Every finding on record at Brooklyn-Queens Nursing Home

Based on observation, record review, and interviews during survey, the facility failed to ensure pharmaceutical services was provided (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident; establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, and that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This was evident for one of five residents (Resident #3) reviewed. Specifically, Resident #3's blister pack with Oxycodone 10 milligrams (30 tablets) and reconciliation (counting) sheet were observed missing on [DATE] at 9:00 PM from a lock narcotic box and has not been located. The facility failed to ensure Resident #3's Oxycodone was accounted for and reconciled to prevent diversion.The findings are:The facility policy titled Controlled Substances revised date 04/2025 documented it is the policy of the facility to prescribe, administer, store and destroy all controlled substances withing the accepted regulations of the responsible governing body. In the event the controlled substance order has been changed, discontinued, contaminated or expired, the controlled blister pack complete with the count sheet must be submitted to the Director of Nursing or designee. All narcotics will be counted and reconciled at the beginning of every shift with outgoing and oncoming nurses. Both must sign the controlled substance count sheets attesting to the presence of the narcotic as stated from the previous shift. Any discrepancies in the count must be reported to the nursing supervisor immediately.Resident #3 was admitted to the facility with diagnosis of dementia, nasal bones fracture and cirrhosis of liver.The Minimum Data Set (a resident assessment tool) dated [DATE] documented Resident #3 had severely impaired cognition.A Pharmacy Log (dispensed from pharmacy) dated [DATE] documented Oxycodone 10 milligram 42 tablets.A Manifest/Order document dated [DATE], signed for by Registered Nurse Supervisor #1 (signature indicates medication was received), documented Oxycodone 10 milligram, amount 42 tablets for Resident #3.A Physician's Order dated [DATE] at 6:33 PM revealed that Oxycodone 10 milligrams (standing order) was discontinued and reordered at 6:35 PM to be given as needed.A review of the Medication Administration Record dated from [DATE] to [DATE] revealed Oxycodone 10 milligrams was last administered to Resident #3 on [DATE] at 1:00 PM. The Oxycodone was then placed on hold at 5:00 PM on [DATE].There was no documented evidence Resident #3 received any Oxycodone from [DATE] to [DATE].A facility Investigation Summary dated [DATE] documented that on [DATE] (no time documented) Licensed Practical Nurse #1 reported Resident #3's Oxycodone blister pack with 30 tablets and the corresponding count sheet was missing. The Nursing Supervisors searched the units, including medications carts, medication rooms, and controlled substance storage areas, to no avail. On [DATE], pharmacy delivered the Oxycodone, and it was signed for by Registered Nurse Supervisor #1 who also delivered the Oxycodone to the unit Licensed Practical Nurse #1. Oxycodone was held on [DATE] due to Resident #3's lethargy. On [DATE] Oxycodone 10 milligrams three times a day (standing) was discontinued and re-ordered to be given as needed. On [DATE] Resident #3 was transferred from the 2nd floor to the 5th floor. Registered Nurse #1 who received Resident #3 reported that they did not receive Oxycodone. Licensed Practical Nurse #5 who transferred Resident #3 to the fifth floor stated they did not transfer the Oxycodone to the fifth floor. The list of controlled substances /count sheets scheduled to be returned for destruction was reviewed and Oxycodone was not removed from the unit for destruction. The pharmacy was contacted and asked to review the returned drug list. Oxycodone had not been returned with non-controlled substances. To date, the missing blister pack and count sheet have not been located.A Loss of Controlled Substances Report (to Bureau of Narcotics) dated [DATE] documented suspected diversion on 2nd and 5th floor. Oxycodone 10 milligrams 30 tablets. Police were notified. During an interview on [DATE] at 1:21 PM, the Complainant stated they worked in the facility as an Assistant Director of Nursing until 04/2026 (unsure of date). The Complainant stated that on [DATE], on the evening shift, they received a message (a group chat that includes Director of Nursing) from Registered Nurse Supervisor #6 stating that Licensed Practical Nurse #1 told them that Resident #3 was asking for pain medication and they were unable to locate Resident #3's Oxycodone. The Complainant stated that the Director of Nursing told them to check the 2nd floor where Resident #3 was residing prior to being transferred to the 5th floor. The Complainant stated that on [DATE], they were told by the Director of Nursing that the Oxycodone was not located. The Complainant stated they were not instructed to report the missing narcotics to law enforcement, Bureau of Narcotics and Department of Health.Licensed Practical Nurse #1 was not interviewed as they are no longer employed by the facility and their whereabouts are unknown. During an interview on [DATE] at 3:27 PM, Licensed Practical Nurse #2, who worked on [DATE] and [DATE] on the 3:00 PM-11:00 PM shift, stated they counted Oxycodone 10 milligram with outgoing nurse (Licensed Practical Nurse #4) at the beginning of the evening shift around 3:00 PM on [DATE]. They stated they did not administer any Oxycodone at 5:00 PM due to Resident #3 being lethargic. Licensed Practical Nurse #2 stated they notified Registered Nurse Supervisor #1 who instructed them to hold the Oxycodone. Licensed Practical Nurse #2 stated that Registered Nurse Supervisor #1 did not notify them that the Oxycodone was changed from a standing order to an as needed order. Licensed Practical Nurse #2 stated that they informed the incoming night nurse (Licensed Practical Nurse #3) that Resident #3's Oxycodone was put on hold due to lethargy. Licensed Practical Nurse #2 stated they counted all the narcotics at around 11:00 PM, including Resident #3's Oxycodone 10 milligrams, with incoming Licensed Practical Nurse #3, then they left work as their shift ended. Licensed Practical Nurse #2 stated that the evening shift Registered Nurse Supervisor #1 did not remove any narcotic blister pack from the medication room during their shift. Licensed Practical Nurse #2 stated that they are supposed to be notified of any medication changes so they can handover the information to the incoming nurse. Licensed Practical Nurse #2 stated the administration called them into the office 10 days after the medication was missing to ask them about the missing Oxycodone and they wrote a statement.During an interview on [DATE] at 4:06 PM, Licensed Practical Nurse #3, who worked on the 11:00 PM-7:00 AM shift on [DATE], [DATE], [DATE], [DATE], and [DATE], stated they counted narcotics on [DATE] at around 11:00 PM with Licensed Practical Nurse #2, but do not recall counting Oxycodone 10 milligram for Resident #3. Licensed Practical Nurse #3 stated they were aware Resident #3 was on Oxycodone, but thought the Oxycodone was discontinued and a nursing supervisor removed it from the unit. Licensed Practical Nurse #3 stated they don't check the electronic Medication Administration record for as needed medications unless a resident requests the medication.During an interview on [DATE] at 7:10 PM, Licensed Practical Nurse #4 who worked on [DATE] and [DATE] on the 7:00 AM- 3:00 PM shift, stated that they administered Oxycodone 10 milligrams to Resident #3 at 9:00 AM and 1:00 PM on [DATE] on the 7:00 AM - 3:00 PM shift. Licensed Practical Nurse #4 stated that they counted the narcotics on [DATE] on the 7:00 AM - 3:00 PM shift with the outgoing Licensed Practical Nurse #3, who worked the night shift from 11:00 PM - 7:00 AM on [DATE], and Resident #3's Oxycodone blister pack and counting sheet was not in the locked cabinet in the medication room. Licensed Practical Nurse #4 stated that Licensed Practical Nurse #3 told them that Resident #3's Oxycodone was discontinued, so they assumed Registered Nurse Supervisor #1 removed the blister pack and counting log for destruction. Licensed Practical Nurse #4 stated they checked the orders and Oxycodone 10 milligrams was discontinued as a standing order, but they did not check the as needed orders. During an interview on [DATE] at 3:31 PM, Registered Nurse Supervisor #1 stated they were called to Resident #3's unit on [DATE] during the evening (3:00 PM - 11:00 PM) (does not recall exact time) because Resident #3 was lethargic. Registered Nurse Supervisor #1 stated they assessed Resident #3 and notified medical doctor and family. Registered Nurse Supervisor #1 gave a telephone order to discontinue the standing order for Oxycodone 10 milligrams and ordered Oxycodone 10 milligrams as needed. Registered Nurse Supervisor #1 stated they notified Licensed Practical Nurse #2 who worked on the evening shift and Registered Nurse Supervisor #2 who worked on the night shift (11:00 PM - 7:00 AM, of the changes in doctor's order. Registered Nurse Supervisor #1 stated they did not remove Oxycodone blister pack and corresponding count sheet from the medication room because the day shift (7:00 AM - 3:00 PM) supervisors are responsible for removing the discontinued medications from the narcotic box. Registered Nurse Supervisor #1 added that Medical Doctor #1 should have sent a new script or called the pharmacy with the changes in Oxycodone. Registered Nurse Supervisor #1 stated that Licensed Practical Nurse #1 (on the 3:00 PM - 11:00 PM shift) informed them on [DATE] that Resident #3 asked for pain medication, but they could not locate the Oxycodone blister pack. Registered Nurse Supervisor #1 stated they notified the Director of Nursing, Assistant Director of Nursing and Medical Doctor #1 (unsure of time). Registered Nurse Supervisor #1 stated they conducted a search, but the Oxycodone blister pack and corresponding count sheet was not located. During an interview on [DATE] at 1:06 PM Registered Nurse Supervisor #2 who worked on [DATE] at 11:00 PM -7:00 AM shift, stated they did not remove Resident #3's discontinued Oxycodone from the narcotic box. They stated that the day shift supervisor is responsible for removing the discontinued narcotics for destruction. Registered Nurse Supervisor #2 stated they were notified of the changes in Oxycodone, but no one asked them to remove the Oxycodone blister pack and counting sheet from the unit.During interview on [DATE] at 5:30 PM Registered Nurse Supervisor #3, who worked [DATE] 7:00 AM - 3:00 PM shift and covered 2nd floor, stated they were not notified, and they did not remove Resident #3's Oxycodone from the unit on [DATE]. Registered Nurse Supervisor #3 stated that when narcotics are removed from the unit, the supervisor puts them in a lock narcotic box in the nursing office, then count the narcotics with the incoming supervisor, then Director of Nursing signs off on the count for destruction. During telephone interview on [DATE] at 6:19 PM, Registered Nurse Supervisor #4 who worked [DATE] on 7:00 AM - 3:00 PM shift, stated they did not collect any control medications from Resident #3's unit on [DATE] on 7:00 AM - 3:00 PM shift. They stated that the Oxycodone blister pack and corresponding count sheet was not logged in by previous shift (11:00 PM - 7:00 AM). Registered Nurse Supervisor #4 stated the discontinued Oxycodone should have been removed from the unit on [DATE] when the medication was discontinued and brought to the nursing office.During an interview on [DATE] at 3:13 PM, Pharmacy Consultant stated they were notified about the medication diversion issue on [DATE] by Director of Nursing. Pharmacy Consultant stated that former Assistant Director of Nursing (complainant) was the Risk Manager at the time the Oxycodone was missing, and they should have immediately reported the missing Oxycodone to the Director of Nursing, Bureau of Narcotics and to them. Pharmacy Consultant stated they were not involved in any corrective actions and didn't recall the outcome of investigation. Pharmacy Consultant stated if the order was discontinued, blister pack with remaining Oxycodone should have been removed from the narcotic box and new order/script should have been sent to the pharmacy. Pharmacy Consultant stated they don't know if a new script was sent.During an interview [DATE] at 11:03 AM, the Director of Nursing stated that the missing Oxycodone should have been investigated, and the outcome reported to them. They stated that the Assistant Director of Nursing should have also reported the missing narcotic to the Bureau of Narcotics and the police. However, the former Assistant Director of Nursing give them an incomplete investigation on [DATE] (unsure of time). The Director of Nursing stated during completion of the investigation, they discovered that the order for Oxycodone was changed from a standing order to as needed, but the blister pack with Oxycodone and counting sheet could not be located. The Director of Nursing stated they checked the narcotics destruction log in the nursing office and Oxycodone 10 milligrams were not on the list for destruction. They stated the incoming nurse should have counted all controlled medications with outgoing nurses and ensure all controlled medications are accounted for. The Director of Nursing stated they completed the investigation and concluded that Resident #3's blister pack with Oxycodone and corresponding counting sheet could not be located. They stated they did not report the incident to the New York State Department of Health. They stated they notified the Administrator, Pharmacist and Medical Director on [DATE].During a follow up interview on [DATE] at 1:31 PM, the Director of Nursing stated the pharmacy consultants perform medication audits and conduct monthly medication regime reviews, but do not conduct narcotic reconciliation. The Director of Nursing stated Licensed Practical Nurse #1 was terminated (unsure of date). During an interview on [DATE] at 4:10 PM, the Administrator stated they were not notified of the missing Oxycodone on [DATE]. The Administrator stated they heard rumors from staff (unsure of date) regarding the missing Oxycodone, and they asked the Director of Nursing about the rumors, and they were told that former Assistant Director of Nursing was investigating the missing Oxycodone. The Administrator stated the Director of Nursing should have informed them withing 24 hours. The Administrator stated the former Assistant Director of Nursing was responsible for investigating and reporting the findings to the Director of Nursing. The Administrator stated that no-one followed up with the investigation to ensure timely completion and the appropriate agencies notified. The Administrator stated that the former Assistant Director of Nursing submitted an incomplete incident report to the consultant on [DATE] (who handed it over to the Director of Nursing). 10 New York Codes, Rules, and Regulations 415.18(a)

