Every finding on record at Chestnut Park Rehabilitation and Nursing Center

Based on observations, record reviews and interviews during a recertification survey, the facility did not ensure it established a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and that it determined that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. Specifically, the facility did not document nursing unit narcotics were counted by two (2) licensed staff members and signed as appropriately done on the facility provided narcotic record sheets.This is evidenced by:The Policy and Procedure titled, Medications - Controlled Substance/Narcotic Management Protocol, effective 2/2021 and last revised 1/2025, documented it was the facility's policy to It is the policy of the facility to prescribe, administer, store and destroy all controlled substances within the accepted regulations of the responsible governing body. All narcotics will be counted and reconciled at the beginning of every shift with the outgoing and oncoming nurse. Both must sign the controlled substance log attesting to the presence of the narcotic as stated from the previous shift. Any discrepancies in the count, must be reported to the unit manager, nursing supervisor immediately. Any suspected tampering of blister packs, packages or documentation of controlled substances must be reported immediately to the unit manager / supervisor. Staff responsible for narcotic administration will not leave the shift until the narcotic count is reconciled. Review of Narcotic and Controlled Substance Shift Count Sheet for the first-floor nursing unit, North side, dated 7/14/2025 through 7/17/2025, did not consistently document signatures by the off-going and oncoming nurse.Review of Narcotic and Controlled Substance Shift Count Sheet for the first-floor nursing unit, North side, dated 7/21/2025 through 7/25/2025, did not consistently document signatures by the off-going and oncoming nurse.Review of Narcotic and Controlled Substance Shift Count Sheet for the first-floor nursing unit, North side, dated 8/30/2025 through 9/04/2025, did not consistently document signatures by the off-going and oncoming nurse.Review of Narcotic and Controlled Substance Shift Count Sheet for the first-floor nursing unit, North side, dated 9/05/2025 through 9/09/2025, did not consistently document signatures by the off-going and oncoming nurse.Review of Narcotic and Controlled Substance Shift Count Sheet for the first-floor nursing unit, North side, dated 9/15/2025 through 9/19/2025, did not consistently document signatures by the off-going and oncoming nurse.Review of Narcotic and Controlled Substance Shift Count Sheet for the first-floor nursing unit, North side, dated 9/21/2025 through 9/24/2025, did not consistently document signatures by the off-going and oncoming nurse.Review of Narcotic and Controlled Substance Shift Count Sheet for the first-floor nursing unit, South side, dated 9/16/2025 through 9/20/2025, did not consistently document signatures by the off-going and oncoming nurse.During an interview on 9/24/2025 at 8:40 AM, Licensed Practical Nurse #2 stated that narcotic sheets were supposed to be signed by two licensed nurses. Licensed Practical Nurse #2 then went and asked Licensed Practical Nurse #3 to sign the narcotic sheets from previous shifts. Licensed Practical Nurse #3 stated that they would have to figure out if they were working the shifts in question, then stated they were in training on the days Licensed Practical Nurse #2 asked them to sign and refused to do so. During an interview on 9/24/2025 at 9:58 AM, Licensed Practical Nurse #1 stated that when narcotic counts were done, the outgoing nurse did the counting, the oncoming nurse did the writing of the count, and then they would both sign the sheets together.During an interview on 9/25/2025 at 8:33 AM, Licensed Practical Nurse #4 stated that white out was not able to be used on narcotic count sheet. [NAME] out was noted on one of the lines for Tramadol on 9/14/2025. A copy of the narcotic sheet was provided.During an interview on 9/26/2025 at 10:37 AM, Director of Nursing #1 stated that both oncoming and off going nurses needed to sign the narcotic sheets to ensure the count was complete and accurate. When asked if they were reviewing the narcotic sheets for signatures, would Director of Nursing #1 ask the missing staff members to sign for past sheets, Director of Nursing #1 stated they would not ask someone to back sign narcotic sheets. They would ensure the count was correct and educate the staff member. If there was an issue with the narcotic sheets, they would immediately bring it to the Administrator's attention. 10 New York Code Rules and Regulations 415.18(a)

Based on observations, record reviews, and interviews during a recertification survey, the facility did not maintain an infection control program in accordance with professional standards of care. Specifically, a) for Resident #7, the licensed practical nurse removed a dressing without wearing gloves and b) the facility did not ensure signage and supplies for transmission-based precautions were readily available and visible.Resident #7The Policy and Procedure titled Wound Care dated 1/2025 stated hands should be washed and dried before and after a dressing change, and gloves should be wornResident #7 was admitted to the facility with the diagnoses of iron deficiency anemia (when there aren't enough healthy red blood cells to carry oxygen throughout the body), pressure ulcer of left buttock (damage to the skin and underlying tissue caused by prolonged pressure, friction, or shear force, most commonly forming on bony areas like the tailbone, hips, heels, and back), and peripheral vascular disease (a circulation disorder where blood flow to the limbs and organs is reduced due to narrowed, blocked, or inflamed blood vessels). The Minimum Data Set (an assessment tool) dated 8/19/2025 documented the resident was understood, could understand others, and was moderately cognitively impaired.During an observation on 9/25/2025 at 1:43 PM, Licensed Practical Nurse #2 removed a dressing from right lateral ankle and replaced the dressing without wearing gloves. Licensed Practical Nurse #2 did not wash hands during observation.A wound care progress note dated 9/18/2025 documented the resident had wounds on their left ischium, left heel, right lateral ankle, left lateral ankle, and left lateral heel.During an interview on 9/25/2-25 at 1:43 PM, Licensed Practical Nurse #2 verbalized the steps to changing a wound dressing and did not include washing hands as a step in the process.FacilityDuring an observation on 9/25/2025 at 9:25 AM, a room was observed with a personal protection equipment cart outside the door without signage.During an observation on 9/26/2025 from 9:30 AM through 10:10 AM on both units, two different rooms were observed with signage on the door indicating enhanced barrier precautions but neither room had readily available carts containing personal protective equipment.During an interview on 9/25/2025 at 9:25 AM, Licensed Practical Nurse #1 stated the resident was on enhanced barrier precautions for a pressure wound and that when rooms were changed, sometimes the sign wouldn't follow the resident immediately. When informed the resident had been in that room since March 2025, Licensed Practical Nurse #1 stated the sign must have fallen off the door. Licensed Practical Nurse #1 stated they should be walking the floor to make sure signage was in place and supplies were available.During an interview on 9/25/2025 at 12:10 PM, Registered Nurse #2 stated that all precautions should have the signage in place to instruct the proper personal protection equipment to be used. Each room on transmission-based precautions should have a cart with personal protection equipment readily available.During an interview on 9/26/2025 at 10:05 AM, Certified Nurse Aide #1 stated they expected clear signage on a room where a resident was on transmission-based precautions and would expect a cart with the right equipment available to staff.During an interview on 9/26/2025 at 10:30 AM, Director of Nursing #1 stated appropriate signage should always be posted to be visible on each room that was under transmission-based precautions and supplies should be available. They stated that extra carts and supplies were stored in the conference room and was readily available to staff through unit managers and supervisors.10 New York Codes, Rules, and Regulations 415.19(a)(1-3)

Based on record review and interview during the recertification survey, the facility did not ensure development of policies and procedures for the monthly drug regimen review that included, but was not limited to, time frames for the different steps in the process. Specifically, the facility policy, titled Medication Therapy, did not identify time frames for the steps in the process. This is evidenced by: The facility policy titled, Medication Therapy, reviewed 01/2025, stated the Consultant Pharmacist would review each resident's medication regimen monthly, as requested by the staff or practitioner, or when a clinically significant adverse consequence is confirmed or suspected, and the Medical Director and Consultant Pharmacist would collaborate to address issues of medication prescribing and monitoring with the practitioners and staff. The policy did not include time frames for each step in the process. During an interview on 09/25/2025 at 12:05 PM, Director of Nursing #1 agreed there should be time frames for each step of the medication review process and did not know why the policy did not include time frames. 10 New York Code Rules and Regulations 415.18(c)(2)

Based on observation, record review, and staff interview during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety. Specifically, the automatic dishwashing machine was not operating within the manufacturer's instructions, sanitizing solution concentration could not be verified, and surfaces, equipment, and floors required cleaning or repair. This is evidenced by: During observations on 09/21/2025 at 10:56 AM: The automatic dishwashing machine final rinse was 197 degrees Fahrenheit at 7 (seven) pounds per square inch of water pressure; the dishwashing machine data plate states that the water pressure is to be between 15 and 25 pounds per square inch. The facility did not have a chemical test kit with graduations above 400 parts per million; the label on the bottle of sanitizer concentrate stated that when sanitizing food contact surfaces the dilution is to be between 200 and 400 parts per million. A wooden block-style knife-rack that cannot be disassembled was being used for knife storage. The drainpipe below the three (3)-compartment sink was leaking. The following items were soiled with food particles, grime, or dirt: can opener holder, fire extinguishers, floor under dishwashing machine, floor right of the stove, dry storage area floor, mop bucket & wringer. The North Wing kitchenette cabinets and South Wing kitchenette cabinets were soiled with food particles.During an interview on 09/21/2025 at 11:49 AM, Assistant Food Service Manager #1 stated that they would speak with the maintenance department about the dishwashing machine & drain leak, talk with the vendor about getting the right test papers, discard the wooden knife rack, and address the cleaning items.New York Codes, Rules, and Regulations Title 10 S415.14(h)

Based on observation and interview during the recertification survey, the facility did not ensure garbage and refuse was disposed properly. Specifically, the garbage dumpster was heavily soiled below the side door and was not rodent proof. This is evidenced by: During observations on 09/21/2025 at 12:02 PM, the right dumpster was heavily soiled below the side door and was missing a drain hole plug and was not rodent proof. During an interview on 09/21/2025 at 12:07 PM, Assistant Food Service Manager #1 stated that they would speak with the maintenance department about having the dumpster cleaned and a drain hole plug installed. New York Codes, Rules, and Regulations Title 10 S415.14(h)

Based on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure Comprehensive Care Plans were reviewed and revised by the interdisciplinary team after each assessment based on changing goals, preferences, and needs of the resident and in response to current interventions for two (2) (Resident #'s 11 and 20) of 19 reviewed. Specifically, Resident #11's Comprehensive Care Plan for Anticoagulants was not resolved after the resident's order for Plavix was discontinued in 2023 and Resident #20's Comprehensive Care Plan was not reviewed or revised to include the resident's diagnosis of constipation and treatment/orders for constipation. This is evidenced by: The facility policy titled, Care Plans, Comprehensive Person-Centered, last revised 01/2025, documented assessments of residents were ongoing, and care plans were revised as information about the resident and the resident's condition changed. The interdisciplinary team would review and update the care plan: (a.) when there was significant change in the resident's condition; (b.) when the desired outcome was not met; (c.) when the resident was readmitted to the facility from a hospital stay; and (d.) at least quarterly, in conjunction with the required quarterly Minimum Data Set assessment. Resident #11 Resident #11 was admitted to the facility with diagnoses of cerebral infarction (a medical condition where blood flow to the brain is interrupted, leading to brain tissue damage), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and peripheral vascular disease (a condition that affects the blood vessels outside of the heart, typically in the legs and arms). The Minimum Data Set (an assessment tool) dated 7/13/2025 documented the resident was able to be understood, was able to understand others, and was cognitively intact. The Comprehensive Care Plan titled, Resident is at risk for bleeding secondary to NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)/anticoagulant use of Plavix (an anti-platelet medication) initiated 01/06/2023 documented the medication was discontinued in 05/2023. The Comprehensive Care Plan remained active with goal that Resident #11 would be free from side effects of anticoagulant. During an interview on 9/25/2025 at 12:05 PM, Director of Nursing #1 stated care plans should be reviewed and updated with each care conference and as needed. They stated they did not know why Resident #11's Comprehensive Care Plan for anticoagulants was still active and that it should not be active if the resident was no longer on the medication. Resident #20 Resident #20 was admitted to the facility with diagnoses of bilateral primary osteoarthritis of knee (a condition where the cartilage in both knees gradually wears down, leading to pain, stiffness, and reduced mobility, type 2 diabetes (an endocrine dysfunction causing unregulated blood glucose levels), and morbid obesity (a severe form of obesity characterized by a Body Mass Index (BMI) of 40 or higher). The Minimum Data Set, dated [DATE], documented that the resident was cognitively intact, could be understood and could understand others. A physician progress note dated 6/24/2025 at 11:26 AM, documented they were notified that Resident #20 complained of constipation, which appeared to be an ongoing issue for the resident. A kidney, ureter, and bladder (KUB) scan was completed and a bowel obstruction was ruled out, but there was a large amount of stool in the rectum. Resident #20 was receiving Senna and Colace for bowels at that time. Additional recommendations were made to include manual disimpaction, fleet enema, MiraLax once a day for 7 days, and to closely monitor the resident. During an observation on 9/22/2025 at 9:58 AM, Resident #20 was lying in bed, crying out. During an interview on 9/22/2024 at 9:58 AM, Resident #20 was crying and stated they were in severe pain because they had not had a bowel movement in several days. A physician order dated 6/17/2025, documented senna-time oral tablet 8.6 milligram, give 1 tablet by mouth two times a day for constipation. A physician order dated 6/17/2025, documented docusate sodium capsule 100 milligram, give 2 capsules by mouth two times a day for constipation, hold for loose stools. A physician order dated 8/03/2025, documented polyethylene glycol 3350 oral powder 17 gram/scoop, give 1 scoop by mouth as needed for constipation, on scoop in the morning if patient has not passed a good stool in 2 days. A physician order dated 9/16/2025, documented bisacodyl rectal suppository 10 milligrams. Insert 1 suppository rectally one time only for constipation for 1 day. The Comprehensive Care Plan for Bowel Incontinence, dated 9/18/2025, documented the resident was incontinent of bowel related to resident choice. Resident #20 refused to use the toilet or bedpan. It was further documented that Resident #20 had anxiety related to their bowels. There was no documented evidence that Resident #20's Comprehensive Care Plan was updated to include the diagnosis of constipation and treatments/orders for constipation after their admission to the facility. During an interview on 9/26/2025, Director of Nursing #1 stated there should be some kind of focus in Resident #20's care plan related to bowels. They reviewed Resident #20's care plan during the interview and acknowledged there was no care plan related to constipation or medications used for constipation. 10 New York Codes, Rules, and Regulations 415.11(c)(2)(i-iii)

