Every finding on record at Colonial Park Rehabilitation and Nursing Center

Based on observations, record review, and interviews the facility failed to ensure a process was in place for residents to have their grievances addressed appropriately for 79 of 79 residents residing in the facility. Specifically, information on how to file a grievance and grievance forms were not available to the residents and the facility did not have a process for residents to file an anonymous grievance. Additionally, six (6) of six (6) anonymous residents present at the resident group meeting stated they did not know if there were grievance forms or where they would be located, of their right to file anonymously, did not know who the grievance officer was, and resident council concerns were not addressed. Findings include:The facility policy Grievances/Complaints, Filing, revised 01/2026, documented residents and their representatives had the right to file grievances concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding their stay at the facility. Grievances may also be voiced or filed regarding care that was not furnished. Residents, family, and resident representatives had the right to voice or file grievances without discrimination or reprisal in any form, and without fear of discrimination or reprisal. Actions on such issues were responded to in writing and included a rationale for the response. On admission, residents were provided with written information on how to file a grievance. Grievances may be submitted orally or in writing and may be filed anonymously. The Administrator delegated the responsibility to the Grievance Officer who was the Director of Social Work. The resident, or person filing the grievance was informed verbally and in writing of the findings of the investigation and the actions taken to correct any identified problems within seven (7) working days of filing the grievance with the facility. A written summary was also provided to the resident. The 2025 grievance log documented eight (8) grievances for the year. The 2026 grievance log documented one (1) grievance in January, two (2) grievances in February, one (1) grievance in March and zero (0) grievances in April. During an observation on 04/14/2026 at 10:58 AM, there was a metal box on the wall across from the receptionist at the main entrance for grievance submissions. There was a sign on the box that said to put the grievance in the box or submit to social work or department manager/supervisor. There were no forms with the box. There were no postings in prominent locations throughout the facility of the right to file grievances orally or in writing; the right to file grievances anonymously; and the contact information of the grievance official with whom a grievance could be filed. During a resident group meeting on 04/14/2026 at 2:00 PM, six (6) anonymous residents stated they did not know if there were grievance forms or how to obtain them and thought they wrote a grievance on their own piece of paper and placed it in the box by the receptionist. There was no way to file a grievance anonymously as the box was in a prominent location and others would see them put the piece of paper in the box. There was no follow up. One resident stated they filed a grievance six (6) to seven (7) months ago and had yet to hear anything about it. They were not sure who the grievance official was. When concerns were voiced in resident council, they went to the Administrator but that was as far as they went. There was no follow up on their concerns and the same concerns went from meeting to meeting unaddressed. Some residents had stopped attending the resident council meetings because they felt it was pointless. During an observation on 04/15/2026 at 10:22 AM, there was a metal box on the wall across from the receptionist at the main entrance for grievance submission. There were four (4) staff members and four (4) residents in view of the box. There was a sign on the box that said to put the grievance in the box or submit to social work or department manager/ supervisor. There were no forms with the box. There were no postings in prominent locations throughout the facility of the right to file grievances orally or in writing; the right to file grievances anonymously; and the contact information of the grievance official with whom a grievance could be filed. During an interview on 04/17/2026 at 9:53 AM, Certified Nurse Aide #14 stated if a resident wanted to file a grievance, there was a pamphlet they could give them to contact the ombudsman. During an interview on 04/17/2026 at 10:08 AM, Licensed Practical Nurse #16 stated if a resident wanted to file a grievance they could verbally come to them, the Director of Social Work, or the Assistant Director of Nursing. They would document a nursing note about it. There was also a poster for the ombudsman, and they were at the facility regularly. During an interview on 04/17/2026 at 10:16 AM, the Assistant Director of Nursing stated any staff member could take a resident grievance. It would go directly to the supervisor or the Director of Social Work. There was a form to file a grievance, and the forms were kept in the social work office or the nursing office. The residents could not file anonymously because they would have to ask for the form. During an interview on 04/17/2026 at 1:43 PM, the Director of Social Work stated there were blank grievance forms behind the nurse's station. They were considered the grievance officer, so they were the gatekeeper. Staff or residents gave them the completed grievance forms. They read them and based on the area of concern it was given to the appropriate department. The investigation was done within five (5) days. After there was a conclusion/resolution, they verbally reviewed it with the resident, and the resident signed the form. Residents had to ask for the grievance form. They thought residents could submit anonymously because there was a box on the wall. They confirmed the box was in a high traffic area. During a follow up interview at 2:34 PM, they did not have a key to the grievance box and did not know who checked it. 10 New York Codes, Rules, and Regulations 415.3(C)(1)(ii)

Based on observations, record review, and interviews (iQIES Intakes 2807999 and 473681) the facility failed to ensure residents maintained acceptable parameters of nutritional status for two (2) of six (6) residents (Residents #7 and #64) reviewed. Specifically, Resident #7 had significant weight loss, weights were not obtained as ordered, and there was no documented evidence a medical provider addressed the resident's weight loss; Resident #64 did not receive their nutritional supplements as ordered, had a decline in their eating abilities, and was not assisted at meals. Findings include:The undated facility policy Comprehensive Nutrition Assessment, documented the Clinical Nutrition team would clarify nutrition issues, needs, and goals in the context of the individual's overall condition. Health care practitioners would help define the nature of the problem, identify causes of nutrition problems (i.e. anorexia and weight loss), tailor interventions to the individual's specific causes and situation, monitor the continued relevance of those interventions.The undated facility policy Weights and Weight Changes, documented each resident's weight was recorded in the medical record. Each resident was weighed monthly or more frequently per physician's order, nursing or dietary recommendations. Monthly weights were obtained by the 10th of the month and a reweight would be obtained within 72 hours if there was a weight change of 5 pounds noted from the previous weight. If after the reweight, the resident had a significant weight change of greater than 5% in 30 days or 10% percent in 180 days, the registered dietitian would reassess within 7 days. Residents with significant weight changes were reviewed by the interdisciplinary team at the weekly weight meeting. 1) Resident #7 had diagnoses including adult failure to thrive (progressive decline in health) and cerebral palsy (neurological disorders affecting movement, muscle tone, and posture). The 02/22/2026 Minimum Data Set (a resident assessment tool) documented the resident had severely impaired cognition, did not reject care, required partial/moderate assistance with eating, weighed 113 pounds, had no significant weight changes at one month or six months, and was on a mechanically altered diet. The 08/19/2024 comprehensive care plan, revised 02/12/2026, documented the resident was at risk for malnutrition related to history of low body weight and history of significant weight changes. Interventions included assistance with feeding, encourage meals in the dining room, encourage intakes, identify/honor food preferences, monitor/document intakes, provide diet as ordered, provide fortified foods and oral nutrition supplements, and report any significant weight changes to registered dietitian and medical provider. The July 2025-February 2026 Treatment Administration Record documented to obtain weekly weights every day shift on Tuesday for weight monitoring.The 08/25/2025 physician orders documented puree texture diet and nectar thick liquids.The comprehensive care plan revised 02/20/2026 documented the resident required partial/moderate assistance at meals and received a puree diet with nectar thick liquids. Alternate between small bites and sips of liquids and remain in an upright position during intakes. The physician orders documented:-on 03/26/2026, 8 fluid ounces of nutritional shake three (3) times a day for weight loss, offer at lunch, dinner and at hour of sleep. -on 03/27/2026, 7.5 milligrams of mirtazapine (antidepressant used as appetite stimulant) once daily at hour of sleep for appetite stimulant and continue weekly weights.The resident's weight record documented:-10/08/2025: 114.2 pounds-11/03/2025: 103.4 pounds (10.8 pound loss/ 9.4% loss at one month)-11/06/2025: 101.7 pounds-11/13/2025: 105 pounds-11/18/2025: 103.4 pounds-11/25/2025: 107.2 pounds-12/02/2025: Licensed Practical Nurse #21 documented the resident refused -12/09/2025: 103.9 pounds-12/13/2025: no documented weight -12/16/2025: Licensed Practical Nurse #21 documented the resident refused-12/23/2025: Licensed Practical Nurse #22 did not document the resident's weight -12/30/2025: 107.4 pounds-01/06/2026: 109.4 pounds-01/09/2026: no documented weight-1/20/2026: no documented weight, Licensed Practical Nurse #20 documented see nursing progress note and documented passing on to next shift. There was no documented evidence the weight obtained-01/27/2026: no documented weight -02/03/2026: 112.6 pounds-02/09/2026: weekly weights discontinued -03/06/2026: 96.2 pounds (16.4 pounds loss/ 14.5% loss at one month) and no documented reweight obtained. -03/20/2026: 96.8 pounds-03/25/2026: 92.2 pounds-04/01/2026: 92.3 pounds-04/10/2026: 98 pounds-04/14/2026: 98.4 pounds The 11/10/2025 Registered Dietitian #3 progress note documented the resident had a significant weight loss over the past month of 10.9%, their body mass index (BMI) was 15.5 (underweight). Their current weight was 101.7 pounds, their estimated nutritional needs were 1562 calories per day, 55-60 grams of protein daily, and 1617 milliliters of fluid daily. The resident's meal preferences were updated, and they would continue with current interventions, including fortified foods at meals and nutrition supplements. Their intakes at meals were good, consuming greater than 75% at meals. The resident was a high nutrition risk. The 11/28/2025 Nurse Practitioner #41 progress note documented they were notified via facility clinical alert to review the chart. No acute issues at this time per nursing notes, the resident was at their baseline functional status. The plan was to order labs for review. There was no documented evidence the medical provider was notified of the sever weight loss from 10/08/2025-11/06/2025The 11/28/2025 Registered Dietitian #3 progress note documented the resident was followed for high nutrition risk and met the criteria for malnutrition. The 12/29/2025 Registered Dietitian #3 progress note documented the resident was continued to be followed for high nutrition risk due to significant weight fluctuations/ loss. The resident's weight continued to fluctuate over the past month, and weights were to be monitored weekly. Their body mass index was considered underweight, and the goal was to promote weight gain until body mass index was greater/equal to 23. The resident's intakes were fair to good, and they would continue with the current nutritional interventions. They would continue to follow as they were high nutrition risk. The 01/21/2026 Registered Dietitian #3 progress note documented updates were made to the resident's meal pattern and to continue to promote intakes. The resident was moderate nutrition risk at this time. The 02/11/2026 Nutrition Assessment completed by Registered Dietitian #3 documented the resident received a puree consistency diet with nectar thick liquids. They received a 4 ounce mighty shake (nutrition supplement), enhanced peanut butter pudding, and yogurt three (3) times daily at meals along with a Magic Cup (nutrition supplement) twice daily. Their current weight was 112.6 pounds, their body mass index was 17.1, and intakes at meals were good. They had no significant weight changes in the past one (1) or six (6) months. The goal was to continue with weight gain until body mass index reached appropriate range. The resident met the criteria for mild malnutrition and per discussion with the resident their meal pattern was updated, and magic cups were removed. The 03/09/2026 Registered Dietitian #3 progress note documented a re-weight was requested to confirm weight as weight had been stable. They continued on a puree diet with nectar liquids and received nutritional supplements and fortified foods at meals. Intakes were good, would trial increasing Might Shakes to 8 ounces at lunch and dinner. They would monitor weight weekly and monitor for re-weight. The 03/26/2026 Registered Dietitian #3 progress note documented the resident was followed for high nutrition risk. Their current weight was 92.2 pounds; their body mass index was 14 and met the criteria for malnutrition. Intakes were variable, ranging poor to excellent, and received puree consistency with nectar liquids. They would try adding an 8 ounces Health Shake at hour of sleep and may consider adding an appetite stimulant if medically beneficial and able. The resident remained high risk for nutrition and they would continue to follow weekly weights for four (4) weeks. There was no documented evidence that a re-weight was obtained timely. The physician order for weekly weights was not entered until 03/27/2026.There was no documented evidence that a medical provider was notified of or addressed the resident's significant weight loss. The resident was observed:- on 04/16/2026 at 8:20 AM, seated in the main dining room. The resident was assisted by Certified Nurse Aide #26, the resident had pureed pancakes, pureed eggs, hot cereal, pureed ham salad, peanut butter pudding, applesauce, nectar thick water and nectar thick coffee. At 8:34 AM, the resident stated they were done with their meal and had consumed 100% of their pancakes and peanut butter pudding, 0-25% hot cereal, and 50% of their nectar thick water and coffee. They did not want any of the pureed ham salad or any more of their hot cereal. - on 04/16/2026 at 12:43 PM, seated in the main dining room being assisted by Licensed Practical Nurse #26. The resident had pureed turkey and gravy, pureed stuffing, pureed creamed spinach, two (2) 4 ounce dishes of pureed turkey salad and pureed chicken salad, four (4) chocolate milk shakes, two (2) yogurt containers, nectar thick coffee, and enhanced peanut butter pudding. At 1:03 PM, the resident consumed 100% of their meal tray. During an interview on 04/17/2026 at 11:46 AM, Registered Nurse Unit Manager #4 stated the registered dietitian provided the unit with the weight list. Nursing staff obtained the weights and the registered dietitian provided a list of residents who needed to reweighed. They did not notify medical if a resident had a significant weight change. The interdisciplinary team did discuss significant weight changes in the weekly weight meeting. The medical providers attended the meeting if they were in the building. Weights were expected to be obtained as ordered and if the resident refused, nursing should document the refusal. During an interview on 04/17/2026 at 12:09 PM Nurse Practitioner #7 stated the registered dietitian notified medical of significant weight changes and if a medical provider was in the building during the weekly weight meeting, they attended. The facility looked at significant weight changes with an interdisciplinary approach. Resident #7 had a significant weight change and their weight was now trending upwards. Nursing should obtain weights as ordered and document any refusals. The facility recently had a change with medical providers. They stated an appetite stimulant was ordered for the resident in March of 2026. If a resident had significant weight changes and the medical team was notified, they should assess the resident and document the findings. During an interview on 04/17/2026 at 12:30 PM Certified Nurse Aide #25 stated a resident's weights were obtained as ordered. Some residents were weighed monthly, and others were weighed weekly. The registered dietitian provided a list of residents who needed to be weighed, and the recertified nurse aides obtained the weights. If a resident refused, they would reapproach the resident and tell the nurse if the refusal. If a resident needed to be reweighed, the registered dietitian provided the unit with a list, and it was the same process. They worked with Resident #7 and the resident never refused to be weighed. The resident was eating well at this time.During an interview on 04/17/2026 at 2:01 PM Registered Dietitian #3 stated the facility recently started a new weight process. The Director of Nursing or the Assistant Director of Nursing generated the weight lists and brought them to the units. Previously they had provided the units with the lists and there were issues, so the facility revised the process. Weights were obtained per the medical order, monthly weights were obtained during the 1st and 10th of the month, and weekly weights were completed as ordered. Any resident who had a significant weight change of 5% at one (1) month, 7.5% percent at three (3) months, or 10% percent at six (6) months a reweight would be obtained within 72 hours to confirm the weight change. If the weight loss was confirmed they reassessed the resident's nutritional needs and the resident was discussed during the weekly weight meeting. The Director of Nursing, Assistant Director of Nursing, and the unit managers attended the weekly weight meeting. The medical providers did not always attend the weekly weight meeting, and they would typically verbally notify the medical providers of significant weight changes. Resident #7 was at risk for weight loss and had weight fluctuations. The resident was supposed to be weighed weekly, and they were not, and reweights were not obtained as requested. They updated the resident's preferences and attempted different supplements, and the resident was started on an appetite stimulant in March to aid with weight gain when they triggered for a weight decline.2) Resident #64 had diagnoses including dementia, adult failure to thrive (progressive decline in overall health), and diabetes. The 03/23/2026 Minimum Data Set (a resident assessment tool) documented the resident had severely impaired cognition, did not reject care, required supervision or touching assistance with eating, weighed 165 pounds, had no significant weight changes at one or six months, and was on a mechanically altered diet. The 04/06/2020 comprehensive care plan, revised 11/23/2025, documented the resident was at risk for malnutrition related to dementia, diabetes, and adult failure to thrive. Interventions include assistance with feeding, encourage intakes, monitor meal consumption, provide diet and supplements as ordered. The 07/27/2022 physician order documented a chopped, thin liquid diet with the expectation of chips and peanut butter and jelly sandwiches. The resident's weight record documented:-02/05/20026: 177.4 pounds-03/19/2026: 172 pounds-03/20/2026 165.4 pounds-03/26/2026: 163 pounds.The 03/23/2026 Registered Dietitian #3 progress note documented the resident met the criteria for malnutrition and had a significant weight loss of 12 pounds/ 6.8% at month. Weekly weights were to be monitored for four (4) weeks until stable and the resident was at high nutrition risk. The 03/26/2026 physician order documented 8 ounces of Ensure Plus (nutrition supplement) with meals three (3) times daily. The resident's weight record documented:-04/02/2026: 156 pounds (16 pounds/9.3% loss at one (1) month)-04/03/2026: 158.2 pounds (13.8 pounds/ 8% loss at one (1) month).The 04/07/2026 Registered Dietitian #3 progress note documented the resident was followed for high nutritional risk. The resident had a significant weight loss of 13.8 pounds/8% within less than one (1) month. The resident continued on a chopped diet with thin liquids and received 8 ounces of Ensure Plus three (3) times daily. They would try a Magic Cup (frozen nutrition supplement) at lunch and supper for additional calories and protein. Weekly weights were to be monitored for four weeks. The resident remained at high nutrition risk. The 04/07/2026 physician order documented Magic Cup at lunch and dinner. The care instructions documented the resident required supervision (in-line of sight) or touching assistance with meals. They received a chopped diet with thin liquids. Alternate small single bites and sips of liquids and observe for pocketing of food and provide supplements as ordered. The following observations of Resident #64 were made:-on 04/14/2026 at 12:28 PM, seated at a table in the dining room with their eyes closed and their lunch meal in front of them. Their meal included sauerkraut, sweet potatoes, a peanut butter and jelly sandwich cut into squares, a Magic Cup, cottage cheese, diced fruit, chocolate milk shake, and ginger ale. At 12:29 PM, Registered Nurse Unit Manager #4 woke the resident up and provided them with their chocolate milk shake and the resident consumed 100% of it. They provided the resident a with a spoonful of sweet potatoes, and the resident declined anymore sweet potatoes. They cut the peanut butter sandwich smaller and assisted the resident with the sandwich. The meal tray did not include Ensure Plus as ordered. -on 04/15/2026 at 12:24 Licensed Practical Nurse #5 provided the resident their meal in the dining room. They poured their milk and soda into cups and asked the resident if they wanted straws. At 12:25 PM, the resident had not started eating or drinking and was looking at their meal tray. At 12:27 PM, Licensed Practical Nurse #5 put the straws in the resident's drink. At 12:31 PM, the resident struggled to bring the cup to their mouth and sip their drink. At 12:32 PM, they picked up their cup of milk and drank it. At 12:34 PM, Certified Nurse Aide #28 unwrapped the resident's peanut butter and jelly sandwich and placed a fork on the plate. The resident had rice, broccoli, cottage cheese, diced pears, a Magic Cup, soda, and a chocolate milk shake. At 12:39 PM, the resident consumed 100% of their chocolate milk, 50% soda, and 50% of the magic cup. At 12:42 PM, the resident put the Magic Cup on the table and looked at the food on their plate. At 12:47 PM, Certified Nurse Aide #28 asked the resident if they were going to eat. Registered Nurse Unit Manager #4 sat next to the resident and assisted them to take bites of their peanut butter and jelly sandwich and Magic Cup. They provided the resident with a fork to feed themselves the cottage cheese. The resident's hands were shaking and Registered Nurse Unit Manager #4 turned away from the resident to attend to another resident at another table. Resident #64 continued to take small bites of cottage cheese. At 1:03 PM, Registered Nurse Unit Manager #4 returned to Resident #64 and removed their meal tray. The resident consumed 25-25% of the cottage cheese, 50% of the peanut butter and jelly sandwich, 100% Magic Cup, 100% chocolate milk shake, and 100% soda. They consumed 0-25% of the broccoli, rice, and diced pears. The meal tray did not include Ensure Plus as ordered.-on 04/16/2026 at 12:48 PM, the resident was seated in the dining room. They had a peanut butter and jelly sandwich cut up into squares, a Magic Cup, 8 ounces of Ensure Plus, peaches, creamed spinach, stuffing, cottage cheese, and ginger ale. No staff assisted the resident with their meal. At 12:54 PM, the resident sat at the table with their eyes closed and had not consumed any food or fluids. At 1:02 PM, the resident continued to sit at the table and had not received any assistance or encouragement to consume their meal. At 1:07 PM, the resident's head was down, and they had not consumed any food or fluids. At 1:08 PM, Certified Nurse Aide #28 asked the resident if they were going to eat, did not offer assistance and walked away. At 1:14 PM, Certified Nurse Aide #29 sat down next to the resident poured their ginger ale into a cup, asked the resident if they wanted any of their ginger ale, and what did they want to eat. At 1:16 PM, Certified Nurse Aide #29 walked away to assist another resident. At 1:21 PM, Certified Nurse Aide #28 asked the resident if they were going to eat and the resident declined. The resident consumed 0-25% of their food and fluids. During an interview on 04/17/2026 at 10:01 AM, Certified Nurse Aide #29 stated the level of assistance a resident required at meals was listed on their care instructions, they also had a yellow meal ticket, and staff could also ask the nurse if they were unsure. If a resident required touching assistance or supervision staff were to encourage them to eat and offer alternatives if they were not eating. If a resident was requiring more assistance at meals than they were care planned for they should tell the nurse. Resident #64 required assistance at meals and did not eat well. Staff should set up the meal for the resident, pour drinks and cut items if needed. If the resident was not eating, staff should assist them with their meal or provide encouragement. The resident received Ensure Plus at meals and typically drank that. This week the kitchen ran out of Ensure Plus and substituted Mighty Shakes (nutritional supplement). During an interview on 04/17/2026 at 10:09 AM Certified Nurse Aide #25 stated Resident #64 sometimes needed assistance with meals and ate better if they were assisted. The resident spilled their drinks, and they thought they would benefit from having lids on their drinks. The resident recently required more assistance at meals. They received supplements at meals and did not receive their Ensure Plus at meal this week, but received a Mighty Shake instead. During an interview on 04/17/2026 at 10:36 AM Licensed Practical Nurse #26 stated if a resident required supervision/ touching assistance at meals staff should assist them with their meal if they were not eating. If a resident was consistently requiring more assistance than what was on their care plan the Unit Manager should be notified and it should be documented. They stated Resident #64 required more assistance with meals than in the past, but they did not consistently work on the unit. Staff should be observing to see if the resident required assistance, as they had a yellow meal ticket. The resident received Ensure Plus and if that was not available the kitchen would substitute Mighty Shakes. They did not document if the Ensure Plus was substituted but verbally told the Unit Manager. During an interview on 04/17/2026 at 12:11 PM Registered Nurse Unit Manger #4 stated if a resident was consistently requiring more assistance the registered dietitian should be notified and discussed with the interdisciplinary team in morning report, so everyone was aware. Resident #64 was able to feed themselves but sometimes did not eat on their own and required more encouragement at times. The resident had been losing weight and did not appear to feed themselves this week. If the resident was not eating staff should provide encouragement and assistance. The resident was supposed to receive Ensure Plus at meals and this week received Mighty Shakes. They thought the registered dietitian should be notified by the kitchen if there was a substitution with nutritional supplements. During an interview on 04/17/2026 at 1:21 PM, the Food Service Director stated sometimes the facility has issues with getting Ensure products, but they typically came within a day. If they did not have any Ensure products they spoke to the registered dietitian and asked what should be substituted. They had a handwritten sheet and stated if it was not available, they would substitute Boost (nutrition supplement) or fortified milk. During an interview on 04/17/2026 at 2:01 PM, Registered Dietitian #3 stated the facility was having issues not receiving all the supplements they ordered from their food vendor. They did not always receive the Ensure products. If the product was not received the kitchen should notify them so a substitution could be made. They were not consistently notified when the products were not available, and they were unaware Ensure Plus was being substituted with Mighty Shakes. Ensure Plus was more calorically dense and had more protein than Mighty Shakes. They were not notified the kitchen was substituting Mighty Shakes for Ensure Plus. Resident #64 was planned to receive Ensure Plus and had weight loss.During an interview on 04/17/2026 at 2:50 PM, the Director of Nursing stated weights should be obtained as ordered. The registered dietitian would provide a list to the units of who needed to be weighed and any needed reweights. The facility had a weekly weight meeting and discussed significant weight changes. Any resident who required more assistance with meals should be re-evaluated.During an interview on 04/17/2026 at 3:02 PM, Physician #30 stated if a resident's ability to eat changed from what they were care planned for they should be re-evaluated. They saw Resident #64 yesterday for weight loss and spoke to the Director of Nursing about re-evaluating the resident's eating abilities. The registered dietitian should be notified if the resident did not receive their supplements as ordered. 10 New York Codes, Rules and Regulations 415.12(i)1

