Every finding on record at Clove Lakes Health Care And Rehabilitation Center,

Based on record review and interviews, the facility did not ensure that all alleged violations involving abuse or neglect, including injuries of unknown origin, were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than twenty four hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the New York State Department of Health. This was evident for three residents (Residents #12, #17, and #35) reviewed for Accidents. Specifically, the following reportable incidences were not reported to the Department of Health:Resident #12 was found on the floor of their room with a hematoma (a firm, raised, painful lump of pooled blood directly under the skin) to the head after an unwitnessed event and was unable to provide an account of the incident,Resident #17 was observed on the floor and noted with a bump to the right side of the forehead after an unwitnessed event and was unable to explain the occurrence,Resident #35 was found to have an open area of skin measuring two centimeters by two centimeters and to have sustained a broken bone of the distal humerus but was unable to provide an account of the injuries. The findings are: The facility policy titled, Prevention/Identification and Reporting of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident's Property, last reviewed 05/26/2026, documents that it is the policy of the facility to report any injury of unknown origin, any injury without any known incident or if the facility is unable to rule out abuse or care plan violation. Reportable incidents may be, but are not limited to unexplained bruises, inappropriate statements made to a resident, fracture of unknown origin and failure to follow the plan of care and/or carry out physician's orders. Resident #12 had diagnoses including an acute posthemorrhagic anemia. The admission Minimum Data Set (a resident assessment tool) assessment dated [DATE] documented that Resident #12 had moderate cognitive impairments and required substantial assistance with transfers. The facility Accident Report dated 04/14/2026 documented that Resident #12 had an unwitnessed fall in their room and was unable to communicate their version of the accident due to being unresponsive. The Registered Nurse Supervisor Note dated 04/14/2026 documented that Resident #12 was found lying on the floor of their room with a hematoma (a firm, raised, painful lump of pooled blood directly under the skin) to the frontal head area. Resident #12 was noted to be drowsy and was not responding verbally. The Fall Risk Evaluation, dated 04/14/2026, documented that Resident #12 was always disoriented. On 08/11/2026 at 10:51 AM, the Director of Nursing was interviewed and stated that Resident #12 was alert and able to communicate their needs when they were initially admitted to the facility, but that the facility Accident Report documented that Resident #12 was unresponsive after the fall that occurred on 04/14/2026. The Director of Nursing stated that because the fall was unwitnessed and Resident #12 was unable to explain what happened, that it should have been reported to the Department of Health, and they did not know why it was not reported. Resident #17 had diagnoses including Burkitt's lymphoma (cancer of the lymphatic system) and diffuse large B-cell lymphoma (cancer of the white blood cells). The facility's Incident Report, dated 08/19/2025, documented the nature of incident as a fall. The report further documented that Resident #17 sustained a bump on the right side of their forehead and was found lying on the floor in front of their wheelchair. Other details included in the report were that the wheelchair brake was in a locked position, the Hoyer Lift pad was in place, Resident #17 was confused and did not say what happened, a bump on the right side of forehead was noted, and the resident did not complain of pain. The Nursing Progress Note, dated 08/19/2025, documented that Resident #17 was found on the floor, next to the wheelchair. Resident #17 was awake, complained of pain to head, and was noted with bump on the right side of head. Resident #17 was able to move all limbs, and no other injuries were noted. Ice was applied to area. The medical doctor was informed and assessed Resident #17. The supervisor was made aware. The family was notified and declined to send Resident #17 to hospital. The Registered Nurse Supervisor Narrative, dated 08/19/2025, documented that Resident #17 was found lying on the floor in front of their wheelchair, inside the room by the left side of the bed. The wheelchair was locked and the floor was dry and clutter free. Resident #17 is a poor historian with intermittent confusion and was unable to provide statement of occurrence. Upon assessment, Resident #17 was noted with a lump on the right side of the forehead and was not on any anticoagulant. Range of motion was within normal limits on all extremities, and Resident #18 had no complaints of pain and discomfort. The Medical Doctor's Note, dated 08/19/2025, documented that Resident #17 was seen and examined for fall and pain control. Resident #17 had an unwitnessed fall in the afternoon and was found near the wheelchair. Resident #17 was alert and stated they hit the right side of head. Contusion and hematoma were noted on scalp, and an ice pack was placed. The Nurse Practitioner's Note, dated 08/19/2025, documented that Resident #17 was seen for an acute visit following a fall, with a hematoma noted to the head. There was no documented evidence that the facility reported Resident #17's injury of unknown origin to the New York State Department of Health. On 08/10/2026 at 4:01 PM, the Director of Nursing Services was interviewed and stated that they report falls with injury to the Department of Health on a case-by-case basis. The Director of Nursing stated that unwitnessed falls with injury do not always have to be called in to the Department of Health. The Director of Nursing stated that in Resident #17's case, it was not reported because Resident #17 was found on the floor, and if Resident #17 was found with a major injury, such as a fracture or hemorrhage, then it would have been called in. The Director of Nursing stated that the Administrator and the Director of Nursing make the decision whether to call in an incident into the Department of Health. The Director of Nursing further stated that they have a criteria list for reporting that they go by and since Resident #17 was found on the floor with a minor injury, they were under the impression it did not have to be called in. Resident #35 had diagnoses that included anxiety, coronary artery disease, dysphagia, gout, hypertensive heart disease with heart failure, neurocognitive disorder, and disorder of the bones. The Minimum Data Set 3.0 (a resident assessment tool) assessment dated [DATE] documented that Resident #35 had moderate cognitive impairment. A review of the care plan titled, Resident is a risk for potential verbal/physical abuse, neglect, mistreatment, exploitation and misappropriation of personal property related to cognitive impairment, self-care deficit and nursing home placement, initiated 12/14/2025, revealed interventions including to observe for change in behavior or triggers which may lead to an episode of abuse. An update, dated 04/18/2026, documented that Resident #35 was noted with open senile purpura (bluish, purplish colored skin due to break in blood vessels that cause discoloration and fragile skin) to the right arm and complained of pain in the right hand by the knuckle area. A review of the care plan titled, Resident has open senile purpura to right upper arm initiated 04/18/2026, revealed interventions that included to monitor affected area each shift, treatment as ordered, and weekly skin checks. A review of Registered Nurse Supervisor Narrative Progress Note, dated 04/18/2026 at 1:49 PM, documented that around 1:00 PM while Certified Nursing Assistant #18 was doing care, they noted an open area to right arm and notified Registered Nurse #11. Resident #35 was unaware of how it happened. Upon assessment, the writer noted around two centimeters by two centimeters area of open senile purpura with no active bleeding noted but with minimal swelling. Resident #35 complained of pain to the right hand. A review of the Nurse's Progress Note, dated 04/20/2026 at 12:02 AM, revealed that radiology had called for x-ray results that included fracture (broken bone) of the distal humerus. Resident #35 was transferred to the hospital. A review of the facility's Incident Report, dated 04/18/2026 at 1:00 PM and documented by Assistant Director of Nursing #1, included that Resident #35 was noted with open senile purpura to right arm and complained of pain in right hand by the knuckle area. Two Tylenol were administered. The right hand was noted to be minimally swollen, and Resident #35 was noted to have a history of gout. A review of the facility's Accident Report, dated 04/19/2026, revealed Resident #35 was transferred to the hospital for further evaluation. A review of the radiology report revealed Resident #35 had a radiological examination of the right elbow and the findings were that the right elbow showed a fracture of the distal humerus. The age of the fracture is indeterminate (bone break where medical professionals cannot precisely determine when the injury occurred based on imaging or clinical findings). During an interview on 08/12/2026 at 1:00 PM, Assistant Director of Nursing #1 stated they remember that on a weekend, an aide was cleaning Resident #35, noticed an open area on the elbow and notified the nursing supervisor. The area was measured, the doctor was notified, and it was diagnosed as an open senile purpura. Assistant Director of Nursing #1 stated that Resident #35 then complained of pain in the right hand and their knuckles were a little bit red. Assistant Director of Nursing #1 further stated that Resident #35 had a history of gout and was receiving medication for it. Resident #35 was seen by physicians and continued to complain about right hand pain. Gout medication was administered and an x-ray of the right hand was ordered, and Resident #35 was sent to the hospital for evaluation, and they were diagnosed with a humeral fracture. There was no report or observation of any injury, fall, or anything indicating abuse. Resident #35 returned to the facility wearing a splint. As per Assistant Director of Nursing #1, they did not report the broken distal humerus to the Department of Health because they did not believe they had to. During an interview on 08/12/2026 at 03:24 PM, Registered Nurse #10, stated that they worked the night shift on 04/17/2026 and that nothing happened. Registered Nurse #10 stated that Resident #35 slept until it was time to administer their medications. Registered Nurse #10 further stated that Resident #35 did not make any complaints to them about having any pain and Registered Nurse #10 did not notice any skin or bruise, during the process of taking Resident #35's vital signs. During an interview on 08/12/2026 at 3:30 PM, Certified Nursing Assistant #18 stated they were working on the 7:00 AM to 3:00 PM shift and provided care for Resident #35 and could not remember if there were any wounds on Resident #35. During an interview on 08/12/2026 at 3:35 PM, Registered Nurse #8, who is also the Nursing Supervisor, stated they were called at the end of their shift and was informed by Certified Nursing Assistant #18 about an open area on Resident #35's right arm. Resident #35's main complaint was pain in the knuckle area and hand. Pain and gout medication was ordered and administered, but Resident #35 still complained of pain. Registered Nurse #8 stated that an x-ray was ordered for Resident #35, but Registered Nurse #8 could not provide any further details regarding the incident. During an interview on 08/13/2026 at 10:21 AM, Registered Nurse #11 stated they took care of Resident #35 on the 7:00 AM to 3:00 PM shift and went to assess Resident #35 due to complaints of pain to their arm. Registered Nurse #11 stated they did not observe any skin tears or bruises on Resident #35 arms as that would be the first thing that they check. The physician checked to see if anything else was wrong and ordered an x-ray. They were informed Resident #35 was diagnosed with an arm fracture when they arrived the following workday. 10 New York Codes, Rules and Regulations 415.4(b)(2)

Based on observations, interviews, and record review, the facility failed to ensure residents who require respiratory care, including nebulizer and oxygen therapy, are provided with such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals. This was evident for one (Resident #3) of one residents reviewed for Respiratory Care. Specifically, there was no documented evidence that the nebulizer and bilevel positive airway pressure (BIPAP) (a type of noninvasive positive pressure ventilation used to help patients breathe more effectively) mask/tubing provided for Resident #3 were changed as per professional standards of care, and there was no documented evidence that Resident #3 was assessed pre- and post-nebulizer treatment as per the physician's order. The findings include:The Centers for Disease Control and Prevention's Guidelines for Preventing Health Care-Associated Pneumonia, dated 2003, documents that in-line and hand-held nebulized should be cleaned, disinfected, rinsed with sterile water, and dried between treatments on the same patient.The Centers for Disease Control and Prevention's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 2024, documents that tubing and medical equipment used for patients should be replaced as per manufacturer's information, when visibly soiled, and when malfunctioning.The American Lung Association's Oxygen Therapy Guidelines, updated 01/28/2026, documents that oxygen tubing should be replaced every 2 months and that the cannula/mask should be replaced every 2-4 weeks and with every sick episode.The facility policy and procedure titled, Nebulizer Treatment, dated 03/2005 and last revised 09/10/2025, documented that the resident should be monitored during treatment. The policy/procedure additionally documented that upon completion, should take about 15 minutes, the resident should be encouraged to cough after several deep breaths. Then, the nebulizer is to be disassembled, cleaned and disinfected after each use. Additional instructions listed in the policy and procedure included: store tubing in mesh bag, monitor and assess nebulizer treatment a minimum of once daily, inspect equipment daily, and to change equipment (tubing, masks) as scheduled, and as needed. The policy/procedure failed to document how frequently oxygen tubing and masks needed to be changed.Resident #3 was admitted to the facility with diagnoses that included coronary artery disease (a common type of heart disease that affects the main blood vessels that supply blood to the heart), hypertension (a chronic condition in which the force of blood pushing against artery walls is consistently too high), and pneumonia (an infection that inflames the air sacs in one or both lungs, which can fill with fluid or pus).The Quarterly Minimum Data Set (an assessment tool) dated 05/22/2026 documented Resident #3 had severe impairment in cognition, required total dependence of staff for all activities of daily living, and received oxygen and nebulizer therapy. On 08/07/2026 at 11:20 AM, Resident #3 was observed lying in bed, receiving continuous oxygen via Nasal Canula. A nebulizer mask and BIPAP (bilevel positive airway pressure) mask was visible on Resident #3's nightstand; items were noted to be left exposed, not enclosed or stored in a protective manner. Items were not labeled or dated.On 08/10/2026 at 9:11 AM, Resident #3 was observed in bed. A nebulizer mask and BIPAP mask were observed stacked on top of each other on Resident #3's nightstand, exposed and not enclosed or stored in a protective manner. Physician's orders dated 07/10/2026 documented Ipratropium-Albuterol 0.5-2.5, 3 milligrams per 3 milliliters, to be inhaled orally every six hours for shortness of breath, BIPAP (bilevel positive airway pressure) ordered for Fraction of inspired Oxygen 40% at a Rate of 14 breaths per minute, with an inspiratory positive airway pressure of 10 centimeters of water at bedtime for hypercapnia, Budesonide Suspension 0.5 milligrams per 2 milliliters, to be inhaled orally every twelve hours for asthma, and oxygen 4 Liters per minute via Nasal Cannula continuously for every shift.There was no documented evidence of a physician's order regarding changing oxygen tubing and nebulizer masks for Resident #3.On 08/10/2026 at 09:20 AM, Licensed Practical Nurse #1 was observed during administration of nebulizer treatment to Resident #3. Licensed Practical Nurse #1 used the nebulizer mask placed on top of nightstand to administer the nebulizer treatment without sanitizing or cleaning the mask. Licensed Practical Nurse #1 checked Resident #3's vital signs including blood pressure, respiration and oxygen saturation. Resident lung sounds were not assessed after the treatment as per physician's order.A review of Resident #3 Medication Administration and Treatment Records from 07/2026 to 08/2026 revealed there was no documented evidence that Resident #3's lungs were being assessed by a registered nurse pre- and post-nebulizer treatments.On 08/10/2026 at 09:35 AM, Licensed Practical Nurse #1 was interviewed and stated that Resident #3 is given nebulizer treatment at 8:00 AM and 12:00 PM during their tour. Licensed Practical Nurse #1 stated that they check blood pressure, respiration, saturation, and pulse, with a machine before and after nebulizer treatment. Licensed Practical Nurse #1 stated that they do not listen to or assess the resident's lungs. Licensed Practical Nurse #1 also stated that Resident #3's nebulizer mask is changed at the end of their shift or if the mask is noted to be dirty.On 08/10/2026 at 09:50 AM, Registered Nurse #3 was interviewed and stated Resident #3's nebulizer mask is supposed to be changed every 24 hours or when it is feasibly dirty, and that it is to be covered in the plastic bag. Registered Nurse #3 also stated that the nurses on the unit check the vital signs pre- and post-nebulizer during administration of the treatment. Registered Nurse #3 further stated that a registered nurse is supposed to assess the lungs before and after the treatment. Registered Nurse #3 could not explain why the assessments of Resident #3's lungs were not being done and documented as per order.On 08/10/2026 at 10:02 AM, the Director of Nursing was interviewed and stated that the mask is changed by the respiratory therapist every Monday and that masks are supposed to be placed in bags, to be covered when not in use. The Director of Nursing stated that they are not aware that the masks are not being covered by the nurses. The Director of Nursing further stated that the registered nurse supervisor on the unit was supposed to be doing the assessment of Resident #3 before and after the treatment as per order and documenting it in the resident's chart. The Director of Nursing stated that they were not aware that the registered nurse supervisor had not done the assessments.On 08/10/2026 at 10:33 AM, Nurse Practitioner #1 was interviewed and stated that they ordered nebulizer treatment for Resident #3 and to assess the resident's lungs for the effectiveness of the nebulizer treatment pre- and post- nebulizer treatment. Nurse Practitioner #1 stated that they have not been giving orders for the mask/tubing change as the mask and tubing is expected to be changed as per the facility protocol. Nurse Practitioner #1 stated that they would have to find out if there should be an order for the mask and tubing change.On 08/11/2026 at 09:20 AM, the Medical Director was interviewed and stated that they had only been at the facility for about a month and is not sure of the facility's protocol for ordering respiratory tubing changes. The Medical Director stated that they believe the staff should be changing the tubing and documenting it in the residents' chart. The Medical Director stated that they would find out to clarify. 10 New York Code, Rules and Regulations 415.12(k)(5)(4).

