Every finding on record at Campbell Hall Rehabilitation Center Inc

Based on observations, record reviews, and interviews conducted during the recertification survey, the facility failed to ensure that one (1) of five (5) residents (Resident # 106) reviewed for pressure ulcers received the necessary care and services to promote healing. Specifically, Resident #106 who was dependent for bed mobility was identified as having a Stage 2 pressure on the sacrum during an assessment by Registered Nurse Supervisor #1 on 10/16/2025. A wound consult was ordered which was not initiated until 11/05/2025. There was no documented evidence of wound assessments from 10/16/2025 to 11/05/2025. The first wound consult identified two (2) Stage 3 pressure ulcers on the right and left buttock. Additionally, there was no documented evidence of the wound progression from 11/12/2025 to 11/19/2025. Resident #106 was admitted to the hospital on [DATE] for worsening of pressure ulcer with a chronic-appearing dusky hue with scattered partial and full thickness ulcerations to the coccyx and bilateral buttocks. This resulted in actual harm to Resident #106 that was not Immediate Jeopardy. Findings include: The policy and procedure titled Pressure Ulcer Treatment last revised 08/01/2025 documented a treatment protocol shall be established for all identified Stage 2 pressure ulcers. The treatment objectives are to cover, protect, hydrate, insulate, and absorb exudate as appropriate. Care will be provided in accordance with the organization's Pressure Ulcer Treatment policy and procedure. A treatment protocol will be established for all identified Stage 3 pressure ulcers. The objective will be to cover, protect, hydrate, insulate, absorb, cleanse, prevent infection, and promote granulation. Resident #106 had diagnoses including diabetes (a blood sugar regulation problem), pressure ulcer (skin impairment) of sacral region (butt bone area), and acute kidney (organ in body for filtering waste) failure (loss of ability to filter waste). The admission Minimum Data Set (a resident assessment tool) dated 08/17/2025, documented Resident #106 had intact cognition, was dependent on staff for bed mobility, was frequently incontinent of bowel and bladder, was at risk for pressure ulcers and did not have any pressure ulcers. Skin and ulcer/injury treatments included pressure reducing devices for the chair and bed. The comprehensive care plan titled 'At Risk for Skin Breakdown Related to Impaired Mobility' dated 08/20/2025, documented the goal was the resident would be maintained with current skin integrity as evidenced by freedom from skin breakdown. Interventions included: complete a pressure ulcer risk assessment (Braden Scale), review quarterly and as needed, Certified Nurse Aide evaluation of skin condition daily during care and report any skin abnormalities to the nurse, the use of pressure reducing cushion when in wheelchair, skin barrier when performing perineal care, and encourage frequent changes in position. The Nursing-Resident Care Summary completed on 09/25/2025, documented the Braden Scale assessed the resident at low risk for pressure ulcer and documented the resident had no sensory perception impairment, was rarely moist, was chairfast, had no mobility limitation, adequate nutrition and a potential problem for friction and shear. Registered Nurse Supervisor #1's progress note dated 10/16/2025 at 9:34 PM documented they were alerted by the certified nurse aide and Licensed Practical Nurse #11 that Resident #106 had a 5-centimeter in diameter Stage 2 pressure ulcer to the sacrum. The wound bed was red and moist, and the surrounding tissue had erythema (superficial reddening of the skin). There was no exudate (drainage) from the site. The resident also had deep tissue injury (DTI) to the bilateral upper posterior thighs just below the buttocks. The findings were discussed with Nurse Practitioner #1. They would add the resident to wound rounds and place a foam dressing to the sacrum and place on a every two (2) hour turning schedule. The physician orders dated 10/16/2025 documented wound consult for new Stage 2 pressure ulcer to sacrum and deep tissue injuries to thighs; cleanse sacral wound with saline, pat dry and cover with foam dressing every 48 hours and as needed for soiling; turn every two (2) hours and float heels; only two (2) hours out of bed to chair; ensure gel cushion is in wheelchair. Licensed Practical Nurse #11's progress note dated 10/16/2025 at 10:57PM documented the certified nurse aide reported the resident had an open sore near the coccyx. The supervisor was notified, and treatment was administered per Nurse Practitioner #1 order. The area would continue to be monitored for signs of pressure ulcer development. Licensed Practical Nurse #8's progress note dated 10/17/2025 at 12:50 PM documented they noted a new open area on resident's buttocks, the nurse practitioner was made aware a new order to start zinc oxide once daily and follow up with wound care. The physician order dated 10/17/2025 at 12:54 PM documented zinc oxide 20% topical ointment once daily to buttocks. The physician order dated 10/29/2025 at 3:06 PM documented air mattress. A review of Resident #106's electronic medical record did not reveal any wound assessments from 10/16/2025 until 11/05/2025. The nurse practitioner progress notes documented the resident was seen on 10/18/2025 for diarrhea, on 10/23/2025 for follow up/COVID-19 exposure, and on 11/02/2025 for follow up on hyperlipidemia (high cholesterol). At each visit, physical exam was documented, however, there was no documentation of any skin impairment. The Wound Physician consult dated 11/5/2025 documented a Stage 3 pressure ulcer on the right buttock, measuring 1.2 centimeter by 0.7 centimeter by 0.1 centimeter with light serous drainage; and a Stage 3 pressure ulcer on the left buttock, measuring 3.5 centimeters by 3.8 centimeters by 0.1 centimeter with light serous drainage. Recommendations were made to apply Leptospermum honey and bordered gauze once daily and as needed and discontinue zinc oxide. Physician order dated 11/06/2025 documented Leptospermum Honey (wound treatment) and border gauze dressing to be applied to left buttocks and right buttocks. The Wound Physician consult dated 11/12/2025 documented a Stage 3 pressure ulcer on the right buttock, measuring 1.8 centimeters by 3.8 centimeters by 0.1 centimeter with light serous drainage; and a Stage 3 pressure ulcer on the left buttock, measuring 3.0 centimeters by 1.0 centimeter by 0.1 centimeter with light serous drainage. Recommendations were to continue Leptospermum honey and bordered gauze once daily and as needed for right and left buttock. Review of the November 2025 Treatment Administration Record (TAR) documented that Leptospermum Honey with a border gauze dressing was applied daily to left and right buttock from 11/07/2025 to 11/19/2025. Registered Nurse Supervisor #1's progress note dated 11/19/2025 at 2:46 PM, documented the resident's family member saw the resident's wound and requested the resident be sent to the hospital. The nursing progress notes dated 11/12/2025 to 11/19/2025 contained no documented evidence of the wound worsening. There was no documented evidence the care plan was reviewed or revised with resident focused interventions when the resident was identified with an actual pressure ulcer on 10/16/2025 and up to the resident's hospitalization on 11/19/2025. Hospital records documented the resident was admitted on [DATE] for a sacral wound. The hospital wound consult dated 11/20/2025 at 9:48 AM, documented wounds to the bilateral buttocks extending to posterior thighs with mix blanchable (skin that temporarily turns white or lighter when pressed) and non-blanchable erythema with a chronic-appearing dusky hue with scattered partial and full thickness ulcerations to the coccyx and bilateral buttocks. The total affected area measured 33 centimeters by 21 centimeters. The most notable wounds were within close proximity to one another with an intact bridge of skin separating wounds. The sacral/coccyx extending to the left buttocks which presents with a full thickness ulceration measuring 7.1 centimeters by 9.3 centimeters by 0.5 centimeter deep. The wound bed presents with 60% black/tan adhered non-viable (dead) tissue and 40% mix pale pink/white/red moist tissue with sloughing/peeling epithelial tissue. The sacral/coccyx extending to the right buttocks presents with a full thickness ulceration measuring 2.4 centimeters by 1.1 centimeters by 0.3 centimeters deep. The wound bed presents with 80% tan adhered non-viable tissue and 20% scattered pink moist tissue. Hospital discharge instructions dated 11/25/2025 documented to cleanse the sacral/coccyx and bilateral buttocks with one quarter strength Dakin's solution (antiseptic for cleansing wounds), apply of collagenase ointment to the tan/black nonviable tissue, cover with a foam dressing, change daily and as needed for soiling. During an observation on 12/09/2025 at 10:29 AM, Resident #106 was positioned on their right side. An undated gauze dressing, saturated with serosanguinous (mix of blood and serum) drainage was removed. An irregular shaped wound was noted on the left buttocks with two (2) open areas with yellowish gray wound beds. The one closest to the coccyx was approximately the size of a quarter and the one lateral was approximately the size of a dime, surrounding the lateral open area was an abraded area (superficial skin removed) with four (4) pinpoint spots of active bleeding. Licensed Practical Nurse #8 cleansed the wound with Dakin's solution, followed by an application of Santyl skin prep to the surrounding skin and covered with a dry dressing. When interviewed during the dressing change, Licensed Practical Nurse #8 stated it was a facility acquired pressure ulcer, they were not sure how long it was present, and they thought it was getting better. During an interview on 12/09/2025 at 4:00 PM, Licensed Practical Nurse #8 stated when they were notified by a certified nurse aide that a resident had a wound, they would look at the wound, notify the supervisor and provider. When they saw the wound on Resident #106, they reported to Registered Nurse Supervisor #1 that the resident had an open area on their buttocks. Licensed Practical Nurse #8 stated that Registered Nurse Supervisor #1 performed the wound assessment. Licensed Practical Nurse #8 further stated that zinc oxide was ordered at that time. During an interview on 12/09/2025 at 4:20 PM, Registered Nurse Supervisor #1 stated they assessed the resident's wound on 10/16/2025 and documented it as a Stage 2 pressure ulcer. They stated a treatment was ordered at that time, the wound team was notified and would see the resident on the next rounds which would have been 10/22/2025. Registered Nurse Supervisor #1 reviewed the resident's record during the interview and stated they were unable to find any wound assessments prior to 11/05/2025. They stated they were unsure what the turnaround time for a wound consult was and did not know why the resident was not seen earlier. They stated the licensed practical nurse applying the treatment was responsible for wound observations while doing the treatment. They stated the licensed practical nurse would let them know if the wound deteriorated and they would notify the provider. They stated they did not look at the wound after their assessment on 10/16/2025. They stated licensed practical nurse could not assess wounds, that had to be done by a registered nurse, they were unsure how often and they did not find any assessments until 11/05/2025. They stated on their assessment 10/16/2025, they documented the resident had a 5-centimeter diameter Stage 2 pressure ulcer to the sacrum and deep tissue injury to both upper thighs just below the buttocks. They stated the wound physician's consult on 11/05/2025 documented a Stage 3 on the right buttock that measured 1.2 centimeters by 0.7 centimeters by 0.1 centimeters, and a Stage 3 on the left buttock that measured 3.5 centimeters by 3.8 centimeters by 0.1 centimeters. Registered Nurse Supervisor #1 stated it had worsened since their observation on 10/16/2025. The physician's recommendation was Leptospermum Honey to both wounds and a gauze border dressing and to discontinue the zinc oxide. They also stated on 11/19/2025, the resident's family member saw the resident's wounds and asked that they transfer the resident to the hospital. During an interview with the Director of Nursing on 12/9/2025 at 4:35 PM, they stated that facility policy required a resident's wound to be assessed by a registered nurse when identified and the resident would be scheduled for the next wound-care visit. They stated wound rounds were done weekly and the resident would be seen unless the resident was hospitalized or refused assessment. The Director of Nursing reviewed the resident's record during the interview and stated the resident's wound was reported on 10/16/2025 as a Stage 2 pressure ulcer and a progress note was entered by Registered Nurse Supervisor #1. They stated the resident was put on turning and positioning and was getting zinc oxide and a foam dressing to the sacrum that was changed to Leptospermum honey in November. The Director of Nursing stated they were not able to find any wound assessments between 10/16/2025 and the wound physician consult of 11/05/2025. They stated they had not seen the wound and it had progressed to Stage 3. They stated they were unsure what happened, there had been a COVID-19 outbreak, and they might have missed a week for wound care rounds. The Director of Nursing further stated that the resident was sent to the hospital on [DATE] at the request of her their family member due to worsening of the wound. During an interview on 12/10/2025 at 3:57 PM, the Medical Director stated there should not have been such a long delay before the resident was evaluated by the wound-care physician. During an interview on 12/10/2025 at 5:00 PM, the Wound Care Physician stated the resident's wound was discovered on 10/16/2025 and was not evaluated by the wound-care team until 11/05/2025. They stated that according to the Director of Nursing, a COVID-19 outbreak in the building delayed wound-care visits. The Wound Physician stated that the wound could potentially have been resolved had it been evaluated earlier and not deteriorated over the 20-day period. 10 NYCRR 415.12(c)(2)

Based on observation, record review and interviews, conducted during the Recertification and Abbreviated surveys (2622355, 2622747) the facility did not ensure that sufficient staff was available to meet the needs of all residents. Specifically, actual staffing levels were below facility assessment desired levels on eleven of ninety shifts as documented on the daily staffing sheets. Residents remained in bed and did not receive showers as planned (See F677) and were not available for activities (See F679). Interviews with staff, residents and family members reported low staffing and care not being completed. The findings include: A Policy and Procedure titled Staffing last revised 10/25/2025 documented it is the facility policy to provide appropriate staff in the Nursing Department to promote the highest practicable levels of function and care for all residents of the facility. The Facility Assessment last reviewed in August 2025 documented the desired staffing for was 13 certified nurse aides for the 7 AM- 3 PM and 3 PM-11 PM shift, and six (6) certified nurse aides for the 11 PM- 7 AM shift. Desired staffing for nurses was six (6) nurses on 7AM-3PM and 3PM-11PM and 3 nurses on the 11PM-7AM shift. A review of the Daily Staffing Sheets from 11/1/2025-11/30/2025 documented on: - 11/1/2025, two (2) Certified Nurse Aides worked the 11 PM–7 AM shift. - 11/2/2025, six (6) Certified Nurse Aides worked the 3 PM–11 PM shift, and eight (8) worked the 7 AM to 3 PM shift. - 11/8/2025, four (4) Nurses worked the 7 AM–3 PM and 3 PM–11 PM shifts. - 11/10/2025, four (4) Certified Nurse Aides worked the 11 PM–7 AM shift. - 11/15/2025, eight (8) Certified Nurse Aides worked the 3 PM–11 PM shift. - 11/16/2025, eight (8) Certified Nurse Aides worked. the 7 AM–3 PM shift. - 11/26/2025, two (2) Nurses worked the 11 PM–7 AM shift. - 11/28/2025, eight (8) Certified Nurse Aides worked the 3 PM–11 PM shift. - 11/29/2025, eight (8) Certified Nurse Aides worked the 3 PM–11 PM shift. During an interview on 12/03/2025 at 10:44 AM Resident #6 stated they had not had a shower in a few weeks and did not get them twice a week because of bad staffing. They stated staff rush to change residents at night then the nurses and aides hang out at the desk. They stated they needed to be transferred by mechanical lift and that was extra work for the certified nurse aides. During a second interview on 12/04/2025 at 10:31 AM, Resident #6 was in bed and stated they did not get a shower yesterday (Wednesday) and was told they (staff) were too busy. Resident #6 stated no one offered to do it today and it looked like they would be staying in bed again today because of short staffing. During an interview on 12/03/2025 at 12:38 PM Resident #81 stated they sometimes had to wait 30 minutes to two (2) hours for aides to help them on the evening and overnight shift. During an interview on 12/04/2025 at 9:22 AM Certified Nurse Aide #6 stated on the weekends they were short staffed. They stated when they had four (4) certified nurse aides, one needed to supervise the day room, leaving only three (3) certified nurse aides to provide resident care for 40 residents. They stated they frequently worked without getting any breaks. During an interview on 12/04/2025 at 9:59 AM, Resident #4 stated the facility was short staffed, especially on the evening and night shift. During an interview on 12/04/2025 at 1:19 PM, a resident's family member stated on the weekends Resident # 73 had been left in bed all weekend due to short staffing. During an interview on12/05/2025 at 1:33 PM, the Administrator stated had been at the facility for a month and were still adjusting. They had asked about staffing and were unaware that staffing was below the desired level at times. They stated they reviewed staffing daily. They encouraged the staffing coordinator or nursing supervisor to reach out to staff. During an interview on 12/05/2025 at 1:36 PM the Human Resource Director stated they were aware every other weekend was short staffed. They reviewed the shifts identified as being below the desired staffing levels and stated the daily staffing sheets were accurate and they were below the desired staffing levels. During an interview on 12/08/2025 at 10:35 AM, Certified Nurse Aide #7 stated staffing could be better, and Fridays were the worst days for staffing. The fewer certified nurse aides working means they had more residents on their assignment. They stated had to cover the Bistro (dining room on the lower level) and it took them away from the residents on the floor and resulted the residents on the floor waiting for assistance. During an interview on 12/08/2025 at 10:55 AM, Registered Nurse Supervisor #1 stated some days were staffed better than others and weekends could be short. They stated they worked as a team and thought all the care got done but sometimes a resident's preference for shower times or days did not get met. [10 NYCRR 415.13(a)(1) (i-iii)]

Based on observations, interviews, and record reviews during the recertification and abbreviated (2670229) surveys from 12/03/2025-12/10/2025, the facility did not ensure the resident's right to a safe, clean, and homelike environment. Specifically, Unit 2 had a strong urine smell, room [ROOM NUMBER] had a very strong urine smell that emanated into the hallway and surrounding areas, Unit 2 floors were visibly soiled or stained (both the hallways and the dining room), the Unit 2 shower room had used linens left on the shower chairs and bagged linens out of receptacles, and there was garbage that was observed on the floor in the shower room, dining room, and unit hallways. The Unit 1 dining room cabinet drawer had garbage in it. room [ROOM NUMBER] was cluttered with an unused oxygen concentrator. room [ROOM NUMBER] had boxes of supplies stored on the floor. The findings include: The facility policy provided was for terminal cleaning only, not routine cleaning. The blank facility environmental rounding log used, and provided for review, included the task of inspection to ensure that rooms are free of odors and that floors are clean and free of debris. During an observation of Unit 2 on 12/03/2025 starting at 9:22 AM, the unit floors were visibly soiled in the hallways and dining room. District 1 floors also had black stains/skids. There was garbage tucked in the handrail outside of room [ROOM NUMBER]. During an observation on 12/03/2025 at 10:35 AM of the Unit 1 dining room a cabinet drawer contained empty food wrappers. During an interview on 12/03/2025 at 10:53 AM the Maintenance Director stated they provide supervision to the housekeepers. The Maintenance Director stated they were not aware the cabinets were being used in the Unit 1 dining room. It is the responsibility of dietary staff to clean the refrigerator, and the housekeepers would clean the cabinets. During an observation on 12/03/2025 at 11:24 AM, the floor in the Unit 2 dining area was soiled with visible dirt and dried substances and plastic packaging/wrappers and a plastic cup top were on the floor. During an observation on 12/03/2025 at 12:09 PM, a urine odor was present upon entering the dining room on Unit 2, diagonally from room [ROOM NUMBER]. The residents were preparing for lunch. During an observation and interview on 12/03/2025 at 12:50 PM, room [ROOM NUMBER] contained an oxygen concentrator that Resident #4 stated was no longer in use and did not need to be kept in the room. During an observation on 12/04/2025 at 1:26 PM, room [ROOM NUMBER] was noted to have 2 cardboard boxes containing supplies on the floor. One on either side of the head of the bed. During an observation on 12/05/2025 at 11:27 AM on Unit 2, a urine odor was present in the hallway down District 3, and a urine odor was present in the hallway outside of room [ROOM NUMBER]. During an observation on 12/09/2025 at 8:29 AM on Unit 2, a urine odor was present in the hallway outside of room [ROOM NUMBER]. During an observation on 12/09/2025 at 8:36AM in the Unit 2 shower room, old towels were observed on a shower chair, an unused brief was sitting on a railing, and a bag of soiled linen was outside of the soiled receptacle in the room. During an interview on 12/09/2025 at 9:47 AM, Housekeeping Aide #19 stated that there was usually a housekeeping aide on each district on Unit 2. They were expected to clean their district daily and assist with other districts of the unit as needed. They were responsible to clean all the rooms and hallway floors on their district; mop, wipe everything down, dispose of any garbage. They thought the floors were stripped a couple months ago. Shared spaces on the unit were cleaned daily, dining room after meals, the shower room once daily, and the nurses station daily. They deep clean a resident room when there was a discharge, or if a resident was on precautions, but there was no schedule to perform deep cleaning in the rooms on a regular basis. There were no special instructions for any rooms to receive additional cleaning or attention on a regular basis, including room [ROOM NUMBER]. However, room [ROOM NUMBER] should be one of the first rooms tended to daily. During an interview on 2/09/2025 at 2:10 PM, the Administrator stated there was currently no housekeeping supervisor, but the facility had one until a few days ago. Housekeeping staff should have been cleaning the rooms, emptying garbage, and cleaning the floors daily. They were not aware of any rooms that received special attention or additional cleaning daily including room [ROOM NUMBER]. They personally checked the facility once or twice daily but did not perform rounds with the housekeeping supervisor on a regular basis. They stated the shower rooms should not have had used towels or soiled items left in the room. The resident rooms should have been cleaned daily, and odors should have been addressed if noticed on the unit. They stated the floors on the unit were cleaned daily and the dining room floors were cleaned after every meal. The floors had not been deep cleaned recently but should be done soon. The Administrator stated Certified Nurse Aides assist in clearing clutter from rooms. Typically, resident supplies were not kept in resident's rooms. If a resident was not using equipment like an oxygen concentrator, then it should have been removed from the room. 10 NYCRR 415.5 (h)(1)