Based on observation, record review, and interview during the recertification survey, the facility did not ensure food brought for residents by family or visitors was stored safely and in a way that is either separate or easily distinguishable from facility food on one (1) of two (2) resident units. Specifically, resident food was not properly labeled, and the facility did not have a policy to assist residents in accessing food brought in to them. This is evidenced by: During observations on the North Wing kitchenette on 09/21/2025 at 11:39 AM, deli chicken salad was not labeled with a resident name, and two (2) homemade sandwiches were not labeled. During an interview on 09/21/2025 at 11:46 AM, Assistant Food Service Manager #1 stated that the homemade sandwiches were likely for a resident, and food brought to residents should be labeled with the resident name and dated. There was no documented evidence that the facility had a policy to date and label with the resident name food brought in to residents. There was no documented evidence that the facility had a policy to ensure facility staff would assist residents in accessing and consuming food if the resident were not able to do so on their own. New York Codes, Rules, and Regulations Title 10 S415.14(h)

Based on record review and interviews conducted during an abbreviated survey (Case #2635234), the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for two (2) of four (4) residents (Resident #1 and 3) reviewed for falls. Specifically, [a.] Resident #1 had severe cognitive impairment and had five (5) unwitnessed falls from [DATE] to [DATE]. The facility failed to develop appropriate interventions to mitigate falls when it was known that the resident was self-transferring. On [DATE] at 11:30 PM, Resident #1 was found on the floor unresponsive, unclothed and cold to the touch by Certified Nurse Aide #1. The resident's body temperature was unmeasurable on a facility thermometer, their oxygen saturation level was 73 percent (normal oxygen saturation levels are 95-100 percent), and they were sent to the hospital with symptoms consistent with hypothermia (occurs when core body temperature drops below 95 degrees Fahrenheit and is a medical emergency). Resident #1 expired on [DATE]. Cause of death was septic shock, pneumonia, acute hypoxic respiratory failure and encephalopathy (a change in brain function due to injury or disease). [b.] Resident #3 had moderate cognitive impairment, Parkinson's disease (movement disorder of the nervous system), and sustained 30 falls from [DATE] to [DATE], of which 20 were documented as unwitnessed. On [DATE] at 3:00 AM, Resident #3 was found crawling on the floor in their room and sustained a left wrist fracture (bone break). The facility was aware these residents were self-ambulating and did not implement appropriate interventions or provide supervision to mitigate falls. This resulted in Substandard Quality of Care, with actual harm, that was Immediate Jeopardy with the likelihood for serious adverse outcome to 23 residents identified at risk for falls.This is evidenced by:Cross-referenced to F695: Respiratory/Tracheostomy Care and Suctioning, F656: Develop/Implement Comprehensive Care Plan. The Policy and Procedure titled, Falling Star Program, reviewed 01/2025, documented that the program identified residents at highest risk for falls and required aggressive monitoring and prevention of injury related to falls. The policy documented that staff were to place a star symbol near the resident's room nameplate, and on the resident's walker or wheelchair, to indicate high fall risk. Staff were to be informed of residents enrolled in the program during shift-to-shift report and rounds. The policy specified that residents demonstrating unsafe behaviors or repeated falls required increased staff awareness and monitoring wherever they were in the facility.The Policy and Procedure titled, Falls and Fall Risk Managing, reviewed 01/2025, documented that based on previous evaluations and current data, staff must identify interventions related to the resident's specific risks and causes of falls. The policy required that when falls recurred, staff would implement additional or different interventions or justify why current interventions remained appropriate. It further directed that if underlying causes were not readily identified, staff would 'try various interventions until falling was reduced or stopped.' The policy required documentation of ongoing monitoring and evaluation of each resident's response to interventions, and physician involvement when falls persisted. Resident #1:Resident #1 was admitted to the facility with diagnoses of unspecified dementia without behavioral/psychotic/mood disturbance (a condition where a person can experience memory loss, confusion, difficulty with thinking and reasoning), history of falling, and generalized anxiety disorder (excessive, ongoing worry that are difficult to control and interfere with day-to-day activities). The Minimum Data Set (a resident assessment tool) dated [DATE], documented the resident had severe cognitive impairment. The resident was able to make themselves understood and understand others. Review of Care Plan titled, At Risk for Functional Decline in Mobility and Self Care related to age related changes, dementia, and benign prostatic hyperplasia (enlarged prostate), revised [DATE], documented the resident had a history of self-transferring. Interventions included encouraging use of the call bell, providing partial assistance for transfers, and ensuring assistive devices were within reach.Review of Care Plan titled, At Risk for Falls related to history of falls, and age-related changes including cataracts, revised [DATE], documented interventions included but were not limited to anticipate and meet resident's needs and bed in lowest position. Review of Care Plan titled, Resident had an Actual Fall related to cognitive deficit, gait/balance problems, history of falls, poor communication/comprehension, revised [DATE], documented five (5) unwitnessed falls related to self-transferring: [DATE] at 8:45 AM; [DATE] at 8:30 PM; [DATE] at 4:10 PM; [DATE] at 5:15 PM; [DATE] at 11:30 PM. Interventions after each fall were limited to environmental reminders (example: a 'Call Do Not Fall' sign, flat call bell). There was no documented evidence of new or updated interventions. During an interview on [DATE] at 11:08 AM, Licensed Practical Nurse #1 stated Resident #1 required assistance with transfers. They stated the resident was 'incredibly impulsive' and would independently transfer themselves and would fall. They stated the resident's legs were getting weaker and weaker. Unwitnessed Fall on [DATE]:Review of the Accident/Incident Report dated [DATE] at 8:45 AM, documented the resident was found sitting on the floor next to their bed following an unwitnessed fall. The resident reported attempting to get to their wheelchair independently. The Fall Risk Evaluation dated [DATE] at 9:23 AM, scored the resident at 13 (moderate risk), noting multiple falls in the prior six (6) months. There was no documented evidence of follow-up or care plan revisions to address the resident's continued self-transferring behavior. Unwitnessed Fall on [DATE]:Review of the Accident/Incident Report dated [DATE] at 8:30 PM, documented another unwitnessed fall as the resident attempted to transfer from wheelchair to bed without assistance. No injuries were noted. There was no documented evidence of a Fall Risk Evaluation. There was no documented evidence of new or updated interventions.Unwitnessed Fall on [DATE]:Review of the Accident/Incident Report dated [DATE] at 4:10 PM, documented the resident was found on the floor beside the bed with an abrasion to the right lower leg and a raised bump on the forehead. Mobility documented wheelchair bound. The resident was educated on the importance of using the call bell for safety and prevention of injuries. The Fall Risk Evaluation score was 11 (moderate risk). There was no documented evidence of new or updated interventions.Unwitnessed Fall on [DATE]:Review of the Accident/Incident Report dated [DATE] at 5:15 PM, documented an unwitnessed fall after the resident attempted to retrieve a cup of tea. A sign reminding the resident to use the call bell was placed at bedside. The Fall Risk Evaluation scored 19 (high risk). The resident had multiple falls within the last six (6) months. The resident was confined to a chair and disoriented. Gait Analysis documented unable to independently come to a standing position, exhibits loss of balance while standing, required hands-on assistance to move from place to place, used assistive device (e.g. cane, walker, etc.). There was no documented evidence of new or updated interventions.Unwitnessed Fall on [DATE]:On [DATE] at 11:30 PM, an Incident and Accident Statement by Certified Nurse Aide #1 documented Resident #1 was on their assignment; Resident #1 was last seen by them when Resident #1 was toileted or changed in the resident's room on [DATE] at 8:30 PM. The statement further documented that Resident #1 was 'very sleepy' at 8:30 PM. It documented that Certified Nurse Aide #1 next saw Resident #1 on [DATE] at 11:30 PM, when they happened to look in the room as they walked by and saw the resident lying on the floor between their bed and the window. On [DATE] at 11:30 PM, an Accident/Incident report by Licensed Practical Nurse #1 documented Resident #1 was found lying on the floor between the bed and the wall. The resident was noted with their head at the foot of the bed. Resident #1 was responsive only to vigorous stimulation and not to verbal stimuli. Vital signs and neurological checks were attempted but unsuccessful. The thermometer was unable to read the temperature of the resident. Staff attempted to obtain a blood pressure with the machine, as well as manually, but were unable to obtain due to the resident shaking. On [DATE] at 11:30 PM, an Incident and Accident Statement by Licensed Practical Nurse #1 documented Resident #1 was found shaking uncontrollably and was too cold for the thermometer to read their temperature. Tremors made taking manual blood pressure difficult. The resident was hypotensive (low blood pressure) and 80/40 was an approximation from the behavior of the needle (on the pressure gauge).Summary of Investigation for Resident #1 dated [DATE] at 11:30 PM, documented the resident's temperature was unreadable. Was unable to determine the blood pressure. Heart rate was 115. Oxygen saturation level was 73 percent but may be inaccurate due to how cold the resident was. The resident was sent to the Emergency Department and admitted to the hospital with mental status changes.Hospital Emergency Department Provider Notes, Medical Decision Making dated [DATE] at 12:37 AM, documented the resident presented to the Emergency Department via Emergency Medical Services from the nursing home for respiratory distress, altered mental status, hypothermia after an unwitnessed fall where they were on the ground for an unknown amount of time. The resident was evaluated immediately upon arrival and report was taken directly from Emergency Medical Services. Initial vital signs reviewed were concerning for hypothermia with a core temperature of 85.6 Fahrenheit taken rectally, tachycardia (increased heart rate) with heart rate in the 160's, tachypnea (abnormally rapid breathing) with respiratory rate of 30, and hypoxia (low levels of oxygen in body tissues) in the mid 80's. Hospital History and Physical dated [DATE] at 6:53 AM, documented the resident was admitted for further evaluation and management of acute respiratory failure with hypoxia secondary to suspected pneumonia and septic shock (a progression from sepsis that causes a dramatic drop in blood pressure that can damage the lungs, kidneys, liver and other organs. When the damage is severe, it can lead to death). Hospital deceased Discharge Summary documented the resident was made comfort measures only on [DATE] and was pronounced deceased on [DATE] at 11:50 PM. Cause of death was septic shock, pneumonia, acute hypoxic respiratory failure and encephalopathy. During an interview on [DATE] at 1:30 PM, Certified Nurse Aide #1 stated they were familiar with Resident #1 and was the assigned Certified Nurse Aide at the time of the [DATE] incident. They stated Resident #1 was known not to use the call bell. Certified Nurse Aide #1 stated that on [DATE], they were told at the start of their shift that Resident #1 had pneumonia and had a COVID-19 test. They stated that they were not instructed to monitor the resident, that Resident #1 had been asleep all day, slept through dinner, and had not voided much. Stated they last checked the resident at 8:30 PM and then found Resident #1 at 11:30 PM on the floor next to their bed by the window. They stated Resident #1's feet were by the head of the bed, and that Resident #1 eyes were closed, and they felt cold.During an interview on [DATE] at 11:08 AM, Licensed Practical Nurse #1 stated on [DATE] at 11:30 PM, Certified Nurse Aide #1 stood in the hallway and yelled to them. Licensed Practical Nurse #1 stated Resident #1 was on the floor of their room naked, shaking uncontrollably, and they could not get them to stop. They stated they tried taking the resident's temperature and they could not get a reading. They stated the thermometer was in good working order. The resident was not verbally responsive, and their eyes were closed. They tried to get the resident's blood pressure but could not hear the resident's pulse. They stated the resident was 'tremoring hard core' and they had never seen a resident in that state. They stated the resident had sheets and blankets on the bed that were hanging off the bed, which they moved out of the way to get to the resident.During an interview on [DATE] at 11:30 AM, Registered Nurse #101 stated they were the Registered Nurse who received Resident #1 into the Emergency Department on [DATE] at around or just after 12:00 AM. They stated the rectal temperature 85.8 degrees Fahrenheit, the resident was in respiratory distress requiring nebulizer treatments, intravenous antibiotics, and lots of warmed intravenous fluids, and stated there was 'no plausible explanation' provided for the hypothermia.During an interview on [DATE] at 9:52 AM, Certified Nurse Aide #4 stated they were told to use the Kardex, some residents were on two (2) hour checks and some on 1 (one) hour checks. They were familiar with Resident #1 who did not use the call bell, nurses would advise if checks should be more frequent for illness, and no training had been provided since [DATE].During an interview on [DATE] at 1:19 PM, Licensed Practical Nurse #2 stated they worked the evening shift on [DATE] and Resident #1 was on their assignment. Resident #1 was a 'frequent faller' and on [DATE], the resident was trying to get up and stand at the side of the bed and tried three (3) or four (4) times throughout the shift. They stated they check residents when residents asked for something. They stated Resident #1would sometimes take their clothes off.During an interview on [DATE] at 10:20 AM, Licensed Practical Nurse #3 stated Resident #1 would not use the call bell; the call bell was flat, and they were able to demonstrate they could use it. During an interview on [DATE] at 3:38 PM, Licensed Practical Nurse #4 stated they were the supervisor on [DATE] when called by Licensed Practical Nurse #1 about Resident #1's fall. Licensed Practical Nurse #4 stated they went to Resident #1's room and saw them on the floor between the bed and wall, called the on-call provider and Director of Nursing #1. They could not recall other details and stated they asked staff when they last saw the resident and were told 20 minutes prior without recalling by whom. During an interview on [DATE] at 11:25 AM, Nurse Practitioner #1 stated they were told Resident #1 had an unwitnessed fall with minimal responsiveness and was holding their head. Nurse Practitioner #1 stated they decided to send the resident to the hospital. They stated they did not recall being told the Resident #1 was unclothed, shivering, or had an unreadable low temperature, nor being informed of their pre-fall respiratory status. Nurse Practitioner #1 stated they worked weekends and usually licensed practical nurses and certified nurse aides were in the building during those times. They stated during the off shift/off hours, it was up to Nurse Practitioner #1 to decide based on limited information given during the call. They stated the way the facility provided care was reactive and not proactive. During an interview on [DATE] at 5:15 PM, Administrator #1 stated Resident #1 had several falls prior to the last fall when they were sent out to the hospital. During an interview on [DATE] at 1:40 PM, Director of Nursing #1 stated they did the investigation on Resident #1 the night of [DATE] because they were on call for the night. Resident #1 was found unresponsive by staff and staff called them on [DATE] around 11:52 PM. The telemedicine provider on-call had been called first, and the resident was already on the way to the hospital, so they stated they had not responded to the building. Director of Nursing #1 stated there had been no care plan violation; the resident had been a fall risk and had four (4) previous falls. Resident #1 had been admitted to the hospital with altered mental status. During an interview on [DATE] at 4:01 PM, Physician #1 stated they had been at the facility when Resident #1 had a fall on [DATE]. They observed and examined the resident on [DATE] for respiratory concerns before the [DATE] hospitalization. They ordered a chest x-ray and a nebulizer treatment for respiratory illness and pneumonia was not noted. They stated there were detailed notes. They stated that when they last examined the resident, nothing indicated the resident needed to be sent out to the hospital. On [DATE], they asked where Resident #1 was and were told they had gone out to the hospital for a change in mental status after a fall. No one had advised them that the resident was hypothermic. They stated that a person with frequent falls should be checked often. The physician was not sure why the 'particulars' had not been given to them. During an interview on [DATE] at 4:32 PM, Director of Rehabilitation #1 stated Resident #1 had been participating in Physical Therapy and Occupational Therapy from [DATE] until [DATE] and was doing well. Resident #1 had been taught to call for assistance and to exit the bed on the side away from the window. They had a fall in [DATE] and resumed therapy on [DATE] due to increased weakness. After the fall on [DATE], the resident had a 'Call don't Fall' sign placed on the bedside table. They were scheduled to be seen two (2) to three (3) times a week. It had been noted all falls were on the side of the bed by the window. They stated no contributing factors were identified other than the resident was declining and had increased confusion, and no further interventions had been put in place because the resident went to the hospital after the last unwitnessed fall.During an interview on [DATE] at 11:30 AM, Registered Nurse #101 stated the resident came into their hospital with severe hypothermia after a fall, and they 'had never seen hypothermia like this unless the patient was homeless.'During an interview on [DATE] at 12:52 PM, Administrator #1 stated they thought their team did a 'very good job' of making a person-centered approach to preventing falls. They would expect the Interdisciplinary team, which included Nursing, Therapy, Activities, Social Work, Administration, Dietary, and the Medical Practitioner to review falls and implement new interventions. They stated they had not identified a timeline for when Resident #1 might have fallen on [DATE]. They checked the nursing documentation and stated the resident was given a bedtime snack at 9:08 PM. They stated they knew Nursing staff was 'in and out' of the room with nebulizer treatments on [DATE]. They stated there was no facility-wide training after the resident fell on [DATE]. Resident #3:Resident #3 was admitted to the facility with diagnoses of iron deficiency anemia (low levels of healthy red blood cells to carry oxygen throughout the body, which causes fatigue and weakness) secondary to chronic blood loss, Parkinson's disease (progressive movement disorder of the nervous system) with dyskinesia (involuntary, erratic, writhing movements of the face, arms, legs and trunk), and repeated falls. The Minimum Data Set, dated [DATE], documented the resident had moderate cognitive impairment. The resident was able to make themselves understood and understood others.Comprehensive Care Plan, focus of Actual Fall Related to Decreased Mobility, initiated [DATE], and additional focus of Actual Fall Related to History of Falls, back issues with pain and self-transferring, initiated [DATE] and revised on [DATE], documented 30 falls from [DATE] to [DATE], of which 20 were documented as unwitnessed (unwitnessed indicated by *asterisk); [DATE], [DATE], [DATE], [DATE]*, [DATE]*, [DATE], [DATE], [DATE]*, [DATE]*, [DATE]*, [DATE], [DATE]*, [DATE]*, [DATE]*, [DATE]*, [DATE], [DATE], [DATE]* 'hit head', [DATE], [DATE], [DATE]* 'with head strike' [sic], [DATE]*, [DATE]*, [DATE]*, [DATE]*, [DATE]*, [DATE]*, [DATE]*, [DATE]*, [DATE]*).Care Plan for Requires Assist with Activities of Daily Living related to advanced Parkinson's disease, revised [DATE], revealed there were no active interventions for the resident's transfer and/or ambulation status. Interventions documented:- Encourage resident to use bell to call for assistance (initiated [DATE]).- An intervention to ambulate in room with extensive assist and one (1) staff was initiated on [DATE] and resolved on [DATE], due to the resident being unable to ambulate. An intervention for transfers with extensive assist and one staff with two-wheeled walker and gait belt was also resolved on [DATE].- Standard wheelchair with automatic brakes with gel cushion and wedge on left side to offset leaning as tolerated (initiated [DATE] and was revised on [DATE]).Care Plan for Resident had an Actual Fall related to history of falls, back issues with pain and self-transferring, revised [DATE], interventions documented:- Frequent reminders to request assistance from staff when reaching for items on the floor (initiated [DATE]).- [DATE] New medication started and will continue to monitor for adverse effects (initiated [DATE] and resolved [DATE]).- [DATE] Bilateral mat bedside when in bed (initiated [DATE]).- [DATE] Two-to-three-hour toilet schedule (initiated [DATE] and cancelled [DATE]).There was no documented evidence of the monitoring for effectiveness and modifying interventions when necessary. Summary of Investigation for Resident #3 dated [DATE] at 3:00 AM, documented Certified Nurse Aide #1 entered the room to perform care on Resident #3's roommate when they found Resident #3 crawling on the floor in between the two (2) beds. The resident stated they slid down the side of the bed onto their buttocks and that they did not hit their head. Due to the resident's cognition and Eliquis (blood thinner) use, the resident was sent to the Emergency Department for imaging to rule out subdural hematoma (bleeding inside the brain).- Conclusion: Resident #3 had cognitive impairments that could present as delusions and impairment related to Parkinson's. Unfortunately, the resident also had chronic deep vein thrombosis (blood clots) and required oral anticoagulation, Eliquis two (2) times a day, putting the resident at risk for intracranial hemorrhage. The resident was sent to the Emergency Department and found wrist fracture to left wrist. The care plan was followed.- Risk Management Summary/Review of plan of care, policies and trend analysis documented Interdisciplinary Review - add every two (2)-to-three (3)-hour toileting schedule as tolerated and bilateral fall mats when in bed for safety. Review of the Kardex (an electronic file system that gives an overview of each resident and their care needs) dated [DATE], documented Falling Star under safety. There was no documented evidence of instructions on the Kardex for checking the resident for incontinence.During an interview on [DATE] at 10:20 AM, Licensed Practical Nurse #3 stated Resident #3 was a frequent faller but typically did not get up and walk by themselves. They stated the resident could make it a few steps, shuffles and would topple over. They stated the resident went to Physical Therapy and became more independent. Over the last couple of months, the resident had a walker, and tasks were just upgraded for the resident to be supervised when using the walker.During an interview on [DATE] at 2:43 PM, Director of Nursing #1 stated Resident #3 fell frequently. They stated the facility had been changing the interventions on the resident's comprehension care plan because they fell so often. Snacks were offered when the resident appeared to be anxious, and they had every two (2) to three (3) hour checks in place. They stated the resident tended to fall at night and was moved closer to the nurse station. Additional Interviews:During an interview on [DATE] at 1:30 PM, Certified Nurse Aide #1 stated they had not received any training since the incident on [DATE].During an interview on [DATE] at 9:30 AM, Certified Nurse Aide #2 stated aides were not given any additional instruction for checking residents who frequently fell, the Kardex usually indicated to check and change a resident every two (2) to three (3) hours, staffing was one (1) nurse and one (1) Certified Nurse Aide on night shift, aside from the Kardex, common practice would be to check more often if a resident was sick with a history of falls. They stated they had not received any training since the incident on [DATE]. During an interview on [DATE] at 9:46 AM, Certified Nurse Aide #3 stated there was no formal protocol for rounding/checking on the residents. During an interview on [DATE] at 11:08 AM Licensed Practical Nurse #1 stated they had not received any training since the incident on [DATE].In summary, staff interviews revealed there was no formal rounding protocol, no increased monitoring for residents with repeated falls, and no training provided after the [DATE] incident. During an interview on [DATE] at 2:24 PM, Medical Director #1 stated residents who were at a high risk for falls should be monitored closely.The facility was notified of the Immediate Jeopardy on [DATE] at 6:40 PM. Record review on [DATE] revealed Resident #9 identified as being at risk for falls. There was no documented evidence that the care plan was reviewed or updated for fall interventions.Record review on [DATE] revealed the facility utilized 'falling stars, a fall and monitoring approach' that staff were trained on. On each resident door, there was a silver star on the wall next to the resident's nameplate. This silver star indicated that the resident, per facility education, was at 'highest risk for falls and then aggressively works to monitor, prevent and minimize injury related to falls.'Interviews with front-line staff on [DATE] corroborated this understanding of 'falling stars.' Observations on [DATE] noted 24 'falling star' resident nameplates (23 residents plus one (1) resident who expired), however, the facility supplied a list of 16 residents at risk for falls. During an interview on [DATE] at approximately 11:05 AM, Assistant Director of Nursing #1 stated they believed there were only 12 residents who fit for 'falling stars,' and that falling stars included residents who were acutely ill.The Immediate Jeopardy was removed on [DATE] at 3:30 PM. The facility's immediacy removal actions included the following: On [DATE], the census was 72. Of the 72 residents, 23 residents were identified with having a high risk for falls. The fall care plans for the 23 residents identified as having a high risk for falls were reviewed. All of the 23 care plans documented 'Hourly rounding. Refer to binder' as an intervention. The care Kardex for the 23 residents identified as having a high risk for falls were reviewed. All 23 Kardex's documented 'Hourly rounding. Refer to binder.' Attestation by Administrator dated [DATE] documented 100 percent of staff working on [DATE] were educated on the systematic changes and policy review (accidents and incidents prevention, investigation, hourly checks, communicating to the emergency management system and hospital system). 95 percent or greater of all active employees were educated on these systemic changes and policy reviews. No staff reported to active duty without having this education. Interview with Medical Director on [DATE] at 2:30 PM. Medical Director was aware of Immediate Jeopardy issued for F689. They attended morning meeting on [DATE] where interventions to abate the Immediate Jeopardy were reviewed. Medical Director agreed with interventions and increased monitoring for residents with high risks for falls. Medical Director was briefed on Resident #1's discharge to the hospital on [DATE] and condition at time of discharge. On [DATE], an ad hoc Quality Assurance Performance Improvement meeting was held. Interviews with Certified Nurse Aides, Licensed Practical Nurses, and Registered Nurses on [DATE] indicated staff were educated regarding the new policy involving hourly checks for residents identified as increased risk for falling. Certified Nursing Assistants documented completion of hourly checks for the identified residents in a binder at the nursing station and nursing staff would verify completion of this task at shift completion. All staff interviewed verbalized understanding of the new policy and procedures involving hourly rounding on residents identified as having a high risk for falls. 10 New York Code of Rules and Regulations 415.12(h)(2)