Based on observations and interviews (iQIES intake 2963932), the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met their daily nutritional needs for six (6) anonymous residents and two (2) of two (2) meals (the 04/15/2026 and 04/16/2026 lunch meals) reviewed. Specifically, the 04/15/2026 lunch meal had hot and cold food served outside of the appropriate temperature range; the 04/16/2026 lunch meal tray had missing food items, missing adaptive meal equipment, and food items were not serviced at palatable temperatures and the 04/16/2026 replacement lunch meal was missing items, the appropriate adaptive equipment was not provided, and the meal ticket directions were not followed; and six (6) anonymous residents present at the resident group meeting stated the food was often cold and the meal tray did not match the meal tickets. Findings include:The undated facility policy Accuracy and Quality of Tray Line Service, documented all meals were checked by food service personnel for accuracy, and by the employees serving the meals prior to the individual being served. Hot foods were kept above 140 degrees Fahrenheit and cold foods were kept below 41 degrees Fahrenheit. Prior to leaving the kitchen, each meal was checked for accuracy that items on the meal tray matched the meal ticket. During an anonymous resident group meeting on 04/14/2026 at 2:00 PM, six residents stated the food was often cold and the meal tickets did not match the food items placed in front of them. During a B unit lunch meal observation on 04/15/2026 at 12:12 PM, Resident #1's lunch meal was the last meal served. The lunch tray was tested and verified with the Regional Director of Food Operations. The ziti measured at 133 degrees Fahrenheit, the broccoli measured at 110 degrees Fahrenheit and was cool to taste, the garlic bread measured at 100 degrees Fahrenheit, the coffee measured at 133 degrees Fahrenheit, and the pineapple measured at 68 degrees Fahrenheit. During an A unit lunch meal observation on 04/16/2026 at 12:39 PM, Resident #4's lunch meal was tested and verified with Certified Nurse Aide #15. Certified Nurse Aide #15 stated the resident was out on an appointment and they were going to have to order a new tray because the tray was wrong. The tray was missing turkey, gravy, creamed spinach, cottage cheese, chilled peaches, diet house shake, Mrs. Dash seasoning, margarine and a scoop plate. The stuffing was measured at 125.1 degrees Fahrenheit and did not taste warm; the carrots were measured at 110.2 degrees Fahrenheit, and the water was measured at 62.8 degrees Fahrenheit. At 1:18 PM, the resident received a replacement tray. The replacement tray was missing gravy, the turkey was not cut up per the meal ticket directions, the resident received a divided plate instead of a scoop plate, and the resident received regular milk instead of the diet house shake. During an interview on 04/17/2026 at 1:21 PM, the Food Service Director stated everyone had a part in ensuring meal ticket accuracy. The meal ticket was referenced by each dietary worker who placed items on the tray. If they were out of something or missing something, it was crossed off the ticket and the resident was made aware. They attended resident food council meetings and was aware of how the residents felt as if items were just not being sent. Residents complained about missing items for the past couple of months. Hot food should be served above 140 degrees Fahrenheit and cold food below 41 degrees Fahrenheit. Any food item outside of those ranges was unacceptable because bacteria could grow and residents deserved to have hot food. 10 New York Codes, Rules, and Regulations 415.14

Based on observations, record review, and interviews, the facility failed to ensure each resident received and the facility provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (1) of one (1) resident (Resident #49) reviewed. Specifically, Resident #49 exhibited behavioral disturbances, did not have a personalized care plan to address triggers or personalized interventions, and the facility did not coordinate with outside behavioral health services for continuity of care. Findings include: There was no documented evidence of a comprehensive care plan policy and an initial care plan policy. Resident #49 had diagnoses including bipolar disorder (fluctuating mood shifts), severe psychotic features (loss of contact with reality), cerebral palsy (movement disorder caused by abnormal brain development or damage), and anxiety. The 03/26/2026 Minimum Data Set documented the resident had intact cognition, had moderate depression, had no behaviors, required moderate assistance or was dependent for all activities of daily living, and received antipsychotic and antianxiety medications. The 06/26/2024 comprehensive care plan, revised 03/23/2026, documented the resident had behavior symptoms including being an inaccurate reporter, accusing others of being verbally aggressive and abusive which were related to their change in environment, mood disorder, and attention seeking. The resident also had inappropriate conversations on the phone on loudspeaker, threw things, punched staff, and talked about staff members to other staff. On 03/19/2025 the resident struck the wall with their left hand and on 03/20/2026 the resident punched a wall. Interventions included the resident was seen by the medical provider on 03/19/2025 and by psychiatry on 03/20/2026 for medication changes, was educated on 03/20/2026 using breathing exercises, had an appointment with their mental health provider on 03/26/2026, administer psychotropic medications as ordered, contract with the resident as needed, determine the cause of behavior and remove resident, distract the resident with activities of interest, to document all behaviors and attempt to identify a patter to target interventions, initiate a psychiatric and psychological evaluation as needed, and modify the environment to reduce episodes of negative behavior. The 06/27/2024 Comprehensive Care Plan, revised 08/04/2025, documented the resident was at risk for alterations in mood due to a diagnosis of anxiety, bipolar and depression. The resident often sought out staff to vent and followed with psychiatric services in the community. Interventions included administering psychotropic medications as ordered, assessing suicidal ideations as needed, encouraging family involvement, encouraging participation in activities offered, encouraging resident to remain social with peers and staff, monitoring for changes in mood, providing opportunities for resident to express themselves, providing support and reassurance, and referring for psychological and psychiatric evaluation as needed. Resident #49's Pre-admission Screening and Resident Review Level II (an in-depth person-centered evaluation required by federal law for nursing facility applicants with suspected or confirmed serious mental illness) documented:- the resident had a history of bipolar with psychotic features and depression. Their symptoms included irritability, feeling hopeless, trouble sleeping, worrying, sadness, and becoming upset when they did not get their way. The resident had a history of paranoia- the staff should provide empathic listening and statements to encourage sense of support, encourage participation in pleasant activities, provide positive reinforcement and redirection. It was helpful to inform the resident what they were doing and why, along with one-to-one attention.- triggers included boredom, feeling people were not listening to them, and not getting their way- it was important to have a good day when everything went right, and their family was supportive. They got mad when people did not treat them well.- coping mechanism included prayer and bible study to manage their symptoms. They also loved the local football team, playing video games, listening to country music, gospel music, cars, and dogs. Staff were to engage the resident in topics of interest and provide opportunities to participate in activities the resident found meaningful.- the resident was to be provided with the development of a written, person-centered psychiatric plan of care that included how the resident experienced their mental health such as past symptoms, mental health services, what can make the symptoms worse, early signs they were not doing well, and how best to support the resident if symptoms increase. There should also be a list of personalized coping skills, ongoing psychiatric consultations and medication management. The 09/26/2025 Psychiatric-Mental Health Nurse Practitioner #24 progress note documented the resident had recent irritability and behaviors and had frequent disagreements with staff and other residents. Symptom triggers included interpersonal issues and loss of independence. Bible study and prayers seemed to be helpful along with medication and counseling which helped in the past. The 9/29/2022025 Psychiatric-Mental Health Nurse Practitioner #24 progress note documented the resident continued with agitation and paranoia regarding their items being stolen. They had frequent disagreements with staff and other residents and discussed the ways they could have staff moved and reported the staff triggered them. The facility reported they continued to have angry outbursts toward staff and other residents, and the resident reported significant frustration today. The 10/13/2025 hospital social work progress note documented the resident was seen due to anxiousness and restlessness. The resident was anxious related to their frustrations with their current nursing home placement. The resident relied on their faith to get them through their mental health concerns and identified great support through their parents and their faith. The 03/20/2026 Assistant Director of Nursing #8 progress note documented the resident reported punching the wall with their right hand because they were mad. The resident requested an x-ray. They educated the resident on breathing techniques to help calm down without using physical force and the resident demonstrated deep breathing technique. The right upper part of the back of the resident's hand was red. Ice was applied, pain medication was administered, and the on-call physician was notified with no new orders. There was no documented evidence of follow up by the social worker following the resident's episode of punching the wall. The 04/14/2026 Nurse Practitioner #7 progress note documented the resident approached the provider in the office without an appointment and demanded to be seen. The provider counseled the resident that unscheduled, non-emergent concerns must follow the standard workflow and would need to wait their turn. The resident refused to leave the office after multiple requests and was persistent in demanding an evaluation. The resident became increasingly agitated, raised their voice, and expressed dissatisfaction with the provider's recommendation. The resident had a history of attention seeking and psychiatric behavior disorder. The resident also had a history of inappropriate healthcare utilization and insistence on unnecessary interventions, behavioral dysregulation with possible underlying psychiatric components such as manipulative and attention-seeking behaviors. The resident was counseled extensively on appropriate process for medical requests and needed to adhere to facility workflow and advised against independently contacting outside providers to demand care. The facility staff should continue with behavior monitoring and reinforce boundaries consistently across care teams. The resident should also follow psychiatric services. There was no documentation of consultations, follow ups, or collaboration from the resident's outside behavioral health appointments from 12/01/2025 to 04/01/2026. During an interview on 04/14/2026 at 2:04 PM, Resident #49 stated they were agitated earlier in the day because they felt the staff were touching their things when they were not in the room. They stated they calmed down and did their anger management by doing bible studies. They had a psychiatrist and a counselor outside the facility who they thought communicated with the facility. During an interview on 04/16/2026 at 9:58 AM, Resident #49 stated they saw their behavioral health every month starting in December 2025 through February 2026 over the phone and in person in March 2026. They did not know if the facility received the consultation from their appointment in December 2025 but was told by the mental health practice, they did not send the consultations for January 2026 and February 2026 and they did not know why. They stated in March 2026 the mental health practice gave the resident a copy. During an observation on 04/16/2026 at 11:24 AM, Resident #49 angrily approached the nurses' station and threw their hat. They were demanding to know where a certified nurse aide was they were angry at because the aide had gotten into an argument with their father in a care conference over lies. The Director of Nursing stood next to the resident while the resident vented and yelled. The Director of Nursing waited for the resident to stop and turned their power wheelchair toward their room and followed the resident into their room. Upset, high pitched yells from the resident could be heard from the resident's room. During an interview on 04/17/2026 at 10:09 AM Certified Nurse Aide #25 stated Resident #49 had behaviors of angry outbursts and punching themself. They tried to be as far away from the resident as possible when they had behaviors. Sometimes the resident came to find them to ask them to talk. At those times, they just tried to comfort the resident, talk to them and calm them down but they mainly gave the resident their space. During an interview on 04/17/2026 at 10:14 AM, Certified Nurse Aide #27 stated the resident had behaviors and their newest behavior was throwing things at the staff. They stated the resident had a short fuse and when they were mad, they would go down the hallway screaming. They stated when they performed the resident's care, they just tried to remain quiet and calm. During an interview on 04/17/2026 at 10:36 AM Licensed Practical Nurse #26 stated interventions for behaviors were on a resident's care plan. Resident #49 had behaviors every day. The behaviors depended on what the resident's mood was. They offered the resident their medications a couple weeks ago and the resident started screaming, throwing things and stated if they wanted their medications they would ask for them. It did not take much to set the resident off. When the resident had behaviors, they tried to get the resident to their room to relax, try not to engage them, speak calmly and leave the resident alone if they were in a safe area. During an interview on 04/17/2026 at 12:11 PM Registered Nurse Unit Manager #4 stated Resident #49 had behaviors. The resident liked to be in control of things. There were several staff the resident did not want to work with and if they even saw the staff in the building, it triggered the resident and they became paranoid the staff were talking about them. Staff tried to redirect Resident #49 when they had behaviors. Calling their parents really helped the resident, along with playing their gaming system, bible study, music, and they went to a specialty behavioral health service. During an interview on 04/17/2026 at 1:06 PM, the Director of Social Services stated the behavior care plans were completed by nursing and should be person-centered. Distracting the resident with activities of interest was only person-centered if the staff knew what the activities of interest were. Resident #49 had behaviors which included a lot of paranoia and mental health concerns. The resident needed a lot of one-to-one attention. After the resident screamed it out, they were okay. Effective interventions included reading scripture, listening to music, and support from their parents. If the resident was not getting along with their parents, that would be a trigger for them. These things should be included in the resident's care plan, but they were not. They were unsure what Nurse Practitioner #7 meant by reinforcing boundaries across staff except the resident could twist words when speaking to multiple staff. The Pre-admission Screening and Resident Review Level II recommendations should be incorporated into the resident's care plan. They had not followed up on not receiving any consultations from the outside behavioral health facility because the resident did a lot of self-directing on their own. There should be some sort of communication between the facility and the outpatient therapist to make sure no recommendations were missed. During an interview on 04/17/2026 at 2:50 PM, the Director of Nursing stated the behavior care plans were jointly done by the unit managers and social worker but mostly by nursing. The care plans should be person-centered and the interventions for behaviors individualized. Encouraging participation in activities of interest, encouraging the resident to remain social with peers/staff, and distracting the resident with activities of interest were not person-centered interventions. Resident #49's behaviors included yelling, going from person to person to tell their story, picking and choosing who took care of them, and refusing medications and care. Going to their room, doing their bible studies, talking to a staff member, talking to their counselor, and talking to their parents helped the resident when they had behaviors. When a resident saw an outside mental health provider, a consult sheet was sent with them and if the resident did not come back with the consult sheet, staff should follow up with the provider. This included telehealth appointments. Sometimes Resident #49's mental health provider called the facility with recommendations or interventions. The calls should be documented in the medical record if they occurred. 10 New York Codes, Rules and Regulations 415.12

Based on observations, record review, and interviews (IQIES Intake 2577870), the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for one (1) of three (3) residents (Resident #64) reviewed. Specifically, Resident #64's wound treatments were not completed as ordered.Findings include:The facility policy Wound Care, reviewed 01/2025, documented during wound care preparation, staff should verify there was a physician's order for the procedure, review the resident's care plan to assess any special needs of the resident, and assemble the equipment and supplies as ordered to perform the procedure. Following the procedure, information should be documented in the resident's medical record. If the resident refused the treatment, document the reason why and notify the supervisor.Resident #64 had diagnoses including dementia, adult failure to thrive (overall physical decline), and a Stage 4 pressure ulcer (full thickness tissue loss with exposed tendon or muscle) of the left heel. The 03/23/2026 Minimum Data Set (a resident assessment tool) documented the resident had moderately impaired cognition; required substantial/maximal assistance with personal hygiene; was dependent for bed mobility; had one (1) Stage 4 pressure ulcer; had one (1) unstageable (full thickness tissue loss in which the base of the ulcer is covered by dead tissue) pressure ulcer presenting as a deep tissue injury (purple/maroon localized area of discolored intact skin due to underlying tissue damage); had moisture associated skin damage; had pressure reducing devices for the bed and chair; and had pressure ulcer/injury care.The 06/25/2025 comprehensive care plan, revised 11/23/2025, documented the resident had alteration in skin integrity with a Stage 4 pressure ulcer to the left heel related to impaired mobility and poor nutrition. Interventions included monitor dressing daily to ensure it was clean, dry and intact, ensure heel protector was in place, and assess the wound weekly.The 02/25/2026 Comprehensive Care Plan documented the resident had alteration in skin integrity with an unstageable pressure ulcer to the right heel related to impaired mobility and poor nutrition. Interventions included monitor dressing daily to ensure it was clean, dry and intact, ensure heel protector was in place, and assess wound weekly.Physician orders documented the following wound care orders:-on 01/30/2024 apply skin prep (protective barrier) to top of toes on bilateral feet every day shift for skin integrity.-on12/17/2025 apply skin prep to the left second toe every day shift for wound care.-on 01/05/2026 wash buttocks, pat dry, apply thick layer of zinc cream (skin protectant) every shift for moisture associated skin damage.-on 03/12/2026 cleanse left heel with wound cleanser, pat dry, apply skin prep to periwound (skin around the wound edge), apply Medihoney (medical-grade honey) to the wound bed, cover with dry gauze, wrap with Kling (rolled gauze), and secure with tape every evening shift and a needed for wound care.-on 03/12/2026 cleanse right heel with wound cleanser, pat dry, apply skin prep to periwound, apply Xeroform (petroleum dressing) to the wound bed, cover with abdominal pad, wrap with Kling, and secure with tape every evening shift and as needed for wound care.-03/12/2026 cleanse scabbed area on the left dorsal (top) foot with wound cleanser, pat dry, and apply skin prep every evening shift for wound care.The April 2026 Treatment Administration Record documented:-apply skin prep to top of toes on bilateral feet every day shift for skin integrity was not completed on 04/02/2026 by Licensed Practical Nurse #26, 04/04/2026 by Licensed Practical Nurse #31, 04/06/2026 by Licensed Practical Nurse #26, and 04/07/2026 by Licensed Practical Nurse #31.-apply skin prep to the left second toe every day shift for wound care was not completed on 04/02/2026 by Licensed Practical Nurse #26, 04/04/2026 by Licensed Practical Nurse #31, 04/06/2026 by Licensed Practical Nurse #26, and 04/07/2026 by Licensed Practical Nurse #31.-cleanse left heel with wound cleanser, pat dry, apply skin prep to periwound, apply Medihoney to the wound bed, cover with dry gauze, wrap with Kling, and secure with tape every evening shift for wound care was not completed on 04/05/2026 by Licensed Practical Nurse #32.-cleanse right heel with wound cleanser, pat dry, apply skin prep to periwound, apply Xeroform to the wound bed, cover with abdominal pad, wrap with Kling, and secure with tape every evening shift for wound care was not completed on 04/05/2026 by Licensed Practical Nurse #32.-cleanse scabbed area on the left dorsal foot with wound cleanser, pat dry, and apply skin prep every evening shift for wound care was not completed on 04/05/2026 by Licensed Practical Nurse #32.-wash buttocks, pat dry, apply thick layer of zinc cream every shift for moisture associated skin damage was not completed on 04/02/2026 day shift by Licensed Practical Nurse #26, 04/04/2026 day shift by Licensed Practical Nurse #31, 04/05/2026 evening shift by Licensed Practical Nurse #32, 04/06/2026 day shift by Licensed Practical Nurse #26, and 04/07/2026 day shift by Licensed Practical Nurse #31.During an interview on 04/17/2026 at 10:36 AM, Licensed Practical Nurse #26 stated they looked at physician orders to determine what kind of wound care a resident needed and after they completed the wound care, they signed it off in the treatment administration record. If it was not signed off it may not have been done. Resident #64 had wounds and orders to complete wound care but when they worked by themself, they were busy and had to focus on passing medications, so sometimes they could not complete the wound care even though they should have completed it before they left for the day.During an interview on 04/17/2026 at 12:11 PM, Registered Nurse Unit Manager #4 stated all wound care should be completed as ordered. If there was no documentation or it was not signed off in the treatment administration record, that meant it was not completed. The nurses sometimes asked for their assistance if they were unable to complete wound care, but they usually had a ton of things to get done themself, so they did not often assist. They were not notified that Resident #64 had various wound care orders not completed. During an interview on 04/17/2026 at 2:13 PM, Wound Nurse Practitioner #33 stated they recently started doing the wound rounds at the facility and they did not have access to the facilities documentation, so they went off the nursing report that was given to them. Resident #64's wounds stayed the same based off report but looked better than last week. They were not aware of any open areas on Resident #64's buttocks but the nurses should have been completing the wound care as ordered. 10 New York Codes, Rules, and Regulations 415.12(c)(1)