Based on observation and interview conducted during the recertification survey from 12/03/2025 to 12/10/2025, the facility did not ensure food was distributed and served in accordance with professional standards for food service safety. Specifically, unlabeled and undated food items were observed in the kitchen and unit pantry, and expired food was observed in kitchen storage pantry and unit pantry.The findings include:The policy titled Food Storage dated 12/11/2025 documented the policy establishes comprehensive guidelines for the proper storage of food items in our facility to ensure food safety, prevent foodborne illness, maintain nutritional quality, and comply with federal and state regulations. We are committed to providing safe, wholesome meals to our residents while minimizing food waste and maintaining cost-effective operations.During the initial tour of the kitchen conducted on 12/03/2025 at 9:25 AM, in the walk-in refrigerator, a jar of chopped garlic and a container of ricotta cheese were open and undated, and a defrosted turkey breast wrapped in plastic and dated 11/26/2025 was observed. In the walk-in freezer an open undated plastic bag of perogies was observed. In the dry storage area, a large unopened container of salad dressing was observed with an expiration date of 08/25/2025. During an observation on 12/03/2025 at 10:30 AM, the first-floor refrigerator in the day room was observed with two (2) open undated bottles of ranch salad dressing and 2 undated bottles of French salad dressing. The first-floor pantry was observed with expired cookies. During an observation of the Unit 1 pantry on 12/03/2025 at 10:45AM, blueberry yogurt dated 11/3/2025 and vanilla yogurt dated 11/13/2025 was observed. An unlabeled open vanilla pudding with mold and a small [NAME] jar, unlabeled/undated, with an unknown substance were also observed.During an interview on 12/03/2025 at 10:53 AM, the Maintenance Director stated dietary was responsible for cleaning the refrigerator and restock snacks. They were unaware the cabinets in the day room were being used to store snacks.During an observation on 12/03/2025 at 11:00AM of the second-floor pantry, there was open and undated beverages including honey thick lemon water, nectar thick orange juice and a small milk container. During an interview on 12/03/2025 at 12:30 PM, Certified Nurse Aide #14 stated dietary was responsible for cleaning out the refrigerator, nursing staff should have labeled and dated any food they put in the refrigerator.During an interview on12/08/2025 at 12:13 PM the Director of Nursing stated the dietary department was responsible to ensure the pantry refrigerators had no undated or expired foods. The nurses should have been dating the juices and thickened water when they open them for medication pass. They were unsure who was responsible for discarding the liquids for medication pass if they were past the 3 days or undated. During an interview on 12/08/2025 at 12:23 PM the Food Service Director stated the dietary staff were responsible to ensure all food items were labeled with date after opened. They did check to ensure that everything was dated, and any expired food was discarded and might have missed some items. The dietary staff did not stock the cabinets on the first-floor day room, and they were not sure who did. The dietary staff was responsible to check the pantry refrigerators to ensure all food was labeled and discarded if it was more than 3 days old. They were unaware how the expired cookies ended up in the cabinets in the day room. They further stated they or their staff were responsible to ensure all food in the kitchen was properly labeled and discarded after 3 days. They also stated any open food in the freezer should have had a date on it.During an interview on 12/09/2025 at 1:33 PM, the Administrator stated the Food Service Director was responsible to ensure all food was labeled and dated. 10 NYCRR 415.14(h)

Based on observation, record review and interview conducted during the Recertification and Abbreviated surveys( 2622747) from 12/3/2025 to 12/10/2025, the facility did not ensure all residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, personal and oral hygiene for three (3) of six (6) (Residents #6 #76, #105) residents reviewed for Activities of Daily Living. Specifically, 1) Resident #6 was not provided showers as scheduled. 2) Resident #105 was observed on multiple days in bed into the afternoon and missed social activities and was not provided showers as scheduled. 3) Resident #76 was observed on multiple soiled in urine while in wheelchair in hallway.Findings include: The facility policy for Bathing dated 5/30/22 documented the facility will ensure proper personal hygiene of all residents. Non bedfast residents are showered or bathed in a tub twice per week and more frequently if needed. Unit Managers will maintain a bathing list, and the type of bath is recorded in the Resident Care Record. 1) Resident #6 had diagnoses which included anxiety, schizoaffective disorder, and obesity. The quarterly Minimum Data Set assessment tool dated 9/26/2025 documented the resident had intact cognition, was dependent on staff for bed to chair transfer with a mechanical lift and was dependent on staff for showering and dressing. The resident was incontinent of bladder and bowel. The facility shower schedule located on the second floor documented Resident#6 was scheduled for a shower on Wednesdays and Saturdays during the evening shift. The resident's care plan for Activities of Daily Living dated 8/22/23 documented interventions which included weekly shower per schedule and as needed. The Resident Certified Nurse Aide documentation for showers from 10/1/2025 through 12/10/2025 documented there were 20 opportunities for a shower, but the resident only received five (5) showers (10/01/2025, 10/08/2025, 11/05/2025, 11/12/2025 and 11/29/2025). Two opportunities were not documented and there were two refusals. The remaining 11 opportunities were documented as bed baths. The nurse's notes were reviewed from 10/1/2025 to 12/10/2025 and there was no documentation of refusals. During an interview on 12/03/2025 at 10:44 AM, Resident #6 was in bed and stated they preferred to take showers but did not get them consistently because they needed to be transferred by mechanical lift, and it was extra work for the Certified Nurse Aides. They stated they were looking forward to a shower because they liked to get their hair washed. During a second interview on 12/09/2025 at 10:19 AM, Resident #6 stated they had a shower two weeks ago and only got bed baths in between their showers, but they would like to get showers twice a week. They stated they went to the beauty parlor today for hair washing and they were told their hair was so dirty it had to be washed twice. They stated they felt ignored when they were in bed all the time and not getting showered. During an interview on 12/09/2025 at 10:27 AM, Certified Nurse Aide #16 stated Resident #6 got showers on Wednesday and Saturday on the 3-11 shift. If staffing was not good, it would be hard to give the shower because Resident #6 required two (2) staff to utilize a mechanical lift for transfers. They stated it was important to get the resident out of bed to participate in activities including showers because it prevented skin breakdown and promoted socialization. During an interview on 12/09/2025 at 11:10 AM, Licensed Practical Nurse #25 stated Resident #6 should get a shower two times a week, on Saturdays and Wednesdays on the evening shift. They stated they did not know why showers were not being performed as scheduled. If a resident refused a shower the Certified Nurse Aides knew they needed to approach the resident again later and try to shower the resident. They stated Resident #6 liked to get showers and looked forward to it. They stated Resident #6 really needed showers due to incontinence and had often told them it felt good and made them feel better. 2) Resident #105 had diagnoses including Depression, Alzheimer's disease and seizures. The quarterly Minimum Data Set assessment tool dated 10/27/2025 documented the resident had severe cognitive impairment and required substantial assistance for bathing. The Activities of Daily Living Care Plan dated 06/03/2022 documented the resident needed extensive assistance of staff for bathing, personal hygiene and eating. The Psychosocial care plan initiated 11/15/2025 documented the resident will maintain a positive psychosocial status by socializing with peers daily over next review. Interventions included to encourage resident to participate in plan of care and daily routine. The Activities care plan dated 7/24/2025 documented the goal was to maintain a level of socialization by joining two to three small group sessions each week. Interventions included to remind and invite the resident to activities, provide support for social interactions and place next to select peers. The facility shower schedule located on the second floor documented Resident#105 was scheduled for a shower on Mondays and Thursdays during the 7-3 shift. A nurse's note dated 10/13/2025 documented the resident refused their shower and a bed bath was performed. There were no other documentations of refusals of showers. The Certified Nurse Aide documentation for showers was reviewed from 10/1/2025 through12/10/2025 and documented there was 19 opportunities for a shower, and the resident received three (12/1/2025, 11/27/2025, 11/24/2025). Six opportunities were not documented and there was one documented refusal. The remaining 10 opportunities were documented as bed baths. The December Activities Calendar documented that on 12/04/2025 a Jingle and Mingle activity was scheduled at 10:00 AM and on 12/05/2025 at 10:00 AM a seasonal art activity was scheduled and at 1:30 PM Eggnog and a movie was scheduled. During an observation on 12/04/2025 at 9:59 AM, the resident was in bed being fed by staff. During an observation on 12/04/2025 at 12:13 PM, the resident was in bed. During an observation on 12/05/2025 at 12:14 PM, the resident was in bed sleeping wearing a hospital gown. During an interview on 12/05/2025 at 12:43 PM, Certified Nurse Aide #6 stated they had 13 residents on their assignment and one shower to give. They stated they decided for themselves that today was a stay in bed day for Resident #105. They stated one staff called out and they could only do showers when staffing was better. They stated the nurse lets them know if residents need to be gotten up for dialysis or an appointment. Certified Nurse Aide #6 stated they made the determinations as to what residents they would get out of bed and did not discuss it with the nurse. They stated today they would change the briefs of the residents who were in bed and those residents would be staying in bed, as it was a hectic morning. They stated that this afternoon would be a more relaxed day. During an observation on 12/05/2025 at 1:51 PM, the resident was in bed wearing a hospital gown, sleeping. A revisit was made at 3:22 PM and the resident was still in bed wearing a hospital gown. During an interview on 12/05/2025 at 3:24 PM, Licensed Practical Nurse #25 stated they worked with two Certified Nurse Aides today and getting all the residents up who should get up was not manageable because the second district (28 residents/district) had more dependent residents and residents with behaviors. The residents had a routine and Certified Nurse Aides had to go by the resident schedules and the residents' schedules could be difficult to manage. They stated they felt bad for the Certified Nurse Aides because two (2) in a district was such a challenge. They did not help the Certified Nurse Aides because they were busy with the medication cart. They stated Resident #105 should have been out of bed as there was no stimulation in their room, and no interaction with others or socialization. They stated the Activities Department had an eggnog and cookies social and Resident #105 would have loved that activity. They stated they tell the Certified Nurse Aides to do their best and they leave the rest up to them. They stated were responsible for supervising the Certified Nurse Aides and ensuring all residents received care, but they were too busy administering medications. During an interview on 12/08/2025 at 1:45PM, Registered Nurse Supervisor #1 stated they were responsible for making sure the residents received good care. They stated they did rounds when they arrived in the morning and addressed problems. They stated Licensed Practical Nurses were responsible for making sure the Certified Nurse Aides were doing what they were supposed to be doing and if the Licensed Practical Nurse found problems, they would report to them. During a follow up interview on 12/09/2025 at 11:39 AM, Licensed Practical Nurse #25 stated when the Certified Nurse Aides see bed bath and shower, they think they can choose, but they should know better than that. The Certified Nurse Aides know what is expected and should be giving the showers according to the schedule. If they cannot, then they should let the nurses know. During a follow up interview on 12/09/2025 at 11:58 AM, the Registered Nurse Supervisor #1 stated showers were important for residents, and it was the Licensed Practical Nurse's job to make sure they were done by the Certified Nurse Aides. If they were not getting done, they needed to ask why. During an interview on 12/10/2025 at 11:34 AM, the Director of Nursing stated the Certified Nurse Aides received their Dementia training and the importance of showers on orientation. They stated staffing was not a good reason to not give showers and it needed to be done. They stated they were working on improving the supervisory staff and recently hire another supervisor. They stated they had good Licensed Practical Nurses, and they should be taking control. They stated the communication needed to improve between the Certified Nurse Aides and the Licensed Practical Nurses. 3) Resident #76 had diagnoses that included, but not limited to, heart failure, depression, and benign prostatic hyperplasia. The Annual Minimum Data Set, dated [DATE] documented Resident #76 had intact cognition, no behaviors including rejection of care, was independent for toileting hygiene, dressing, footwear, and shower. They required maximal assistance for personal hygiene. They were not on a toileting program, occasionally incontinent urine, frequently incontinent of bowel, and medications included an antidepressant. The current Resident Nursing Instructions for Resident #76 documented no behaviors, showers preferred at start of shift, continent of bowel and bladder with occasional incontinence. The active Activities of Daily Living care plan effective 04/14/2013 documented the resident has self-care deficit including toileting and personal hygiene related to medical conditions. The goal was that resident was dependent for cares and would be maintained at optimal hygienic cleanliness. Interventions included supervision and setup or assist as requested for toileting and extensive assist of one staff for personal hygiene. The active Refusals care plan effective 1/13/2017 documented refusals to change clothing daily/showers, wound care, dressing change, podiatry visits, and fingersticks. Interventions included providing education on the importance of maintaining optimal hygiene. The care plan did not document that resident refused incontinence care, brief use, or assistance with toileting. The active Urinary Incontinence care plan effective 10/16/2025 documented resident has urinary incontinence with urgency and frequency. The goals documented resident will be free of skin breakdown secondary to incontinence and will have incontinence care rendered. Interventions included monitor for redness or skin breakdown during toileting/diaper change every 2 - 4 hours. Maintain toileting schedule with no specified scheduled. Review of the medical record found documented evidence from 10/01-12/10/2025, of any behavior including refusals of care; any education provided to resident on importance of regular incontinence care or hygiene practice; or any social work support related to refusals of care and hygiene practice. The Psychiatric Nurse Practitioner progress note dated 10/17/2025 documented continued self-care deficits noted. Escitalopram order was in place for the treatment of depression. No recommendations for changes in medication. Nursing would continue to monitor and document for signs/symptoms of anxiety, depression, and insomnia. The Psychiatric Nurse Practitioner progress note did not document any other interventions were recommended. During an observation on 12/03/2025 at 10:34 AM, Resident #76 was sitting up in a wheelchair in their room with a towel covering their lap, pants appeared wet, and a strong urine smell was present in the room. During an observation on 12/05/2025 at 3:22 PM Resident #76 was sitting at the nursing station on the phone, stained towel covering lap, pants visibly wet/soiled down both legs, and smell of urine emanating from them. During an observation on 12/08/2025 at 12:38 PM, Resident #76 was in their room, their bedding and blanket was soiled. The sheets had a dry yellow fluid stain, the fitted sheet had a large brown stain on the side of the sheet, there was a dry round stain on the bed pad, and strong urine smell in and around their room. At 3:48 PM Resident #76's room was observed with sheets, bed pad, blankets all soiled as they were at 12:38PM and there was a very strong odor of urine in and around the room. Resident #76's had a soiled towel in their lap. During an interview on 12/08/2025 at 3:50 PM, Certified Nurse Aide #17 accompanied this surveyor into Resident #76's room. They stated they just started their shift at 3PM but saw that the bedding needed to be changed. They stated Resident #76 had not refused their assistance with linens being changed or incontinence care. During an interview on 12/09/2025 at 9:30 AM, Certified Nurse Aide #16 stated Resident #76 allowed the room to be cleaned, including changing the bed sheets/linens, and refused care at times. They were not on a toileting program. They always kept a towel in their lap and allowed them to provide a clean one but did not always allow assistance with changing clothing. During an interview on 12/10/2025 at 9:35 AM, the Social Worker stated that Resident #76 was followed by another Social Worker who no longer worked at the facility. They stated they were not very familiar with Resident #76 and had not met with them. They were aware that Resident #76 had a history of incontinence and refused care at times. During an interview on 12/10/2025 at 11:11 AM, Registered Nurse Supervisor #1 stated Resident #76 was incontinent and did have a refusal care plan for incontinence care. They were aware that they could be soiled at times and that there was a strong urine smell in and around their room on the unit affecting themself and other residents. They stated it could create dignity, skin, and general hygiene concerns. They spoke with the resident once regarding the effects on their skin, and they did not know that anyone specific was working with Resident #76 regarding their refusals on a regular basis. Resident #76 was followed by the Psychiatric Nurse Practitioner who had discussed the issue with the resident in the past. Registered Nurse Supervisor #1 was unable to provide documented evidence of recent discussion or new interventions to address it. 10NYCRR 415.12(a)(3)

Based on observations, interviews, and record review conducted during the Recertification and Abbreviated Surveys (2610401) from 12/3/2025 to 12/10/2025, the facility did not ensure that residents were free from significant medication errors one (1) of three (3) residents (Resident #98) reviewed for medications. Specifically, Resident #98 had a physician order for Lamictal (anti-seizure medication), five (5) doses were missed, the physician was not notified, and Resident #98 experienced a breakthrough seizure. The finding include:The policy and Procedure titled Medication Administration last revised 9/20/2024 documented all medication administration issues are identified and reported to the unit manager, charge nurse, or supervisor before the end of the shift. Medication-related and operational concerns including but not limited to labeling errors, unavailable medications, shortages, low inventory, discrepancies in controlled substance counts. These issues are addressed and corrected in accordance with applicable organizational policies and procedures.Resident #98 had diagnoses including epilepsy (brain disorder that causes repeated seizures), dementia, and headaches.The admission Minimum Data Set (MDS) (a resident assessment tool) dated 9/5/2025 documented Resident #98 had severe cognitive impairment, a seizure disorder, and was receiving an anticonvulsant medication.The comprehensive care plan titled Seizure Disorder, dated 9/2/2025, documented that the resident had a diagnosis of seizure disorder and directed staff to monitor drug treatment and adjust dosage as needed to minimize adverse reactions or interactions with other medications.The physician's order dated 9/2/2025 documented Lamictal 100 milligrams, 1 tablet by mouth two (2) times a day.The September 2025 Medication Administration Record (MAR) documented on 9/3/2025 Lamictal was signed as administered at 8 AM and 5 PM by Licensed Practical Nurse #12. On 9/4/2025 Lamictal was signed as held per physician order at 8 AM by Licensed Practical Nurse #8, and signed as given at 5 PM by Licensed Practical Nurse #11. On 9/5/2025 Lamictal was signed as held per physician order at 8 AM and 5 PM by Licensed Practical Nurse #8.Registered Nurse Supervisor #1's progress note dated 9/5/2025 at 5:50PM documented they were called to the resident's room by a family member who reported Resident#98 had experienced a seizure. The nurse practitioner was notified, and the resident was transferred to the hospital.Discharge Summary from the hospital dated 9/6/2025 documented the clinical impression was seizure activity. Laboratory results indicated a phenytoin level below the therapeutic range. Discharge instructions included follow-up with neurology and the primary care physician.The nurse practitioner's note dated 09/07/2025 documented the resident was seen for a follow-up visit status post emergency room visit for seizure. The facility 5-day investigation, submitted to the New York State Department of Health completed 09/09/2025, documented Lamictal was not given by Licensed Practical Nurse #12 (responsible for doses on 09/03/2025). The investigation did not address the doses held per physician order for a total of 5 missed doses.During an interview with the resident's family member 12/5/2025 at 11:24 AM, they stated that in early September Resident # 98 had a seizure slid out of bed. They rang the call bell, and staff responded and transferred to the hospital. During an interview on 12/8/2025 at 1:25 PM, Licensed Practical Nurse #12 stated they signed for giving Lamictal on the Medication Administration Record, however it was not given on 09/03/2025 at 8 AM and 5 PM because it was not available. They stated they called the pharmacy but did not notify the physician or the supervisor.During an interview on 12/8/2025 at 1:37 PM, Licensed Practical Nurse #11 stated they gave Resident #98 the Lamictal on 9/4/2025 at 5:00 PM, the medication was delivered from the pharmacy.During an interview on 12/8/2025 at 2:00 PM, Licensed Practical Nurse #8 stated the Lamictal was not given on 9/4/2025 at 8:00 AM and 9/5/2025 at 8:00 AM and 5:00 PM. They stated the medication was not available, they called the pharmacy, but they did not notify the physician or the nursing supervisor.During an interview with the pharmacist on 12/8/2025 at 8:50 AM, they stated that Lamictal was delivered on 9/3/2025 at 12:35 AM. They stated only 4 pills were delivered because there were questions regarding the interaction with the phenytoin (another anti-seizure medication). The pharmacist stated the order was received after 6 PM on the previous day, and the last scheduled delivery was at 10 PM; therefore, the medication was included in the next delivery at 12:35 AM.During an interview on 12/8/2025 at 3:15 PM, Registered Nurse Supervisor #1 stated they spoke with the pharmacist and was told the medication was not sent because they had questions regarding interaction with phenytoin. During an interview on 12/9/2025 at 11:44 AM, the Medical Director stated the resident experienced a breakthrough seizure. The Medical Director stated they did not think the missed doses caused the seizure. 10NYCRR415.12(M)(2)

Based on observations record review and interviews on recertification and abbreviated surveys (2670229) from 12/3/25 to 12/11/25 the facility did not ensure drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. Specifically, 37 nurse signatures of 624 opportunities over 104 days were missing from the change of shift narcotic count log from 8/5/25 to 11/17/25.The facility policy for Narcotic Counting and Control dated 3/8/24 documented a complete count of all narcotics present on a nursing assignment, shall take place at any change of personnel which results in exchange of keys and change of responsibility for narcotic supply. This may occur at traditional shift change, or a mid-shift personnel change.The narcotic sheets are to be counted and logged with every count as part of the correct and accurate narcotic count procedure. Signature indicates agreement with accuracy of the sheet count as well as medications. Upon completion of the correct narcotic count, the keys are transferred to the oncoming nurse. The shift change signature sheet is signed by both nurses only upon completion of the correct count. All nurses are reminded that signing of the shift change signature sheet indicates acceptance of responsibility for the narcotic supply that is managed by those keys. Narcotic count sheets were reviewed from 08/05/25 to 11/17/25. There were 37 missing signatures of 104 days reviewed indicating the narcotic count was not completed before acquiring the narcotic keys. There were no medication count discrepancies. During an observation on the second floor on12/05/2025 at 3:12 PM of the change of shift narcotic count between day Licensed Practical Nurse #25 and evening Registered Nurse #29 the count was completed including a count of how many blister packs. The controlled medications were counted and the oncoming an off going nurses signed the sheets. During an interview on 12/09/2025 at 12:57 PM Licensed Practical Nurse#18 stated the narcotic count was performed between the oncoming and off going nurses to ensure the controlled drugs count was correct. They stated they could not leave their shift until the count was completed and did not know why there were blanks and no signatures. During an interview on 12/4/25 at 10:04 AM the Director of Nursing stated they were informed there were missing signatures on the Narcotic count sheets. They went back and did a recount of the narcotics and found the count numbers were correct, but the signatures were not there to prove reconciliation took place. They did a whole house nurse education to stress the importance to ensure the count was completed and signed for. The unit nurses know they are supposed to perform an accurate narcotic count and document their signatures at the end of the count at the passing of the narcotic keys to the next shift. They stated the nurses left signature spots blank because they either forgot or they were rushing and busy or had to get back to the floor. Regardless of what the nurses said it has to be done, and a signature proves the count and exchange of keys was done. The Director of Nursing provided documentation of in-service education and training which was completed in November 2025 for all nurses regarding the Narcotic Count at the change of shift in reference to these discrepancies. It was determined the deficient practice was corrected and is cited as past non-compliance. 415.18(b)(1)(2)(3)