Based on observation, record review, and interviews, the facility failed to ensure all alleged violations were thoroughly investigated. This was evident in three (Residents #144, #135, and #68) of seven residents reviewed for accidents and abuse. Specifically, the facility failed to conduct thorough investigations regarding: 1.) Resident #144, who intentionally punched a window, causing it to shatter and resulting in multiple lacerations and a fractured finger; 2.) Resident #135, who was found on the floor with left orbital swelling and pain and subsequently alleged being pushed; and 3.) Resident #68, who was observed with bruise of unknown origin to the left thigh. The findings include: The facility's policy titled Accidents and Incidents – Investigating and Reporting, reviewed 08/2025, stated that all accidents and incidents involving residents shall be investigated and reported to the Administrator. The policy further stated that the Director of Nursing is responsible for ensuring the Administrator receives a copy of each accident/incident report. 1. Resident #144 had diagnoses that included Unspecified dementia, adjustment disorder, and peripheral vascular disease. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment and physical behavioral symptoms. A nursing note dated 03/12/2026 at 9:23 AM documented that Resident #144 punched and shattered a bedroom window resulting in bleeding lacerations to the right hand. A nursing note dated 03/13/2026 at 10:37 PM documented that Resident #144 returned from the hospital emergency department. X-ray of the right hand showed fracture on the fourth finger. The facility investigation summary dated 03/18/2026 documented that Resident #144 intentionally struck the window with the right hand, causing the glass to shatter and resulting in multiple lacerations. The summary further documented that interviews were conducted with residents in adjacent rooms and others who may have had contact with the resident prior to the incident. However, review of the investigation revealed no documented statements from residents reportedly interviewed. The investigation contained statements from the assigned Certified Nursing Assistant, Licensed Practical Nurse, and Registered Nurse, but did not include statements from all staff assigned to or present on the unit at the time of the incident. 2. Resident #135 had diagnoses that included dementia, Alzheimer's disease, and history of falls. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment and history of falls with no injury since admission. The facility accident/incident report dated 09/22/2025 documented that Resident #135 stated they had been pushed and fell. The facility's five-day investigation summary documented that Resident #135 described the alleged perpetrator as a female wearing red. Review of the investigation revealed statements were obtained from nursing personnel assigned to the unit; however, no statements were obtained from recreation staff who were the only employees who routinely wore red coats, matching the resident's description of the alleged perpetrator. During an interview on 05/29/2026 at 11:44 AM, the Director of Nursing stated that facility protocol required obtaining statements from all staff who may have had knowledge of an allegation or incident. The Director of Nursing further stated that recreation staff wore red coats and should have been interviewed based on the resident's description and acknowledged the investigation was not thorough as they failed to obtain statement from the recreation staff. They stated that the Assistant Director of Nursing was primarily responsible for conducting investigations and failed to obtain statements from all relevant staff and residents. They stated the assistant director's employment was terminated in April 2026 due to deficiencies in conducting investigations. During an interview on 05/29/2026 at 2:45 PM, the Administrator acknowledged that investigations involving Residents #135 and #144 were not completed thoroughly because statements were not obtained from all relevant staff and residents and stated the former Assistant Director of Nursing's employment was terminated due to these failures. 3. Resident #68 had diagnoses that included Alzheimer's disease, dementia, and seizure disorder. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment and wandering. A nurse's note dated 03/30/2026 documented that at 8:23 AM, a palm sized discoloration to Resident #68's left dorsal thigh area. The physician was notified and ordered monitoring. The facility accident/incident report dated 03/30/2026 documented that a Certified Nursing Assistant observed a five by three-centimeter purple discoloration to the resident's left posterior thigh during morning care. The report documented that Resident #68 was unable to state how the injury occurred. Review of the facility's investigation revealed no investigation summary, conclusion, or findings sufficient to determine the cause of the injury or rule out abuse, neglect, or mistreatment. During an interview on 06/02/2026 at 2:11 PM, the Director of Nursing stated the Assistant Director of Nursing, who was responsible for investigations, failed to complete the investigation and that several incomplete investigations were later discovered. During an interview on 06/02/2026 at 2:27 PM, the Administrator stated they were unaware of the incident until 06/02/2026 and stated that the Director of Nursing is trying to put information together to complete the investigation. 10 New York Codes, Rules and Regulations 415.4

Based on observation, record review and interviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury to the State Survey Agency. This was evident in three (Residents #144, #135, and #68) of seven residents reviewed for accidents and abuse. Specifically, the facility failed to timely report the following incidents to the New York State Department of Health: 1.) On 03/12/2026, Resident #144 intentionally punched a window in their room, shattering the glass and sustaining multiple lacerations to the right hand from broken glass shards; 2.) On 09/22/2025, Resident #135 was found on the floor with a large hematoma on the left orbital area, stated they were pushed; 3) On 03/30/2026, Resident #68 sustained a bruise of unknown origin on the left thigh that was not reported to the New York State Department of Health. The findings include: The facility policy titled Prevention of Abuse, Neglect, Misappropriation of Resident Property and Exploitation, reviewed on 02/2026, required that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source be reported immediately , but not later than 2 hours after the allegation was made, to the Administrator and State Survey Agency. 1) Resident #144 had diagnoses that included Unspecified dementia, adjustment disorder, and peripheral vascular disease. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment and physical behavioral symptoms. A nursing note dated 03/12/2026 at 9:23 AM documented that Resident #144 punched and shattered a bedroom window resulting in bleeding lacerations to the right hand. A nursing note dated 03/13/2026 at 10:37 PM documented that Resident #144 returned from the hospital emergency department. X-ray of the right hand showed fracture on the fourth finger. The Nursing Home Facility Incident Report documented the Administrator became aware of the incident on 03/12/2026 at 6:45 PM. However, the incident was not reported to the New York State Department of Health until 03/13/2026 at 1:32 PM, more than two hours after the facility became aware of the event and 2) Resident #135 had diagnoses that included dementia, Alzheimer's disease, and history of falls. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment and history of falls with no injury since admission. The facility's accident report dated 09/22/2025 documented that Resident #135 was found on the floor at 12:00 PM with a large hematoma on the left orbital area. The report documented that they had been pushed and subsequently fell. The Nursing Home Facility Incident Report documented the Administrator became aware of the incident on 09/22/2025 at 1:00 PM. However, the incident was not reported to the New York State Department of Health until on 09/23/2025 at 10:49 AM, exceeding the required two-hour time frame. During an interview on 05/29/2026 at 11:44 AM, the Director of Nursing stated that allegations involving injuries of unknown source and resident self-harm are required to be reported to the New York State Department of Health immediately but no later than two hours after the facility becomes aware of the allegation. The Director of Nursing confirmed that the incidents involving Residents #135 and #144 were not reported within the required timeframe and attributed the failures to the former Assistant Director of Nursing , who was responsible for investigations and reporting. During an interview on 05/29/2026 at 2:45 PM, the Administrator confirmed the facility failed to comply with reporting requirements for allegations involving injuries of unknown source and resident self-harm, and stated the former Assistant Director of Nursing's employment was terminated due to these failures. 3. Resident #68 had diagnoses that included Alzheimer's disease, dementia, and seizure disorder. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment and wandering. A nurse's note dated 03/30/2026 documented that at 8:23 AM, a palm sized discoloration to Resident #68's left dorsal thigh area. The physician was notified and ordered monitoring. The facility's accident/ incident report documented a purple discoloration, however, the facility investigation did not contain conclusion sufficient to rule out abuse, neglect, or mistreatment. During an interview on 06/02/2026 at 1:00 PM, Certified Nursing Assistant #13, the aide assigned to Resident #68, stated the bruise was discovered during morning care. During an interview on 06/02/2026 at 1:04 PM, Registered Nurse #2 stated an incident report was completed and forwarded to the Assistant Director of Nursing but was unaware whether the incident had been reported to the New York State Department of Health. During an interview on 06/02/2026 at 2:11 PM, the Director of Nursing stated the Assistant Director of Nursing was responsible for investigations and State reporting and failed to complete the investigation or submit the required report to the State. The Director of Nursing acknowledged the incident should have been reported to the New York State Department of Health. During an interview on 06/02/2026 at 2:27 PM, the Administrator stated they were unaware of the incident until 06/02/2026 and confirmed the incident would have been reported had they been informed. 10 New York Codes, Rules and Regulations 415.4

Based on observation, record review, and interviews the facility failed to ensure that a resident who required assistance with activities of daily living received necessary grooming and personal hygiene services. This was evident in one (Resident #95) of three residents reviewed for Activities of Daily Living out of 30 total sampled residents. Specifically, Resident #95, who required staff assistance with personal hygiene, was observed on multiple occasions with unkempt and unshaven facial hair. The findings include:The facility's policy titled Shaving Residents, last reviewed 07/2025, stated that shaving is performed to promote cleanliness and provide skin care. The policy further directed staff to ask residents whether they wished to be shaved.Resident #95 had diagnoses that included Cerebrovascular Accident and Non -Alzheimer's Dementia.The Annual Minimum Data Set assessment dated [DATE] documented that Resident #95 had severely impaired cognition and required moderate assistance with personal hygiene, including shaving.The Quarterly Minimum Data Set assessment dated [DATE] continued to document severe cognitive impairment and the need for moderate assistance with personal hygiene.The comprehensive care plan titled, Functional Status: Self-Care/Personal Hygiene, effective 09/10/2024, identified that Resident #95 required partial to moderate assistance with personal hygiene. Interventions included providing assistance and verbal cueing as needed to maintain personal hygiene needs.Resident #95 was observed on four separate occasions with unkempt and unshaven facial hair while seated in the dining room: on 05/27/2026 at 12:28 PM, 05/28/2026 at 11:14 AM, 06/01/2026 at 12:18 PM and on 06/02/2026 at 12:30 PM.A review of the Certified Nursing Assistant Accountability Records for May and June 2026 failed to reveal documentation that Resident #95 was offered shaving services, received shaving assistance, or refused shaving.A review of Resident #95's medical record further revealed no documentation that Resident #95 had refused to be shaved.On 06/02/2026 at 12:10 PM, Certified Nursing Assistant #16 was interviewed and stated that Resident #95 was assigned to them that day and had received a bed bath. They stated that Resident #95 sometimes wanted to shave and sometimes did not; however, they had not asked the resident whether they wished to be shaved on that day and did not know when the resident had last been shaved.During an interview on 06/02/2026 at 12:27 PM, Certified Nursing Assistant #13 stated that when assigned to Resident #95, they typically shaved the resident using an electric razor; however, they could not recall when the resident was last shaved. On 06/02/2026 at 12:18 PM, Registered Nurse #2 was interviewed and stated that Resident #95 was able to express preferences and did not have a known preference regarding shaving. Registered Nurse #2 further stated they were unaware if Resident #95 had refused to shave and reported that when asked, Resident #95 stated they would like to be shaved.During an interview on 06/02/2026 at 2:12 PM, the Director of Nursing stated that Certified Nursing Assistants are expected to offer shaving services to residents and notify nursing staff if a resident refuses. The Director of Nursing further stated that refusals should be communicated and documented through the facility's stop and watch tool.During an interview on 06/02/2026 at 2:21 PM, the Administrator stated that Certified Nursing Assistants receive education on providing residents' assistance with activities of daily living. The Administrator further stated that when a resident refuses grooming services, staff are expected to notify nursing staff so the refusal can be addressed.10 New York Codes Rules Regulations 415.12(a)

