, normal care of the resident a happening involving visitors, malfunctioning equipment, or observation of a condition which might be a safety hazard. It also documented these occurrences must be evaluated and investigated. Resident #18 had diagnoses which included Cerebral infarction, Altered Mental Status, and Unspecified speech disturbances. The Admission Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #18 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 10, did not walk, and required total care for locomotion. The complainant reported on 6/20/23 they were working at the Emergency Department (ED) of [NAME] County Hospital. Resident #18 was found sitting in a wheelchair and unsupervised on the hospital campus by a hospital Security Officer. The hospital Security Officer took Resident #18 to the ED for safety. Resident #18 was not able to communicate. The ED staff contacted Resident #18's family member by looking up the name on Resident #18's wrist band and then called the facility to pick up Resident #18. The Residents Clinical Appointments sheet located at the security station dated June 20, 2023, documented Resident #18 was to be picked up by the transportation for a dental appointment at 6:30 AM for an appointment at 7:30 AM. It also documented Resident #18 left the facility at 6:33 AM and returned at 9:45 AM. The facility's incident list from [DATE] - [DATE], documented Resident #18 had an incident happened during the 7AM-3PM shift at 12:00 PM on 6/21/23. The incident type was Other and the detail type was New Type. The Accident/Incident Statement Form completed by the Home Health Aide (HHA) dated 6/21/23 documented they were assigned to escort Resident #18 to a dental appointment on 6/20/23. The pickup time was 6:30 AM. The HHA documented they clocked in at 6:28 AM. The HHA also documented Resident #18 was not in the room upon their arrival. The HHA further documented they were instructed to take a taxi to the hospital to look for Resident #18. The HHA documented they met Resident #18 at the ED of the hospital, missed the dental appointment, and escorted Resident #18 back to the facility. The Accident/Incident Statement Form completed by Security Officer #2 dated 6/21/23 documented they were on duty when Resident #18 came down with a staff member for transportation to a community clinical appointment. It also documented that the transportation driver placed Resident #18 inside the van, the staff member came back into the facility, and the van left with Resident #18 unescorted. The document titled Full QA Report by the facility dated 6/21/23 documented the incident happened on 6/21/23. Resident #18 had an appointment at the hospital, was placed in the transportation, and the driver left without waiting for the escort. The assigned escort HHA went to the hospital campus, found Resident #18 and escorted Resident #18 back to the facility. It also documented the Administrator, Director of Nursing, and Assistant Director of Nursing were notified of the incident on 6/21/23 at 12:00 PM. On 10/30/23 at 12:27 PM, the Home Health Aide (HHA) was interviewed and stated they were scheduled to escort Resident #18 to a dental appointment on 6/20/23 at 6:30 AM. The HHA also stated they could not locate Resident #18 in their room or on the unit when they arrived on the unit on the morning of 6/20/23. They were informed by the unit staff that Licensed Practical Nurse (LPN) had already taken Resident #18 downstairs. The HHA further stated that they met LPN #1 in the lobby and was informed that Resident #18 had been picked up by transportation and the driver had already left the facility. The HHA called their supervisor and notified Registered Nurse #6 about what had happened. The HHA stated they were instructed to take an Uber to the hospital to look for Resident #18. They went to the dental office at around 7:15 AM and did not see Resident #18 there and notified RN #6. The HHA stated they were then told by RN #6 to pick up Resident #18 at the Emergency Department (ED) as the ED staff had called the facility to report that Resident #18 was there. The HHA further stated they met Resident #18 and left the ED at around 8:30 AM. On 11/01/23 at 09:06 AM, the Security Guard (SG) #2 was interviewed and stated they worked the night shift from 12 AM to 8:30 AM. SG #2 also stated they were working in the front security station on the day when the incident happened on 6/20/23. They called the unit to inform staff that the driver was there to pick up Resident #18 for the community appointment after confirming Resident #18 was on the Residents Clinical Appointments sheet for the day. LPN #1 brought Resident #18 down to meet the driver outside the facility. LPN #1 came back to the facility after the driver put Resident #18 into the van. SG #2 also stated the driver left without any staff escorting Resident #18 and they called RN #6 and informed them immediately. On 10/31/23 at 08:22 AM, Licensed Practical Nurse (LPN) #1 was interviewed and stated they usually work on the night shift. LPN #1 also stated that on 6/20/23 they took Resident #18 down to the lobby when they did not see the HHA on the unit when it was time for the resident's clinic appointment. LPN #1 further stated they were supposed to meet the escorting HHA in the lobby and there was some miscommunication because they did not see the HHA in the lobby. LPN #1 stated they left Resident #18 with another staff to wait for the HHA and returned to the unit. LPN #1 also stated they could not recall which staff they left Resident #18 with at that time. LPN #1 