Based on observations, record review, and interviews, the facility failed to ensure residents who were fed by enteral means (tube feeding, delivery of nutrition directly to the stomach or small intestine) received the appropriate treatment and services to prevent complications of enteral feeding for one (1) of one (1) resident (Resident #52) reviewed. Specifically, Resident #52's tube feeding was not infusing at the ordered rate; they did not receive their water flushes as ordered; their tube feeding was not dated: and their tube feeding pump was unclean with brownish streaks on the monitor. Findings include: The facility policy Enteral Feeding Via Continuous Pump, revised 03/2022, documented to verify the physician order and connect the infusion pump set rate, and press start. The facility policy did not document dating and timing of tube feeding when administered. Resident #52 had diagnoses including cerebral palsy (neurological disorders affecting movement), dysphagia (difficulty swallowing), and Alzheimer's Disease. The 04/16/2026, Minimum Data Set (a resident assessment tool) documented the resident had severely impaired cognition, did not reject care, weighed 158 pounds, and received nutrition through a feeding tube.The comprehensive care plan initiated 02/15/2024, and revised 12/11/2025, documented the resident required a tube feeding related to poor nutrition and dysphagia. Interventions included to administer water flushes and tube feeding as ordered.Physician orders documented:-12/08/2025 nothing by mouth and 100 milliliters free water flushes before and after each feeding twice daily, at 2:00 PM and 10:00 AM.-01/04/2026 150 milliliters free water flushes three (3) times daily via percutaneous endoscopic gastrostomy (a type of feeding tube) tube every shift. -03/17/2026 30 milliliters of liquid protein supplement once daily, for nutrition, via percutaneous endoscopic gastrostomy tube.-03/17/2026 Jevity 1.5 (tube feeding formula) at 55 milliliters an hour for 20 hours/ day via percutaneous endoscopic gastrostomy tube, start time 2:00 PM and end time 10:00 AM.The 03/17/2026 at 3:12 PM Registered Dietitian #3 Nutrition Assessment documented based on estimated nutritional needs, they recommended to increase the resident's tube feeding rate from 50 milliliters an hour to 55 milliliters an hour for 20 hours a day. This would provide 1750 calories, 85 grams protein, and 1846 milliliters of free water, meeting 99% of their estimated calorie needs, 100% protein needs, and greater than 100% of their fluid needs. They discussed their plan with the nurse practitioner and the Assistant Director of Nursing. The resident remained at high nutritional risk. The April 2026 Medication Administration Record documented Jevity 1.5 (tube feeding formula) at 55 milliliters an hour for 20 hours/ day via percutaneous endoscopic gastrostomy tube, start time 2:00 PM and end time 10:00 AM. Licensed Practical Nurse #5 documented they started the tube feeding and it was infusing at the ordered rate of 55 milliliters on 4/15/2026 at 2:00 PM.The following observations were made:-on 04/14/2026 at 11:16 AM, the resident was in bed. A plastic bottle of Jevity 1.5 was hanging from the tube feeding pump and was not dated or timed. The tube feeding pump monitor was unclean with brownish streaks on it. -on 04/15/2026 at 3:15 PM, the resident was in bed. The pump indicated the tube feeding was infusing at 50 milliliters per hour and 201 milliliters of formula had infused. -on 04/15/2026 at 3:52 PM, the resident in bed. The pump indicated the tube feeding was infusing at 50 milliliters per hour and 234 milliliters of formula had infused.-on 04/16/2026 at 7:24 AM, the resident was in bed. The pump indicated the tube feeding was infusing at 50 milliliters per hour and 23 milliliters had infused. At 8:37 AM, The pump indicated the tube feeding was infusing at 50 milliliters per hour and 87 milliliters had infused. The tube feeding pump monitor was unclean with brownish streaks on it.-on 04/16/2026 at 9:45 AM, the resident's tube feeding pump was alarming and was heard in the hallway. At 9:53 AM, Licensed Practical Nurse #6 donned personal protective equipment and entered the resident's room. They observed the tube feeding pump was alarming and checked the bottle of tube feeding formula. They stated the formula needed to be replaced, as it was empty. They turned off the tube feeding pump, doffed personal protective equipment, and exited the resident's room to gather supplies. At 10:00 AM, Licensed Practical Nurse #6 donned personal protective equipment and entered the resident's room. They shook a 1000 milliliter plastic bottle of Jevity 1.5 and dated the bottle and a plastic piston syringe. They stated they thought the tube feeding infused at 50 milliliters an hour, as that is what they saw on the pump prior to turning it off. They attached the new bottle of formula to the resident's percutaneous endoscopic gastrostomy tube. They checked for gastric residuals (amount of formula, water, and digestive fluids remaining in the stomach) and gastric Ph (acid-alkaline ratio) of the gastric contents. They flushed the percutaneous endoscopic gastrostomy tube with 60 milliliters of water, turned on the pump, which was set at 50 milliliters and hour and exited the room. The tube feeding pump monitor remained unclean with brownish streaks on it.During an interview on 04/16/2026 at 10:48 AM, Licensed Practical Nurse #6 stated prior to administering tube feedings and water flushes staff should check the physician orders to ensure the proper amount of fluids, correct tube feeding formula, and correct rate. They did not review or verify the resident's tube formula or water flush orders prior to administering the tube feeding and water flushes. They stated they reviewed the order after exiting the room and shut off the feeding pump, as the resident's feeding ended at 10:00 AM. Staff should always check the orders as the resident relied on the tube feeding and water flushes to meet their nutritional and hydration needs. During an interview on 04/16/2026 at 11:42 AM Registered Nurse Unit Manager #4 stated all physician orders including tube feeding and water flushes should be followed. Staff should review the orders prior to administering the tube feeding and water flushes to ensure accuracy. If the order was not followed it could have an impact on their nutritional, hydration, and weight status. They were unaware the resident did not receive their tube feeding or water flushes as ordered.During an interview on 04/17/2026 at 11:43 AM Licensed Practical Nurse #5 stated they were supposed to verify the physician orders prior to administering the tube feeding. They did not check the physician orders prior to administering the resident's tube feeding on 4/15/2026. If the resident did not receive their tube feeding as ordered, they would not receive all the nutrients they required. Staff should wipe down the tube feeding pump anytime it was unclean as it was not homelike.During an interview on 04/17/2026 at 12:09 PM Nurse Practitioner #7 stated they expected staff to follow the physician orders for tube feeding and water flushes. They expected to be notified if a resident did not receive their tube feeding or water flushes as ordered, and they were not notified about Resident #52. The resident was dependent on their tube feeding and water flushes to maintain their nutritional and hydration status. During an interview on 04/17/2026 at 2:01 PM Registered Dietitian #3 stated nursing staff should administer the tube feeding and water flushes as ordered. They recommended to increase the resident's tube feeding rate in March 2026 to maintain their usual body weight of 150 pounds. If a resident did not receive their tube feeding or water flushes as ordered it could impact their nutritional, hydration, and weight status. They were not aware the resident did not receive their tube feeding as ordered and would expect to be notified. 10 New York Codes, Rules and Regulations 415.12(g)(2)

Based on observations, record review, and interviews the facility failed to ensure that residents who required dialysis (used to filter waste products from the blood when the kidneys do not work properly) received such services consistent with professional standards of practice for one (1) of one (1) resident (Resident #4) reviewed. Specifically, Resident #4 received hemodialysis treatments at a community-based dialysis center and did not have on-going assessments and oversight before and after dialysis treatments including assessment of the dialysis access site.Findings include: The facility policy Dialysis, last reviewed 01/2025, documented a communication log was be used for each resident that leaves the building for the dialysis center to communicate the resident's needs and response to dialysis treatment. The facility was to track and follow up. The policy did not include assessing the dialysis access sites or vital signs.Resident #4 had diagnoses including end-stage renal (kidney) disease. The 02/12/2026 Minimum Data Set assessment (a health status assessment tool) documented the resident was cognitively intact and required hemodialysis treatments.The comprehensive care plan initiated 08/05/2025 documented the resident needed hemodialysis treatments related to kidney failure. Interventions included dialysis three times a week on Monday, Wednesday, and Friday; monitor the hemodialysis port on the right upper chest for signs and symptoms of bleeding or infection and notify the supervisor immediately. The plan did not include pre and post dialysis assessments.The 12/09/2025 updated physician order documented dialysis three times a week, pre and post dialysis assessments, and monitoring of right upper chest dialysis site for signs and symptoms of bleeding and infection every shift.There was no documented evidence that post-dialysis information was reviewed by the facility for all dialysis treatments between 03/16/2026 and 04/13/2026.There was no documented evidence of access site assessments for 03/16/2026, 03/18/2026, 03/20/2026, 03/23/2026, and 04/03/2026 through 04/13/2026.There was no documented evidence of post-dialysis access site assessments for 03/16/2026, 03/25/2026, 03/27/2026, 03/30/2026, and 04/03/2026 through 04/13/2026.There was no documented evidence of completed dialysis communication reports for 03/25/2026, 03/29/2026, 03/30/3026, and 04/01/2026 in the medical record.During an observation on 04/14/2026 at 11:20 AM, Resident #4 had a hemodialysis access site to the right upper chest. The dressing was clean and intact. During an interview on 04/17/22026 at 10:45 AM, Licensed Practical Nurse #16 stated the general procedure for all dialysis residents was before dialysis, they got vital signs, filled out the dialysis communication sheet, and documented the pre-dialysis information in the electronic health record. When the resident returned, they reviewed the comments and recommendations from the dialysis center and transcribed the information from the dialysis communication form into the electronic health record. They were supposed to monitor dialysis access sites every shift because it could be the source of severe medical complications. They reported any concerns to the nursing supervisor. During an interview on 04/17/22026 at 12:15 PM, Assistant Director of Nursing stated the general procedure for all dialysis residents was the licensed practical nurse performed a pre-dialysis evaluation including monitoring the access site and performing vital signs. They recorded this on the dialysis communication form and in the electronic health record. This assessment was repeated upon return to the facility. The licensed practical nurse also looked at return information from the dialysis center and would report significant findings to the nursing supervisor. Staff placed the dialysis communication form in the resident's personal binder kept at the nurse's station where medical records picked them up and scanned them into the electronic health record.10 New York Codes, Rules and Regulations 483.25(l)

Based on observations, record review, and interviews during the recertification survey, the facility failed to consult with the physician when there was a significant change in the resident's physical status for one (1) of one (1) resident (Resident #3) reviewed. Specifically, Resident #3 had significant weight gain, weights were not obtained as ordered, there was no documented evidence that the physician was notified of a significant weight gain, and the resident was hospitalized .Findings include:The facility policy Change of Resident Condition, revised 01/2025, documented the nurse would notify the physician when there was a significant change in the resident's physical/ emotional/mental condition. A significant change of condition was a major decline or improvement in the resident status that would not normally resolve itself without intervention by staff. Resident #3 had diagnoses including heart failure, chronic kidney disease stage 4 and hypertension. The 04/01/2026 Minimum Data Set (a resident assessment tool) documented the resident had intact cognition, weighed 159 pounds, had weight loss of five (5) percent at one (1) month or ten (10) percent at six (6) months, and received a mechanically altered and therapeutic diet. The resident's weight record documented:-on 01/07/2026 167.5 pounds-on 01/08/2026 167.5 pounds The 01/25/2026 at 7:30 AM, Nurse Practitioner #37 progress note documented nursing staff reported the resident's face was swollen at baseline. The resident had a history of end stage renal disease and refused dialysis (medical procedure that filters blood when kidneys fail). Nursing staff was advised to administer furosemide as ordered and monitor urine output, vital signs, oxygen saturation, and respiratory status closely. Notify the provider immediately if there were any changes in respiratory status, urine output, or worsening edema. The 01/25/2026 at 9:20 AM, Nurse Practitioner #37 progress note documented nursing staff called and reported the resident complained of itching and mild pain eye pain. Given new symptoms of eye pain in the presence of facial edema and renal failure the resident would be sent to the hospital for further evaluation. The 01/29/2026 Physician #34 progress note documented the resident was readmitted to the facility. They recently were started on losartan (high blood pressure medication) and presented with angioedema (deep facial swelling) due to losartan. The medication was discontinued, and allergy list was updated. The resident's hospital course was complicated by acute congestive heart failure (a life-threatening medical emergency characterized by rapid onset of severe symptoms due to fluid buildup in the lungs and body), acute kidney injury, and chronic kidney disease. Management included furosemide (diuretic) 40 milligrams twice daily, and renal dietary restrictions including 1500 milliliter fluid restriction. Physician orders documented:-on 01/29/2026 - 02/03/2026: weekly weights every day shift on Tuesday for weight monitoring-on 01/30/2026 - 02/25/2026: 40 milligrams of Furosemide twice daily for edema -on 02/03/2026: Renal (a diet limiting sodium, potassium, phosphorus, to reduce kidney workload), no concentrated sweet, and 1500 milliliter fluid restriction. –on 02/03/2026 - 03/10/2026: weights upon admission, the next day, and weekly for four weeks thereafter. If no noted weight concerns weights would be monitored monthly. -on 02/04/2026: remove compression stockings before bed for bilateral lower extremity for 3+ pitting edema (swelling that leaves indentation after pressure is applied).-on 02/05/2026: apply compression stockings in the morning for bilateral lower extremity 3+ pitting edema. The resident's weight record documented: -on 02/01/2026 166.8 pounds-on 02/10/2026 178.6 pounds (11.8 pound/ 7% gain) in nine (9) days. There was no documentation that a reweigh was obtained. There was no documented evidence that a reweight was obtained and the medical provider was notified of the severe weight gain from 02/02/2026 to 02/10/2026. The 02/11/2026 Registered Dietitian #3 progress note documented the resident's weight on 02/10/2026 was 178.6 pounds, this was greater than five (5) pound change from previous weight and a reweight was requested. There was no documented evidence that a reweight was obtained and the medical provider was notified of the severe weight gain from 02/02/2026 to 02/10/2026. On 02/16/2026 Registered Nurse #35 documented the resident had 2+ edema, their face edema had increased, and labs were drawn. There was no documented evidence of a weekly weight on 02/17/2026. The 02/19/2026 Registered Nurse #35 progress note documented the resident had 2+ edema, their face edema had increased, and labs were drawn. The 02/20/2026 Licensed Practical Nurse #36 progress note documented the resident's lower extremities were swollen, the supervisor was made aware, and compression stockings would not be worn due to swelling. There was no documented evidence the medical provider was notified of the resident's worsening edema. The 02/24/2026 Assistant Director of Nursing/ Licensed Practical Nurse #8 progress note documented the resident had increased angioedema, was unable to open eyes, and complained of difficulty breathing. Their bilateral lower extremities were observed with 4+ pitting edema (indicates significant fluid retention). Medical was notified and the resident would be sent to the hospital. The 02/24/2026 Physician #34 progress note documented the resident reported difficulty breathing and facial swelling. They were unable to open their eyes due to increased angioedema. They had bilateral lower extremity 4+ edema. Their assessment documented acute angioedema with airway compromise, fluid overload secondary to chronic kidney disease with pulmonary (lung) congestion, and significant peripheral edema. The resident was to be sent to the emergency room for acute management. The 01/24/2026 hospital emergency department summary documented the resident presented with facial and leg swelling. The resident was ill-appearing, had diffuse facial swelling, decreased breath sounds, and right and left lower leg edema. During an interview on 04/17/2026 at 1:17 PM, Certified Nurse Aide #14 stated the registered dietitian provided the unit with a weight list for monthly weights. The Director of Nursing provided a list of weekly weights and the certified nurse aides obtained weights. Resident #3 had weight fluctuations related to their fluid status and was on weekly weights. During an interview on 04/17/2026 at 1:46 PM, Licensed Practical Nurse #16 stated residents were weighed as ordered. Weights were obtained as soon as possible and if a resident refused to be weighed nursing would document the refusal. They did not know if Resident #3 had any weight changes. During an interview on 04/17/2026 at 1:47 PM, Assistant Director of Nursing #8 stated weights were obtained as ordered and the registered dietitian requested reweights as needed. Significant weight changes were discussed during the weekly weight meeting, and the registered dietitian notified the medical provider of any significant weight changes. They were unsure if Resident #3 had any significant weight changes, but they went to the hospital for fluid overload. The facility was monitoring their edema and if staff were unable to obtain the resident's weight, they should notify the nursing supervisor and document the weight was unable to be obtained. During an interview on 04/17/2026 at 1:59 PM, Registered Dietitian #3 stated the weight process recently changed at the facility as they were having issues getting weights as ordered. The Director of Nursing or the Assistant Director of Nursing provided the units with a weight list. Any resident who had a weight change of five (5) pounds should have a reweight. Residents who had a significant weight change were discussed in the weekly weight meeting. The medical team did not always attend the weight meetings, and they notified the medical provider verbally of any significant weight changes. Resident #3's weights were not obtained as ordered and they had fluctuations. It was important to obtain weights as ordered to monitor the resident's fluid status. During an interview on 04/17/2026 at 2:44 PM, Nurse Practitioner #7 stated they expected weights to be obtained as ordered, and if the resident refused it should be documented. Medical attended the weight meeting if they were in the building and if they were not at the meeting they would expect to be notified. They expected the medical providers to assess the resident and document on significant weight changes if they were notified. During an interview with the Director of Nursing on 04/17/2026 at 2:50 PM, they stated weights were to be obtained as ordered, the registered dietitian provided a list to the units of who needed to be weighed and any needed reweights. The facility had a weekly weight meeting and discussed significant weight changes. 10 New York Codes, Rules, and Regulations 415.3(2)(ii)(a)