Based on record review and interview, the facility failed to ensure that each resident received adequate supervision and assistive devices to prevent avoidable accidents. This was evident for one (Resident #10) of one residents investigated for Accidents. Specifically, on 11/06/2025, Certified Nursing Assistant #29 attempted to transfer Resident #10 out of bed and into a wheelchair without the use of a Hoyer Device, resulting in Resident #10 falling. At the time of the incident, Resident #10 required dependent-level assistance and had an active order to be transferred with the use of a Hoyer Device. The facility policy titled, Mechanical Resident Lift/Hoyer Lift, last reviewed 01/15/2026, documented that the Hoyer Lift provided a means for lifting and transferring residents who otherwise would be unsafe and/or difficult to manually lift, and to provide safety for both the resident and staff. The policy also documented that the Charge Nurse is responsible for making the nursing assessment of the resident's transfer status and indicating that a mechanical lift is to be used in the nursing care plan and on the certified nursing assistant tasks. A minimum of two people is necessary for safe transfer with a mechanical lift.Resident #10 had diagnoses including an acquired absence of the right leg above the knee and muscle weakness.The Comprehensive Minimum Data Set (a resident assessment tool) assessment dated [DATE] documented that Resident #10 had intact cognition and required dependent-level assistance when transferring from bed to chair.The Comprehensive Task Listing Report dated 11/06/2025 documented that Resident #10 required dependent level assistance using a Hoyer Lift for bed-to-chair transfers.The Nursing Home Investigative Report dated 11/14/2025 documented that on 11/07/2025, Resident #10 reported that on 11/06/2025, they fell during a transfer from their bed to a wheelchair when a certified nursing assistant transferred them without the use of a Hoyer Lift. The report also documented that Certified Nursing Assistant #29 was interviewed and stated on 11/06/2025 they put Resident #10's wheelchair next to the bed and transferred Resident #10 without a Hoyer Lift machine. Additionally, the report documented that Registered Nurse #24, who was assigned to Resident #10's unit when the fall occurred, was interviewed and stated that around 12:00 PM on 11/06/2026, Certified Nursing Assistant #29 requested assistance, and when Registered Nurse #24 responded to Resident #10's room, they had found Resident #10 sitting on the floor. Registered Nurse #24 stated they Resident #10 said they fell while Certified Nursing Assistant #29 attempted to transfer them. The report also included documentation that Registered Nurse #23, who was the registered nurse supervisor assigned to Resident #10's unit at that time, was interviewed and stated that at around 11:47 AM on 11/06/2026, they were notified that Resident #10 fell while being transferred from the bed to the chair. The Nursing Home Investigative Report further documented that Certified Nursing Assistant #29, Registered Nurse #23, and Registered Nurse #24 resigned effective immediately during the investigation and disciplinary process.On 08/11/2026 at 10:43 AM, the Director of Nursing was interviewed and stated that Certified Nursing Assistant #29 was responsible for checking the task instructions for all their assigned residents at the start of their shift, which included each resident's transfer instructions. The Director of Nursing stated that they did not know if Certified Nursing Assistant #29 did this at the start of their shift on 11/06/2025, but that if they had reviewed this, they would have been aware of Resident #10 required utilization of the Hoyer Lift during transfers. The Director of Nursing stated that Certified Nursing Assistant #29 failed to follow Resident #10's plan of care by attempting to transfer them without a Hoyer Lift. The Director of Nursing stated that Registered Nurse #23 and Certified Nursing Assistant #29 both resigned during the investigative and disciplinary proceedings, but they would have been terminated due to their failures to adhere to facility policies. 10 New York Codes, Rules and Regulations 415.12(h)(1)

Based on observation, record reviews, and interviews conducted during survey, the facility failed to ensure that five (5) of seven (7) residents (Resident #7, Resident #9, Resident #10, Resident #11 and Resident #12) received adequate supervision and interventions to prevent accidents. Specifically, 1) On 04/16/2026 at 1:30 PM Resident #7 was observed entering the smoking room while using oxygen. Smoking Monitor #1 did not prevent Resident #7 from entering the smoking room nor did they attempt to remove Resident #7's oxygen. Resident #7 also had three (3) known incidents of smoking in their room while using oxygen.2) On 04/17/2026, the facility conducted room searches for all 35 identified smokers and 19 were found with smoking materials. Four (4) out of 19 residents (Resident #9, Resident #10, Resident #11 and Resident #12) were found with lighters, and two (2) of them (Resident #9 and Resident #10) were found with continuous use oxygen order in their room. There was no documented evidence that a smoking reassessment was provided for safe smoking for the four (4) residents after they were found with lighters. These circumstances subjected all 565 residents to the likelihood of serious adverse outcome that was Immediate Jeopardy.3) The facility failed to provide adequate supervision and interventions to address one (1) of five (5) residents (Resident #2) at risk of falls. Resident #2 experienced recurring falls on seven (7) occasions between 08/29/2025 and 02/24/2026. Preventive supervision of Resident #2 was not documented in the care plan. Resident #2 sustained injuries in three (3) of the fall incidents (09/02/2025, 12/17/2025, and 02/07/2026). These circumstances resulted in actual harm that was not Immediate Jeopardy.The findings are: A review of the facility's policy and procedure titled Smoking Regulations, Fire Prevention and Smoke Free Act Air with a reviewed date 10/2025 documented the facility has a designated Smoking Room in building A first floor for residents who smoke. Only staff assigned to assist and/or familiar with the residents' smoking plan are allowed to give out smoking materials or light up cigarettes for residents. All staff, upon witnessing a resident smoking in their room/non-designated area, inform the resident that they are not permitted to smoke in that area and immediately report the incident and stay with the resident until the charge nurse arrives. Notify the nursing supervisor and speak to the resident and inform him/her of the rules and regulations, remove all smoking materials from resident's possession and secure them at nurse's station. The person and room are to be searched. The Social Service (staff) will set up a team meeting to discuss and develop residents' discharge plan and then initiate process. Resident #7Resident #7 was admitted to the facility with diagnoses that included chronic obstructive disease, pulmonary fibrosis (scarring of lung tissue).The Annual Minimum Data Set (a resident assessment tool) dated 03/02/2026 documented that Resident #7 was cognitively intact. The Section J assessment did not identify Current Tobacco Use.A review of the Smoking Regulation Agreement dated 12/04/2024 documented Resident #7 as an identified smoker and Resident #7's signature was noted on the agreement.A review of the Smoking assessment dated [DATE] documented Resident #7 was a smoker.A review of the Physician's order dated 02/04/2026 documented Oxygen five (5) liters per minute through nasal cannula every shift for shortness of breath. A review of Comprehensive Care Plan titled Known Smoker dated 01/12/2026 documented Resident #7 was a smoker with interventions of Resident #7 will smoke safely within the designated smoking area with supervision, review smoking policy, and encourage smoking cessation. A review of the hourly safety check dated 03/2026 revealed there was no documented evidence Resident #7 was provided with more frequent safety checks after the three (3) incidents of unsafe smoking.A review of the nursing notes dated 01/12/2026 at 7:55 PM by Registered Nurse #6 documented Resident #7 closed the door and started smoking. Two (2) boxes of cigarettes and one (1) lighter were confiscated. Resident #7 was aware of the smoking protocol in the facility and put themselves and facility in danger. A review of the nursing note by Registered Nurse #7 dated 01/16/2026 at 9:40 PM, documented Certified Nursing Assistant #7 observed Resident #7 smoking in their room and immediately notified the nursing staff. A review of the nursing note by Registered Nurse #8 dated 03/11/2026 at 10:01 PM, documented that it was reported to them that Resident #7 was found smoking in their room while oxygen was in use.On 04/16/2026 at 1:30 PM Resident #7 was observed entering the smoking room while using oxygen. Smoking Monitor #1 did not prevent Resident #7 from entering the smoking room nor did they attempt to remove the oxygen. During an interview on 04/20/2026 at 5:13 PM, the Director of Recreation stated they conduct smoking assessments upon admission on ly. The Director of Recreation stated that on 04/16/2026 Smoking Monitor #1 should have removed the oxygen before Resident #7 entered the smoking room. The Director of Recreation stated residents should have no smoking materials with them as all smoking materials should be kept in the Recreation office in the designated locked cabinet. The Director of Recreation stated Resident #7 received counselling for non-compliant behavior, but they could not describe or provide documentation of the counselling. During an interview on 04/20/2026 at 6:45 PM, the Director of Nursing stated Resident #7 was on hourly checks for safety. Director of Nursing stated they have not increased the frequency of monitoring or safety checks after each incident, and they do not reassess Resident #7 for safe smoking after each smoking incident.During an interview on 04/20/2026 at 7:10 PM, the Administrator stated they continuously provide education (to Resident #7) by reviewing the facility policy and procedure and smoking agreement after each incident. Administrator stated smoking assessments are completed upon admission and as needed. During an interview on 04/21/2026 at 4:19 PM, the Medical Director stated they were not the direct care giver to Resident #7, so they are not the most appropriate person to answer questions. The Medical Director stated they did not know of Resident #7's noncompliant behavior with smoking. The Medical Director stated if Resident #7 has noncompliant behavior, the facility should keep educating them. The Medical Director stated smoking in a room with continuous oxygen is dangerous. The Medical Director stated they cannot determine at this time if Resident #7 was a safe smoker or not. A review of the facility's Accident Prevention Program with a review date of 02/18/2026 documented an accident is defined as an event which results in serious bodily harm, such as fractures, lacerations which require closure, second or third degree burns or any other requiring admission to a hospital. The Licensed Nurse/Nurse Supervisor reviews resident's medical record and completes fall risk status, develops care plan interventions, reviews/revises resident's plan of care as needed, and updates Certified Nursing Assistant Assignment as applicable. Resident #2Resident #2 was admitted to the facility with diagnoses including bilateral nasal bone fracture due to fall, Alzheimer's dementia, muscle weakness, and vitamin D deficiency.A review of the Minimum Data Set, dated [DATE] documented that Resident #2's cognition was severely impaired. Resident #2 required supervision/touching assistance with bed mobility and transfer and was able to ambulate 10 to 50 feet. A review of Fall Risk Evaluation dated 07/24/2025 documented Resident #2 as a high risk for falls. Resident #2 was reevaluated after each fall incident, but there was no change to the resident's fall risk category. A review of the Comprehensive Care Plan for At Risk for Fall with a facility review date of 07/29/2025 documented interventions of anticipate and meet resident's needs, ensure a clean and dry environment, and ensure well-fitting shoes. A review of the Comprehensive Care Plans titled Actual Fall dated 08/29/2025, 09/02/2025, 12/17/2025, 12/28/2025, 02/07/2026, 02/17/2026 and 02/24/2026 revealed there was no documented evidence of supervision reflected in Resident #2's care plan to implement/ensure adequate supervision. A review of the Task List Report (instructions for certified nursing assistants) dated 04/16/2025 revealed Resident #2 was on hourly safety check monitoring. A review of the Kardex Report (instructions for certified nursing assistants) for 08/29/2025 under toileting, documented to check Resident #2 every two (2) hours and as needed, anticipate needs and meet needs. It also indicated be sure call light is within reach and monitor/document/report as needed any changes and decline in function.Incidents: A review of the Incident Report dated 08/29/2025 at 10:30 AM documented Resident #2 was found on the floor on the side of their bed. Resident #2 was assessed by Registered Nurse Supervisor #4 and there was no injury. Medical Doctor and family notified. Recommended measure was to increase supervision. The investigation concluded there was no reasonable suspicion of abuse or neglect. A review of the Documentation Survey Report (certified nursing assistants accountability record documentation sheet) dated 08/29/2025 between 10:00 AM-11:00 AM revealed no documented evidence that Resident #2 was monitored for safety.A review of the actual Care Plan dated 08/29/2025 revealed interventions to monitor/document for pain, bruises, and change in mental status. There was no documented evidence of an increase in supervision for Resident #2 reflected in the care plan or Task List Report.A review of the Incident Report dated 09/02/2025 at 8:30 AM revealed Resident #2 was found sitting on the bathroom floor by Registered Nurse #5 and Resident #2 stated they lost their balance. Resident #2 was assessed and observed with a one (1) inch laceration to their left middle finger. Medical Doctor was notified, and treatment was ordered. Recommended preventive measures were to increase supervision and provide frequent checks. The investigation concluded there was no reasonable suspicion of abuse or neglect.A review of the actual care plan dated 09/02/2025 revealed to administer treatment as directed and neuro checks times three (3) days. There were no preventive measures to increase supervision or frequent checks reflected in the care plan and Task List Report (instructions to certified nursing assistants).A review of the Incident Report dated 12/17/2025 at 3:25 AM revealed Licensed Practical Nurse #5 heard a noise in the hallway and observed Resident #2 sitting on the floor and stated they walked and wanted to go to the bathroom and then later said, they do not need to go. Resident #2 was assessed and noted with open skin tear to right elbow. There was no pain. Medical Doctor was notified, and treatment was ordered. A care plan was updated with the intervention to determine and address causative factors of the fall. The investigation concluded there was no reasonable suspicion of abuse or neglect.A review of the actual care plan dated 12/17/2025 revealed interventions to determine and address causative factors of the fall and ensure that resident is wearing appropriate footwear while in the wheelchair. There was no documented evidence of increased supervision.A review of the Incident Report dated 12/28/2025 at 10:20 AM documented Resident #2 was found sitting on the floor near their room door. Resident #2 was assessed and no injury and did not complain of pain. Recommendation of preventive measures to increase supervision. The investigation concluded no reasonable suspicion of abuse or neglect. A review of the actual fall care plan dated 12/28/2025 revealed there was no documented evidence of increased supervision reflected in the care plan. A review of Documentation Survey Reports dated 12/28/2025 between 5:00 AM - 6:00 AM and 10:00 AM-11:00 AM revealed there was no documented evidence that Resident #2 was monitored for safety.A review of the Incident Report dated 02/07/2026 at 4:35 AM revealed Resident #2 was found lying on the floor on the right side of their bed, bleeding noted on their right eyebrow. Resident #2 was assessed and observed with laceration on their right eyebrow, measuring 3.0-centimeter by 0.5-centimeter by 0.5 centimeter and cold compress applied. Medical Doctor notified. Resident #2 was transferred to hospital and returned on the same day after receiving six (6) stitches to their right eyebrow. The investigation concluded no reasonable suspicion of abuse or neglect.A review of the actual care plan dated 02/07/2026 revealed there was no documented evidence of increased supervision for Resident #2. A nursing note dated 02/07/2026 at 1:25 PM by Licensed Practical Nurse # 6 documented Resident #2 returned from emergency room visit at 12:20 PM. Observed six (6) stitches in their right eyebrow. No complaint of pain. Neuro checks maintained. Record review of the hospital records dated 02/07/2026 at 7:36 AM revealed Resident #2 with 1.5-centimeter laceration noted to the right eyebrow. Laceration irrigated and repaired without complication and discharged back to facility. The Incident Report dated 02/17/2026 at 11:00 AM documented Resident #2, unwitnessed, slid out of the wheelchair and was found sitting on the floor. Resident #2 was last seen two (2) minutes before the incident. Resident #2 was assessed by Registered Nurse Supervisor #6 and there was no injury. Recommendation to continue close observation by nurse's station. The investigation concluded no reasonable suspicion of abuse or neglect.A review of the actual care plan dated 02/17/2026 revealed there was no documented evidence of increased supervision reflected in the care plan. A review of the Incident Report dated 02/24/2026 at 5:42 AM documented Resident #2 was found sitting on the floor and trying to pull themself up by holding onto the side rail. Resident #2 was assessed and there was no injury. Recommendation for preventive measures of frequent observation every 30 minutes. The investigation concluded no reasonable suspicion of abuse or neglect.A review of actual care plan dated 02/24/2026 revealed there was no documented evidence of increased supervision reflected in the care plan. During an interview on 04/24/2026 at 12:12 PM, Registered Nurse Supervisor #5 stated they were one of the supervisors who assessed Resident #2 during their 12/28/2025 fall incident. Registered Nurse Supervisor #5 stated they reviewed and updated the care plan but did not reflect frequency of adequate supervision in the care plan.During an interview on 04/27/2026 at 10:26 AM, Registered Nurse Supervisor #6 stated Resident #2 had an unwitnessed fall in the hallway and there should have been staff monitoring Resident #2 to prevent them from falling. Registered Nurse Supervisor #6 stated they should have added new interventions in Resident #2's care plan. During an interview on 04/27/2026 at 9:16 AM, the Director of Nursing stated every incident must have a care plan review and an update of the care plan by the nursing supervisor. Director of Nursing stated there should be supervision documented in the care plan. Director of Nursing stated they reviewed the care plan, and there were not enough interventions in place. Director of Nursing stated there was no formal root cause analysis done for the incidents. During an interview on 04/27/2026 at 11:25 AM, Social Worker #1 stated they had a care plan meeting with regard to fall incidents of Resident #2 and spoke to Adult Child #1 about the plan of care to ensure Resident #2 has appropriate footwear and to continue to monitor Resident #2, but they do not recall discussing the root cause analysis of their fall. Social Worker #1 stated going forward they need to check to see if they should discuss or offer a room change with the team. During an interview on 04/27/2026 at 11:35 AM, Medical Doctor #2 stated Resident #2 was very uncooperative and restless at times. Medical Doctor #2 stated prior to facility admission, Resident #2 had multiple injuries with fractures due to falls at home. Medical Doctor #2 stated they tried to talk to Resident #2,but they would not listen, but sometimes they listened. Medical Doctor #2 stated they were aware that Resident #2 had multiple fall incidents in the facility that were unwitnessed, but staff continued to monitor them to prevent them from falling. Medical Doctor #2 stated Resident #2's accidents are mostly unavoidable because it was hard to find out what happened due to unwitnessed incidents. Medical Doctor #2 stated they do not attend care plan meetings but discussed the plan of care to the unit supervisor and other nursing staff in the unit. On 04/22/2026 at 2:34 PM, Immediate Jeopardy was identified and declared. The Director of Nursing and Administrator were notified.The Director of Nursing and Administrator returned the signed IJ Template on 04/22/2026 at 2:41 PM. On 04/22/2026 at 5:15 PM, the facility presented a removal plan that listed the immediate action the facility would take to prevent serious harm from occurring or recurring. The facility's removal plan was revised and later accepted on 04/22/2026 at 7:57 PM. Based on observation, interview, and record review, the facility completed implementation of the removal plan on 04/22/2026 at 7:57 PM. The Immediate Jeopardy was lifted based on the following corrective actions taken by the facility: Resident #7 was placed on 1:1 supervision starting 04/20/2026 until possible discharge. Physician and Medical Director were notified of the issued IJ Template F689 immediately on 04/22/2026. Quality Assurance Performance Improvement meeting was held with multidisciplinary team on 04/22/2026. Unit Physician conducted a physical assessment on Resident #7 on 04/22/2026 and no injuries were found. Education focused on safe smoking was provided by the Unit Physician and Resident #7 was offered smoking cessation options. Oxygen removed by the smoking monitor prior to allowing residents access to the smoking area starting 04/22/2026, utilizing a smoking safety audit tool. A comprehensive smoking reassessment was completed for Resident #7 on 04/22/2026. Resident #7's care plan updated to reflect increased supervision and safety precautions on 04/20/2026. Resident #7 received re-education regarding smoking risks with oxygen with 2 witnesses present on 04/22/2026. Resident #7 verbalized understanding but refused to sign. All (35) identified smokers underwent immediate reassessment and received education regarding safe smoking practices on 04/22/2026. Policy and Procedure on Smoking was reviewed and revised on 04/17/2026 to include increased frequency of Smoking Assessments on admission/readmission, quarterly and/or as needed. Non-compliant smokers, monitoring will be increased to every 30 minutes, immediately upon identification. Care Plan will be updated as necessary. Any resident identified smoking in undesignated area/times will be placed on 1:1 supervision until alternate placement is identified. It was determined by the State Agency that the facility fully implemented their plan to remove the immediate jeopardy as of 04/22/2026 at 7:57 PM. 10 New York Codes, Rules, and Regulations 415.12 (h)(2)