Based on record review and interview conducted during an abbreviated survey (Case #2635234), the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for one (1) of four (4) residents (Resident #1) reviewed. Specifically, on [DATE] at 11:30 PM, Resident #1 was found unresponsive with an oxygen saturation of 73 percent (normal 95 to100 percent) and signs of respiratory distress. Emergency Medical Services documented 'extreme' wheezing in all lung fields and a clinical impression of pneumonia (an infection in one or both lungs). The resident was admitted to the hospital with septic shock (a progression from sepsis that causes a dramatic drop in blood pressure that can damage the lungs, kidneys, liver and other organs. When the damage is severe, it can lead to death) secondary to pneumonia/acute hypoxic respiratory failure (a medical condition characterized by a rapid decline in oxygen level in the blood leading to inadequate oxygen delivery to the body's tissues) and encephalopathy (a change in brain function due to injury or disease). Resident #1 was pronounced dead on [DATE] at 11:50 PM. The cause of death was listed as septic shock, pneumonia, acute hypoxic respiratory failure, and encephalopathy. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy. This is evidenced by: Cross-referenced to F689: Free of Accidents Hazards/Supervision/Devices; F656: Develop/Implement Comprehensive Care Plan The Policy and Procedure titled, Administering Medications through a Small Volume Nebulizer (a handheld medical device that converts liquid medication into a fine mist, allowing it to be directly inhaled into lungs), revised 01/2025, documented the purpose of the procedure was to safely and aseptically administer aerosolized particles of medication into the resident's airway. General Guidelines documented to follow the medication administration guidelines and document in residents medical record condition prior, during, and after administered treatment. Policy and Procedure titled, Administering Medications, reviewed 01/2025, documented medications would be administered in a safe and timely manner, and as prescribed. The Policy and Procedure titled, Acute Condition Changes - Clinical Protocol, revised 01/2025, Assessment and Recognition documented direct care staff would report and assess within their scope, any change in condition to Attending Physician. The Attending Physician would identify and authorize appropriate treatments, including authorize transfer to hospital if needed. The Policy and Procedure titled 24-Hour Report, revised 08/2025, documented the 24-hour Report outlined documentation, communicating, and follow up on significant resident care events that occurred during a 24-hour period. Resident #1 was admitted to the facility with diagnoses of unspecified dementia without behavioral/psychotic/mood disturbance (a condition where a person can experience memory loss, confusion, difficulty with thinking and reasoning), history of falling, and generalized anxiety disorder (excessive, ongoing worry that is difficult to control and interferes with day-to-day activities). The Minimum Data Set (a resident assessment tool) dated [DATE], documented the resident had severe cognitive impairment. The resident was able to make themselves understood and understood others. Record review of facility document titled, admission Record (Face Sheet), printed on [DATE], documented information as wheezing with an onset date of [DATE]. Review of Comprehensive Care Plans revealed: -Care Plan for At Risk for/has an Alteration in Respiratory Function related to (cause not documented), was initiated on [DATE] and resolved on the same day, [DATE]. There were no interventions documented. -There was no documented evidence a comprehensive care plan was created for respiratory care and services for the management of the resident's diagnosis of wheezing and that the resident was ordered to have nebulizer treatments as needed for shortness of breath or wheezing. -Care Plan for Nutritional Problem or Potential Nutritional Problem, documented and revised [DATE], included wheezing as one of the relational causes. Interventions documented were related to the resident's nutritional needs. Order Listing Report for order date range [DATE] to [DATE], documented: - Order dated [DATE] for Ipratropium 0.5 milligrams/Albuterol Solution 3 milligrams (Duoneb) 3 milliliter vial, inhale orally every four (4) hours as needed for shortness of breath or wheezing related to wheezing via nebulizer. - Order dated [DATE] for Ipratropium 0.5 milligram/Albuterol Solution 3 milligrams (Duoneb) 3 milliliter inhaled orally one (1) time only for wheezing. Physician's Progress Note dated [DATE] at 9:47 PM by on-call Nurse Practitioner #2, documented a late entry note. Subjective findings documented the registered nurse called because the resident was complaining of shortness of breath. Objective findings documented blood pressure 86 over 63, oxygen saturation 97 percent, and inspiratory and expiratory wheezes. Assessment was shortness of breath with low blood pressure and wheezing. Plan was immediate chest X-ray, administer Ipratropium/Albuterol Solution (Duoneb) one (1) time, registered nurse to monitor treatment effectiveness, and report if condition did not improve or worsened. 24-Hour Report dated [DATE], during the evening shift (3 PM - 11 PM), documented Resident #1 refused care with labored breathing, wheezing, and blood pressure of 98 over 48. There was no documented evidence on the 24-Hour Report that Resident #1's respiratory status was monitored per physician's orders. Medication Administration Record dated [DATE], documented the Ipratropium/Albuterol Solution (Duoneb) was to start on [DATE] at 10:15 PM. The medication was documented as administered on [DATE] at 2:09 AM. There was no documented evidence in Nursing Notes about the effectiveness of the treatment or ongoing assessment, and monitoring of Resident #1's respiratory status on [DATE]. During an interview on [DATE] at 4:01 PM, Physician #1 stated they had been at the facility when Resident #1 had a fall on [DATE]. They observed and examined the resident before the latest hospitalization on [DATE]. They ordered a chest x-ray and a nebulizer treatment for some respiratory illness and pneumonia was not noted. They stated there were detailed notes. They stated nothing indicated that the resident needed to be sent out to the hospital. They stated they are in the building 4 days a week and when they returned on Monday ([DATE]) they asked where Resident #1 was and was told they had gone out to the hospital for a change in mental status after a fall. Physician #1 stated no one had advised them that the resident was hypothermic. They stated that a person with frequent falls should be checked often. The physician was not sure why the particulars had not been given to them. Radiology Report dated [DATE], documented two (2) views of the chest for diagnosis of wheezing. Impression was diffuse interstitial (widespread inflammation or scaring, and airspace opacities (air sacs filled with fluid puss or other material) are seen in both lungs, mildly worsened bilaterally since previous ([DATE]).There was no documented evidence in Nursing Notes that the physician was notified of the results. 24-Hour Report dated [DATE], for the day shift (7 AM - 3 PM) documented Resident #1was positive for pneumonia and negative for pleural effusion (collection of fluid around the lungs). There was no documented evidence for where diagnoses originated. There was no documented evidence on the 24-Hour Report that Resident #1's respiratory status was monitored per physician's orders. 24-Hour Report dated [DATE], the evening shift, documented Resident #1 was very confused and combative. There was no documented evidence on the 24-Hour Report that Resident #1's respiratory status was monitored per physician's orders. There was no documented evidence on the [DATE] 24-Hour Report for the night shift, that Resident #1's respiratory status was monitored per physician's orders. The report was blank. Nursing Note dated [DATE] at 12:55 PM by Registered Nurse #2, documented the resident had mental status changes, was unable to stand with assist, and 'not able to form words into a sentence.' Respiratory rate at 28 breaths per minute (normal 12 to 20 breaths per minute), oxygen saturation level 96 percent. Lungs with expiratory wheezes bilaterally, harsh breathing sounds. Discussed with Physician #1, nebulizer provided with plan to monitor. Medication Administration Note dated [DATE] at 12:37 PM by Registered Nurse #2 documented Ipratropium/Albuterol Solution (Duoneb) 0.5-2.5/ 3 milligrams/milliliter, inhale orally every four (4) hours as needed for shortness of breath or wheezing related to wheezing via nebulizer. Medication Administration Record documented Ipratropium/Albuterol Solution (Duoneb) was administered on [DATE] at 12:37 PM by Registered Nurse #2. On [DATE] at 2:16 PM, the Medication Administration Note by Licensed Practical Nurse #2, documented Ipratropium/Albuterol Solution (Duoneb) as needed was administered, and the effectiveness was 'unknown.' The Physician Note, Acute Care Visit dated [DATE] at 2:16 PM by Physician #1, documented chief complaint was difficulty breathing. The resident was re-assessed on [DATE] after nurses reported difficulty in breathing. The resident's oxygen saturation was within normal limits and there was no fever. Given that there were active COVID-19 positive cases in the facility, testing was ordered. Assessment/Diagnosis: unspecified dyspnea (difficulty breathing). Plan: COVID-19 test order; monitor results, monitor oxygen saturation and respiratory status 'closely,' notify provider if symptoms worsen, and 'nurses have been instructed to keep an eye on the patient.' During an interview on [DATE] at 11:20 AM, Physician #1 stated any acute change in condition such as hypothermia/hyperthermia, hypoxia, or altered mental status needed to be reported to the medical provider in-house or on-call. They stated when they documented in their note dated [DATE], to monitor oxygen saturation and respiratory status closely, they expected the nurse to be checking the resident every hour. They stated nurses could auscultate the chest (listen to lung sounds with a stethoscope), assess the oxygen saturation level, and obtain vital signs. They stated it was not acceptable for the nurse to leave the room after they applied the mask for the nebulizer treatment. They stated the nurse needed to stay with the resident and should be obtaining the oxygen saturation level before and after the procedure. The nurse needed to monitor the resident for any changes and for the effectiveness of the treatment, which should be documented in a note. They stated for the treatment to be effective, it needed to last at least 5 (five) consecutive minutes so the blood vessels could dilate in the nose as well as the lungs, to help the resident breathe easier. Physician #1 stated their responsibility was to assess the resident and order the medications and treatments. It was the nurse's responsibility to ensure medications were administered as ordered and if there were any concerns about the resident not receiving them, they were to notify the provider. They stated nurses needed more education related to administering medications via a nebulizer machine. There were no documented orders to monitor the resident's vital signs or to check Resident #1 hourly as Physician #1 stated, and there was no documented evidence in nursing notes that the resident's respiratory status was monitored closely on [DATE] and [DATE]. 24-Hour Report dated [DATE], during the day shift (7 AM 3 3 PM), documented Resident #1 had shortness of breath with respiratory rate of 28. Ipratropium/Albuterol Solution (Duoneb) administered at 12:37 PM and resident was tested for COVID-19. There was no documented evidence the effectiveness of the nebulizer treatment was assessed. Medication Administration Note dated [DATE] at 4:52 PM by Licensed Practical Nurse #2, documented Ipratropium/Albuterol Solution (Duoneb) 0.5-2.5/3 milligrams/milliliter, inhale orally every four (4) hours as needed for shortness of breath or wheezing related to wheezing via nebulizer. Medication Administration Record documented Ipratropium/Albuterol Solution (Duoneb) was administered on [DATE] at 4:52 PM by Licensed Practical Nurse #2. There was no documented evidence in a Nursing Note about the effectiveness of the nebulizer treatment. During an interview on [DATE] at 1:19 PM, Licensed Practical Nurse #2 stated they worked the evening shift on [DATE] and Resident #1 was on their assignment. They were aware Resident #1 was sick and stated the resident was receiving nebulizer treatments. They stated they would start the nebulizer treatment and walk away. When they went back into the room, they saw that the resident had the nebulizer mask off, and Licensed Practical Nurse #2 would put it back on. They stated they were told the resident needed to be monitored and said they were checking the resident constantly and obtained vital signs several times. They stated they were not sure if they documented them. They stated they gave the resident medications on [DATE] at 6:00 PM. They thought someone told them the resident did not want to eat dinner but could not recall which staff member. They stated they told the Certified Nurse Aide they needed to monitor the resident but could not recall who they told. During an interview on [DATE] at 10:45 AM, Director of Nursing #1 stated the facility had a step-by-step policy for how nurses were to administer medications via a nebulizer and any vitals that needed to be taken. After a treatment starts, the pulse and respirations were to be assessed. Nurses should stay with the resident during the administration. The nurse should be doing the follow up vitals and documentation of the effectiveness. During the treatment, nurses monitor the resident and notify the provider if there were any changes from their baseline. They stated they did not have a policy for monitoring the residents' conditions. The expectation was the nurse would go to the room and check on the resident as often they could to ensure the resident did not have a change from baseline. Review of Weights and Vitals Summary documented the resident's vital signs were obtained one (1) time by Licensed Practical Nurse #2 during the evening shift on [DATE] at 5:24 PM. 24-Hour Report dated [DATE], the evening shift (3 PM - 11 PM) documented Resident #1 had a respiratory rate of 22. Ipratropium/Albuterol Solution (Duoneb) administered; time was not documented. Results were documented as 'pending.' Physician Progress Note dated [DATE] at 11:47 PM by the on-call Nurse Practitioner #1, documented they were notified by Licensed Practical Nurse #4 about the resident's condition and about an unwitnessed fall. There was no documented evidence that Nurse Practitioner #1 was made aware of resident's respiratory status prior to the [DATE] fall. 24-Hour Report dated [DATE], during the night shift (11 PM - 7 AM), documented Resident #1 fell at 11:30 PM. Resident was unresponsive, and was sent to the hospital. During an interview on [DATE] at 11:25 AM, on-call Nurse Practitioner #1 stated they were told of an unwitnessed fall and minimal responsiveness, did not recall being told of respiratory status or monitoring prior to transfer to the hospital. They stated the way the facility provided care was reactive and not proactive. Emergency Services Patient Care Record dated [DATE], documented extreme expiratory wheezing in all lung fields. Primary impression was pneumonia. Signs and Symptoms were wheezing (primary), cough, and hypothermia. Lung sounds bilaterally were noted with rhonchi (continuous low-pitched sounds best heard when breathing out) wheezing, and expiratory wheezing (high-pitched whistling sound heard when exhaling). Resident was administered oxygen to maintain airway patency and a Ipratropium/Albuterol Solution (Duoneb) treatment was provided via nebulizer to address respiratory concerns. Hospital History and Physical dated [DATE] at 6:53 AM, documented the resident was admitted for further evaluation and management of acute respiratory failure with hypoxia secondary to suspected pneumonia and septic shock (a progression from sepsis that causes a dramatic drop in blood pressure that can damage the lungs, kidneys, liver and other organs. When the damage is severe, it can lead to death). During an interview on [DATE] at 11:30 AM, Registered Nurse #101 stated they were the Registered Nurse that received Resident #1 into the Emergency Department on [DATE] at around or just after 12:00 AM. They stated resident arrived in respiratory distress, required nebulizer treatments, intravenous antibiotics, and warmed intravenous fluids due to low core body temperature. Registered Nurse #101 stated the call from the facility was brief and lacked detail about in-facility respiratory treatment or monitoring. Hospital deceased Discharge Summary documented the resident was made comfort measures only on [DATE] and was pronounced dead on [DATE] at 11:50 PM. Cause of death was septic shock, pneumonia, acute hypoxic respiratory failure and encephalopathy. During an interview on [DATE] at 1:30 PM, Certified Nurse Aide #1 stated they were familiar with Resident #1 and was the assigned Certified Nurse Aide at the time of the [DATE] incident. They stated Resident #1 did not use the call bell. Certified Nurse Aide #1 stated that on [DATE], they were told at the start of their shift that Resident #1 had pneumonia and had a COVID-19 test. They stated that they were not instructed to monitor the resident, that Resident #1 had been asleep all day, slept through dinner, and had not voided much. During an interview on [DATE] at 10:30 AM, Registered Nurse #2 stated the order was to stabilize in the facility, that a Licensed Practical Nurse would administer nebulizer, ideally a nurse should stay and monitor the effectiveness during treatment, and the oncoming nurse would ensure treatments were given as ordered. During an interview on [DATE] at 12:52 PM, Administrator #1 stated they knew Nursing staff were 'in and out' of the room with nebulizer treatments on [DATE]. 10 New York Code of Rules and Regulations 415.12(k)(6)