stated that Resident #18 was confused and had to be escorted by a staff all the time for safety. LPN #1 further stated they were not aware that the driver had left the facility with Resident #18 without an escort. On 10/30/23 at 11:56 AM, Registered Nurse (RN) #6, also the Unit Manager, was interviewed and stated that Resident #18 was alert and oriented to person and place only sometimes with episodes of confusion. RN # 6 also stated that Resident #18 was scheduled to go to the hospital for a dental appointment on 6/20/23. The transportation schedule documented the pickup time was 6:30 AM on 6/20/23. LPN #1 took Resident #18 down to the lobby to meet the transportation vehicle while the HHA was on the elevator heading up to the unit to pick up Resident #18. RN #6 stated that LPN #1 and the HHA missed each other and resident was placed on the van and had left the facility already when the HHA got to the lobby. RN #6 further stated that the hospital security told the HHA that Resident #18 was at the ED when the HHA arrived at the hospital and the HHA found Resident #18 at the ED and returned to the facility with Resident #18. On 10/31/23 at 12:42 PM, the Director of Nursing (DNS) was interviewed and stated all residents are escorted by a staff to clinical appointments in the community. The only exception is an alert and oriented resident who can go to the clinic appointments by themselves if they prefer to do so. The DNS also stated that staff usually picked up Resident #18 from the unit and escorted them to clinical appointments in the community. The DNS further stated they did not know exactly what happened on 6/20/23 except that Resident #18 left the facility with transportation without a staff to escort them. The DNS also stated Resident #18 was confused and it was not safe for the resident to be alone in the community. The DNS further stated Resident #18 was not supervised by any facility staff for about 2 hours after Resident #18 left the facility. 415.12(h)(1)

Based on observation, record review, and interview during the Recertification and complaint (NY00317301) survey conducted from 10/26/23 to 11/2/23, the facility did not ensure that the physician reviewed the resident's total plan of care including medications and treatments. This was evident for 1 of 1 resident reviewed for Dialysis (Resident #44) and 1 out of 2 residents investigated for Insulin (Resident #236) out of sample of 40 residents. Specifically, 1) there were no orders in place for a resident who received Dialysis and 2). a resident admitted with a diagnosis of Diabetes Mellitus received no medications for diabetes management after 5/18/2023, there was no documented evidence finger sticks were monitored after 8/3/2023, and no documented evidence medication coverage was provided for fingerstick over 200mg/dL on multiple occasions, despite multiple medical progress notes consistently documenting resident was on insulin and currently receiving oral hypoglycemics for diabetes. The finding is: 1.The facility Policy entitled Dialysis Management last revised 5/2020 documented residents receiving Hemodialysis treatments will be assessed and monitored to ensure quality of life and wellbeing. The policy further documented the nurse will obtain orders for monitoring of site, and interventions as appropriate and orders to include Hemodialysis Center, location, contact number and scheduled days, and Access site/type. Resident #44 admitted to the facility with diagnoses which includes Non-Alzheimer's Dementia, End Stage Renal Disease (ESRD), and on Hemodialysis (HD). The Quarterly Minimum Data Set (MDS ) assessment dated [DATE] documented the resident had short and long term memory impairment, and received Dialysis while a resident. The Physician's orders last reviewed on 10/27/2023 had no documented orders for dialysis care or for monitoring of the dialysis site. The Comprehensive Care Plan (CCP) titled Resident needs hemodialysis 3 times a week related to ESRD dated created 9/21/2021 and last evaluation note 2/5/2023 had interventions which included check and change dressing daily at access site, change dressing if ordered by MD, communicate with Dialysis Center as needed and monitor/document/report to Medical Doctor (MD) and as needed any signs/symptoms of infection to access site. There was no documented evidence of Physician orders for the Resident #44's dialysis treatments and for monitoring of the dialysis site. On 11/01/23 at 9:06 AM, an interview was conducted with the Licensed Practical Nurse (LPN) #3 who stated the resident receives dialysis three times a week on Mondays, Wednesdays, and Fridays. LPN# 3 also stated the dialysis center is located in the basement, and resident is escorted by a transporter to dialysis. LPN #3 further stated the resident has an Arteriovenous fistula (AVF) which is an irregular connection between a vein and artery created to be used for dialysis. LPN #3 also stated that the resident also has a Permacath (a catheter inserted into a blood vessel). On 11/01/23 at 09:10 AM, an interview was conducted with Registered Nurse (RN) #6 who was also the Unit Manager. RN #6 stated that the resident receives dialysis three times weekly, has an AVF on the left forearm, and a Permacath to the left chest wall. RN #6 also stated that orders for dialysis care are placed on admission, and that they, the Nurse Practitioner, and the Physician's Assistant also check the orders and confirm that all the orders are in. RN #6 further stated that the resident went out to the hospital recently and the orders for Dialysis