Based on observation, interview and record review during recertification and abbreviated survey (2637641) from 12/3/25 to 12/10/25, the facility did not ensure the residents rights to be free from physical abuse one (1) of four (4) residents reviewed for abuse (Resident #110). Specifically, Resident #110 was lying in bed when Resident #7, who had a history of wandering into other residents' rooms, wandered into Resident #110's room, and proceeded to hit Resident #110 with a Reacher (an assistive device), scratched their upper right arm causing their Dexcom sensor (a glucose monitoring system) to come off, leaving red scratch marks on their arm, and also threatened them with scissors. The findings include: The facility Policy and Procedure titled Abuse Identification, last modified 05/22/2025, documented all staff are trained to identify physical abuse, psychological/ emotional abuse, sexual abuse, financial/ material abuse, mistreatment, neglect, and self-neglect. Physical Abuse shall mean inappropriate physical contact with a resident of the facility, while such resident is under the supervision of the facility, which harms or is likely to harm the resident. Inappropriate physical contact includes, but is not limited to, striking, pinching, kicking, shoving and bumping. It also includes controlling behavior through corporal punishment. - Resident #110 was admitted to the facility with diagnoses including hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness) following cerebral infarction (stroke), diabetes, and major depressive disorder. The Minimum Data Set (MDS- an assessment tool) dated 07/24/2025, documented Resident #110 had intact cognition. Resident #110 required substantial to maximal assist for toileting, and showering; and needed partial to moderate assist for bed mobility and transfer.The At Risk for Abuse Care Plan dated 9/16/2025, documented Resident #110 was at risk for abuse. The goal was the resident would remain free of abuse. Interventions included to refer to psychiatry as needed, and social worker evaluation upon admission, quarterly, yearly, and as needed. - Resident #7 was admitted to the facility with diagnoses including dementia, schizophrenia and history of falling. The Minimum Data Set (MDS- an assessment tool) dated 08/01/2025, documented Resident #7 had severely impaired cognition. Resident#7 required substantial to maximal assist for bathing, bed mobility and transfer and was dependent for toileting and used a wheelchair for mobility. There were no behavior symptoms or wandering noted on this assessmentThe care plan for Behavior dated 09/05/2023 documented Resident #7's behaviors included wandering and resistance to care.The care plan for Wandering/Elopement effective 2/14/2024 documented the goal was the resident would remain in appropriate areas. Interventions included Resident #7 would be monitored while up in their wheelchair.- The Incident Report dated 10/7/25 documented Resident#7 was observed in Resident #110's room by certified nurse aides and was resistant to leaving room. Resident #110 stated that Resident#7 hit them with their grabber tool, threw belongings and attempted to stab them with scissors. Resident#7 was removed from the room and put back to bed. The investigative summary dated 10/7/25 documented the following to be the route cause analysis: Resident #7 had severe cognitive deficit became confused and thought Resident #110 was in their room. Resident #7 behavioral reaction was due to their dementia diagnosis exhibiting behaviors associated confusion and accusations. The documented corrective action was to immediately separate residents, Resident #7 room was changed and both residents to be seen by social work. The conclusion was documented as Resident #7 did not recall the incident, both residents to be seen by social work and psych and Resident #7 will be on safety checks. Review of Resident #7's care plan had no documented evidence interventions were put in place, after the 10/07/2025 incident, to protect other residents from Resident #7's wandering and abusive behavior.Observation of the facility video camera footage dated 10/10/2025, revealed at 6:20 AM the Resident #110 was seen going down the hall of Resident #110's room and at 6:26 AM a staff member took Resident #7 back to the Day Room. At 6:29 AM Resident #7 was visible in the hallway again and at 6:31 AM they had gone past Resident #110's room and were at the end of the hall at the exit door. At 6:32 AM, Resident #7 went through the door undetected.During an interview on 12/10/2025 at 10:31 AM, Registered Nurse #22 stated they were made aware the Resident #7 had an altercation with Resident #110 on 10/7/25. Registered Nurse #22 stated they were not informed of any additional interventions implemented after the incident besides changing the resident's room. They further stated no new behavior monitoring interventions were put in place at that time. During an interview on 12/10/2025 at 11:23 AM, the Former Director of Social Work stated Resident #7 was moved after the incident with Resident #110. Resident #7 wandered and was exit seeking and was moved to the hallway that put them closest to the nursing station, which would allow nursing staff to visually see them when they crossed in front of the nursing station. The former Director of Social Work stated if specific monitoring was put in place, it would be put in writing and to their knowledge it was not.During an interview on 12/10/2025 at 1:16 PM, Certified Nurse Aide #23 stated when they arrived at the room, Resident #7 was holding on to door jamb and refusing to leave the room. They stated Resident #7 could get agitated at times and refused care at times. Certified Nurse Aide #23 stated Resident #7 would yell at the staff and say they were going to bite them. Certified Nurse Aide #23 stated they were unaware of interventions for monitoring Resident #7 and stated they had to keep an eye on the resident. During an interview on 12/10/2025 at 1:26 PM, Certified Nurse Aide #24 stated they were assigned to Resident #7 and heard the resident yelling. They went down the hall and when they got to the room, Resident #7 was trying to grab Resident #110's stuff and they pulled Resident #7 out of the room in their wheelchair. Certified Nurse Aide #24 stated they were informed that Resident #7's room was changed to another hallway on the unit. Certified Nurse Aide #24 stated they were not aware of any specific monitoring interventions put in place for the either of the residents after the altercation. During an interview on 12/10/2025 at 1:42 PM, Registered Nurse Supervisor #1stated they were not at the facility during the incident but spoke to Resident #110 after the incident and also to the State police. Resident #110 had scratches to upper right arm and the Dexcom sensor was dangling so it was removed and provided another one on the same day. Registered Nurse Supervisor #1 stated Resident #110 informed them that Resident#7 was always wandering into their room. Registered Nurse Supervisor #1 stated they were not aware of this prior to the incident. Registered Nurse Supervisor #1 stated they usually only updated care plans for incidents specifically for falls.During an interview on 12/10/2025 at 2:26 PM, the Director of Nursing stated they moved Resident #7 room was changed to another district further away on the same unit near the nursing station. Director of Nursing stated the other intervention was for resident to be seen by psychiatry. 415.4(b)

Based on observation, record review and interviews during a recertification survey conducted from 12/03/2025 to 12/10/2025, the facility did not ensure adequate nutrition care and services for two (2) of eight (8) residents reviewed for Nutrition (Resident #1 and Resident #3). Specifically, 1) Resident #1 had a 12% weight loss over five (5) months; a sacral wound with no supplemental protein to promote wound healing, and their meal intake was not consistently monitored. 2) Resident #3 had a 9.8% weight loss in six (6) weeks; they consumed less than 50% of over half of all meals served during the survey, and there was a delay in providing a dietary supplement for weight loss.Findings include: The policy titled Nutrition Assessment and Monitoring reviewed 09/04/2025 documented Nursing staff collect and report intake data daily. Care plans are updated immediately to reflect weight changes.The policy titled Unintended Weight Loss reviewed 09/26/2023 documented procedures to address poor intake and or unintentional weight loss: obtaining food preferences, additions of snacks and/or supplements, three-day food intake study, change in diet and diet consistency. 1) Resident #1 had diagnoses including sepsis, prostate cancer, and diabetes. The 10/31/2025 Minimum Data Set assessment documented the resident had moderately impaired cognition and required supervision with eating and had a Stage 3 pressure ulcer. The 06/24/2025 care plan titled Alteration in Nutrition and Hydration did not document any food preferences. The care plan titled Nutrition Status did not have any interventions.The 10/28/2025 Medical/Psychiatry note documented a voice mail was left for the next of kin to discuss Resident #1's weight loss and poor appetite. The resident's weight was 97 pounds, down from 101pounds. The 11/26/2025 Physician order documented a no concentrated sweets diet, normal consistency, and thin liquids with special instructions of no added salt, renal diet. Resident #1's weight records documented on 06/13/2025 they weighed 106.6 pounds, on 07/02/2025 they weighed 104.6 pounds, on 08/01/2025 they weighed 101.2 pounds, on 09/12/2025 they weighed 96 pounds, on 10/15/2025 they weighed 92.8 pounds, on 11/23/2025 they weighed 93.8 pounds. The dietary readmission (hospitalized from [DATE]-[DATE]) note dated 12/02/2025 documented Resident #1 had a diet order of no concentrated sweets, no added salt diet with fair to good appetite, ordered take-out food, weight pending, and 11/25/2025 albumin 2.1 (Albumin is protein in the blood to measure nutrition status with a normal range of 3.4-5.4 grams/dL). The plan was to monitor for weight and follow up as needed.During the survey period from 12/03/2025 to 12/10/2025, the Certified Nurse Aide documentation record for eating had 13 out of 24 meals left blank (the resident's intake was not documented). During an observation and interview on 12/04/2025 at 1:55 PM, Resident #1 was in their bed after lunch and stated they did not eat the food, they ordered take out because they did not like the food at the facility. During an interview on 12/08/2025 at 11:01 AM, the Registered Dietitian reported there were no documented food preferences in meal tracker for Resident #1. They were a picky eater and ordered take out of what they preferred. During an interview on 12/09/2025 at 1:24 PM, the Registered Dietitian stated if a resident's wound was not healing, they would add a protein supplement. The wound team sends a weekly report that can be reviewed for interventions and the nutrition care plan would reflect any new additions.During an interview on 12/10/2025 at 10:22 AM Licensed Practical Nurse #9 stated Resident #1 did not like the taste of food the facility provides but would eat it at times. Resident #1 had been offered supplements in the past but refused to consume. 2) Resident #3 had diagnoses including Chronic Obstructive Pulmonary Disease, Acute Respiratory Failure with hypoxia, and diabetes. The 11/03/2025 Minimum Data Set Assessment documented Resident #3 had severe cognitive impairment and required supervision with eating.The Care Plan dated 06/24/2025 titled, Nutrition Status documented Resident #3 will eat at least 75% of meal as the goal. Interventions included food preferences, offer between meal nourishment/supplement. The care plan did not document a specific nutrition supplement.Resident #3's weight record documented on 10/07/2025 they weighed 152.4 pounds and on 11/25/2025 they weighed 137.4 poundsThe 11/21/2025 Dietary progress note documented most meals consumed were 50% intake and a weight loss of 6# in one (1) week with a recommendation to add Magic cup daily.The 11/23/2025 Physician order documented a no added salt, chopped texture diet. The 11/23/2025 Medical note documented the diet consult indicating mild weight loss due to decreased intake and to order Magic cup daily to prevent further weight loss. A physician order dated 11/28/2025 documented Magic Cup at 10 AM daily. During the survey period from 12/03/2025 to 12/10/2025, the Certified Nurse Aide documentation record for eating, documented for 16 out of 24 meals the resident's intake was less than 50% intake. During an observation on 12/03/2025 at 9:26 AM, Resident #3 was in bed feeding themself breakfast with built up utensil. During an observation on 12/05/2025 at 11:59 AM Resident #3 was served lunch in the Bistro. Resident #3 was served soup and never took a bite of the soup, even with staff cues. The entree was served, chopped chicken and Certified Nurse Aide # 14 assisted Resident #3 with feeding. Resident #3 had a pile of chewed up chicken on the side of the placemat that they had spit out despite being served a chopped diet texture. Resident consumed 25-50% of the meal. During an interview on 12/05/2025 at 1:27 PM the Speech Therapist stated Resident #3 was followed for dysphagia and cognition. The chopped diet was Resident #3's preference. Resident #3 was trialed on ground texture, but the resident was not interested in that texture. The Speech Therapist stated they had not witnessed Resident #3 spit food out.During an interview on 12/05/2025 at 1:45 PM, the Registered Dietitian was not sure why the order for Magic cup was not started until 11/28/2025 when they had ordered it on 11/21/2025.During an interview on 12/08/2025 at 11:04 AM the Registered Dietitian stated there were no documented food preferences for Resident #3. 10NYCRR 415.12(i)(1)

Based on observations, record reviews and interviews during a recertification and abbreviated survey (2637641) from 12/03/25 to 12/10/25 the facility did not ensure that each resident received adequate supervision to prevent accidents for one (1)( Resident#7) of six (6) residents reviewed for accidents. Specifically, Resident#7 who had a history of wandering by self-propelling in their wheelchair, accessed an alarmed stairwell door and fell down the stairwell in their wheelchair. The resident sustained two fractured vertebrae and a hematoma on their scalp.The findings include: Resident #7 was admitted to the facility with diagnoses including dementia, schizophrenia and history of falling. The Minimum Data Set (MDS- an assessment tool) dated 08/01/2025, documented Resident #7 had severely impaired cognition. Resident#7 required substantial to maximal assist for bathing, bed mobility and transfer and was dependent for toileting and used a wheelchair for mobility. There were no behavior symptoms or wandering noted on this assessment. The care plan for Behavior dated 09/05/2023 documented Resident #7's behaviors included wandering and resistance to care.The care plan for Wandering/Elopement effective 2/14/2024 documented the goal was the resident would remain in appropriate areas. Interventions included Resident #7 would be monitored while up in their wheelchair.The 8/6/25 Fall Assessment documented Resident #7 was a high risk for falls. It further documented they had a history of falls, wandering and confusion. The Incident Report dated 10/7/25 documented Resident#7 was observed in Resident #110's room by certified nurse aides and was resistant to leaving room. Resident #110 stated that Resident#7 hit them with their grabber tool, threw belongings and attempted to stab them with scissors. Resident#7 was removed from the room and put back to bed.The investigative summary dated 10/7/25 documented the route cause analysis was Resident #7 had severe cognitive deficit became confused and thought Resident #110 was in their room. Resident #7 behavioral reaction was due to their dementia diagnosis exhibiting behaviors associated confusion and accusations. The documented corrective action was to immediately separate residents, Resident #7 room was changed and both residents to be seen by social work. The conclusion was documented as Resident #7 did not recall the incident, both residents to be seen by social work and psych and Resident #7 would be on safety checks.Review of Resident #7's care plan had no documented evidence interventions were put in place including increased supervision after the 10/07/2025 incident to address Resident #7's wandering behavior and being an aggressor in a resident-to-resident altercation.The 10/7/25 Elopement Risk Assessment documented Resident #7 was a high risk for elopement.A nurses note dated 10/09/25 at 6:11PM documented the resident was an elopement risk and wore a wandergard on their left wrist.A nurses note dated 10/10/25 at 7:40AM documented at 6:35 AM staff responded to a door alarm by Discrtict#2 hallway. Resident#7 was down the stairs with the wheelchair close to them. Resident#7 was observed on their back both legs extended and was able to move arms and legs without restriction. Skin break noted to the back of their head. The resident was alert and verbal and reported their head and back hurt. The Supervisor was made aware. Transferred by Emergency Medical Services at 0700AM.The Registered Nurse Supervisor #1's progress note dated 10/10/2025 at 8:44 PM documented Resident #7 returned from the Emergency Room. They spoke to the emergency room physician who communicated the resident had two (2) fractured lumbar transverse processes and would need pain management and follow-up with orthopedics. They were also diagnosed with a urinary tract infection and started on an antibiotic. Resident #7 had three lidocaine patches to the right hip.The 10/10/25 Incident Report documented Resident #7 fell down the stairs at 6:35 AM with injury/skin break to back of resident's head with moderate amount of bleeding. Resident #7 was observed lying in a supine position down the stairs at the end of district 2 hallway with their wheelchair by their side. When Resident #7 was asked how they fell the resident responded, my head and back hurt. The resident was sent to emergency room at 7:15 AM. A written statement from Certified Nurse Aides #28 dated 10/10/2025, documented they did morning care for the resident at approximately 5:30 AM and then the resident was in the Day Room. At around 6:25 AM, the resident was in the hallway wheeling toward the the rear door and they brought the resident back to the Day Room. They were in another resident's room providing care when they heard the alarm go off around 6:30 AM for the back door. They checked the back door and saw the resident down the stairs. They told the nurse on the floor and the Supervisor.The Internal Investigation Report by the Supervising Administrator, completed on 10/15/2025 documented on 10/10/25 the resident had a fall with major injury and fell down the district 2 hallway alarmed door. The summary of investigator's findings was the resident was observed in dining room at 6:20 AM, at 6:26 AM preceding to leave the dining room at 6:29 AM. At 6:31 AM the resident was seen at the alarmed door and falls at 6:32 AM, staff respond at 6:34 AM. Immediate Action: resident was assessed for injuries, sent to hospital and treated for urinary tract infection. Report showed 2 fractures to the lumbar spine. Corrective Actions included a magnetic stop sign placed on emergency door to prevent the resident from going near the door. Fifteen-minute safety checks implemented and then withdrawn due to the resident's injury and immobility from the bed. The conclusion was the resident was being treated for a urinary tract infection which contributed to the fall.During an observation on 12/03/2025 at 11:40 AM, the second-floor stair well door in district 2 hallway could not be opened without a code. There was not a magnetic stop sign on the stairwell door as planned. During an observation on 12/3/2025 at 2:42 PM, the surveyor attempted to open the second-floor district 2 stairwell door. The alarm sounded, when holding and pressing against door, the door released and opened after about 15 seconds. The whole time the door was being pressed to open the alarm was sounded loud and shrill. There were no stop signs on any stairwell doors on the second floor. During an interview on 12/03/2025 at 2:43PM, Certified Nurse Aide #27 stated the door would open even if alarm sounded after a certain time period. They stated they did not know how long it took and knew the all the doors would eventually open after alarm sounded. During an observation on 12/09/2025 at 11:58 AM of video surveillance from 10/10/2025, Resident #7 was observed going down district 2 hallway on second floor at 6:20 AM. At 6:26 AM staff observed Resident #7 going down district 2 hallway, came to get the resident and returned the resident to the Day Room by the nursing station. At 6:29 AM, Resident #7 was visible in district 2 hallway for the second time, and staff were visible at the nursing station. At 6:31:45 AM, Resident #7 was visibly attempting to open and pushing at district 2 hallway stairwell door. At 6:32:30 AM, Resident #7 opened the door and enter the stairwell. At 6:32:54 AM, the stairwell door shut, and Resident #7 was no longer visible. At 6:33:34 AM, staff were visible at the nursing station. At 6:34:25 AM Certified Nurse Aide arrived at the door, looked through the stairwell window and turned around, went back to the desk and summoned other staff. At 6:35 AM, three staff went through the stairwell door. During an interview on 12/09/2025 at 1:32 PM, Certified Nurse Aide #28 stated they were assigned to Resident #7, they worked the night shift and the night shift was responsible for getting the resident up. Certified Nurse Aide #28 stated they got Resident #7 up and placed them in the Day Room by the nursing station so that somebody could keep an eye on them. They stated Resident #7 usually stayed in the Day Room when they put them there. They stated they were responsible for monitoring District 2 hallway on the second floor, and they were in another room giving care when they heard the alarm go off. Certified Nurse Aide #28 stated after they heard the alarm, they went down district 2 hallway. They stated Resident #7 went down district 2 hallway earlier and another certified nurse aide brought them back to the Day Room. They stated when they were providing care to room [ROOM NUMBER], they heard alarm go off and by the time they got down there the resident was already down the stairs on the platform. Certified Nurse Aide #28 stated the alarm at the door sounded with a continuous alarm and was very loud. They stated when they came out of room [ROOM NUMBER], they looked at the nursing station and asked where the alarm was sounding but they did not remember if anybody said anything back to them. They stated they just proceeded to the doorway. Certified Nurse Aide #28 stated when they went to peak through window on the door at end of district 2 hallway, they saw Resident #7 down the stairwell and screamed out to the nurse, and then they ran down to nursing station to get the nurse. Certified Nurse Aide #28 stated one nurse went in and then they were told to go back and call the nursing supervisor. During an interview on 12/10/2025 10:31 AM, Registered Nurse #22 stated they were called that day because Resident #7 was found in the district 2 stairwell. The stairwell was locked and alarmed. They stated they went to the stairwell and found Resident #7 lying there. The resident went down the stairs in their wheelchair and it was next to them on the landing in the stairwell. When they arrived at the door to stairwell the alarm was already turned off by staff. Registered Nurse #22 stated Resident #7 had a behavior of getting into their wheelchair and moving about the unit. Registered Nurse #22 stated according to the certified nurse aides Resident #7 would sometimes go toward doors and they would have to redirect the resident. During an interview on 12/10/2025 at 3:48 PM, the Nurse Practitioner stated they were informed of incident on 10/10/25 where Resident #7 went downstairs with their wheelchair and stated the resident was sent to the hospital. Nurse Practitioner stated Resident #7 had a fractured lumbar and was to follow up with ortho. Nurse Practitioner stated they did not believe there was anything that could have been done to prevent the fall, and stated Resident #7 had a wander guard already. Nurse Practitioner stated Resident #7 did suffer harm as a result of the fall. During an interview on 12/10/2025 at 4:03 PM, the Medical Director stated they were not made aware of the incident that occurred on 10/7/25. They further stated Resident #7 was a fall risk and was to be seen by psychiatry. They further stated they were not directly involved in the investigation and had nothing further to add. 415.12(h)(1)

Based on record review and interview conducted during the recertification survey from 7/29/25 to 8/5/25, the facility did not ensure certified nurse aides were provided the required 12 hours of training to ensure safe delivery of care. Specifically, the facility was unable to provide evidence that 5 of 5 Certified Nurse Aides (#15, #26, #27, #28 and #29) reviewed for nurse aide in-service training were provided 12 hours of mandatory annual in-service training, including dementia training. The findings included:The Corporate Facility Policy titled, Continuing Education In-Service and Competence Training, (revised 11/4/24) documented In-service training must be sufficient to ensure the continuing competence of nurse aides but be no less than 12 hours per year.During interviews and observations on 8/1/24 at 1:29 PM and 8/4/2025 at 1:31 PM, the Staff Educator Resident Nurse provided three hours of annual in-services for Certified Nurse Aide #15, one hour and 10 minutes for Certified Nurse Aide #26, one hour for Certified Nurse Aides #27 and #28 and two hours, forty-five minutes for Certified Nurse Aide #29. The Staff Educator Registered Nurse stated they were responsible for certified nurse aide annual in-services since April 2025 and were not aware of annual in-services completed prior to that time. They stated they were not able to provide twelve hours of annual certified nurse aide in-services for Certified Nurse Aides #15, #26, #27, #28 and #29 or evidence of an in-service on dementia. During an interview on 08/05/2025 at 1:31 PM, the Director of Nursing stated the requirement of twelve hours on annual in-services for certified nurse aide staff will improve with the recent hiring of a Staff Educator. 10NYCRR 415.26