Based on observation, record reviews, and interviews conducted during survey, the facility failed to ensure that resident was free from neglect. This was evident for one (1) of five (5) residents (Resident #1) sampled. Specifically, the facility failed to ensure Registered Nurse #1 or other direct care service providers (Certified Nursing Assistant #1) provided Resident #1 with goods, services and care that were necessary to prevent physical harm. On [DATE], Registered Nurse #1 neglected to ensure that Resident #1, who had an order for continuous oxygen, received significant medications and treatments that were scheduled for 4:00 PM, 8:00 PM and 9:00 PM. In addition, Certified Nursing Assistant #1 neglected to provide hourly monitoring of Resident #1 who was assessed as at risk for falls and to ensure the resident had received and ate dinner. At 9:49 PM on [DATE], Resident #1 was found unresponsive on the floor face down with no pulse and no breathing. Cardiopulmonary resuscitation was initiated until Emergency Medical Services(911) arrived at 10:07 PM and assumed care. Resident #1 expired at 10:24 PM. This resulted in actual harm to Resident #1 that was Immediate Jeopardy. The findings are: A review of the facility's policy, Prevention/Identification and Reporting of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident's Property with a review date [DATE], documented residents must not be subjected to abuse, neglect, exploitation, mistreatment and misappropriation of residents' property by anyone. It is the policy of the facility to report any suspected patient verbal and/or physical abuse, neglect, exploitation, mistreatment and misappropriation of resident's property occurring within the facility. The term neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. A review of the facility's policy, Accident Prevention Program with a review date of [DATE], documented an accident is defined as an event which results in serious bodily harm, such as fractures, lacerations which require closure, second- or third-degree burns or any other requiring admission to a hospital. The Licensed Nurse and/or Nursing Supervisor reviews/revises resident's plan of care as needed. Resident #1 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease, (poor air flow to the lung), diabetes mellitus, (high sugar in the blood), and heart failure (heart muscle does not pump enough blood). The Minimum Data Set (a resident assessment tool) dated [DATE] documented Resident #1's cognition was intact. Resident #1 required supervision/touching assistance with activities of daily living care. Resident #1 required continuous oxygen therapy. A review of Fall Risk Evaluation dated [DATE] identified Resident #1 at high risk for falls. Resident #1 had a history of falls in the facility.A review of the Comprehensive Care Plan for At Risk of Abuse, Neglect, with a review date of [DATE] documented interventions to allow Resident #1 to express feelings of being fearful and anxious, as necessary. Provide physical and emotional support for resident safety. A review of the Comprehensive Care Plan for At Risk of Falls, with a review date of [DATE] documented interventions for staff to anticipate and meet resident's needs, ensure resident's call light is within reach and encourage to use it for assistance as needed. Ensure a clean and dry environment. A review of the Order Summary Report (Physician's orders) from [DATE] through [DATE] revealed Resident #1 had orders for Fluticasone-Salmeterol inhalation aerosol two (2) times daily and Incruse Ellipta inhalation aerosol one (1) time a day for chronic obstructive pulmonary disease, Metformin 500 milligram tablet two (2) times daily for diabetes mellitus, and Sertraline 100 milligram two (2) times daily for major depressive disorder, Varenicline Tartrate 1 milligram every 12 hours for smoking cessation, Atorvastatin 20 milligram one (1) tablet at bedtime for high fat level in the blood Quetiapine Fumarate (antipsychotic medication) 300 milligram 1 tablet at bedtime for major depressive disorder, Trazodone 100 milligram tablet at bedtime for depression, and oxygen at 3-liters per minute via nasal cannula continuously every shift for chronic obstructive pulmonary disease. A review of the Medication Administration Record dated [DATE] for the evening shift (3:00 PM-11:00 PM) showed Resident #1 was scheduled to receive the above medications at 4:00 PM, 8:00 PM, and 9:00 PM. There was no documented evidence Resident #1 received any medications or treatment during the evening shift on [DATE]. A review of a Task List Report (instructions for certified nursing assistants) dated [DATE] revealed Resident #1 was placed on hourly visual checks for safety. This plan was in place until the date of the incident ([DATE]). There was no documented evidence Resident #1 was provided hourly monitoring from 2:45 PM to 9:40 PM on [DATE].A review of the nutritional intake form dated [DATE] revealed no documented evidence that Resident #1 had been served a meal or snack from 2:45 PM to 9:40 PM on [DATE].A review of the visitor's log dated [DATE] revealed there was no documented evidence that a visitor had visited Resident #1. The nursing progress note by Registered Nurse #1 dated [DATE] at 11:53 PM documented at 9:49 PM Resident #1 was found on the floor unresponsive with no pulse, no breathing, called STAT (an action must be taken immediately) at 9:50 PM and cardiopulmonary resuscitation initiated right away, nonrebreather mask attached to run at 15 liters per minute. At 9:51 PM 911 was called, intravenous line inserted at right peripheral arm and normal saline 0.9 bolus started. At 10:07 PM, 911 arrived and took over. At 10:24 PM, Resident #1 was pronounced expired by Emergency Medical Services. Registered Nurse #1 notified Adult Child #1.A review of the Accident/Incident Investigation form dated [DATE] at 9:49 PM incident revealed after the investigation, the incident appears to have been related to a medical event. Resident #1 was found lying on the floor beside their bed unresponsive. No measurable vital signs were obtained. Stat was called and cardiopulmonary resuscitation initiated, and Emergency Medical Services arrived. Resident #1 was pronounced by Emergency Medical Services at 10:24 PM. On initial assessment Resident #1 had no visible injuries and skin was intact. During postmortem care a large skin tear was observed to Resident #1's right cheek. On investigation the call bell was found to be within reach but had not been activated. Bed was in lowest and locked position. Floor of the room was clean and dry, free of clutter. After investigation the interdisciplinary team determined that there is no cause to believe an alleged abuse, mistreatment, or neglect regarding this resident had occurred. There was no documentation in the incident report that from 4:15 PM to 9:48 PM Resident #1 was missing, staff were unaware of Resident #1's whereabouts until the resident was found unresponsive, Resident #1 did not receive any medications on the evening shift, and when the resident was found, they were not connected to any oxygen. There was no documentation the nursing supervisor and medical doctor were notified. During an interview on [DATE] at 3:52 PM, Adult Child #1 (complainant) stated Registered Nurse #1 called them at 9:43 PM and stated Resident #1 was missing and was asked if they had taken Resident #1 with them and they said no. Adult Child #1 stated Registered Nurse #1 called them again (unsure of time) and stated they found Resident #1 unresponsive beside their bed. Adult Child #1 stated they arrived in the facility, and they stated Resident #1 expired at 10:24 PM. Adult Child #1 stated they observed skin peeled off Resident #1's right side of face that looked like a burned skin injury. Adult Child #1 stated they asked Registered Nurse Supervisor #1 about the facial injury, and they stated that the Emergency Medical Services had caused the injury. During an interview on [DATE] at 2:37 PM, Registered Nurse #1 stated they arrived on the unit on [DATE] at 4:15 PM and did not see Resident #1 on the unit during their rounds. Registered Nurse #1 stated they received information (unsure of staff to whom they received it) that Resident #1 had a visitor. Registered Nurse #1 stated they did not look for Resident #1 (thinking they were with visitor) and continued to work. Registered Nurse #1 stated they were not sure if Resident #1 came back in the unit and started looking for them at 9:40 PM and briefly looked in Resident #1's room and did not see them. Registered Nurse #1 stated that at approximately 9:43 PM, they called the Adult Child #1 and asked if they had taken Resident #1 with them and was told no. Registered Nurse #1 stated they immediately contacted Registered Nurse Supervisor #1 to inform them that they could not locate Resident #1. Registered Nurse #1 stated they started the search in Resident #1's room again and at 9:49 PM, they found Resident #1 unresponsive beside their bed face down on the floor. During an interview on [DATE] at 6:02 PM, Certified Nursing Assistant #1 stated they worked on [DATE] from 3:00 PM-11:00 PM and was assigned to the care of Resident #1. Certified Nursing Assistant #1 stated when they received their assignment at 3:30 PM, they observed Resident #1 in their room sitting on their bed. Certified Nursing Assistant #1 stated they did not see a visitor for Resident #1 in the room. Certified Nursing Assistant #1 stated Resident #1 used the call light when they needed assistance. Certified Nursing Assistant #1 stated they did not serve a dinner tray to Resident #1 because they were serving residents on the other side of the unit. They stated that they did not know if Resident #1 ate or not. Certified Nursing Assistant #1 stated they did not ask the other certified nursing assistant if Resident #1 ate. Certified Nursing Assistant #1 stated they are supposed to check Resident #1 during meals and document. Certified Nursing Assistant #1 stated they did not perform hourly checks on Resident #1. They stated that the second time they checked Resident #1 was at approximately 8:30 PM in their room. They stated that they asked Resident #1 if they needed anything and they said they were okay. Certified Nursing Assistant #1 stated Registered Nurse #1 did not communicate with them that Resident #1 was missing and never had communication with Registered Nurse #1 during their shift. During an interview on [DATE] at 5:43 PM, Registered Nurse Supervisor #1 stated they were the assigned unit supervisor on the date of the incident. Registered Nurse Supervisor #1 stated Registered Nurse #1 called the nursing office on [DATE] (time unknown) and reported that Resident #1 was not in bed, the wheelchair was there but the room was empty. Registered Nurse Supervisor #1 stated together with the other supervisors they immediately responded to the unit to search but when they arrived in the unit, Registered Nurse #1 and other staff had already found Resident #1. Registered Nurse Supervisor #1 stated they observed Resident #1 laying on the floor face down and when they turned them on their back, Resident #1 had no pulse, was not breathing, called a stat and started cardiopulmonary resuscitation at 9:50 PM, and notified Medical Doctor #1 (unsure of time). Registered Nurse Supervisor #1 stated they did not notice blood on the floor and the skin on Resident #1's face was intact. Registered Nurse Supervisor #1 stated the Emergency Medical Services arrived on the unit at 10:07 PM and took over. Registered Nurse Supervisor #1 stated Emergency Medical Services intubated Resident #1. Registered Nurse Supervisor #1 stated after Emergency Medical Services left they observed the skin on the right side of Resident #1's face peeled off and looked like an open blister. Registered Nurse Supervisor #1 stated Medical Emergency Services pronounced Resident #1 expired at 10:24 PM. Registered Nurse Supervisor #1 stated they spoke to Registered Nurse #1, and they did not report Resident #1 was initially missing or how long the resident was missing. Registered Nurse Supervisor #1 stated they were not aware Resident #1 did not receive their scheduled evening medications on [DATE].During an interview on [DATE] at 7:10 PM, Registered Nurse Supervisor #2 stated they also responded to the call of Registered Nurse #1 on [DATE] (unsure of time). Registered Nurse Supervisor #2 stated they immediately responded to do the search on the unit but when they arrived at the unit, Resident #1 was found already laying on the floor unresponsive at the right side of their bed. Registered Nurse Supervisor #2 stated they did not observe oxygen connected to Resident #1's nose.During an interview on [DATE] at 4:17 PM, the Infection Control Director stated they were the on-call staff person responsible for covering the weekend on [DATE] during the evening when incident occurred. Infection Control Director stated they received a call report from Registered Nurse Supervisor #2 stating that Resident #1 could not be found, and the family was called. Infection Control Director stated this information should have been reported in the morning report on [DATE] (Monday) and it should have been included in the accident/incident report.During an interview on [DATE] at 3:14 PM, Director of Nursing stated that on [DATE] between 2:00 AM to 3:00 AM, they received a message from Registered Nurse Supervisor #1 through hospitalization chat (group chat) that on [DATE] at 9:49 PM, Resident #1 was found on the floor unresponsive, a stat was called, cardiopulmonary resuscitation was initiated until Emergency Medical Services took over the scene and pronounced Resident #1 expired at 10:24 PM. The Director of Nursing stated that not until [DATE] were they notified that Resident #1 had been reported missing by nursing staff. The Director of Nursing stated that the Infection Control Director was on duty, and it was initially reported to them. The Director of Nursing stated that the Infection Control Preventionist failed to report this information to them during the morning meeting on [DATE]. The Director of Nursing reviewed the certified nursing assistant accountability record for the [DATE] from 3:00 PM-11:00 PM shift and acknowledged that there was no documentation for hourly safety checks, or meal consumption. The last documentation was 2:45 PM for hourly safety checks. The Director of Nursing also reviewed the medication administration record and stated that it revealed that there were no medications administered to Resident #1 from 4:00 PM to 9:49 PM the time they were found. During an interview on [DATE] at 4:00 PM, The Administrator stated the first time they were made aware of the incident was through the hospitalization chat received on [DATE] at 12:20 AM by Registered Nurse Supervisor #1 that Resident #1 was found unresponsive on [DATE] at 9:49 PM. The Administrator stated they were not made aware Resident #1 had not been seen by nursing and direct care staff for hours or that the resident had not received ordered medications, or treatments or a meal because staff thought the resident was missing or out with family During an interview on [DATE] at 1:37 PM, the Medical Director stated they never heard Resident #1 was missing for several hours on [DATE] on the evening shift. The Medical Director stated they were not made aware that Resident #1 was missing prior to [DATE]. The Medical Director stated they were not made aware of the incident on [DATE], but they became aware after a day or two (2) after, through the hospitalization chat received. The Medical Director stated they did not review the chart. They were not made aware Resident #1 did not receive medications scheduled for 4:00 PM through 9:00 PM until [DATE]. The Medical Director stated they cannot opine whether Resident #1 missing one (1) cycle of medications caused them to collapse and expire. 10 New York Codes, Rules, and Regulations 415.4(b)(1)(i)On [DATE] at 4:39 PM, Immediate Jeopardy was identified and declared. The Director of Nursing and Quality Assurance Performance Improvement Coordinator were notified.The Director of Nursing returned the signed IJ Template on [DATE] at 5:30 PM. On [DATE] at 6:39 PM, the facility presented a removal plan that listed the immediate action the facility would take to prevent serious harm from occurring or recurring. The removal plan was accepted on [DATE] at 6:53 PM.The facility revised removal plan was accepted on [DATE] at 8:31 PM. Based on observation, interviews, and record review, the facility completed implementation of the removal plan on [DATE] at 5:00 PM. Immediate Jeopardy was lifted based on the following corrective actions taken by the facility: Registered Nurse #1 was terminated on [DATE]. Certified Nursing Assistant #1 was terminated dated [DATE]. A facility wide headcount and room-to-room safety check was completed on [DATE]. All 572 residents were immediately accounted for and assessed for safety and supervision needs. All 572 residents were immediately accounted for and assessed for safety and supervision needs. Dinner on [DATE] was observed and noted to have been served. Meals served audit dated [DATE] to [DATE]. The Administrator and the Medical Director were notified of identified care gaps on [DATE] at 5:00 PM. A meeting was conveyed immediately on [DATE] with Registered Nurse Supervisors with Nursing Leadership, reinforcing rounding and communication protocols. Immediate audit of medication administration practices and all were noted to be administered on [DATE]. Review of Policy and Procedures on [DATE] and no changes were made Abuse/neglect prevention (F600), Missing Resident Procedures and Medication Administration. Facility-wide education on Abuse, Neglect, and Mistreatment, Rounding on Residents, Code Orange-Missing Resident, and Missed Medication Administration were initiated. The lesson plan and Facility-wide education on Abuse, Neglect, and Mistreatment, Rounding on Residents, Code Orange-Missing Resident, and Missed Medication Administration were initiated dated [DATE] to [DATE]. Staff attendance sheet received and reviewed. Total staff: 642, Total In-service : 642, Overall Percentage : 100 % Certified nursing assistants will be educated to ensure that missed meals are documented and reported to the Unit Nursing Supervisor on [DATE] to [DATE]. It was determined by the State Agency that the facility fully implemented their plan to abate the immediate jeopardy as of [DATE] at 5:00 PM.