Based on record review and interviews during an abbreviated survey (Case # 2635234), the facility did not ensure the development and implementation of a person-centered care plan that included measurable objectives and timeframes to meet the resident's needs for 2 (two) (Resident #s 1 and 3) of 4 (four) residents reviewed. Specifically, the facility did not ensure it developed, implemented, monitored, and evaluated appropriate person-centered care plan interventions to mitigate falls for Resident #'s 1 and 3, who had multiple unwitnessed falls in their rooms related to self-ambulation. This is evidenced by: Cross-referenced to F689: Free of Accident Hazards/Supervision/Devices The Policy and Procedure titled, Falls and Fall Risk Managing, reviewed 1/2025, documented that based on previous evaluations and current data, staff must identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. If falling reoccurred despite initial interventions, staff would implement additional or different interventions or indicate why the current intervention remained appropriate. If underlying causes could not be readily identified or corrected, staff would try various interventions, based on the assessment of the nature or category of falling, until falling was reduced or stopped, or until the reason for the continuation of the falling was identified as unavoidable. The policy required documentation of ongoing monitoring and evaluation of each resident's response to interventions. If the resident continued to fall, staff would re-evaluate the situation and whether it was appropriate to continue or change current interventions. The policy documented physician involvement when falls persisted. The Policy and Procedure titled, Falling Star Program, reviewed 1/2025, documented that the program identified residents at highest risk for falls and required aggressive monitoring and prevention of injury related to falls. The policy documented that staff were to place a star symbol near the resident's room nameplate, and on the resident's walker or wheelchair, to indicate high fall risk. Staff were to be informed of residents enrolled in the program during shift-to-shift report and rounds. The policy specified that residents demonstrating unsafe behaviors or repeated falls required increased staff awareness and monitoring wherever they were in the facility. Resident #1: Resident #1 was admitted to the facility with diagnoses of unspecified dementia without behavioral/psychotic/mood disturbance (a condition where a person experiences cognitive decline [memory loss, confusion, difficulty with thinking and reasoning] but the specific cause of the decline cannot be determined), history of falling, and generalized anxiety disorder (excessive, ongoing anxiety and worry that are difficult to control and interfere with day-to-day activities). The Minimum Data Set (an assessment tool) dated 7/17/2025, documented the resident had severe cognitive impairment. The resident was able to make themselves understood and understand others. The Discharge Minimum Data Set, dated [DATE], documented the resident's height was 63 inches and weight was 164 pounds, a body mass index (BMI) of 29.0 classified as overweight. Review of Care Plan titled, At Risk for Functional Decline in Mobility and Self Care related to age related changes, dementia, and benign prostatic hyperplasia (enlarged prostate), revised 7/2/2025, documented the resident had a history of self-transferring. Interventions included encouraging use of the call bell, providing partial assistance for transfers, and ensuring assistive devices were within reach. Review of Care Plan titled, At Risk for Falls related to history of falls, and age-related changes including cataracts, revised 6/12/2025, documented interventions included but were not limited to 'anticipate and meet resident's needs' and bed in lowest position. Review of Care Plan titled, Resident had an Actual Fall related to cognitive deficit, gait/balance problems, history of falls, poor communication/comprehension, revised 9/29/2025, documented five (5) unwitnessed falls related to self-transferring: 7/07/2025 at 8:45 AM; 8/24/2025 at 8:30 PM; 9/22/2025 at 4:10 PM; 9/24/2025 at 5:15 PM; 9/28/2025 at 11:30 PM. Interventions after each fall were limited to environmental reminders (example: a 'Call Do Not Fall' sign, flat call bell). There was no documented evidence in Resident #1's comprehensive care plan, of the development, implementation, monitoring, and evaluation of appropriate person-centered care plan interventions to mitigate falls. During an interview on 10/08/2025 at 10:20 AM, Licensed Practical Nurse #3 stated Resident #1 would not use the call bell; the call bell was flat, and the resident was able to demonstrate its use. During an interview on 10/08/2025 at 1:19 PM, Licensed Practical Nurse #2 stated they worked the evening shift on 9/28/2025 and Resident #1 was on their assignment. Resident #1 was a frequent faller. During an interview on 10/08/2025 at 4:01 PM, Physician #1 stated that a person with frequent falls should be checked often. During an interview on 10/08/2025 at 5:15 PM, Administrator #1 stated Resident #1 had several falls prior to the last fall where they were sent out to the hospital. Resident #3: Resident #3 was admitted to the facility with diagnoses of iron deficiency anemia (low levels of healthy red blood cells to carry oxygen throughout the body, which causes fatigue and weakness) secondary to chronic blood loss, Parkinson's disease (progressive movement disorder of the nervous system) with dyskinesia (involuntary, erratic, writhing movements of the face, arms, legs and trunk), and repeated falls. The Minimum Data Set, dated [DATE], documented the resident had moderate cognitive impairment. The resident was able to make themselves understood and understood others. Care Plan, focus of Actual Fall Related to Decreased Mobility, initiated 10/09/2023, and additional focus of Actual Fall Related to History of Falls, back issues with pain and self-transferring, initiated 10/28/2024 and revised on 10/07/2025, documented 30 falls from 10/07/2023 to 9/22/2025, of which 20 were documented as unwitnessed. Record review of Care Plan titled, Requires Assist with Activities of Daily Living related to advanced Parkinson's disease, revised 10/07/2025, revealed there were no active interventions for the resident's transfer or ambulation. Prior interventions such as assistance with a two-wheeled walker and gait belt were resolved in October 2023. Record review of Care Plan titled, Resident had an Actual Fall related to history of falls, back issues with pain and self-transferring, revised 10/09/2025, documented interventions such as frequent reminders to request assistance, bilateral mats bedside, and a two-to-three-hour toilet schedule, some of which had been discontinued. There was no documented evidence of ongoing monitoring or revision of interventions in response to continued falls. During an interview on 10/08/2025 at 10:20 AM, Licensed Practical Nurse #3 stated Resident #3 was a frequent faller but typically did not get up and walk by themselves. They stated the resident could make it a few steps before toppling over. They stated that after physical therapy, the resident became more independent and tasks were upgraded to supervision when using a walker. During an interview on 10/17/2025 at 2:43 PM, Director of Nursing #1 stated Resident #3 fell frequently and that interventions were changed often because of this. They stated the resident was moved closer to the nurse station, was checked every two (2) to three (3) hours, and was offered snacks when anxious. Additional interviews: During an interview on 10/08/2025 at 9:30 AM, Certified Nurse Aide #2 stated aides were not given any additional instruction for checking residents who frequently fell. During an interview on 10/08/2025 at 9:46 AM, Certified Nurse Aide #3 stated there was no formal protocol for rounding/checking on the residents. During an interview on 10/08/2025 at 12:52 PM, Administrator #1 stated they thought their team did a 'very good job' of making a person-centered approach to preventing falls. They would expect the Interdisciplinary team, which included Nursing, Therapy, Activities, Social Work, Administration, Dietary, and the Medical Practitioner to review falls and implement new interventions. During an interview on 10/10/2025 at 2:24 PM, Medical Director #1 stated residents who were at a high risk for falls should be monitored closely. 10 New York Code of Rules and Regulations 415.11(c)(1)