Based on record review and interview conducted during the recertification from 7/29/25 to 8/5/25, the facility did not ensure there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the staffing schedule from 6/27/25 through 8/4/25 documented the facility did not consistently provide adequate staffing on all units/shifts to meet the needs of the residents on 34 of the 39 days reviewed. The findings included: The Facility Wide Assessment updated 5/23/25 documented: Day shift and evening shifts one registered nurse weekdays and weekends, five licensed practical nurses weekdays and four weekends, twelve certified nurse aides weekdays and ten weekends. Night shift: one registered nurse weekdays and weekends, three licensed practical nurses weekdays and two weekends, six certified nurse aides weekdays and weekends. The facility staffing from June 27, 2025 through August 4, 2025 and the staffing plan based on Facility Wide Assessment, documented the facility was understaffed 34/39 days for Certified Nurse Aides. On 28 of the 39 days reviewed, the facility was short-staffed for certified nurse aide staff during various shifts and on 15 of the 39 days reviewed the facility was short-staffed for licensed practical nurses or registered nurses during various shifts. During an interview on 07/29/2025 at 11:27 AM, Resident #93 stated that the facility is understaffed and the staff they do have are overworked. During a Resident Council meeting on 7/30/2025 at 12:58PM residents were interviewed about facility staffing. Residents collectively stated that they do have to wait for extended periods of time when they ring call bells for assistance. They stated that the overnight shift is the worst. Resident #101 stated that some staff do not always do as thorough a job and work is rushed. Resident #125 stated that staff has been observed sleeping at night. They also complained that staff do not always return as they say they will. They say they will assist at a particular time and then don't follow through. They described this as a regular occurrence. During an interview on 08/04/2025 at 11:37 AM with Registered Nurse #5, they stated the facility could use more licensed practical and registered nurse to assist with treatments and medication administration. They stated that completion of these tasks does not leave time for tasks such as updating resident care plans. They stated that they believe the facility has sufficient certified nurse aide staff. They stated the facility has their own staffing agency which is mostly used for staffing. During an interview and observation on 08/05/2025 11:39 AM, the Director of Human Resources/ Staffing Coordinator stated staffing is planned daily as per the Facility Assessment recommendations. They stated staff callouts are problem some. When call outs occur, staff from previous shift are asked to stay or next shift asked to come in earlier. Staff not on schedule are also offered shift. Incentives and overtime are offered to meet staffing guidelines. They stated licensed practical nurse and registered nurse staffing goals are very difficult to meet. They stated recruitment is on-going and not many licensed practical nurses apply. On-going recruitment includes job fairs and hiring web sites. They stated the facility has their own staffing agency and outside staffing agencies are no longer used due to the expense. During an interview on 08/05/2025 at 12:14 PM, the Administrator stated there is frequently not enough staff available, especially with licensed practical nurses and registered nurses. They stated that the facility has been trying to hire Unit Managers and have not had many applicants. They stated that there are many nursing home facilities in area, and they are all competing for same pool of potential hires. Administrator stated that when staffing levels are low, support staff will assist with resident tray distribution and call bell response. Overtime is offered to staff willing to cover open shift. During an interview on 08/05/2025 at 1:12 PM Licensed Practical Nurse #8 stated staffing of certified nurse aides and licensed practical nurses had recently has improved but has been shorter again over past few weeks. They stated that the facility uses mostly agency staff. They stated not having a Unit Manager on second floor unit has had a big impact on cares such as care plans and physician orders not being entered. They stated certified nurse aides staffing is usually sufficient and a Unit Manager could assist in their supervision and ensuring tasks are completed. During an interview on 08/05/2025 at 1:26 PM, Certified Nurse Aide #9 stated that staffing during weekends can be low at times. During an interview on 08/05/2025 at 1:31 PM, the Director of Nursing stated the facility recently hired a full-time evening Nurse Supervisor and are currently working with local schools for new graduate licensed practical nurses. They stated that both facility units would benefit with a Unit Manager and the hiring search for these roles continues. NY CRR 415.13(a)(1)(i-iii)

Based on observation, record review, and interviews during the recertification and abbreviated surveys (NY00374242) from 7/29/25-8/5/25, the facility did not ensure each resident received care, consistent with professional standards of practice, to prevent and treat pressure ulcers for 2 of 4 residents (Residents #34 and #114) reviewed for pressure ulcers. Specifically, 1) Resident #34 had a physician's order to offload their heels in bed. The resident was observed in bed with their heels resting directly on the mattress and there was no pillow on the mattress to offload the resident's feet. The physician's order, dated 7/22/25, to offload heels in bed was not added to the resident's care plan or certified nurse aide instructions. 2) Resident #114 had pressure ulcers and wound care treatment was not provided consistently as ordered. The findings included:1) Resident #34 diagnoses included: vascular dementia, retention of urine and type 2 diabetes mellitus. The 7/9/25 Quarterly Minimum Data Set (a resident assessment tool) documented Resident #34 had severe cognitive impairment and required substantial/maximal assistance with bed mobility, toileting and bathing and was dependent on staff for transfers. The 7/22/25 physician's order documented to off load heels in bed. The 7/23/25 Skin Integrity care plan documented the Resident was at risk for skin breakdown related to decreased mobility, pain, incontinence. Interventions included Certified Nurse Aide evaluation of skin condition daily during care and report any skin abnormalities to nurse, encourage frequent position changes, prevent friction during transfers, resident care and bed mobility, and turn and repositioning schedule as recommended. There was no documented evidence that the care plan was updated to include the 7/22/25 physician's order to offload resident heels while in bed.The 7/22/25 hospital discharge summary note documented wound consult in hospital. Bilateral foot wounds. Scattered scabs to multiple toes with the most notable lateral on the bilateral bunion area, right foot. Recommendation: float heels with pillows. During observations on 07/30/2025 at 10:38 AM, 7/31/25 at 12:46 PM, and 8/1/2025 at 9:22 AM, Resident #34's bilateral heels were observed on their mattress, and not offloaded. Red scabs were observed on the resident's bilateral upper feet near and on their great toes. During an interview on 08/01/2025 at 9:22 AM, Certified Nurse Aide #15 stated they believe Resident #34's heels should be offloaded while they are in bed. They were not aware of an order or task for off-loading the resident's heels or if that was documented on the certified nurse aide instructions or tasks. They stated they will offload Resident #34's heels anyway as they probably should be. During an observation and interview on 08/04/2025 at 11:25 AM, Registered Nurse #5 stated Resident #34's bilateral heels should be offloaded. During a review of the electronic medical record, Registered Nurse #5 stated that a physician's order for Resident #34's heels to be offloaded was entered on 7/22/25 and that the skin integrity care plan for Resident #34 and the certified nurse aide instructions and tasks were not updated to reflect the physician order. They stated they are responsible for overseeing certified nurse aides on unit and for updating resident care plans. They stated that the staff member who entered the order could have updated the care plan and certified nurse aid instructions and tasks at that time. During an interview on 08/05/2025 at 1:40 PM, the Director of Nursing stated that when a physician's order is entered into the electronic medical record to offload a resident's heels, the expectation is that it be done. They stated that unit nurses should be assuring that physician's orders are added to resident care plans, interventions, and to the certified nurse aide instructions and tasks.2) Resident #114 had diagnoses that included end stage renal disease, diabetes mellitus, and heart failure. The facility Pressure Ulcer Treatment policy last reviewed 8/1/2025 documented general guidelines for the treatment of pressure ulcers and protocols based on the condition of the wound. Residents with congestive heart failure, renal disease, liver disease and diabetes, would be evaluated on a case-to-case basis. The 2/11/24 Quarterly Minimum Data Set documented moderately impaired cognition, no behaviors including refusal of care, dependent on assistance for most activities of daily living, incontinent bowel and bladder, unhealed pressure ulcers, two stage 4 ulcers (1 present on admission), interventions include pressure relief bed, chair, turn and position, nutritional management, pressure ulcer care, and application of ointment. The 12/22/2023 Skin Integrity Presence of Pressure Ulcer Care Plan documented Resident #114 had pressure ulcers. The goals were documented as remaining free of infection and that the wound will show signs of healing. Interventions included wound rounds weekly, turn and position every two hours, apply treatments as ordered by the physician, and air mattress. The 12/21/2023 physician's order documented check integrity and verify settings of air mattress every shift.The 12/21/2023 physician's order documented Santyl 250 unit/gram topical ointment, apply 1 applicatorful by topical route once daily in the morning to the coccyx wound after cleaning with normal saline. The 12/29/23 Annual Minimum Data Set documented intact cognition and no behavioral symptoms or refusal of care. Resident required maximal assistance or dependent assistance with activities of daily living, catheter, incontinent of bowel, risk for pressure ulcer, has 2 stage 4 unhealed pressure ulcers (1 present on admission). Interventions included pressure relief bed, chair, turn and position, nutritional management, pressure ulcer care, application of ointment and dressing application. The 1/31/2024 wound care note documented a stage 4 to the coccyx (site 3) measuring 3.6 x 0.6 x 0.5 cm. Recommendations included offload wound, reposition per protocol, limit sitting. Factors complicating wound healing included end stage renal disease and heart failure. The 2/21/2024 wound care note documented the stage 4 to the coccyx (site 3) measured 3.9 cm x 0.9 cm x 0.6 cm. Recommendations for offloading and repositioning continued.The 4/3/2024 wound care note documented the stage 4 to the coccyx (site 3) measured 4.1 cm x 1.0 cm x 0.8 cm. New recommendations included Dakin's solution and mupirocin topical 2%. There was no documented evidence of Physician's orders for Dakin's solution or mupirocin topical 2%.The Treatment Administration Records dated 1/1/2024-4/5/2024 had twenty omissions for the daily wound care treatment to the coccyx.The Treatment Administration Record dated 1/1/2024-4/5/2024 had forty-two omissions for checking the air mattress integrity and settings. During an interview on 08/05/2025 at 2:55 PM, the Director of Nursing stated that Resident #114 was seen on wound rounds and did have treatments ordered. They stated there should be no omissions on the treatment or medication administration records, and if a medication or treatment was not documented there was no evidence that the treatment was done. 10NYCRR 415.12(c)(1)

Based on observations and interviews during the recertification survey from 7/29/2025-8/5/2025, the facility did not ensure a safe, clean, comfortable and homelike environment in multiple resident rooms during environmental observations. Specifically, air conditioner casings were not secured, loose, or detached in resident rooms 120, 124, 130, and 131, Rooms 2-206-D and 2-220-W had unfinished plaster patches behind beds, and room [ROOM NUMBER]-209-P had an approximate 5-inch x 3-inch hole in the wall behind the resident's bed. During an observation on 7/30/2025 at 10:06AM, the air conditioner casing in room [ROOM NUMBER] was off the wall and not secured. During an observation on 07/31/2025 12:50 PM, the air conditioner casing in room [ROOM NUMBER] was loose and not secured. Resident #93 was able to remove the panel. During observations on 08/04/2025 at 8:25 AM, the air conditioner casing in rooms [ROOM NUMBERS] were loose and not secured. During an interview on 08/05/2025 at 8:39 AM, the Director of Maintenance stated that the the air conditioner units should be enclosed in the casing. The casings should be secure and not off free standing in the room because they could fall off, or fall over if free standing, and that would be a safety concern. During an observation of room [ROOM NUMBER]-206-D on 07/29/2025 at 10:22 AM, five unfinished plaster areas were observed behind the resident's bed. During an observation of room [ROOM NUMBER]-220-W on 07/29/2025 3:06 PM, scuff marks were observed on the closet door and an approximate 2.5-foot area of unfinished plaster was observed on the right side of the resident's bed. During an observation and interview on 8/5/2 at 12:34 PM, the Director of Maintenance stated the walls in Rooms 2-206-D were plastered approximately ten days ago and should be painted. They stated room [ROOM NUMBER]-220-W needs to be painted, including the area with unfinished plaster behind the resident's bed and closet scuff marks. They stated the hole in the wall behind resident bed in Room should be plastered and repaired. During an observation on 07/29/2025 at 11:22 AM, an approximately 5 inch by 3 inch hole was observed near the baseboard in Resident 2-209-P room. During an observation and interview on 8/5/2 at 12:34 PM, the Director of Maintenance stated the hole in the wall behind the resident's bed in room [ROOM NUMBER]-209-P should be repaired and plastered. 10NYCRR 415.5 (h)(2)

Based on observation, record review, and interviews conducted during the recertification survey from July 29, 2025, to August 5, 2025, the facility did not develop and implement a comprehensive, person-centered care plan with measurable goals, time frames, and interventions to meet the needs of 3 out of 3 residents (Resident #2, Resident #13, and Resident #34) reviewed for care plans. Specifically, Resident #13 lacked a care plan addressing the use of anti-anxiety and antidepressant medications. Resident #2 and Resident #34 did not have comprehensive care plans developed for nutrition. The findings include: A facility policy titled Unintended Weight Loss, last reviewed 9/26/23, documented: It is the policy of facility to ensure residents with poor intake and/ or unintentional weight loss are assessed and have Care Plans developed addressing their clinical condition and risk factors. The Policy and Procedure titled Comprehensive Care Plan, last revised 5/19/25, documents that a Comprehensive Care Plan is developed for each resident by the 21st day of admission, updated quarterly, annually, upon readmission, and with any significant change of condition. 1) Resident #13 had diagnoses including Dementia, Generalized anxiety disorder, and Mood Disorder. The 7/15/2025 Quarterly Minimum Data Set, an assessment tool, documented that Resident #13 had severe cognitive impairment. The 1/15/25 physician's order documented Buspar 10 milligram tablet to be administered three times daily for anxiety, and Lexapro 10 milligram tablet to be administered once daily for depression. There was no documented evidence that a Care Plan was developed for anxiety or depression for Resident #13. During an interview on 08/05/2025 at 2:26 PM, the Director of Nursing stated that all the nurses are responsible for resident care plans. They stated that Registered Nurses initiate care plans, and Licensed Practical Nurses can update care plans. They stated Resident #13 should have a care plan in place for all medications. They stated that there was no unit manager assigned to the unit. During an interview on 08/05/2025 at 2:26 PM, Registered Nurse #5 stated that all the nurses are responsible for care plans. Registered Nurses initiate care plans, and Licensed Practical Nurses can update care plans. 2) Resident #2 had diagnoses including unspecified dementia, major depressive disorder recurrent, generalized anxiety disorder, and bipolar disorder unspecified. A five-day reentry Minimum Data Set, dated [DATE] documented Resident #2 had severe cognitive impairment, required set/up clean up assistance with eating and had a therapeutic diet. There was no active nutrition care plan in the electronic medical record. The 7/17/25 physician's order documented: no added salt, regular diet, thin liquids. Ensure Plus three times a day. Resident #2's weights documented a weight loss of 5.7% from 05/02/2025 to 8/1/2025. During an interview and observation on 08/05/2025 at 1:05 PM, Licensed Practical Nurse #8 stated they were aware that Resident #2 had lost weight. During a review of the electronic medical record, Licensed Practical Nurse stated they were unable to locate an active nutrition care plan for Resident #2. They stated the facility has not had a Dietician for quite some time. Licensed Practical Nurse #8 stated they were not aware of care plan interventions in place for Resident #2. During an interview and observation on 08/05/2025 at 1:36 PM, the Director of Nursing stated they were aware of Resident #2's weight loss. During a review of the electronic medical record, the Director of Nursing stated Resident #2 did not have an active nutrition care plan in place. They stated Resident #2 had been hospitalized in July 2025 and a nutrition care plan had not been put in place / updated upon Resident #2's return to the facility. They stated the last dietary assessment for Resident #2 was in March 2025. They stated a new hire per-diem Dietician would be starting in facility on 8/5/25. They stated an interdisciplinary team member should have re-activated the nutritional care plan and updated the interventions if necessary. 3) Resident #34 had diagnoses including vascular dementia, unspecified severity with mood disturbance, type 2 diabetes mellitus and repeated falls. The 7/9/25 Quarterly Minimum Data Set (a resident assessment tool) documented Resident #34 had severe cognitive impairment, had weight loss of 5% or more in the last month or loss of 10% or more in the last six month and was on a therapeutic diet. There was no active nutrition care plan in the electronic medical record. The 7/28/25 physician's order documented: Dietary: No concentrated sweets, ground consistency. General swallow precautions, no by mouth intake if lethargic, ensure upright positioning. Resident #34's weights documented a 12.49% weight loss from 3/28/25 to 8/1/25. During an interview on 07/30/2025 at 10:38 AM, the resident's representative stated they were aware that Resident #34 had lost weight and were not aware of interventions in place to address the weight loss. During a brief interview on 07/31/2025 at 12:01 PM, the Administrator stated facility Dietician left employment about a month ago and a new part-time dietician has been hired who has not yet started. They stated that the nursing staff is monitoring resident nutritional status during the absence of a Dietician. During an interview and observation on 07/31/2025 at 12:02 PM, the Director of Nursing stated they were unable to observe an active nutrition care plan for Resident #34 in their electronic medical record. They stated that Resident #34's nutrition care plans were not re-activated and reviewed/updated in the electronic medical record after a recent hospitalization. They stated when Resident #34 returned to the facility, there was no Dietician employed at facility so an Interdisciplinary Team member should have re-activated the nutritional care plan and updated the interventions if necessary. 10NYCRR415.(c)(1)

Based on observations, interviews, and record review during the recertification and abbreviated (NY00371600) surveys from 7/29/2025-8/5/2025, the facility did not ensure that the comprehensive care plans were reviewed and revised to reflect changes and updates in residents status for one of one resident reviewed for care planning (Resident #93), two of four residents reviewed for pressure ulcers (Resident #34 and #11). Specifically, 1) Resident #93 had no updates to their care plan for discharge planning, 2) Resident 34's care plan was not updated to include a physician's order to offload their heels, and 3), Resident #11's fall care plan was not updated to reflect a new order for neuro- checks. The facility policy Comprehensive Care Plans last reviewed 5/19/2025 documented that resident's comprehensive care plans will be individualized and remain up to date, reflecting the resident's current status and needs. Care plans must be updated within seven days of completing each comprehensive assessment and after any new event, order, condition change. 1) Resident #93 had diagnoses that included osteomyelitis, amputation, and peripheral vascular disease. The 3/29/2025 Five-Day Minimum Data Set assessment documented Resident #93 had intact cognition, required set up assistance for most activities of daily living, but required moderate assistance for lower body dressing and maximal assistance needed for putting on footwear. The resident was independent for bed mobility and touch assistance needed for transfers. Occupational and physical therapy received. No active discharge plan, resident was involved in goal setting. The 6/3/2025 Quarterly Minimum Data Set assessment documented the resident had intact cognition, required set up assistance needed for eating, hygiene, and upper body dressing, moderate assistance needed for showers and lower body dressing, and maximal assistance needed for footwear. The resident was independent for bed mobility and touch assist for transfers. Occupational and physical therapy received. No discharge planning to return to community, resident involved in goal setting. The Comprehensive Care Plan for Resident #93 had no documented evidence of any discharge planning or discussion. The care plan meeting record for Resident #93 documented the last care plan meeting was held on 3/6/2025. The social work progress notes had no documented evidence of discharge planning. During an interview on 07/29/2025 at 11:29 AM, Resident #93 stated that care plan meetings have not been happening routinely. They stated they are planning to go home but there has been no discussion or planning for their discharge. They stated the communication at the facility is very poor. During an interview on 08/04/2025 at 11:22 AM, the Director of Social Work stated that Resident #93's goal was to go home. They stated that discharge planning starts at the time of admission. They stated they had been working on Resident #93's discharge, however, the care plan and progress notes did not reflect this. They stated social work was responsible for discharge care plans and they will update the notes and care plan. 2) Resident #34's diagnoses included: vascular dementia, unspecified severity with mood disturbance, type 2 diabetes mellitus and repeated falls. The 7/9/25 Quarterly Minimum Data Set (a resident assessment tool) documented Resident #34 had severe cognitive impairment and required substantial/maximal assistance for toileting and bathing and was dependent for transfers. The 7/22/25 physician's order documented to offload heels in bed. Resident #34's skin integrity care plan which was last updated on 7/23/25, did not documented to offload the resident's heels while in bed. During an interview and observation on 08/04/2025 at 11:25 AM, Registered Nurse #5 stated they did not find documented evidence of an intervention to offload Resident #34's heels in bed. During an interview on 08/05/2025 at 1:40 PM, the Director of Nursing stated that physician's orders should be added to care plan interventions by the unit nurse staff. 3) Resident #11 was diagnosed with Alzheimer's disease, schizoaffective disorder, and diabetes mellitus. The 7/17/25 Minimum Data Set (a resident assessment tool), documented that Resident #11 had severe cognitive impairment. The assessment indicated that the resident required assistance from staff to complete activities of daily living, including personal care. Additionally, the resident used a wheelchair for mobility. The 2/8/25 internal investigation documented the resident was found sitting on the floor in their assigned room. The 2/8/25 at 3:05 PM Progress Notes written by Licensed Practical Nurse #23 documented that a patient called the nursing station, stating, Please help me, I fell on the floor. The nurse responded and found the patient lying on the floor in their room. The supervisor was notified. The patient was observed to have a skin tear on their right lower leg and reported pain in their head, along with bruising to the head. The 2/8/2025 Fall at High-Risk care plan did not include an intervention for neuro-checks. The 2/9/25 at 9:22 AM Progress Note written by Registered Nurse Supervisor #4 documented that the resident returned at 11:39 PM from the hospital emergency room following a fall incident. The resident had bruising on both upper and lower extremities due to the fall, along with a laceration on the right lower leg, which had been sutured. Following the emergency department discharge summary, a physician's order was given for neurological checks for 24 hours. The 2/9/25 physician's order documented neurological checks every 2 hours for 48 hours. During an interview on 8/5/25, at 8:09 AM, Registered Nurse Supervisor #4 stated that the process for updating a care plan following a resident's fall included updating the care plan with relevant interventions and new orders each time residents experience a fall. 10 NYCRR 415.11(c)(2) (i-iii)