Based on observation, record review, and interviews, the facility failed to ensure a resident requiring oxygen therapy received respiratory care in accordance with physician orders and accepted standards of nursing practice. This was evident in one (Resident #145) of two residents reviewed for respiratory care out of 30 total sampled residents. Specifically, Resident #145 was observed receiving oxygen via nasal cannula at a flow rate of three liters per minute despite a physician's order directing oxygen administration at two liters per minute. The findings include:The facility's policy titled Oxygen Administration, last reviewed 10/2024, directed staff to review physician orders prior to administering oxygen therapy and to ensure oxygen is administered at the rate prescribed by the physician.Resident #145 had diagnoses that included Chronic obstructive pulmonary disease, Major depressive disorder, and Nicotine dependence.The admission Minimum Data Set assessment dated [DATE] documented that Resident #145 had moderately impaired cognition and received oxygen therapy while residing in the facility.A physician's order dated 05/12/2026 documented that Resident #145 was to receive oxygen via nasal cannula at a rate of two liters per minute for shortness of breath.During observations conducted between 05/26/2026 at 10:34 AM and 05/29/2026 at 10:45 AM, Resident #145 was observed seated at the bedside receiving oxygen through a nasal cannula. The oxygen concentrator located adjacent to the resident's bed was observed set at three liters per minute rather than the ordered two liters per minute.During an interview on 05/29/2026 at 10:50 AM, Registered Nurse #1 stated that nursing staff were responsible for verifying oxygen settings and confirmed that Resident #145 had a physician order for continuous oxygen at two liters per minute. Registered Nurse #1 was unable to explain why the oxygen concentrator had been operating at three liters per minute during survey observations.During an interview on 05/29/2026 at 11:44 AM, the Director of Nursing stated that residents receiving continuous oxygen therapy should have oxygen flow rates verified at least once per shift to ensure administration is consistent with physician orders. The Director of Nursing further stated that verifying oxygen settings was the responsibility of the licensed nurse assigned to the resident10 New York Codes, Rules and Regulations 415.12(k)(6)

Based on observation, record review, and interviews, the facility failed to implement and maintain an effective infection prevention and control program designed to prevent the transmission of communicable diseases and infections. This was evident in one (Resident #18) of four residents observed during medication administration. Specifically, staff failed to follow Enhanced Barrier Precautions when administering medications to Resident #18 via a Percutaneous Endoscopic Gastrostomy tube. The resident's room was clearly identified as requiring Enhanced Barrier Precautions, and facility policy required the use of personal protective equipment during feeding tube care and use.The findings include:The facility policy titled, Enhanced Barrier Precautions, last reviewed 05/2025, stated that Enhanced Barrier Precautions are an infection control intervention designed to reduce the transmission of multidrug-resistant organisms in nursing homes. The policy required the use of gowns and gloves during high-contact resident care activities for residents with wounds, indwelling medical devices, or other identified risk factors.The Centers for Disease Control and Prevention guidance, Implementation of Personal Protective Equipment in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (04/02/2024), identifies feeding tube care and use as a high-contact resident care activity requiring gown and glove use under Enhanced Barrier Precautions.Resident #18 had diagnoses including dysphagia, legal blindness, and multiple muscle contractures.A Significant Change Minimum Data Set assessment dated [DATE] documented that Resident #18 had severely impaired cognition and had a feeding tube.The comprehensive care plan related to speech and swallowing, initiated 02/18/2026 and last reviewed 05/20/2026, documented that Resident #18 had dysphagia (difficulty swallowing), was nothing by mouth, and had a Percutaneous Endoscopic Gastrostomy tube.A physician's order dated 05/12/2026 directed administration of multiple medications through the Percutaneous Endoscopic Gastrostomy tube, including Finasteride, Acetaminophen, Methenamine Hippurate, and a multivitamin.During medication administration observation on 05/27/2026 at 9:37 AM, Registered Nurse #3 was observed administering medications to Resident #18 through the Percutaneous Endoscopic Gastrostomy tube without wearing a gown or gloves. At the time of the observation, an Enhanced Barrier Precautions signage was prominently displayed on the resident's door with instruction for staff to wear a gown and gloves during high-contact resident care activities, including feeding tube care and use; and a star sticker was posted outside the room to identify the resident as requiring Enhanced Barrier Precautions.During an interview on 05/27/2026 at 9:53 AM, Registered Nurse #3 stated that Resident #18 was on Enhanced Barrier Precautions due to the presence of Percutaneous Endoscopic Gastrostomy tube and acknowledged that gown and gloves were required when administering medications through the feeding tube. Registered Nurse #3 further stated they had received training on Enhanced Barrier Precautions but forgot to don the required personal protective equipment before administering the medications.During an interview on 06/01/2026 at 11:01 AM, the Infection Preventionist stated that residents with feeding tubes, urinary catheters, wounds, and similar devices were placed on Enhanced Barrier Precautions. The Infection Preventionist stated that a star sticker and Enhanced Barrier Precautions signage were used to identify affected residents and that personal protective equipment was readily available throughout the unit. The Infection Preventionist further stated that staff were educated on Enhanced Barrier Precautions during orientation and annual training and that gown and glove use was required during Percutaneous Endoscopic Gastrostomy tube care and medication administration to prevent the spread of infection.During an interview on 05/29/2026 at 11:52 AM, the Director of Nursing stated that nursing staff were required to wear the appropriate personal protective equipment before administering medications through a Percutaneous Endoscopic Gastrostomy tube. The Director of Nursing further stated that failure to wear the required gown and gloves during Percutaneous Endoscopic Gastrostomy tube care constituted a breach of infection control practices.10 New York Codes, Rules and Regulations 415.19(a) (1-3)

Based on observations, record review and staff interviews conducted during the Recertification survey and Complaint survey (NY00348151) from 09/03/2024 to 09/10/2024, the facility did not ensure that residents comprehensive care plans were reviewed and revised to reflect the resident's status. This was evident for 1 (Resident #91) of 2 residents reviewed for Activities of Daily Living, 1 (Resident #105) of 6 residents reviewed for Abuse and 1 (Resident #7) of 5 residents reviewed for Unnecessary Medication out of 31 sampled residents. Specifically, 1). Resident #91's comprehensive care plan was not reviewed and revised to reflect their preference for wearing hospital-style gowns, and refusal to have their hair care needs addressed, 2). Resident #105's comprehensive care plan related to Victimization was not reviewed and revised after the Minimum Data Set Assessment was completed, and 3). Resident #7's comprehensive care plans related to Pain and Anticoagulant use were not reviewed or revised after the Minimum Data Set Assessment was completed. The finding is: The facility policy titled Care Planning Process last revised 6/24 documented comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team. The policy further documented care plans must be reviewed and modify as needed by appropriate disciplines prior to scheduled care plan meeting. Each comprehensive care plan problems, goals and interventions should be reviewed for appropriateness to the resident's condition. Each care plan should have a review note completed prior to/during the comprehensive care plan meeting evaluating effectiveness. 1. Resident # 91 had diagnoses which includes Depression, Paranoid Schizophrenia, and Insomnia. The Quarterly Minimum Data Set, dated dated dated [DATE] documented that Resident #91 had severely impaired cognition and required supervision to set up assistance for shower and bath and was independent with personal hygiene. The Quarterly Minimum Data set further documented Resident #91 had physical behavioral symptoms directed toward others, other behavioral symptoms not directed toward others such as pacing, and there was no rejection of care. On 09/03/24 at 12:40 PM, Resident #91 was observed eating lunch in the unit dining area wearing hospital-type gown. Resident #91's hair appeared long on the sides and there was a large, matted clump of hair at the back of Resident #91's head. On 09/04/24 at 09:40 AM, Resident #91 was observed walking in the hallway and entered dining area wearing a hospital-type gown. Hair to the back of Resident #91's head was observed to be in a matted clump. On 09/05/24 at 09:05 AM, and on 09/05/24 at 11:29 AM, Resident #91 was observed walking from the dining area to their room in a hospital-type gown with hair that remained matted to the back of resident's head in long clump. Resident #91 did not answer when greeted. On 09/09/24 at 09:03 AM, on 09/09/24 at 11:51 AM, and on 09/10/24 at 08:51 AM, Resident #91 was observed walking on unit from dining area to room in a hospital-type gown. Resident #91 continued to have a clump of matted hair to the back of the head. The Comprehensive Care Plan titled Functional Status: Self Care effective 1/17/2024 and last updated documented 7/24/2024 documented Resident #91 required supervision/touching assistance for shower/bathe self and was independent for Personal Hygiene. Interventions included encourage resident to perform self-care as independently as possible, observe for safety, review progress or lack of progress toward discharge goals and update as needed, and continue annual and quarterly assessments to monitor status. The Comprehensive Care Plan titled Behavioral Symptoms Etiology: Resident exhibits behavior problems as evidenced by refusing medications, psychiatric diagnosis of Paranoid Schizophrenia dated effective 4/3/2024 with last evaluation note dated 7/17/2024. Interventions included monitor behavior episodes and attempt to determine underlying cause, consider location, time of day, persons involved, and situations, document behavior and potential causes, re-enforce/praise positive behavior and progress, explain to resident the risk of non-adherence and risk of negative outcomes/impact, and refer to physician/psychiatrist as needed. The Certified Nursing Assistant Accountability Record dated January 2024 through September 2024 documented resident received showers and contained no documented evidence that Resident #91 refused care or refused to clean their hair. There was no documentation of Resident #91's preferences for care on the Certified Nursing Assistant Accountability record. The Comprehensive Care Plan meeting dated 10/26/2023, 1/30/2024, 5/2/2024 and 8/1/2024 documented Resident #91 was receiving showers, but there was no documented evidence that Resident #91 Activities of Daily Living, specifically hair grooming and preference for gowns was addressed with Resident #91 and/or representative. The Nursing progress note dated 07/16/2024 at 10:34 AM, documented behavior Note: Even with much encouragement resident refuses to let hair get washed and to put on clothing- prefers to wear the gown. There was no documented evidence that Resident #91's care plan was reviewed or revised to include their preference for hospital-style gowns, or to include interventions and or a plan to address Resident #91's matted and unkempt hair. During an interview on 09/06/24 at 10:28 AM, Certified Nursing Assistant #8 stated that they were assigned to care for Resident #91 last month and the only thing Resident #91 allowed Certified Nursing Assistant #8 do for them is provide them with two hospital-style gowns, make their bed, and give them their breakfast and lunch trays. Certified Nursing Assistant #8 also stated that Resident #91 handled all other care by themself and refused to dress in anything other than hospital-style gowns. Certified Nursing Assistant #8 further stated that Resident #91 would only shower when they wanted to shower, despite having designated days to shower on Mondays and Thursdays and they always refused to have their hair washed or cut. Certified Nursing Assistant #8 stated that Resident #91 needed a lot of encouragement to go into the shower, and during shower time the Certified Nursing Assistant stays with Resident #91 but cannot touch their hair. Certified Nursing Assistant #8 stated they were aware of Resident #91's hair needs care, and they did not document that Resident #91 refused to clean their hair because there was no place to document this. Certified Nursing Assistant #8 stated they verbally inform the nurse on the unit that Resident #91 is refusing to wash their hair. During an interview on 09/06/24 at 02:06 PM, Licensed Practical Nurse #2 stated they are aware that Resident #91's hair is matted and cannot be combed out, and they have personally offered Resident #91 a haircut on multiple occasions, but Resident #91 refused. Licensed Practical Nurse #2 also stated that Resident #91 does not like to be touched and walks around in a hospital-style gown all day. Licensed Practical Nurse #2 further stated that Resident #91 is independent with Activities of Daily Living, is compliant with all medications, very engaging, low speech, has no combative behaviors at present. Licensed Practical Nurse #2 stated that they reported the noncompliance with hair care and matted hair to the supervisor and Social Worker, but nothing was done. Licensed Practical Nurse #2 also stated they do not participate in the care planning meetings and did not document the multiple times they offered Resident #91 a haircut. During an interview on 09/06/24 at 02:50 PM, Registered Nurse Supervisor #2 stated that Resident #91 walks up and down in the hallway in a hospital-style gown. Registered Nurse Supervisor #2 also stated that Resident #91 was admitted with matted hair and Resident #91 was encouraged to clean hair during an interdisciplinary team meeting, but they could not recall when this was. Registered Nurse Supervisor #2 further stated that they have approached Resident #91 on several occasions to offer a shower which Resident #91 accepted, but Resident #91 refuses to allow anyone to touch their hair. Registered Nurse Supervisor #2 stated if anyone attempts to touch their hair, Resident #91 turns red, folds arms, and says no, no and walks up and down the hallway. Registered Nurse Supervisor #2 also stated they did not document any of the meetings with Resident #91 or the plan for Resident #91, but there was a note in July 2024 stating that Resident #91 refused to have hair washed, and their preference was to wear hospital-style gowns on the unit. Registered Nurse Supervisor #2 stated they are not responsible for care plans and did not initiate or update the care plan for resident preference of gowns and refusing to wash hair as there was someone specifically assigned to do the care plans, but they are not sure what happened to that. During an interview 09/10/24 at 01:38 PM, the Director of Nursing stated were just told that the Resident #91 had matted hair, was resistive to care, refused activity of daily living care. The Director of Nursing also stated Registered Nurse Supervisors are responsible for creating and revising all care plans and they would instruct them to ensure that the appropriate care plans are in place for Resident #91. 44843 2. Resident #105 (NY00348151) was admitted to the facility with diagnoses which included Vascular Dementia, Cerebral Atherosclerosis, and Cerebral Infarction. The Admission Minimum Data Set 3.0 assessment dated [DATE] documented Resident #105 was had severely impaired cognition and no physical/verbal behavioral symptoms directed toward others. The Nursing note dated 7/12/2024 documented Resident #105 was observed with discoloration on the left upper arm area which was blueish in color and in the size measured 10cm x 5 cm. The Medical note dated 7/15/2024 documented date of service was on 7/12/2024 to assess Resident #105 for complaint of bruise with mild hematoma over the left arm. The Medical note also documented that Certified Nursing Assistant reported to the nurse that Resident #105 had a bruise over the left arm. The Medical Note further documented that Resident #105 was not able to give a proper history due to poor cognitive function. The Medical note documented that the Certified Nursing Assistant and nurses did not see Resident #105 falling from their bed or was there any history of accidents happening while Resident #105 was in their room. The Accident /Incident Occurrence Report/Investigation form documented the occurrence happened at 12:00 PM on 7/12/2024. The Comprehensive Care Plan related to Victimization created 4/16/2024 documented interventions which included to keep Resident #105 separated from other residents possibly disturbed by the behaviors exhibited whenever possible, provide a safe environment, and provide emotional support/reassurance for Resident #105 to express feelings. There was no documented evidence Resident #105's comprehensive care plan related to Victimization was reviewed and/or revised after Resident #105 was observed with an injury of unknown source or after the Admission Minimum Data Set assessment was completed on 4/23/2024 or the Quarterly Minimum Data Set assessment completed on 7/24/2024. 3. Resident #7 had diagnoses of Unspecified Atrial Fibrillation, Unspecified Pain, and Chronic Pain Syndrome. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #7 was cognitively intact. The Minimum Data Set assessment also documented that Resident #7 received anticoagulant and opioid medication. The Physician's order dated 10/21/2023 renewed on 9/3/2024 documented that Resident #7 was to receive Oxycodone-Acetaminophen 10mg-325mg tablet, 1 tablet by mouth every 6 hours for Pain. The Physician's order dated 11/10/2022 renewed on 9/3/2024 documented that Resident #7 was to receive Eliquis 5 mg tablet, give 1 tablet by mouth every 12 hours for Unspecified Atrial Fibrillation. The Medication Administration Record dated August 2024 documented that Oxycodone-Acetaminophen and Eliquis were administered to Resident #7 every day as ordered. The Comprehensive Care Plan with focus on Pain created on 11/10/2022 and last updated 3/29/2024 included interventions of assess for breakthrough pain and need for supplemental doses, assess nature, intensity, location, duration, and frequency of pain, and educate Resident #7 and/or family regarding importance of reporting pain and pain control. The Comprehensive Care Plan with focus on Anticoagulant Use initiated 11/10/2022 and last updated 5/13/2024 documented interventions which included to administer medications as per Medical Doctor orders, avoid bumping and handle resident gently when providing hands on care, and monitor/document/report to Medical Doctor as needed for signs/symptoms of anticoagulant and/or antiplatelet complications. There was no documented evidence that Resident #7's comprehensive care plans related to Pain and Anticoagulant Use were reviewed or revised after the last Minimum Data Set assessment completed on 6/3/2024. On 09/05/2024 at 02:17 PM, Registered Nurse #1 was interviewed and stated they were responsible for reviewing the care plans for residents at least every three months after the Minimum Data Set assessments and as needed. Registered Nurse #1 also stated they were able to check which residents were due for Minimum Data Set assessment in the electronic medical record system and review their care plans accordingly. Registered Nurse #1 further stated they updated or documented to continue the care plan if no change was needed. Registered Nurse #1 stated they updated some care plans for Resident #105 and #7, and it may be an oversight that all care plans were not updated. On 09/09/2024 at 10:17 AM, the Director of Nursing was interviewed and stated the day shift Registered Nurse for the unit was responsible for reviewing and updating the care plans at least every three months after the Minimum Data Set assessment and as needed. The Director of Nursing also stated the Registered Nurse is supposed to document the care plan was reviewed and continue the current care plan if there was no change in the care plan. The Director of Nursing reviewed the medical record and was not able to explain why some care plans were not reviewed or updated in a timely manner for Resident #105 and Resident #7. The Director of Nursing stated the registered nurses were professional and they did not monitor if the Registered Nurse had reviewed and updated the care plans. 10 NYCRR 415.11(c)(2)(iii)