and monitoring were not replaced. RN #6 stated they checked the resident orders and because of recent hospitalization from [DATE] to 8/22/2023 the order was not put in place. On 11/01/23 at 09:29 AM, an interview was conducted with Nurse Practitioner (NP) #1 via telephone who stated that they were aware that the resident is on Dialysis three times, weekly and was recently readmitted to the facility. NP #1 also stated they will place orders today for Dialysis and monitoring site and gave no reason why the order was not already in the resident's medical records. On 11/01/23 at 09:28 AM, an interview was conducted with the Physician Assistant (PA) #1who stated that they work with Resident #44's Attending Physician and is responsible for reviewing and placing orders. PA #1 also stated the resident they are aware that the resident receives dialysis three times a week did not know why there were no orders in place for Dialysis, or for monitoring for the resident access sites. PA #1 stated that it is possible the orders were not placed because the resident was recently returned to the facility. 2. The facility policy titled Diabetes Mellitus Guidelines last revised 01/2023 documented the facility will assist the resident to establish a balance between diet, exercise, and insulin and they would recognize, treat, or prevent complications related to Diabetes. Resident #236 (NY00317301) was admitted to the facility with diagnoses that included Chronic Kidney Disease/ Renal insufficiency, Diabetes Mellitus, Polyneuropathy, and Morbid Obesity. The Quarterly MDS assessment dated [DATE] documented that Resident # 236 had intact cognition and required limited assistance of staff with Activities of Daily Living. On 10/31/23 at 12:09 PM, Resident #236 was interviewed and stated that when they came back from the hospital on 08/26/2023 no fingerstick was done and no insulin was given, and the staff kept saying there were no orders for that. Resident #236 also stated they have been diagnosed with diabetes since 1998 and staff was not helping to keep track of their condition. Resident #236 further stated they have always received medications for diabetes. The Admission Patient Review Instrument (PRI) for Resident #236 dated 01/12/2023 documented diagnosis of Diabetes Type II and receives Levemir 5 units at bedtime subcutaneous and Fingerstick with Novolog Insulin Subcutaneous sliding scale before breakfast and Dinner as below: 101-150: 2 units. 151-200: 4 units. 201-250: 5 units. 251-300: 5 units. recheck in 30 minutes if 300. Diet: Renal Diabetic. The Physician's orders dated last reviewed 10/26/2023 had no orders for diabetes medications, and no documented orders for monitoring of finger sticks. The Comprehensive Care Plan titled Resident has Diabetes Mellitus created 01/26/2023 with last evaluation note dated 9/18/2023 had interventions which included monitor for signs/symptoms of hyperglycemia (increased blood sugar), administer medications per Medical Doctor (MD) orders, monitor blood glucose finger stick per MD orders, monitor for effectiveness of medications given, and monitor for signs/symptoms of hypoglycemia (decreased blood sugar). The Medical progress notes dated 05/23/2023, 06/08/2023, 07/07/2023 and 10/13/2023 documented a medication list which included Levemir Flex Pen Solution Pen-injector 100 UNIT/ML, Inject 5 unit subcutaneously at bedtime for DM, 100UNIT/ML effective 01/27/2023, Insulin Aspart, NovoLog Flex Pen Subcutaneous Solution Pen-injector 100 UNIT/ML, with a sliding scale for administration effective 01/27/2023 and Glipizide Tablet 5 MG, Give 1 tablet by mouth two times a day for diabetes which were active 3/30/2023. There were no stop dates documented for any of the medications. The Medical progress notes dated 07/4/2023, 08/18/2023, 08/16/2023, 08/10/2023, 09/26/2023 and 10/11/2023 documented a medication list which included Insulin Detemir, Levemir Flex Pen inject 5 unit subcutaneously at bedtime for DM which was active from 1/27/2023, Glipizide Tablet 5 MG, Give 1 tablet by mouth two times a day for diabetes, 5MG, Active 3/30/2023, Insulin Aspart, NovoLog Flex Pen Subcutaneous Solution Pen-injector 100 UNIT/ML with a sliding scale which was active from 01/27/2023. There was no end date documented for any of the medications listed. The Medication Administration Record (MAR) dated April 2023, May 2023, June 2023, and July 2023 documented blood sugar testing was done four times daily. The MAR documented blood sugar readings over 200mg/dL on 14 occasions, 19 occasions, 28 occasions and 12 occasions respectively. Parameters for the order documented notify PCP if blood glucose is < 70 or > 300. The Medication Administration Record dated May 2023 documented that Glipizide 5mg twice daily was discontinued on 5/18/23. The Medication Administration Record dated August 2023 documented a blood sugar reading of 214 on 8/01/2023. The MAR also documented that on 08/10/23 the order was changed to monitoring three times weekly which was subsequently discontinued on 8/21/23. The Lab Results Report with a collection date of 03/15/23 documented a Hemoglobin A1c (a blood test that shows blood sugar level over the past three months) result of 5.6%. There was no documented evidence that the Hemoglobin A1c had been monitored every three months. The Lab Results Report with a collection date of 10/27/2023, completed during the survey, documented a Hemoglobin A1c result of 6.3%. There was no documented evidence that resident had any active orders for diabetes medication since Glipizide was discontinued on 05/18/2023. On 