Based on record reviews and interviews conducted during survey, the facility failed to ensure that residents are free of significant medication errors. This was evident in one (1) out of five (5) residents sampled (Resident #1). Specifically, on [DATE], Registered Nurse #1 did not administer significant medications at 4:00 PM, 8:00 PM, and 9:00 PM to Resident #1 in accordance with Physician's orders. Additionally, Resident #1 did not receive ordered oxygen 3-Liters via nasal cannula continuously every shift for chronic obstructive pulmonary disease. From 4:15 PM to 9:49 PM on [DATE], Registered Nurse #1 and other direct care staff were unaware of Resident #1's whereabouts until Resident #1 was found unresponsive on the floor face down with no pulse and no breathing. Cardiopulmonary resuscitation was initiated until Emergency Medical Services arrived at 10:07 PM and assumed care. Resident #1 expired at 10:24 PM. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy. Cross Reference: F658 - Services Meet Professional StandardsThe findings are:The facility policy and procedure titled Medication Administration with a review date [DATE] documented it is a standard of practice that medications be administered as ordered by the physician. Medications are administered to the resident within a one-hour time frame before/after the indicated administration time, unless otherwise specified by drug information. Electronic-Medication Administration Record must be signed by the nurse who administered the medication. When medication cannot be administered, or is refused, it is to be documented electronically on the electronic- Medication Administration Record including the reason and physician notification. The facility policy and procedure titled Medication Errors with a review date [DATE] documented it is the facility policy that a medication error will be reported as soon as it is recognized. In the event of significant error: one (1) occurrence of a significant error may result in termination. It is noted that the safe, appropriate administration of all prescribed medications and treatments is one of the major responsibilities of the licensed professional nurse. Failure to consistently follow the medications policies and procedures and/or repeated medication errors may be cause to termination employment. Resident #1 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (poor air flow to the lung), diabetes mellitus (high sugar in the blood), and heart failure (heart muscle do not pump enough blood), and Resident #1 was receiving continuous oxygen. A review of the Minimum Data Set (a resident assessment tool) dated [DATE] documented Resident #1's cognition was intact. Resident #1 was assessed to be on an antipsychotic medication, antidepressant medication, and hypoglycemic medication.A review of the Order Summary Report (Physician's orders) from [DATE] through [DATE] revealed Resident #1 had orders for Fluticasone-Salmeterol inhalation aerosol two (2) times daily and Incruse Ellipta inhalation aerosol one (1) time a day for chronic obstructive pulmonary disease, Metformin 500 milligram tablet two (2) times daily for diabetes mellitus, and Sertraline 100 milligram two(2) times daily for Major Depressive Disorder, Varenicline Tartrate one (1) milligram every 12 hours for smoking cessation, Atorvastatin 20 milligram one (1) tablet at bedtime for high fat level in the blood, Quetiapine Fumarate (antipsychotic medication) 300 milligram one (1) tablet at bedtime for major depressive disorder and Trazodone 100 milligram tablet at bedtime for depression. Oxygen at 3-liters per minute via nasal cannula continuously every shift for chronic obstructive pulmonary disease. A review of the Medication Administration Record dated [DATE] for the 3:00 PM-11:00 PM shift revealed Resident #1 was scheduled to receive the above medications at 4:00 PM, 8:00 PM, and 9:00 PM. There was no documented evidence Resident #1 received their medications and treatment on [DATE] as ordered and scheduled. During an interview on [DATE] at 2:37 PM, Registered Nurse #1 stated they arrived on the unit on [DATE] at 4:15 PM and did not see Resident #1 on the unit during their rounds. Registered Nurse #1 stated they received information (from unknown staff) that Resident #1 had a visitor. Registered Nurse #1 stated they did not look for Resident #1 and continued working on the unit. Registered Nurse #1 stated they were not sure Resident #1 had returned to the unit but started looking for Resident #1 at 9:40 PM to administer their medications. Registered Nurse #1 stated they briefly looked in Resident # 1's room but did not see them. Registered Nurse #1 stated Resident #1's 4:00 PM medications were not given because they thought Resident #1 was with a visitor. Registered Nurse #1 stated they have an hour before and an hour after to give scheduled medications. Registered Nurse #1 stated they were aware that the 4:00 PM, 8:00 PM and 9:00 PM medications were not given but does not recall notifying Registered Nure Supervisor #1 or Medical Doctor #1. Registered Nurse #1 stated they knew they were supposed to notify their supervisor and medical doctor when Resident #1 did not receive their medications.During an interview on [DATE] at 5:43 PM, Registered Nurse Supervisor #1 stated they were the assigned unit supervisor on the date of the incident. Registered Nurse Supervisor #1 stated they were not aware Resident #1 did not receive their scheduled medications on [DATE]. Registered Nurse Supervisor #1 stated Registered Nurse #1 should have notified them that the medications were not given, and they would have notified the medical doctor. Registered Nurse Supervisor #1 stated that when medications are not administered it must be documented in the electronic Medication Administration Record along with the reason. Registered Nurse Supervisor #1 stated Registered Nurse #1 called the nursing office on [DATE] (unsure of time) and reported that Resident #1 was not in bed, the wheelchair was there but the room was empty. Registered Nurse Supervisor #1 stated together with the other supervisors, they immediately responded to the unit to do search but when they arrived in the unit, Registered Nurse #1 and other staff had already found Resident #1 laying on the floor face down and when they turned them on their back, Resident #1 had no pulse, was not breathing, called STAT (an action must be taken immediately) and started cardiopulmonary resuscitation, Emergency Medical Services (911) were called. Registered Nurse Supervisor #1 stated Emergency Medical Services pronounced Resident #1 expired at 10:24 PM. Registered Nurse Supervisor #1 stated they spoke to Registered Nurse #1, and they reported Resident #1 was initially missing, but did not mention to them what time Resident #1 was missing. During an interview on [DATE] at 7:10 PM, Registered Nurse Supervisor #2 stated they also responded to the call of Registered Nurse #1 on [DATE] (unsure of time). Registered Nurse Supervisor #2 stated they did not observe oxygen connected to Resident #1's nose.During an interview on [DATE] at 1:37 PM, the Medical Director stated they never heard Resident #1 was missing for several hours for several hours on [DATE] during the evening shift incident. The Medical Director stated they were not made aware that Resident #1 was missing prior to [DATE]. The Medical Director stated they were not made aware of the incident on [DATE], but they became aware after a day or two (2) through the hospitalization chat (group chat) received. The Medical Director stated they did not review Resident #1's chart and they were not made aware Resident #1 did not receive medications scheduled for 4:00 PM through 9:00 PM until [DATE]. The Medical Director stated they cannot opine whether Resident #1 missing one (1) cycle of medications caused them to collapse and expire. During an interview on [DATE] at 3:14 PM, the Director of Nursing stated that on [DATE] between 2:00 AM to 3:00 AM they received a message from Registered Nurse Supervisor #1 through hospitalization chat that on [DATE] at 9:49 PM Resident #1 was found on the floor unresponsive, and that a stat was called, cardiopulmonary resuscitation was initiated until emergency medical services took over the scene and pronounced Resident #1 expired at 10:24 PM. The Director of Nursing stated that not until [DATE] were they notified that Resident #1 had been reported missing by nursing staff. The Director of Nursing stated that the Infection Control Preventionist was on duty, and it was initially reported to them. The Director of Nursing stated that the Infection Control Preventionist failed to report this information to them during the morning meeting on [DATE]. The Director of Nursing reviewed the certified nursing assistant accountability record for the [DATE] from 3:00 PM-11:00 PM shift and acknowledged that there was no documentation for hourly safety checks, or meal consumption. The last documentation was 2:45 PM for hourly safety checks. The Director of Nursing also reviewed the medications administration record and stated that it revealed that there were no medications administered to Resident #1 from 4:00 PM to 9:49 PM. During an interview on [DATE] at 9:42 AM, Medical Doctor #1 stated they were Resident #1's assigned doctor. Medical Doctor #1 stated they received a call from Registered Nurse #1 and Registered Nurse Supervisor #1 at different times (unsure of time) on [DATE] notifying them Resident #1 was found unresponsive and that emergency measures were provided. Medical Doctor #1 stated Registered Nurse #1 did not notify them Resident #1 did not receive their medications as ordered. 10 New York Codes, Rules, and Regulations 415.12(m)(2)

Based on record review, and interviews during survey, the facility failed to ensure that services provided or arranged by the facility met professional standards of quality. This was evident in one (1) of five (5) residents (Resident #1) sampled. Specifically, on [DATE], Registered Nurse #1 failed to administer Resident 1's significant medications and treatments that were ordered between the hours of 4:00PM and 9:00 PM including continuous oxygen as per Physician's orders. Registered Nurse #1 did not notify the physician and Registered Nurse Supervisor #1 when the medications were not administered. Additionally, from 4:15 PM to 9:49 PM on [DATE], Registered Nurse #1 and other direct care staff were unaware of Resident #1's whereabouts until Resident #1 was found unresponsive on the floor, face down with no pulse and no breathing. Cardiopulmonary resuscitation was initiated until Emergency Medical Services (911) arrived at 10:07 PM and assumed care. Resident #1 expired at 10:24 PM. This resulted in actual harm to Resident #1 that is not Immediate Jeopardy. Cross Reference: F760 - Residents Are Free of Significant Medication ErrorsThe findings are: The facility policy and procedure titled Medication Administration with a review date [DATE] documented it is a standard of practice that medications be administered as ordered by the physician. Medications be administered to the resident within a one-hour time frame before/after the indicated administration time, unless otherwise specified by drug information. Electronic-Medication Administration Record must be signed by the nurse who administered the medication. When medication cannot be administered, or is refused, it is to be documented electronically on the Electronic- Medication Administration Record including the reason and physician notification.The facility policy and procedure titled Medication Errors with a review date [DATE] documented it is the facility policy that a medication error will be reported as soon as it is recognized. In the event of significant error: One (1) occurrence of a significant error may result in termination. It is noted that the safe, appropriate administration of all prescribed medications and treatments is one of the major responsibilities of the licensed professional nurse. Failure to consistently follow the medications policies and procedures and/or repeated medication errors may be cause for termination of employment.Resident #1 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (poor air flow to the lung), diabetes mellitus (high sugar in the blood), and heart failure (heart muscle does not pump enough blood), and Resident #1 was receiving continuous oxygen. The Minimum Data Set (a resident assessment tool) dated [DATE] documented that Resident #1's cognition was intact. Resident #1 was assessed to be on an antipsychotic medication, antidepressant medication, and hypoglycemic medication.A review of the Order Summary Report (Physician's order) from [DATE] through [DATE] revealed Resident #1 had orders for Fluticasone-Salmeterol inhalation aerosol two (2) times daily and Incruse Ellipta inhalation aerosol one (1) time a day for chronic obstructive pulmonary disease, Metformin 500 milligram tablet two (2) times daily for diabetes mellitus, and Sertraline 100 milligram two (2) times daily for Major Depressive Disorder, Varenicline Tartrate 1 milligram every 12 hours for smoking cessation, Atorvastatin 20 milligram one (1) tablet at bedtime for high fat level in the blood, Quetiapine Fumarate (antipsychotic medication) 300 milligram one (1) tablet at bedtime for major depressive disorder and Trazodone 100 milligram tablet at bedtime for depression. Oxygen at 3-liters per minute via nasal cannula continuously every shift for chronic obstructive pulmonary disease. A review of the Medication Administration Record dated [DATE] for the 3:00 PM-11:00 PM shift revealed Resident #1 was scheduled to receive the above medications at 4:00 PM, 8:00 PM, and 9:00 PM. There was no documented evidence Resident #1 received any medications and treatment during the evening shift. A review of the Accident/Incident Investigation form dated [DATE] at 9:49 PM incident revealed after the investigation, the incident appears to have been related to a medical event. Resident #1 was found lying on the floor beside their bed unresponsive. No measurable vital signs were obtained. Stat (emergency call to act immediately) was called and cardiopulmonary resuscitation initiated, and Emergency Medical Services arrived. Resident #1 was pronounced by Emergency Medical Services at 10:24 PM. On initial assessment Resident #1 had no visible injuries and skin was intact. During postmortem care a large skin tear was observed to Resident #1's right cheek. On investigation the call bell was found to be within reach but had not been activated. Bed was in lowest and locked position. Floor of the room was clean and dry, free of clutter. After investigation, the interdisciplinary team determined that there is no cause to believe alleged abuse, mistreatment, or neglect regarding this resident has occurred. There was no documentation in the incident report that from 4:15 PM to 9:48 PM Resident #1 was missing, staff were unaware of Resident #1's whereabouts until the resident was found unresponsive, Resident #1 did not receive any medications on the evening shift, and when the resident was found, they were not connected to any oxygen tank or concentrator. A review of the nursing progress note by Registered Nurse #1 dated [DATE] at 11:53 PM, documented at 9:49 PM Resident #1 was found on the floor unresponsive with no pulse, no breathing, called stat at 9:50 PM and cardiopulmonary resuscitation initiated right away. A nonrebreather mask attached to run at 15 liters per minute. At 9:51 PM 911 was called, intravenous line inserted at right peripheral arm and normal saline 0.9 bolus started. At 10:07 PM, 911 arrived and took over. At 10:24 PM, Resident #1 was pronounced expired by Emergency Medical Services. Registered Nurse #1 notified Adult Child #1.There was no documentation in the report that Resident #1 was missing for several hours prior to being found face down on the floor not breathing nor that Resident #1 did not receive 4:00 PM, 8:00 PM and 9:00 PM medications and was not connected to their oxygen when they were found. There was no documentation Resident #1's whereabouts were unknown from 4:15 PM to 9:49 PM. During an interview on [DATE] at 2:37 PM, Registered Nurse #1 stated they arrived on the unit on [DATE] at 4:15 PM and did not see Resident #1 on the unit during their rounds. Registered Nurse #1 stated they received information (from unknown staff) that Resident #1 had a visitor. Registered Nurse #1 stated they did not look for Resident #1 (thinking they were with visitor) and continued working. Registered Nurse #1 stated they were not sure Resident #1 had returned to the unit but started looking for Resident #1 at 9:40 PM and briefly looked in Resident #1's room but did not see them. Registered Nurse #1 stated Resident #1's 4:00 PM medications were not given because they thought Resident #1 was with a visitor. Registered Nurse #1 stated they have an hour before and an hour after to give scheduled medications. Registered Nurse #1 stated they were aware that the 4:00 PM, 8:00 PM and 9:00 PM medications were not given but does not recall notifying Registered Nure Supervisor #1 or Medical Doctor #1. Registered Nurse #1 stated they knew they were supposed to notify their supervisor and medical doctor when Resident #1 did not receive their medications.During an interview on [DATE] at 5:43 PM, Registered Nurse Supervisor #1 stated they were the assigned unit supervisor on the date of the incident. Registered Nurse Supervisor #1 stated Registered Nurse #1 called the nursing office on [DATE] (unsure of time) and reported that Resident #1 was not in bed, the wheelchair was there but the room was empty. Registered Nurse Supervisor #1 stated together with the other supervisors they immediately responded to the unit to search but when they arrived in the unit, Registered Nurse #1 and other staff had already found Resident #1. Registered Nurse Supervisor #1 stated they observed Resident #1 laying on the floor face down and when they turned them on their back, Resident #1 had no pulse, was not breathing, called a stat and started cardiopulmonary resuscitation at 9:50 PM, and notified Medical Doctor #1 (unsure of time). Registered Nurse Supervisor #1 stated they did not notice blood on the floor and the skin on Resident #1's face was intact. Registered Nurse Supervisor #1 stated the Emergency Medical Services arrived on the unit at 10:07 PM and took over. Registered Nurse Supervisor #1 stated the Emergency Medical Services intubated Resident #1. Registered Nurse Supervisor #1 stated after the Emergency Medical Services left they observed the skin on the right side of Resident #1's face peeled off and looked like an open blister. Registered Nurse Supervisor #1 stated Emergency Medical Services pronounced Resident #1 expired at 10:24 PM. Registered Nurse Supervisor #1 stated they spoke to Registered Nurse #1, and they did not report Resident #1 was initially missing or how long the resident was missing. Registered Nurse Supervisor #1 stated they were not aware Resident #1 did not receive their evening medications on [DATE]. During an interview on [DATE] at 7:10 PM, Registered Nurse Supervisor #2 stated they also responded to the call of Registered Nurse #1 on [DATE] (unsure of time). Registered Nurse Supervisor #2 stated they immediately responded to search on the unit, but when they arrived at the unit, Resident #1 was found already laying on the floor unresponsive at the right side of their bed. Registered Nurse Supervisor #2 stated they did not observe oxygen connected to Resident #1's nose.During an interview on [DATE] at 1:37 PM, the Medical Director stated they never heard Resident #1 was not found for several hours on [DATE] during the evening shift incident. The Medical Director stated they were not made aware that Resident #1 was missing prior to [DATE]. The Medical Director stated they were not made aware of the incident on [DATE], but they became aware after a day or two (2) after through the hospitalization chat (group chat) received. Medical Director stated they did not review the chart. They were not made aware that Resident #1 did not receive medications scheduled for 4:00 PM through 9:00 PM until [DATE]. The Medical Director stated they cannot opine whether Resident #1 missing one (1) cycle of medications caused them to collapse and expire. During an interview on [DATE] at 3:14 PM, the Director of Nursing stated that on [DATE] between 2:00 AM to 3:00 AM they received a message from Registered Nurse Supervisor #1 through hospitalization chat that on [DATE] at 9:49 PM, Resident #1 was found on the floor unresponsive, and that a stat was called, cardiopulmonary resuscitation was initiated until emergency medical services took over the scene and pronounced Resident #1 expired at 10:24 PM. The Director of Nursing stated that not until [DATE] were they notified that Resident #1 had been reported missing by nursing staff. The Director of Nursing stated that the Infection Control Preventionist was on duty, and it was initially reported to them. The Director of Nursing stated that the Infection Control Preventionist failed to report this information to them during the morning meeting on [DATE]. The Director of Nursing reviewed the Certified Nursing Assistant accountability record for the [DATE] 3:00 PM-11:00 PM shift and acknowledged that there was no documentation for hourly safety checks, or meal consumption for Resident #1 The last documentation was 2:45 PM for hourly safety checks. The Director of Nursing also reviewed the medications administration record and stated that it revealed that there were no medications administered to Resident #1 from 4:00 PM to 9:49 PM.During an interview on [DATE] at 4:00 PM, the Administrator stated the first time they were made aware of the incident was through the hospitalization chat received on [DATE] at 12:20 AM by Registered Nurse Supervisor #1 that Resident #1 was found unresponsive on [DATE] at 9:49 PM. The Administrator stated they were not made aware Resident #1 had not been seen by nursing and direct care staff for hours or that the resident had not received ordered medications, or treatments or a meal because staff thought the resident was missing or out with family. This was not reported to them. During an interview on [DATE] at 9:42 AM, Medical Doctor #1 stated they were Resident #1's assigned doctor. Medical Doctor #1 stated they received a call from Registered Nurse #1 and Registered Nurse Supervisor #1 at different times (unsure of time) on [DATE] notifying them Resident #1 was found unresponsive and that emergency measures were provided. Medical Doctor #1 stated Registered Nurse #1 did not notify them Resident #1 did not receive their medications as ordered on the evening shift of the incident. 10 New York Codes, Rules, and Regulations 415.11(c)(3)(i)