Based on record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (1) of one (1) resident (Resident #85) reviewed. Specifically, Resident #85 was admitted to the facility, was not assessed by a registered nurse until three (3) days later on the day they were discharged against medical advice; physician orders were not completed; treatments were not provided as ordered; diagnostic testing was not completed as ordered; and care was not provided for two (2) of nine (9) shifts during the residents admission. Additionally, when the resident was discharged against medical advice there was no documented evidence of who the resident left with, if education was provided to the resident, and if a medical provider was notified. Findings include: There was no documented evidence of a policy addressing admission assessments by a registered nurse. The undated facility admission Agreement documented residents received basic services including 24-hour a day professional nursing care. The facility policy Against Medical Advice, revised 08/2025, documented residents and family members understood their rights to request an immediate discharge without physician's approval. Nursing staff informed medical staff and social work if a resident or representative requested an immediate discharge. The Director of Social Work notified the Director of Admissions, Director of Nursing, and the Administrator of the resident leaving against medical advice. Medical staff/ social work documented and discussed with the resident and family member the current medical condition and consequences of discharge. Prescriptions were provided at the physician's discretion. Social work asked where they were going and how they were going to get there. Social Work called Adult Protective Services regarding the discharge. Social work documented in the Medical Record the names of the individuals they spoke with from various agencies. Resident #85's 03/18/2026 at 10:00 AM Hospital Discharge Summary/Instructions documented the resident was hospitalized from [DATE] through 03/18/2026. The resident was in the intensive care unit until 03/11/2026 when they were transferred to a medical floor. They were critically ill and required mechanical ventilation three (3) times, emergency surgery, medications to maintain their blood pressure, intravenous antibiotics, artificial feeding (tube delivered nutrition directly to the stomach), and had a post-surgical wound vacuum (device used to close wounds). Follow up care with surgery, neurology, neurosurgeon, cardiovascular, and primary care provider was recommended. Their discharge diagnoses included atrial fibrillation and flutter (irregular heartbeat), acute respiratory failure (breathing problems), stomach perforation (hole through the stomach wall), upper gastrointestinal hemorrhage (internal bleeding), acute kidney failure, ischemic stroke (blood flow and oxygen are cut off to part of the brain) with dysphagia (difficulty swallowing), and expressive language disorder (difficulty with verbal communication). Activity recommendations included activity as tolerated, three (3) liters of oxygen via nasal cannula continuously, bilevel positive airway pressure mask (device that aids breathing) at night. Dietary recommendations included mechanical soft texture with nectar thickened liquids and one (1) can of Ensure High Protein (nutritional supplement) twice a day. Additional instructions documented wound care with wound cleanser, pack with moistened kerlix, cover with dry gauze and change daily. The resident was discharged to the facility for short term rehabilitation. There was no documented evidence of a nursing progress notes addressing the resident's admission to the facility. There was no documented evidence a nursing admission assessment was completed. The 03/18/2026 facility staffing documented there was not a registered nurse working on the evening or night shifts. The 03/17/2026 physician orders with a start date of 03/18/2026 documented:-By Physician #38 pre-assessment: administer incentive spirometer (a device used to expand lungs) therapy to resident at least daily for 14 days to assist with lung function.-By Physician #34 post assessment: administer incentive spirometer therapy to resident at least daily for 14 days to assist with lung function. There was no documented evidence the resident was provided with incentive spirometry therapy or pre and post assessments were completed. The 03/18/2026 physician orders documented:-By Nurse Practitioner #39, cleanse abdominal incision/wound with wound cleanser, pack with moistened gauze, and cover with dry gauze daily. There were no orders for wound monitoring. -By Physician #34, laboratory tests including complete blood count with differential (lab test that measures blood cells), iron, folate, ferritin, total iron binding capacity, complete metabolic panel, prealbumin level, lipid profile, liver function tests, vitamin D, glycated hemoglobin (HgbA1C), thyroid-stimulating hormone, and free thyroxin, Vitamin B12 (diagnostic blood tests) one time only for monitoring. There was no documented evidence the abdominal wound was assessed/ monitored, or the diagnostic blood tests were collected. The 03/19/2026 physician orders documented:-By Physician #34, drain the Jackson Pratt drain (removes extra fluids from a surgical site) to the abdomen every shift status post full exploratory laparotomy (abdominal surgery); oxygen via nasal cannula at three (3) liters per minute continuously for acute respiratory failure with hypoxia (lungs do not oxygenate the blood sufficiently). There were no orders for site monitoring or dressing changes around the drain site.-By Nurse Practitioner #39, complete blood count, complete metabolic panel, phosphorus, and magnesium (diagnostic blood tests) one time related to acute kidney failure. There was no documented evidence the drain site was assessed, a dressing around the drain was changed, or the diagnostic blood tests were collected. There was no documented evidence of a physician order for the use of bilevel positive airway pressure mask at night. The 03/20/2026 at 9:25 AM, Director of Social Work admission assessment documented the resident's family was supportive and motivated to have the resident return to their home to care for them. The family ordered a mechanical lift for the home. The 03/20/2026 at 12:33 PM, Registered Nurse #35 progress note documented the resident's family wished to take them home and would purchase a mechanical lift if needed. The 03/21/2026 at 7:57 AM Registered Nurse #23 admission progress note documented the resident was admitted on [DATE] at 1:16 PM from an acute hospital for short term rehabilitation (four days after admission). The 03/21/2026 at 2:21 PM Registered Nurse #23 progress note documented the resident was not satisfied with the care provided at the facility. Their abdominal dressing was changed this morning, and their oxygen was on. There was no documented evidence the resident received activity of daily living care on 03/20/2026 on the evening shift, or on 03/21/2026 on the day shift. The 03/21/2026 Discharge Minimum Data Set assessment (a health status assessment tool) documented return was not anticipated. The discharge was unplanned, and the resident was discharged home. The resident had severely impaired cognitive decision-making skills. The resident required substantial/ maximum assistance or was dependent with most activities of daily living. The 03/21/2026 facility transfer/discharge report documented the resident was discharged at 3:00 PM to a private home with no home health services. The 03/21/2026 at 3:09 PM Post admission Note by Registered Nurse #23 documented the resident was admitted on [DATE]. They had skilled needs for rehabilitation, nutritional, respiratory, cardiac, and wounds. They received physical, occupational, and speech therapies. They required assistance of two for activities of daily living. Required nursing interventions included medication and treatment administration as per physician orders, intakes and outputs were monitored, assistance with activities of daily living, Jackson Pratt drain care and abdominal wound dressing changes. They needed a ground texture diet with nectar thickened liquids and aspiration precautions. They received oxygen via nasal cannula at three (3) liters per minute continuously. There was no documented evidence the resident left against medical advice; who they left with; or if they/ their representative were educated on their medication conditions, altered diet, medications, wound care, care of the Jackson Pratt drain, oxygen therapy, follow up care with their medical providers, and risks of leaving against medical advice; and the medical provider was notified. The 03/23/2026 at 9:30 AM Director of Social Work progress note documented they were updated the resident left against medical advice on 03/21/2026. They called the resident's family that morning, left a voicemail message, and was waiting for a call back. They contacted Adult Protective Services to relay contact information. The note did not document who they spoke with at Adult Protective Services or if the medical provider was notified. The 03/23/2026 at 1:15 PM, Physician #38 progress note (late entry) documented it was confirmed the resident left against medical advice from a social work note that posted on 03/23/2026. There was no documentation about medical team involvement. During an interview on 04/17/2026 at 9:53 AM, Certified Nurse Aide #14 stated when there was a new admission, they introduced themselves, got their weight, and oriented them to their room. The nursing supervisor or any registered nurse could go in and do their assessment. In the event a resident wished to discharge against medical advice, they would get any staff member that was above them. They did not recall Resident #85. During an interview on 04/17/2026 at 10:08 AM, Licensed Practical Nurse #16 stated when a new admission came in, the resident received an entrance packet, was weighed, and initial vital signs were obtained. They then informed the Director of Nursing there was a new admission or the Unit Manager to do an assessment. They did not currently have a unit manager, so the Assistance Director of Nursing was filling in that role. The admission assessment was completed by a registered nurse as soon as they arrived within 24 hours. If a resident wanted to leave against medical advice, they talked to them to determine what the issue or driving force was. They informed the Director of Social Work to intervene. If the resident did leave against medical advice, they charted a nursing note and notified the supervisor. They did not recall Resident #85. During an interview on 04/17/2026 at 10:16 AM, the Assistant Director of Nursing stated they were covering as the A wing unit manager. In the event of an admission, they greeted the resident, obtained a weight, and escorted them to their room. They notified all department heads, told the staff on the floor, and obtained a diet order. They could not assess them as a licensed practical nurse so either B wing Registered Nurse Unit Manager #4, the Director of Nursing, or the registered nurse supervisor on the evening shift was responsible the resident was assessed within 24 hours. If a resident wished to leave against medical advice, they educated them on the risks associated and tried to convince them otherwise because it was not in their best interest. They could not assist residents that were discharged against medical advice, and they were on their own. There was a paper they signed if they discharged against medical advice. There was a progress note, and the orders were discontinued. Adult Protective services and the resident's primary care provider were notified. They did not recall Resident #85 but looked up their electronic medical chart. They were not assessed by a registered nurse within 24 hours. The admission assessment was important to ensure orders and care were correctly coordinated. There was not a nursing note indicating the resident left against medical advice. The medical team should have been notified if a resident left against medical advice in case there was something they needed to tell them. During an interview on 04/17/2026 at 1:43 PM, the Director of Social Work stated if a resident wanted to leave against medical advice, they notified a medical provider if they were present and if not a nurse or a nurse supervisor. If the resident was adamant about leaving, they signed an against medical advice form. They documented in a note the form was signed, who the resident left with, and that adult protective services was notified. If this happened during off hours, the supervisor or a nurse should enter a progress note. Resident #85 left on a Saturday (03/21/2026) and they found out about it on Monday (03/23/2026). They did not recall how they found out. There was no nursing documentation. Physician #38's note documented they found out from their progress note the following Monday. Things needed to be explained to the resident medically, so they understood the severity of the risks. During a telephone interview on 04/17/2026 at 1:48 PM, Physician #38 stated a member of the medical team optimally was notified if a resident wished to leave against medical advice. That way the medical team had the opportunity to interact with the resident and answer any questions to ensure their safety, reviewed risks versus benefits and alternatives to ensure continuity of care and safe transitions, and provided a bridge of therapy while in the transition from skilled nursing to the outpatient world. They looked up Resident #85 in the electronic medical record and recalled they were not at the facility for long. They were not notified of the discharge against medical advice in real time. The resident was discharged on a Saturday but there was an on-call service and a satellite team that could have facilitated the opportunity to interact with the resident for the previously stated reasons. During an interview on 04/17/2026 at 2:36 PM, the Director of Nursing stated Resident #85 was admitted on [DATE]. admission assessments were expected to be completed within 24 hours by the registered nurse on duty. The order notes went in around 3:30 PM by the Assistant Director of Nursing and they should have contacted the registered nurse supervisor. There should have been a registered nurse for the evening shift. The resident did not have a registered nurse assessment until 03/21/2026 on the day they discharged against medical advice. The admission assessment was to determine what the resident needed to be properly cared for. There was a social work note the resident left against medical advice. The registered nurse supervisor was responsible to ensure medical was notified and it was documented. The resident signed an against medical advice form, but Resident #85 did not have one in their electronic record. Also, education on the risks of leaving against medical advice should have been provided but they did not see documentation of that either. The resident's electronic record did not reveal where they went, who they went with, why, and if any education was provided, so there was really no way of knowing what happened. 10 New York Codes, Rules, and Regulations 415.12

Based on observations, record review, and interviews, the facility failed to ensure services provided met professional standards of clinical practice for one (1) of four (4) residents (Resident #7) reviewed. Specifically, Resident #7 regularly refused their ordered inhaler and nebulizer treatments (respiratory treatments) and there was no documented evidence the physician was notified of the refusals or reviewed the resident's medication administration records during their monthly visits; there was no documented evidence the irregularity of the refused medications were noted by the pharmacist during their monthly medication reviews; and there was no documented evidence of a care plan related to the resident's refusals of their medications. Findings include: The facility policy Medication Orders, last reviewed 01/2025, documented each resident must be under the care of a licensed physician authorized to practice medicine in this state and must be seen by the physician at least every sixty days. A current list of orders must be maintained in the clinical record of each resident. Physician orders and progress notes must be signed and dated every thirty days unless the frequency was increased to 60 days by the attending physician and the Utilization Review Committee. The facility policy Medication Regime Review, revised 08/2025, documented the consultant pharmacist performed a comprehensive medication regimen review at least monthly. The review included evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. In performing medication regimen reviews, the consultant pharmacist incorporates federally mandated standards of care, in addition to other applicable professional standards. The consultant pharmacist identifies irregularities through a variety of sources including medication administration records. Resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented on a Medication Regimen Review form and reported to the Director of Nursing, physician and the Medical Director. Resident #7 had diagnoses including chronic obstructive pulmonary disease (lung disease) and cerebral palsy. The 02/22/2026 Minimum Data Set documented the resident had severely impaired cognition, had no behavioral symptoms, and required moderate assistance for all activities of daily living. The 08/19/2024 Comprehensive Care Plan, revised 09/05/2025, documented the resident had an alteration in their respiratory system related to chronic obstructive pulmonary disease, being a smoker, shortness of breath while lying flat and a lung nodule. Interventions included administer treatments (nebulizer) and medication per the medical orders, provide psychiatric services for anxiety or fear, and observe vital signs as ordered and report to the medical provider any abnormalities. Physician orders documented:-on 06/12/2025 inhale 3 milliliters of ipratropium-albuterol Solution 0.5-2.5 milligrams/3 milliliters orally three times a day for chronic obstructive pulmonary disease and lung nodule.-on 11/17/2025 inhale 2 milliliters of budesonide inhalation suspension 0.5 milligrams/2 milliliters orally two times a day for chronic obstructive pulmonary disease and asthma wheeze and rinse mouth after. The March 2026 Medication Administration Record documented the resident refused their two budesonide inhalation suspension 0.5 milligram/2 milliliter except for the:- 8:00 AM dose on 03/03/2026, 03/10/2026, and 03/24/2026;- 7:00 PM dose on 03/02/2026, 03/06/2026, 03/07/2026, 03/10/2026, 03/11/2026, 03/13/2026, 03/14/2026, 03/20/2026, 03/21/2026, 03/24/2026, 03/25/2026, and 03/28/2026. The March 2026 Medication Administration Record documented the resident refused their ipratropium-albuterol Solution 0.5-2.5 milligram/3 milliliter except for the:- 8:00 AM dose on 03/03/2026, 03/10/2026 and 3/24/2026;- 2:00 PM dose on 03/06/2026, 03/10/2026, 3/13/2026, and 3/24/2026;- 7:00 PM dose on 03/02/2026, 03/06/2026, 03/10/2026, 03/11/2026, 03/13/2026, 03/14/2026, 03/20/2026, 03/21/2026, 03/24/2026, 03/25/2026, and 03/28/2026. The April 2026 Medication Administration Record documented the resident refused their budesonide inhalation suspension 0.5 milligram/2 milliliter except for the:- 8:00 AM dose on 04/04/2026 and 04/07/2026;- 7:00 PM dose on 04/02/2026 through 04/04/2026, 04/07/2026, 04/08/2026, 04/11/2026, 04/13/2026, 04/15/2026, and 04/16/2026. The April 2026 Medication Administration Record documented the resident refused their ipratropium-albuterol Solution 0.5-2.5 milligram/3 milliliter except for the:- 8:00 AM dose on 04/04/2026- 2:00 PM dose on 04/08/2026- 7:00 PM dose on 04/03/2026, 04/04/2026, 04/07/2026, 04/08/2026, 04/11/2026, 04/13/2026, 04/15/2026, and 04/16/2026 There was no documented care plan related to the resident's refusals of medications. The 03/28/2026 Physician #30 progress note documented the resident was seen for a routine monthly follow up and medication review. The staff reported no shortness of breath or any new or worsening concerns. The plan of care for the resident's chronic obstructive pulmonary disease was the resident was stable on albuterol nebulization 2.5/3 milliliter inhale and budesonide inhalation 0.5mg/2 milliliters inhaler twice daily. There was no documented evidence the provider was notified regarding the resident refusals of budesonide inhalation suspension or ipratropium-albuterol solution breathing treatment, or a review of the resident's medication administration record was completed. The February and March 2026 pharmacy reviews completed by Pharmacist #40 had no recommendations or irregularities noted. During an interview on 04/07/2026 at 10:36 AM, Licensed Practical Nurse #26 stated if a resident refused medications or treatments, they tried to educate the resident on the medication and encourage them to take it. If a resident still refused their medication or treatment, they notified Registered Nurse Unit Manager #4 and wrote a progress note. Resident #7 had not taken their inhaler or nebulizer treatment for a long time. They inquired about getting the medications discontinued or made as needed since the resident did not take them. During an interview on 04/17/2026 at 12:11 PM, Registered Nurse Unit Manager #4 stated if a resident refused a medication or treatment the nurse should tell them as the unit manager, and they should probably tell someone else. They were aware Resident #7 refused both their inhaler and their nebulizer treatment on a consistent basis. The resident did not even allow the nebulizer machine in their room. They had a conversation with the provider, who was no longer at the facility, about getting rid of the orders. They believed they had a conversation with the current providers but was unsure. They tried to discontinue the orders themself but was unable to. If the orders were not going to be discontinued, the resident should have a refusal care plan. During an interview on 04/17/2026 at 1:48 PM, Medical Director #38 stated ideally the medical provider should review the medication and treatment administration records for medication compliance. The medical team should be notified if a resident was consistently refusing an inhaler or a nebulizer. They met with Resident #7 on 04/16/2026 regarding their pulmonary history and lung nodule/pulmonary mass. They stated they were unaware the resident did not consistently take their inhaler or nebulizer. That is something they should have been made aware of as the resident may not need to be on the medications if they were stable without them. During an interview on 04/17/2026 at 2:04 PM, Pharmacist #40 stated they reviewed the resident's medication and treatment administration records for medication compliance when they did a pharmacy review. If they noticed a resident had a lot of refusals, they read the nursing progress notes to see if there was a pattern and they would write it up. During a follow up interview at 2:33 PM, Pharmacist #40 stated they met with the Director of Nursing and the nurses every month to go over medications and discontinue unnecessary medications. They were aware Resident #7 was refusing their inhaler and their nebulizer treatment and had put in their own notes that the resident had a lung nodule and chronic obstructive pulmonary disease. When a resident had diagnoses such as these attached to the medications, they did not recommend discontinuing medications as it was out of their scope. 10 New York Codes, Rules, and Regulations 415.11(c)(3)(i)

Based on observations and interviews the facility failed to ensure the results of the most recent Federal and State surveys were posted in a place readily accessible where individuals who wished to examine the survey results did not have to ask for them. Specifically, the facility did not provide records for the standard health survey results or any complaint survey results and subsequently, there was no posted notification of the availability of the previous three (3) years of survey reports. Findings include:The New York State Department of Health Your Rights as a Nursing Home Resident in New York State documented residents had the right to read the results of the most recent State and Federal inspection survey and the facility's plan to correct any violations. During an anonymous resident group meeting on 04/14/2026 at 2:00 PM, six residents stated they had never seen any previous survey results and did not know where they were located. During a walk-through of the entire facility on 04/14/2026 at 11:22 AM and on 04/15/2026 at 10:22 AM, there was no posted notification of the availability of survey reports and there were no surveys readily available for individuals who wished to examine the survey results without asking. During an interview on 04/17/2026 at 9:53 AM, Certified Nurse Aide #14 stated they did not know how the residents were able to review the previous survey results. During an interview on 04/17/2026 at 10:08 AM, Licensed Practical Nurse #16 stated they thought the previous survey results were in the Director of Nursing's office. During an interview on 04/17/2026 at 10:16 AM, the Assistant Director of Nursing stated they would have to ask the Director of Nursing where the previous survey results were located. During an interview on 04/17/2026 at 2:36 PM, the Director of nursing stated they thought there was a binder of previous survey results on the bulletin board near the front entrance. It was a resident right to review the previous survey results, so they knew what was going on and happening in their home. 10 New York Codes, Rules and Regulations 415.3(1)(c)(1)(v)

Based on record review and interviews the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries for one (1) of three (3) residents (Resident #93) reviewed. Specifically, Resident #93 remained in the facility after discontinuation of Medicare Part A services and the facility did not provide the resident with timely Notice of Medicare Non-Coverage (Centers for Medicare and Medicaid Services-10123) when Medicare Part A coverage was ending, nor a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (Centers for Medicare and Medicaid Services-10055) for Medicare Part A, as required.Findings include: The undated facility policy Advance Beneficiary Notification and Notice of Medicare Non-Coverage, documented the facility follows the Centers for Medicare and Medicaid Services guidelines for both the Advance Beneficiary Notification and Notice of Medicare Non-Coverage. When a resident is no longer eligible for skilled coverage under Medicare Part A, the facility must issue an Advance Beneficiary Notification and Notice of Medicare Non-Coverage to the resident or their legal representative with a minimum notice of two days. If a resident is competent the facility may deliver the Advance Beneficiary Notification/Notice of Medicare Non-Coverage in person and obtain the residents' signature and date and leave a signed copy with the resident. If the resident is incompetent, the facility may deliver the Advance Beneficiary Notification/Notice of Medicare Non-Coverage to the resident's legal representative. The facility must also notify the representative in person if available or via phone. The staff is to document the representative's name, phone number, date and time you spoke with them and send certified mail on the same day you spoke with them. When a resident is on Medicare Part A and has a planned discharge a Notice of Medicare Non-Coverage must be delivered to the resident or their legal representative with a minimum notice of two days.The Centers for Medicare and Medicaid form instructions for the Notice of Medicare Non-Coverage (CMS Form 10123; expiration date 11/30/2027) documents a Medicare provider must give a completed copy of this notice to beneficiaries receiving services from skilled nursing facilities not later than two (2) days before the termination of services.The Centers for Medicare and Medicaid Services form instructions for the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage Center for Medicare and Medicaid Services-10055 (10/31/2024 Edition), documented a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (form 10055) must be issued by providers to beneficiaries in situations where Medicare payment was expected to be denied. The Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage must be delivered far enough in advance that the beneficiary or representative had time to consider the options and make an informed choice prior to services ending.Resident #93 had diagnoses including stroke and right side paralysis and weakness. The 12/14/2025 Minimum Data Set assessment documented it was a Skilled Nursing Facility Part A Prospective Payment System (a method of reimbursement used by Medicare that pays a predetermined amount for a service) discharge assessment, and the resident had a Medicare-covered stay with a start date of 10/01/2025 and an end date of 12/13/2025. The resident had intact cognition. There was no documented evidence Centers for Medicare and Medicaid Services Forms 10055 and 10123 were provided to Resident #93 when Medicare benefits ended. During an interview on 04/16/2026 at 12:18 PM, the Rehabilitation Director stated they were responsible for providing the Centers for Medicare and Medicaid Services Form- 10123, and the Notice of Medicare Non-Coverage and Centers for Medicare and Medicaid Services Form 10055 Advance Beneficiary Notification to residents. They stated they assumed this responsibility after the facility's Minimum Data [NAME] Coordinator left the organization, but they did not receive any training for the task. The Centers for Medicare and Medicaid Services Form 10055 was not provided to Resident #93 but should have been. The Centers for Medicare and Medicaid Services Form 10123 was provided to Resident #93, but the facility was unable to locate the copy. Due to a system process previously in place, many of the Centers for Medicare and Medicaid Services Forms 10123 and 10055 provided to residents were lost, and the facility was unable to locate them. They stated it was important to provide these notices to residents to provide adequate notice their coverage would be ending; to ensure residents were aware of out of pocket costs for continued services; to ensure the resident had the opportunity to appeal the decision; and to ensure residents would not receive a bill for services they could not afford to pay. During an interview on 04/17/2026 at 11:34 AM, the Administrator stated they were familiar with the Notice of Medicare Non-coverage and Advanced Beneficiary Notices, however, they were not involved in the process. The Administrator stated they were aware the facility had a problem with locating the Centers for Medicare and Medicaid Services Form 10123 and Centers for Medicare and Medicaid Services Form 10055 provided to residents, and that was a deficient practice of the facility. They stated providing these notices to residents was important to make sure residents were aware of their options in case their benefits ran out; to prevent residents from incurring charges they were not prepared for, creating hardship for the residents; and to provide the residents peace of mind. 10 New York Codes Rules and Regulations 483.10 (g) (18)