10/31/23 at 08:37 AM, an interview was conducted with the Assistant Director of Nursing (ADON) who stated that Resident #236 was admitted in January and can be very difficult at times. The ADON also stated that the resident has a diagnosis of Diabetes and the blood glucose is well controlled staying under 200 most of the time. Resident #236 was admitted on Levemir, but this was discontinued in January. The ADON further stated the resident's blood sugar levels are within normal and not over 200mg/dL and based on the hemoglobin A1c result finger sticks was discontinued. The ADON stated that the resident was being monitored by fingerstick and did not need medications as their diabetes was controlled. The ADON also stated that they were not aware of the physician's notes documenting that the resident was receiving medications for diabetes and they were also not aware that the resident had multiple fingerstick readings over 200mg/dL. On 10/31/23 at 02:53 PM, an interview was conducted with Nurse Practitioner (NP) #2 who stated that they had been covering care for Resident #236 for the past two weeks as the Attending Doctor was on vacation. NP #2 stated the protocol for a resident with diabetes is to check the hemoglobin A1c, order finger sticks to see the trends, and if medications are needed will order after looking at the finger stick trends. NP #2 also stated finger sticks as well as medications depends on the Hemoglobin A1c result however every provider and every case is different. The NP #2 further stated they did see Resident #236 on 10/27/2023 but had not had a chance to review the lab results yet. The NP #2 stated that they were not sure when the medications mentioned in the medical notes were discontinued. On 11/01/23 at 10:04 AM, an interview was conducted with Physician Assistant (PA) #2 working under the Medical Director for the facility, and who is also the resident's Medical Doctor. PA #2 stated that Resident #236 was admitted on Levemir 5 units at bedtime and Novolog Insulin for coverage in January 2023. Levemir 5 mg was changed to Lantus 5 mg at bedtime and the Novolog was changed to Humalog at some point because of insurance coverage. PA #2 also stated the resident's hypoglycemic medication was discontinued by another provider who is no longer in the facility. PA #2 further stated that they last saw Resident #236 on 10/13/2023 and did document the resident was currently receiving Levemir at bedtime, insulin on a sliding scale and oral hypoglycemics, however this documentation is not reflective of what the resident is currently receiving but is prepopulated in the software. PA #2 had no response when asked if they check the resident's orders before writing progress notes and they stated that the resident had not verbalized any concerns to them regarding their diabetes management. PA #2 stated for the resident's age group and comorbidities, a Hemoglobin A1c of 7% will be a concern, and if given medications at this time the resident will be at risk for hypoglycemia. On 11/02/23 at 12:36 PM, an attempt to reach the Medical Director who is also the Resident #236's Medical Doctor was unsuccessful. 415.15 (b)(2)(iii)

Based on observation and staff interview during the Recertification survey completed 10/26/23 - 11/02/23, the facility did not ensure that medications and biologicals drugs were stored, labeled, and discarded in accordance with currently accepted professional principles. Specifically, 8 insulin pens were not labeled with open or discard dates. This was evident for 1 out of 5 units observed for the Medication Storage and Labeling facility task. (Unit 2) The findings are: The facility policy titled Medication Storage last revised 1/2023 documented the center will have medications stored in a manner that maintains the integrity of the product, ensures the safety of the residents, and is in accordance with Department of Health guidelines. On 10/30/23 at 03:21 PM, 2 insulin pens in use were observed to be stored in the medication cart without open and discard dates. (Unit 2, South, Cart A) On 10/30/23 at 03:21 PM, 2 insulin pens in use were observed to be stored in the medication cart without open and discard dates. (Unit 2, South, Cart B) On 10/30/23 at 03:29 PM, 4 insulin pens in use were observed to be stored in the medication cart without open and discard dates. (Unit 2, North) On 10/30/23 at 03:29 PM, an interview was conducted with Licensed Practical Nurse (LPN) #2 who stated that there would usually be dates on them, but the nurse may have forgotten to add the date when the medication was opened. LPN #2 also stated that the nurse opening a new pen is responsible for dating the medication, and all nurses are required to check the dates prior to administering to the resident. On 10/30/23 at 03:55 PM, an interview was conducted with the Registered Nurse Unit Manager (RN #3) who stated that when in use, insulin pens must be labeled with open and discard dates. RN #3 also stated that this is monitored by the unit managers through spot checks which are usually done weekly. On 11/02/23 at 01:47 PM, an interview was conducted with the Director of Nursing (DON) who stated that insulin pens added to the cart should have an open date and a discard date. The DON also stated that all nurses are given education, spots checks, and rounds are conducted and carts checked to ensure compliance. 415.18(d)