Based on record review and interviews conducted during the Recertification survey from 09/03/2024 to 09/10/2024, the facility did not ensure that, to the extent practicable, the resident or resident representative participated in the development, review, and revision of the comprehensive care plan. Specifically, Resident #78 and/or their designated representative were not afforded the opportunity to participate in the initial care plan meeting. This was evident in 1 out of 3 residents reviewed for Care Plan. The findings are: The facility policy titled Care Planning Process with an effective date of 11/12/20 and last revised date 6/24 stated that Resident/family/responsible parties will be invited to the comprehensive care plan meeting by the Social Work department. The policy also stated that every effort will be made to accommodate attendance at these meetings. The policy further stated that an explanation should be documented in the medical record if it was determined that participation of the resident or representative is not practicable for the development of the care plan. Resident #78 had diagnoses which included Major Depressive Disorder, Multidrug Resistant Organism and End Stage Renal Disease. The Admission Minimum Data Set assessment dated [DATE] documented that Resident #78 was cognitively intact and had no behavior issue. Section Q0110 of the Admission Minimum Data Set documented that Resident #78, nor their representative participated in the assessment. On 09/03/2024 at 10:42 AM, Resident #78 was interviewed and stated they were admitted to the facility about three months ago and did not recall being invited to a care plan meeting. Resident #78 also stated they made decision themselves. The Care Plan Meeting report documented the initial care plan meeting was held on 06/27/2024. and did not document that Resident # 78 and/or their representative attended the meeting. There was no documented evidence in the medical record that Resident #78 and/or their representative were invited to or participated in the care plan meeting on 06/27/2024. Social Services notes dated 06/27/2024 to 08/28/2024 contained no documented evidence that Resident #78 and/or their representative was invited to a care plan meeting. On 09/06/2024 at 10:52 AM, Licensed Practical Nurse #1 was interviewed and stated Resident #78 was cognitively intact, made decision themselves, and did not refuse care. Licensed Practical Nurse #1 also stated the Social Worker was responsible to invite the resident and/or their representative to the care plan meeting. On 09/06/2024 at 11:46 AM, the Director of Social Services was interviewed and stated they provide social services for Resident #78, and they invited the resident and/or their representative to the care plan meeting about one week ahead of the scheduled care plan meeting. The Director of Social Services also stated the invitation to care plan meeting had to be documented in the medical record as a proof an invitation was done. The Director of Social Services further stated Resident #78 was alert and oriented and made decision themselves. The Director of Social Services reviewed the medical record of Resident # 78 and could not locate or provide any documented evidence that Resident #78 and/or their representative were invited to the initial care plan meeting on 6/27/2024. The Director of Social Services stated it was an oversight that Resident #78 and/or their representative were not invited to care plan meeting. 10 NYCRR 415.3(f)(1)(v)

Based on record review and interviews conducted during the Recertification survey from 09/03/2024 to 09/10/2024, the facility did not ensure that the Minimum Data Set 3.0 assessments were accurately coded to reflect the residents and/or their representatives' participation in the assessment and goal setting. This was evident for 3 (Resident #18, #7, and #78) out of 31 total sampled residents. Specifically, the Minimum Data Set assessment for Residents #18, #7, and #78 did not accurately code that the residents participated in the assessment. The findings are: The facility policy titled MDS (Minimum Data Set) assessment with an effective date of 11/12/20 and last revised 6/24 documented Social Work was assigned to complete section Q in the Minimum Data Set assessment. 1. Resident #18 had diagnoses of Hypertension, Peripheral Vascular Disease, and Chronic Respiratory Failure. During an interview on 09/10/24 at 09:56 AM, Resident #18 stated they always take part in the Care Plan meeting and talks with the team about their plan of care. The Quarterly Minimum Data Set 3.0 assessment dated [DATE] documented Resident #18 was cognitively intact, had no behavior problems, and no rejection of care. Section Q 0110, Participation in Assessment and Goal Setting, in the assessment documented none of the above and did not reflect that Resident #18 had participated in the assessment. 44843 2. Resident #7 had diagnoses which included Congestive Heart Failure, Major Depressive Disorder, and Unspecified Pain. On 09/10/2024 at 09:31 AM, Resident #7 was interviewed and stated the staff from different disciplines met with them for assessment about every 3 months. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #7 was cognitively intact and did not reject care. Section Q 0110, Participation in Assessment and Goal Setting, in the assessment documented none of the above and did not reflect that Resident #7 had participated in the assessment. 3. Resident #78 had diagnoses which included Major Depressive Disorder, Multidrug Resistant Organism and End Stage Renal Disease. On 09/10/24 at 09:46 AM, Resident #78 was interviewed and stated the interdisciplinary team members visited them at the beginning of admission and again last week for assessment. The Admission Minimum Data Set assessment dated [DATE] documented Resident #78 was cognitively intact and did not reject care. Section Q 0110, Participation in Assessment and Goal Setting, in the assessment documented none of the above and did not reflect that Resident #78 had participated in the assessment. On 09/09/2024 at 03:08 PM, the Minimum Data Set Coordinator was interviewed and stated they interviewed the residents and/or representatives for the Minimum Data Set assessment. The Minimum Data Set Coordinator also stated that the Social Service department was responsible to answer the question Q0110, Participation in Assessment and Goal Setting, in section Q of the assessment. The Minimum Data Set Coordinator stated they were not responsible for the accuracy of the Minimum Data Set assessment but to make sure the Minimum Data Set assessments were completed and submitted in a timely manner. On 09/09/2024 at 03:23 PM, the Director of Social Services was interviewed and stated their department answered the question Q 0110 - Participation in Assessment and Goal Setting in the Minimum Data Set assessment. The Director of Social Services also stated the interdisciplinary team did involve the residents and/or their representatives for the Minimum Data Set assessment. The Director of Social Services further stated that it was the Assistant Director of Social Services' responsibility to answer question Q 0110. The Director of Social Services stated the Assistant Director of Social Services left the facility several weeks ago. The Director of Social Services further stated it was an error to code that residents and/or their representatives had not participated in the assessments. The Director of Social Services also stated that they provided training to the Assistant Director of Social Services and reviewed the completed assessments for accuracy of the Social Services section after the training, then discontinued doing so when there were no concerns with the way the assessments were completed. On 09/10/2024 at 10:01 AM, the Administrator was interviewed and stated the interdisciplinary team had the residents and/or their representatives participate in the Minimum Data Set assessment. The Administrator also stated they were not aware it was coded to reflect that the residents and/or their representatives did not participate in the assessments. The Administrator further stated it may be misunderstanding of the question that the staff answered question Q 0110 incorrectly. 10 NYCRR 415.11(b)