Based on observations, interviews, and record review during the recertification survey from 7/29-8/5/2025, the facility did not ensure that one of two residents (Resident #6) reviewed for hydration and one of four residents (#34) reviewed for nutrition were maintained within acceptable parameters of nutritional status. Specifically, 1) for Resident #6 who received oral and tube feedings, a nutritional assessment was not completed upon admission to the facility, or any time after admission, to assess for adequate intake, and 2) Resident #34 had a documented weight loss of 12.49% weight loss from 3/28/25 to 8/1/25 and there was no documented evidence of an active nutrition care plan in place with new interventions related to nutritional status. The findings included: 1) Resident #6 had diagnoses that included Down Syndrome, severe protein calorie malnutrition, and heart disease. The 6/20/2025 admission Minimum Data Set documented severely impaired cognition, dependent for all activities of daily living, feeding tube and mechanically altered diet, majority of calories through tube feeding and more than five hundred and one milliliters of fluid through tube feeding daily. The 7/2/25 Nutritional Status Care Plan documented Resident #6 was at risk for weight loss/gain and altered nutrition and hydration secondary to multiple diagnoses. Goals included, but not limited to, resident will adhere to therapeutic diet and maintain adequate fluid intake. Interventions included Bolus feed via gastrostomy tube between meals and labs monitored. The 6/25/2025 physician's order documented Jevity 1.2 Cal oral liquid. Give 250 milliliters by peg tube route five times per day. Free water flush 60 milliliters before and after each feeding The 7/23/2025 physician's order documented pureed diet, nectar thick liquids at mealtimes. Only feed as tolerated and perform oral care before and after oral intake. During an observation on 07/29/2025 at 2:46 PM, Resident #6 was observed with dry lips and dry flaky skin to their perimeter. During an observation on 07/31/2025 at 12:17 PM, Resident #6 was observed sitting in a gerichair in the common dining area. Their lips and tongue appeared very dry. Resident #6 was moving their tongue in and out of their mouth and licking the air. During an interview and observation on 07/31/2025 at 12:55 PM, Resident #6 was observed in the first-floor dining room eating lunch with the assistance of Certified Nurse Aide #24. Certified Nurse Aide #24 stated that Resident #6 ate one hundred percent of their food but only took about two ounces of fluids. During an observation on 08/01/2025 at 12:58 PM, a certified nurse aide was observed assisting Resident #6 with lunch. No fluids were offered, and fifty percent of their solid food was eaten. During an observation on 08/04/2025 at 8:22 AM, Resident #6 was observed sitting in the first-floor dining area in a geri chair. Their lips appeared dry with flaky skin around them, and the resident had a dry cough. During an interview on 08/05/2025 at 11:32 AM, Certified Nurse Aide #30 stated that Resident #6 was dependent for most cares. They assisted Resident #6 with eating this morning. At breakfast Resident #6 took approximately 60 milliliters of juice, but they also received their bolus feed. They stated it takes a lot of staff encouragement for the resident to take fluids orally. During an interview on 08/05/2025 at 12:48 PM, Licensed Practical Nurse #25 stated Resident #6 gets both oral intake and tube feedings. Water is administered with the feedings and with medications. They believed there was a dietician at the facility who was responsible for monitoring the resident's input, calories, and weight. During an interview on 08/05/2025 at 2:40 PM, the Director of Nursing stated that a Dietician was starting again that evening. They were without a dietician for a short time. Nursing was monitoring all nutritional issues or concerns while there was no dietician at the facility. A nutritional assessment was never completed for Resident #6. The orders for food and fluid were continued as ordered for Resident #6 at the hospital prior to coming to the facility. 2) Resident #34's diagnoses included vascular dementia, unspecified severity with mood disturbance, type 2 diabetes mellitus and repeated falls. The 7/9/25 Quarterly Minimum Data Set (a resident assessment tool) documented Resident #34 had severe cognitive impairment, had weight loss of 5% or more in the last month or loss of 10% or more in the last six months, and was on a therapeutic diet. Resident #34's weights documented a 12.49% weight loss from 3/28/25 to 8/1/25. There was no documented evidence of an active nutrition care plan in Resident #34's electronic medical record. The 7/28/25 physician's order documented no concentrated sweets diet, ground consistency, general swallow precautions, nothing by mouth if lethargic, and ensure upright positioning. There was no documented evidence of physician's orders for a supplement, assistance with meals, or weight monitoring. The 6/19/25 Dietary/Nutrition Assessment progress note documented diagnoses with nutritional implications, vascular dementia, cardiovascular disease, type II diabetes mellitus and depression. The clinical summary documented nutritional status was reviewed. Resident reports good appetite and intake by mouth without recent change. Per nursing report/documentation, resident has been consuming 75 to 100%. No supplementation. Lab results. No swallowing difficulties. Feeding ability/assisted devices for meals documented partial feed. Nutrition problem: at risk for malnutrition related to altered mental state. Nutritional risk factors: impaired cognition. Nutrition Plan of care: continue current diet as tolerated. Encourage intake of dietary protein and fiber, limit portions sizes of carbohydrates. Encourage meals/fluids, assist as needed. Honor resident food preferences, update as needed. Monitor and document weight trends, diet adequacy and tolerance, labs, skin and gastrointestinal patterns. During an interview on 07/30/2025 at 10:38 AM, the Resident's representative stated they were aware that Resident #34 had lost weight but they were not aware of interventions in place to address the weight loss. They stated they visit Resident #34 at lunch three times a week and that Resident #34 will complete 75% of meal when assisted with eating. During an observation on 07/31/2025 at 8:51 AM, Resident #34 was observed being assisted with eating breakfast by a certified nurse aide. Resident consumed 100% farina, 50% of egg/sausage and all fluids. During an interview on 07/31/2025 at 12:01 PM, the Administrator stated the facility dietician left employment about a month ago and a new part-time dietician has been hired who has not yet started. The Administrator stated nursing staff are monitoring resident's nutritional status during the time there is no dietician employed by facility. During an interview on 07/31/2025 at 12:02 PM, the Director of Nursing stated they could not provide evidence of an active nutrition care plan for Resident #34 on the electronic medical record. They stated Resident #34 had a nutrition consult on 6/19/25, although it did not document Resident 34's weight loss over last four months. They could not provide documented evidence of a physician's visit that addressed the resident's weight loss. They stated there were not aware why new interventions were not put in place related to the resident's significant weight loss. They stated they were not aware that certified nurse aides were assisting Resident #34 with eating. They stated that new interventions should be added to a care plan when a resident has a significant weight loss. They stated that Resident #34's nutritional/care plan had not been re-activated or reviewed or updated after a recent hospitalization. They stated that an Interdisciplinary Team member should have re-activated the nutritional care plan and updated interventions as necessary. During an observation and interview on 07/31/2025 at 12:46 PM, Resident #34's representative was assisting Resident #34 with lunch. Resident #34 completed 75% of their lunch. A vanilla magic cup container was observed on Resident #34's tray and the resident's representative was assisting them to eat it. The meal ticket on Resident #34's tray did not document a magic cup as part of the lunch meal. During an observation on 08/01/2025 at 9:22 AM, Certified Nurse Aide #15 observed assisting Resident #34 with breakfast. During a telephone interview on 08/05/2025 at 6:48 PM, Nurse Practitioner #1 stated they recently assessed Resident #34 after a hospitalization. They stated they did not assess weight loss due to not being aware of weight loss. They stated they are usually made aware of resident weight loss by the facility Dietician and the facility has not had a dietician for a few months. 10NYCRR 415.12(i)(1)

Based on observations, interviews, and record reviews during the recertification survey from 7/29/25-8/5/2025, the facility did not ensure that a licensed dietician was employed from 6/28/2025 until 8/4/2025. Specifically, there was no qualified dietician on staff full time, part time, or as a consultant during this period to oversee the dietary needs of residents.The findings included: During an interview on 07/31/2025 at 12:01 PM, the Administrator stated facility dietician left employment over a month ago and a new part-time dietician was hired and had not yet started. They stated that Nursing was monitoring resident nutritional status during the absence of a dietician. During an interview on 08/05/2025 at 2:40 PM, the Director of Nursing stated that a Dietician started again at the facility that day (08/05/2025). Nursing was monitoring all nutritional issues or concerns in the meantime while they had no dietician. There was no dietician for a brief period. During a telephone interview on 08/05/2025 at 6:48 PM, Nurse Practitioner #1 stated they were usually made aware of resident weight loss by the facility dietician and the facility had not had a dietician for a few months. 10 NYCRR 415.14(a)(1)(2)

Based on observations, interviews, and record review during the recertification survey from 7/29-8/6/2025, the facility did not ensure that the menus were followed for one of two residents reviewed for food (Resident #73), one resident observed during dining (Resident #37), and one of four residents reviewed for nutrition (#34). Specifically, 1) Resident #73 did not receive the items as specified on their meal ticket; 2) Resident #37 did not receive the type of milk as specified on their meal ticket; 3)Resident #34 received a magic cup that was not ordered or on their meal ticket.1) Resident #73 had diagnoses that included cerebrovascular accident, hypertension, and diabetes mellitus. The Annual Minimum Data Set, dated [DATE] documented the resident had intact cognition and required set up assistance for eating. During an interview on 7/30/2025 at 10:33AM, Resident #73 stated the food was terrible, the facility dietician was always changing, and the kitchen staff were not accommodating when requests were made. During an observation on 8/1/2025 at 12:31PM, Resident #73's lunch tray ticket and tray were observed. The contents of the tray did not match the meal ticket. The ticket documented a no concentrated sweets diet, no sandwiches, Italian sausage and peppers, alternate vegetable, white rice, saltine crackers, apple slices, whole milk 8 ounces, coffee, creamer, and assorted juice. There was a note documenting no pork or turkey (except bacon and sausage is okay), no cold cuts, extra portion non starch vegetable, and send Mrs. dash. The resident tray was observed with one pot pie, one yogurt, four ounces of juice, coffee, four ounces of milk, apple slices, two equal, two salt, and two creamers. 2) During an observation on 07/30/2025 at 8:50 AM in the first-floor dining room Resident #37's breakfast ticket listed whole milk and skim milk was on the tray. During an interview on 08/05/2025 at 1:54 PM, the Administrator stated residents had discussed inconsistencies with their tickets, but they did not believe it was a regular occurrence. The dietary aides were responsible for checking the tickets before loading the food trucks. The Food Service Director oversaw the aides. During an interview on 08/05/2025 at 5:28 PM, the Food Service Director stated that the tickets on the food trays were checked by the dietary aides on the food line. Two checks were performed and the nursing staff should be checking the tickets on the floors before distributing the trays. All details of the ticket should be examined, including condiments and preferences. The ticket should match what is on the tray. 3) Resident #34 had diagnoses that included vascular dementia, type 2 diabetes mellitus, and repeated falls. The Quarterly Minimum Data Set, dated [DATE] documented the resident had severely impaired cognition and required set up assistance for eating. There was no documented evidence of a physician order for a magic cup for Resident #34. During an observation on 07/31/2025 at 12:46 PM, a magic cup vanilla ice cream container was observed on Resident #34's tray which the resident representative was feeding to them. A review of the meal ticket on the tray did not have a magic cup documented as part of the lunch meal. During an interview on 07/31/2025 at 12:58 PM, Licensed Practical Nurse #25 observed the electronic medical record for Resident #34. They stated they were not able to locate a physician order or care plan intervention for a magic cup for Resident #34. They stated they were not aware why the magic cup was on their tray. During an observation on 08/01/2025 at 12:49 PM, the Food Service Director stated meal tickets were printed out from Meal Tracker software on the computer. Additional items should not be added on resident trays if not documented on the ticket. A magic cup would not be placed on a tray unless it was on ticket. They stated that the magic cup that was placed on Resident #34's tray was an error by an assembly line kitchen aide. 10NYCRR 415.14(c)(1-3)

Based on interviews and record review during the recertification survey from 7/29/2025-8/5/2025, the facility did not ensure that resident grievances were acted on promptly, or responded to, for two of seven residents (Resident # 7 and Resident #34) investigated for missing property. Specifically, 1) Resident #7 reported a pair of missing shorts to staff, completed a form, and never received the results of the investigation or replacement of the item; 2) Resident #34's spouse reported a pair of missing sneakers, completed a grievance form, and never received the results of the investigation or replacement of the item.The Facility Grievance Policy last reviewed 5/26/2022 documented that it is the policy of the facility to assist residents, their representatives (sponsors), other interested family members, or advocates in filing grievances or complaints when such requests are made. The Social Services Department is responsible for investigating the grievances and submit their findings in a written report to the Administrator in five days. 1) The Quarterly Minimum Data Set submitted 7/9/2025 documented Resident #7 had moderately impaired cognition.During an interview at the Resident Council Meeting on 7/30/2025 at 12:58PM, Resident #7 stated that they lost a pair of their shorts that were labeled with their name. They stated they completed a form to report the missing item, but the shorts were never found, and they never received any follow up to the grievance. The Facility Grievance Log had no documented evidence of any missing items for Resident #7 . During a telephone interview on 08/01/2025 at 10:22 AM, the Director of Social Work stated that residents, family, and staff members can complete a grievance form for missing items. Once received, social work staff completes an investigation and would replace or reimburse the resident for the item if it is on their inventory log and not found. They stated that they were not aware that Resident #7 was missing shorts, or that Resident #34 was missing sneakers. They stated they never received a grievance for either resident. They stated that staff should know grievances and grievance forms are handled by the Social Work Department. During an interview on 08/04/2025 at 8:33 AM, Certified Nurse Aide #16 stated that when a resident reports a missing an item, they report the missing item to the floor nurse or nurse supervisor. They stated they have never filled out a grievance form. During an interview on 08/04/2025 at 11:36 AM, the Director of Social Work confirmed that Resident #7 was missing shorts and Resident #34 was missing sneakers, and they would be replacing those items. They stated staff needed re-education on the process of reporting grievances.2) Resident #34 diagnoses included: vascular dementia, retention of urine, unspecified and type 2 diabetes mellitus. The Quarterly Minimum Data Set (a resident assessment tool) dated 7/9/25 documented Resident #34 had severe cognitive impairment.During an interview on 07/30/2025 at 10:33 AM, Resident #34's representative stated that Resident #34 had a pair of sneakers that went missing from their room in April 2025. They stated the missing sneakers were reported to nursing staff and they believe to the social work staff. They stated they have not been provided with follow-up information regarding the missing sneakers and have not been reimbursed for the sneakers. During an interview on 08/01/2025 at 11:39 AM, Registered Nurse #5 stated when a resident reports missing items, the Social Work Department is informed. They stated if a missing item is reported Monday to Friday 9:00AM to 5:00pm, Grievance Reports are completed by Social Work Department who will provide resident or resident representative a Grievance Form to complete. If a report is made after hours, Grievance Reports can be obtained at front desk in Nurse Supervisor binder and Nurse Supervisor or Director of Nursing should be notified immediately. Registered Nurse #5 stated investigations are completed by members of the Interdisciplinary Team which includes unit staff. Social work staff will notify unit staff and resident/resident representative of outcome if investigation. During an interview of 08/04/2025 at 10:56 AM, Certified Nurse Aide #15 stated that if a resident reports missing items, they report to Nurse Supervisor on unit or Director of Nursing. They stated they do not fill out a form and are not aware of a form that needs to be completed. The facility Grievance Log had no documented evidence of any missing items for Resident #34.During an interview on 08/04/2025 at 12:56 PM, the Director of Social Work stated that Resident #34's representative reported the missing items to a staff member who is no longer at the facility and that the staff member did not inform Social Work Department. Therefore, an investigation was not completed. They stated social work staff has confirmed that Resident #34 had sneakers documented on their admission Items Form. They stated the investigation will be completed and Resident #34 will be reimbursed. The Director of Social Work stated they are unaware why the missing items were not reported immediately to the Social Work Department. 10NYCRR 415.5(c)(6)

Based on observation, record review, and interview during the recertification, abbreviated (NY00359302), and extended surveys from 12/15/2024 to 12/22/2024, the facility failed to provide adequate supervision to prevent accidents related to smoking for 6 of 6 residents (#2, #6, #9, #29, #41 and #54) identified as smokers. Specifically, Resident #41 was a known smoker in a non-smoking facility and the facility failed to complete safety assessments or develop and implement a plan of care to ensure their safety, when it was known that the resident continued to smoke outside of the facility. On 11/1/2024 a fire was started on the outside patio when Resident #41 threw a cigarette butt into dry leaves. There were no facility staff supervising the resident during this smoking activity. Facility staff was alerted to the fire when the Director of Human Resources observed the smoke and fire from their office window. Facility staff had to remove residents from the area and extinguish the fire. Additionally, 2) Resident #54 had cigarettes and lighters with a strong odor of cigarette smoke in their room; 3) Residents # 2, #29, #41, and #54 were observed smoking on the patio without supervision. The patio was observed with cigarette butts in raised flower planters; there were no ashtrays or cigarette receptacles on the patio. The facility was aware the residents continued smoking and did not complete safety assessments or provide supervision. This resulted in Substandard Quality of Care, with no actual harm, that was Immediate Jeopardy with the likelihood for serious adverse outcome to all 102 residents in the facility. Findings include: The facility Smoking Policy and Procedure dated 1/21/2022 documented residents could smoke, and the Nursing Supervisor would assess the residents' ability to smoke safely by completing a smoking assessment that included an evaluation of the resident safety awareness, judgement, cognitive ability, and manual dexterity. The policy listed designated times for smoking and supplies would be marked with the resident's name and kept in a locked drawer in the copy room. The facility Smoking Policy dated 6/23/2022 documented smoking would not be permitted by residents. The policy did not address how to accommodate the residents that were smoking prior to the policy change. The policy did not address resident smoking contracts, agreements or participation in smoking cessation programs. 1) Resident #41 was admitted to the facility on [DATE] with diagnoses of Paraplegia (an impairment in motor or sensory function of the lower extremities), Schizoaffective and Borderline Personality disorder(Mental illness) . The Minimum Data Set (resident assessment tool) dated 10/18/2024 documented the resident had moderately impaired cognition and did not document tobacco use. Resident self ambulates by wheelchair. Resident #41's smoking assessment dated [DATE] documented the resident could only smoke while supervised. There were no further directions guiding the resident during smoking activity. There were no other smoking assessments in the resident's medical record. Resident #41's smoking care plan dated 9/1/2023, and a care plan review note dated 6/28/2024, documented the resident was found smoking in their room. Interventions included to review smoking policy with resident and family on admission, readmission and as needed. Staff will continue to counsel resident on a daily basis to ensure the safety of smoking in the facility is complied with. Resident has been referred to psychologist and psychiatrist due to his noncompliance with the facility policy of non-smoking, the resident will be educated and offered smoke cessation, visually observe residents clothing and surroundings regularly for signs of unsafe smoking including smoke, ashes and burns on hands and clothing. A nursing progress note dated 10/3/2024 documented staff approached Resident #41 regarding the aroma and visible smoke emanating from the resident's room. The resident was reminded that the facility was smoke free and instructed not to smoke in the facility. The resident acknowledged awareness of the policy and stated that smoking would not occur indoors in the future. A facility investigation dated 11/4/2024, completed by the facility Administrator, documented on 11/1/2024 around 4:15 PM, Resident #41 was smoking in the gazebo and put out a cigarette in the leaves behind the gazebo starting a fire. The root cause analysis determined Resident #41 was a smoker, frequently used the patio and put ashes on the gazebo and the ground surrounding it. The dry air and warm environment contributed to the cigarette butt lighting the dry leaves on fire. The immediate action was the patio was closed on the weekend and reopened on Monday 11/4/2024. The corrective action was Resident #41's patio privileges were revoked until further notice. The Director of Human Resources written statement, dated 11/1/2024, documented they smelled smoke from an open window, looked outside and saw a small fire starting to grow from behind the gazebo on the facility patio. Code Red was called, and they used extinguishers to put out the fire. The Social Worker was stomping the leaves, and Certified Nurse Aide #9 threw a fire blanket on the fire. Two residents were on the patio and taken back inside. Once the fire was out, they locked the patio door. There was no documented evidence Resident #41's comprehensive care plan was updated to reflect the need for increased supervision after the fire on 11/1/2024. During an interview on 12/15/2024 at 11:00 AM, at the entrance conference, the Administrator stated it was a non-smoking facility. They stated there were residents that smoked, and they were care planned for non-compliance. During an observation on 12/15/2024 at 1:15 PM, 12 cigarette butts were in the planter closest to the patio door with entrance into the building. The doors were labeled with no smoking signs. There were no ashtrays on the patio. During an interview on 12/15/2024 at 12:59 PM, Certified Nurse Aide #6 stated the facility was a non-smoking facility but there were residents that smoked. Cigarettes were taken from residents and held by the Administrator if the resident was a known smoker. They stated they believed there was a resident downstairs that got cigarettes and distributed them to other residents. Residents were not escorted outside to smoke by staff and could only smoke when on a leave of absence from the facility. They stated there was not a formal list of smokers but knew for certain that Resident #41 and Resident #6 smoked. - at 1:09 PM Licensed Practical Nurse #8 stated the facility was a non-smoking facility. They stated they thought there were residents that smoked but they were not tracked or listed anywhere. During an interview on 12/15/2024 at 1:10PM the receptionist stated the residents were allowed to go outside alone on the patio and the patio was open from 7:00 AM to7:00 PM. They stated no one should be smoking on the patio, not staff, residents, or visitors. They stated Resident #54 has an uncle that visits twice a week and takes the resident up by the entrance to smoke. They stated Residents #2, #6, #9, #29, #41 and #54 were known smokers. During an interview on 12/15/2024 at 1:25 PM Certified Nurse Aide #5 stated Resident #41 was a known smoker, and they had been advised by facility administration to watch the resident closely. They stated they had smelled cigarette smoke in the facility in the past but had not observed matches, cigarettes, or lighters in the resident rooms. During an interview on 12/15/2024 t 1:34 PM Certified Nurse Aide #1 stated Resident #54 and Resident #41 smoked on the patio and sometimes in their rooms. -at 1:46 PM the Registered Nurse Supervisor#2 stated it was a non-smoking facility and when the residents went out with their families they could smoke. They stated there was not supposed to be smoking on the patio, but some of the residents smoked on the patio including Resident #54. During an interview on 12/15/2024 at 1:11 PM, Resident #41 stated they were allowed to smoke when they were admitted to the facility and the facility changed the rules without discussion with residents. They stated no accommodations were made for smokers. They stated they had been accused of smoking and privileges had been taken away. During a follow up interview on 12/15/2024 at 4:25PM, Resident #41 stated they were not given a smoking contract or education regarding noncompliance after the fire. During an interview on 12/15/2024 at 2:00 PM the Administrator stated the facility was non-smoking but had residents who smoked. The Administrator stated residents who smoked were care planned for non-compliance with the smoking policy. They stated they were aware that smoking unsupervised on the patio, and residents could come and go freely. The Administrator provided a list of residents that smoked including Residents #2, #6, #9, #29, #41, and #54. During an interview on 12/16/2024 at 11:30 AM, the Administrator stated they were notified of the fire on 11/1/2024 but was out of the facility and did not return until Monday 11/4/2024. An investigation was initiated, and statements were taken immediately after the incident from staff and residents. The patio was closed for the weekend. Video evidence and interviews indicated that Resident #41 caused the fire. Resident #41 was indefinitely banned from the patio. The fire was investigated, and no new systematic interventions were put in place to prevent unsupervised smoking. Resident #41's patio privilege was revoked on 11/1/2024 and reinstated on 11/18/2024. During an interview on 12/16/2024 at 11:58 AM, the Director of Nursing stated they were aware that residents smoked on the patio unsupervised. They stated they viewed the video from the fire that occurred on 11/1/2024 and reviewed Resident #41's statement after the incident. They stated they did not put any interventions in place after the incident and stated the Smoking care plan documented regular monitoring. They stated the monitoring was not documented. During an interview on 12/16/2024 at 12:27 PM, the Director of Human Resources stated on 11/1/2024 the window was open, and they smelled burning leaves. They went to the patio and saw the fire by the gazebo. They told the receptionist to call Code Red and grabbed the fire extinguisher and used it. Neither the Administrator or Director of Nursing were in facility, both were notified and neither returned back to the facility. The Administrator directed them to lock the patio door. They did view the video and it showed Resident #41 going outside to the patio and then back inside. The Director of Human Resources stated the flames were high. They stated they were aware that residents smoked on patio, but no one including staff, visitors, or residents were allowed to smoke on facility property. During an interview on 12/16/2024 at 12:44 PM, the Social Worker stated when the fire code was called, they ran to the patio, staff was struggling with extinguisher, so they stomped on the fire. They were not notified of any resident patio privileges being lifted. They stated they had not witnessed residents smoking out on patio but stated that they had smelled smoke. During an observation and interview on 12/16/2024 at 1:15 PM, with the Maintenance Director, 2 residents were observed smoking in the gazebo located on the patio. There was no staff present and no ashtrays or metal containers with self-closing devices in the area. The Maintenance Director stated they told the residents many times that smoking was not allowed but the residents did not care and still smoked. They stated they could smell cigarette smoke coming from residents' rooms. They further stated that administration was aware that residents smoked unsupervised on the patio. The Maintenance Director stated that they did not know if the wooden gazebo was fireproofed. They stated that it was a nonsmoking facility, and that was why there were no ashtrays. During the resident council meeting on 12/16/2024 at 1:30 PM, multiple residents stated they knew there was smoking in resident rooms as well as outside. They stated they could smell both weed and cigarettes. The residents stated there was once a fire outside caused by smoking. The Resident Council did not complain about the smoking as a group. However, during the meeting several residents stated that they have complained to staff about residents smoking in the facility. During an observation on 12/17/2024 at 11:18 AM, Resident #41 was self-propelling their wheelchair on the patio heading to the gazebo. At the gazebo the resident took out their lighter and cigarettes, lit the cigarette and started smoking. No staff were observed monitoring the resident, patio area, or gazebo. During an observation on 12/17/2024 at 1:32 PM, Resident #41 was observed smoking cigarettes on the patio with Resident #6 and Resident #29. No staff was present on the patio while the residents were smoking. During an interview on 12/22/2024 at 2:30 PM, the owner of the facility stated they were aware the residents smoked, and they had some problematic residents which they had been trying to discharge. They stated the issue was not brought up at the Quality Assurance/Performance Improvement committee meetings. 2. Resident #54 was admitted to the facility on [DATE] with diagnoses including nicotine dependence, cannabis dependence, quadriplegia and muscle spasms. The Minimum Data Set, dated dated dated [DATE] documented intact cognition and functional limitations in range of motion to both upper and lower extremities. Resident utilizes a motorized wheelchair for mobility. A smoking evaluation, dated 7/8/2021, documented Resident #54 could smoke with supervision only. There were no other smoking assessments in the resident's medical record to determine if the resident could smoke safely. The care plan titled Non-Compliance last updated 5/22/2024, documented interventions to educate the resident on the nonsmoking policy, monitor resident for smoking regularly and upon return from leave of absence for signs of smoking. Report any issues to the supervisor immediately and smoking cessation support was to be offered. There was no documented evidence that smoking cessation materials were ordered or administered to the residents who smoke. The care plan titled Smoking last updated 10/1/2024, documented Resident #54 was a known smoker, including smoking marijuana. The interventions include to check the resident's clothing regularly and upon return from leave of absence for evidence of unsafe smoking practice. The smoking policy was to be reviewed with the resident and family upon admission and as necessary. Smoking cessation support was to be offered. A 12/4/2024 a physiatry note documented Resident #54 had bilateral upper extremity spasticity with some use of the right hand. On 12/15/2024 at 9:30 AM, Resident #54 was observed with smoking materials including cigarettes, 2 lighters and a dried shredded green/brown mix of stems, seeds, and leaves, on the resident's overbed table; a heavy odor of cigarette smoke was noted in their room. The resident was interviewed at the time of observation and stated the cigarettes and lighters belonged to them. They stated they smoked outside on the patio, without staff present and lit their own cigarettes. During an observation on the patio on 12/15/2024 at 1:15 PM 12 cigarette butts were identified in the planter closest to the patio door leading to the building. The doors were clearly marked with No Smoking signs. When interviewed on 12/15/2024 at 1:34 PM, Certified Nurse Aide #1 stated Resident #54 and Resident #41 smoked on the patio and sometimes in their rooms. 3. Resident #29 was admitted to the facility on [DATE] with diagnosis of Schizophrenia (mental disorder) diabetes and anxiety disorder. The 10/14/2024 Quarterly Minimum Data Set documented Resident #29 demonstrated intact cognition and is dependent on staff for activity of daily living. Resident utilizes a wheelchair for mobility. Review of the electronic health record revealed Resident #29 had no care plan for smoking or non-compliance. During an interview on 12/15/2024 at 1:27 PM, Resident #29 stated there were residents in the facility who smoked outside at night. During an observation of the patio on 12/15/2024 at 4:18 PM, Residents #29 and #2 were outside the patio door on their way into the facility. A strong odor of cigarette smoke was present, no staff members were observed providing supervision on the patio. The residents were interviewed at the time and Resident #29 stated they were not smoking but Resident #2 was. Resident #2 was aphasic (a disorder that impairs the ability to communicate) but shook their head no. Resident #29 stated they were allowed to smoke when they were admitted to the facility and one day they were told they could no longer smoke at the facility. During an observation on 12/16/2024 at 1:15 PM, with the Director of Maintenance present, Residents #29 and #54 were observed smoking in the gazebo located on the patio without supervision. Resident #29 was interviewed at the time and stated that they discarded their ashes in the snow. During an observation on 12/17/2024 at 1:32 PM, Resident #6, Resident #29, and Resident #41 were observed smoking cigarettes on the patio without staff supervision. The facility was notified of the Immediate Jeopardy on 12/18/2024 at 4:39 PM. The Immediate Jeopardy was lifted on 12/21/2024 prior to the completion of the survey based on the following corrective actions: 1. The Smoking Policy was reviewed and updated to include that residents admitted to the facility prior to the implementation of the nonsmoking policy would be given smoking privileges. These residents who desired to smoke would be permitted to do so if the facility Interdisciplinary Team determined that the practice was safe for the residents, and they do so in the facility designated area. 2. A nursing assessment by a Registered Nurse was done for all smokers. They examined the residents and clothing for any burns. This was completed this on 12/18/2024. 3. All residents that currently smoke were assessed to determine if they were safe to smoke or require supervision and or assistance. This was completed 12/18/2024. 4. Safe smoking contracts were established for residents that smoke. This was completed on 12/18/2024. 5. A safe smoking area 30 feet from the building was established on 12/18/2024. 6. Appropriate receptacle for cigarettes butts was installed. On 12/18/2024 the receptacle was ordered with a delivery date 12/23/2024. On 12/20/2024 a small metal step-on garbage can that self-closed was installed. Surveyors observed garbage can being utilized during smoking activity. Two residents (#29, #41) were observed smoking on the patio under staff supervision. Cigarettes were disposed of in the can under the supervision of the facility staff. On 12/21/2024 at 10:00 AM, Residents #54, #29, #2 and #41 were observed smoking on the patio in the designated area under staff supervision. The small metal step-on garbage can was in use. 7. Sign for supervised smoking area was posted on 12/18/2024. 8. Smoking aprons were placed by exit to patio for those residents assessed to need an apron. On 12/21/2024 two smoking aprons were observed stored in two tier plastic storage bins by the [NAME] room door. 9. A standard size all-purpose fire extinguisher was located near the patio door on 12/18/2024. 10. Smoking materials for all residents were removed from resident rooms and placed in a locked medication cart, completed 12/18/24. 11. Supervised smoking times were assigned for 10:00 AM, 2:00 PM and 6:30 PM; doors were locked when smoking was not in session, completed 12/18/2024. 12. Schedule of staff supervision was completed 12/19/2024. 13. Care plans for all 6 smokers were completed for safe smoking on 12/19/2024. 14. Physician orders for each smoker documented residents were care planned to smoke in facility designated area only. 15. The facility employs 109 staff members. Of these, 102 completed the in-service training, including supervisors. Dates of the in-service were 12/18/2024, 12/19/2024 and 12/20/2024. A sample of staff members from Nursing, Rehabilitation, Administration, and Recreation were interviewed and verified they received the education. 16. All supervisor staff were educated on facility procedures particularly their role to call 911 in the event of a fire. 17. An hourly smoking monitoring log was maintained to check resident rooms for signs of smoking. 18. The patio door was locked and remained locked except during the smoking times. Staff was observed supervising the smokers, unlocking the door to allow the residents into the smoking area and locking the door when smoking was completed. 10 NYCRR 415.5(f)(2) 44673