Based on observation, record review, and interviews conducted during the Recertification survey completed 10/26/23 -11/02/23, the facility did not ensure that a resident requiring oral/dental care was promptly referred for dental evaluation and care. This was evident for 1 of 5 residents reviewed for Dental out of a sample of 40 residents. Specifically, Resident #99 was observed to have a severe buildup of debris at the base of lower gums and had not been scheduled to be evaluated by the dentist. The findings are: The facility policy titled Dental Services last revised 2/2023 documented that both routine and emergency dental services are available to meet the resident's oral health care needs based upon resident assessment and plan of care. Resident #99 was admitted with diagnoses that included Depression, Dementia, and Hemiplegia. On 10/30/23 at 2:51 PM and on 11/02/23 at 9:46 AM, Resident #99 was observed sitting in wheelchair in the common/dining area watching television. The surveyor observed the resident to have a severe buildup of debris at the base of lower gums. The Quarterly Minimum Data Set (MDS) dated [DATE] documented that resident was moderately cognitively impaired. The Annual MDS dated [DATE] documented that resident had obvious or likely cavities or broken natural teeth. The Comprehensive Care Plan related to Oral/Dental problems with effective date 2/4/2020 with no revision date, documented interventions to refer the resident to the dentist as needed, monitor/document/report to the doctor PRN with signs and symptoms of oral/dental problems needing attention: Debris in mouth and pain in gums. The Physician's Order dated 3/7/23 documented dental consult as needed. The Physician Progress Note dated 02/10/2020 located in the Electronic Medical Record (EMR) documented that resident had partial upper and lower dentures and functions as is. No treatment at present. Next visit annual exam 02/2021. The Physician Progress Note dated 11/08/2021 located in the EMR documented that Resident #99 has teeth, and previously had partial upper and lower dentures which may be in the resident's drawer. No treatment was recommended. There was no documented evidence in the electronic medical record that Resident #99 had been evaluated by the dentist after 11/08/2021. An unsigned, handwritten note dated 11/7/22 was provided to the survey team, but it was not clear who had authored the note and when it was created. The dentist was unavailable for interview. On 11/02/23 at 10:04 AM, an interview was conducted with Licensed Practical Nurse (LPN) #7 who stated that they are very familiar with the resident, and usually administer medications to the resident on the evening shift. LPN #7 stated that Resident #99 had never verbalized any dental concerns and they had not observed the resident to have any oral or dental problems. LPN #7 further stated that if there were any concerns about the resident, they would report to the Nurse Practitioner or Unit Manager who will then create a request for a dental consultation. On 10/31/23 at 02:51 PM, an interview was conducted with the Registered Nurse Unit Manager (RN #6) who stated that residents are seen by the dentist every 6 months or annually, and sometimes residents can be seen before then if they have urgent issues like pain. The request for the consultation is submitted by the Unit Manager (UM) to the Nursing Office, the Medical Doctor then reviews and enters an order for the consultation, and then the resident will be scheduled to be seen by the dentist. If the dentist is not available an appointment can be scheduled externally. On 11/02/23 at 10:09 AM, an interview was conducted with Certified Nursing Assistant (CNA) #3 who stated that they assist Resident #99 with care including with eating. CNA #3 also stated that Resident #99 eats well, has voiced no complaints and there have been no signs of any discomfort. CNA #3 further stated that they also provide oral care to Resident #99 and had not noticed any issues with the resident teeth or gums during oral care. On 11/02/23 at 10:21 AM, an interview was conducted with the Quality Assurance Representative (QAR) at Dent Serve (the contract agency for Dental Services) who stated that the dentist is in the facility every Monday or every other Monday for longer sessions. Care provided to the residents includes denture care, bedside cleaning, and general dental maintenances. The QAR also stated that residents are seen based on the New Admission List and consultations from the facility. Progress notes are paraphrased, and the dentist usually shreds residents notes once entered into the Electronic Medical Record (EMR). On 11/02/23 at 12:47 PM, an interview was conducted with the Facility Administrator who stated that all documentation is expected to be entered into the Electronic Medical Record (EMR). Concerns will be verbalized to the staff if there are urgent concerns. The dentist usually has a working list for follow-up visits, the facility provides a new admission list and a consultation list. 415.17 (a-d)