Based on interviews and record review conducted during the abbreviated survey (Case # 2635234), the facility did not thoroughly investigate accidents for 1 (one) of 4 (four) residents reviewed for accidents. Specifically, on 9/28/2025 at 11:30 PM, Resident #1 was found in their room on the floor next to their bed. Resident #1 was unresponsive except to painful stimuli and had uncontrollable shaking. Resident #1 was left for an undetermined amount of time without providing care. Subsequently, when assessing Resident #1's vital signs (key indicators of the body's essential physiological functions including temperature, heart rate, breathing rate, and blood pressure), Resident #1's body temperature was too low to be read by a thermometer. The facility did not have documented evidence of a thorough investigation to rule out if Resident #1 was abused and/or neglected.This is evidenced by:Cross-referenced to F689: Free of Accident Hazards/Supervision/DevicesThe Policy and Procedure titled, Accident and Incident-Investigating and Reporting-Resident, reviewed 01/2025, documented all accidents or incidents involving residents occurring on the premises would be investigated and reported to the Administrator. The following data, as applicable, would be included on the Report of Incident/Accident form: the date and time the accident or incident took place; the nature of the injury/illness; the circumstances surrounding the accident or incident; where the accident or incident took place; the condition of the injured person, including their vital signs; other pertinent data as necessary or required. The Policy and Procedure titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, reviewed 01/2025, documented residents had the right to be free from abuse and neglect. Implementation of the policy and procedure consisted of a facility-wide commitment and resource allocation to support the following objectives: develop and implement policies and protocols to prevent and identify abuse or mistreatment of residents, neglect of residents and to identify and investigate all possible incidents of abuse and neglect.Resident #1 was admitted to the facility with diagnoses of unspecified dementia without behavioral/psychotic/mood disturbance (a condition where a person experiences cognitive decline [memory loss, confusion, difficulty with thinking and reasoning] but the specific cause of the decline cannot be determined), history of falling, and generalized anxiety disorder (excessive, ongoing anxiety and worry that are difficult to control and interfere with day-to-day activities). The Minimum Data Set (an assessment tool) dated 07/17/2025, documented the resident had severe cognitive impairment. The resident was able to make themselves understood and understand others. Incident and Accident Statement Form completed on 09/28/2025 by Certified Nurse Aide #1 documented on 09/28/2025 at 11:30 PM, they walked by Resident #1's room, looked in and saw Resident #1 on the floor between their bed and the window. This statement documented the last time Resident #1 was toileted or changed was on 09/28/2025 at 8:30 PM. On 09/28/2025 at 11:30 PM, an Accident/Incident Report by Licensed Practical Nurse #1 documented Resident #1 was found lying on the floor between their bed and the wall. The resident was noted with their head at the foot of the bed. Resident #1 was responsive only to vigorous stimulation and not to verbal stimuli. Vital signs and neurological checks were attempted but unsuccessful. The thermometer was unable to read the temperature of the resident. Staff attempted to obtain a blood pressure with the machine as well as manually but was unable to obtain due to the resident shaking. Summary of Investigation Report dated 09/29/2025 documented on 09/28/2025 at 11:30 PM, Resident #1 was found in their room after an unwitnessed fall from their bed to the floor. There was a small skin tear on their left elbow and a bump on the left back of their head. Resident #1's temperature was unreadable. Was unable to determine the blood pressure. Heart rate was 115. Oxygen saturation level was 73 percent 'but may be inaccurate due to how cold the resident was.' The summary further documented that Resident #1 was sent to the Emergency Department and admitted to the hospital with changes in mental status. The Summary of Investigation Report did not include an investigation of the amount of time Resident #1 was on the floor or factors that contributed to why Resident #1 was cold and their body temperature was unreadable. Physician progress note dated 09/28/2025 at 11:47 PM documented nursing staff noted Resident #1 had an unwitnessed fall. They were found sitting on the floor next to their bed. It appeared the resident slid out of the bed and on to the floor. Body check was performed. No visible injuries. No open wounds or abrasions. Resident was unreliable to tell whether they had a head strike. Nursing staff noted the resident was holding their head. No mental status changes. The resident was not on any systemic anticoagulation (medical treatment that prevents blood clots from forming or growing). Vital signs were stable.There was no documented evidence in the Investigation Report that addressed the discrepancies between the Physician progress note dated 09/28/2025 at 11:47 PM, including but not limited to vital signs and mental status.Hospital Emergency Department Provider Notes, Medical Decision Making dated 09/29/2029 at 12:37 AM, documented Resident #1 presented to the Emergency Department after an unwitnessed fall where they were on the ground for an unknown amount of time. Initial vital signs reviewed were 'concerning for hypothermia with a core temperature of 85.6 Fahrenheit taken rectally,' tachycardia (increased heart rate) with heart rate in the 160's, tachypnea (abnormally rapid breathing) with respiratory rate of 30, and hypoxia (low levels of oxygen in body tissues) in the mid 80's. During an interview on 10/23/2025 at 11:30 AM, Registered Nurse #101 stated they were the Registered Nurse who received Resident #1 into the Emergency Department on 09/29/2025 at around or just after 12:00 AM. They stated the rectal temperature was 85.8 degrees Fahrenheit, the resident was in respiratory distress requiring nebulizer treatments, intravenous antibiotics, and lots of warmed intravenous fluids, and stated there was 'no plausible explanation' provided for the hypothermia.During an interview on 10/14/2025 at 3:15 PM, Director of Nursing #1 stated they were the Registered Nurse on-call on 09/28/2025. They stated they were called by Licensed Practical Nurse #4 and was told the resident fell, had an acute change in condition and they were unable to obtain vital signs. It was not reported to them that the resident was found naked, cold and shivering, or that their body temperature was unreadable because it was so low. Director of Nursing #1 stated they did not have that information upon initial investigation and did not ask any further questions about the resident.During an interview on 10/08/2025 at 1:40 PM, Director of Nursing #1 stated a statement from Resident #1's roommate regarding the unwitnessed fall on 09/28/2025 was not obtained. They further stated that Resident #1's roommate should have been interviewed as the roommate was alert and oriented and may have been able to provide information pertaining to the fall. During an interview on 10/08/2025 at 12:52 PM, Administrator #1 stated they had not identified a timeline for when the resident might have fallen on 09/28/2025. New York Codes, Rules and Regulations 483.12(c)(2)