Based on record review and interviews during an abbreviated survey (NY00340632, NY00340457) the facility did not ensure the resident environment was free of accident hazards and that each resident received adequate supervision to prevent accidents for 1(Resident #1) out of 3 residents reviewed for accidents. Specifically, on 4/28/2024 at 5:45 AM Resident #1 is seen on video surveillance walking with their cane and pushed open the locked inner lobby door with their body. Licensed Practical Nurse #1 was seen coming from outside the facility, passed through the outer lobby door and pushed the inner lobby door against Resident #1, which caused Resident #1 to fall to the floor. Subsequently, Resident #1 sustained a bloody nose, black right eye, and a bruised left ankle. The actions taken by Licensed Practical Nurse #1 to stop Resident #1 from passing through the lobby door resulted in actual harm that is not immediate jeopardy. Findings include: Resident #1 was initially admitted to the facility with diagnosis including, but not limited to, Chronic Obstructive Pulmonary Disease (a disease characterized by persistent breathlessness and cough), schizoaffective disorder (a disorder that is marked by dramatic changes in their thoughts, mood, behaviors) and Alzheimer's disease. A quarterly Minimum Data Set (an assessment tool) dated 5/22/2024 documented Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 15, associated with intact cognition. Resident #1 required set up assistance with eating, supervision for toileting, and was independent for bed mobility and transfers. Resident #1 ambulated with a walker or used a wheelchair for locomotion. Resident #1 exhibited verbal behaviors directed towards others, wandering behaviors and was frequently incontinent of bowel and occasionally incontinent of bladder. Review of an elopement risk assessment dated [DATE] documented Resident #1 had a history of wandering, opening doors to the outside and/or elopement, and making statements about leaving. The assessment documented the facility will care plan as a high risk for elopement, educate staff and enter notation on certified nurse assistant accountability sheet. There was no documented evidence of any elopement measures/interventions in place. Review of a behavior care plan dated 3/25/2024 listed behavior problems as follows: verbally abusive, physically abusive, socially inappropriate/disruptive, resists care and resists medications. Interventions listed included: medical and psychiatric management as per physician's order, psychiatric evaluation and follow up, psychological services, administer psychoactive medications as per physician's order, provide emotional support, remove resident from public areas when behavior or language is unacceptable. There was no documentation identifying wandering as a behavior exhibited by the resident. Review of the admission assessment dated [DATE] documented Resident #1 had a history of falls and was a high risk for falls. Review of a Falls Care Plan dated 5/19/2024 documented no identified risk. Interventions listed included: ensure a safe clutter free environment, ensure proper footwear. The fall care plan was not updated with the incident that occurred on 4/28/2024. Review of the video surveillance for 4/28/2024 at 5:45 AM revealed Resident #1 ambulating with a cane to the facility front doors. Resident #1 bumped against the inner door, and it opened slightly. Resident #1 put their foot and cane into the space of the opened door. Licensed Practical Nurse #1 was seen running from the parking lot through the outer door and pushing the inner door against Resident #1 causing Resident #1 to fall to the ground. Review of Physician Assistant #1's progress note dated 4/30/2024 documented the reason for the consult was status post traumatic fall. The progress note documented Resident #1 had a fall to the floor over the last few days and the preceding events to the fall were under review. Physician Assistant # 1 documented Resident #1 reported they were stiff after the fall and upon examination Resident #1 had ecchymosis to the right eye orbit with no discernable tenderness and some swelling to lower extremity. Review of Physician Assistant #2's progress note dated 5/1/2024 documented Resident #1 presented for evaluation following a recent fall and x-ray review. Physician Assistant #2 documented the resident reported experiencing chest discomfort due to the fall and is currently on pain management medications. Physician Assistant #2 documented the resident is non-compliant with safety precautions and has a history of multiple falls. The assessment and plan documented status post fall, x-ray was reviewed and was negative for significant injury or fracture and resident was encouraged to adhere to safety precautions to prevent future falls. During an interview on 6/17/2024 at 2:40 PM Licensed Practical Nurse #1 stated they have been working in the facility for 4 and a 1/2 years. They stated they were outside in their car for break and saw Resident #1 walking in the lobby. When Resident #1 approached the front door, Licensed Practical Nurse #1 stated they got out of their car and ran to the door and tried to prevent Resident #1 from exiting. Licensed Practical Nurse #1 stated they did not realize Resident #1 was close to the door, because they were running, and their adrenaline was pumping. The Licensed Practical Nurse stated the door hit the resident and the resident fell to the floor. Licensed Practical Nurse #1 stated they entered the lobby, the alarm was sounding, so they reset the alarm, and called out for the supervisor from the lobby because they did not want to leave the resident alone. Licensed Practical Nurse #1 stated when Registered Nurse Supervisor #1 arrived, they assessed Resident #1, and they placed a wet cloth on the resident's face because the resident's nose was bleeding. Licensed Practical Nurse #1 stated they asked Resident #1 if anything hurt, and they stated only their nose hurt. Licensed Practical Nurse #1 stated they put Resident #1 into a wheelchair and took them to their room. The physician was made aware, and they ordered to send Resident #1 to the hospital. Licensed Practical Nurse #1 stated Resident #1 refused, despite encouragement. Licensed Practical Nurse #1 stated the resident had x-rays done to ensure there were no injuries. Licensed Practical Nurse #1 stated Resident #1 was known to attempt to exit the building and had previously exited the building. Licensed Practical Nurse #1 stated Resident #1 had broken the glass of the front door before. Licensed Practical Nurse #1 stated Resident #1 has had wander guards applied before, and they cut them off. Licensed Practical Nurse #1 stated Resident #1 kept saying they know Licensed Practical Nurse #1 did not mean it and that it was their fault. Licensed Practical Nurse #1 stated they believe the unit manager and the Director of Nursing made updates to the care plan after the incident. During an interview on 6/17/2024 at 3:00 PM Registered Nurse Supervisor #1 stated Resident #1 exited their room by the nurse's station and was going in the opposite direction towards the elevators in a hurry. Registered Nurse Supervisor #1 stated Resident #1 then leaned up against the wall because they were out of breath. They stated they got on the elevator to go look for Resident #1 and found them on the basement level. Registered Nurse Supervisor #1 stated Resident #1 told them to get off the elevator and stop following them, so they got off the elevator and got on the next one. Registered Nurse Supervisor #1 stated the elevators left the basement level at the same time, but by the time they got to the first floor they heard Resident #1 screaming and Licensed Practical Nurse #1 saying Resident #1 was hurt. Registered Nurse Supervisor #1 stated Resident #1 had a nosebleed and kept saying their nose was broken. They stated they did not witness the incident because by the time they got to the lobby, Resident #1 was already on the floor. Registered Nurse Supervisor #1 stated Resident #1 was frail, frequently ran out of breath, and used oxygen. During an interview on 6/18/2024 at 10:20 AM the Director of Nursing stated they were called and told Resident #1 had tried to get out of the building. The Director of Nursing stated prior to 2023, Resident #1 had broken the glass to the front door and tried to exit. Resident #1's behavior is more attention seeking than an elopement risk. They stated the facility has tried everything to make sure Resident #1 was safe and they tried to use wander guards, but Resident #1 is ambulatory with their walker or cane and takes the wander guard off. The Director of Nursing stated the resident is extremely accusatory. The Director of Nursing stated they have informally done 1:1 monitoring with Resident #1, but it is impossible to have a 1:1 monitoring in place due to the size of the building. The Director of Nursing stated these events happen with Resident #1 daily so someone would have to follow them all the time and that having 1:1 monitoring in place with Resident #1 may make the situation worse. During an interview on 6/18/2024 at 1:15 PM the Administrator stated Resident #1 does this all the time and previously had broken the front door glass. The Administrator stated Resident #1 is always trying to leave the building and once they are outside, they will just sit down. The Administrator stated Resident #1 is alert, and they will remove the wander guard if one is placed on them. During an interview on 7/10/2024 at 1:30 PM Resident #1 stated they remember running out of oxygen in their tank on 4/28/2024. Resident #1 stated they asked for another tank and the staff were taking too long, so they went to get one themself and they got very dizzy and could not make it to the oxygen tank. Resident #1 stated Registered Nurse Supervisor #1 showed up and tried to get them to sit down in another resident's wheelchair. Resident #1 stated they do not sit in other resident's wheelchairs. They stated they were out of it, but they were still refusing to sit in the wheelchair. Resident #1 stated Registered Nurse Supervisor #1 yelled out to the staff, this resident does not get help with anything, no oxygen, no nothing. They stated they needed oxygen, and they were dizzy. Resident #1 stated they know they could go to the front door and get more fresh air in between the front doors. They stated they bumped the front door open with their bottom and the next thing they knew they were being attacked from behind. Resident #1 stated their leg was locked between the 2 doors and Licensed Practical Nurse #1 slammed them down to the floor. Resident #1 stated blood was gushing out of their nose and lip and that they were on blood thinners. Resident #1 stated they also had pain in their chest, and they have a bad heart, and it felt like a knee was in their back. Resident #1 stated they were trying to get air when they tried to exit. Resident #1 stated they go outside when they need some air. The resident stated they were not trying to leave the building they were just trying to get some air. Resident #1 stated when they are dazed and confused, they may wander to the front door in attempt to get air. Resident #1 stated they are not allowed to have a one to one, even though they asked for that and the facility has more staff now. Resident #1 stated they hit the wrong button in the elevator and went to the basement level. The resident stated Registered Nurse Supervisor #1 came down in a separate elevator and asked why they went down there. During a telephone interview on 7/11/2024 at 11:20 AM Physician's Assistant #1 stated they believe the injuries sustained by Resident #1, matched the reported incident that occurred on 4/28/2024. Physician's Assistant #1 stated Resident #1 is a very aggressive individual, not only verbally but physically, and that Resident #1 was physically aggressive towards them before. Physician's Assistant #1 stated Resident #1 has a very unsteady gait and can barely walk with a walker, so having an injury or bruising is not unusual. They stated they were informed by the nursing staff that Resident #1 had a fall after trying to break the door down and sustained a bruise to their eye. 10 NYCRR 415.12(h)(2)

Based on observation, interviews and record review during a Focused Infection Control and abbreviated survey (#NY 820) completed on 08/12/2020, the facility did not ensure that residents are free of significant medication errors for 40 out of 93 residents reviewed for Medication Administration. Specifically, on 08/04/2020 at 5:00 PM the facility experienced a power outage disabling their Electronic Medical Record (EMR) System. Staff were not knowledgeable on how to operationalize their back up system for EMRs. Residents did not receive significant medications including insulin, anti-coagulants, antibiotics, and anti-[CONDITION(S)] medications, as ordered by the physician until the following day, 08/05/2020 at approximately 11:45 AM. This was evident but not limited to Residents #2, #7, #10, #11, #17, #28, #43, #53, #54, #70, #72, #75. This resulted in potential for serious harm that is Immediate Jeopardy to the health and safety of 93 residents in the facility. The findings include but are not limited to: A Facility Policy & Procedure on Administration of Medications, reviewed and revised on 06/2016, documented that a licensed nurse will be responsible for passing medications to residents according to techniques approved for use at this facility in compliance with the New York State Codes, Rules and Regulations and other applicable State and Federal Laws. An undated Facility Policy & Procedure on the Electronic Medical Record Backup System (EMRBS) Internet Downtime submitted by the Director of Nursing (DON) on 08/05/2020 documented that the delivery of nursing care will continue in the event of internet loss via utilization of the EMRBS. If the Electronic Medical Record (EMR) appears to be offline, staff will inform the nursing supervisor. The nursing supervisor will contact the Administrator. If the EMR is confirmed to be offline, the EMRBS will be implemented, and staff will print out necessary Administration Records, Certified Nursing Assistant (CNA) documentation sheets and Nurse instructions. During an observation on 08/05/2020 at 09:45 AM, it was noted that the facility's staff were unable to access the EMR system due to power outage that occurred on 08/04/2020 at 5:00 PM. In addition, staff were not knowledgeable on how to activate the EMRBS. There was no documented evidence of any formal training provided regarding the EMRBS. 1) Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Medication Administration Record (MAR) dated 08/05/2020 at 1:11 PM revealed that the resident's [CONDITION(S)] medication [MEDICATION(S)] 100 mg/ml oral solution, 10ml (1000mg) orally twice a day was not administered on 08/04/2020 at 6 PM and 08/05/2020 at 6 AM. 2) Resident #70 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of MAR dated 08/05/2020 at 1:34 PM revealed that the antibiotic [MEDICATION(S)] 100 mg 2 capsule orally twice a day was not administered on 08/04/2020 at 6 PM and 08/05/2020 at 6 AM. [MEDICATION(S)] 180 mg orally daily for opioid dependence, was not administered on 08/05/2020 at 9 AM. 3) Resident #11 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of MAR dated 08/05/2020 at 1:18PM revealed that Insulin [MEDICATION(S)] 100 mg/mL 8 units subcutaneous route three times a day before meals for DM, was not administered on 08/04/2020 at 4:30 PM and 08/05/2020 at 7:30 AM. [MEDICATION(S)] Insulin 100 unit/mL inject 50 units by subcutaneous route for DM was not administered on 08/04/2020 at 10 PM, and anticoagulant [MEDICATION(S)] 5 mg 1 tablet orally every 12 hours was not administered on 08/04/2020 at 9 PM and 08/05/2020 at 9 AM. 4) Resident #75 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR dated 08/05/2020 at 1:36 PM revealed that [MEDICATION(S)] 1.25 gm/250 ml in [MEDICATION(S)] intravenous (IV) route three times a day for [CONDITION(S)] was not administered on 08/04/2020 at 9AM and 8 PM, and on 08/05/2020 at 1 AM and 9 AM. There was no evidence that the Medical Director was notified of medication administration issues until 8/5/2020, when nurses requested for an order to hold Morning medications due to the power outage. An interview was conducted on 08/05/2020 at 9:30 AM and at 5:48PM, with the Infection Control Nurse (ICN)/Staff Development Coordinator (SDC). She stated she was the covering Nursing Supervisor on 08/04/2020. She stated during the shift at 5:00PM, the power went out. She stated the generator was working so they had lights and elevators, and she made sure that resident beds, air mattresses, and oxygen concentrators were plugged into the red outlets in the residents' rooms. She stated she assumed EMRBS was functioning as none of the nurses informed her of a problem with medication administration. The ICN/SDC stated that she left for the day when the evening supervisor came in at 5:45 PM on 08/04/2020. An interview was conducted on 08/06/2020 at 12:53 PM with the evening supervisor, Licensed Practical Nurse (LPN) Supervisor #1. She stated she was the evening supervisor on duty 08/04/2020 and she relieved the ICN around 5:45 PM. The Human Resource (HR) Officer informed her that the power was out and that the Administrator and Facility Owner (FO) was aware. The HR also instructed her that if the power does not come back to call the Administrator. The supervisor stated that she called the administrator around 6:50 PM to inform him that the power was still out and that the phones were not working, she called him again at 8 PM then at 9 PM. The supervisor stated the nurses were able to administer medications through personal hotspots. She stated that she did not inform the Administrator or the DON of any issues regarding medication administration because nobody informed her that there were issues with Sigma Care (Cloud Based EMRBS). An interview was conducted on 08/05/2020 at 9:45 AM with two Licensed Practical Nurses (LPN #1 and LPN #2) assigned to the second floor. The LPN #1 and 2 stated that due to the power outage, the medication administration was on hold per management, and were waiting on doctors' orders as to how to proceed. LPN #1 and #2 stated that they did not know how to use the EMRBS and could not recall any training on how to operate it. An interview was conducted on 08/05/2020 at 10:12 AM with the first floor Unit Manager (UM). UM stated she found out about the power outage when she came on the unit at 7:30 AM. The UM stated she was not able to administer the 8 AM, 9 AM and 10 AM medications because the computers were not working. She was not provided with the printed Medication Administration Records (MAR). The UM stated that she was not trained to use the EMRBS and the Supervisor was supposed to provide the printed copy of MARS from the EMRBS. An interview was conducted on 08/05/2020 at 11:45 AM, with the Administrator. He stated he was not in the facility when the power went out. He stated that he received a phone call from Human Resources (HR) informing him that the power was out, and the generator was running, so he did not return to the facility. He stated that the day before the electrical power was on and off the whole day, and he thought it would be the same thing. He stated that before he left, he instructed the ICN to check all concentrators, beds, and mattresses to ensure they were plugged into the red outlets. He stated he was not aware of the EMRBS issue, and he is not familiar with the EMR. He stated later in the evening, he was informed by the evening supervisor that the power was still out, and the generator was working. The supervisor informed him that there were some omissions in the medications, but she was able to connect to a hot spot. The Administrator stated that everything seemed okay, so he did not call the DON. The Administrator stated that he did not know about the EMRBS issue until this morning. He stated that the EMRBS was not plugged into a generator outlet, so it did not work. On 08/05/2020 at 2:34 PM, the DON was interviewed. She stated that she found out about the power outage and the EMRBS failure to generate the MAR forms when she arrived this morning around 7:30 AM. She stated she attempted to troubleshoot the EMRBS herself but did not check whether Sigma Care was plugged in to the generator outlet. A telephone interview was conducted with the Medical Director on 08/06/2020 at 3:07 PM who stated that he was not aware of the power failure or any medications not given due to the power failure on 08/04/2020. He stated that he found out on 08/05/2020 when the nurses asked him to hold the morning medications due to the power outage. At around 11 AM, he gave an order to give all 9 AM meds as soon as the nurses can sign the MAR. 415.12(m)(2)