Based on observations, record review, and interviews conducted during the Recertification survey from 10/26/23 to 11/2/23, the facility did not ensure that infection control practices were maintained. This was evident for 1 of 7 units (Unit - 5 ) observed for Infection Control. Specifically, a Home Health Aide (HHA) was observed using a blood pressure cuff (BPC) and pulse oximetry on multiple residents without sanitizing the BPC and pulse oximetry between residents and did not perform hand hygiene between residents. The findings are: The facility policy titled Cleaning/Disinfecting Resident Care Items and Equipment reviewed 05/18/2023, documented reusable resident care items and equipment will be cleaned and disinfected according to current CDC recommendations for disinfection of health care facilities and the OSHA Blood borne Pathogens standards. Shared resident care items/equipment refers to items and equipment that can be used in the care of multiple residents. These reusable items are cleaned and disinfected between residents and uses (for example blood pressure cuff). Shared resident care items/equipment shall be cleaned/disinfected between each resident and use according to manufacturer instructions for use. During an observation on 10/30/2023 from 9:54AM -10:09AM, Certified Nursing Assistant #12 was observed placing the pulse oximeter on the on left second digit and blood pressure (BP) cuff on the left arm of Resident #40. CNA #12 then documented the vital signs. Without performing hand hygiene or cleaning the equipment, CNA #12 then approached Resident #17 rubbed them on the back with their bare hands, then applied the BP cuff on left arm and pulse oximetry on left hand 2nd digit. After the blood pressure was done for Resident #17, CNA #12 placed the blood pressure cuff back in the carrier and documented the vital signs. CNA #12 then proceeded to the activity table, next to Resident #56 and began playing with the activity ball. CNA #12then took a hand wipe and cleaned Resident #39's mouth, disposed of the wipe and continued touching the activity ball while participating in an activity with six other residents. The vital signs machine was not cleaned after use, and CNA #12 did not perform hand hygiene between residents, after handling the vital signs equipment, after assisting residents and before handling the activity ball. On 10/30/2023 at 10:16 AM at 10:16 AM, CNA #12 was interviewed and stated that they make sure that they clean the vital signs machine with alcohol pads. CNA #12 also stated that normally the nurse gives them the alcohol pads to clean the equipment, but they were not there to give to them. CNA #12 also stated that they should clean in between residents, and this is what they normally do. CNA #12 further stated that they had in-service on hand washing and infection control. On 10/30/2023 at 10:39 AM, LPN # 3 stated they do rounds in the morning, at the end of the day and before they leave for the day. The vital signs machine should be cleaned between residents to prevent the spread of infection. For the machine we use Clorox wipes and let them dry. LPN #3 also stated that if they are passing medications in the dining room is doing vital signs they will observe the Certified Nursing Assistant (CNA) or HHA doing vital signs. They should have they are wipes and there are wipes on the counter that they can use. LPN #3 further stated that staff should be doing hand hygiene very often such as after patient care, in between residents and when feeding residents. On 10/30/2023 at 10:44 AM, Registered Nurse (RN) #2 stated that they make rounds in the morning and every 30 minutes when on the unit. RN #2 also stated that they have observed staff when doing vitals signs and they should wipe the equipment prior to use including the probe, pulse oximeter, and wiring prior to use and in between resident and after use. RN #2 further stated that staff has been in-serviced on this last week. Staff should wash their hands if visibly soiled and washed before interaction and in between residents. On 11/01/2023 at 5:55PM, Infection Preventionist (IP) was interviewed and stated that they do rounds weekly on the units and they also do hand washing competencies. The IP stated that shared equipment such as blood pressure cuffs and pulse oximeter should be cleaned with bleach cloths and allowed to sit to air dry to make sure it is properly disinfected. The IP further stated that hand hygiene competencies are done by the ADON and they assist with education of the staff. 415.19 (a)(1),(b)(4)

Based on observation, interview and record review conducted during an abbreviated survey (NY00304943), the facility failed to accurately identify Resident #1's Advance Directive (AD) status and initiated Cardiopulmonary Resuscitation (CPR) after Resident #1 was found unresponsive and with no palpable pulse. This was evident for 1 out of 41 residents reviewed for Advance Directive (Resident #1). Specifically, Resident #1, who had a Do Not Resuscitate (DNR) and Do Not Intubate (DNI) code status as documented in the Physician's Order dated [DATE], Social Worker's (SW) note, and Comprehensive Care Plan for DNR, was provided with life-saving CPR when found unresponsive. Licensed Practical Nurse (LPN #1) verified Resident #1's code status in the Electronic Health Record (EHR) which read full code. The facility did not follow their process to ensure that staff had access to accurate and up to date information regarding residents' code status. There was potential for serious harm for 41 Residents with DNR code status that was immediate jeopardy and substandard quality of care. The findings are: Facility Policy and Procedures entitled Do Not Resuscitate Orders dated ,d+[DATE] documented that the facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. Do not resuscitate orders must be signed by the resident's Attending Physician on the physician's order sheet maintained in the resident's medical record. A Do Not Resuscitate Order form must be completed and signed by the Attending Physician and resident (or resident's legal surrogate, as permitted by State law) and placed in the front of the resident's medical record. (Note: Use only State approved DNR forms MOLST (Medical Orders for Life-Sustaining Treatment (MOLST)), POLST (Physician Order for Life Sustaining Treatment), etc. If no State form is required, used Company approved form). State specific medical order forms: MOLST, POLST, TPOPP (Transportable Physician Orders for patient Preference) must be completed by the resident's Attending Physician or other medical provider (Physician's Assistant)/NP) approved by the State, and a copy of the form placed in the front of the resident's medical record. Resident #1 was admitted to the facility with a history of Atherosclerotic Heart Disease, Diabetes and Right Femur facture. Resident #1 required total assistance with all activities of daily living. The Minimum Data Set (MDS, a resident assessment tool) dated [DATE] documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) that indicated moderately impaired cognition. A Comprehensive Care Plan (CCP) dated [DATE] documented that Resident #1 had a Medical Orders for Life-Sustaining Treatment that indicated DNR/DNI. The interventions documented to educate the resident and or designated representative on advance directives quarterly and as needed; and to review and revise monthly orders to reflect advance directives status. The CCP lacked interventions on what staff should do if Resident #1 was observed unresponsive. The Hospital and Community Patent Review Instrument (PRI) dated [DATE] documented Life saving measures-Code Status: Full Code Status. On [DATE], Nurse Practitioner (NP) #1 documented that a discussion was held with family and that Resident #1's code status was changed from Full Code to a DNR/DNI status. On [DATE], Social Worker (SW) #1 documented that Advance Directives reviewed with family. MOLST/ DNR/DN1 and DNH (Do Not Hospitalize) was initiated at this time as per family's request. A Physician's written order dated [DATE] documented Do Not Resuscitate and Do Not Intubate. The facility's incident report dated [DATE] documented that Certified Nursing Assistant (CNA) #1 found Resident #1 unresponsive at 4:20AM. Resident #1 was last seen alive at 4:00AM by CNA #2 while making rounds. CNA #1 alerted LPN #1 who observed that Resident #1 Resident #1 was unresponsive and had no palpable pulse or respiration. LPN #1 checked the code status for Resident #1 in the EHR Care Profile/Special Instructions section of the chart and noted Resident #1 to be Full Code/Attempt CPR. Registered Nurse Supervisor (RNS) #1 was notified. CPR Code was called, and CPR was initiated. Resident #1's hospital code status documented Full Code. Resident #1's status was changed on [DATE] to reflect a DNR/DNI status. The MOLST order template in the EHR was not utilized to enter Resident #1's order and to change the Resident's new code status. This resulted in the Physician's Order documenting DNR/DNI and the Special Care Profile/Special Instructions section of the EHR stating full code. RNS #1 checked the EHR later which indicated that Resident #1 was a DNR. The facility concluded that CPR was done on Resident #1 who had a MOLST in place for DNR/DNI. NP #1 was not aware of the process to change a resident's code status in the EHR. NP #1 entered the DNR order in the EHR instead of in the DNR Template in the EHR, which once entered would have populated the special instructions section, which then would have entered the DNR/DNI information in the doctor's order section and in Resident #1's profile. Resident #1's code status in the EHR was not changed and remained as a full code. The Nursing Progress Note, by LPN #1, dated [DATE] at 12:00 AM, documented that at about 4:20AM, CNA #1 called LPN #1 to Resident #1's room. Resident #1 was found unresponsive. The supervisor (RNS #1) was notified, and code blue (medical emergency) was initiated. CPR was started and Emergency Medical Service (EMS) was called. Resident #1 was already on oxygen, and ambu bagging (use of a manual resuscitator to ventilate a patient) was being done. The EMS arrived at about 4:38 AM and pronounced Resident #1 deceased at 5:11AM. During an interview on [DATE] at 4:10 PM CNA #1 stated that they received shift report from LPN #1 who informed the CNAs of the Residents' code status. CNA #1 stated that they made rounds at approximately 11:00 PM and Resident #1 was in bed receiving oxygen therapy via nasal cannula. CNA #1 stated that they provided care to Resident #1 at approximately 12:30 AM - 12:45 AM. CNA #1 stated that they made rounds at 2:45AM and observed Resident #1 awake and was pulling on their gown. CNA #1 stated at 4:20 AM they went to Resident #1's room and Resident #1 was unresponsive. CNA #1 stated that they notified LPN #1. LPN #1 provided a statement to the facility dated [DATE]. The statement documented that LPN #1 was alerted by CNA #1 to come to Resident #1's room. Resident #1 was observed unresponsive, and LPN #1 immediately notified RNS #1. LPN #1 checked Resident #1's demographic in the computer and noted Resident #1 was full code. LPN #1 called a code and initiated CPR and called 911. LPN #1 stated that they were later informed that Resident #1 was DNR/DNI. During an interview on [DATE] at 12:08 PM RNS #1 stated that they received a call from LPN #1 stating that Resident #1 was not breathing and had no palpable pulse. RNS #1 stated that they asked LPN #1 if LPN #1 had checked Resident #1 code status and LPN #1 stated that Resident #1 was full code. RNS #1 stated that when they arrived on the unit, CPR was in progress and continued. RNS #1 stated that Resident #1 did not regain consciousness. RNS #1 stated that 911 was called and EMS responded, took over CPR, and pronounced Resident #1 at 