Based on observation, record review, and interviews during an abbreviated survey (Case #NY00357658), the facility did not ensure it protected the resident's right to be free from abuse and neglect for 1 (Resident #1) of 3 residents reviewed. Specifically, Registered Nurse #1 forcefully removed Resident #1 from the floor after the resident became unsteady and fell to the floor. Registered Nurse #1 did not assess the resident for injury prior to getting the resident up and ambulating them to their room. This is evidenced by: The Facility's Abuse Policy Prevention program updated on 10/20/2024 documented the following: Residents had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This included but was not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Resident #1 was admitted to the facility with diagnoses of non-Alzheimer's dementia with behaviors (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), osteopenia (loss of bone density), and adjustment disorder (when your body and brain have an extreme reaction to stress). The Minimum Data Set (an assessment tool) dated 09/11/2024, documented Resident #1 could sometimes be understood and sometimes understand others with severely impaired cognition for daily decision making. The facility's abuse investigation dated 10/17/2024 through 10/18/2024, documented that Video footage identified that Registered Nurse #1 approached Resident #1 on 10/17/2024 at 11:19 PM at the nurse's station as Resident #1 was urinating on the floor. Registered Nurse #1 attempted to turn Resident #1 and direct them to their room. Resident #1 lost their balance and fell to the floor. Registered Nurse #1 picked the resident up off the floor by their left arm and then led Resident #1 down the hallway towards their room. Resident #1's pants were about a quarter way down their rear end as they walked, swaying back and forth. The record indicated that Certified Nurse Aide #1 heard a commotion on 10/17/2024 at approximately 11:15 PM and saw Registered Nurse #1 ushering the resident down the hallway. Resident #1 was on the floor, Registered Nurse #1 told Certified Nurse Aide #1 to leave the resident on the floor to calm down. Registered Nurse #1 was using foul language and was angry so Certified Nurse Aide #1, waited until they could safely leave the unit, then they went and notified Licensed Nurse #1, on the other unit of the suspected abuse. Licensed Practical Nurse #1 called The Registered Nurse Supervisor on call and notified them of the suspected abuse. Licensed Practical Nurse #1 was told to tell Registered Nurse #1 to leave the building Registered Nurse #1 turned in their medication keys and left the building. Registered Nurse #2 and the Administrator #1 arrived at the facility by 1:30 AM. Resident #1 was assessed; the physician was notified, and the significant other was called. Police responded to the call and arrived at the building at 3:15 AM on 10/18/2024 and took the report of the suspected abuse. The family declined pressing charges. The on-call physician was notified at 2:15 AM. X-rays were done, and no physical harm was identified. Staff monitored Resident #1, and no psychosocial harm was observed. New York State Department of Health was notified per regulation. The investigation was started and review of the cameras on the unit was done which provided evidence that substantiated and corroborated the report from Certified Nurse Aide #1. The facility determined abuse had occurred, and Registered Nurse #1 was suspended and later terminated. Re-education on abuse/neglect and reporting of suspected abuse regardless of who is suspected was completed with all facility staff A facility video that began on (time stamp of) 10/17/2024 at 11:15 PM, was reviewed and documented the following: - Resident #1 was by the nurse's station on their unit. - Registered Nurse #1 was seated at the nurses' station, across from Resident #1. They did not engage with the resident. No other staff was seen in video view. -Resident #1 stood with their back to grabbed the resident from behind and placing their hands on the residents' shoulders. - Resident #1 appeared startled and became unsteady, fell to the floor on their right side, and their left arm to shoot up in the air. Registered Nurse #1 grabbed Resident #1's left arm with both hands and pulled the resident to their feet and directed them to their room. - Noted that no assessment was done by Registered Nurse #1 prior to pulling Resident #1 to their feet. A physician progress note dated 10/18/2024 at 2:16 AM, documented the following: Resident #1 had an incident with staff on 10/18/2024 where they were urinating on the floor at the nurse's station. Staff member was forcefully escorting resident back to their room and the resident fell on to the floor, landing on their right side. Resident #1 was then forcefully pulled up from the floor by their left arm and hurried down the hall back to their room. They then apparently fell again in the doorway. Imaging done shows no acute injury. A physician progress note dated 10/21/2024 documented the following: Resident #1 had an incident with staff on 10/18/2024 where they urinated on the floor at the nurses' station. Staff member was seen forcefully escorting resident back to their room and resident fell on to the floor, landing on their right side. Resident was then forcefully pulled up from the floor by their left arm and hurried down the hall back to his room. Resident #1 had dementia with psychosis and did not recall the incident. Resident denied any chest pain, dizziness, sob, cough, pain, or discomfort. During an interview on 10/21/2024 at 10:45 AM, Administrator #1 stated they had been notified by the on call Registered Nurse Supervisor of the incident and went to the facility. When they arrived at approximately 1:30 AM on 10/18/2024, Resident #1 was assessed for injuries; Administrator #1 watched video from cameras on the unit; Abuse was identified after watching the video, the on-call physician was notified, and orders for x-rays were obtained to assess for any fractures (bone breaks) after seeing how the resident was yanked off the floor by Registered Nurse #1. Administrator #1 further stated they notified Resident #1's Health Care Proxy and police; Police Officers arrived on 10/18/2024 at 3:15 AM and took a report. Administrator stated: Resident #1's Health Care Proxy declined to press charges; Staff and Physician continued to monitor Resident #1 for physical and psychosocial harm; All staff received education on reporting abuse; Registered Nurse #1 was reported to the [New York State Department of Education State Board of Nursing] by the facility for abuse. Administrator #1 stated there was no doubt that abuse occurred after the video was watched, and that Registered Nurse #1 had not assessed the resident after the fall. Administrator #1 stated they should have called the doctor and waited for someone to assist them before getting the resident up off the floor. During a phone interview on 10/22/2024 at 9:35 AM, Certified Nurse Aide #1 stated they thought Registered Nurse #1 'was acting funny,' witnessed Registered Nurse #1 pull the resident up off the floor, but did see them, rushing Resident #1 to their room. Certified Nurse Aide #1 stated Nurse Supervisor was notified that abuse of a resident was suspected, and Registered Nurse #1 was asked to leave the building. During an interview on 10/22/2024 at 10:35 AM, Registered Nurse #1 stated during the night shift, Resident #1 was urinating on the floor by the nurse's station; they attempted to stop the resident and turned them around to take them back to their room. Resident #1 became unsteady and 'went to the floor.' Registered Nurse #1 stated that in the attempt to lower the resident to the floor, Registered Nurse #1 grabbed the resident by the arm and tried to lower them, then picked the resident up off the floor and walked them to their room. Registered Nurse #1 stated they should have gotten someone to help them and should have followed policy and procedure to prevent injury to the resident. Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement at the time of this survey. 1. Developed and implemented education to address concerns with reporting allegations of abuse no matter who the accuser was. 2. Posters were placed in areas with expectations that demonstrated reporting for any allegations of abuse. 3. Power Point and reeducation to all facility staff with 100 percent compliance on abuse and neglect and reporting 4. Registered Nurse #1 was removed from resident care immediately and terminated from the facility after the investigation was completed within 5 days of the incident. 5. Resident #1 Comprehensive Care Plan for Victim of Abuse was implemented, and Behaviors Care Plan was updated. 6. Family/Physician/and Police notification was completed within 2 hours of the incident on 10/17/2024 7. Reporting to New York State Department of Health was completed within 2 hours of the incident on 10/17/2024 8. An investigation was started October 18, 2024, at 1:30 AM, and was completed on October 22, 2024, by 5:30 PM and presented to the surveyor. 9. Resident #1 was assessed on 10/18/2024 for injury and orders for x-rays completed to further assess. No injuries found. 10. Audits on going to ensure staff knowledge and response education has been sufficient. Every week for 4 weeks and monthly for 4 months. 10 New York Codes, Rules, and Regulations 415.4(b)(1)(i)

Based on record review and interviews during an abbreviated survey (NY00326640), the facility did not ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used for excessive duration and without adequate indication for 1 (Resident #10) of 1 resident reviewed. Specifically, Resident #10 was administered Atarax (an antihistamine used to treat anxiety, nausea, vomiting, itching and skin rash without obtaining a physician's order. This is evidenced by: Resident #10 was admitted to the facility with the diagnoses of hemiplegia (total or partial paralysis of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body), cerebral infarction (stroke), and depression. The Minimum Data Set (an assessment tool) dated 03/19/2024 documented resident was cognitively intact, could be understood and able to understand others. The Facility's Policy and Procedure Titled Administering Medication revised on 1/2023 documented Medications must be administered in accordance with the orders including any required time frame. Resident #10's Medication Administration Record dated October 2023 had orders for Hydroxyzine hydrochloride Tablet 10 milligram (Atarax) Give 1 tablet by mouth two times a day for Rash to trunk, arms, and legs for 3 Days -Start Date 10/26/2023 at 19:30 PM. The Medication Error Incident Report dated 10/23/2023, documented Resident #10 was given 10 milligram Atarax by mouth, no physician order present on 10/21/2023. Resident #10 showed no adverse effects from the incident. The Facility Investigative Report dated 10/23/2023, documented Licensed Practical Nurse #2 initially denied giving Resident #10 Atarax medication from a discharged resident medication supply. They later changed their statement and admitted to giving Resident #10 Atarax 10 milligrams from a discharged resident medication supply. The Facility Investigative Report documented Licensed Practical Nurse #2 stated they changed their story because they were initially afraid. During an interview on 4/03/2024 at 11:45 AM, Resident #10 stated some staff at this facility were not good. However, Licensed Practical Nurse #2 always gave them medications on time and was nice. Resident #10 stated nurses never told them what medications they were given, and they just took what they gave them. During an interview on 4/03/2024 at 11:16 AM, Certified Nurse Aide #2 stated on 10/21/2023 at approximately 1:00 PM, Resident #10 was anxious. Certified Nurse Aide #2 stated they knew Resident #10 had a pill for anxiety that they received in the past. Certified Nurse Aide #2 asked Licensed Practical Nurse #2 if Resident #10 could have something for their anxiety. Licensed Practical Nurse #2 was noted to have in their personal backpack a blister pack medication for discharged Resident #15. Licensed Practical Nurse #2 gave the medication from their backpack to Resident #10. During an interview on 4/03/2024 12:00 PM, Certified Nurse Aide #1 stated they personally did not see Licensed Practical Nurse #2 give medication from their backpack to Resident #10. Instead, they observed Licensed Practical Nurse #2 take something from their backpack, put something in their mouth and returned backpack to cubby. They notified Director of Nursing #1. During an interview on 4/03/2024 12:10 PM, Administrator #1 stated the day after incident on 10/21/2023, they interviewed Licensed Practical Nurse #2. Licensed Practical Nurse #2 stated they gave Resident #10 the medication because the resident was itching. Administrator #1 asked why they did not get an order. Licensed Practical Nurse #2 did not have an answer. They were terminated from their job immediately after incident, and a report filed with the Department of Health. During an interview on 4/08/2024 at 2:00 PM, Licensed Practical Nurse #2 stated they obtained an order for Atarax 10 milligrams from Nurse Practitioner for Resident #10 on 10/21/2023 prior to administering the medication. They stated they do not recall name of the ordering Nurse Practitioner. Licensed Practical Nurse #2 stated they did not enter the order before giving the medication and stated they should have entered the order. They stated due to short staffing they were very busy and forgot to enter the order. 10 New York Codes, Rules, and Regulations 415.12(l)(1)

Based on interviews and record review conducted during an abbreviated survey (Case #NY00316477), the facility did not ensure residents were free from significant medication errors for 1 (Resident #3) of 1 resident reviewed. Specifically, the facility did not ensure significant medications were accurately transcribed from Hospital Discharge instructions for Resident #3. Subsequently, Resident #3 did not receive orders for respiratory nebulizer treatments from 5/11/2023 to 5/13/2023 and was re-admitted to the hospital on [DATE] for respiratory distress. This is evidenced by: Resident #3 Resident #3 was admitted to the facility with diagnosis of metabolic encephalopathy (A problem in the brain caused by a chemical imbalance in the blood), acute and chronic respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body. It can happen all at once (acute) or come on over time (chronic), and myocardial infarction (heart attack). The Minimum Data Set (an assessment tool) dated 5/13/2023, documented the resident could be understood and could understand others. The Facility's Policy and Procedure Titled Administering Medication' revised 1/2023 documented Medications must be administered in accordance with the orders including any required time frame. The Hospital Discharge summary, dated [DATE], included discharge medications Budesonide (Pulmicort) 0.5 milligrams via nebulizer every 12 hours; Albuterol sulfate 2.5 milligrams via nebulizer every 6 hours as needed for wheezing. Physician progress note dated 5/13/2023 at 15:39 PM, documented Past Medical History: respiratory failure, status post extubating, Chronic Obstructive Pulmonary Disease. Respiratory medications not ordered on admission. Start Symbicort to continue Budesonide used inpatient but may switch to Breo or Advair based on availability. Breo is preferred in case patient progresses to eventually requiring triple therapy with addition of Long-Acting Muscarinic Antagonist. Albuterol inhaler as needed. Primary provider to follow up respiratory management. During an interview on 3/27/2024 at 1:30 PM, Director of Nursing #1 stated Resident #3 was sent to the hospital for respiratory distress on 5/14/2023. Resident's son complained to Registered Nurse #1 that resident was not receiving prescribed respiratory medication. The Director of Nursing stated, Registered Nurse #1 spoke to Resident's son, and they did not address the son's concern over respiratory medications. The Director of Nursing stated that due to a covid outbreak, the facility did not use any nebulizers. During an interview on 3/28/2024 at 1:15PM, Registered Nurse #1 stated they do not recall Resident #3. In general, when they admit a resident, the process included assessing the weight of resident; a head-to-toe assessment; and reconciliation of medications with provider. They enter the assessment into the computer. If the provider was in the building, the provider would look over the medication list from hospital discharge summary and decide if there would be any changes . If no provider was present, the admitting nurse would call the on-call provider and review medications with provider. Registered Nurse #1 stated Director of Nursing had not delegated family complaints to them. If there were a complaint, the Director of Nursing and Administrator would discuss for further direction. Registered Nurse #1 stated at one point, the facility was not prescribing nebulizer treatments if there was a COVID outbreak in the building. During an interview on 4/3/2024 at 12:25 PM, Nurse Practitioner #1, stated new admission discharge summary medications were reviewed. Alternate medications would have been prescribed or they would have documented why medication would be discontinued. 10 New York Codes, Rules, and Regulations 415.12(m)(2)