Based on observation, interviews and record review during a Focused Infection Control and abbreviated survey (#NY 820) completed on 08/12/2020, the facility did not ensure that residents are free of significant medication errors for 40 out of 93 residents reviewed for Medication Administration. Specifically, on 08/04/2020 at 5:00 PM the facility experienced a power outage disabling their Electronic Medical Record (EMR) System. Staff were not knowledgeable on how to operationalize their back up system for EMRs. Residents did not receive significant medications including insulin, anti-coagulants, antibiotics, and anti-[MEDICAL CONDITION] medications, as ordered by the physician until the following day, 08/05/2020 at approximately 11:45 AM. This was evident but not limited to Residents #2, #7, #10, #11, #17, #28, #43, #53, #54, #70, #72, #75. This resulted in potential for serious harm that is Immediate Jeopardy to the health and safety of 93 residents in the facility. The findings include but are not limited to: A Facility Policy & Procedure on Administration of Medications, reviewed and revised on 06/2016, documented that a licensed nurse will be responsible for passing medications to residents according to techniques approved for use at this facility in compliance with the New York State Codes, Rules and Regulations and other applicable State and Federal Laws. An undated Facility Policy & Procedure on the Electronic Medical Record Backup System (EMRBS) Internet Downtime submitted by the Director of Nursing (DON) on 08/05/2020 documented that the delivery of nursing care will continue in the event of internet loss via utilization of the EMRBS. If the Electronic Medical Record (EMR) appears to be offline, staff will inform the nursing supervisor. The nursing supervisor will contact the Administrator. If the EMR is confirmed to be offline, the EMRBS will be implemented, and staff will print out necessary Administration Records, Certified Nursing Assistant (CNA) documentation sheets and Nurse instructions. During an observation on 08/05/2020 at 09:45 AM, it was noted that the facility's staff were unable to access the EMR system due to power outage that occurred on 08/04/2020 at 5:00 PM. In addition, staff were not knowledgeable on how to activate the EMRBS. There was no documented evidence of any formal training provided regarding the EMRBS. 1) Resident #2 had [DIAGNOSES REDACTED]. Review of Medication Administration Record (MAR) dated 08/05/2020 at 1:11 PM revealed that the resident's [MEDICAL CONDITION] medication [MEDICATION NAME] 100 mg/ml oral solution, 10ml (1000mg) orally twice a day was not administered on 08/04/2020 at 6 PM and 08/05/2020 at 6 AM. 2) Resident #70 had [DIAGNOSES REDACTED]. Review of MAR dated 08/05/2020 at 1:34 PM revealed that the antibiotic [MEDICATION NAME] 100 mg 2 capsule orally twice a day was not administered on 08/04/2020 at 6 PM and 08/05/2020 at 6 AM. [MEDICATION NAME] 180 mg orally daily for opioid dependence, was not administered on 08/05/2020 at 9 AM. 3) Resident #11 had [DIAGNOSES REDACTED]. Review of MAR dated 08/05/2020 at 1:18PM revealed that Insulin [MEDICATION NAME] 100 mg/mL 8 units subcutaneous route three times a day before meals for DM, was not administered on 08/04/2020 at 4:30 PM and 08/05/2020 at 7:30 AM. [MEDICATION NAME] Insulin 100 unit/mL inject 50 units by subcutaneous route for DM was not administered on 08/04/2020 at 10 PM, and anticoagulant Eliquis 5 mg 1 tablet orally every 12 hours was not administered on 08/04/2020 at 9 PM and 08/05/2020 at 9 AM. 4) Resident #75 had [DIAGNOSES REDACTED]. Review of the MAR dated 08/05/2020 at 1:36 PM revealed that [MEDICATION NAME] 1.25 gm/250 ml in 0.9% sodium chloride intravenous (IV) route three times a day for [DIAGNOSES REDACTED] was not administered on 08/04/2020 at 9AM and 8 PM, and on 08/05/2020 at 1 AM and 9 AM. There was no evidence that the Medical Director was notified of medication administration issues until 8/5/2020, when nurses requested for an order to hold Morning medications due to the power outage. An interview was conducted on 08/05/2020 at 9:30 AM and at 5:48PM, with the Infection Control Nurse (ICN)/Staff Development Coordinator (SDC). She stated she was the covering Nursing Supervisor on 08/04/2020. She stated during the shift at 5:00PM, the power went out. She stated the generator was working so they had lights and elevators, and she made sure that resident beds, air mattresses, and oxygen concentrators were plugged into the red outlets in the residents' rooms. She stated she assumed EMRBS was functioning as none of the nurses informed her of a problem with medication administration. The ICN/SDC stated that she left for the day when the evening supervisor came in at 5:45 PM on 08/04/2020. An interview was conducted on 08/06/2020 at 12:53 PM with the evening supervisor, Licensed Practical Nurse (LPN) Supervisor #1. She stated she was the evening supervisor on duty 08/04/2020 and she relieved the ICN around 5:45 PM. The Human Resource (HR) Officer informed her that the power was out and that the Administrator and Facility Owner (FO) was aware. The HR also instructed her that if the power does not come back to call the Administrator. The supervisor stated that she called the administrator around 6:50 PM to inform him that the power was still out and that the phones were not working, she called him again at 8 PM then at 9 PM. The supervisor stated the nurses were able to administer medications through personal hotspots. She stated that she did not inform the Administrator or the DON of any issues regarding medication administration because nobody informed her that there were issues with Sigma Care (Cloud Based EMRBS). An interview was conducted on 08/05/2020 at 9:45 AM with two Licensed Practical Nurses (LPN #1 and LPN #2) assigned to the second floor. The LPN #1 and 2 stated that due to the power outage, the medication administration was on hold per management, and were waiting on doctors' orders as to how to proceed. LPN #1 and #2 stated that they did not know how to use the EMRBS and could not recall any training on how to operate it. An interview was conducted on 08/05/2020 at 10:12 AM with the first floor Unit Manager (UM). UM stated she found out about the power outage when she came on the unit at 7:30 AM. The UM stated she was not able to administer the 8 AM, 9 AM and 10 AM medications because the computers were not working. She was not provided with the printed Medication Administration Records (MAR). The UM stated that she was not trained to use the EMRBS and the Supervisor was supposed to provide the printed copy of MARS from the EMRBS. An interview was conducted on 08/05/2020 at 11:45 AM, with the Administrator. He stated he was not in the facility when the power went out. He stated that he received a phone call from Human Resources (HR) informing him that the power was out, and the generator was running, so he did not return to the facility. He stated that the day before the electrical power was on and off the whole day, and he thought it would be the same thing. He stated that before he left, he instructed the ICN to check all concentrators, beds, and mattresses to ensure they were plugged into the red outlets. He stated he was not aware of the EMRBS issue, and he is not familiar with the EMR. He stated later in the evening, he was informed by the evening supervisor that the power was still out, and the generator was working. The supervisor informed him that there were some omissions in the medications, but she was able to connect to a hot spot. The Administrator stated that everything seemed okay, so he did not call the DON. The Administrator stated that he did not know about the EMRBS issue until this morning. He stated that the EMRBS was not plugged into a generator outlet, so it did not work. On 08/05/2020 at 2:34 PM, the DON was interviewed. She stated that she found out about the power outage and the EMRBS failure to generate the MAR forms when she arrived this morning around 7:30 AM. She stated she attempted to troubleshoot the EMRBS herself but did not check whether Sigma Care was plugged in to the generator outlet. A telephone interview was conducted with the Medical Director on 08/06/2020 at 3:07 PM who stated that he was not aware of the power failure or any medications not given due to the power failure on 08/04/2020. He stated that he found out on 08/05/2020 when the nurses asked him to hold the morning medications due to the power outage. At around 11 AM, he gave an order to give all 9 AM meds as soon as the nurses can sign the MAR. 415.12(m)(2)

Based on record review and staff interview conducted during an abbreviated survey (Complaint Investigation), the facility did not provide the resident with sufficient fluid intake to maintain proper hydration for 1 of 3 residents reviewed for tube feeding and significant weight loss (Resident #1). Specifically, the facility failed to ensure that a high risk resident received adequate fluids to prevent dehydration. This resulted in actual harm that is not immediate jeopardy. Complaint Intake #NY 693 The findings are: Resident #1 is [AGE] years old and was admitted to the facility 4/25/14 with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS; a resident assessment tool) of 5/2/14 indicated that the resident had severe cognitive impairment and that he required extensive assistance for completion of his activities of daily living; had a feeding tube in place; height was 66 inches and weighed 110 lbs. at the time of assessment. The physician's orders [REDACTED]. On 5/1/2014, the attending physician ordered to "Provide 200 cc water flush via PEG (gastric tube) before and after tube feeding; Nepro Carb Steady 0.08 gram -1.80 kcal/ml oral liquid; give 56 cc water per hour by gastric tube every 24 hours (56cc/hour for 18 hours from 4PM to 10AM, Flush of 25 cc/hr. from 4PM to 10AM. Water flush of 30 cc before start of feeding, 330 cc at completion of feeding, water flush of 30 cc before and after medication administration". The laboratory tests dated 4/28/14 revealed that the blood sodium level was 147 (normal range is 133-145), BUN 30 (blood urea nitrogen; normal range is 8-23), chlorides 108 (normal range is 96-108). The weight monitoring record dated 5/7/14 indicated that the resident had an 11.1 lbs. weight loss. The resident's weight recorded on 4/30/14 was 110.2 lbs and 99.1 lbs. on 5/7/2014. The dietary progress note dated 5/8/14 indicated that the feeding pump, used to administer the nutritional supplements, was not functioning. This note further stated that one of the feeding formulas that was started on 5/4/14, was still being administered on 5/8/14, contrary to the rate and frequency that was ordered by the attending physician on 4/25/14. The laboratory tests dated 5/9/2014 revealed the blood sodium level was 156 (normal range 135-145), BUN 48 (blood urea nitrogen normal range is 8-23), chlorides 118 (normal range 96-108). This test was conducted after it was identified that the resident did not receive the amount of formula and fluids prescribed by the physician. The Physician was made aware of the laboratory results of 5/9/14. A physician note dated 5/11/14 indicated the [DIAGNOSES REDACTED]. These abnormal laboratory values were indicative of possible dehydration. Review of the Resident's Medical Record and the Medication Administration Record [REDACTED]. There was no policy in place for monitoring the total amount of fluid infused per shift. The Registered Dietitian (RD) was interviewed on 6/5/2014 at 1:50 PM and stated that the resident's feeding pump was not working properly and the formula bag, that was being administered on 5/8/14 was labeled 5/4/14. The RD stated that during a weekly weight loss meeting, it was revealed that the resident had a significant weight loss. The RD immediately conducted an investigation. The DON was also interviewed at this time and stated that the feeding pump was not functioning at that time and that the resident did not receive the prescribed amount of fluids and supplements ordered by the physician. During further interview at this time, the DON stated that when the feeding pumps "beep", the nurses should know that they are not working. The DON further stated that the nurses should have notified the physician for consideration of alternate type of feeding order, either by bolus or gravity. The Licensed Practical Nurse (LPN #1) was interviewed on 6/5/14 at 2:20 PM and stated that she first learned about the defective feeding pump on 5/8/2014 after the DON and the RD checked the feeding pump and brought it to her attention. LPN #1 further stated she worked on 5/3/2014 and 5/4/2014, and on 5/4/2014 she observed the date 5/2/2014 written on the feeding formula bag and that the feeding pump was not working. LPN #1 stated that she left the feeding bag hanging because the resident did not receive his feeding. She states she reported this to the Registered Nurse Supervisor (RN #1), but did not check the feeding bag for amount. She states that she did not realize that the feeding formula dated 5/4/2014 was still being administered for two days until the DON brought it to her attention on 5/8/2014. There was no evidence prior to 5/8/2014 that monitoring for actual total amounts of fluid was documented after notification of the non funtioning feeding pump. Review of physican progress note dated 5/09/2014, entered 5/11/2014 documented, "presenting symtoms of [DEVICE] malfuntion, crushed medications and flushes OK, feedings were backing up." "Pump was replaced with correction of problem." "[DIAGNOSES REDACTED]." RN #1 was interviewed on 6/24/2014 at 11:00 AM. She stated that she instructed LPN #1 to check the feeding pump and then to call her back. RN #1 stated that LPN #1 did not call her and that she did not know what happened until she was suspended by the DON. In a signed statement dated 7/10/14, the other assigned LPN (LPN #2) stated that she was not familiar with the process of administering feeding via a gastrostomy tube and told another nurse on duty on 5/5/14 that she did not know how. LPN #2 wrote that she was instructed by this nurse to do the medication pass and that she would take care of the feeding. LPN #2 documented that the feeding was administered but she did not check the resident and did not check to ensure there was a problem with the feeding pump. 415.12(j)

Based on Observations, staff interviews and record review during an abbreviated survey the facility failed to ensure that for each resident a Comprehensive Care Plan (CCP) had been developed with measurable goals and timetables to meet residents' medical, nursing, mental and psychosocial needs for three (#1, #2 #3 ) of three residents reviewed for wandering behaviors. Specifically, the facility did not develop CCPs for residents that exhibited unsafe wandering behaviors, which resulted in the hospitalization and admission to the intensive care unit for Resident #1 after she exited a fire exit door unknown to staff. This resulted in actual harm to Resident #1 that is not Immediate Jeopardy and no actual harm with potential for more than minimal harm to Resident #2 and Resident #3. Complaint number NY 766 Findings are: Resident #1 is a [AGE] year-old female admitted to the facility 7/25/2012 with [DIAGNOSES REDACTED]. Review of the hospital record dated 5/23/2013 documented resident was admitted to Westchester Medical Center Intensive Care unit with "C-Spine Fractures status [REDACTED]. The Minimum Data Set (MDS) (assessment tool) dated 3/15/2013 documents resident has severely impaired cognitive skills for daily decision making. Review of the facility policy and procedure for Elopement/Wandering updated 5/2007 documented that residents identified as wanderers or the potential for elopement will have a care plan meeting to develop a viable interdisciplinary plan in order to protect the resident. Review of resident's Wandering/Elopement risk evaluation dated 3/22/2013 documented resident had a total score of 5 which indicated resident was a low risk for elopement. (Scores of 10 or higher indicates high risk). During an interview with Registered Nurse (RN) supervisor on 5/23/2013 at 4PM, who found Resident #1 under basement stairwell, stated that resident sets the alarm off at least once a night during her shift and she has to reset the alarm. She also stated that resident often wanders through the halls during her shift and has found the resident in other resident rooms. During interviews on 5/23/2013 from 2:20PM through 3:30PM three Certified Nursing Assistants (CNAs) (CNA #1, #2, and #3) from the day shift, and two CNAs (CNA #4, and #5) from the evening shift all stated that Resident #1 is always wandering up and down the unit hall, and at least 2-3 times per week she sets off the fire exit door alarms. All 5 CNAs stated that they did not consider this exit seeking behavior, because the resident never verbally expressed she wanted to go home. CNA #5 stated, " Resident #1 has never tried to get out, she only touches the door alarm and sometimes opens the door but does not try to get out." During interview on 5/23/2013 at 4:30 PM, with the RN unit manager, she stated that she was new to this unit and has not seen Resident #1 trying to elope or exit through the fire doors. She states that resident is confused and has never said that she was trying to leave the facility. She stated that the resident wanders up and down the halls all the time, then stated resident did not have an wandering plan of care because resident is not an elopement risk. Review of the Resident #1 CCPs did not contain a care plan in place to address resident's elopement/wandering behaviors, or her attempts to exit through alarmed fire exit doors. Resident #2 is a [AGE] year old female admitted to the facility 11/1/2012. Her [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documents Resident#2 with a BIMS score of 3, which indicates she has severely impaired cognitive skills for daily decision making. Review of Resident #2 Wandering/Elopement risk evaluation dated 1/28/2013 documented resident had a total score of 15 which indicated resident was a high risk for elopement. Observation of Resident #2 at 5:10 PM who was wheeling herself down the hall and stated to surveyor, "I want to go home, I only live up the road." Resident #2 was then observed going to the phone booth, where she picked up the phone and was heard asking for a taxi to come and get her. Review of Resident #2 CCP for falls, documented a note dated 1/02/2013 that resident was found on the floor in another resident's room. Review of the Resident #2 medical record did not contain a Comprehensive Care Plan in place to address resident 's assessment of being a high risk for elopement or her wandering behaviors. Resident#3 is a [AGE] year old male who was admitted to the facility 8/5/2010. His [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] documents Resident#3 with a BIMS score of 6, which indicates he has severe impaired cognitive skills for daily decision making. Review of Resident's Fall CCP note dated 2/5/2013 documeted that the resident was found on the floor in another persons room, resident was unable to relate details but appears that he was trying to get into bed. During interview with the RN unit manger at 4:40 PM on 5/23/2013, she stated Resident#3 wanders up and down the halls and on occasion is found in other resident rooms. She further stated that Resident #3 has never tried to exit or elope off the unit and when he is found in places like another residents room staff will wheel him back to the nurse station. The DON stated in interview on 5/23/2013 at 5:15 PM that she should have had a CCP in place. She further stated she was not aware that these 3 residents did not have elopement/wandering CCPs in place for the 3 residents reviewed, or that Resident #1 Elopement/Risk assessment evaluation dated 3/22/2013 was inaccurate. 415.11(c)(1)