5:11AM. RNS #1 stated that they did not check Resident #1's code status as LPN #1 had already checked. RNS #1 stated after Resident #1 was pronounced, they went to discontinue the orders in the computer and discovered that Resident #1 had an order for DNR/DNI. RNS #1 stated that if a Resident is found unresponsive the nurse should check the resident's profile in the EHR for the resident code status. RNS #1 stated that the nurse can also check the paper chart for the MOLST form. RNS #1 stated that once the computer is open the nurse will see the resident's code status appear in the special instruction section on the computer screen. During an interview on [DATE] at 3:00PM NP #1 stated that they were not aware of the DNR template in the EHR (a DNR template is a special screen that allows the information entered to be populated in an order and in the special instructions section of the computer). NP #1 stated that they spoke with Resident #1's family regarding changing Resident #1 from full code to DNR/DNI status. NP #1 stated that they entered the DNR/DNI order in EHR but did not discontinue the full code in the EHR. NP #1 stated that on [DATE] they wrote the new order in the EHR for DNR/DNI and thought that once the nurses confirmed the order for DNR, the full code status would have been discontinued automatically and the DNR/DNI status would show up in the special instructions on Resident #1's profile. During an interview on [DATE] at 2:20 PM, Social Worker (SW) #1 stated that Resident #1 was admitted to the facility with full code status. SW #1 stated that advance directive was discussed with the Resident #1's family during an interdisciplinary meeting. SW #1 stated Resident #1's family spoke with NP #1 and requested that Resident #1's status changed from full code to DNR/DNI. SW #1 stated that NP #1 wrote the order for DNR/DNI. SW #1 stated that they prepared a MOLST Resident #1's family and medical doctor signed the copy. During an interview on [DATE] at 3:00PM the Medical Director (MD) #1 stated that all new providers usually shadow another provider during orientation to learn about the facility protocol. MD #1 stated that NP #1 was oriented on the computer. MD #1 stated that they were not aware that NP #1 did not know how to use the DNR template. MD #1 stated that NP #1 has been entering orders into computer without any problems. MD #1 stated that the facility has superusers (a person that trains new staff) that assist other users on how to enter and discontinue orders into the computer. MD #1 stated that they were notified of the incident on [DATE]. During an interview on [DATE] at 3:30PM Director of Nursing (DON) #1 stated that they were informed of the incident by RNS #1 at approximately 5:30AM on [DATE]. DON #1 stated when RNS #1 was discontinuing Resident #1's orders they discovered that an error had been made regarding Resident #1's code status. DON #1 stated that they initiated an investigation immediately. DON #1 stated on arrival to the facility they reviewed Resident #1's record and discovered that Resident #1's code status had been changed from full code to DNR/DNI on [DATE]. DON #1 stated that when the new order was entered, the provider did not discontinue the full code order before entering the DNR/DNI order. DON #1 stated the provider entered the DNR/DNI order without using the DNR template, which would have populated in the special instruction section on Resident #1's profile. DON #1 stated when Resident #1 was found unresponsive, LPN #1 reported checking Resident #1's demographic for code status, which was still documenting full code. DON #1 stated that CPR was performed on Resident #1 and the Resident #1 did not re-gain consciousness. The IJ was determined to have been initiated on [DATE]. The Administrator was informed of the Immediate Jeopardy and provided with the Past Noncompliance Immediate Jeopardy Template on [DATE] at 5:52PM. Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement prior to and during the time of this survey. A Plan of Correction is not required for this citation. The facility took immediate corrective actions and was found to be in substantial compliance on [DATE] prior to surveyor's onsite visit [DATE]. On [DATE] the facility conducted an audit of all 41 residents with DNR status. Physician's Orders and care plans were in place. No DNR issues were identified in the EHR. Mandatory in-service with attendance record for MOLST, CPR/DNR, Code [NAME] dated [DATE] to [DATE] provided to staff. As of [DATE] the facility in-serviced 311 out 327 which is 95 % of staff members. The remaining 5 % percent are on vacation and will be in-serviced prior to commencing work. Interviews conducted on [DATE] to [DATE] with staff (,d+[DATE] MDs, ,d+[DATE] PA, ,d+[DATE] NPs, ,d+[DATE] Administrator, 23 CNAs, 7 LPNs, 5 RNS, 3 SW, 5 Housekeeping, 14 Rehab, 5 Kitchen/Dietary and 3 Home Health Aide (HHA). All staff were knowledgeable on the process for DNR. NPs and ,d+[DATE] PA interviewed and were able to describe the process for entering DNR status in the DNR Template. All were knowledgeable. ,d+[DATE] MDs interviewed via telephone and were knowledgeable of the process for entering DNR orders in the DNR Template. Code Blue Drill dated [DATE] DNR Policy was reviewed with no changes Facility wide care plan audit-of all residents with advanced directive care plans with no issues identified. Facility wide EHR Audit-checked all residents for CPR and DNR orders for accuracy. The facility checked all the residents' physicians' orders for CPR and DNR status. 10 NYC RR 483.24(a)(3)