Based on observations, record review, and interviews conducted during the Recertification Survey from [DATE] to [DATE], the facility did not ensure that food was stored in accordance with professional standards for food service safety. This was evident during the kitchen task and pantry inspections. Specifically, there were multiple expired food items in the kitchen dry storage room, emergency food room, and in the pantry on the 5th floor. The findings are: The facility policy titled Storage Procedure revised ,d+[DATE] documented food shall be received and stored in a manner that complies with current practices for safe food handling. Dry foods that are stored in bins will be removed from original packaging labeled and dated (use by date). Such foods will be rotated using a first in - first out system. An initial tour of the kitchen and emergency food storage area was conducted on [DATE] from 09:16AM-09:53AM with Dietary Aide #2 and Dietitian. In the dry storage room of the kitchen 10 carboard boxes of 24 count 8 ounces Jevity 1.5 with use by dates of 1 [DATE] and 1 [DATE], and one box containing 33 individual containers of 4-ounce Ready Care Clear Choice Thickened Lemon-Flavored Water with a marked expiration date of 10 [DATE] were observed. In the emergency food storage area Boost Pudding Rich chocolate with expiration date of 30 [DATE], and Two Cal HN containing 23 cartons of 8 ounce with use by date of 1 [DATE] were observed. During a tour of the pantry on the 5th floor on [DATE] at 11:00AM-11:01AM, a box containing 21 cartons of Nepro Carb Steady Homemade vanilla with use by date of 1 [DATE] was observed. During an interview on [DATE] at 11:21AM, the Dietary Aide #1 stated they get deliveries weekly and rotate items at the end of the month when new items come in. In the dry storage new items are placed in the back and older items in the front. Dietary Aide #1 also stated they noticed some expired items two weeks ago and at the end of last month they did not have time to get rid of the items. Dietary Aide #1 further stated that they do not have a supervisor on the weekend and their new supervisor started yesterday. During an interview on [DATE] at 11:01AM, Certified Nursing Assistant #4 was interviewed and stated that they do not normally have anything to do with the box of supplements, and there are no residents on the unit that receive Nepro but there are residents who use Ensure supplement. Certified Nursing Assistant #4 also stated that the kitchen staff drops off the supplements and leaves them in the pantry. Certified Nursing Assistant #4 further stated that when they get supplements for residents, they look for the resident's name, residents room number and check to see if the supplement is expired. During an interview on [DATE] at 11:07AM, Licensed Practical Nurse #4 stated they went into the cabinets in the pantry to get cups and they did not notice the expired supplements but believes no residents on the unit are using that supplement. Licensed Practical Nurse #4 also stated that the supplements expired on 1 [DATE], and should have been thrown out. Licensed Practical Nurse #4 further stated that supplements are brought up to the unit on a tray by food services and are typically not brought up in boxes. During an interview on [DATE] at 11:22AM, Registered Nurse Supervisor #1 stated that they do not believe the supplements were given out. Registered Nurse Supervisor #1 that the last time they did rounds on the unit they did not look at the pantry, however the nurse on the floor should be checking the pantry along with the Certified Nursing Assistants. Registered Nurse Supervisor #1 further stated that they did do not know how the supplements got in the pantry and normally the kitchen does not send up expired items. During an interview on [DATE] at 12:53PM, Dietary Aide #1 was interviewed, and stated they delivered today's 10AM snacks and supplements to the units. Dietary Aide #1 also stated they did not look in the pantry cabinets as they did not think dietary department had anything in the cabinet, and they bring supplements to the unit every day labeled with that day's date. Dietary Aide #1 further stated that the last time there was a resident receiving Nepro was in February 2024. During an interview on [DATE] at 03:25 PM, the Food Service Supervisor stated that they supervise dietary staff, and they look at the dry storage store room area three times a week, and at the emergency storage area two times a week. The Food Service Supervisor also stated that they inspected the dry storage room once a week on Mondays and did not notice the expired items on the shelf. The Food Service Supervisor further stated that the Dietary Aide is in charge of the storeroom and responsible for putting away food deliveries. The Food Service Supervisor stated that they do not give boxes of supplements to the units or look at the pantries upstairs, and they do not know who checks to see whether there are expired food items upstairs. During an interview on [DATE] at 12:49PM, the Director of Nursing stated when they do random unit checks they do not zero in on any particular area, and they do not look in the cabinets in the pantry. The Director of Nursing also stated that the Certified Nursing Assistants and Dietary staff have responsibility for the pantry. Supplements and enteral feeding are not kept in the pantry and are brought up to the units and labeled to be used at specific mealtimes. The Director of Nursing further stated that enteral feeding would come up per the order for administration and are not to be stored prior to use, as someone might see it there and use it which is not according to their protocol. The Director of Nursing stated the Licensed Practical Nurse or Registered Nurse supervisor should be supervising the Certified Nursing Assistants on the unit. 10 NYCRR 415.14(h)

Based on interviews and record review conducted during the Recertification/Complaint survey (NY00348151) from 09/3/2024 to 09/10/2024, the facility did not ensure all alleged violations involving injuries of unknown source were reported immediately, but not later than 2 hours after the allegations were made, to the State Survey Agency. This was evident for 1 (Resident #105) out of 6 residents reviewed for Abuse. Specifically, the facility did not report that Resident #105 was found with injuries of an unknown source to the New York State Department of Health within 2 hours. The findings are: The facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property with effective date 6/2020 and last review date 5/2024 documented that the facility will ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after allegation is made. Resident #105 was admitted to the facility with diagnoses which included Vascular Dementia, Cerebral atherosclerosis, and Cerebral Infarction. The Admission Minimum Data Set 3.0 assessment dated [DATE] documented Resident #105 had severely impaired cognition and no physical/verbal behavioral symptoms directed toward others. The Nursing note dated 7/12/2024 documented Resident #105 was observed with discoloration on the left upper arm area which was blueish in color and measured 10cm x 5 cm. The Medical note dated 7/15/2024 documented date of service was on 7/12/2024 to assess Resident #105 for complaint of bruise with mild hematoma over the left arm. The Medical note also documented that Certified Nursing Assistant reported to the nurse that Resident #105 had a bruise over the left arm. The Medical Note further documented that Resident #105 was not able to give a proper history due to poor cognitive function. The Medical note documented that the Certified Nursing Assistant and nurses did not see Resident #105 falling from their bed or was there any history of accidents happening while Resident #105 was in their room. The Accident /Incident Occurrence Report/Investigation form documented the occurrence happened at 12:00 PM on 7/12/2024. The Webform submission from Nursing Home Facility Incident Report emailed to the Administrator documented the incident was submitted to New York State Department of Health at 03:46 on 7/13/2024. On 09/05/2024 at 02:17 PM, Registered Nurse #1 was interviewed and stated Resident #105 was found to have a bruise on the left upper arm when the Certified Nurse Assistant provided care to Resident #105 on 7/12/2024. Registered Nurse #1 also stated the cause of the bruise was unknown at that time. Registered Nurse #1 further stated they reported the incident immediately to the Director of Nursing. The Director of Nursing was no longer employed at the facility and could not be reached for interview. On 09/05/2024 at 02:38 PM, the Administrator was interviewed and stated the staff on the floor immediately report all the incidents that occur to the Director of Nursing no matter what time and the Director of Nursing and themselves only were responsible for reporting to Department of Health. The Administrator also stated that the Director of Nursing discussed with them if the incident was reportable to Department of Health, and they knew the facility had to report any allegation of abuse including unknown injury to the state agency immediately within 2 hours of awareness. The Administrator further stated that the bruise on left upper arm for Resident #105 was considered to be an unknown injury and had to be reported to Department of Health within 2 hours of awareness. The Administrator stated that the Director of Nursing had problems logging in the system and the Administrator logged in for the Director of Nursing to submit the report. The Administrator also stated they terminated the Director of Nursing several weeks ago and they had no explanation why the incident which occurred 07/12/2024 was not reported to the Department of Health until 07/13/2024. 10 NYCRR 415.4(b)(2)

Based on observations, record review, and interviews during an abbreviated survey (NY00340994), the facility did not ensure that a resident care plan was reviewed and revised by the interdisciplinary team. This was evident in 1 out of 5 residents (Resident #1) sampled. Specifically, the facility's Accident/Incident Report dated 05/02/2024 documented at 6:05 pm, Resident #9's visitor reported that Resident #2 walked over to Resident #1 with a knife (black handle stainless steel knife) in their hand on 05/02/2024. The staff were alerted by Resident #9's visitor who took the knife from Resident #2. The facility investigated the incident but did not review and revised Resident #1's care plan. The findings include: The facility's Policy and Procedure titled Care Planning, Comprehensive with a revised date of 06/01/2023, documented a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs are developed and implemented for each resident. The policy further documents that a comprehensive care plan is revised as needed based on changes in the resident's condition, order changes or any change in status. Resident #1 was admitted to the facility with diagnoses including Non-Alzheimer's Dementia (memory loss), Hypertension, and Diabetes Mellitus. Minimum Data Set (a resident assessment tool) dated 05/01/2024 documented Resident #1 had a Brief Interview of Mental Status score of 9 out of 15, indicating moderately impaired cognition. A Comprehensive Care Plan for Victimization dated 04/19/2024, documented interventions to provide emotional support and reassurance for resident to express feelings. The care plan was not updated to reflect on the knife incident of 05/02/2024. The facility's Accident/Incident Report dated 05/02/2024 at 6:05 pm documented Resident #2's family visited and left food with utensils for Resident #2. Resident #2 walked over to Resident #1's bedside with a knife. The facility investigation concluded that abuse did not occur. Resident #2 was in possession of a knife because their family brought them food. During an interview on 06/03/2024 at 2:36 pm, Registered Nurse Supervisor #2 stated that the supervisors are responsible for initiating the care plans and updating them as needed. 10 NYCRR 415.11(c)(1)

Based on observations, record review, and interviews conducted during an abbreviated survey (NY00340994), the facility did not ensure a resident's designated representative was notified of changes in condition. This was evident in 1 out of 5 residents (Resident #1) sampled. Specifically, the Nurse's Progress Note dated 04/29/2024 documented that Resident #1 sustained an excoriation to the right elbow because of friction (the action of one surface or object rubbing against another). The Medical Doctor was notified, and Bacitracin Ointment was ordered. Record review revealed that Resident #1's designated representative was not notified. The findings are: The facility policy titled Change in Resident's Condition or Status dated 06/2024 documented the facility promptly notifies the resident, attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. Resident #1 was admitted to the facility with diagnoses including Non-Alzheimer's Dementia (memory loss), Hypertension, and Diabetes Mellitus. The Minimum Data Set, dated dated dated [DATE] documented that Resident #1 had a Brief Interview of Mental Status score of 9 out of 15, indicating moderately impaired cognition. A Nurse's Progress Note dated 04/29/2024 documented Resident #1 was observed twitching (jerking or convulsive movement) in bed. Not new, right elbow noted with adhesion from body rubbing on the bed sheets (friction). The Medical Doctor and wound care nurse were notified. A Wound Care Note, by wound care nurse, dated 05/03/2024 documented that Resident #1 was seen by the Wound Care Medical Doctor during rounds. The excoriation to Resident #1's right elbow measured 2centimeter x 2centermeter x 0.1centimeter with 100 percent epithelial tissue. The wound must be cleansed with Normal Saline, pat dry, and apply Xeroform (occlusive dressing) daily and as needed. A Medical Doctor's Note dated 05/05/2024 documented clean wound and peri-wound (the area around the wound) with Normal Saline prior to applying primary dressing. Peri wound should be treated with routine cleaning protocol. A Physician's Order's dated 04/29/2024 with revised date of 05/08/2024 documented clean right elbow with Normal Saline, pat dry, and apply Xeroform and cover with dry dressing daily and as needed. There was no documented evidence that Resident #1's representative was notified. During a telephone interview on 07/11/2024 at 9:46 am, the Wound Care Nurse stated that they did not inform or have any conversation with Resident #1's representative regarding the skin impairment to Resident #1's right elbow. During an interview on 07/11/2024 at 11:40 am, Director of Nursing #2 stated that they could not locate any documentation of Resident #1's representative being notified of the right elbow excoriation. 10 NYCRR 415.3(f)(2)(ii)(c)