Based on staff interviews and record reviews conducted during an Abbreviated Survey, it was determined that the facility failed to provide adequate supervision to prevent accidents for one (Resident #1) of three residents reviewed for accidents. Specifically, the facility did not provide supervision for a known wandering resident (Resident #1). Subsequently Resident #1 wandered into a stairwell without staff knowledge and was found at the bottom of the stairwell and required admission to Intensive Care Unit in the hospital. This resulted in actual harm that is not immediate jeopardy. Complaint # NY 766 Findings are: Resident #1 is a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) (assessment tool) dated 3/15/2013 documents Resident #1 has severely impaired cognitive skills for daily decision making. It further documents that she required two person assist with bed mobility, transfers, and toileting, she is documented as one person assist for locomotion on unit in wheelchair, bathing eating and dressing. Review of Resident #1 Wandering/Elopement risk evaluation dated 3/22/2013 documented resident had a total score of 5 which indicated resident was a low risk for elopement. (Scores of 10 or higher indicates resident at high risk). During an interview with the Director of Nursing (DON) on 5/23/2013 at 12:15 PM, she stated she was called by staff at 7 PM on 5/22/2013 after staff found resident on the bottom floor of stairwell after she exited a fire exit door from the 2nd floor. The DON stated that when she arrived at the facility the door alarm was not functioning. She stated that she called Maintenance who came immediately and replaced the battery and the door was then functioning. She stated that she reviewed the facility's camera tapes of 5/22/2013 but did not have a full view of the fire exit door Resident#1 exited but it did show: -4:06PM, maintenance staff seen walking towards fire exit door for nightly check of alarms. At this time, the resident is seen wheeling herself in a wheelchair towards the fire exit door she exited. The Maintenance staff is seen then walked across the hall to check the oxygen room, then walking back towards the nurses' station. -4:08PM, the resident is seen still wheeling down the hall toward the fire exit door. After 4:08PM the resident is not seen again on the camera. -5:45PM the Registered Nurse (RN) evening supervisor, was seen walking down the hall toward exit door checking resident rooms. -5:46PM, staff is seen running from the end of hall from direction of the fire exit door to nurses' station. DON then stated sometime between 4:08PM and 5:45PM the resident exited the fire exit door and alarm did not go off, the RN evening supervisor found Resident #1 under the basement stair well with a gash on her forehead and called 911 to have resident sent to the hospital. Review of facility's Occurrence Report dated 5/22/2013 documented that between 3:00 and 4:00PM three CNA's documented Resident #1 set off the fire exit alarm at the opposite end of hall. The CNAs then placed Resident#1 in front of the nurses' station. There was no documented evidence in the medical record that staff provided any interventions or supervision for the resident after she exhibited this exit seeking behavior. On 5/23/2013 at 4PM., the RN evening supervisor was interviewed and stated, "While passing dinner trays out I noticed that Resident #1 was not in the dining room, so we began to search for her. I went room to room towards the west end hall where I remembered seeing her last." She continued stating, "I don't know what made me look through the fire door window, because the alarm was not ringing, but when I did I see a wheelchair tipped over down the first flight of stairs. I went down to the basement and found the resident under the stairs where she had crawled. I found her alert, able to move arms and legs, and a laceration to her forehead with visible bleeding. I instructed an aide to call 911 and the physician. " RNS stated that the physician and Emergency medical technicians arrived at about 6:30 PM and transported the resident to the hospital for evaluation. She further added that Resident#1 wanders all the time up and down the halls, using the handrails and frequently sets off the door alarms. Three CNAs (CNA#1, #2, and #3) from the day shift and two (CNAs) (CNA #4, and #5) from the evening shift were interviewed on 5/23/2013 from 2:20PM through 3:30PM. All 5 CNAs stated that Resident#1 is always wandering up and down the unit hall, and at least 2-3 times per week she sets off the fire exit door alarms. All 5 CNAs stated that they did not consider this exit seeking behavior because the resident never verbally expressed she wanted to go home. CNA #5 stated, "Resident #1 has never tried to get out, she only touches the door alarm and sometimes opens the door but does not try to get out." All CNAs state that after Residet #1 sets off the fire alarms, opens doors, or they find her in another resident room they wheel her to the nurses station or the dining room if its meal time. During an interview with RN Unit Manager on 5/23/2013 at 4:30PM, she stated that Resident #1 wanders up and down the halls all the time independently. "If resident goes or is found someplace she is not supposed to be we guide her back to the nurses' station." She further stated that the resident does not have an elopement/wandering CCP because the resident was not an elopement risk. After interviews with staff it was revealed that Resident #1 had Wandering/Elopement behaviors that placed her at high risk which was not identified on the 3/22/2013 Wandering/Elopement risk assessment. Review of the medical record for Resident #1 found that resident did not have a CCP with interventions to protect, supervise, and prevent wandering/elopement. Review of the hospital record dated 5/23/2013 documented resident was admitted to Weschester Medcial Center Intensive Care unit with "C-Spine Fractures status [REDACTED]. When interviewed on 5/23/2013 at 5:15 PM the DON stated that she was not aware that resident did not have an elopement/wandering plan of care, or that the assessment for resident Elopement/Risk evaluation dated 3/22/2013 was inaccurate. 415.12(h)(2)

Based on observation, record review and interview the facility failed to ensure that newly-admitted residents as well as residents that are confused, mobile and not identified as at risk for unsafe wandering, are supervised and have interventions in place to prevent them from exiting the facility undetected. The facility also failed to have a back-up system in place for the front door, which only had a wanderguard alarm, was unlocked and was not monitored after 8:00 PM. Specifically, a newly-admitted resident who was assessed as not at-risk for elopement or unsafe wandering, left the facility undetected via the front door. The resident was missing from the facility for 2 ? hours during the night. Facility staff were not aware the resident was missing until he was returned by the police. This was evident for 1 of 7 residents reviewed during an abbreviated survey. (Resident #1) This resulted in the potential for serious harm to resident health and safety that is Immediate Jeopardy and Substandard Quality of Care. Complaint ID Number: NY 018 The findings are: Resident #1 is a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's cognitive status is documented as confused with impaired memory. Observation of the resident on 12/22/11 at 10:00AM revealed multiple abrasions on both arms and knees. During an interview with the resident at that time he revealed he walked out of the facility because he just wanted to go home. The resident added that no one was around so he walked out the front door. He recalled being poorly dressed and feeling very cold upon his return. He could not recall how he obtained the abrasions on his arms and legs. The wandering/elopement risk evaluation performed upon admission documents he is not at risk for unsafe wandering/elopement. It does not assess the resident's cognitive status and ambulation status when determining wandering/elopement risk An interview was conducted with the Registered Nurse (RN) on 12/22/11 at 3:30PM who performed the initial wandering/elopement risk evaluation. She revealed she obtained the information about the resident from the initial nursing assessment and did not perform an actual wandering/elopement risk assessment of the resident. Review of the nurses notes dated 12/14/11 and 12/15/11 document the resident has periods of confusion and ambulates on his own. Review of the initial Physician's admission notes dated 12/14/11 document that the resident has dementia and a change in mental status. Review of the Patient Review Instrument (PRI)( a patient assessment completed by the discharging hospital) dated 12/13/11 documented one of the resident 's primary [DIAGNOSES REDACTED]. Review of the resident care plan initiated upon admission revealed no interventions to address the resident's history of dementia, confusion and the change in mental status. Review of the policy and procedure for elopement dated 5/07 and updated on 11/10 documents that the residents will be maintained in a safe and secure manner and protected from actual harm. Review of the facility investigation and the videotape revealed the resident was last seen on 12/17/11 at 2:25 AM ambulating up the hall on the first floor. He was wearing a coat, sweatpants and socks and no shoes walking toward the nurses' station. He spoke briefly to a Certified Nursing Assistant (C.N.A #1). He then walked to the lobby and exited via the front door unnoticed. Further review of the video revealed the resident being escorted back into the facility by the police at 4:52 AM. During a telephone interview on 12/22/11 at 11:00 AM with the assigned CNA #1, she stated she usually does rounds every 2 hours to check the status of her residents. She passed by his room and noted the privacy curtain was drawn. The CNA was supposed to check on the resident at 4:00 AM but she stated she did not do so. During a telephone interview with the Charge Nurse-RN on 12/22/11 at 12:05 PM she revealed "I do not do rounds. I last saw the resident at 2:00 AM. At 12:00 AM he stated he did not want the nebulizer treatment at 4:00 AM because he wanted to sleep. I did not go back to check on the resident at 4:00 AM." At 5:19A M on 12/17/11 the Charge Nurse-RN documented that the resident was in his room during 3:00 AM rounds. She documented that the resident was in the bathroom and responsive with appropriate verbalization to questions. Review of the medication administration record (MAR) revealed that the Registered Nurse did not administer the resident's nebulizer treatment at 4:00 AM on 12/17/11. However, she documented that the resident's oxygen saturation level was 98% and the resident's respiratory rate was 18 per minute at 4:00 AM. During an observation of the front door on 12/22/11 at 9:30 AM it was noted to have no exit alarm. However, a Wanderguard alarm was present. During an interview with the Assistant Director of Nursing on 12/21/11 at 11:30AM she stated "we could not have followed our missing person policy because we didn't know he was gone until 5:00AM when the cops brought him back." During an interview with the Administrator on 12/22/11 at 10:30 AM she stated the door is monitored by the receptionist, who is present daily from 7:00am to 8:00pm. This unlocked and unalarmed door is not monitored from 8:00pm until 7:00am daily. The Administrator added "the door has been like this as long as I know. It would be a fire hazard to lock that door." She further stated there was no back-up system in place such as monitoring by staff. The facility utilized a wandering/elopement risk evaluation tool that does not address residents' impaired cognition and mobility status as being high risk for wandering/elopement. Prior to survey staff exiting the facility, interventions were implemented to remove the potential for serious harm to the health and safety of residents. A CNA was assigned to monitor the front door after the receptionist left for the day. In addition, the facility's policies and procedures were revised regarding the assessment of newly-admitted residents to the facility. This includes all new admissions will have 30 minute checks to be performed for the first 72 hours and then a reassessment of elopement risk will be done. Further, an alarm and motion detector were installed at the front door. The facility staff were inserviced regarding the revised policy and procedure. 415.12(h)(1)(2)

Based on observation, record review and interview the Administrator failed to ensure that there were policies and procedures in place to maintain the safety and well being of newly-admitted residents as well as residents that are confused, mobile and not identified as at risk for unsafe wandering. In addition, the Administrator failed to ensure that residents were supervised and there were interventions in place to prevent these residents from exiting the facility undetected. The Administrator also failed to ensure that there was a back-up system in place for the front door, which only had a wanderguard alarm, was unlocked and was not monitored after 8:00 PM. Specifically, a newly-admitted resident eloped from the facility undetected during the night through an unlocked, unalarmed front entrance door. He was returned 2 1/2 hours later by police who retrieved him from a private residence wearing a coat, pants and socks, but no footwear. The resident was treated for [REDACTED]. This was evident for 1 of 7 residents reviewed during an abbreviated survey. (Resident #1). This resulted in the potential for serious harm to resident health and safety that is Immediate Jeopardy. The facility employed interventions to remove the immediate jeopardy prior to completion of the survey. Refer to F 323 (Accidents and Supervision). Complaint ID Number: NY 018 The findings are: Review of the facility's investigation dated 12/17/11 revealed that Resident #1 (admitted on [DATE]) exited the facility undetected via the front door at 2:25 AM on 12/17/11. He was seen on the facility's video camera walking out wearing a coat, sweat pants and socks, but no shoes. He was escorted back to the facility at 4:52 AM by police officers who retrieved him from a private residence nearby. The facility was unaware the resident was missing until he returned with the police. Upon his return Resident #1 was assessed by nursing with several abrasions on his arms and legs. Review of the elopement/wandering risk assessment dated [DATE] revealed that Resident #1 was not at risk for elopement. The wandering/elopement risk evaluation did not accurately reflect the resident's cognitive status or ambulation status when determining wandering/elopement risk. During a telephone interview with the Charge Nurse-Registered Nurse (RN) on 12/22/11 at 12:05 PM she revealed "I do not do rounds. I last saw the resident at 2:00 AM. At 12:00 AM he stated he did not want the nebulizer treatment at 4:00 AM because he wanted to sleep. I did not go back to check on the resident at 4:00 AM." During an interview with the Assistant Director of Nursing on 12/21/11 at 11:30AM she stated "we could not have followed our missing person policy because we didn't know he was gone until 5:00AM when the cops brought him back." During an interview with the Administrator on 12/22/11 at 10:30 AM she stated the door is monitored by the receptionist, who is present daily from 7:00 AM to 8:00 PM. This unlocked and unalarmed door is not monitored from 8:00 PM until 7:00 AM daily. The Administrator added "the door has been like this as long as I know. It would be a fire hazard to lock that door." She further stated there was no back-up system in place such as monitoring by staff. 415.26

Based on observation, record review, and resident, and staff interviews during an abbreviated survey, the facility did not respect the private space and property of a resident. Specifically, the facility's Administrator entered the room of a resident and told her she was moving upstairs and began rummaging through the resident's personal belongings without the resident's permission and over the resident's strong objections. The Administrator then summoned housekeeping staff to the resident's room for the purpose of moving the resident's belongings in the room and spoke to the resident in a demeaning manner. This caused distress to the resident. This was evident for one of one resident reviewed for dignity (Resident #1). This resulted in actual harm that is not Immediate Jeopardy. Complaint ID Number: NY 834 The findings are: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) (a resident assessment tool) dated 6/18/11 revealed she has a score of 15 (high) for cognitive skills. The resident is alert and oriented. The current care plan of 6/30/11 revealed the resident has an identified problem with crying and yelling out at times, with interventions that include providing emotional support. The care plan noted that the resident has been crying less than she did in December, 2010. During an interview with Employee #1 conducted on 7/27/11 at 11:00 AM, she stated she went into the resident's room on Monday, 7/11/11. She said the resident volunteered how upset she had become over an incident that occurred on Friday, 7/08/11. The resident informed Employee #1 that the Administrator came into her room and was "unkind" to her and told the resident she would be moving upstairs to another room. The resident then told Employee #1 that the Administrator "threw away her belongings into the garbage without asking and spoke to her as if she were a child." Employee #1 stated she tried to calm the resident after hearing her story. The resident asked her what she should do and Employee #1 told her she should talk to Employee #2. Employee #1 then informed Employee #2 of the resident's complaint. During an interview with Resident #1 on 7/27/11 at 12:05 PM, the resident was observed to be weepy and upset when recalling the incident of 7/8/11. She stated the Administrator came into her room and told her she was moving upstairs began moving her property and her possessions. The resident said this happened so fast, it surprised her. She said the Administrator threw some of her property in the garbage. She further stated the Administrator informed her that she would be moving upstairs, to another room, and that the Administrator spoke to her in a "disturbing" manner. The resident continued by stating the Administrator told her she could not keep her vitamins and herbal medicines, but the resident explained that "these are very important to me, as I have [MEDICAL CONDITIONS] Arthritis and I take care of myself." The resident explained that she uses the vitamins and herbal medicines to help her manage her illnesses, and these were moved into the drawers. The resident also said she had facial wipes, items in closed zip lock bags, and magazines in her room, and the Administrator threw them in the garbage. The resident said she was very upset and told the Administrator that she did not want to move upstairs because she believed she would die if she were moved out of her room. The resident stated that when Emplyee #3 and a facility corporate nurse spoke to her about this incident, she withheld information but only because she believed telling the truth about what the Administrator had done would jeopardize her position in the nursing home. The resident concluded the interview on 7/27/11 by stating that, even though she is still in her room, she is so afraid that "a bomb may go off anytime" and she is not sure what they will do with her. During an interview with Employee #2 on 7/27/11 at 11:20 AM, she stated Employee #1 told her on 7/11/11 that the resident complained to her about the incident with the Administrator. Employee #2 went to Employee #3 and told the her she did not report this incident before but now decided that "abuse" occurred. Employee #3 then went with her to interview the resident. During this interview, the resident did not tell Employee #3 everything that transpired with the Administrator. Employee #2 did not know why the resident did not tell the entire story to Employee #3 and withheld information regarding the incident. Employee #2 then explained that during the morning report of 7/08/11, it was decided that the resident was going to be moved upstairs. The resident's son was informed of this room change and he called the resident to inform her of this decision. Employee #2 and the Administrator entered the resident's room to notify her of the room change. The resident was already upset as the son had called her to notify her of the move and was crying stating, "I can't go upstairs." Before Employee #2 could explain to the resident about the move, the Administrator told the resident "you are going upstairs" in a firm tone while pointing her finger towards the resident. Employee #2 further stated that the resident became even more upset and her crying increased when the Administrator opened the resident's closet and began rummaging through the resident's belongings without asking for the resident's permission. Employee #2 also stated that the Administrator told the resident she could not use the entire room and that the resident's things "had to go." According to Employee #2, the Administrator then summoned Employee #4 and Employee #5 to the room and directed them to move the resident's belongings in the room. The resident continued crying, according to Employee #2, and told the Administrator that she considered her room her "home" and that the Administrator had no right to touch her personal property. Eventually, the Administrator told the resident she was staying in her room, but she would have to share it with another resident. After the Administrator left the room, Employee #2 stayed with the resident as she was crying and upset and tried to calm her down. When Employee #2 was asked who was in the room with her during this incident, other than the resident and the Administrator, she said three other employees. During an interview with Employee #5 on 7/27/11 at 1:30 PM, she stated the Administrator summoned her to Resident #1's room on the day of the incident. Employee #5 stated the Administrator was talking to the resident in a loud voice, but was not yelling. She further stated that the Administrator was "too rough on the resident, a bit nasty." Employee #5 also stated the resident was "crying hysterically." According to Employee #5, the Administrator told the resident she had too many things on her sink and that they had to move things around the room. Employee #5 tried to calm the resident because she was so upset. During an interview with Employee #6 on 7/27/11 at 2:45 PM, she stated she was walking by Resident #1's room on the day of the incident and entered the room because she could hear that the resident was upset. Employee #6 said that the Administrator was in the room and threw a bottle and some other things in the garbage. The Administrator was also moving items from the sink and moving other items around the resident's room. She further stated that the Administrator told the resident "her stuff" had to go and she could not keep her vitamins. Employee #6 said the resident was crying, but it was different from her normal crying episodes, which are designed to get attention. She also stated that the Administrator's tone of voice was condescending towards the resident. She was talking to the resident "like she was a child." Employee #6 said she tried to calm the resident. She took her out of the room in her wheelchair, telling her she was going to take her upstairs just to take a look at the other room. During an interview with Employee #7 on 7/28/11 at 12:05 PM, she stated that when she was passing Resident #1's room while walking in the hallway, she heard yelling and crying. She heard the resident say "how can you do this to me." Upon hearing this, she said she entered the resident's room. She stated the resident was "very, very upset" and crying. Employee #7 said the resident does cry to get attention, but that this was a different kind of crying. Employee #7 witnessed the Administrator re-arranging the resident's room. She heard the Administrator tell the resident "you can't keep all these stuff here, you cannot keep anything by the sink, you are going upstairs, and you have to have a roommate." The resident was saying, " why can't I rearrange this myself, this is considered my home." Employee #7 said the Administrator spoke to the resident as if she were scolding a child. She further stated that the Administrator showed no [MEDICATION NAME] towards the resident and ignored the resident's pleas. Employee #7 concluded the interview by stating that Employee #5 and the Administrator continued to move the resident's belongings and the Administrator made no attempt to work this out with the resident or manage the situation in a better way. During an interview with the Administrator on 7/27/11 at 3:15 PM, she stated she did not upset the resident. She said it was the Social Worker who came into the room and first told the resident either "we're gonna move you upstairs," or we're here to talk to you about moving upstairs." The Administrator said the resident started screaming and saying, "I'll die if I go up there." The Administrator stated she and the staff listened to her. The resident was informed she cannot take up a semi-private room by herself. She did not want a roommate. She was told they had to clean up the resident's room and that she could not have all her things all over the room. The Administrator further stated she touched some bags that were under the resident's sink and put bottles on top of the closet. She called housekeeping and maintenance. The resident calmed down and she thought that the resident agreed to have a roommate. The resident was allowed to stay in the room. 415.5 (a)

Based on record review and staff and resident interviews conducted during an abbreviated survey, the Administrator did not ensure that the dignity and privacy of residents were maintained. Specifically, the Administrator did not respect the private space and personal property of a resident (Resident #1). The Administrator entered the room of a resident, told her she was being moved to another room and began rummaging through the resident's belongings without the resident's permission and over the resident's strong objections. The Administrator spoke to the resident in a demeaning manner while pointing her finger at her. The Administrator's actions caused the resident to experience emotional distress. Furthermore, the facility did not conduct a thorough investigation into this incident to determine if resident abuse, neglect or mistreatment occurred. This resulted in actual harm that is not Immediate Jeopardy. See F- 241, and F - 225 The findings are: During an interview with Resident #1 on 7/27/11 at 12:05 PM, the resident was observed to be weepy and upset when recalling an incident that occurred on 7/8/11 that involved the resident and the Administrator. She stated the Administrator came into her room and told her she was moving upstairs. The Administrator then began moving her property, went into her closet and rummaged through her personal belongings without her permission and over her strong objections. The resident said this happened so fast, it surprised her. She said the Administrator threw some of her property in the garbage. She further stated the Administrator spoke to her in a "disturbing" manner. The resident said she was very upset and told the Administrator that she did not want to move upstairs because she believed she "would die if she were moved out of her room." The resident concluded the interview on 7/27/11 by stating that, even though she is still in her room, she is so afraid that "a bomb may go off anytime" and she is not sure what they will do with her. During an interview with the Administrator on 7/27/11 at 3:15 PM, she stated she did not upset the resident. The Administrator said the resident started screaming and saying, "I'll die if I go up there." The Administrator further stated she touched some bags that were under the resident's sink and put bottles on top of the closet. The Administrator stated she called housekeeping to move the residents' personal belongings in the room. During an interview with Employee #2 on 7/27/11 at 11:20 AM, she stated she and the Administrator entered the resident's room and the resident was already upset as the son had called her to notify her of the move and was crying. Before Employee #2 could explain to the resident about the move, the Administrator told the resident "you are going upstairs" in a firm tone while pointing her fingers toward the resident. Employee #2 further stated that the resident became even more upset and her crying increased when the Administrator opened the resident's closet and began rummaging through the resident's belongings without asking for the resident's permission. According to Employee #2, the Administrator then summoned Employee #5 to the room and directed them to move the resident's belongings in the room. The resident continued crying and told the Administrator that she considered her room her "home" and that the Administrator had no right to touch her personal property. During an interview with Employee #5 on 7/27/11 at 2:45 PM, she stated the Administrator summoned her to Resident #1's room and the Administrator was talking to the resident in a loud voice, but was not yelling. She further stated that the Administrator was "too rough on the resident, a bit nasty." Employee #5 also stated the resident was "crying hysterically." She said the Administrator told the resident she had too many things on her sink and that they had to move things around the room. Employee #5 tried to calm the resident who was so upset. During the interview with Employee #6 on 7/27/11 at 2:45 PM, she stated she entered the room as she could hear that the resident was upset. Employee #6 stated the Administrator was in the room and she saw her throw a bottle and other things in the garbage. The Administrator was also moving items from the sink and other items in the resident's room and told the resident her "stuff" had to go. Employee #6 said the resident was crying, but it was a different cry from her normal crying episodes, which are designed to get attention. She also stated the Administrator's tone of voice was condescending towards the resident. She was talking to the resident "like she was a child." Employee #6 said she tried to calm the resident. During an interview with Employee #7 on 7/28/11 at 12:05 PM, she stated that when she was passing Resident #1's room, she heard yelling and crying. She heard the resident say "how can you do this to me." Upon hearing this, she said she entered the resident's room. She stated the resident was "very, very upset" and crying. Employee #7 said the resident does cry to get attention, but that this was a different kind of crying. Employee #7 witnessed the Administrator re-arranging the resident's room. She heard the Administrator tell the resident "you can't keep all these stuff here, you cannot keep anything by the sink, you are going upstairs, and you have to have a roommate." The resident was saying, " why can't I rearrange this myself, this is considered my home." Employee #7 said the Administrator spoke to the resident as if she were scolding a child. She further stated that the Administrator showed no [MEDICATION NAME] towards the resident and ignored the resident's pleas. Employee #7 concluded the interview by stating that Employee #5 and the Administrator continued to move the resident's belongings and the Administrator made no attempt to work this out with the resident or manage the situation in a better way. An interview with the corporate nurse on 7/28/11 at 4:00 PM revealed that during her investigation of this incident on 7/14/11, she did not know that several other facility staff were in the room on the day of this incident, witnessed what had occurred and could corroborate what had happened. She stated the Administrator said, "only the Social Worker and her were in the room, that she never moved anything around in the room." The corporate nurse stated she feels she did a thorough investigation despite the fact that she did not interview anyone else who was in the room during the incident other than those staff that were identified by the Administrator. 415.26