Based on record review and interview during the recertification survey and an abbreviated survey (Case #NY00316948) dated 05/15/23 through 05/22/23, the facility failed to protect the resident's right to be free from neglect for 1 (Resident #23) of 4 residents reviewed for abuse/neglect. Specifically, on 04/16/2023 Certified Nurse Aide (CNA) #2 did not use two staff for bed mobility as documented in Resident #23's Comprehensive Care Plan (CCP) . Subsequently, on 4/16/2023 Resident #23 rolled out of bed onto the floor sustaining a fracture of their left elbow and a gash requiring stitches on their left elbow. This resulted in actual harm that is not immediate jeopardy for Resident #23. This was evidenced by: Resident #23 was admitted to the facility with diagnoses of multiple sclerosis, Chronic Obstructive Pulmonary Disorder (COPD), and diabetes. The Minimum Data Set (MDS - an assessment tool) dated 02/04/2023 documented the resident was able to make themselves understood, was able to understand others, and was cognitively intact. The Policy and Procedure (P&P), titled Abuse Prevention Program/Abuse and Neglect - Clinical Prevention Protocol/Abuse Investigation and Reporting, with a review date of 01/2023, documented neglect was defined as the failure of the facility, its employees, or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect typically meant, among others, the failure to provide a resident with personal safety. The Comprehensive Care Plan (CCP), titled Decline in Activities of Daily Living (ADLs), revised 02/02/2023, documented the resident was totally dependent on 2 staff for bed mobility. The CNA Kardex (used by CNAs to know what care to provide), dated 04/16/2023, documented the resident was totally dependent on 2 staff for bed mobility. A Progress Note dated 04/16/2023 at 01:22 PM, documented the resident rolled out of bed (OOB) during morning (AM) care while CNA #2 was attempting to change their linens. The resident sustained 2 skin tears; one on the back of their left hand that was closed with steri-strips (thin adhesive bandages), and another that was more significant and was covered with a dressing for protection. The on-call provider was contacted, and the resident was sent to the hospital for evaluation and treatment. A Progress Note, dated 04/16/2023 at 05:10 PM, documented Resident #23 returned from the Emergency Department (ED). A dressing was in place on their left arm with multiple stitches on a laceration on their left elbow. Radiology reports showed a fracture of the left arm, and the arm was in a sling. The resident reported they felt sore, their pain level was 3 out of 10 and tolerable; Tylenol was provided in the ED for pain. Radiology reports of the left elbow, dated 04/16/2023, documented a there was suspicion of a traumatic fracture. The facility Accident and Incident (A&I) report, dated 04/16/2023 at 08:15 AM, documented Resident #23 fell OOB (out of bed) and was lying between their bed and window on their stomach complaining of arm pain; 2 skin tears on their left hand and forearm were documented. CNA #2 was the only documented witness to the event. During an interview on 05/15/23 at 01:48 PM, Resident #23 stated they had fallen a few weeks ago, resulting in stitches in their left arm and a broken elbow, and said, it was one of those freak things. During an interview on 05/17/2023 at 03:39 PM, CNA #2 stated they were responsible for reviewing each resident's Kardex every day to know what care the residents needed such as their bed mobility status. On 04/16/2023, they were assigned to Resident #23. The resident required an extensive assist of 2 people for bed mobility. While providing incontinence care, they attempted to roll the resident on to their side by themselves and the resident rolled onto the floor. CNA #2 stated they knew they needed another staff member to help with rolling the resident and asked for help but decided to roll the resident in bed anyway before help arrived because they wanted to complete the resident's care, and Resident #23 fell OOB. During an interview on 05/18/2023 at 10:09 AM, CNA #4 stated each resident's bed mobility status was documented on the Kardex. When a resident was documented as 2 people for bed mobility, they would have to get another staff member to roll the resident in bed; they would not attempt to perform this by themselves. During an interview on 05/18/2023 at 12:09 PM, RN #2 stated that, at the time of Resident #23's fall they were working with the nurse educator when they heard Resident #23 was on the floor. CNA #2 had rolled the resident in bed, and they fell . They did not realize at the time that the resident required the total assistance of 2 people for bed mobility, but a second person should have been there to help. The resident had 2 skin tears, one on the top of their left hand, and one on their forearm. Nurse Practitioner (NP) #1 was notified, and the resident was sent to the hospital for further evaluation. During an interview on 05/18/2023 at 02:52 PM, Resident #23 stated that, on 04/16/2023, they fell OOB while a staff member was turning them onto their side. They sustained a left elbow fracture and skin tears from the incident. The elbow had healed since then, the skin tears had been healing more slowly. During an interview on 05/18/2023 at 12:54 PM, the RN Educator stated CNA education regarding using and documenting on the Kardex and was provided during orientation of newly hired staff, and as needed when changes were made in the Electronic Medical Record (EMR). They were in the facility when Resident #23 fell , and they heard the resident was on the floor and went to see them. They helped get the resident back to bed, but they did not recall the resident complaining of any significant pain at the time. They informed the Director of Nursing (DON) about the incident, but could not recall if it was by text message or by verbal conversation. They recalled the facility was concerned about the incident, because Resident #23 required the assistance of 2 people for bed mobility, which was not provided. Since the resident required 2 people for bed mobility, there should have been a second staff present to help to turn the resident in bed. During an interview on 05/19/2023 10:24 AM, the Medical Director stated facility staff were supposed to do whatever was documented on each resident's CCP and Kardex. When a resident had it documented that they required 2 staff to provide support for any of their care activities, 2 staff should be provided. During an interview on 05/22/2023 10:18 AM, the DON stated when they were initially informed of the resident fall, they were aware of the skin tears, but not the fracture; the investigation commenced when they were informed about the fracture. During an interview on 05/22/2023 11:31 AM, the Administrator stated that, after Resident #23's fall and elbow fracture on 04/16/2023, they were aware the resident required the total assistance of 2 people for bed mobility, and that turning someone side to side in bed could be considered bed mobility. 10 NYCRR 415.4(b)(1)(i)

Based on observation, record review, and interviews during the recertification survey dated 05/15/23 through 05/22/23, the facility did not ensure necessary housekeeping and maintenance services were provided to maintain a clean and homelike environment on two (2) of 2 resident units. Specifically, on the South Wing Unit, the floors were soiled with dirt and a black build-up where the door frame meets the floor and along the wall in the dining room, corridor, ice machine area, Beauty Shop, and in resident room #'s 102, 104, 108, and #116; the floor was soiled with dust and dirt below the chests of drawers in room #'s 205, 222, and #226; the radiators were soiled with food drips in room #'s 215, 222, and #226; the radiator cover was falling off in room [ROOM NUMBER]; and the 1/2 size oxygen tanks in the oxygen tank storage area were dusty. On the North Wing Unit, the floors were soiled with dirt where the door frame meets the floor and along the wall in the the dining room, nurse's station, linen closet, left medical supply room, soiled workroom, and resident room #'s 202, 215, 222, 226, and #228; the floors were dusty in the Supply Closet, and IT closet; the fan was dusty in the Dental Office; and the heat radiator covers were falling off in resident room #'s 102, 104, 113, and 116. This is evidenced as follows: Finding #1 - South Wing Unit: During observations on 05/17/23 at 1:59 PM, the floors were soiled with dirt and a black build-up where the door frame meets the floor and along the wall in the dining room, corridors, ice machine area, Beauty Shop, and in resident room #s 102, 104, 108, and 116; the floor was soiled with dust and dirt below the chests of drawers in room #s 205, 222, and #226; the radiators were soiled with food drips in room #s 215, 222, and 226; the radiator cover was falling off in room [ROOM NUMBER]; and the 1/2 size oxygen tanks in the oxygen tank storage area were dusty. Finding #2 - North Wing Unit: During observations on 05/17/23 at 1:59 PM, the floors were soiled with dirt where the door frame meets the floor and along the wall in the dining room, nurse's station, linen closet, left medical supply room, soiled workroom, and resident room #'s 202, 215, 222, 226, and #228; the floors were dusty in the supply closet, and IT closet; the fan was dusty in the Dental Office; and the heat radiator covers were falling off in resident room #s 102, 104, 113, and #116. Interviews: During an interview on 05/17/23 at 3:21 PM, the Administrator, Maintenance Director, and Director of Housekeeping stated that a person was hired part time to focus on scrapes and painting, and the cleaning items will be addressed. The Maintenance Director stated that the radiator covers will be reattached and cleaned. The Director of Housekeeping stated that the facility has an audit sheet for cleaning resident rooms but not for the Physical Therapy room, and the housekeeping staff recently hired will need to be re-educated to have a more critical eye as they are expected to keep rooms clean in the corners and along walls. The Administrator and Director of Housekeeping stated that more audits will be conducted to ensure that all areas are kept clean. 483.10(i)(2); 10 NYCRR 415.5(h)(4)

Based on observation and interviews during the recertification survey dated [DATE] through [DATE], the facility did not prepare or serve food in accordance with professional standards for food service safety. Specifically, the test papers used to check the concentration of the chemical used to manually sanitize food equipment were expired (expiration dates [DATE] and [DATE]). The food temperature thermometer being used by cook #1 was found out of calibration when checked by the standard ice-bath method (temperature registered less than the lowest graduation on the thermometer scale). In the main kitchen, the can opener holder, microwave oven, scale, stove, shelving, reach-in freezer door gaskets, walls by stove, kitchen window still, ceiling, kitchen floor under equipment, floor under dishwashing machine, dry storage area floor, fire extinguisher, and kitchen fire suppression system canister were soiled with food particles, grime, or dirt; in the North Wing kitchenette, the drawers and floor were soiled with food particles; and in the South Wing kitchenette, the freezer door gasket and floor under the refrigerator were soiled with food particles. The laminate on the cabinetry in the North Unit kitchenette was peeling. This is evidenced as follows: During observations on [DATE] at 10:04 AM, the the test papers used to check the concentration of the chemical used to manually sanitize food equipment were expired (expiration dates [DATE] and [DATE]). The food temperature thermometer being used by cook #1 was found out of calibration when checked by the standard ice-bath method (temperature registered less than the lowest graduation on the thermometer scale). In the main kitchen, the can opener holder, microwave oven, scale, stove, shelving, reach-in freezer door gaskets, walls by stove, kitchen window still, ceiling, kitchen floor under equipment, floor under dishwashing machine, dry storage area floor, fire extinguisher, and kitchen fire suppression system canister were soiled with food particles, grime, or dirt; in the North Wing kitchenette, the drawers and floor were soiled with food particles; and in the South Wing kitchenette, the freezer door gasket and floor under the refrigerator were soiled with food particles. The laminate on the cabinetry in the North Unit kitchenette was peeling. During an interview on [DATE] at 10:21 AM, the Administrator, Regional Director of Operations, and Dietary Director stated that new test papers and thermometers have been purchased and the soiled areas and items found in the kitchen and kitchenettes will be cleaned. The Administrator and Dietary Manager stated that the cleaning items in the kitchen have been an issue with staff turnover, but kitchen staff training on cleaning is ongoing. The Dietary Manager stated that going forward, individual staff will be assigned certain areas of the kitchen to keep clean. The Administrator stated that about 2 weeks ago the facility audited the kitchenettes and is in the process of purchasing new cabinetry and developing a cleaning schedule. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart ,d+[DATE]

Based on record review and interviews during the recertification survey conducted from 5/15/2023 through 5/22/2023, the facility did not ensure drug regimen irregularities were reported by the pharmacist to the attending physician for 1 (Resident #67) of 5 residents reviewed for unnecessary medications. Specifically, for Resident #67, the facility did not ensure an irregularity in the monitoring orders for Alendronate (used to prevent and treat certain types of bone loss (osteoporosis) in adults) was documented and reported to the physician by the consultant pharmacist on 5/2/2023. This was evidenced by: Resident #67 Resident #67 was admitted to the facility with the diagnoses of cerebrovascular accident (CVA), chronic obstructive pulmonary disease (COPD), and depression. The Minimum Data Set (MDS -an assessment tool) dated 04/11/2023, documented the resident had severely impaired cognition, could understand others, and could make themselves understood. The policy and procedure titled Medication Therapy/Drug Regimen Review, reviewed 1/2023, documented the Consultant Pharmacist would review each resident's medication regimen monthly, as requested by the staff or practitioner when clinically significant. The Medical Director and Consultant Pharmacist should collaborate to address issues of medication prescribing and monitoring with the practitioners and staff. In the event issues were found, the physician (or physician- designee) would be contacted by midnight of the next calendar day and the clinician would address prescribed/recommended actions by day 14. A physician's order dated 4/10/2023, documented the medication Alendronate 70 mg documented; take 1 tablet by mouth one time a day every Wednesday. Take on empty stomach with full glass of water and do not stay in upright position for 30 minutes. The Medication Administration Record (MAR) documented the medication (Alendronate) was administered on 4/19/2023, 4/26/2023, 5/3/2023, 5/10/2023, and 5/17/2023. A document titled Consultant Pharmacist Drug Regimen Review, dated 5/2/2023 did not include documentation for recommendations for Alendronate that the resident should be in an upright position after taking this medication for at least 30 minutes. During an interview on 5/18/2023 at 02:22 pm, the Consultant Pharmacist (CS) #1 stated they participated in a monthly medication review with physicians, nurses, and administration. They were familiar with Alendronate, and stated the current order was written incorrectly and the monitoring should document that the resident needed to be in an upright position after taking it for at least 30 minutes. They missed this in their most recent medication review on 5/2/2023 and should have identified it as an irregularity. During an interview on 5/19/2023 at 1:55 pm, Registered Nurse (RN) #1 stated they normally input medication orders after receiving them from the physician, but sometimes this was done by the Licensed Practical Nurses (LPNs). The current order for Alendronate did not have the correct monitoring instructions, there must have been an error made when transcribing the order; the order was entered by LPN #3. The staff were familiar with this medication, someone should have noticed this and reported it so it could have been followed up on with the provider. During an interview on 5/22/2023 at 1110, LPN #3 stated they did not recall placing the order for Alendronate on 4/10/2023, but if their name was on the order then it must have been them. When someone was receiving Alendronate, they should not be lying down after the medication was administered. The current monitoring instructions, that documented for the resident to lie down following administration of Alendronate were incorrect; this should have been identified and the physician should have been informed. During an interview on 05/22/2023 at 1115, the physician (MD) #1 stated nursing entered orders for medications into the Electronic Medical Record (EMR), and they signed off on them after they were reviewed. Most of the time, they reviewed their orders prior to signing off on them. Residents taking Alendronate should be instructed to lie down following administration of that medication; they must have missed this when they signed off on the order for Alendronate dated 4/10/2023. Once the error was made, someone should have identified it and informed them so it could have been corrected. During an interview on 5/22/2023 at 1220, the Director of Nursing (DON) stated the MD order was incorrect, and the consultant pharmacist should have identified it during their monthly review on 5/2/2023. NYCRR10 415.18(c)(2)