Based on observations, record review, and interviews during an abbreviated survey (NY00340994), the facility did not develop and implement a comprehensive person-centered care plan with measurable objectives and time frames to meet a resident's status. This was evident in 1 out of 5 residents (Resident #1) sampled. Specifically, on 04/29/2024 at 3:41 pm, Resident #1 was observed with an excoriation to their right elbow due to friction (the action of one surface or object rubbing against another). A care plan was not developed with interventions to prevent friction. The findings include: The facility's Policy and Procedure titled Care Planning, Comprehensive with a revised date of 06/01/2023, documented a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs are developed and implemented for each resident. The policy further documents that a comprehensive care plan is revised as needed based on changes in the resident's condition, order changes or any change in status. Resident #1 was admitted to the facility with diagnoses including Non-Alzheimer's Dementia (memory loss), Hypertension, and Diabetes Mellitus. The Minimum Data Set (an assessment tool) dated 05/01/2024 documented Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) score of 9 out of 15, indicating moderately impaired cognition. There was no care plan developed for the skin impairment to Resident #1's right elbow. A Nurse's Progress Note dated 04/29/2024 documented that Resident #1 was observed twitching (jerking or convulsive movement) in bed. Not new, right elbow noted with adhesion from body rubbing to bed sheets (friction). The Medical Doctor and wound care nurse informed. During a telephone interview on 07/11/2024 at 9:24 am, the Wound Care Nurse stated that Resident #1 developed an excoriation from rubbing their right elbow on the bed sheet. The Wound Care Nurse stated that they assessed Resident #1's elbow and there was no bleeding. The Wound Care Nurse stated that an order was obtained to apply Bacitracin Ointment to the areas and to cover with dry dressing. The Wound Care Nurse went on to say that Resident #1 has uncontrollable movements and monitoring was ordered. The Wound Care Nurse stated that Resident #1 was being followed by the wound team and the area was in healing process. The Wound Nurse stated that Resident #1 did not have a bruise on their right foot. The Wound Care Nurse stated that a skin impairment care plan was not initiated, and that one should have been implemented. Several attempts were made to contact Registered Nurse Supervisor #3 but was unsuccessful. Registered Nurse Supervisor #3 is no longer working at the facility. 10 NYCRR 415.11(c)(1)

Based on record review and interviews conducted during an abbreviated survey (NY00324097), the facility failed to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This was evident in 1 out of 3 residents sampled (Residents #3). Specifically, on 09/16/2023 at approximately 6:00 pm, Resident #3 was observed on the floor mat in their room. The facility completed their investigation on 10/17/2023 and submitted the findings to New York State Department of Health on 10/17/2023. The facility did not complete and submit the investigation report within 5 working days to New York State Department of Health. The findings include: The Facility's Policy and Procedure on Abuse and Neglect, revised 05/2024, states on page 11 report the results of all investigations to the Administrator or his or her designated representative and to the officials in accordance with State Law, including immediate or 24-hour reporting to the State Survey Agency, law enforcement and the follow-up report to the State Agency, within 5 working days of the incident. Resident #3 was admitted to the facility with diagnoses including Traumatic Brain Injury, Hemiplegia and Seizure Disorder. The Minimum Data Set (an assessment tool) dated 09/18/2023 documented that Resident #3 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) score of 3 associated with severely impaired cognition. The facility's Investigation Summary dated 09/16/2023 with completion date of 10/17/2023, documented that Resident #3 had an unwitnessed fall and was observed lying on their left side on the floor mat. Resident #3 was alert and confused. The investigation concluded that the fall was an accident. Staff were educated on fall safety and prevention, hourly rounding protocol, anticipating resident's needs, and resident teaching was provided. A Webform Submission from Nursing Home Facility Incident Report showed that the facility submitted their completed investigation to New York State Department Of Health on 10/17/2023 at 6:21 pm. During a telephone interview on 06/17/2024 at 11:00 am, the Director of Nursing stated that the investigation summary was supposed to be reported to the Department of Health within 5 days. The Director of Nursing stated that the investigation was not reported because they thought that further actions was not needed. During a telephone interview on 06/17/2024 at 12:21 pm, the Administrator stated that the completed investigation should have been submitted to the Department of Health within 5 business days. The Administrator went on to say that they do not know why the investigation was submitted so late; and that it must have been an oversight. 10 NYCRR 415.4 (b)(1)(ii)

Based on observation, interview and record review conducted during an Abbreviated Survey (NY00322751), the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practices, the comprehensive person-centered care plan, and the resident's goals and preferences. This was evident for 1 out of 3 residents (Resident #2) sampled. Specifically, Resident #2 (Resident #1's roommate, who has intact cognition) reported that on 08/24/2023, they heard Resident #2 yelling out that Resident #2 was in pain while Certified Nursing Assistants (CNA #3 and CNA #4) were providing care to Resident #2 on 08/23/2023. CNA #3 reported that they did not report the complaint of pain immediately but reported it to the Licensed Practical Nurse (LPN) #2 after completing care for Resident #2. The findings are: The Policy and Procedure on Pain Assessment and Management dated 09/2023 states that the purpose of this procedure is to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes. Resident #2 was initially admitted to the facility on [DATE] with diagnosis of Dementia, Anxiety, Lower Back Pain. The MDS dated [DATE], documented that Resident #2 had severely impaired cognition. Resident #2 required extensive assist of two people for bed mobility and toileting use. A Potential for Pain/Discomfort Care Plan dated 08/15/2023 documented that interventions that include staff to anticipate Resident #2 needs for pain relief, observe closely during care, report and respond immediately to any signs of complaint of pain. The Accident/Incident Occurrence Report dated 08/24/2023 at 8:30PM documented that Resident #3 reported on 08/24/23 (time not documented) that they observed CNA #3 & CNA #4 being rough while giving care to Resident #2 on 08/23/2023 (time unknown). The Investigation Summary documented that it appears that the CNAs did not intentionally try to hurt Resident #2 even though procedure may have been uncomfortable. There is no documented evidence that Resident #2 was assessed for pain on 08/23/2023. Review of the physician's order and the medication administration record revealed that Resident #2 was not on any pain medication. During an interview on 09/06/2023 at 1:55PM, Certified Nursing Assistant (CNA) #3 stated that they provided incontinent care for Resident #1 with the assistance of CNA #4. CNA #3 stated that when they (CNA #3) were lowering Resident #2's bed, Resident #2 said that their body was in pain. CNA #3 stated that they stopped lowering the bed and waited for a while then asked Resident #2 if they were still in pain and Resident #2 said no. CNA #3 stated that they asked Resident #2 if it was okay for them to start care and Resident #2 said yes, it is okay. CNA #3 said that while CNA #3 and CNA #4 were changing Resident #2's incontinent brief, Resident #2 started yelling and screaming. CNA #3 said that this was Resident #1's usual behavior during care (yell and scream). CNA #3 stated that they did not inform the nurse that Resident #2 complained of pain while they were lowering the bed. CNA #3 said that they notified LPN #2 about Resident #2's complaint of pain after incontinent care was completed. During an interview on 09/06/2023 at 1:30PM, CNA #4 stated that they assisted CNA #3 to provide incontinent care to Resident #2. CNA #4 stated that Resident #2 usually screams and yells during Activity of Daily Living (ADL) care. CNA #4 stated that when Resident #2 was yelling and screaming, they (CNA #3 and CNA #4) stopped care and allowed Resident #2 to calm down. CNA #4 stated that after Resident #2 was calmed, they reapproach Resident #2 and completed care. CNA #4 stated that they did not tell the nurse that Resident #2 was yelling and screaming during care. CNA #4 said that they did not hear Resident #2 complain of pain. During a telephone interview on 09/06/2023 at 5:00PM, LPN #2 stated that none of the staff members or residents reported any incident to LPN #2. LPN #2 stated that CNA #3 did not notify LPN #2 that Resident #1 complained of pain during care. LPN #2 stated that when the CNAs are providing care for the residents, they are instructed if a resident complained of pain, to stop providing care and report any complaints of pain the nurse immediately. LPN #2 explained that they would have notified the supervisor or call the Medical Doctor to obtain an order for pain medication for Resident #2. During an interview on 09/06/2023 at 5:45PM, the Charge Nurse (CN) #1 stated that staff members notified CN #1 that Resident #2 was combative but did not notify them that Resident #1 complained of pain. During an interview on 09/06/2023 at 4:40PM, the Director of Nursing (DON) #1 stated that on 08/24/23 at 5:30PM, Resident #3 reported to the DON that on 08/23/23 (not sure of the time) Resident #3 observed two CNAs (CNA #3 & CNA #4) providing care to Resident #2 and Resident #2 said stop, stop. DON #1 stated that Resident #3 explained that Resident #3 also heard Resident #2 yelling out loud, but Resident #3 could not understand what Resident #2 was saying. DON #1 stated that Resident #3 also explained that when other staff members washed Resident #2, Resident #2 usually yelled, but Resident #2 never reacted like Resident #2 did with CNA #3 and CNA #4 on 08/23/23. DON #1 said that they performed a full body assessment on Resident #2 and there was no redness, discoloration, facial grimacing, discomfort, or pain was observed. During a telephone interview on 09/11/2023 at 1:00PM, the Medical Doctor (MD) #2 stated that when they reviewed Resident #2's medical record, Resident #2 had a history of lower back pain. MD #2 stated that they performed Resident #2's admission assessment and that Resident #2 never complained of pain and denied pain. MD #2 stated that they did not receive a phone call notifying them that Resident #2 complained of pain. MD #2 stated that Resident #2 was on Physical and Occupation Therapy (PT/OT) and that non-pharmacological intervention such as hot compress was used for pain during PT services. 10 NYCRR415.2

Based on observation, interviews, and record review conducted during an Abbreviated Survey (NY00321311), the facility did not ensure that an alleged violation involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 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 or 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). This was evident for 1 out of 3 residents (Resident #1) sampled for abuse. Specifically, on 8/02/23 at 7:45AM Resident #1 reported to Licensed Practical Nurse (LPN) #1 that they were struck with brush during morning care by Certified Nursing Assistant (CNA) #1. Resident #1 was examined on 8/02/2023, by Registered Nurse Manager (RN#1), and was observed with a horizontal scratch on the forehead approximately 2 inches in length. The facility reported the alleged allegation of abuse to local law enforcement on 09/07/23 at 3:00PM while Department of Health surveyor was onsite conducting the investigation. The findings are: The facility Policy and Procedure for Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, Reporting and Response, most recent review date 05/2023. The policy states that abuse allegations (verbal, mental, sexual, or physical abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 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. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in the facility. Resident #1 was admitted to the facility on [DATE] with diagnoses included Alzheimer's Disease and Adult failure to thrive. An Accident/Incident Report dated 09/07/23, revealed that Resident #1 gave a statement naming CNA #1 as the staff who hit Resident #1. During a morning tour Resident #1 stated that they were hit by CNA #1. The alleged occurrence resulted in a scratch to nose and forehead of Resident #1. Resident #1 was assessed for further injury and MD (Medical Doctor) #1 was notified. An Investigation Summary dated 09/07/23, revealed that the facility concluded that abuse was unsubstantiated because there were no witnesses to the alleged incident. A Nursing Progress Note, written by Registered Nurse Manager (RNM) #1, dated 8/02/23 at 9:52AM documented that Resident #1 was interviewed and reported that while Resident #1 was being shaved this morning (08/02/23), CNA #1 hit Resident #1. Resident #1 was observed with a horizontal scratch on the forehead approximately 2 in length. Resident #1 denied pain/discomfort. Assigned CNA #1 was removed from the unit immediately and sent home. MD #1 was notified, and a new order was received to transfer Resident #1 to the emergency room (ER) for evaluation and treatment. During an interview on 09/07/23 at 10:44 AM, LPN #1 stated that at around 7:30AM, CNA #1 approached them stating that Resident #1 was nick on the cheek from shaving during morning care. LPN #1 stated that CNA #1 also asked LPN #1 to go to the dining room and check Resident #1. LPN #1 said that Resident #1 was observed with a red line, and scant blood across Resident #1's forehead down to the left nostril. LPN #1 said that they asked Resident #1 what happened, and Resident #1 said that CNA #1 hit Resident #1 with a brush. LPN #1 explained that they asked CNA #1 what happen, and CNA #1 said that they were shaving Resident #1 and did not notice the red line on Resident #1's forehead. During an interview on 09/07/23 at 2:30 PM, Director of Nursing (DON) #1 stated that the former DON (DON #2) investigated the alleged violation of abuse it was not reported to local law enforcement. DON #1 said that they called local law enforcement on 09/07/2023 at 3:00PM after discussion with Department of Health Surveyor who was onsite 09/06/23 to 09/07/23. DON #1 said that two Police Officers came to the facility on [DATE] at 5:30PM. During an interview on 09/12/23 at 12:03 PM, the Administrator did not comment on as to why the alleged violation of abuse was not reported to local law enforcement timely. 10 NYC RR 415.4(b)