Based on observation, record review, and interviews, the facility failed to ensure the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, 1) The Administrator and the Director of Nursing failed to ensure that the residents were free from neglect. Immediate Jeopardy was determined on [DATE] when direct care and nursing staff failed to ensure that Resident #1 received medications, dinner meal, oxygen therapy and safety monitoring. This resulted in actual harm for Resident #1 who was found unresponsive and expired. 2) The Administrator and the Medical Director failed to ensure enforcement of smoking safety policies for residents with known unsafe smoking behavior and oxygen use. Immediate Jeopardy was determined on [DATE]. Cross Reference: F600 -Resident Neglect. F689- Free of Accident Hazards/Supervision/Devices The findings include:The facility's policy and procedure titled Administration Management with a reviewed date [DATE] documented to establish a structured administrative management system that ensures the skilled nursing facility operates efficiently, maintains compliance with federal, state, and local regulations, promotes resident-centered care, and supports quality improvement initiatives. The facility Administrator shall oversee the daily operations of the facility and ensure that all departments function in accordance with applicable laws, regulations, facility policies, and standards of car. Administrative management shall promote resident safety, dignity, quality of life, staff accountability, and organizational effectiveness. 1. Immediate Jeopardy was determined [DATE]. The facility failed to ensure systems were in place and functioning to account for and monitor Resident #1, a resident with continuous oxygen use and high fall risk, after staff became aware the resident could not be located on the unit. The facility failed to ensure implementation of required hourly safety checks, medication administration, oxygen therapy, meal provision, staff communication, physician notification, and timely escalation of concerns after Resident #1 was reportedly not seen beginning at approximately 4:15 PM on [DATE]. In addition, the Director of Nursing, Administrator, and Medical Director, were unaware until weeks later that Resident #1 had reportedly been missing for several hours prior to being found unresponsive on the floor at 9:49 PM. During an interview on [DATE] at 3:14 PM, the Director of Nursing stated the facility uses a hospitalization group chat and recalled seeing a message from Registered Nurse Supervisor #1 sent between 2:00 AM and 3:00 AM on [DATE] reporting that Resident #1 was found unresponsive on the floor on [DATE] at 9:49 PM. A STAT (an action must be taken immediately) call was made, cardiopulmonary resuscitation was initiated, 911 responders later took over and pronounced the resident deceased at 10:24 PM. The Director of Nursing stated they were not informed that Resident #1 had been reported missing prior to the incident and only became aware of this on [DATE]. They also stated the Infection Control Director knew the resident had initially been reported missing, but this information was not discussed during the morning meeting on [DATE].During an interview on [DATE] at 4:00 PM, the Administrator stated they first became aware of the incident through a hospitalization group chat message received on [DATE] at 12:20 AM. The Administrator reported they were unaware that Resident #1 had initially been reported missing prior to the incident and did not know the resident had not been monitored hourly, had no documented dinner intake, and had not received medications between 4:00 PM and 9:00 PM.2) The facility failed to ensure enforcement of smoking safety policies for residents with known unsafe smoking behaviors and oxygen use, failed to reassess residents after repeated smoking incidents, failed to remove prohibited smoking materials, and failed to implement effective monitoring and/or supervision interventions. During an interview on [DATE] at 5:13 PM, Director of Recreation stated they conduct smoking assessments upon admission on ly. Director of Recreation stated they do not reassess residents when they find smoking materials but continue providing them with education about the smoking policy. Director of Recreation stated they bring it to the interdisciplinary team to decide what further intervention to put in place (did not identify what kind of intervention would be in place). Director of Recreation stated Smoking Monitor #1 should monitor the smoking room during smoking hours and should have removed the oxygen prior Resident #7 entered the smoking room on [DATE]. Director of Recreation stated residents should have no smoking materials with them. Director of Recreation stated Resident #7 received counselling for non-compliant behavior (could not describe what type of counselling). Director of Recreation also stated room searching was conducted for all 35 smokers and any found smoking materials were surrendered to Recreation Department. During an interview on 04/2026 at 6:45 PM, Director of Nursing stated Resident #7 was on hourly checks for safety. Director of Nursing stated they have not increased the frequency of monitoring or safety checks after each incident, and they do not reassess Resident #7 for safe smoking after each smoking incident. Director of Nursing stated they did not know that the other residents had smoking materials with them and they did not know any issue with smoking until the surveyors walked in in the facility. During an interview on [DATE] at 12:00 PM, Director of Social Worker stated the Recreation Department took over the Smoking Assessment on 10/2025 and they were not involved in Smoking Assessment anymore. Director of Social Worker stated together with the social service department and nursing they conducted room search to all identified smokers with their consent and those found with smoking materials were confiscated and given to Recreation for safekeeping then Director of Social Worker stated they provided reeducation and smoking agreement to all smokers after room search.During an interview on [DATE] at 4:19 PM, Medical Director stated they were not the direct care giver to Resident #7, so they are not the most appropriate person to answer questions. Medical Director stated they did not know of Resident #7's noncompliant behavior with smoking. Medical Director stated if Resident #7 has noncompliant behavior the facility should keep educating them. Medical Director stated smoking in a room with continuous oxygen is dangerous. Medical Director stated they cannot determine at this time if Resident #7 was a safe smoker or not. During an interview on [DATE] at 7:10 PM, the Administrator stated they continuously provide education (to Resident #7) by reviewing the facility policy and procedure and smoking agreement after each incident. Administrator stated smoking assessment is being done upon admission and as needed.10 New York Codes, Rules, and Regulations 415.26

Based on observation, record review, and interview, the facility did not ensure that the Minimum Data Set assessment accurately reflected a resident's status. This was evident for five residents (Resident #6, # 7, #8, #10, and #11) out of seven total sampled residents. Specifically, the Minimum Data Set assessments for Residents #6, #7, #8, #10, and #11 did not reflect that the residents were active smokers. The findings are:The facility's policy titled Accuracy of Assessment'' with a last reviewed date of 10/2025 documented it is the policy of the facility to ensure accurate assessment of all residents in accordance with Federal and State Operations Manual. The policy stated the assessment will include direct observations, and communication with the residents, as well as communication with resident and direct care staff on all shifts. 1) Resident #6 was admitted to the facility with diagnoses including chronic obstructive disease, benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland), and diabetes.During observations on 04/21/2026 at 1:00 PM and on 04/22/2026 at 1:30 PM, Resident #6 was in the smoking room seated in the wheelchair and was smoking with other residents. A Smoking Regulation Agreement dated 08/08/2024 documented Resident #6 identified as a smoker and was signed by Resident #6. A Smoking assessment dated [DATE] documented Resident #6 was a smoker.A care plan tilted Known Smoker initiated as 09/26/2024 documented Resident #6 was a smoker, and Resident will smoke safely within the designated smoking area. The Annual Minimum Data Set (an assessment tool) dated 12/29/2025 documented that Resident #6 was cognitively intact and the assessment did not document Current Tobacco Use in Section J1300.2) Resident #7 was admitted to the facility with diagnoses including chronic obstructive disease, pulmonary fibrosis, and testicular cancer.During the observations on 04/20/2026 at 10:40 AM, 1:00 PM, 4:00 PM and on 04/21/2026 at 10:00 AM, 1:00PM, and on 04/22/2026 1:00 PM, Resident #7 was in the smoking room, seated in the wheelchair and smoking with other residents. A Smoking Regulation Agreement dated 12/04/2024 documented Resident #7 identified as a smoker and was signed by Resident #7. A Smoking assessment dated [DATE] documented Resident #7 was a smoker.A nursing progress note dated 03/11/2026 at 10:01PM documented that Resident #7 was found smoking in the room while oxygen in use.A care plan tilted Known smoker initiated as 01/12/2026 documented Resident #7 was a smoker, and Resident will smoke safely within the designated smoking area. The Annual Minimum Data Set, dated [DATE] documented that Resident #7 was cognitively intact and the assessment did not document Current Tobacco Use in Section J 1300.3) Resident #8 was admitted to the facility with diagnoses including hypertension, schizophrenia, and paraplegia (the inability to voluntarily move the lower parts of the body).During the observations on 04/22/2026 at 1:30 PM and 4:00 PM, Resident #8 was in the smoking room, seated in the wheelchair and was smoking with other residents. A Smoking Regulation Agreement dated 05/23/2024 documented Resident #8 identified as a smoker and was signed by Resident #8.A Smoking assessment dated [DATE] documented Resident #8 was a smoker.A care plan tilted Known Smoker initiated on 09/10/2024 documented Resident #8 was a smoker, and Resident will smoke safely within the designated smoking area. The admission Minimum Data Set, dated [DATE] documented that Resident #8 was cognitively intact and the assessment did not document Current Tobacco Use in Section J1300.4) Resident #10 was admitted to the facility with diagnoses that included heart failure, chronic pancreatitis, and depression.During the observations on 04/20/2026 at 1:00 PM, 4:00 PM and on 04/21/2026 at 10:00 AM, and 1:00 PM, Resident #10 was in the smoking room, seated in the wheelchair and smoking with other residents. A Smoking Regulation Agreement dated 03/13/2026 documented Resident#10 identified as a smoker and was signed by Resident #10. A Smoking assessment dated [DATE] documented Resident #10 was a smoker.A care plan tilted Known Smoker initiated on 03/13/2026 documented Resident #10 was a smoker, and Resident will smoke safely within the designated smoking area. The Annual Minimum Data Set, dated [DATE] documented that Resident #10 was cognitively intact and the assessment did not document Current Tobacco Use in Section J1300.5) Resident #11 was admitted to the facility with diagnoses including hypertensive heart disease, epilepsy, and depression.During the observations on 04/20/2026 at 1:00 PM, 4:00 PM and on 04/21/2026 at 10:00 AM, 1:00 PM, Resident #11 was in the smoking room, seated in the wheelchair and smoking with other residents. A Smoking Regulation Agreement dated 05/25/2025 documented Resident #11 identified as a smoker and Resident#11's signature present. A Smoking assessment dated [DATE] documented Resident #11 was a smoker.A care plan tilted Known Smoker initiated as 08/16/2025 documented Resident #11 is a smoker, and Resident will smoke safely within the designated smoking area. The Significant Minimum Data Set assessment dated [DATE] documented that Resident #11 was cognitively intact and the assessment did not document Current Tobacco Use in Section J1300.On 04/22/2026 at 5:28 PM, Minimum Data Set Manager was interviewed and stated that the Current [NAME] Use section on Minimum Data (J1300) Assessment was completed by Minimum Data Set Department. Minimum Data Set Manager stated that they collected information from residents' assessments, staff interviews, and reviewed of the medical records to complete the Minimum Data Set assessments. Minimum Data Set Manager also stated that they obtained smoking residents' list from Recreation department for about every two weeks in regular basis and each Minimum Data Set nurse have responsible for accuracy for section of J1300 (Current [NAME] Use). Minimum Data Set Manager stated for accuracy, they check Minimum Data Set Assessment randomly for random sections for every month. Minimum Data Set Manager stated that they were not aware of the discrepancies in Resident #6, # 7, #8, #10, and #11's Minimum Data Set assessments.10 New York Codes, Rules, and Regulations 415.11(b)

Based on observation, interview, and record review conducted during the abbreviated survey the facility's assessment failed to address/include an evaluation of staff competencies that are necessary to provide the level and types of care needed for the resident population. This was evident for one (1) out of four (4) smoking monitors. Specifically, the facility designated the Activities staff to provide assessments of residents who smoke to identify residents who exhibit unsafe smoking practices. The Activities staff were also designated to conduct monitoring during residents smoking activity. A review of the Facility assessment dated 09/2025 revealed the position for Activity Aide did not identify the knowledge, training and /or skills required in safe smoking monitoring and oxygen safety. The findings include: The facility policy titled Facility assessment dated 09/2025 documented identifying resident's acuity levels will help evaluate level of care and services needed to provide sufficient care for facility's residents. The facility's vision is to provide continuous care through consistency. The facility's staffing plan is based on the resident population and their needs for care and support. The facility reviews their residents' acuities and census in order to determine if they need to staff enough employees for each position to meet the needs of the residents at any given time. A review of the Facility assessment dated 09/2025 revealed the position for Activity Aide did not identify the knowledge, training and /or skills required in safe smoking monitoring and oxygen safety. During an interview on 04/27/2026 at 2:29 PM, the Administrator stated when the have a newly hired smoking monitor staff (Recreation Transporter) they made sure they get specific training and are evaluated through demonstration that shows how to properly monitor the residents in the smoking room and residents with oxygen. Administrator stated that when they have residents with noncompliant behavior in smoking, they continuously reeducate staff on the smoking policy and remind them of the smoking agreement. Administrator stated their Facility Assessment indicated that they determined that smoking was another special care needs of residents in the facility. The Administrator said the smoking monitoring was documented in the facility assessment under the other special needs, and on services related to buildings. However, it did not elaborate on the actual training for monitoring for safe smoking. 10 New York Codes, Rules, and Regulations 415.5(h)(2)