Based on observations and interviews, the facility failed to ensure nurse staffing information was posted daily at the beginning of each shift and included the daily current resident census and the total number, and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift in a prominent location readily accessible to residents and visitors for four (4) of four (4) days (04/14/2026, 04/15/2026, 04/16/2026, and 04/17/2026) reviewed. Specifically, the facility did not post the daily nurse staffing on 04/14/2026 and the posted daily nurse staffing on 04/15/2026, 04/16/2026, and 04/17/2026 did not include the resident census and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care as required.Findings include:The undated facility policy Posting Direct Care Daily Staffing Numbers, documented the facility would post the number of nursing personnel responsible for providing direct care to residents on a daily basis for each shift. The information recorded on the form should include: the name of the facility, the date for which the information was posted, the resident census at the beginning of the shift for which the information was posted, the actual time worked during the shift for each category and type of nursing staff, and the total number of licensed and non-licensed nursing staff working for the posted shift.During observations on 04/14/2026 at 11:00 AM and 4:00 PM, the daily nurse staffing information was not posted in the main lobby, on the main entrance doors, or down the main hallway in between both units. The daily nurse staffing information was posted on the wall in a clear plastic frame in the main hallway across from the Administrator's office and did not include the resident census or actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care on 04/15/2026 at 1:11 PM; on 04/16/2026 at 8:18 AM and 5:00 PM; and on 04/17/2026 at 8:19 AM.During an interview on 04/17/2026 at 11:30 AM, Nursing Scheduler #18 stated they were responsible for making the nursing schedule and for posting the daily nurse staffing information for the day and evening shift. The nursing supervisor was responsible for posting the night shift and weekend nurse staffing when they were not working, and it was supposed to be posted in the hallway outside of the Administrator's office. They thought they had posted the nurse staffing on 04/14/2026 but could not recall. They were not aware the daily census or actual hours worked by licensed and unlicensed nursing staff were required. 10 New York Codes, Rules, and Regulations 415.13

Based on record review and interviews during the abbreviated (iQIES reference number 2610929) survey the facility did not ensure laboratory services were obtained to meet the needs of its residents for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Resident #1 had physician orders for laboratory tests to check their vancomycin (antibiotic) trough level (blood test used to monitor the antibiotic's effectiveness and to minimize toxicity) and the laboratory tests were not performed timely or accurately. Findings include:The facility policy Vancomycin Management, dated 01/2025, documented renal function should be monitored at least twice weekly or more frequently based on physician orders. Trough level monitoring should be completed to ensure adequate serum levels for efficacy while avoiding toxicity. Lab draw should happen within 30 minutes prior to the fourth dose, after dose adjustments, significant changes in renal function, or during prolonged therapy. With prolonged therapy testing should be repeated every 3-5 fays or per physician orders. Nursing would initiate orders per physician ordered timing with laboratory to ensure timely blood draws. Resident #1 had diagnoses including osteomyelitis (bone infection) of thoracic vertebra and local infection of skin and underlaying tissue. The 04/16/2025 Minimum Data Set assessment documented the resident was cognitively intact and received antibiotics. The Comprehensive Care Plan initiated 04/7/2025 and revised on 04/22/2025 documented the resident received antibacterial therapy for sepsis (systematic infection of the blood), discitis of the thoracic region (infection of the spinal discs), and osteomyelitis of the thoracic vertebrae. Interventions included monitor for side effects of the antibiotic, report all side effects to the medical provider, and monitor for efficacy of the antibiotic chosen as well as adverse reactions during the course of antibiotic and post completion. The 3/28/2025 hospital Physician #15 Hospital Discharge Summary documented Resident #1 was started on cefepime and vancomycin on 04/04/2025. Infectious Disease Physician #16 recommended to continue with both antibiotics until 06/27/2025. Monitor vancomycin trough level weekly to maintain between 18 microgram/milliliter and 20 microgram/milliliter. Monitor weekly complete blood count, complete metabolic panel, and c-reactive protein while on the intravenous antibiotics. Physician orders documented: -04/07/2025 by Physician #1 vancomycin intravenous solution one (1) gram intravenously every 12 hours for anti-infective agent, on hold from 04/18/2025-04/23/2025. -04/14/2025 by Physician #1 vancomycin trough every Monday until 06/30/2025.-04/18/2025 by Physician #1 vancomycin trough one time only the last dose of vancomycin given 04/17/2025 at 8:00 PM, to start on 04/18/2025. The 04/2025 Laboratory Administration Record documented to check the vancomycin trough one time only for 1-day, last dose of vancomycin given 04/17/20205. The Laboratory Administration Record was blank/not signed on 04/18/2025 and 04/19/2025 for the completion of the labs. There was no documented evidence the resident's vancomycin trough was completed on 4/14/2025 or 4/21/2025. During a telephone interview on 10/16/2025 at 9:59 AM, Consultant Pharmacist #18 stated they expected the facility to contact them with vancomycin trough levels, and they could assist with dosing amounts and administrations times. The trough should be drawn after the fourth dose, a half hour before the next dose. The facility did not contact them about vancomycin troughs. They stated they did not recall Resident #1, and there was nothing in the computer for them to reference. The facility never contacted them about Resident #1 or their vancomycin troughs. During a telephone interview on 10/16/2025 at 10:09 AM, Pharmacist #19 (from the Medication Delivery Pharmacy) stated they supplied the facility with medications. The vancomycin trough should be drawn for weekly monitoring for a set dose, or long-time user. Upon review of the pharmacy records, Pharmacist #19 stated the resident started on vancomycin on 04/07/2025. The pharmacy contacted the facility on 04/11/2025 about the need for a vancomycin trough. The pharmacy was told the facility would draw the trough on 04/14/2025. On 04/14/2025, the pharmacy followed up and the facility stated they were going to draw the trough on 04/16/2025. On 4/18/2025, the facility stated the lab sat too long and needed to be redrawn and would be drawn again on 04/21/2025. On 4/21/2025, the facility stated the trough was high and the resident was sent to the hospital, and the vancomycin was put on hold. During a telephone interview on 10/16/2025 at 11:58 AM, Registered Nurse #5 stated the registered nurses in the facility drew the blood for the labs from the peripherally inserted central catheters (venous access). The lab order was completed, and they called the lab to come get the specimens. During an interview on 10/16/2025 at 12:57 PM, Assistant Director of Nursing #7 stated labs went out on Monday, Wednesday, and Friday. Orders were usually placed with a 3-day window so they could be drawn on one of those days. A list of who needed labs drawn was provided to the phlebotomist (person who draws blood). The phlebotomist completed a venipuncture (drawing blood with a needle) for a resident with a peripherally inserted central catheter, or the registered nurse could draw the blood and give the vial to the phlebotomist to bring to the lab. The vancomycin trough should be drawn before the next dose was given. Resident #1 got vancomycin at 9:00 AM and 9:00 PM, the trough should be drawn at 8:00 AM. The 1:00 PM or 4:00 PM draw would not be appropriate. The trough was meant to see the lowest level of vancomycin in the body system, so it needed to be before the next dose. If the trough was not done at the appropriate time it could result in a higher value due to the timing of the dose completion. The 04/14/2025 laboratory order should have been done, and they were not sure why it was not. Upon review of the records, Assistant Director of Nursing #7 stated the only vancomycin trough they could find was on 04/18/2025. There was no trough done on 04/14/2025. There was a note on 04/15/2025 documenting labs were drawn, but did not specify if the labs were for vancomycin. There were no laboratory results for 04/14/2025 in the computer. During an interview on 10/16/2025 at 1:40 PM, the Director of Nursing #3 stated the vancomycin trough was outlined on the hospital discharge paperwork. If it was due on Tuesday, it was drawn one hour before the next dose. Resident #1 was on intravenous vancomycin. They stated they did not remember the resident and the only information they had was based on what they read in the chart. Peripheral inserted central catheter laboratory draws were done by a registered nurse. If the resident had an order for a vancomycin draw on 04/14/2025, it should have been drawn. They did not know why it was not done. The registered nurses knew if there was a vancomycin trough order, it should be drawn before the next dose was given. They stated 1:00 PM and 4:00 PM were not appropriate time to draw a vancomycin trough if the resident got their antibiotics at 9:00 AM and 9:00 PM. It should have been drawn at 8:00 AM. During a telephone interview on 10/20/2025 at 3:15 PM, Physician #1 stated Resident #1 was admitted on vancomycin, the treatment course was to continue for approximately six weeks. Vancomycin trough levels should be monitored daily in residents with renal impairment or at least every three days. Vancomycin trough levels must be drawn approximately one hour before the next scheduled dose. A trough obtained at 1:00 PM would not be appropriate if it did not align with the dosing schedule. Additionally, waiting four days to draw a trough was not acceptable and they should have been notified. Elevated vancomycin levels, 40-50 micrograms/ milliliter could cause renal impairment, regardless of pre-existing kidney disease, failure to obtain the vancomycin trough every three days could lead to nephrotoxicity. If they had had the trough levels, they would have stopped the medication. 10 NYCRR 415.20

Based on record review and interviews during the abbreviated (iQIES reference number 2610929) survey the facility did not ensure residents were free of significant medication errors for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Resident #1 had a physician order for intravenous (directly into a vein) cefepime and vancomycin (antibiotics) every 12 hours that were not administered on 04/10/2025, 04/13/2025, 04/14/2025, 04/15/2025, 04/18/2025, and 04/19/2025.Findings include:The facility policy Administering Medications, reviewed 01/2025 documented medications must be administered in accordance with the orders, including any required time frame. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified. If a drug was withheld, refused, or given at a time other than the scheduled time, the individual administering the medication should document in the electronic Medication Administration Record for that drug and dose. The person who withheld, received the refusal, or administered medication at a different time would notify the attending /covering physician. The individual that administered the medication must sign the resident's electronic Medication Administration Record as indicated by the software after giving each medication and before administering the next ones.Resident #1 had diagnoses including osteomyelitis (bone infection) of thoracic vertebrae (upper spine) and local infection of skin and underlaying tissue. The 04/16/2025 Minimum Data Set assessment documented the resident was cognitively intact and received antibiotics. The Comprehensive Care Plan initiated 04/07/2025 and revised on 04/22/2025 documented the resident received antibacterial therapy for sepsis (systematic infection), discitis of the thoracic region (infection of the discs of the spinal bones), and osteomyelitis of the thoracic vertebrae. Interventions included monitor for side effects of the antibiotic, report all side effects to the medical provider, and monitor for efficacy of the antibiotic chosen as well as adverse reactions during antibiotic use and post completion. The 04/07/2025 Physician #1's order documented:-cefepime HCl intravenous solution 2 gram/100 milliliters, use 2 grams intravenously every 12 hours for 162 administrations.-vancomycin HCl intravenous solution, use 1 gram intravenously every 12 hours for anti-infective agent for 162 administrations. The 04/2025 Medication Administration Record documented cefepime HCl intravenous solution 2 grams/100 milliliters, use 2 grams intravenously every 12 hours for cephalosporin for 162 administrations with a start date of 04/08/2025 at 9:00 AM. The Medication Administration Record was blank/not signed on 04/14/2025 at 9:00 AM, 04/15/2025 at 9:00 PM, 04/18/2025 at 9:00 PM, and 04/19/2025 at 9:00 PM to verify the medication was administered. The 04/2025 Medication Administration Record documented vancomycin HCl intravenous solution, use 1 gram intravenously every 12 hours for anti-infective agent for 162 administrations with a start date of 04/08/2025 at 9:00 AM. The Medication Administration Record was blank/ not signed on 04/10/2025 at 9:00 AM, 04/13/2025 at 9:00 AM, 04/14/2025 at 9:00 AM, and 04/15/2025 at 9:00 AM and 9:00 PM to verify the medication was administered. There was no documented evidence in the nursing progress notes from 04/07/2025-04/22/2025 of missed doses of Cefepime or Vancomycin, or notification to the provider of the missed doses. The resident was transferred to the hospital on [DATE] at 9:20 AM for altered mental status. Physician assessments or physician progress notes were not provided when requested. During an interview on 10/16/2025 at 11:00 AM, Licensed Practical Nurse #4 stated there was not always a registered nurse in the building. The medications were normally scheduled during a time when there was a registered nurse on the schedule. If the medication was listed on the Registered Nurse Medication Administration Record, they would not be alerted for the medication administration time. If it was listed on the electronic regular Licensed Practical Nurse Medication Administration Record the medication would be highlighted yellow when it was due and turn red when it was overdue. If the medication was missed the provider should be notified. They did not always know who was covering the intravenous therapy treatments each day. The Unit Manager could do it during the day, or possibly the Director of Nursing. The Medication Administration Record should have something in each box, they were not sure why the boxes were blank. During a telephone interview on 10/16/2025 at 11:58 AM, Registered Nurse Supervisor #5 stated they were the only Registered Nurse on the weekend. They were never alerted that Resident #1 missed medications. There were two days they were given late. They always gave the medications, and they put a check mark on their paperwork. They made a to do list for themselves while on shift. If there was a blank box on the Medication Administration Record it meant the medication was not documented on. They always gave the medication with enough time for the medication to finish and be flushed before the 10:00 PM supervisor came in. The medications were sometime late, because they got busy. They could not recall if they wrote a note, as they used their checklist; and sometimes people had to remind them to document on a medication because they forgot. During a telephone interview on 10/16/2025 at 12:34 PM, Registered Nurse Supervisor #6 stated they were the afternoon supervisor and responsible for administering the afternoon intravenous medication on the 2:00 PM to 10:00 PM shift. There was no book for intravenous medications just a shift-to-shift report. All medication administrations were completed in the computer. They were not familiar with the Medication Administration Record containing boxes. They stated they always signed for their medications in the computer. If the resident refused, they would have written a note. The stated they gave Resident #1 their medications when they were on shift. They would have clicked given or not given with a reason. They used the computer to document everything. There were not sure about the specific dates as it was a long time ago, and they did not have access to the record. During an interview on 10/16/2025 at 12:57 PM, the Assistant Director of Nursing stated medications should be administered on time as scheduled. Registered nurses typically cared for intravenous devices at the facility. If a resident needed assistance or had a treatment with their intravenous device during the day, there were several registered nurses in the building to help. On the off shifts the supervisors were all registered nurses, and they would care for the intravenous devices. They reviewed medication administrations, if the box was empty on the Medication Administration Record that meant it was not signed for. It could have been given and not signed for or it could have not been given and not signed of. It meant it was unaccounted for, an unknown. A blank box on the Medication Administration Record was a medication error. If the medication was not given, it could be a significant medication error. The provider should have been notified of the missed medication, and it should have been documented in a progress note. During an interview on 10/16/2025 at 1:40 PM, the Director of Nursing stated they expected intravenous devices be managed per the orders. The registered nurses administered antibiotics. The blank box on the Medication Administration Record meant it was not signed for. The Unit Managers gave the intravenous antibiotics during the shift and were both registered nurses when Resident #1 resided in the facility. If the blank box was investigated and deemed that the medication was not given, it would be a medication error. They were not aware of any investigations done about the missing medications administrations. They stated given it was only five doses missing, they were not sure it was a significant medication error. If the provider was notified of the missing medications, there should be a note from the person who contacted the provider. The note should include why they were contacted and what the decision was from the conversation. They expected something in every box of the Medication Administration Record. The Unit Managers should be reviewing the Medication Administration Records and should have investigated it, but they were unable to speak to what happen. During a telephone interview on 10/20/2025 at 3:15 PM, Physician #1 stated they were responsible for the oversight of residents' medical care, review of hospital discharge recommendations, and management of medications upon admission. Hospital discharge recommendations were reviewed promptly upon a resident's admission. They reviewed all medication recommendations by the hospital and ensured nursing staff implemented them. Resident #1 was admitted on vancomycin, the treatment course was to continue for approximately six weeks, with vancomycin trough levels (blood test used for monitoring to ensure the antibiotic is effective and to minimize the risk of toxicity) monitored daily in residents with renal impairment or at least every three days. If a resident missed an intravenous antibiotic dose, they expected immediate notification from nursing staff and documentation of the communication. They were not notified Resident #1 missed any doses of vancomycin or cefepime. It was a significant medication error and should have been reported.10NYCRR 415.12(m)(2)