Based on observation, interview and record review conducted during a Recertification and abbreviated survey from 05/21/23 to 05/26/23, the facility did not ensure residents received proper treatment to maintain vision abilities. This was evident for 1 (Resident #78) of 2 residents reviewed for Communication/Sensory out of a sample of 26 residents. Specifically, the facility did assist Resident #78 with obtaining an Ophthalmology consultation. The findings are: The policy and procedure titled Consultants dated 8/3/2021, last reviewed 8/21/2022 documented that consultants services may be utilized in different areas included the medical areas which are Podiatry, Audiology, Ophthalmology, Optometry and Dental services. Written, signed and dated agreements are maintained for each consultant agreement. Consultants document their provision of care to the facility's electronic medical record. Such documentation may contain recommendations like plan for implementation, findings and plan for continued assessments. The facility retains the professional and admisistrative responsibility provided by the consultants. Resident #78 was admitted to the facility on [DATE] with the diagnoses of bilateral Ocular Hypertention, Myopia, Age related Cataract, Vascular Dementia. The Minimum Data Set 3.0 (MDS) quarterly assessment dated [DATE] documented Resident #78 was cognitively impaired. Resident is extensive and one assist for bed mobility,transfer,dressing, toilet use and personal hygiene. Limited assist of one for eating. The Comprehensive Care Plan titled potential for visual problem related to disease process as evidenced by Cataract, Myopia, Diebetic retinopathy, Glaucoma. Last revised on 4/24/23 included goal that resident will be free of eye pain and/or discomfort in the next 90 days. Intervention included assess visual functioning and notify MD of any changes. The Optometry consult dated 9-20-22 documented Glaucoma suspected drops are not indicated at this time. To be performed in 12 months. There was no documented evidence the facility scheduled an Ophthalmology consult for Resident #78 since admission. On 05/26/23 at 11:47 AM, an interview was conducted with the Assistant Director of Nursing (ADON), (#3). The ADON stated that when a resident is admitted to the facility, they automatically put a consult for dental, podiatry and vision. Based on the resident's diagnoses, other consults are added as needed. The ADON further stated that they are going to expedite an Ophthalmology consultation request for Resident #78. On 05/26/23 at 01:22 PM, an interview was conducted with the resident's Primary Medical Doctor (PMD #7). The PMD #7 stated they did not oversee Resident #78's care upon admission, and they joined the care team one month ago. PMD #7 stated Resident #78 should be seen annually by an Ophthalmologist, and they will ensure the resident is seen. 415.12(3)(b)

Based on observation, record review, and staff interviews, during the recertification survey, the facility did not ensure that a resident's comprehensive care plan (CCP) was reviewed and revised with changes in the resident's needs and conditions. This was evident for 1 of 26 residents reviewed in the investigation sample (Resident #47). Specifically, Resident #47's CCP was not reviewed and revised after Resident #47 had an altercation with another resident, (Resident #78) The findings are: The facility Comprehensive Care Plan policy and procedure titled Care Planning Comprehensive, initiated 8/2011 and revised May 2022, documented CCPs should be revised as needed based on changes in the resident's condition, orders, or any change in status. Resident #47 was admitted to the facility with diagnoses which include Multiple Myeloma in remission, AtrioventrIcular block, and venous insufficiency. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. The MDS further documented that the resident is extensive assist of one for bed mobility, dressing and personal hygiene. Extensive assist of 2 for transfer and toilet use. Limited assist of one for eating. The nursing progress notes dated 5/3/2023 documented Resident #47 was punched in the face by another resident in an altercation. The nursing progress notes dated 5/4/2023 documented Resident #47 returned to the facility from the hospital and denied pain and discomfort. The Physician progress notes dated 5/5/2023 documented Resident #47 was seen for follow-up after returning to the facility from the emergency room (ER). Resident #47 sustained no injury, was in no distress, and was at baseline with no pain and discomfort. There was no documented evidence that the CCP was reviewed and revised to address the resident's changing needs after he was punched by another resident. On 5/26/23 at 3:48 PM, the unit Registered Nurse Supervisor (RNS #2) was interviewed. The RNS #2 stated that when there is an issue, they will assess it and put a care plan in right after the assessment. The RNS #2 further stated that the care plan should be updated quarterly, annually, with a significant change, and as needed. Furthermore he stated that following an assessment, the nurse should proceed with the care plan. The care plan should have been updated right after the altercation. The care plan was updated 3 weeks after the altercation while the Surveyors were in the facility. 415.11(c)(2)(i-iii)

Based on observations and interviews conducted during the Recertification survey, the facility did not ensure that a safe, clean, comfortable, and homelike environment was maintained. This was observed during environmental observations on 1 of 4 units. (Unit 2, room [ROOM NUMBER]) Specifically, a resident's room was observed with an air conditioner in disrepair and dirty bedside nightsand drawers. The findings are: The facility policy and procedure titled Home Like Environment dated 9/3/2021 and revised on 8/21/22 documented that the maintenance policy and procedure is for the facility staff and management to maximize to the extent possible the characteristic of the facility that reflect a personalized and homelike setting. During observations of the environment conducted on Unit 2 on 5/21/2023 at 11:37 AM and on 5/26/22 at 3:35 PM with the Director of facility, room [ROOM NUMBER] was observed with a broken, dirty and rusty air conditioner. The bedside drawers were observed dirty with a lot of brown stain. On 5/26/2023 at 3:34 PM, an interview was conducted with the unit Housekeeper (housekeeper #8). He stated that as an evening housekeeper, his job is to maintain what was done during the day shift. He further stated that he did not go to into room [ROOM NUMBER] because it looks clean. As per the housekeeper, he is not aware of any equipment in disrepair in room [ROOM NUMBER] On 5/26/2023 at 3:37 PM, an interview was conducted with the Director of facility while making environmental round with him. He agreed that the air conditioner and the drawers are a concern. Furthermore, he said that they are going to replace the broken air conditioner and the drawers. On 5/26/2023 at 3:45 PM, CNA #2 was interviewed and stated that the air conditioner in room [ROOM NUMBER] is very questionable and was told by maintenance staff that the air conditioner is working. CNA #2 further stated that everyone is responsible to keep the drawers clean. If it is in disrepair, it should be reported to be fixed. 415.5(h)(1)

Based on observation, record review, and interviews conducted during an Abbreviated and Partially Extended Survey (Case # NY00314584), the facility failed to prevent further potential abuse, neglect, exploitation, or mistreatment while an investigation in allegation of abuse was in progress. This was evident for (Resident #1, 2, 3) out of the 14 residents reviewed. Specifically, on 04/12/2023 at 3:06 am, Licensed Practical Nurse (LPN) #1 and Certified Nurse Assistant (CNA) #2 heard a loud noise in Resident #1's room and responded to the room. Resident #1 was sitting at the edge of the foot of their bed and CNA #1 was standing, facing Resident #1. CNA #1 was visibly shaken, and Resident #1 was screaming, and dressed in a hospital gown with no adult brief on and touching their private parts. LPN #1 reported to Registered Nurse Supervisor #1 (RNS #1) that they suspected CNA #1 had sexually abused Resident #1. RNS #1 completed a full body assessment, and redness was observed on the right side of Resident #1's vaginal area. There were no swelling, blood, or skin tears to the vaginal area, but RNS #1 observed a little clear secretion from the resident's private area. Emergency Medical Services transferred Resident #1 to the Hospital Emergency Department. From 03:06 am to 5:30 am, CNA #1 sat at the nursing station. From 5:40 am until clocking out of the facility at 07:03 am, CNA #1 provided morning care to 14 residents on their assignment with no facility staff present. This resulted in Immediate Jeopardy and Substandard Quality of Care with the likelihood for serious harm to 14 residents. The findings are: The Facility Policy and Procedure for Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property last review date 10/2022, documented that it is the policy of this facility that the resident(s) will be protected from the alleged offender(s). The alleged perpetrator will immediately be removed, and the resident protected. Employees accused of alleged abuse will be immediately removed from the facility and remain removed pending the result of a thorough investigation. Resident #1 was admitted to the facility with diagnoses that included Dementia, Osteoporosis, and Cystitis (bladder infection). The Minimum Data Set (MDS, a resident assessment tool) dated 01/18/2023, documented that Resident #1 had short-term and long-term memory problems and was severely cognitive impaired. A Nurse's note dated 04/12/2023 at 6:38 AM, written by RNS #2 documented that on 04/12/2023 at approximately 03:06 AM, LPN #1 called the Nursing Supervisors to the unit and reported a possible sexual assault to Resident #1 by CNA #1. LPN #1 and CNA #2 reported that they heard a loud scream coming from Resident #1's room. Resident #1's bed linen was wet with a reddish color on the bottom sheet. New York Police Department (NYPD) was called. The EMS came and took Resident #1 to the hospital accompanied by CNA #3. A Fire Department New York (FDNY) Prehospital Care Summary Report dated 04/12/2023, documented call was received at 03:28 AM, arrived on the scene at 03:35 AM, and left the scene at 05:00 AM. The Resident was transferred to the hospital for evaluation. A Census Detail Report (CNA assessment) dated 04/12/2023, documented that CNA #1 was assigned to the 14 residents. A facility's employee Timecard dated 04/11/2023 to 04/12/2023, documented that CNA #1 clocked out on 04/12/2023 at 07:04 AM. During an interview on 04/17/2023 at 12:54 PM, CNA #1 stated that on 04/12/2023 at 03:00 AM, after they responded to screaming from Resident #1's room, five to six seconds later, CNA #2 and LPN #1 arrived in the Resident's room. CNA #1 stated that they changed the Resident's bed linen, then left the room and sat at the nursing station on the 4th unit. The CNA said that at 05:40 AM, they toilet, washed, clean and changed adult briefs of residents on their assignment and then they clocked out of the facility at 07:03 AM. The CNA said that on 04/12/2023, they received a call from the Special Victim Unit (SVU), telling them to come to the office because there was a complaint against them. The CNA stated that they went to the SVU office on 04/13/2023 and gave consent for a mouth swab. During an interview on 04/18/2023 at 07:51 AM, CNA #2 stated that they were assigned and checked on Resident #1 at 02:00 AM and 03:00 AM on 04/12/2023. The CNA said that at 03:00 AM, Resident #1 was awake in bed wearing a hospital gown and covered with a sheet. The CNA said at 03:06 AM, they were sitting in the hallway watching both corridors when they heard screaming in the right corridor. The CNA stated that CNA #2 and LPN #1 ran towards the noise which was coming from Resident #1's room. The CNA said that LPN #1 opened the door and CNA #2 observed CNA #1 fully dressed standing at the foot of Resident #1's bed and was visibly shaken. The CNA stated that Resident #1 was screaming, dressed in a hospital gown with no adult brief on, and touching their private parts. The CNA said that LPN #1 instructed them to stay with Resident #1 while LPN #1 went to call RNS #1. During an interview on 04/18/2023 at 09:39 AM, LPN #1 stated that on 04/12/2023, at around 03:00 AM, they heard screaming and yelling and went to Resident #1's room with CNA #2. LPN #1 said that they opened Resident #1's room door and observed Resident #1 sitting on the edge of the foot of their bed and CNA #1 was standing over and facing Resident #1. The LPN said that after the bed linen was changed, CNA #1 left Resident #1's room and was sitting at the nursing station while they went to notify RNS #1. The LPN said that RNS #1 called 911 and EMS, and the police arrived on the unit. Resident #1 was taken to the hospital. The LPN said that after the police left the floor, CNA #1 was sitting at the desk, and then went to toilet, wash, clean, change adult brief, and dress the residents on their assignment. LPN #1 said that they observed CNA #1 going in and out of rooms of the residents on CNA #1's assignment. The LPN said that after CNA #1 completed their assignment, CNA #1 left the unit at the end of their shift. During an interview on 04/17/2023 at 10:33 PM, RNS #1 stated that on 04/12/2023 at 03:06 AM, LPN #1 reported that they suspected that CNA #1 raped Resident #1. RNS #1 observed Resident #1 laying in the bed, visibly upset. Resident #1 did not answer questions. A full body assessment was completed, and redness was observed on the right side of Resident #1's vaginal area. There was no swelling, blood, or skin tears to the vaginal area, but RNS #1 observed a little clear secretion from the Resident's vaginal area. RNS #1 called 911, and the EMS and the police arrived. The RNS said that the police told them not to ask CNA #1 any questions because they did not want CNA #1 to change their story and RNS #1 should leave CNA #1 where the CNA was. RNS #1 informed the Director of Nursing (DON) of the police instructions, and the DON said, okay. The RNS said that CNA #1 remained on the unit until the end of their shift. During an interview on 04/18/2023 at 11:55 AM, the DON stated on 04/12/2023, they received a phone call at approximately 03:50 AM from RNS #2 who said that they have an allegation of abuse involving CNA #1. The DON stated that they notified the Administrator around 5:00 AM. The DON stated that RNS #1 and RNS #2 informed the DON that the police told them they already alerted the Special Victims Unit (SVU) in [NAME] and that the SVU will take CNA #1 from the facility. The DON stated that they called the police officers who were on-site to confirm that SVU will pick up CNA #1 from the building. The DON also stated that the police instructed them to not approach CNA #1 or remove CNA #1 from the unit. The DON stated that CNA #1 was allowed by RNS #1 and RNS #2 to continue their assignment and to toilet, wash, clean, change adult brief, and dress the residents on their assignment on the unit. The DON said, it is facility's policy to remove accused staff from the schedule pending an investigation. During the interview on 04/19/2023 at 09:56 AM, the Administrator stated, on 4/12/2023 at around 05:40 AM, they got a text message from the DON about the alleged sexual molestation of Resident #1 by the staff member. The Police were notified and were in the building. The message also said that CNA #1 was waiting in the building to be interviewed by SVU. The Administrator was not made aware that CNA #1 remained on the 4th floor and was allowed to continue to wash, clean, change adult brief, and dress 14 residents on their assignment and left the facility at the end of their shift. The Administrator stated that CNA #1 should be removed from the unit and placed in the nursing office, or an area with no residents. The Administrator stated that it was the facility's policy that the alleged perpetrator would be removed from the unit and from the schedule, immediately pending the result of the investigation. During an interview on 04/19/2023 at 06:44 PM, Detective from SVU stated that they came to the facility on [DATE] at 10:00 AM and spoke with the DON. The Detective stated that the DON was concerned that the Police told them not to remove CNA #1 from their assignment. The Detective stated that they were not aware of what the Patrol Officers said to the staff in the facility. The Detective stated that they did not tell RNS #1 or #2 to allow CNA #1 to continue working. Immediate Jeopardy (IJ) was identified and declared. The facility Administrator and Director of Nursing were notified on 04/19/2023 at 07:15 PM. The facility submitted a removal plan that was reviewed and accepted by NYS DOH on 04/19/2023 at 10:17 PM. 10 NYCRR 415.4 (b)(3)