Based on observation, record review, and interviews, the facility failed to ensure that alleged violations involving abuse were thoroughly investigated. This was evident for one (1) of five (5) residents (Resident #1) sampled. Specifically, on [DATE] Registered Nurse #1 arrived in the unit at 4:15 PM and was informed by staff (unsure of staff) that Resident #1 had a visitor. Registered Nurse #1 did not check for Resident #1 until 9:40 PM to give their medications and did not locate Resident #1. At 9:49 PM, Resident #1 was found unresponsive on the floor face down with no pulse and no breathing. Resident #1 was pronounced deceased by Emergency Medical Services. The facility did not conduct a thorough investigation to ascertain how Resident #1 was found to be unresponsive.The findings are:A review of the facility's policy on Prevention/Identification and Reporting of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident's Property with a reviewed date [DATE], documented Residents of the facility will be protected from abuse, neglect, mistreatment, and misappropriation of property in accordance with State and Federal regulations. The policy also documented all alleged or suspected incidents of abuse, neglect, mistreatment or misappropriation of resident's property will be thoroughly investigated and findings documented and reported.Resident #1 was admitted to the facility with diagnosis including chronic obstructive pulmonary disease, respiratory failure, and diabetes mellitus. A review of the Minimum Data Set (a resident assessment tool) dated [DATE] documented that Resident #1's cognition was intact and required supervision/touching assistance with activities of daily living care. They received continuous oxygen therapy. A review of the nursing progress notes dated [DATE] at 11:53 PM by Registered Nurse #1 documented at 9:49 PM Resident #1 was found on the floor unresponsive with no pulse, no breathing, called emergency call was made at 9:50 PM and cardiopulmonary resuscitation initiated right away. At 9:51 PM 911 was called, At 10:07 PM, 911 arrived and took over. At 10:24 PM, Resident #1 was pronounced expired by Emergency Medical Services. Registered Nurse #1 notified Adult Child #1.A review of the nursing progress notes, and accident/incident investigation form dated [DATE], revealed there was no documented evidence that Resident #1 was missing from 4:15 PM until 9:48 PM. There was no documentation that nursing supervisor and medical doctor were notified. A review of the Accident/Incident Investigation form dated [DATE] at 9:49 PM, incident documented after the investigation the incident appears to have been related to a medical event. Resident #1 was found lying on the floor beside their bed unresponsive. No measurable vital signs were obtained. Emergency was called and cardiopulmonary resuscitation initiated, and Emergency Medical Services (911) arrived. Resident #1 was pronounced by Emergency Medical Services at 10:24 PM. On initial assessment Resident #1 had no visible injuries and skin was intact. During postmortem care a large skin tear was observed to Resident #1's right cheek. On investigation the call bell was found to be within reach but had not been activated. The bed was in lowest and locked position. The floor of the room was clean and dry, free of clutter. After investigation the interdisciplinary team determined that there is no cause to believe an alleged abuse, mistreatment, or neglect regarding this resident has occurred. The facility did not conduct a thorough investigation to ascertain how Resident #1 was found to be unresponsive.During an interview on [DATE] at 4:37 PM, Assistant Director of Nursing stated they were Risk Management and responsible for the completion and accuracy of the incident. Assistant Director of Nursing stated they received the incident report and statement given by Infection Control Director the following day on [DATE]. Assistant Director of Nursing stated it was their first time hearing that Resident #1 was initially reported that could not be found, the Adult Child #1 was called by Registered Nurse #1 and arrived after the incident, the position how Resident #1 was found on the floor should have been included in the incident report and all of these they are expected to know . Assistant Director of Nursing stated if that information was provided to them; they would further re-investigate the incident to find out what led to the incident. During an interview on [DATE] at 3:14 PM, Director of Nursing stated the facility utilizes a hospitalization group chat and they saw a message approximately on [DATE] between 2:00 AM to 3:00 AM from Registered Nurse Supervisor #1 that Resident #1 was found on the floor unresponsive on [DATE] at 9:49 PM, a stat was called, cardiopulmonary resuscitation was initiated and until the 911 took over the scene and pronounced Resident #1 expired at 10:24 PM. Director of Nursing stated the Registered Nurse Supervisor #1 also notified them of the injury to Resident #'s face that when they came in the morning of [DATE] they asked the Infection came during the attempt of intubation by the Emergency Medical Services. Director of Nursing stated this was not noted in the nursing notes, but they should have documented it. Director of Nursing stated they were not notified of Resident #1 reported missing prior to the incident and they heard it only yesterday ([DATE]). Director of Nursing stated the Infection Control Director, aware of the Resident #1 was reported to them initially missing and was not reported to them in the morning meeting on [DATE]. Director of Nursing stated with all this information and if it was investigated thoroughly the investigation would draw a different conclusion. During an interview on [DATE] at 4:00 PM, Administrator stated the first time they made aware of the incident was through the hospitalization chat received on [DATE] at 12:20 AM. Administrator stated they were not aware that Resident #1 was initially missing prior to the incident, not aware that Resident #1 was not monitored hourly, had no record if they had eaten their dinner meal and not received their medication at 4:00 PM to 9:00 PM, not aware when Registered Nurse #1 has not seen Resident #1 from 4:15 PM, had called the Adult Child #1 to look for Resident #1 and called the Registered Nurse Supervisor #1 to report they were missing. Administrator stated they made aware of Resident #1 that they were initially missing yesterday only, [DATE]. Administrator stated it was not reported to Department of Health because they were not aware of the other information that was left out in the investigation and had it known, the facility would re-investigate the incident.10 New York Codes, Rules, and Regulations 415.4(b)(3)

Based on observation, record reviews, and interviews, conducted during survey, the facility failed to ensure that all alleged violations involving abuse, exploitation, or mistreatment, including injuries of unknown source are reported immediately but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This was evident for one (1) of five (5) residents (Resident #1) sampled. Specifically, on [DATE], Registered Nurse #1 arrived in the unit at 4:15 PM and was informed by staff (unsure of staff) that Resident #1 had a visitor. Registered Nurse #1 did not check for Resident #1 until 9:40 PM and was unable to locate Resident #1 to give their medication. At 9:49 PM, Resident #1 was found unresponsive on the floor face down with no pulse and no breathing. Resident #1 was pronounced expired by Emergency Medical Services. The facility did not report the alleged allegation of abuse to New York State Department of Health.The findings include: A review of the facility's policy titled Prevention/Identification and Reporting of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident's Property with a review date [DATE] documented, all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to New York State Department of Health.Resident #1 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (poor air flow to the lung), diabetes mellitus (high sugar in the blood), and heart failure (heart muscle do not pump enough blood), and Resident #1 was receiving continuous oxygen.A review of the Minimum Data Set (a resident assessment tool) dated on [DATE] documented that Resident #1's cognition was intact and required supervision/touching assistance with activities of daily living care. They received continuous oxygen therapy. A review of the Comprehensive Care Plan for at risk of abuse, neglect with a reviewed date [DATE], documented interventions allow resident to express feelings of being fearful, anxious, as necessary and provide physical and emotional support for resident safety. A review of the nursing progress notes dated [DATE] at 11:53 PM, by Registered Nurse #1 documented at 9:49 PM Resident #1 was found on the floor unresponsive with no pulse, no breathing, emergency was called at 9:50 PM and cardiopulmonary resuscitation initiated. At 9:51 PM, emergency 911 was called. At 10:07 PM, 911 arrived and took over. At 10:24 PM, Resident #1 was pronounced expired by Emergency Medical Services. Registered Nurse #1 notified Adult Child #1.A review of the nursing progress notes, and accident/incident investigation form dated [DATE], revealed there was no documented evidence that Resident #1 was missing from 4:15 PM until 9:48 PM. There was no documentation that nursing supervisor and medical doctor were notified. A review of the Accident/Incident Investigation form dated [DATE] at 9:49 PM, documented after the investigation the incident appears to have been related to a medical event. Resident #1 was found lying on the floor beside their bed unresponsive. No measurable vital signs were obtained. Emergency help was called and cardiopulmonary resuscitation initiated, and Emergency Medical Services (911) arrived. Resident #1 was pronounced by Emergency Medical Services at 10:24 PM. On initial assessment Resident #1 had no visible injuries and skin was intact. During postmortem care a large skin tear was observed to Resident #1's right cheek. On investigation the call bell was found to be within reach but had not been activated. Bed was in lowest and locked position. Floor of the room was clean and dry, free of clutter. After investigation the interdisciplinary team determined that there is no cause to believe an alleged abuse, mistreatment, or neglect regarding this resident has occurred. Therefore, the allegation of abuse was not investigated or reported to the Department of Health.During an interview on [DATE] at 3:14 PM, Director of Nursing stated the facility utilizes a hospitalization group chat and they saw a message approximately on [DATE] between 2:00 AM to 3:00 AM from Registered Nurse Supervisor #1 that Resident #1 was found on the floor unresponsive on [DATE] at 9:49 PM, emergency was called, cardiopulmonary resuscitation was initiated until the 911 emergency took over the scene and pronounced Resident #1 expired at 10:24 PM. Director of Nursing stated they were not notified of Resident #1 reported missing prior to the incident and they heard it only yesterday ([DATE]). Director of Nursing stated the Infection Control Director, aware of the Resident #1 was reported to them initially missing and was not reported to them in the morning meeting on [DATE]. Director of Nursing stated looking at the Certified Nursing Assistant accountability on [DATE] from 3:00 PM-11:00 PM shift; there was no documentation for dinner, the hourly safety checks the last documentation was 2:45 PM meaning Resident #1 was not accounted for and reviewing the medications administration record that there were no medications received by Resident #1. Director of Nursing stated with all of this information and if it was investigated thoroughly the investigation would draw a different conclusion. Therefore, the allegation of abuse or neglect was not investigated or reported to the Department of Health.During an interview on [DATE] at 4:00 PM, Administrator stated the first time they made aware of the incident was through the hospitalization chat received on [DATE] at 12:20 AM. Administrator stated they were not aware that Resident #1 was initially missing prior to the incident, not aware that Resident #1 was not monitored hourly, had no record if they had eaten their dinner meal and not received their medication at 4:00 PM to 9:00 PM, not aware when Registered Nurse #1 has not seen Resident #1 from 4:15 PM, had called the Adult Child #1 to look for Resident #1 and called the Registered Nurse Supervisor #1 to report they were missing. Administrator stated they made aware of Resident #1 that they were initially missing yesterday [DATE]. The Administrator stated it was not reported to Department of Health because they were not aware of the other information that was left out in the investigation. 10 New York Codes, Rules, and Regulations 415.4(b)(1)(i)

Based on observations, record review, and interviews, conducted during an abbreviated survey (659849), the facility did not ensure each resident received food that accommodated resident allergies, intolerances, and preferences. This was evident for one (1) out of six (6) residents (Resident #6) sampled. Specifically, Resident #6, who was allergic to mushroom, ate mushrooms that was served to them on their meal tray on 06/05/2025 at 1:20 PM. Resident #6 had an allergic reaction and was immediately administered Solumedrol (used to treat allergic reaction) Intramuscular and Benadryl (used to relieve symptoms of allergies) 25 milligram every six (6) hours.The findings are:The facility's policy titled 'Resident with food allergies and intolerances' dated 01/2025 states that the facility will ensures that all residents who have allergies and/or food intolerances to food items will not receive them on their meal trays. The facility's policy titled 'Meal Delivery' dated 10/2024 states that food service personnel are responsible for ensuring proper diet with the individual preferences are on each resident's tray.Resident #6 was admitted to the facility with diagnoses including anxiety disorder and depression.The Minimum Data Set (a resident assessment tool) dated 04/16/2025 documented Resident #6 had intact cognition and required supervision with eating.An updated Dietary Nutritional assessment dated [DATE] documented Resident #6 had allergies to mushrooms.A Comprehensive Care Plan titled 'known allergies to mushrooms' dated 04/21/2025 documented intervention to monitor for changes in condition and report to the medical team as needed. A review of a Physician's Order Recap Report dated 05/01/25-05/31/2025 documented Resident #6 was allergic to mushrooms. A review of Resident #6 meal tickets dated from 06/01/2025-06/05/2025, revealed no documented evidence Resident #6 had allergy to mushrooms.A Nursing Progress note by Registered Nurse #1 dated 06/05/2025 at 2:38 PM documented that Resident #6 was allergic to mushrooms and had accidently eaten mushrooms. Resident #6 had an allergic reaction of red rash on both arms and upper/lower lips. Registered Nurse Supervisor #1 and Medical Doctor #1 were both notified. An order for Solumedrol Intramuscular immediately and Benadryl 25 milligram every six (6) hours. Resident #6 was assessed and there was no labored breathing observed. A Nursing Progress note by Registered Nurse Supervisor #1 dated 06/05/2025 at 2:55 PM documented that they assessed Resident #6 who had mild redness and raised rash on both arms. Resident #6 also reported tingling on their tongue. There were no reported respiratory issues. Medical Doctor #1 was notified and ordered 40 milligrams of Solumedrol now and Benadryl every six hours for two days. Medications were administered and tolerated. The facility's investigation dated 06/10/2025, revealed that Registered Nurse Supervisor #1 inspected Resident #6's tray and observed pasta, baked chicken, vegetables, and a spoon with sauce on the side of Resident #6's plate. The facility concluded there was no substantial evidence that Resident #6 had an allergic reaction to mushroom. During an interview on 09/12/2025 at 12:18 PM Resident #6 stated that the facility served them mushroom for lunch. They stated they could not recall the exact date; however, they were served chicken and underneath the chicken were mushrooms. They stated that they immediately felt itching in their throat, and they notified Registered Nurse Supervisor #1.During an interview on 09/12/2025 at 2:40 PM Dietician #1 stated when a resident is admitted to the facility, they are responsible for reviewing their chart and then follow up with an interview about any food allergies. They stated on 07/18/2024, during an interview with Resident #6, Resident #6 verbalized that they were not allergic to anything. However, sometime in January of 2025, Resident #6 verbalized to them that they did not like mushrooms. They stated that [NAME] sauce contains mushrooms, and that chicken [NAME] was served to Resident #6 on the day (06/05/2025) of the incident, and they became aware of the mushroom allergy after the incident. They stated they are unsure about the care plan that was initiated on 04/21/2025 stating Resident #6 was allergic to mushrooms. They stated the electronic medical record does not generate an alert for allergy unless the resident is a readmission or new admission. They stated the allergy should have been verbally discussed with them and that the meal ticket was updated post incident to include Resident #6 allergy. They stated that the Dietary Supervisor is responsible for ensuring that the meal ticket matches what is being served on the tray. During a telephone interview on 09/25/2025 at 10:07 AM, Registered Nurse # 1 stated Resident #6 reported allergic reaction to mushrooms and that they observed mushrooms on Resident #6's meal tray that was still in their room. They immediately reported it to Registered Nurse Supervisor #1. During an interview on 09/12/2025 at 3:01 PM, Registered Nurse Supervisor #1 stated they entered Resident #6's room at 1:20 PM on 06/05/2025 while Resident #6 was eating. They stated that Resident #6 picked up the chicken that was on the plate and showed them the mushroom that was under the chicken and pasta. They stated Resident #6 reported that their tongue was feeling tingly, and both their arms were itching. They stated Resident #6's arms were observed to be slightly red with raised rash. During a telephone interview on 09/26/2025 at 12:29 PM, Certified Nursing Assistant #2 stated that Resident #6 reported to them that they were feeling weird after eating from the tray. They stated they observed mushrooms on the resident's plate. They checked the meal ticket on the tray, and it states allergies and dislike to mushrooms. During a telephone interview on 09/29/2025 at 11:30 AM, Director of Nursing stated their investigation concluded that Resident #6's alleged allergy to mushroom was not verified. They stated on admission; Resident #6 had a dislike for mushroom and the hospital records did not document mushroom as an allergy. They stated the allergy was updated in March 2025 and they do not know why the system did not update the meal ticket to include the allergy when it was updated. During a telephone interview on 11/18/2025 at 9:28 AM, Physician #1 stated as per nursing documentation, several attempts were made to contact them about the allergic reaction incident, however, they do not recall that. They stated the nursing staff contacted another Physician, and orders were put in place. They stated it was documented in Resident #6's chart that they are allergic to mushroom, however, they do not believe Resident #6 received mushroom from the facility because Resident #6 buys food from outside routinely. They stated they evaluated Resident #6 on 06/06/2025 or 06/07/2025 and Resident #6 reported that they received mushroom from the facility. They stated when they evaluated Resident #6, their symptoms had cleared. 10 NYCRR 415.14(d)(4)