Based on record review and interviews during the abbreviated survey (NY00334012), the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 3 residents (Resident #2) reviewed. Specifically, Resident #2 did not receive medications as ordered on multiple occasions. Findings include: The facility policy, Medication Administration, revised 1/2024, documented the nurse should document all medications administered to each resident on the resident's medication administration record. Documentation must include name and strength of the drug, dosage, method of administration, date and time, and reason(s) why a medication was withheld, not administered, or refused. In the event a medication pass time had passed, the nurse would inform the medical professional and obtain orders to either give the medication, hold, or discontinue. The nurse must inform the Nursing Supervisor of the medication administration event. Resident #2 had diagnoses including depression, diabetes, chronic obstructive pulmonary disease (lung disorder), and Parkinson's Disease (a progressive neurological disease). The 2/24/2024 Minimum Data Set assessment documented the resident had intact cognition. The 2/18/2024 Comprehensive Care Plan documented the resident had an alteration in respiratory system, had insulin dependent diabetes, was prescribed psychotropic medication related to depression/anxiety and was at risk for functional decline in mobility and self-care related to Parkinson's disease. Interventions included to administer treatments (nebulizers) and medications per physician orders. The 2/18/2024 Physician #9 progress note documented the resident was recently discharged from the hospital. They had Parkinson's Disease, and they were to continue their Parkinson's medication. The 2/18/2024 physician orders included: -Novolog (rapid acting insulin-reduces blood sugar) Injection Solution, inject per sliding scale before meals and at bedtime. If blood sugar was 70-120 (milligrams/deciliter), give 1 unit; 121-170, give 2 units; 171-220, give 2 units; 221-270, give 3 units; 271-320, give 3 units; 321-370, give 3 units; 371-400, give 4 units. -Pulmicort (respiratory medication, reduces inflammation) Suspension 0.5 milligrams/2 milliliters, 0.5 milligrams inhaled orally twice daily for chronic obstructive pulmonary disease (restrictive lung disease). -Rytary (treats symptoms of Parkinson's disease) 48.75-195 milligrams, 3 capsules four times daily. -vilazodone (antidepressant) 20 milligrams tablet in the afternoon. On 2/18/2024, Medication Administration Notes completed by Licensed Practical Nurse #1 documented the following medications were not available: - at 7:55 AM, Rytary, and Pulmicort; - at 10:10 AM, Rytary and vilazodone; and - at 2:39 PM and 6:52 PM, Rytary. On 2/19/2024, the Medication Administration Record and Medication Administration Notes completed by Licensed Practical Nurse #2 documented the following medications were on order/not available: - at 7:30 AM, Novolog. The resident's blood sugar was 181 (2 units of insulin was required per physician ordered sliding scale); and - at 2:35 PM, vilazodone, Pulmicort, and Novolog. The resident's blood sugar was 218 (2 units of insulin was required per physician ordered sliding scale). On 2/20/2024, Medication Administration Notes completed by Licensed Practical Nurse #2 documented the following medications were not available: - at 7:00 AM, Pulmicort; - at 11:53 AM, Novolog. The resident's blood sugar was 170 milligrams/deciliter (2 units of insulin was required per physician ordered sliding scale); and - at 12:00 PM, vilazodone. There was no documented evidence a provider was notified that medications were not available. The 2/20/2024 at 2:19 PM Physician Assistant #10 progress note documented they were notified the resident was having more dysarthria (slurred speech), they complained of chest pain, and they had some nausea the previous night. The resident was sent to hospital. Not sure if need but was hoping to correlate to missing meds. The 2/20/2024 hospital report documented the resident complained of chest pain and anxiety that started last night and was still present. The resident stated they vomited yesterday and did not take their medications today. The resident reported they were experiencing distress regarding their current living situation. Labs were essentially normal, and the resident was discharged back to the facility. The 2/23/2024 Physician #9 progress note documented the resident's Parkinson's was unstable and the disease was progressing. The resident was to continue their Parkinson's medication and was to follow up with neurology. The Medication Administration Record documented Rytary was not available on: - 2/23/2024 at 3:00 PM and 7:00 PM by Licensed Practical Nurse #3; - 2/24/2024 at 7:00 AM, 11:00 AM, and 3:00 PM by Licensed Practical Nurse #1; - 2/29/2024 at 3:00 PM and 7:00 PM by Licensed Practical Nurse #3; - 3/1/2024 at 7:00 AM and 11:00 AM by Licensed Practical Nurse #4 and at 3:00 PM and 7:00 PM by Licensed Practical Nurse #5; - 3/2/2024 at 7:00 AM and 11:00 AM by Licensed Practical Nurse #4 and at 3:00 PM and 7:00 PM by Licensed Practical Nurse #6; - 3/3/2024 at 7:00 AM and 11:00 AM by Licensed Practical Nurse #4 and at 3:00 PM and 7:00 PM by Licensed Practical Nurse #6; - 3/4/2024 at 7:00 AM and 11:00 AM by Licensed Practical Nurse #7 and at 3:00 PM and 7:00 PM by Licensed Practical Nurse #5; - 3/5/2024 at 7:00 AM and 11:00 AM by Licensed Practical Nurse #4 and at 3:00 PM and 7:00 PM by Licensed Practical Nurse #8; and - 3/6/2024 at 7:00 AM, 11:00 AM, 3:00 PM and 7:00 PM by Licensed Practical Nurse #4. During a telephone interview on 10/31/2024 at 10:43 AM, Pharmacist #11 stated medications were typically delivered to the facility the same day they were ordered. Most resident's entering the facility as a new admission were on Medicare and the facility was responsible for paying for their medications. The facility practice was any medication costing over 50 dollars required corporate approval before the medication could be filled and sent to the facility. Additionally, if a resident was admitted after 5:00 PM, it could take until the next day or the following day for medications to be filled due to corporate needing to approve medications first. Rytary was a Parkinson's disease medication, was very expensive and should be given on time. If not given on time, residents were at risk of adverse reactions including having their Parkinson's symptoms recurring such as tremors. On 2/17/2024, the order for the resident's Rytary was received at the pharmacy and the facility Corporate Pharmacy Liaison #12 did not approve the medication until 2/19/2024. On 2/24/2024, they received corporate approval again and sent 4.5 days' worth of medication to the facility. On 3/4/2024, the facility requested a refill, corporate approved it on 3/5/2024 and the medication was sent that day. Vilazodone, Novolog and Pulmicort also were expensive and needed corporate approval before they could be sent to the facility. On 2/18/2024, the order for Novolog was received at the pharmacy and was not approved by corporate until 2/20/2024. The facility could have used a short acting insulin from the Cubex (on-site medication dispensing machine) but would need a physician order to do so. During a telephone interview on 10/31/2024 at 12:25 PM, Licensed Practical Nurse #4 stated medications not being available had been an issue and they had seen some medications not available for up to 2 weeks. When a medication was not available, they notified their supervisor. They were not sure if a provider was notified. They did not recall the resident or why they documented Rytary was not available from 3/1/2024 through 3/3/2024 and from 3/5/2024 to 3/6/2024. During a telephone interview on 10/31/2024 at 12:40 PM, Licensed Practical Nurse #2 stated when a medication ran out, they ordered it directly through the electronic medication administration record or called the pharmacy directly to refill the medication. If a medication could not be obtained in time for administration, they should notify their Unit Manager who would notify a provider. On 2/19/2024 and 2/20/2024, medications were not yet available from the pharmacy. Sometimes medications were not sent immediately after admission because the medications required prior authorization, however, they were not sure this was the case for the resident. Medications were also available through the Cubex however if they were given, they would have signed for the medications. They did not recall noticing any side effects and the resident did not complain of side effects from missing medications. During a telephone interview on 11/1/2024 at 11:29 AM, facility Corporate Pharmacy Liaison #12 stated when a medication was not covered and needed prior authorization, the pharmacy notified them, and they relayed what covered alternative medication could be used to the Director of Nursing and the clinical team including the physician. If the team agreed, they or the clinical team notified the pharmacy. This was all done in the same day. If the clinical team did not agree with the covered alternative, the team had them work with the pharmacy to get prior authorization for the original medication. There was no waste of time and the medication should be available the same day depending on the pharmacy delivery. There were also medications available in the Cubex. They did not recall the resident and would have to look through the resident's medical information. The stated they did not think it was acceptable when the resident went 2 days without Novolog, Pulmicort, vilazodone and Rytary. They stated staff could have accessed the Cubex for medications. When the resident went without Rytary from 2/23 to 2/24/2024 and 2/29 to 3/6/2024, they stated they were not sure why and would have to look into it. During a telephone interview on 11/1/2024 at 1:51 PM, the Director of Nursing stated the facility wanted to provide the best care for all residents, and they followed what the physician ordered for a resident's specific needs. The facility had a For Your Information email that was sent by the pharmacy whenever a medication was over 50 dollars. They stated they did not have to approve the cost prior to the pharmacy sending the medication and they were not sure if anyone else needed to approve the cost. The Director of Nursing stated they had spoken to Corporate Pharmacy Liaison #12 a few times when they called and had questions about different medications and wanted to know if there was an alternative that could be used. When staff documented medications were not available from 2/18/2024-2/20/2024, they expected the pharmacy to be called to find out where the medication was, and the physician should have been notified. The resident should not have gone 3 days without ordered medications. The resident should not have missed their Rytary dose for 2 days on 2/23/2024 and 2/24/2024 and should not have gone 7 days without ordered Rytary from 2/29/2024-3/6/2024. Nobody notified them of the missing medications and staff should have notified them. During a telephone interview on 11/5/2024 at 9:30 AM, the Medical Director stated physician orders were for needed medications. If a medication was not available, they expected staff to notify the Director of Nursing or the Administrator. If staff were not able to obtain the medication, they expected to be notified. They were not aware of a facility process requiring approval of medications over 50 dollars. Rytary was used to treat the symptoms of Parkinson's Disease. If a resident went several days without the medication the symptoms of Parkinson's could return. They stated when the resident went multiple days without Rytary, it was not acceptable. If a particular brand was not available, another brand could have been substituted. Staff should have notified the Director of Nursing and/or the Administrator when the resident's medications could not have been obtained. A week without Rytary was too long and patient care was number one. 10NYCRR 415.12

Based on observation, record review, and interview during the recertification survey conducted 7/15/2024-7/22/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Specifically, hot food was improperly cooled, the mechanical dishwasher was not functioning as designed, and outdated foods were present in the walk-in cooler. Findings include: The facility policy, Food Safety and Sanitation dated as reviewed 1/2024, documented leftovers were used within 72 hours (or discarded). The facility policy, Cleaning Dishes/Dish Machine, dated as reviewed 1/2023 documented the dish machine would be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitizing. The facility Cook/Time Temperature Cooling Log revised 12/1/2017, documented items had 2 hours to decrease from 135 degrees Fahrenheit to 70 degrees Fahrenheit and 4 hours to decrease from 70 degrees Fahrenheit to 41 degrees Fahrenheit. Improper Cooling: During an observation on 7/16/2024 at 11:50 AM a pan of rice labeled 7/16 was on the bottom shelf of the walk-in cooler and its temperature was measured at 123 degrees Fahrenheit. The pan (4-inch deep, 1/4 hotel pan) was covered by plastic wrap. The rice temperature was measured at 1:20 PM at 101 degrees Fahrenheit. During an interview on 7/16/2024 at 1:23 PM, [NAME] #37 stated they made the rice around 10:30 AM that morning. They did not measure the temperature of the rice. They cooked it, wrapped it, labeled it, and placed it in the walk-in cooler. Sometimes they kept leftovers after meal service. They measured the temperature before items went into the cooler, wrapped them, labeled them, and put a note in the menu book to use those items the next time that meal came up. They also had a cooling log they recorded for the proteins like beef, pork, and turkey which were often cooked and cooled the day before they were served. The Cook/Time Temperature Cooling Log documented 17 food items from 3/6/2024 to 7/14/2024 were recorded. All items listed had incomplete records similar to the following; on 7/13/2024 turkey was 180 degrees Fahrenheit at 3:30 PM, at 5:00 PM it was 148 degrees Fahrenheit. That was the end of the documentation of cooling for the turkey. A pork loin on 7/14/2024 was documented at 2:30 PM as 181 degrees Fahrenheit and at 3:00 PM as 150 degrees Fahrenheit. That was the end of the documentation when the log was reviewed on 7/16/2024 at 12:05 PM. The log provided by the facility on 7/22/2024 had additional entries under the 2 hour column of 71, and 4 hour column of 41. The facility did not provide an explanation for the additional entries. During an interview on 7/16/2024 at 1:41 PM, the Temporary Food Service Director stated they kept certain items from one meal to the next, but not much required cooling, just the meats. They only had a census of 67 people so not much was cooked ahead of time. If it was it must be cooled properly. After two hours the properly cooled food must be measured at or below 75 degrees Fahrenheit, and again after another 4 hours it must be down to 41 degrees Fahrenheit. During an interview and observation on 7/16/2024 at 1:48 PM, the pan of rice on the bottom shelf of the walk-in cooler was measured at 99 degrees Fahrenheit. The Temporary Food Service Director stated it was not cooled properly and it had to go in the garbage. During an observation on 7/18/2024 at 1:35 PM, a 6-inch deep 1/4 hotel pan of scrambled eggs located on the bottom shelf of the walk-in cooler was measured at 63 degrees Fahrenheit. The pan was covered with plastic wrap and labeled, 7/18 use by 7/19. At 2:57 PM the eggs were measured at 58 degrees Fahrenheit and at 4:42 PM at 54 degrees Fahrenheit. During an interview on 7/18/2024 at 4:42 PM, the Regional Director of Operations stated they were not sure what time the eggs were made that day. The eggs were located on the bottom shelf where staff had placed leftovers, and the eggs had probably been placed there after breakfast around 10:00 AM that morning because they were beside a pan of breakfast sausage that only contained a few sausage links. The Regional Director of Operations stated the eggs were not cooled properly and they did not have documentation on the cooling process for those eggs, so they needed to be discarded. Improper Dishwashing: The mechanical dishwasher's specifications documented the required wash temperature was 150 degrees Fahrenheit and the final rinse temperature was 180 degrees Fahrenheit. The facility's dish machine washing log documented the temperatures measured in July 2024 were recorded three times a day for wash (150-165 degrees Fahrenheit), final rinse (120/120 degrees Fahrenheit), and chlorine sanitizer (50 parts per million). The final rinse ranged from 115 to 179 degrees Fahrenheit. The wash temperatures on 7/4/2024, 7/5/2024, 7/6/2024, 7/7/2024, 7/13/2024, and 7/14/2024 were documented below 150 degrees Fahrenheit. The chlorine sanitizer was documented three times each day in a range of 350 to 400 parts per million. During an observation on 7/16/2024 at 11:44 AM, the mechanical dishwasher wash temperatures were observed and measured at 153 degrees Fahrenheit. The final rinse digital display read 107 to 108 degrees Fahrenheit. The surveyor used their probe thermometer in the side of the unit and the temperature started to drop as it switched from wash to rinse, at the end of the cycle the temperature measured was down to 134 degrees Fahrenheit. During an interview on 7/18/2024 at 12:54 PM, the Regional Director of Operations stated the dishwasher was a high temperature machine and was checked 3 times a day around the end of each meal service which was recorded on a log sheet. They were not aware of any issues with the dishwasher. During a follow up interview at 1:36 PM, they stated the machine was down recently and operated as low temperature sanitization. On 7/3/2024 the part was replaced because it was sporadically maintaining temperature. They stated the Temporary Food Service Director met with staff regarding the low temperature final rinse and they opted to keep that in there because of the inconsistent temperatures. During an observation on 7/18/2044 at 1:43 PM, the Regional Director of Operations attempted to check the level of chlorine sanitizer in the final rinse, but it was not registering, air could be seen in the line and the chlorine solution was not reaching the machine. The facility's dish machine ware washing log documented the morning temperatures and sanitization level were recorded by Dietary Aide #36. During an interview and observation on 7/18/2024 at 1:44 PM, Dietary Aide #36 stated they checked the temperature and the sanitizer by reading the digital display below the machine for the temperatures and using the test strips that were located with the clipboard that contained the log. They stated if it was not within range, they would let somebody know and hopefully maintenance would come and figure it out. Dietary Aide #36 identified that they had been using the quaternary test strips to measure the level of chlorine sanitization. During an observation on 7/18/2024 at 4:44 PM the mechanical dishwasher chlorine sanitization was measured at 10 parts per million. During an interview on 7/18/2024 at 5:03 PM, the Maintenance Director stated the mechanical dishwasher was supposed to be a high temperature machine that the facility owned and maintained. They stated the heating element had been broken on the machine for longer than they had been at the facility which was about a year. The previous Director dealt with that and added the chemical sanitizer, but when they took over as Director about three months ago, they were able to get the part to repair the machine on 7/3/2024 for which they provided email documentation. An email dated 6/28/2024 documented the Maintenance Director had emailed corporate asking to purchase a new heating element which was needed to help with the sanitization of the dishware. The facility's dish machine ware washing log documented one issue on 6/12/2024 for breakfast and lunch, machine down - use paper was recorded. April, May, and June were provided and documented that acceptable temperatures were measured three times daily. No documentation of chemical sanitization was recorded. Outdated food in the walk-in cooler: During an observation on 7/16/2024 at 11:50 AM the bottom shelf of the walk-in contained a pan (half hotel, 4-inch deep) of chicken [NAME] covered with plastic wrap and labeled 7/11. A bag of cooked potatoes (commercial product) was opened and wrapped with plastic wrap that was dated 7/3. During an interview on 7/16/2024 at 1:23 PM, [NAME] #37 stated they did not have a specific person who reviewed the contents of the coolers. All staff looked for anything older than 3-4 days. What was handwritten was when it was opened. 7/3 for the raw potato, that was still good, but if it was cooked then it would have to be removed within 3 days. The pan of chicken [NAME] on the bottom shelf labeled 7/11 was something that had to be discarded. They stated that was from lunch on 7/11 and they were not sure why it was saved. During an interview on 7/16/2024 at 1:41 PM, the Temporary Food Service Director stated they kept certain things from one meal to the next, but nothing was kept beyond 3 days. They stated the chicken [NAME] from 7/11 or the bag of cooked potatoes that was labeled 7/3 should not have been in the cooler. They checked the cooler the previous day and must have missed those outdated items. 10NYCRR 415.14(h)

Based on record review, observation, and interview during the recertification and abbreviated (NY00340720) surveys conducted 7/15/2024-7/22/2024, the facility did not ensure they had a process in place for residents to have their grievances addressed appropriately for 13 of 13 (12 anonymous residents, and Resident #16) reviewed. Specifically, 12 anonymous residents present at the Resident Council meeting stated they did not know who the grievance officer was, how grievances were handled, or receive communication on the progress of grievance resolutions; and Resident #16 filed a grievance regarding a care concern that was not resolved. Findings include: The facility policy, Filing Grievance Complaints, last reviewed 1/2024, documented the facility must establish a grievance policy that ensured the prompt resolution of all grievances regarding the residents' rights. The facility assisted residents in filing grievances and/or complaints when such requests were made. The facility notified residents individually or through postings in prominent locations throughout the facility of the right to file grievances either orally (meaning spoken) or in writing. The facility ensured that all written grievance decisions included the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concern, a statement as to whether the statement was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued. The New York State Department of Health document Your Rights as a Nursing Home Resident, was included in the admission packet provided to residents and documented a resident had the right to be cared for in a manner that enhanced quality of life, freedom from humiliation, harassment, or threats. Rights of self-determination were to receive services with reasonable accommodations for individual needs and preferences, and to participate in the planning of care and services. Rights for complaints expected the facility investigated and tried to resolve concerns promptly. During a Resident Council Meeting on 7/15/2024 at 1:57 PM, twelve anonymous residents stated they were unaware of who the facility grievance officer was. They reported their concerns to their social worker or the Administrator. They stated they did not always receive follow up on their expressed grievances. During an observation on 7/15/2024 at 2:45 PM the phone number for the New York State Complaint hotline labeled Patient Care Hotline and the New York State Ombudsman poster were in a glass case by the Administrator's office. There was no facility grievance officer or contact information posted. 1) Resident #16 had diagnoses including cerebral palsy (damage to the brain causing movement disorders), anxiety disorder, and depression. The 5/10/2024 Minimum Data Set admission assessment documented the resident had intact cognition, did not have behavioral symptoms, did not reject care or wander, used an electric wheelchair, and was dependent on staff for most activities of daily living. The 5/6/2024 Comprehensive Care Plan documented the resident was at risk for an adjustment problem related to a new environment. Interventions included encourage family involvement, provide emotional support and encouragement, and allow the resident the opportunity to express himself/herself. During an interview on 7/15/2024 at 10:32 AM, Resident #16 stated Certified Nurse Aides #20 and #21 were touchy/feely with each other while providing care. They touched each other on their butts and private areas, and this made the resident very uncomfortable. The resident felt this was unprofessional and reported it to Registered Nurse Unit Manager #5. The resident did not want to be cared for by these staff members anymore and did not feel the facility addressed their concerns. All grievances for May 2024-July 2024 were requested. There was one grievance dated 6/5/2024 for Resident #16. The grievance form dated 6/5/2024 documented Resident #16 expressed concern they asked Certified Nurse Aides #20 and #21 to unlock the door for family members that were trying to visit. The staff responded to the resident, You'll have to figure that out yourself. The delegation of responsibility was listed as the Nursing department and Administration. The follow up action was both staff members were educated on customer service. The social service follow-up documented the resident was aware the incident was being investigated. The action taken summary was blank, the report was provided to and signed by the Administrator on 6/7/2024. There was a handwritten summary of the complaint by Registered Nurse Unit Manger #5 that outlined the incident. A 6/7/2024 form addressed to the resident documented their grievance had been addressed and action had been taken to resolve the issue. The document was unsigned and did not include the outcome of the investigation, the action taken, or if the resident was apprised of the grievance outcome. There was affirmation of re-education signed by Certified Nurse Aide #20 that documented one of the topics reviewed was professionalism with co-workers and residents. There was no documented reeducation for Certified Nurse Aide #21. During an interview on 7/19/2024 at 1:26 PM, Social Worker #16 stated if they were notified of a grievance, they filled out a grievance form. They interviewed the resident, and then delegated the investigation to the appropriate department head. They followed up daily to make sure it was resolved. Grievances were only supposed to be open a maximum of 3 days. Once resolved they reported the findings to the resident or the family. Resident #16's grievance dated 6/5/2024 was documented as resolved, and they had multiple verbal conversations with the resident, but did not document those. The resolution was education on Customer Service with the staff involved. The resident was not completely satisfied with the resolution. The resident did not want Certified Nurse Aide #20 to provide care to them anymore. The Social Worker believed that was a resident right. They had repeatedly communicated this to nursing and were not sure if anything had been done about it. There were 2 certified nurse aides involved and only one was educated. Both certified nurse aides should have been educated. It was important to residents to improve their quality of care and honor their rights. During an interview on 7/19/2024 at 1:54 PM, Registered Nurse Unit Manger #5 stated they interviewed Resident #16 regarding an incident 6/5/2024 involving Certified Nurse Aides #20 and #21, not letting visitors in when requested. They wrote a statement and provided it to either the Director of Nursing or the Assistant Director of Nursing. It was then out of their hands, and an investigation should have been completed. The resident had also complained about the same 2 certified nurse aides touching each other inappropriately, and breaking the resident's fan while care was provided. They stated they told the Director of Nursing or the Assistant Director of Nursing. They did not document the incidents and realized they should have. Residents should have their choices honored about not being provided care by a staff member that made them uncomfortable. During an interview on 7/19/2024 at 3:24 PM, the Director of Nursing stated care concerns should be reported to the Director of Nursing or the Assistant Director of Nursing. It would then go up the chain of command, ultimately ending up with Administration. The resident and staff involved were interviewed and would be documented in a file. They did not have a file for Resident #16's complaints other than the one dated 6/5/2024. Depending on what was determined they would go forward and there may be education of staff if needed. They did not recall reports of care concerns for Resident #16. All staff involved in the incident should have been educated. A resident had the right to request not to receive care from a staff member that made them feel uncomfortable and the assignment could be changed if needed. This should be communicated to Supervisors, and the Director of Nursing or the Assistant Director of Nursing should be aware of the concerns. They stated they knew about the resident's fan getting broken, and provided a During an interview on 7/19/2024 at 3:40 PM, the Administrator stated resident concerns should be brought to the attention of the Director of Nursing or the Assistant Director of Nursing and the Administrator in a timely fashion. Grievances should be closed out within 72 hours. It was a resident's right to ask that a staff member they were uncomfortable with not provide care. Grievance resolution should be documented, and education should be provided to all staff involved. During an interview on 7/19/2024 at 3:51 PM, the Nursing Staffing Coordinator stated they were notified by Registered Nurse Unit Manager #5 on 7/8/2024 to try to keep Certified Nurse Aide #20 on Unit 1 (a different Unit than Resident #16 resided on). They were not notified by the Director of Nursing or the Assistant Director of Nursing. 10NYCRR 415.3(C)(1)(ii) 49448