Based on record review and interviews during the recertification survey and an abbreviated survey (Case #NY00316948), the facility did not prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress for 1 (Resident #23) of 4 residents reviewed for abuse/neglect. Specifically, for Resident #23, the facility did not ensure to prevent further potential abuse, neglect, exploitation, or mistreatment when the facility did not remove a staff member from resident care on 4/16/2023 when the staff member did not follow Resident #23's Comprehensive Care Plan (CCP) revised on 2/2/2023 and Kardex dated 4/16/2023 that documented the resident required 2 persons for bed mobility. This resulted in a a fracture and a laceration requiring sutures to the resident's left elbow from a fall out of bed. The facility did not identify that the residents fall out of bed resulting in injury when a staff member did not follow the care plan required an investigation when the incident occurred on 4/16/2023. The facility identified that an investigation was needed on 4/17/2023, did not remove the staff member from resident care. This was evidenced by: Please refer to F600. Resident #23 Resident #23 was admitted to the facility with diagnoses of multiple sclerosis, Chronic Obstructive Pulmonary Disorder (COPD), and diabetes. The Minimum Data Set (MDS - an assessment tool) dated 02/04/2023 documented the resident was able to make themselves understood, able to understand others, and was cognitively intact. The Policy and Procedure (P&P), titled Abuse Prevention Program/Abuse and Neglect - Clinical Prevention Protocol/Abuse Investigation and Reporting, reviewed 01/2023, documented the Interdisciplinary Team (IDT) would investigate alleged occurrences of abuse and neglect to clarify details of the occurrence and identify possible causes. If an investigation involved an employee, the employee would be suspended pending the outcome of the investigation. The facility investigation summary, dated 04/17/2023, documented on 04/16/2023, Resident #24 fell OOB while incontinence care was being provided by CNA #2. The resident required a total assist x 1 for incontinence care, and total assist x 2 for bed mobility and bathing. At the time of the fall, Resident #23 had been incontinent, and CNA #2 was cleaning the resident. When they attempted to roll the resident toward the window, and away from their body, the resident rolled off the bed and onto the floor. An A&I (Accident and Incident) was completed by the Registered Nurse (RN) #2, NP #1 was contacted, and orders were received to send the resident to the Emergency Department (ED) related to lacerations sustained during the fall. Stitches were required for the lacerations, and x-rays showed a non-displaced fracture of the left elbow. The facility documented CNA #2 was following Resident #23's CCP by providing 1 assist for incontinence care, but they did not roll the resident properly; CNA #2 should have rolled the resident towards them instead of away from them. The incident was not reported to the NYSDOH, and the summary did not include documentation that CNA #2 was suspended during the facility's investigation. During an interview on 05/18/2023 at 03:18 PM, Registered Nurse (RN) #1 stated, even though Certified Nurse Aide (CNA) #2 was providing incontinence care to Resident #23 on 04/16/2023, they should have had a second person to help them roll the resident when they fell out of bed because the resident was an assist x 2 for bed mobility; this was a failure to follow the care plan/Kardex for bed mobility. They did not know whether CNA #2 was suspended during the facility's investigation. During an interview on 05/22/2023 10:18 AM, the Director of Nursing (DON) stated not following the resident's care plan/Kardex, resulting in a resident injury, would be defined as neglect. When there was a potential case of neglect involving a staff member, the staff member needed to be suspended during the course of the facility's investigation. They were not aware of CNA #2 being suspended from the facility during the investigation into Resident #23's fall on 04/16/2023. During an interview on 05/22/2023 11:31 AM, the Administrator stated any time a potential case of neglect was suspected, any potential staff members involved needed to be suspended from work for the duration of the facility's investigation of the incident. Following Resident #23's fall and elbow fracture on 04/16/2023, the facility did not suspend CNA #2 during their investigation. 10 NYCRR 415.4(b)(3)

Based on observations, interviews, and record review during the recertification survey and an abbreviated survey (Case #NY00316948), the facility did not ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, were reported immediately, but not later than 2 hours after the allegation was made for 1 (Resident #23) of 4 residents reviewed for abuse/neglect. Specifically, for Resident #23, the facility did not report that Resident #23 sustained a fractured elbow and a laceration on their left elbow requiring sutures when on 04/16/2023, the facility did not ensure that a staff member utilized 2 persons for bed mobility as documented both in their Comprehensive Care Plan (CCP) revised on 2/2/2023 and Kardex dated 4/16/2023. This was evidenced by: Please refer to F600. Resident #23 Resident #23 was admitted to the facility with diagnoses of multiple sclerosis, Chronic Obstructive Pulmonary Disorder (COPD), and diabetes. The Minimum Data Set (MDS - an assessment tool) dated 02/04/2023 documented the resident was able to make themselves understood, able to understand others, and was cognitively intact. The Policy and Procedure (P&P), titled Abuse Prevention Program/Abuse and Neglect - Clinical Prevention Protocol/Abuse Investigation and Reporting, reviewed 01/2023, documented an alleged violation of abuse, neglect, exploitation, or mistreatment would be reported immediately, but no later than 2 hours if the alleged violation involved abuse or resulted in serious bodily injury. The Comprehensive Care Plan (CCP), titled Decline in Activities of Daily Living (ADLs), revised 02/02/2023, documented: - Bed Mobility: totally dependent x 2 staff. The Kardex (instructions for providing resident care), dated 04/16/2023, documented: - Bed Mobility: Totally dependent x 2 staff. Radiology reports of the left elbow, dated 04/16/2023, documented a joint effusion was suspicious for traumatic fracture, and a questionable irregularity of the radial head and capitellum (a bone in the lower part of the arm) with a nondisplaced fracture a consideration. A progress note, dated 04/16/2023 at 05:10 PM, documented the resident returned from the ED. A dressing was in place on their left arm with multiple sutures in place on a laceration on their left elbow, no drainage from the site observed. Radiology reports showed a non-displaced fracture of the left radial head (the top of the radius bone in the arm), their left arm was in a sling. The resident reported they felt sore, their pain level was 3 out of 10 and tolerable; Tylenol was provided in the ED for pain. During an interview on 05/18/2023 at 03:18 PM, Registered Nurse (RN) #1 stated, even though Certified Nurse Aide (CNA) #2 was providing incontinence care to Resident #23 on 04/16/2023, they should have had a second person to help them roll the resident when they fell out of bed because the resident was an assist x 2 for bed mobility; this was a failure to follow the care plan/Kardex for bed mobility. They did not know whether the incident had been reported to the New_York State Department of Health (NYSDOH). During an interview on 05/22/2023 10:18 AM, the Director of Nursing (DON) stated not following the resident's care plan/Kardex, resulting in a resident injury, would be defined as neglect. Potential cases of neglect needed to be reported to the Administrator or the DON and reported within 2 hours of the suspicion of neglect. They were not working on 4/17/2023 when the investigation into Resident #23's fall on 4/16/2023 concluded and was not involved in the decision on whether to report the incident to the NYSDOH; the facility's Administrator made the decision regarding reporting. During an interview on 05/22/2023 11:31 AM, the Administrator stated any time a potential case of neglect was suspected, the facility would be required to be report the incident to the NYSDOH within 2 hours of the formation of the suspicion. Following Resident #23's fall and elbow fracture on 04/16/2023, the facility did not report the fall to the NYSDOH because CNA #2 had been providing incontinence care at the time, and the resident only required an assist x 1 for that task. They stated they were aware at the time of the investigation the resident was a total assist x 2 for bed mobility, and that turning someone side to side in bed could be considered bed mobility. 10 NYCRR 415.4(b)

Based on record review and interviews conducted during an abbreviated survey on 4/1/21 (Case #NY 307), the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 (Resident #7) of 4 residents reviewed. Specifically, the facility did not ensure Resident #7 received blood [CONDITION(S)] as ordered by the physician and nurse practitioner on 8/31/20, 9/3/20 and 9/4/20. Subsequently, Resident #7 had critically low blood values and was transferred to the hospital with a rapid heart rate and low blood pressure. This resulted in actual harm that is not immediate jeopardy. This is evidenced by: The Policy and Procedure (P&P) titled Medication and Treatment Orders last revised in 3/2020, did not include a process to instruct staff of what to do when a medication or treatment was withheld or not given as ordered. An email dated 03/25/21 at 7:38 AM from the Administrator to New York State Department of Health documented the facility did not have a P&P for blood products because blood [CONDITION(S)] were not performed at the facility. Resident #7: Resident #7 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 1/9/21, documented the resident was cognitively intact. The Comprehensive Care plan (CCP) did not include a nursing care plan for the care and management of [CONDITION(S)]. A Laboratory Report dated 8/31/20 documented Resident #7 had a critical hemoglobin (HGB) of 6.7 (reference range 11.5 to 18), and this was reported to Director of Nursing (DON) at 8/31/20 at 1:35 PM. A Nursing Progress note dated 8/31/20 at 2:53 PM, documented Nurse Practitioner (NP) #1 was contacted with the 8/31/20 critical HGB result (6.7), and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nurse Practitioner's (NP) Progress Note dated 8/31/20, and electronically signed by NP #1 at 8:51 PM, documented Resident #7 had an HGB of 6.3 and a hematocrit (HCT) of 23.4 (reference range 35 to 50) on 8/7/20. The plan was to transfuse 2 units of blood. A facility document titled, Verbal Orders, dated 8/31/20 documented an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A Laboratory Report dated 9/3/20 documented Resident #7 had a critically low HGB of 6.2, and this was reported to Licensed Practical Nurse (LPN) #3 on 9/3/20 at 12:49 PM. A NP Progress Note dated 9/3/20, signed at 1:35 PM, documented to transfuse 2 units of blood for Resident #7 as soon as possible as per previous orders. A progress note dated 9/3/20 signed by the DON, documented a phone call was placed to Hematology/oncology in an attempt to make an appointment. The facility was advised to send the resident to the emergency room for a transfusion. The DON documented the head doctor reviewed the case and did not feel the resident was bleeding out, and the head doctor wanted the resident to be seen by the hematology department. An appointment for 9/11/20 for Resident #7 was made with the hematology office. A Medical Doctor's (MD) Progress Note dated 9/4/20, signed at 4:16 PM, documented Resident #7 had a HGB of 6.2. MD #2 documented Resident #7 required a blood transfusion secondary to his/her history of [CONDITION(S)] and heart disease. MD#2 documented I gave an order to send (the resident) for a blood transfusion today. Under the Plan portion of the note, MD #2 documented, Transfuse 2 units of (blood) asap, and Resident #7 had a hematology appointment scheduled for 9/11/20. A Nursing Progress note dated 9/4/20 at 10:06 AM, documented Medical Doctor (MD) #2 reviewed the resident's labs and ordered Resident #7 to receive 2 units of blood as soon as possible. It documented the DON was given this order as she was handling the resident's care. A Nursing Progress note dated 9/4/20 at 11:04 AM, documented MD #2 did not think Resident #7 was actively bleeding, and MD #2 was also made aware that the resident had a hematology appointment scheduled for 9/11/20. There were no lab reports, Nursing Progress notes or MD Progress Notes from 9/5/20 until 9/10/20 that addressed the transfusion of blood for Resident #7. A Laboratory Report dated 9/10/20 documented Resident #7 had a critical HGB of 5.7, and this was reported to Registered Nurse (RN) #2 on 9/10/20 at 11:27 AM. An NP Progress Note dated 9/10/20, documented Resident #7 had yet to receive a blood transfusion despite orders given by in-house providers. NP #1 documented the resident had weakness, palpitations, confusion and was pale in color. The resident's apical pulse was [CONDITION(S)] (a heart rate greater than 100 beats per minute), he/she had low blood pressure and reported not feeling well. Resident #7 had an HGB of 5.7 and a HCT of 21.9. An order to send Resident #7 to the hospital immediately was placed. During an interview on 3/24/21 at 3:30 PM the DON reviewed her progress note dated 8/31/20 and stated she spoke to NP#1 regarding the order for a blood transfusion. The DON did not obtain an order to hold or discontinue the order for a blood transfusion. The DON reviewed her progress note dated 9/3/20, and was unable to recall the name of the head doctor she referred to in her note, and stated she did not obtain an order to hold or discontinue the blood transfusion. The DON stated the head doctor was ok with the facility not transferring the resident to the emergency room for a transfusion as directed by the Hematology/outpatient transfusion clinic but did not document this in her notes. During an interview on 3/24/21 at 3:47 PM, the DON stated when the MD or NP identified an order had not been completed, the ordering provider should have alerted administration at the facility to ensure the order was followed. She was aware of the critical lab values for Resident #7 were being reported to the nursing staff and was aware of the providers' repeated orders over several days for a blood transfusion. The DON stated the providers were aware the facility did not transfuse blood products, and that the ordering provider should have indicated that the resident needed to be sent out of the facility for a service the facility did not provide. During an interview on 3/25/21 at 8:56 AM, MD #2 stated Resident #7's HGB of 5.7 was considered a medical emergency and required an immediate transfer to the emergency department. MD#1 stated he was aware the facility did not administer blood products when the order for blood transfusion was given, and he would have expected the facility to transfer the resident to an outpatient clinic or emergency department to receive the treatment ordered. During an interview on 3/25/21 at 9:45 AM, NP#1 stated Resident #7 had a critical HGB and HCT. She ordered blood [CONDITION(S)] over the course of several days that were not administered. NP#1 stated she was aware the facility did not transfuse blood products but would have expected the facility to send the resident to either an outpatient clinic or the emergency department to receive the transfusion. NP#1 stated the transfusion was needed to ensure the resident remained hemodynamically stable (a medical term used to describe a stable blood flow). She stated she instructed the DON to send Resident #7 to the emergency room for a blood transfusion when told the outpatient clinic could not see him/her on 8/31/20. 10 NYCRR 415.12