Based on observation, interview and documentation review during an abbreviated survey, the facility did not implement policies and procedures to identify or provide adequate supervision to residents at risk for elopement. Specifically, Resident #1 was able to elope from the facility via an alarmed exit door and the facility staff did not discover that the resident was missing for 3 hours. The police returned the resident to the facility 30 hours later. The resident returned to the facility with a swollen left eye and was transferred to the hospital. For 4 out of 9 sampled residents (Residents # 2, #4, #6 and #8) record review revealed that there were no elopement risk assessments completed. For 2 out of 8 residents at risk for elopement (Resident #1 and #3), the facility did not implement comprehensive care plans. This was evident in 6 out of 9 sampled residents. (Resident #1, #2, #3, #4, #6 and #8). This resulted in actual harm to 1 resident (Resident #1) that is not Immediate Jeopardy and the potential for more than minimal harm that is not Immediate Jeopardy for 5 out of 9 sampled residents ( Residents #2, #3, #4, #6, and #8). Complaint ID#: NY 204 The findings are: Resident #1 was admitted to the facility on [DATE]. The resident was admitted with [DIAGNOSES REDACTED]. The resident ' s Minimum Data Set (MDS) Assessment 3.0 (a resident assessment tool), dated 9/21/11 identified that the resident had severe impairment in mental status. The resident required limited assistance with bed mobility, transferring, ambulating off the unit, dressing, toileting and providing personal hygiene. The facility policy titled " Elopement/Missing Resident! Prevention and Management " dated 10/08 was reviewed. The policy stated the facility is responsible to identify residents at risk for elopement, provide appropriate interventions and communicate to all the members of the interdisciplinary team including security. The policy stated that an elopement risk assessment is completed on all residents on admission, quarterly, significant change, annually and after an elopement event. When a resident is identified as at risk for elopement, then their name is added to a list kept at security and photograph is taken and posted at security. Security staff is made aware. The policy also stated that appropriate interventions are put in place such as ankle/transmitter. The policy stated to document the problem and the intervention in the comprehensive care plan and CNA Accountability Record. The Elopement Risk Assessment, dated 9/21/11 identified that the resident is at risk for elopement. The note stated that a family member reported that the resident had a history of [REDACTED]. A review of the medical record did not reveal a Comprehensive Care Plan (CCP) for elopement. A nursing note dated 9/24/11 at 2:10PM stated that the resident had pushed an exit door and stated he is going home. The note stated elopement precautions were maintained. A nursing note dated 10/6/11 at 10:30PM stated that the 1st floor Charge Nurse reported that the resident was missing. A Code E was called and staff responded. The DNS was informed. A nursing note dated 10/8/11 indicated that the resident was brought to the nursing home by 2 police officers at 2:35AM. The resident stated he was hungry and was provided a sandwich. The resident reported that he went across the street to watch a movie and did not know how to get back to the facility. The resident was noted with swelling to his left eye. The resident reported that he had fallen when in the community. As per the Patient Transfer Form, dated 10/8/11 the resident was transferred to the hospital. The Medication Administration Record (MAR), dated 9/21/11-10/19/11 revealed that the resident was prescribed Remeron 7.5 milligrams, orally at bedtime 9:00PM. The MAR revealed that the staff documented administration of the medication to the resident on 10/6/11 at 9PM. The MD orders dated 9/21/11 did not include that the resident was at risk for elopement. On 10/12/11 at 12:15PM the security video of the exit door on 10/6/11 was reviewed. The security video revealed that at 6:54 PM Resident #1 exited the facility via the back door, street access exit. The lights are flashing in the hallway indicating that the alarm is going off. The security guard is observed disabling the alarm at 6:58PM. On 10/11/11 at 3:20PM an interview was conducted with CNA #1. CNA #1 was assigned to Resident #1 on the day that the resident eloped from the facility. The CNA stated that he was not aware that Resident #1 was at risk for elopement. He said that the resident did not " seem " like he was at risk for elopement. The CNA was not aware that the resident had a history of [REDACTED]. The CNA said that he was not given any special instructions regarding monitoring of Resident #1. On the day of the incident, he had seen the resident in the day room around 7:00PM. From 8:00PM- 9:00PM the CNA went on his lunch break. The CNA stated that he did not check on Resident #1 when he returned from break. He stated that he began working on providing care to the residents on his assignment. Around 10:00PM he noticed that Resident #1 was missing. He informed the nurse and they implemented the missing person protocol. On 10/11/11 at 5:07PM an interview was conducted with CNA #3. CNA #3 was working on Resident #1 ' s unit on the night that the resident eloped from the facility. The CNA stated that she had floated to the unit. The CNA stated that she did not know what elopement meant. The questions regarding elopement were rephrased in multiple ways, but the CNA did not reveal comprehension of the topic of elopement precautions. The CNA was asked if she had been told to monitor Resident #1 or look out for him leaving the unit. She stated that she was not told any special instructions regarding Resident #1. On 10/11/11 at 2:15PM an interview was conducted with CNA #4. CNA #4 worked on Resident #1 ' s unit. The CNA stated that she was familiar with Resident #1. She acknowledged that she was aware that he had tried to exit the unit and triggered the alarm a few weeks ago, but stated that he was " not really " at risk for elopement. On 10/9/11 at 2:30PM an interview was conducted with unit LPN #2. The LPN stated that on 9/24/11 Resident #1 had stated he wanted to go home and had triggered the exit door that is located on the unit. She stated that following this incident she informed the staff that they needed to monitor the resident closely and keep him in the dayroom for observation. The LPN said that she did not implement any enhanced monitoring schedule, such as 30 minute checks, because the resident did not show any more signs of elopement. She stated that all the staff knew the resident was at risk for elopement. On 10/13/11 at 11:00AM an interview was conducted RN Supervisor #1 (RNS). The RNS had completed Resident #1 ' s admission paperwork including his elopement risk assessment. The RN Supervisor was asked if it was her responsibility to complete a comprehensive care plan for Resident #1 in response to the elopement risk assessment. She said that it is normally her responsibility, but that if she is too busy on her shift, then the responsibility is then left to the oncoming shifts ' supervisor. She stated that she was very busy that night. On 10/9/11 at approximately 2:00PM the weekend RNS (RNS #2) was interviewed. The RNS was asked for a list of residents at risk for elopement. RNS #2 stated that there is a list of residents at risk for elopement, but she did not know where it was located. The RNS provided copies of wanderguard transmitter log check sheets for functioing and placement from each unit. On 10/12/11 at 11:00AM a telephone interview was conducted with the LPN (LPN #3) that had documented the administration of Remeron to the resident at 9:00PM on 10/6/11. The LPN was not able to provide a clear explanation regarding the documented administration of Remeron on 10/6/11. There were multiple attempts to contact the security guard who responded to the door alarm on 10/6/11. The attempts to contact were not successful as the security guard is no longer employed at the facility. On 10/12/11 at 10:15AM an interview was conducted with the Director of Nursing Services (DNS). The DNS stated that the facility concluded in their investigation of the incident that Resident #1 eloped from the facility because the security officer did not respond properly to the alarmed door. The DNS also stated that around 8:00PM on the night of the elopement half of the unit staff had responded to a Code Blue (Cardiopulmonary Emergency). The DNS was asked about responsibility of unit staff during the 3 hours that the resident was not monitored. The DNS stated that when a CNA goes to lunch it is the responsibility of all staff on the unit to respond to the needs of the residents. When asked if CNA #1 should have checked on all his residents upon his return from break she responded by saying " as a DNS, that ' s not a bad idea, but it is not a part of the policy and procedure. " The DNS was asked if during her investigation, she had identified that the resident did not have a CCP for elopement. She stated that she did not know that the resident did not have the CCP. She stated that the RNS who had completed the elopement risk screen should have implemented the care plan. The DNS stated that upon admission all the RNS on duty are responsible for certain assessments. The DNS stated that a resident only gets an elopement assessment if they trigger as at risk for elopement. The DNS stated that every resident does not automatically get assessed for elopement by completing the elopement risk form. If there is a behavior or history of elopement triggered by the nurse when reviewing the admission, then she would initiate the elopement risk assessment form. The LPN on the unit is responsible for documenting the resident ' s elopement status on the CNA Accountability sheet. Following the interview, the DNS stated that she wanted to clarify her previous statement. She said that all RNSs will " eyeball " the elopement risk assessment for new admission, but that they do not necessarily complete the assessment unless there is a trigger. On 10/12/11 at 9:19AM an interview was conducted with the Administrator. The Administrator stated that the facility had identified that the problem that occurred was due to the security guard who did not follow protocol, specifically that the security guard did not respond to the alarm in a timely manner and did not extesnively check for a resident when he did respond to the alarm. In regards to Resident #1 who was missing unnoticed from approximately 7:00PM- 10:00PM, the Administrator stated that there were mitigating circumstances. The Administrator said that the mitigating circumstances included a Code Blue (staff response for cardiopulmonary resuscitation) that was called around the time of the resident ' s elopement. Resident #2 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The MDS 3.0 Assessment, dated 7/27/11 identified that the resident had severe cognitive impairment. Resident #2 was identified as at risk for elopement based on the unit list of residents at risk for elopement. A review of the resident ' s medical record revealed that the resident did not have a completed elopement risk assessment. A review of the CNA Accountability for Resident #2 revealed that the facility did not document elopement status on the accountability record. Resident #3 was admitted to the facility on [DATE]. The resident ' s [DIAGNOSES REDACTED]. The MDS 3.0 assessment dated [DATE] identified that the resident had severe cognitive impairment. Resident #3 was at risk for elopement based on an undated/unsigned elopement risk assessment located in the resident ' s chart. The resident did not have an elopement care plan in place. A review of the CNA Accountability record revealed that the there was no indication that the resident was at risk for elopement or on elopement precautions. Resident #4 was admitted to the facility on [DATE]. The resident ' s [DIAGNOSES REDACTED]. The MDS 3.0 Assessment, dated 7/16/11 identified that the resident had severe cognitive impairment. The medical record review revealed that on 7/13/11 at 6:30AM Resident #4 had left the unit for the lobby and refused to return to the unit. The resident was redirected but it was not effective. The record review revealed that the resident did not have an elopement risk assessment. The resident was not identified as at risk for elopement. 415.12 (h) (1)