Based on observation, record review, and interview during the recertification survey conducted 7/15/2024-7/22/2024, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles and include the expiration date when applicable for 3 of 3 medication carts (Unit 1- medication cart 1, Unit 2- medication cart 1, and Unit 2- medication cart 2) reviewed. Specifically, - Unit 1- medication cart 1 contained 7 medications that were not labeled with resident specific identifiers or with opened/ discard dates; 7 resident specific multidose insulin (treats blood sugar) pens, 1 multidose eye drop, and 1 multidose eye ointment that were not labeled with opened and discard dates; and 1 unopened insulin pen that was not stored appropriately in the refrigerator. - Unit 2- medication cart 1 contained 1 multidose insulin pen that was not labeled with resident specific information and 1 resident specific multidose insulin pen that was not labeled with an opened or discard date. - Unit 2- medication cart 2 contained stock medications that were expired. Findings include: The facility policy, Administering Medications, revised 1/2023 documented the expiration/ beyond use date on the medication label must be checked prior to administering. When a multi-dose container was opened, the date opened was recorded on the container. Insulin pens containing multiple doses were for single-resident use only. Insulin pens should be clearly labeled with the resident's name and other identifying information. Prior to administering insulin, the nurse verified the correct pen was being used. Each nurse's station had a current medication reference. The facility policy, Insulin Administration, reviewed 1/2024 documented prior to insulin being administered, the expiration date was checked. If a new vial was opened, the expiration date and time was recorded on the vial. Manufacturer recommendations for expiration after opened were followed. The facility policy, Storage of Medications, reviewed 1/2024 documented the facility stored all drugs and biologicals in a safe, secure, and orderly manner. Drug containers that had missing, incomplete, improper, or incorrect labels should be returned to the pharmacy for proper labeling before storing. The facility should not use discontinued, outdated, or deteriorated drugs or biologicals. Any such drugs should be returned to the pharmacy or destroyed. Medications requiring refrigeration must be stored in the refrigerator in the drug room. The nursing staff was responsible that medication storage was maintained in a safe manner. During an observation on 7/16/2024 at 1:01 PM of the Unit 2- medication cart 2 and interview with Licensed Practical Nurse #8, there was an opened stock container of loratadine (treats allergy symptoms) 10 milligram tablets labeled with an expiration date of 5/2024. Licensed Practical Nurse #8 stated the medication was expired and Assistant Director of Nursing checked all the medication carts a week or two ago for expired medications. They were not sure if they administered that medication to any residents today. During a medication cart review of the Unit 1- medication cart 1 on 7/16/2024 at 1:04 PM with Licensed Practical Nurse #18, the following medications were observed: -4 budesonide inhalation suspension 0.5 milligram/ 2 milliliter (used to treat wheezing and shortness of breath associated with asthma) vials in an unboxed opened bag, that were not labeled with resident specific information and/or opened/ discard dates. - 1 opened vial of Haldol 5 milligram/milliliter (antipsychotic), that was not labeled with resident specific information and/or opened/ discard dates. - 1 unopened hydroxyzine 25 milligrams/milliliter (antihistamine) vial, that was not labeled with resident specific information and/or opened/ discard dates. - 1 opened insulin Aspart (short-acting) multidose vial that was not labeled with resident specific information and/or opened/ discard dates. - 2 multidose insulin pens (Basaglar, long-acting) and Lantus (long-acting) for Resident #55 that were not labeled with opened or discard dates. - 1 multidose Lantus insulin pen for Resident #7 that was not labeled with opened or discard dates. - 2 multidose insulin pens (glargine, long-acting and Aspart) for Resident #23 that were not labeled with opened or discard dates. - 1 multidose Basaglar insulin pen for Resident #4 that was not labeled with opened or discard dates. - 1 multidose insulin glargine pen for Resident #61 that was not labeled with opened or discard dates. - Atropine eye drops 1% and erythromycin (antibiotic) eye ointment for Resident #7 that were not labeled with opened or discard dates. - 1 unopened multidose Admelog (short-acting) insulin pen for Resident #55 that was not refrigerated until opened as required. None of the insulin pens in the cart were labeled or stored appropriately. Licensed Practical Nurse #18 stated insulin pens should be stored in the refrigerator until opened. Without an opened date, an expiration date would be unknown. Expired medications may not be as effective and could lead to uncontrolled blood sugars or the medications may not effectively treat the intended purpose. Whoever opened the medication was responsible to ensure it was dated as opened. If they found a medication that was not dated, it should be discarded. They stated they did administer the undated Lantus insulin pen to Resident #7 today and they did not check for a date on the pen prior to the medication being administered but they should have. They stated without resident identifiers they would not know who the medication was intended for. Medications should be labeled to ensure the right medication was going to the right resident. If a medication was not labeled when opened, they would not know if they were giving expired medications. They were not sure how long eye drops were good for after opened. During a medication cart review of the Unit 2- medication cart 1 on 7/16/2024 at 1:26 PM with Licensed Practical Nurse #1, there was one multidose Humalog (short-acting) insulin pen that was not labeled with resident specific information or an opened or discard date and one multidose insulin Glargine pen for Resident #15 that was not labeled with an opened or discard date. Licensed Practical Nurse #1 stated they would not use the medication because they did not know who it was intended for or if it was expired. Insulin was good for 30 days after opened. These medications were considered expired as there were no opened dates. They stated the Assistant Director of Nursing checked all the medication carts a couple of weeks ago for expiration dates. All nurses were supposed to check the individual medications for expiration dates prior to any medication being administered. The nurse that opened the insulin pen was responsible it was labeled with an opened date. During an interview on 7/16/2024 at 1:40 PM Registered Nurse Unit Manager #5 stated once an insulin pen was removed from the refrigerator the nurse should make sure it was labeled with a resident name and document the opened date on the pen. It was important it was labeled as opened because insulin was only good for a certain amount of time and without an opened date it would be unknown if it was expired. They did not know how long insulin was good for after opened. If a nurse pulled a pen from the cart that was not dated, it should be discarded. If a resident received expired insulin, it may not be effective in treating their blood sugar. Unopened insulin pens were kept in the refrigerator to keep them viable/ effective. Eye drops were also dated as opened as they were only good for a certain amount of time and could possibly not effectively treat their intended use if administered after they were expired. Prior to medication administration, the nurses should make sure the expiration date was checked. The Assistant Director of Nursing did a medication cart audit a couple of weeks ago and they were surprised these medications were not caught as expired/ undated. There was not currently an educator for the facility, and they were unsure when staff was educated last on medication storage. During an interview on 7/16/2024 at 1:43 PM Registered Nurse Unit Manager #2 stated they were not sure how long insulin was good for after opened. They did not know who checked for expiration dates, but each nurse was supposed to check for expiration dates prior to medications being administered. They were not sure where overstock medications were kept. During an interview on 7/16/2024 at 1:51 PM the Assistant Director of Nursing stated nurses were expected to check expiration dates every time they administered a medication. The night shift nurses were supposed to go through the medication carts, medication rooms, and medication refrigerators for expiration dates weekly. They were not sure if these checks were documented anywhere. Insulin pens were good for 30 days and the nurse that opened the pen was responsible to make sure the pen was dated when opened. Every insulin pen should have resident identifiers to prevent cross contamination as the pens were resident specific could not be shared. They had done a medication cart audit a couple of weeks ago and the stock loratadine pills were expired and must have been an oversight and should not have been in the cart. They were unsure when education on medication storage was last provided. 10NYCRR 415.18(d)

Based on observation, record review, and interview during the recertification survey conducted 7/15/2024-7/22/2024, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 resident (Resident #59) reviewed. Specifically, staff was observed not wearing the required personal protective equipment in Resident #59's room who was on transmission-based precautions. Findings include: The undated facility policy. Isolation-Categories of Transmission-Based Precautions, documented transmission-based precautions were additional measures that protected staff, visitors, and other residents from becoming infected. When a resident was placed on transmission-based precautions, appropriate notification was placed on the room entrance door, so personnel and visitors were aware of the need for the type of precaution. The signage informed staff of the type of precautions, instructions for personal protective equipment and/ or instructions to see a nurse before the room was entered. Contact precautions were implemented for residents known or suspected to be infected with microorganisms that could be transmitted by direct contact with the resident or indirect contact with the environment surfaces or resident-care items in the resident's environment. Staff and visitors wore gloves and disposable gowns when entering the resident's room, and gloves and gown were removed, and hand hygiene was performed before leaving the room. Staff avoided touching potentially contaminated environmental surfaces or items in the resident's room after gloves and gown were removed. Resident #59 had diagnoses including recurrent enterocolitis (inflammation throughout the intestines) due to clostridium difficile (a highly contagious bacteria that can cause diarrhea), end stage renal (kidney) disease, and sepsis (a serious condition in which the body responds improperly to an infection). The 7/8/2024 Minimum Data Set assessment dated [DATE] documented the resident was cognitively intact, was dependent for toileting, was frequently incontinent of bowel, and did not have any infections. The 7/1/2024 hospital discharge summary documented the principal discharge diagnosis was clostridium difficile colitis. The 7/2/2024 Physician #24 progress note documented a call was received from nursing staff the resident was readmitted back to the facility. The resident had a new medication fidaxomicin for clostridium difficile. The nurse was advised to follow protocols for clostridium difficile precautions. The 7/2/2024 physician order documented fidaxomicin 200 milligram oral tablet twice daily for clostridium difficile. There were no physician orders for transmission-based precautions. The comprehensive care plan initiated on 7/2/2024 did not document the resident was on transmission-based precautions. During an observation and interview on 7/15/2024 at 2:49 PM, Resident #59 was sitting up in bed in their room, there was a contact precaution sign next to the door frame. They stated they were on precautions for clostridium difficile which they had when they were in the hospital. The brown signage on the right hand side of the door frame outside of the room documented contact/ enteric precautions- everyone must wash hands with sanitizer upon entering the room and wash with soap and water when exiting the room. Gown and gloves must be on when entering the room. Doctors and staff must use patient dedicated or disposable equipment, clean and disinfect shared equipment when leaving the room. During an observation on 7/16/2024 at 9:09 AM, Certified Nurse Aide #25 was in Resident #59's room changing the bed linens (the resident was not in the room). They were not wearing gloves or a gown. Certified Nurse Aide #25 exited the room at 9:13 AM without performing hand hygiene, and immediately went to the room next door and changed the bed linens. During an observation on 7/18/2024 at 9:30 AM, Registered Nurse Unit Manager #5 exited Resident #59's room without gown or gloves, holding a personal blanket and oxygen tubing from the resident's room. They stated the resident was going to dialysis. During an observation on 7/19/2024 at 12:31 PM, Licensed Practical Nurse #13 entered the resident's room with the resident's lunch tray and exited the room with the lunch tray lid. They did not perform hand hygiene, placed the lid on top of the warming cart in the hallway by the nursing station, picked up a pen, documented meal consumption on another resident's ticket, picked up a different meal tray and placed it in the cart. Licensed Practical Nurse #13 then entered the dining room to assist other residents and did not perform hand hygiene. During an interview on 7/19/2024 at 1:28 PM Licensed Practical Nurse #13 stated prior to entering Resident #59's room they performed hand hygiene and put on gloves and a gown. They stated the resident was on neutropenic precautions (precautions used for residents who are immunocompromised) for end stage renal disease. They stated the resident was on medications for clostridium difficile, but the precautions were not for that, they were to protect the resident from germs that could cause death. During an interview on 7/19/2024 at 1:37 PM Registered Nurse Unit Manager #5 stated gowns and gloves needed to be worn any time Resident #59's room was entered as they were on precautions for clostridium difficile. They should not have given the resident their personal blanket to take to dialysis because it could be contaminated. The certified nurse aides should not be changing bed linens without appropriate personal protective equipment and should not have left Resident #59s room to enter another room as they were carrying the germs from room to room. They did not know why there was no order for the resident to be on contact precautions. They were responsible for placing those orders. They expected the nurses to know why a resident was on precautions and if they did not know, they should ask. During an interview on 7/19/2024 at 1:47 PM Certified Nurse Aide #25 stated Resident #59 was on precautions for clostridium difficile and they put a gown and gloves on every time they went in the resident's room even if the resident was not in the room. They stated they did not change the resident's bed linens on 7/16/2024 and was picking up the resident's things. They did not wear personal protective equipment, but they should have so they did not contaminate other residents. During an interview on 7/22/2024 at 1:12 PM the Director of Nursing/ Infection Preventionist stated staff were expected to follow the signage outside the door of an isolation room. There was never a time it was appropriate to enter an isolation room without the required personal protective equipment. Resident #59 was on precautions for clostridium difficile. The nurse should have given the resident a clean blanket for dialysis and not their personal blanket. The personal blanket could have been contaminated. Personal protective equipment and hand hygiene were important to prevent the spread of infection. 10NYCRR 415.19(a)(2)

Based on record review and interview during the abbreviated survey (NY00321800), the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #3) reviewed. Specifically, Resident #3, who was previously diagnosed with brain cancer, had recommendations for a magnetic resonance imaging scan (specialized x-ray) and follow-up with oncology (cancer specialist) and neurology (doctor who specializes in diseases of the brain/spinal cord), and there was no documented evidence the follow-up appointment or scan was scheduled or occurred. Subsequently, the resident experienced a decline in their neurological function. This resulted in actual harm to Resident #3 that was not immediate jeopardy. Finding include: The revised 1/2024 Consultation Policy documented the facility was responsible to provide consultation services for any resident as needed. The facility assumed responsibility for obtaining services that met professional standards and principles that applied to professionals providing services in such a facility, and the timeliness of the services. The procedure included the attending physician writing and order for a consult and documenting the reason for the consult in the medical record. Designated staff were to schedule the consult, arrange transportation, and notify the resident/designated representative of the appointment. The facility or designated representative would escort the resident to the appointment and supply nursing staff with the consultation report upon return to facility. Nursing staff would notify the physician of any recommendations and the physician would approve any orders they agreed with. The consultation report would be added to the resident's record. Resident #3 had diagnoses including a seizure disorder, malnutrition, and brain cancer. The 7/11/2023 Minimum Data Set assessment documented the resident's cognition was intact and they required extensive assistance with bed mobility and transfers. The 6/1/2023 hospital discharge summary documented the resident had glioma blastoma multiform (brain cancer) and was admitted to the hospital with seizures. The resident was followed by a local cancer center and the family member reported the resident was currently not receiving chemotherapy (cancer treatment) for one month. The resident was to follow-up with their primary care physician in 1 week and the cancer center as scheduled. The 6/1/2023 comprehensive care plan documented the resident required assistance with activities of daily living including total assistance from 2 staff for locomotion and extensive assistance from 2 staff with toileting and transfers. There was no documentation of a plan related to follow-up for the resident's brain cancer diagnosis. The 6/3/2023 attending physician #12's progress note documented the resident was at the facility for recovery and rehabilitation and was recently hospitalized with seizures. The resident had 2 brain surgeries and chemotherapy in the past, and their prognosis was poor with a long-term history of brain cancer. The resident needed close follow-up from neurosurgery. There was no documented evidence a follow-up appointment with neurosurgery was ordered. The 8/9/2023 at 1:39 PM, Director of Nursing's progress note documented the resident's family requested they be sent to the hospital for a decline in condition as the resident now required a mechanical lift to transfer, was unable to stand on their feet, and leaned to the left. The 8/10/23 hospital discharge summary documented the resident was admitted under observation status and discharged back to the facility. The note documented the resident needed close follow-up with their primary care medical provider and close follow-up with oncology and neurology. The 8/10/2023 attending physician #12's order documented to follow-up with oncology and neurology. The 8/11/2023 attending physician #12's progress note documented the resident was recently hospitalized overnight and diagnosed with weakness and returned to the facility. The resident was to follow-up with oncology . There is no documented evidence a follow-up appointment with oncology was scheduled. The 9/15/2023 attending physician #12's progress note documented the resident was seen for family concerns of their overall health status. The resident was progressively weaker and chose not to ambulate anymore. Nursing reported they now needed a mechanical lift for transfers and recently acquired COVID-19. The note documented they would consider a computed tomography (specialized imaging) scan of the head to see if there were any changes related to the resident's brain cancer. The resident should also have neurology/neurosurgery follow-up with the progression of symptoms. There is no documented evidence a follow-up appointment with neurology/neurosurgery was scheduled. The 9/29/2023 nurse practitioner #11's progress note documented the resident was seen to determine healthcare decision making capacity. The resident's cognition was currently moderately impaired, and they were alert with confusion and had memory loss. They had significant cognitive deficits and no longer had capacity to make their own medical decisions. The resident's spouse was documented as the Surrogate Decision Maker. The 9/29/2023 prescription from the resident's neurology/oncology provider, faxed to the facility on [DATE], documented the resident needed an urgent magnetic resonance imaging scan with and without contrast. The 10/5/2023 at 10:48 AM, Registered Nurse Manager #10's progress note documented the resident's spouse asked about the magnetic resonance imaging scan and the nurse reported they were working on it. The 10/6/2023 at 9:19 AM, Registered Nurse Manager #10's progress note documented the resident's family was notified the magnetic resonance imaging scan was scheduled on 10/26/2023. There was no documented evidence the magnetic resonance imaging scan was completed on 10/26/2023. The 11/2/2023 at 1:36 PM, licensed practical nurse #17's progress note documented the resident was leaning towards the left side when out of bed, even with attempts to reposition. The unit Manager was aware. The 12/12/2023 physical therapist #14's progress note documented the resident was given an ankle orthotic (brace) due to noted inversion (bending inward towards the body) contracture (permanent tightening of muscles, tendons, and skin). The 12/12/2023 occupational therapist #15's progress note documented the resident's left hand was noted in contracture compared with the last visit. A resting hand splint was applied. The nurse practitioner (nurse practitioner #11) was consulted about the resident's condition and recent onset of contraction. The 12/12/2023 at 1:29 PM, nurse practitioner #11's progress note documented the resident was seen per nursing for continued decline. The resident had increased confusion the last few weeks and they were told the resident developed contractures to the left upper arm and left lower leg over the last few days that were rapid in presentation. Contractures were noted on exam. The resident was not currently undergoing treatment for metastatic (cancer that spread) brain cancer, the brain cancer was likely progressing and causing the decline, and they asked staff to ensure follow-up with the resident's oncologist as soon as possible. Staff were to notify the medical provider of any acute change in condition. There was no documented evidence the resident followed-up with oncology and no documentation of an order for an oncology follow-up appointment. The 12/26/2023 at 11:36 AM, social worker #18's progress note documented the resident left with their family for the holiday and was taken to the hospital by the family. The 1/3/2024 hospital discharge summary documented the resident was admitted to the hospital on 12/25/2023 with altered mental status and lethargy. From admission, the objective was to see if there was reversible cause for their decline. After several days, it was evident the decline was likely related to underlying brain cancer. A repeat magnetic resonance imaging scan was completed 12/28/2023 which showed a mass in the right temporal lobe (part of the brain) that was considered enlarged since the previous scan. They discussed with the spouse the resident should follow-up with oncology to go over the scan results to make further decisions based on new information. On 1/3/2024, the comprehensive care plan was updated and documented the resident was at risk for neoplastic disorders (condition that causes tumor growth) related to brain cancer. Interventions included facilitate resident treatments (radiation/chemotherapy) per medical provider and to refer to oncology/hematology (doctor that specialized in conditions that affected the blood or bone marrow cells) as needed. The 1/3/2024 nurse practitioner #16's progress note documented they received a call from nursing the resident was returning to the facility from the hospital. At that time, the resident appeared stable, was to continue the current medication regimen, and have blood work and imaging per protocol. There was no documented evidence of a physician's order for an oncology follow-up and no documented evidence the resident followed up with oncology as recommended in the hospital report. The 1/31/2024 at 5:32 PM, registered nurse #13's progress note documented the resident had a change in mental status. The resident typically yelled out continuously, however was now not verbally responding or yelling out. The on-call medical provider was notified with new orders for a chest x-ray, antibiotics, and Duoneb (breathing treatment). The resident's spouse requested the resident be transferred to the hospital. The resident was discharged to the hospital and there was no documentation they returned to the facility. The resident's medical records from the cancer center were reviewed from 6/1/2023 through 1/31/2024 and there were no documented visits for the resident and no documented communication from the facility to the cancer center's medical provider. During a telephone interview on 3/14/2024 at 11:44 AM, Registered Nurse Manager #10 stated they started as Manager in 8/2023 and was still trying to figure out how appointments with outside providers occurred at the facility. They stated follow-up appointments were scheduled based on recommendations noted on the hospital discharge summary and orders were needed to schedule an appointment. They stated when the resident was admitted , they were not the Manager but at some point, they believed they were told that residents of the facility could not receive chemotherapy and they thought that had something to do with billing. They believed they discussed this with the Director of Nursing and Assistant Director of Nursing. They thought the resident went for a magnetic resonance imaging scan on 10/26/2023 and was not sure why they did not have the report. They did not recall nurse practitioner #11's note on 12/11/2023 and typically the medical provider wrote their recommendations in a communication book and then nursing wrote orders. They were not sure if nurse practitioner #11 wrote a note referring the resident to oncology that day. They were not sure why there was no oncology referral after the resident returned to the facility on [DATE]. During a telephone interview on 3/19/2024 at 11:53 AM, physical therapist #14 stated on 12/12/2023, they noticed the resident's left ankle was turning inwards at times and that could occur from tightness or from a contracture. They also noticed the resident's left wrist and fingers were flexed inwards and they told occupational therapist #15 who assessed the resident's hand. They stated they discussed the concerns with nursing and issued the resident an ankle orthotic. During a telephone interview on 3/19/2024 at 12:00 PM, occupational therapist #15 stated on 12/12/2023, they assessed the resident and found they had a flexion contracture of the left arm that was turning inwards. They notified nursing staff that day though could not recall who. A flexion contracture could be caused by an issue with the brain, especially since the resident had concerns on one side of the body. During a telephone interview on 3/20/2024 at 7:47 AM, nurse practitioner #11 stated nursing staff became aware of their recommendations for follow-up appointments through written orders or via telephone calls when they were not in the building. When they wrote their note on 12/11/2023, they assumed they spoke with the unit Manager when they recommended the resident follow-up with oncology. They were not sure the resident's new onset contractures were related to brain cancer, but they were a change in condition, and they felt the resident needed to be seen by oncology. They expected the oncologist to have been notified and it was up to the oncologist whether the resident needed to be seen or not. They were not aware there was no documentation the oncologist was called and not aware there was no documentation a follow-up appointment occurred. During a telephone interview on 3/20/2024 at 10 AM, the Director of Nursing stated if a medical provider ordered an outside consult, then they expected the appointment to occur. They recalled when the resident was admitted to the facility, they were to follow up for chemotherapy after they discharged from the facility. They stated if the hospital discharge summary documented to follow-up with oncology and the facility medical provider ordered the follow-up, then they expected it to be completed. They stated they did not recall having conversations with Registered Nurse Manager #10 regarding the resident's chemotherapy. They were not aware nurse practitioner #11 wanted the resident to follow-up with oncology and they expected it to have been done. During a telephone interview on 3/20/2024 at 10:29 AM, attending physician #12 stated when they wanted a resident to have a procedure or follow-up, they went to nursing staff and told them and it required an order whether written or verbal. Follow-up appointments on the hospital discharge summary were usually set up before residents were admitted to the facility. When they wrote in their 6/3/2023 note the resident needed close follow-up from neurosurgery, they were not sure how aggressive the family wanted to be with treatment, and it was unclear to them if the family wanted to follow-up. On 8/11/2023, when they documented the resident continued to follow-up with oncology, the resident persistently refused and stated they did not want anything done. On 9/15/2023, when they documented the resident should have neurology/neurosurgery follow up for progression of symptoms the resident was again reluctant to have follow up. They were not aware the cancer center faxed a prescription for an urgent magnetic resonance imaging scan and stated if the family and resident wanted it then they expected it to be completed. They stated they left the facility in 11/2023 and could not provide any further information regarding the resident's care at the facility. 10 NYCRR 415.12