Based on observation, record review, and interviews conducted during the abbreviated survey (NY00361247), the facility failed to develop and implement a comprehensive person-centered care plan for the resident, consistent with the resident's rights. This was evident for one (1) out of ten (10) residents sampled. (Resident #1). Specifically, there was no documented evidence that a care plan was developed when Resident #1 was noted with macerated skin around the stoma on 11/21/2024. The Nurse Practitioner evaluated Resident #1 and ordered Maalox suspension to be applied to the affected area for 10 days. Findings are: The facility policy titled Comprehensive Person-Centered Care Planning, revised 11/2024, documented that Comprehensive Person-Centered Care planning is done to develop an individualized interdisciplinary care plan for each resident based on Care Area Assessment to ensure that residents receive treatment and care in accordance with perfectional standards of practice, the comprehensive person-centered care plan and the resident's choices. Resident #1 was admitted with diagnoses that include Malignant neoplasm of the Colon, Ileostomy, and Diabetes. A Minimum Data Set Version 3.0 (a resident assessment tool) dated 01/14/2024, documented short and long-memory problems and severely impaired cognitive decision-making. Registered Nurse Supervisor #1's Narrative Note dated 11/21/2024 at 2:46 PM, documented a new problem: Skin Integrity. Resident #1 is alert and verbally responsive, noted with macerated skin around the stoma. The Nurse Practitioner was notified, evaluated Resident #1, and order to start on Maalox suspension to be applied to the affected area. A Physician Order dated 11/21/2024 at 2:46 PM, documented Maalox Max Oral Suspension 400-400-40 MG/5ML (Alum & Mag Hydrox-Simethicone). Apply to the affected area topically every day and evening shift for macerated skin around the stoma for 10 Days after cleaning with soap and water, then pat dry. A Physician's Note dated 11/21/2024 at 00:00, documented Resident #1 was followed -up for excoriation around the stoma. Ordered Maalox Max 400-400-40 mg/5 mL topical daily and during the evening shift for 10 days. A Wound Care Note dated 01/22/2025 at 12:31, PM written by Wound Nurse #1 documented that Resident #1 was noted with rashes on the right lateral side of the abdomen. Instructed Certified Nursing Assistants and nurses on proper ostomy care. A Physician Order dated 01/22/2025, documented Consultation Dermatology for the worsening rash to the abdomen and back. A Physician Order dated 01/24/2025, documented Geri-Lanta Oral Suspension 200-200-20 MG/5ML (Alum & Mag Hydrox-Simethicone). Apply to stoma area topically every shift for rash A review of Comprehensive Care Plans revealed there was no documented evidence that a care plan was developed regarding the maceration of Resident #1's skin around the stoma on 11/21/2024 and the rash on the right lateral side of the abdomen. During an interview on 01/30/25 at 12:36 PM, Registered Nurse Supervisor #1 stated that Registered Nurses and Registered Nurse Supervisors were responsible for developing the care plan for risk skin impairment and updated when Resident #1 was noted with maceration or rash around the stoma. Registered Nurse Supervisor #1 stated the care plan was not developed. During an interview on 01/30/2025 at 5:00 PM, the Director of Nursing stated the admission nurse should have initiated the care plan at risk for skin impairment upon admission. The Director of Nursing stated the Registered Nurse on the unit or Registered Nurse Supervisor should have updated the care plan when Resident #1 was noted with maceration around the stoma on 11/21/2024 and a rash on the abdomen area. The Director of Nursing further stated the supervisors on the units are responsible for monitoring the care plans. The Director of Nursing stated they are in the process of working with corporate to have care plans set upon admission. 10 NYCRR 415.11(c)(1)

Based on observation, interviews, and record review during an abbreviated survey (NY00333881), the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. In addition, the facility did not ensure that violations involving sexual abuse was reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This was evident for 2 out of 10 residents sampled (Resident #2 and Resident #3). Specifically, On 02/18/2024 at 1:15 PM, a visitor reported to Certified Nursing Assistant #1 that they observed Resident #2 putting their hand in Resident #3's pajamas pants. The facility did not have a policy for reporting to local law enforcement and the did not report the sexual allegation to local law enforcement. The finding is: The facility Policy and Procedure titled, Prevention/Identification and Reporting of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident' Property, states Residents must not be subjected to abuse, neglect, exploitation, mistreatment and misappropriation of resident's property by anyone, including, but not limited to facility, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends or other individuals. It is the policy of this facility to report any suspected patient verbal/and/or physical abuse, neglect, exploitation, mistreatment and misappropriation of resident's property occurring with the facility. It is the policy of the facility to report the suspicion of suspected crime resulting in serious bodily injury to the injury to the resident no later than 2 hours after forming the suspicion. If there is no bodily injury the facility will report the suspicion no later than 24 hours after forming the suspicion. The facility policy did not mention reporting suspicion of a crime to local law enforcement. Resident #2 was admitted to the facility on [DATE] with diagnoses including Dementia and Type 2 Diabetes Mellitus. The Minimum Data Set assessment dated [DATE] documented Resident # 2 had intact cognition. Resident #3 was admitted to the facility on [DATE] with diagnoses including Dementia and Depressive disorder. The Minimum Data Set assessment dated [DATE] documented Resident #3 had moderately impaired cognition. The facility's Incident Report of the investigation dated 02/18/2024 documented that it was reported at 1:15 PM that Resident #2 was observed with their hand under Resident #3's pajama (pants). Resident #3 was assessed with no acute distress. The Social Worker conducted an interview with Resident #3 whose cognition was identified as moderately impaired. A full body assessment was conducted on Resident #3 had no bruising, redness, or acute skin impairment. Resident #2 was interviewed and denied the allegation stating that they were talking to Resident #3 in the hallway and helped fixed Resident #3's clothes. The facility concluded there was no reasonable suspicion. During an interview on 10/11/2024 at 1:40 PM, Certified Nursing Assistant #1 stated that another resident's family member reported to them that they observed Resident #2 with their hand into Resident #3's pants. Certified Nursing Assistant #1 stated that they immediately went into the hallway and observed Resident #2 with their hand into Resident #3's pants. Certified Nursing Assistant #1 stated that they screamed don't do that and Resident #2 immediately pulled their hand out of Resident #3's pants stating, I did not do anything. Certified Nursing Assistant #1 stated that Resident #2 and Resident #3 were sitting in the hallway next to each other. Certified Nursing Assistant #1 stated that they scream for the nurse as there were no other staff members in view. The nurse was administering medication in another resident's room. Certified Nursing Assistant #1 stated that they stayed with both residents until the nurse arrived and separated the residents. Certified Nursing Assistant #1 stated that Resident #2 had a surprised look on their face. Certified Nursing Assistant #1 stated that Resident #3 was fully dressed and there was no skin exposed. During an interview on 10/11/2024 at 4:30 PM, the Director of Nursing stated Resident #3 has a baseline of being confused. The Director of Nursing stated at the time of the incident, Resident #2 and Resident #3 were interviewed. The Director of Nursing stated there were no evidence to support that sexual abuse had occurred and that Resident #3 could not recall the incident. Resident #2 stated they were trying to help Resident #3 pull up their pants because Resident #3 was undressing in the hallway. The Director of Nursing stated that Resident #2 is the President of the Resident Council. The Director of Nursing stated that Resident #2 was immediately taken off the unit and was placed on another unit away from Resident #1. The Director of Nursing stated that local law enforcement was not contacted because the investigation concluded there was no suspicion of a crime. The Director of Nursing stated the facility does not have a policy and procedure for reporting to law enforcement. 10 NYCRR 415.4(b)(2)

Based on observation, record review, and interviews conducted during an Abbreviated Survey (NY00330767), the facility failed to protect the resident's right to be free from physical abuse by a nursing home staff. This was evident for one out of seven residents (Resident #4) sampled for abuse. Specifically, on 12/30/2023 at 2:44 AM, the facility's surveillance video recording showed Certified Nursing Assistant #2 roughly pulling some incontinent briefs away from Resident #4 who was sitting in their wheelchair in the hallway. Nurse Supervisor #2 assessed Resident #4 who did not sustain any visible injuries nor complained of pain. The findings are: The facility Policy and Procedure for Prevention/Identification and Reporting of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident's Property was last updated on 11/11/2022. The policy states that residents must not be subjected to abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property by anyone, including, but not limited to facility staff. Resident #4 was admitted to the facility with diagnoses that include Hypertensive Heart Disease, Chronic Kidney Disease and Depression. The Minimum Data Set assessment dated [DATE] documented Resident #4 had intact cognition. An Abuse Care Plan for Resident #4 was implemented on 05/26/2022. The interventions include to assess Resident #4 for signs/symptoms of abuse, neglect, bruises, and behavior, and to report to appropriate resources. The care plan was updated post incident of 12/30/2023 with additional interventions. The facility surveillance video camera recording dated 12/30/2023 at 2:44 AM was reviewed with the Director of Nursing on 10/08/2024. The video recording is blurry. The surveillance recording showed the following: At 2:43:49 AM, Resident #4 wheeled themself down the hallway to a linen cart stationed in the hallway. At 2:44: AM, Resident #4 removed items (identified as incontinent briefs) from the linen cart. Resident #4 was in the process of wheeling themself away from the linen cart but was stopped by Certified Nursing Assistant #2. Certified Nursing Assistant #2 could be seen on the camera roughly trying to pull the incontinent briefs away from Resident #4 and Resident #4 was pulling back/while holding on to the incontinent briefs. At 2:44:19 AM, Resident #4 was wheeling themself up the hallway. Certified Nursing Assistant #2, who was holding multiple brown incontinent briefs in their hand, caught up/stopped Resident #4. At 2:45:01 AM, Certified Nursing Assistant #2 attempted to hand Resident #4 the brown incontinent briefs which Resident #4 was refusing. Certified Nursing Assistant #2 observed struggling to pull the blue incontinent briefs away from Resident #4. Certified Nursing Assistant #2 was also holding onto Resident 4's arm with their (Certified Nursing Assistant #2) left hand while using their right hand to roughly pull the incontinent briefs away from Resident #4. At 2:45:44 AM, Certified Nursing Assistant #2 was able to pull the incontinent brief away from Resident #4 and walked away leaving two incontinent briefs on the floor. At 2:45:52 AM, Certified Nursing Assistant #3 appeared in front of Resident #4 and was talking to Resident #4. Certified Nursing Assistant #3 picked up the incontinent briefs off the floor and wheeled Resident #4 away from the area and out of camera's view. The facility Incident Investigation report dated 12/30/2023 documented that Resident #4 reported that Certified Nursing Assistant #2 took an incontinent brief away from them. Resident #4 also reported wanting to push Certified Nursing Assistant #2 to the floor but did not. Resident #4 also reported feeling upset. Resident #4 was assessed with no visible injuries and no complaints of pain or discomfort. Certified Nursing Assistant #2 was removed from the unit. Several residents were interviewed, and all stated they had no issues with Certified Nursing Assistant #2. The Director of Nursing and the Administrator were immediately notified. The facility's investigation concluded that Certified Nursing Assistant #2's hands, had physical contact with Resident #4's arm. The investigation also concluded that the outcome of the investigation is inconclusive. The police were contacted, and two Police Officers reported to the facility on [DATE] (badge numbers are documented in the incident report). A Nursing progress note dated 12/30/2023 at 8:25 AM, written by Licensed Practical Nurse #1, documented at around 3:10 AM, Certified Nurse Assistant #2 reported that Resident #4 was upset because the incontinent brief was taken away. There were no visible injury or openings observed on Resident #4. Resident #4 was upset upon entry into Resident #4's room. Resident #4 was assessed at their bedside by the Nursing Supervisor who was called. Multiple attempts were made to contact Certified Nursing Assistant #2 but was unsuccessful. Certified Nursing Assistant #2 resigned from the facility. A certified letter was mailed out to Certified Nursing Assistant #2. Awaiting response. Certified Nurse Assistant #2 submitted a written statement to the facility dated 12/30/2023. The statement documented that they are not allowed to leave briefs into the rooms, so when Resident #4 took all the briefs from the cart, they told Resident #4 to take two and Resident #4 said no. the statement documents that Certified Nursing Assistant #2 told Resident #4 that they will need the briefs back and Resident #4 said no. It is documented that Certified Nursing Assistant #2 tried to take the briefs away from Resident #4 and Resident #4 refused to give back the briefs. Certified Nursing Assistant #2 left Resident #4 with the briefs and Resident #4 took the briefs back to their room. Resident #4 was not on Certified Nursing Assistant #2's assignment. Certified Nursing Assistant #3 provided an undated written statement to the facility. The statement documents that on 12/30/2023 at around 3:10 AM, they heard someone screaming for help. The statement documents that they observed Certified Nursing Assistant #2 and Resident #4 in the hallway and Resident #4 was crying. Resident #4 reported that they went to the cart to get a brief and Certified Nursing Assistant #2 took the briefs away from them. Certified Nursing Assistant #3 took Resident #4 to their room and reported to the nurse (Licensed Practical Nurse #1). During a telephone interview on 10/10/2024 at 10:41 AM, Licensed Practical Nurse # 1, stated that they do not recall Resident #4 and ended the interview. Licensed Practical Nurse #1 provided the facility with a written statement dated 12/30/2023. The statement documents that when Licensed Practical Nurse #1 returned to the unit, Resident #4 reported to Licensed Practical Nurse #1 that they are mad because Certified Nursing Assistant #2 took the brief away from them. Resident #4 was anxious and stated that they needed something, maybe Tramadol (a pain medication). Nursing Supervisor #1 was notified. Resident #4 continued to verbalize that Certified Nursing Assistant #2 snatched the brief away from them. Multiple attempts were made to contact Nursing Supervisor #1 but was unsuccessful. Nursing Supervisor #1 provided a written statement to the facility dated 12/30/2023. The statement documented that Resident #4 was observed lying in bed alert and oriented times three. Resident #4 reported that they went to take a brief from the cart and Certified Nursing Assistant #2 hold my forearm and took the brief away from them. Resident #4 also stated that they wanted to push Certified Nursing Assistant #4 to the floor. Resident #4 was assessed with no visible injury and had no complaints of pain or discomfort. During a face-to-face interview on 10/09/2024 at 11:40 AM, the Director of Nursing, stated the incident occurred at around 2:44 AM on 12/30/2023. The Director of Nursing stated Resident #4 wheeled themself down the hallway to the linen cart and took multiple brown and green incontinent briefs from the linen cart and proceeding to go back to their room. The Director of Nursing stated that Certified Nurse Assistant #2 came up from behind and started to grab the incontinent briefs from Resident #4. The Director of Nursing stated that while Certified Nursing Assistant #2 was grabbing the incontinent briefs out of Resident #4's hands, Certified Nurse Assistant #2 also grabbed Resident #4's right forearm. The Director of Nursing stated that they reviewed the video surveillance recording and investigated the incident. The Director of Nursing stated Certified Nursing Assistant #2 was called back to view the video recording and after Certified Nurse Assistant #2 was shown the video, Certified Nursing Assistant #2 immediately resigned. The Director of Nursing stated the investigation was inconclusive for abuse. 10 NYCRR 415.4(b)(1)(i)

Based on observations, record review, and staff interviews conducted during the recertification survey from 10/08/2024 to 10/16/2024, the facility did not ensure assessments were coordinated with the Pre-Admission Screening and Resident Review (PASARR) program under Medicaid. Specifically, a resident with a new diagnosis of a serious mental disorder was not referred for a PASARR Level II Evaluation. This was evident for 1 of 1 residents reviewed for PASARR services (Resident #228). The findings are: A facility Policy and Procedure titled Screen/Pre-Admission Screen Resident Review (PASSR) Process did not include any procedure related to referring residents with new diagnoses of serious mental health disorders for a PASARR Level II evaluation. Resident #228 was admitted to the facility on [DATE] with diagnoses including Nondisplaced fracture of medial condyle of left tibia, Anxiety Disorder, and Depression. The Minimum Data Set Admission assessment dated [DATE] documented that the resident did not have any hallucinations or delusions, did not display any physical or verbal behaviors directed at themselves or others, and did not reject care. A SCREEN dated 09/23/2022 documented that Resident #228 did not have a diagnosis of a serious mental illness or dementia. Multiple Behavior Notes created between 12/09/2022 and 03/25/2023 documented that the resident had behaviors including refusing medication, hiding medications, calling the police, talking to themselves, portraying agitated and verbally abusive behavior towards others, and threatening to physically assault others. On 12/23/2022, a Nursing Progress Note documented that the Resident #228 called 911 despite being in no apparent distress. A Nurse Practitioner was notified of this and ordered for the resident to be sent to the emergency room for a psychiatric evaluation. The resident's family refused the transfer to the emergency room and the facility did not send the resident to the emergency room . On 12/27/2022, an order was placed for Haldol Solution 5 mg/mL, inject 0.4 mL intramuscularly once daily for psychosis. A Psychiatric Assessment completed on 02/25/2023 documented that the resident was diagnosed with Psychosis, Not Otherwise Specified, due to behaviors including noncompliance with treatment, irritability, and paranoid behaviors. The Minimum Data Set Comprehensive assessment dated [DATE] documented that Resident #228 had diagnoses including Psychotic Disorder. On 10/15/2024 at 10:52 AM, Registered Nurse #12 was interviewed and stated that they had provided care to Resident #228 on multiple occasions. Registered Nurse #12 stated that the resident displayed behaviors including being physically and verbally aggressive and combative. They stated that Resident #228 was off the charts psychologically well and that the doctors and staff working with the resident were all aware of this. Registered Nurse #12 stated that the facility should have referred her to a higher level of care such as a psychiatric hospital, but the facility wanted the money so they kept the resident even though they knew that she was a danger to staff. On 10/15/2024 at 11:58 AM, The Director of Social Services was interviewed and stated that the Social Work department is responsible for PASARR screens. They stated that the facility did not rescreen Resident #228 for a possible Level II referral because the facility does not complete PASARR Level II screens in the facility, even if a resident has a psychiatric change in condition. The Director of Social Services stated that PASARR Level II screens would only be completed if a resident is transferred to a psychiatric hospital and the screen is completed by the hospital. 10 NYCRR 415.11(e)

Based on observations, record review, and staff interviews conducted during the Recertification survey between 10/08/2024 and 10/16/2024, the facility did not ensure that Minimum Data Set (MDS) 3.0 assessments accurately reflected the residents' status. Specifically, the most recent Minimum Data Set (MDS) 3.0 assessments did not reflect that a resident had psychiatric behaviors. This was evident for 1 of 1 residents reviewed for Assessment Accuracy out of a sample of 39 residents (Resident #228). The findings are: Resident #228 was admitted to the facility on [DATE] with diagnoses including Nondisplaced fracture of medial condyle of left tibia, Anxiety Disorder, and Depression. The Minimum Data Set Admission assessment dated [DATE] documented that the Resident #228 did not have any hallucinations or delusions, did not display any physical or verbal behaviors directed at themselves or others, and did not reject care. The Minimum Data Set Quarterly assessment dated [DATE] and the Minimum Data Set Quarterly assessment dated [DATE] documented that the resident did not have any hallucinations or delusions, did not display any physical or verbal behaviors directed at themselves or others, and did not reject care. The Minimum Data Set Comprehensive assessment dated [DATE] documented that Resident #228 had a new diagnosis of Psychotic Disorder. It documented that the resident did not have any hallucinations or delusions, did not display any physical or verbal behaviors directed at themselves or others, and did not reject care. Multiple Behavior Notes created between 12/09/2022 and 03/25/2023 documented that the resident had behaviors including refusing medication, hiding medications, calling the police, talking to themselves, portraying agitated and verbally abusive behavior towards others, and threatening to physically assault others. On 12/23/2022, a Nursing Progress Note documented that the Resident #228 called 911 despite being in no apparent distress. A Nurse Practitioner was notified of this and ordered for the resident to be sent to the emergency room for a psychiatric evaluation. The resident's family refused the transfer to the emergency room and the facility did not send the resident to the emergency room . On 12/27/2022, an order was placed for Haldol Solution 5 mg/mL, inject 0.4 mL intramuscularly once daily for psychosis. A psychiatric assessment completed on 02/25/2023 documented that the Resident #228 was diagnosed with Psychosis, Not Otherwise Specified, due to behaviors including noncompliance with treatment, irritability, physical aggression, and paranoid behaviors. A behavior care plan was created for Resident #228 on 10/26/2022 and revised on 10/08/2024 with a focus of Resident demonstrates problem behavior as evidenced by: accusatory behavior, verbally inappropriate towards staff and other residents, calls specific names. The care plan references that on 10/18/2023, the resident was verbally aggressive towards staff. On 01/04/2023, the resident called 911 for transport to go home despite not being discharged , and on 03/13/2024, the resident called 911 with vague complaints. On 10/15/2024 at 10:11 AM, Registered Nurse Supervisor #4 was interviewed and stated that Resident #228 has many behaviors including screaming, cursing, hitting staff members, talking to themselves, and refusing care. On 10/15/2024 at 10:52 AM, Registered Nurse #12 was interviewed and stated that the resident displayed behaviors including being physically and verbally aggressive and combative. They stated that Resident #228 was off the charts psychologically unwell and that the doctors and staff working with the resident were all aware of this. Registered Nurse #12 stated that the facility should have referred the resident to a higher level of care such as a psychiatric hospital, but the facility wanted the money so they kept the resident even though they knew that they were a danger to staff. On 10/16/2024 at 11:02 AM, Certified Nursing Assistant #12 was interviewed and stated that they have provided care to Resident #228 for around 1 or 2 years. Certified Nursing Assistant #12 stated that the resident has many behaviors problems including cursing, yell, accusatory behaviors against staff members, and refusing care. On 10/16/2024 at 11:15 AM, the Director of Nursing was interviewed and stated that Resident #228 has been discussed frequently in the facility's staff meetings regarding behavior concerns. They stated that Resident #228's behaviors include yelling, using profane language towards anyone who passes her door including staff and visitors, refusing care, refusing medications, and verbal aggression. On 10/15/2024 at 11:53 AM, the Minimum Data Set Coordinator was interviewed and stated that the Social Services department is responsible for inputting the Minimum Data Set information related to mood and behavior. On 10/15/2024 at 11:58 AM, the Director of Social Services was interviewed and stated that the Social Services department is responsible for inputting the Minimum Data Set information related to mood and behavior. They do this by reviewing the behavior progress notes in the resident's chart, speaking with staff members that care for the resident, and utilizing any contact they have had when communicating with the resident. The Director of Social Services stated that they did not know why the behaviors were not listed in the assessments but that if the resident had behaviors including refusing care, having physical and verbal behavior symptoms, and calling 911, that they should have all been coded in the Minimum Data Set. 10 NYCRR 415.11 (b)

Based on observation, interview, and record review during the recertification survey from 10/8/2024 to 10/16/2024, the facility did not ensure each resident had the right to be fully informed in a language that they can understand. This was evident for 1 (Resident #548) out of 41 total sampled residents. Specifically, Resident #548 was not fully informed of their health care status in a language the resident understood, and communication tools were not used by direct care staff to determine the resident's needs. The findings are: The facility's policy and procedure titled Language Policy dated 1/2024 documented that facility will make every effort to provide interpretive services for residents who primary language is other than English. Resources available for language access service during hours of facility operation, include language interpreting services, communication boards and bilingual staff members who are able to interpret during working hours. Resident #548 was admitted to the facility with End Stage Renal Disease and Hyperlipidemia. The Minimum Data Set, dated dated dated [DATE] documented resident has intact cognition and needs Chinese interpreter to communicate with a doctor or health care staff. During multiple observations from 10/8/2024 at 11:02 AM to 10/10/2024 at 12:12 PM, Resident #548 was observed without a communication board or interpreter services available in their language to communicate with the staff. On 10/10/2024 at 12:12 PM, Resident #548 was interviewed using Cantonese interpretation service. Resident #548 stated they do not understand when staff communicates in English. There are no Cantonese speaking staff on the unit, so staff tries their best using simple words/body language/gesture to communicate with the resident. The Social Work assessment dated [DATE] documented Resident #548's primary language is Cantonese and will need an interpreter to communicate with staff. The Comprehensive Care Plan initiated 9/19/2024 documented Resident #548 has language barrier; primary language is Chinese. It documented to allow resident to express with words/sounds/gestures, and to use communication board as needed. The review of Certified Nurse Aid's instructions revealed there is no documented evidence that staff tried to utilize a translator or communication board to communicate with Resident #548. On 10/11/2024 at 11:33 AM, Certified Nurse Aid #15 was interviewed and stated, Resident #548 speaks primarily Chinese and can communicate using simple English words to verbalizes their need. Resident #548 does understand bathroom or shower when asked and will respond yes or no. Certified Nurse Aid #15 recalled that they have utilized communication board with other non-English speaking residents in the past on a different unit. However, Certified Nurse Aid #15 stated they have not seen communication board in Cantonese for this resident. On 10/11/2024 at 10:43 AM, Registered Nurse Manager (RNS #7) stated there is interpretation phone service that staff can utilize to communicate with resident who has a language barrier. The nursing staff on the unit can also utilize this service for daily Activities for Daily Living Care. Registered Nurse Manager further stated they were not aware about the communication board and does not recall this tool being used. On 10/16/2024 at 11:24 AM, Registered Nurse Manager (RNS #6) was interviewed and stated, resident's need for interpreter service is assessed upon admission by all departments especially nursing, social services, and recreational services. The communication tools are implemented for staff to communicate effectively with the resident. Registered Nurse Manager is responsible to initiate and implement the communication tools in resident's care and communicated to nursing staff. Registered Nurse Manager stated they are not sure how it was missed for this resident. On 10/16/2024 at 2:56 PM the Administrator was interviewed and stated, I understand the importance of communicating with residents in their language using an interpreter. There are few Cantonese speaking staff, but they are not always on duty therefore, staff can utilize Google translator and an interpretation phone service. Administrator further stated that all residents have the right to understand and be able to communicate their needs. 10 NYCRR 415.3(f)(1)(i)

Based on observation, record review and interviews conducted during the Recertification Survey from 10/08/24 to 10/16/24 the facility did not ensure residents' person-centered comprehensive care plans were developed and implemented to meet residents' needs. This was evident for 2 out of 40 sampled residents investigated for area of potential concerns. (Resident #147 and #391). Specifically,1) Comprehensive care plans were not developed and implemented for resident #147 who was on Hemodialysis, Antipsychotic and Anticoagulant medications. 2.) Comprehensive Care plans were not developed and implemented for resident #391 who was assessed as a smoker. Findings are: The facility policy titled Care Plans - Comprehensive with a last revision date of 12/2023 documented that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Each resident's comprehensive care plan is designed to incorporate identified problem areas, reflect treatment goals, and reflect currently recognized standards of practice for problem areas and condition. 1) Resident # 147 was admitted to the facility with diagnoses which include Anemia, Hypertension, Renal insufficiency, renal failure, End Stage Renal Failure (ESRD), Diabetes mellitus (DM), Bipolar Disorder. The most recent Minimum Data Set Version 3.0 (a resident assessment tool) dated 8/28/2024 documented that the resident's cognition was moderately intact, and also documented that the resident was on Hemodialysis. Physician order dated 7/24/24 documented the following: Hemodialysis - 3 times per week. A further review of physician order dated 7/24/2024, last renewed on 10/8/2024 documented that the resident was on Haloperidol Tablet 10 MG Give 1 tablet by mouth every 12 hours for Major Depressive Disorder with psychotic features, Aripiprazole Oral Tablet 2 MG (Aripiprazole) Give 1 tablet by mouth one time a day for MAJOR depressive disorder, recurrent, Lexapro Oral Tablet 5 MG (Escitalopram Oxalate) Give 5 mg orally at bedtime for major depressive disorder, recurrent and Eliquis Oral Tablet 2.5 MG (Apixaban) Give 1 tablet by mouth two times a day for anticoagulant. On 10/15/24 at 10:24 AM the resident was observed in bed, alert and awake. The resident was interviewed about their health as a whole. They stated that they go to dialysis three times a week. The resident also stated that they like the services they received here and staff are nice to them. The resident was observed with permcath to left upper chest. Review of the Comprehensive Care Plans reveals there is no documented evidenced of a Hemodialysis care plan, a Psychotropic care plan or an Anticoagulant care plan. On 10/15/24 at 11:21 AM, the Registered Nurse Manager #4 was interviewed and stated that they have just reviewed the resident's comprehensive care plans but was unable to locate a Hemodialysis care plan, Psychotropic care plan or an Anticoagulant care plan. They stated that part of their responsibility is the completion of a comprehensive assessment, development of care plans and management of the clinical aspect of residents. The Registered Nurse who performs the assessment initiates the care plans. They will then follow through any other medical conditions the resident may develop later. The Registered Nurse Manager #4 could not explain why the Hemodialysis care plan, Psychotropic care plan and Anticoagulant care plan were missed. On 10/16/24 at 12:21 PM, an interview conducted with the Director of Nursing who stated that care plans should be started immediately when residents is admitted to the facility. The Director of Nursing also stated that care plans are also needed to be updated if residents condition changed, such as new medications or falls. The Director of Nursing further stated that the Interdisciplinary Team had discussed the issues of care planning before due to some delays in completing the updates, however, they have ran an audit before for care plans but could not explain why they missed this resident. The Director of Nursing concluded it was an oversight. 44472 2) Resident #391 was admitted to the facility on [DATE] with diagnoses including Asthma, Chronic Obstructive Pulmonary Disease, Tobacco use and Coronary Artery Disease. Resident #391 Minimum Data Set Version 3.0 (a resident assessment tool) dated 09/25/2024 documented that the resident has a Brief Interview for Mental Status score of 15. Review of Smoking assessment dated [DATE], signed by Resident #391 and Social Worker # 3 documents resident smokes. The resident's care plans were reviewed and revealed that no care plans were in place for smoking. On 10/15/2024 Review of Recreation Director Progress Notes dated 10/3/2024 revealed Resident #391 was smoking in the smoking room. On 10/08/24 at 12:56 PM Resident #391 was interviewed in their room and stated they smoke, but does not want their family to know that they smoke On 10/15/24 at 01:34 PM Registered Nurse #10 was interviewed and stated, as a nurse on the floor, they do not create, nor update any care plans. Care plans are created and updated by the Registered Nurse Nursing Supervisors. On 10/15/24 at 01:46 PM the Director of Recreation was interviewed and stated on October 3, 2024, Resident #391 was observed by the staff smoking in the smoking room during the allotted time. Director of Recreation further stated Resident #391 is compliant with the smoking rules and is on the current list of smokers. On 10/15/24 at 03:36 PM Social Worker #3 was interviewed and stated, they were notified by the recreation staff on 10/3/2024 that Resident #391 was smoking in the smoking room. On 10/16/24 at 01:07 PM the Director of Nursing was interviewed and admitted the care plan for smoking was not done on admission when Resident #391 was identified using Tobacco and it could have been an oversight. They further stated the smoking care plan should have been initiated upon admission or right after smoking assessment was done and or when we were made aware resident was observed smoking. They also stated to prevent future failure of not developing care plans the Nursing Supervisors will audit care plans that have been initiated upon admission or as new problem arises. 10 NYCRR 415.11(c)(1)

Based on interviews and record review during an abbreviated survey, the facility did not ensure that a resident received the necessary care and services to attain or maintain the highest practicable physical well-being in accordance with the comprehensive assessment and plan of care. This was evident for 1 out of 3 sampled residents (Resident #1). Resident #1 ' s Certified Nursing Aides (CNAs) identified a left heel skin break on 11/19/11 and notified the unit Registered Nurse (RN). The facility did not assess or initiate treatment to the left heel ulcer until 11/21/11. Upon Medical Doctor (MD) assessment on 11/21/11, the resident was diagnosed with [REDACTED]. This resulted in Actual Harm that is not Immediate Jeopardy. Complaint # NY 739 The findings include: Resident #1 was a [AGE] year old admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) 3.0 dated 11/09/11 identified that the resident was moderately impaired in cognitive skills for daily decision making. A Comprehensive Care Plan initiated 10/27/11 documented that the resident had the potential for pressure ulcers. The initial interventions included providing protective skin care, providing incontinence care and monitoring bony prominences during daily care. The Nursing Admission Assessment, dated 10/27/11 did not identify any skin breakdowns or redness on the resident ' s right or left heels. A Physician ' s progress note dated 11/21/11 documented that Resident #1 was seen by the Primary MD. The MD documented that the resident had Stage 4 bilateral vascular heel ulcers. The MD ordered treatment including cleanse with normal saline, apply Silvadine Cream and cover with dry dressing twice daily. A nurse ' s note dated 11/21/11 documented that Resident #1 was seen by the Primary Physician on 11/21/11 and Silvadine Cream was ordered and applied to " new areas, (L) heel, (R) heel. " A Medication Order Sheet documented that Silvadine Cream 1% was ordered for Resident #1 on 11/21/11 for the resident ' s bilateral vascular heel ulcers. On 9/18/2012 at 10:34 AM an interview was conducted with CNA #1 who was assigned to the resident on 11/19/11 and 11/20/11 7:00AM - 3:00PM. She stated that CNA #2 assisted her with providing care to the resident. She stated that during care, the CNAs observed that Resident #1 had a skin break to his left heel which was bleeding and left a blood stain on the linen. She stated that they notified the nurse on duty (RN #1) of the observation and reminded the RN of the skin break during the course of the day. She stated that on 11/20/11 she observed that the resident ' s heel area was covered with a gauze dressing. She stated that she did not know if it was a treatment dressing or not because she was not present when it was done. On 5/11/12 at 3:59PM an interview was conducted with CNA #2 who assisted with providing care to the resident on 11/19/11 7:00AM-3:00PM. He stated that on 11/19/11 he observed a skin break to Resident #1 ' s left heel area. He stated that the skin break left some blood on the resident ' s linen. He stated that he immediately notified the unit Registered Nurse (RN #1) . He stated that on 11/20/11 he reminded RN #1 about the resident ' s heel ulcer and that she stated she would look for heel boots for the protection of the areas. He stated that he did not remember if he observed any skin breakdown on the right heel. On 6/14/12 at 12:15PM an interview was conducted with the Registered Nurse (RN #1) who was on duty on 11/19/11 and 11/20/11 7:00AM and 3:00PM. She stated that on 11/19/11 a male aide who had assisted Resident #1, requested heel booties for preventative reasons. She stated that she placed the order for the booties. She stated that she did not assess the resident ' s condition because the CNA requested the heel booties for prevention and not for treatment purposes. She denied that she was informed that the resident had a skin breakdown. On 5/11/12 at 2:06PM an interview was conducted with the Rehab RN Coordinator. She stated that she was informed that the resident had heel ulcers on 11/21/211. She stated that as soon as she was told that Resident #1 had ulcers to his heels, she went and assessed the condition and noted that there was slough with drainage. She stated that she immediately notified the MD, who examined the resident and noted Stage 4 vascular ulcers. She stated that the MD ordered Silvadine Cream for treatment of [REDACTED]. On 6/14/12 at 10:56AM Resident #1 ' s Primary MD was interviewed. The MD stated that she was made aware of Resident #1 ' s bilateral heel ulcer sites on 11/21/11. She stated that she examined the resident and noted Stage 4 vascular ulcers. She ordered Silvadine Cream for treatment of [REDACTED]. 415.12