Based on record review and interview during the abbreviated survey (NY 478) conducted on 1/13/2022, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 4 residents reviewed (Resident #1). Specifically, for Resident #1 who was admitted to the facility with surgical wounds (amputated toes), there was no documentation the wounds were assessed, a treatment was not ordered timely, and the wounds were not regularly monitored. When the wounds worsened, there was no documented evidence of timely reassessments by qualified professionals. The resident was subsequently sent to the hospital unresponsive and found to have infected and gangrenous (dead tissue caused by an infection or lack of blood flow) left toes requiring a left below the knee leg amputation. This resulted in actual harm to Resident #1 that was not immediate jeopardy. Findings include: The 2/2019 facility's Change in Resident Condition Policy documents should a resident experience a medical change in condition, it is the expectation that the registered nurse (RN) on duty will perform a full assessment of the resident, document changes in the medical record, and notify the physician of the changes. A change in condition may include, but is not limited to an accident/incident, injury of unknown source, medication reaction, significant change in physical/emotional/mental condition, a need to alter medical treatment significantly, refusals of medication, a need to transfer to the hospital, a discharge without proper medical authority, worsening pain not relieved by medication, change in behavior/mood, change in cognition, and change in vital signs. The Nurse Supervisor/Charge Nurse will document in the record information relative to the change in status including the full assessment conducted by a RN, including interventions started/stopped, who was notified and when (provider, resident and/or family), and new orders obtained. Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 11/2/2021 Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired, required extensive assistance from 2 staff members with most activities of daily living (ADL), had a surgical wound, and received surgical wound care. The 10/22/2021 hospital report documented the resident was admitted to the hospital with [CONDITION(S)] (infection) of the left foot. On 10/7/2021, the resident's dry gangrenous (dead tissue caused by an infection or lack of blood flow) left great toe was amputated and on 10/12/2021, the resident's left second toe was amputated. The resident was discharged to the facility, was to follow up with [CONDITION(S)] and continue wound care as instructed. There were no wound care instructions included with the hospital report. Registered nurse Supervisor (RNS) #4's admission progress note dated 10/22/21 at 7:35 PM, documented the resident was admitted with an amputated toe and would not allow the dressing to be removed at that time. The 24-hour nursing Supervisor's report sheet dated 10/22/21 documented the resident had a left toe amputation, was confused, alert, yelled, and was anxious. The documentation was handwritten and entered under both the 6 AM to 2 PM and 2 PM to 10 PM shift. The report did not document the need for a surgical wound assessment or treatment order. The comprehensive care plan (CCP), initiated 10/22/2021, documented the resident had impaired skin integrity related to [CONDITION(S)] (PVD, impaired circulation) and diabetes. Interventions included treatments per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The CCP did not document the resident's surgical wounds, the location of the wounds, or treatment orders for the surgical wounds. The 10/22/2021 physician #5's orders documented diabetic foot checks daily and to report abnormalities to the RN. The orders did not document a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility nursing schedule for 10/23/21 (Saturday) documented RNS #1 was scheduled to work 6:00 AM- 10:00 PM on that date. From 10/22/2021 to 10/26/2021, there was no documentation in the medical record of an assessment of the resident's left foot surgical wounds. The 10/26/2021 at 1:00 AM, physician #5's admission progress note documented the resident was admitted for short-term rehabilitation for [CONDITION(S)] of the left foot resulting in amputation due to gangrene necrosis (dead tissue). Staff had no new medical issues to discuss with the physician. The assessment documented an encounter for orthopedic aftercare following surgical amputation and the plan included wound care per surgeon's orders and the resident was discharged from the hospital on [MEDICATION(S)] (antibiotic), 100 milligrams (mg) twice daily. There was no documentation the surgical wounds on the left foot were assessed by the physician at that time. The 10/2021 Treatment Administration Record (TAR) documentation included: -Diabetic foot check daily-report any abnormalities to RN for further assessment one time a day for diabetic foot monitoring. Check for color, redness and wound. The TAR documented the foot checks were done on 10/23/21, 10/24/21 and 10/26/21 and color, redness and wound were all documented as no. On 10/25/21 LPN #3 documented other/see nursing notes. The 10/25/21 LPN #3 nursing note at 12:58 PM documented the resident was out of the facility, not done. - from 10/22/2021 to 10/26/2021, there was no documentation a treatment was ordered or administered to the resident's left foot surgical wounds. - On 10/27/21 at 7:00 AM, a diabetic foot check was completed by licensed practical nurse (LPN) #9. The TAR documented the resident had redness and a wound. There was no documentation if the observations were the left or right foot. There was no documentation the resident was assessed by a qualified professional. The 10/27/2021 (5 days after admission) physician #5's orders, entered by RN #4 documented for the right toe surgical site (resident's surgical site was on the left foot): cleanse with normal saline (NS) and apply a dry dressing daily for wound care. The 10/2021 TAR documented on 10/27/2021, a new order to cleanse the right toe surgical site (resident's surgical site was on the left foot) with NS and apply a dry dressing one time a day for wound care. The treatment was not documented as completed on 10/29/21. Nursing progress notes written by LPN #3 documented: - on 11/1/21 at 10:26 AM, the resident had a diabetic foot check with the left forefoot red and blanchable, cool to touch, and the foot was black and scabbed over where the wound was. The right fourth toe and second toe had scabbing on top, and the hallux (big toe) had a small, blackened area (first documentation of impaired skin on right foot). - On 11/2/21 at 10:37 AM, the resident had a diabetic foot check, and the inner aspect of the right fourth toe had an old dressing. The dressing was removed and there was a small piece of tissue hanging that was not able to be trimmed off. The area was cleansed with soap and water and a dry dressing applied. The left toes had a small amount of old red drainage and around the wound bed was whitish in color. The 11/2021 TAR documented the treatment to the right toe surgical site (resident's surgical site was on the left foot) of cleanse with NS and apply dry dressing one time a day for wound care was done on 11/1/2021 and 11/2/2021 by LPN #3. RNS #1's progress note dated 11/2/21 at 6:02 PM documented new order to follow up with the vascular physician. There was no documentation for the reason for the ordered follow-up and no documentation of an assessment. The 11/3/21 at 11:41 PM, RNS #1's progress note documented the resident was unresponsive upon return from [CONDITION(S)]. The resident's vital signs were unstable, blood sugar was 23 milligrams per deciliter (mg/dl, normal 70-100 mg/dl) and the resident was transported to the hospital. The hospital medical record documented: - The resident was admitted to the hospital on 11/3/21 and was discharged on [DATE]. - On 11/3/21, a History and Physical noted the resident was previously hospitalized for gangrene of the left foot and had 2 toes amputated. The resident was seen 11/3/2021 and was unresponsive after [CONDITION(S)] with a blood sugar that was very low on arrival. The wound on the left foot was black, their foot was red, and their white blood cell count was elevated (sign of infection). Gangrenous changes were noted to the left foot. The plan was to culture the wound and add antibiotics for septic (infection that spread to the blood) treatment. - On 11/11/21, the hospital physician documented the resident came to the emergency room obtunded (slow to respond), had very low blood sugar, and an infected wound. The resident had gangrenous changes at the tip of the left foot and the third toe also looked gangrenous. The resident underwent [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with LPN #3 on 12/29/2021 at 12:57 PM, they stated Resident #1 had a wound on their foot and the toes were involved and they did not recall what foot had the wounds. LPN #3 stated the resident's toes were blackened. LPN #3 stated the RN should have been notified if there were any changes in the wound and if there were treatment orders in place, LPN #3 stated they would not call the RN every day about changes. LPN #3 stated they would document if they notified the RN of something. During a second interview with LPN #3 on 1/7/2022 at 10:06 AM, they stated a diabetic foot check could be completed by either an LPN or RN depending on who was assigned to do treatments. The foot check included looking at the feet and ankles for any increased redness, sores, or skin impairment, and if changes were noted, they would write a note and let the Supervisor know. LPN #3 stated they were not involved with taking orders from medical providers. During an interview with RNS #4 on 1/7/22 at 1:35 PM, they stated when a resident was admitted , they were responsible for the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RNS #4 stated at the time of an admission, they reviewed the hospital discharge orders and took the orders from there. They called the physician to review and approve the orders. RNS #4 stated most of the time they did not receive verbal report from the discharging hospital and rarely received orders for treatments and would find them buried in the hospital medical record. RNS #4 stated the day the resident was admitted , they started doing a head-to-toe assessment but by the time they got to the toes, the resident had enough, wanted to be done, and refused to allow RN #4 to assess the toes where the surgical wounds were. RNS #4 stated they wrote a note and documented on report so the nurse on the day shift would know an assessment was needed. RNS #4 stated they were not aware a treatment order was not obtained on admission or that an assessment of the surgical site on the toes was not done. RNS #4 stated the day shift should have checked and made sure there was a treatment order in place. RNS #4 stated when the treatment order was obtained, it was for the left toe surgical sites and not the right as documented in the order. RNS #4 stated the treatments were done on the left toes. During an interview with the Director of Nursing (DON) on 1/10/2022 at 9:35 AM, they stated when a resident was admitted , orders were completed by reviewing the hospital paperwork and receiving verbal report from the hospital. Once the resident arrived at the facility, an assessment would be done, and the nurse would talk to the physician to approve the orders. If an assessment could not be completed on admission, it should be documented on the Supervisor's report and the next shift should complete the assessment. If the next shift was the overnight shift, the day shift would complete the assessment if the resident was asleep. The purpose of assessing a wound on admission was to determine the treatment and monitor the wound's progress or lack of progress. An assessment should be performed by a RN. The DON stated they were unaware the resident's surgical wounds were not assessed on admission and there should have been an RN assessment completed. During an interview with physician #5 on 1/10/2022 at 11:32 AM, they stated when a resident was admitted to the facility, the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse who admitted a resident would review the hospital orders with the physician for approval. If there were no orders for surgical wound care, the admitting nurse should reach out to the hospital or the surgeon to obtain orders. Residents should be assessed upon admission. If a resident refused assessment, it would be up to the DON to determine when the next assessment should be attempted. The goal would be to have it done as soon as possible. The physician stated there were weekly skin assessments done and they would be reported to the DON or Supervisor. They stated when they went to the facility, the nurses did not usually round with them due to time constraints or staffing but any concerns would be relayed to the physician. The physician did not recall visualizing the resident's left foot surgical wounds during the initial History and Physical as the toes were likely dressed at that time. They stated if they saw the wounds, the evaluation would be included in their progress notes. The physician stated no concerns were brought to their attention regarding the surgical wounds. The physician stated the resident's wounds should have been assessed and a treatment ordered soon after admission. During an interview on 1/11/22 at 10:12 AM with LPN #9, they stated performing a diabetic foot check included looking at both legs starting with the calf and checking for pedal pulses, color, temperature, cracks, marks, wounds, and anything out of the ordinary. LPN #9 stated on 10/27/2021, they documented the resident had redness and a wound. LPN #9 considered a wound to mean anything more than a crack and it could mean a new or existing wound. The TAR did not specify if the areas were on the right or left foot so they would write a progress note when needed. LPN #9 stated they would let the nursing Supervisor know of concerns and they would assess the area. LPN #9 stated they were unable to recall what side of the body they were referring to on the 10/27/2021 TAR and did not recall if a skin assessment was completed. During an interview with RNS #1 on 1/13/22 at 3:24 PM, they stated they remembered the resident had many wounds on both of their lower extremities due to poor circulation. The first time the resident came to the facility, they had toe amputations. The RNS stated they did not remember when they saw the toes but remembered they looked better at some point. RNS #1 stated the vascular order on 11/2/21 was for both legs but the resident had new areas on the right leg. RNS #1 had notified the physician and they ordered the vascular consult. RNS #1 stated they were not aware the resident had no treatments ordered for the surgical sites on the left toes and that the toes had not been assessed for a period of time. If a resident refused an assessment upon admission during the evening shift, it should be reported. There were usually no RNs during the night shift so it would be done the following day when an RN was available. 10NYCRR 415.12

Based on record review and interviews conducted during the standard survey it was determined for 2 of 6 residents (Residents #1 and 15), reviewed for catheters (urinary drainage tube), the facility did not ensure appropriate treatment and services were provided. Specifically for Resident #1, the suprapubic catheter (urinary drainage tube through abdomen into the bladder) became displaced on two occasions and the resident was sent to the hospital; a urology consult was not done as recommended by the hospital; and the physician was not notified the suprapubic catheter required frequent changing. Resident #15 experienced pain, and was transferred to the hospital for evaluation when the urinary catheter was incorrectly placed. This resulted in actual harm for Residents #1 and 15 that is not immediate jeopardy for Resident #1. Findings include: 1) Resident #15 had [DIAGNOSES REDACTED]. The physician orders, dated 7/22/2014, documented the resident had an indwelling Foley catheter size 18 French (F) with a 10 cc (cubic centimeter) balloon (small balloon on the end of the catheter that secures inside the bladder), for [MEDICAL CONDITION], that was to be changed monthly and as needed. The comprehensive care plan (CCP), dated 7/24/2014, documented the resident required an indwelling Foley catheter, and the goal was to have catheter care managed appropriately as evidenced by not exhibiting signs of infection or urethral trauma. The Minimum Data Set (MDS) assessment, dated 7/29/2014, documented the resident was cognitively intact, required extensive assistance for most activities of daily living (ADL), and had an indwelling urinary catheter. The TAR dated 9/2014 documented the resident's Foley catheter was to be changed on the seventh of the month and was scheduled for the 10 PM - 6 AM shift. Registered nurse (RN) #9 progress note, dated 9/8/2014 at 12:44 AM, documented licensed practical nurse (LPN) #10 changed the resident's catheter, and did not get a urine return. The resident complained of pain and pressure when the LPN inflated the balloon. The RN documented she deflated the balloon, readjusted the catheter and reinflated the balloon with 7 - 8 cc of sterile water. She documented the resident complained of increased pain and pressure and there was no urine flow. She also documented the resident stated "it sometimes takes a while for the urine to flow, but he has not had this much pressure and discomfort before." The nurse practitioner was notified and ordered to deflate the balloon by a "few cc's", encourage fluids, reposition, watch for 2 hours, and if no urine flow or increased pain send to the hospital. RN #9 progress note, dated 9/8/2014 at 3:15 AM, documented the resident had no urine flow, and she was sending him to the hospital. The TAR, dated 9/8/2014 at 3:18 AM, documented the "catheter was inserted with no return flow." The LPN #10 progress note, dated 9/8/2014 at 3:57 AM, documented she gave the resident [MEDICATION NAME] (narcotic pain reliever) at 3:10 AM, for complaints of "pain in general and with Foley catheter." RN #9 progress notes, dated 9/8/2014, documented: - at 4:04 AM, the resident complained of abdominal distention; - at 4:15 AM, the resident was transferred to the hospital via ambulance; - at 4:33 AM, the hospital notified the facility the resident's catheter was changed and drained 700 cc of urine; and - at 4:50 AM, the resident's family member called the facility and requested routine catheter changes be done on the day shift. During an interview, on 10/9/2014 at 10:50 AM, the resident stated the nurse came in one night and told him he was scheduled for a Foley catheter change. He stated there were two nurses trying to put the Foley catheter in, and he had never had so much pain. He stated he told them he was in pain, and they left the Foley catheter in for hours. He stated he had a Foley catheter for years and never had any problems changing it. He stated the nurses did not know what they were doing, and had told him they did this all the time. He stated they finally sent him to the hospital and within 5 minutes the hospital nurse had the catheter changed. He stated he told the nurses repeatedly he was in pain and "never had pain like that." During an interview, on 10/9/2014 at 12:05 PM, LPN #11 stated when putting a Foley catheter in, the balloon was inflated only after seeing a urine return. She stated if she did not see a urine return she took the catheter out and called the RN. During an interview, on 10/9/2014 at 12:08 PM, RN #12 Unit Manager stated he was aware of an incident on night shift when the staff could not get the catheter in the resident, and he complained of pain, and went to the hospital. He stated the catheter should have been removed if there was no urine return. During a phone interview with LPN #10, on 10/9/2014 at 1:15 PM, she stated she inserted the catheter in the resident on 9/8/2014, it went in easy and she did not get a urine return. She stated she tried again, the resident became uncomfortable, and she called RN #9 Supervisor. She stated RN #9 inserted the catheter, inflated the balloon, and called the physician. She stated the catheter was left inside the resident with the balloon inflated, she checked for urine every half hour, the resident continued to be uncomfortable and was sent to the hospital after a couple of hours. During an interview with the NP, on 10/9/2014 at 1:30 PM, she stated she vaguely remembered the call, and was told the resident's catheter was not draining. The NP stated she thought the underlying cause could have been a kinked catheter, a prostate problem, or dehydration. She stated she did not recall anything about inflating the balloon, and suggested trying to reposition the resident, giving fluids, and if that did not work to send to the hospital. She stated it did not occur to her the catheter was not inserted correctly. During a phone interview, on 10/9/2014 at 2:30 PM, RN #9 Supervisor stated the resident was in pain after the catheter balloon was inflated. She stated she thought there might have been a drop of urine when she inserted the catheter. RN #9 stated the NP told her to leave the resident's catheter in, reduce the amount of water in the balloon, and see if it drained. She stated the resident did not allow proper positioning as he was in a recliner chair. She stated the resident was in pain, she took the catheter out, called the physician and sent the resident to the hospital. During an interview, on 10/9/2014 at 2:45 PM, the Director of Nursing (DON) stated urine should have drained from the catheter prior to the balloon being inflated. She stated she was aware of an incident when the resident's Foley was changed, and there was no urine return. She stated it would have been painful if the catheter was not in all the way and the balloon was inflated. She stated leaving the catheter in for a prolonged period would have been uncomfortable, and it should not have been left in for hours if the resident was uncomfortable. 2) Resident #1 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP), dated 9/7/2012, documented the resident was at risk for urinary tract infection [MEDICAL CONDITION] related to the use of an indwelling urinary catheter, and a history of UTI and urosepsis (infection in the urinary tract which spreads to the bloodstream). On 11/11/2013, the CCP documented the resident had a suprapubic catheter. The physician's orders [REDACTED]. The nursing progress note, dated 4/5/2014 at 8:29 AM, documented the resident's suprapubic catheter was "no longer patent no longer able to be flushed" and was changed by a registered nurse (RN). The nursing progress note dated 4/6/2014 at 11:34 AM, documented during care staff noted a "white object protruding from the resident's rectum, upon inspection it appeared to be the tip of suprapubic catheter." The resident was sent to the emergency room . The hospital discharge summary dated 4/12/2014 documented the resident had a suprapubic catheter with suspicion of a fistula (abnormal opening) between the bladder and rectum, a fistula between the bladder and vagina. The report documented the resident had a urinary tract infection [MEDICAL CONDITION] and was to follow up with an outpatient [MEDICAL CONDITION] (GU) consult. The physician's progress note, dated 4/15/2014, documented a (GU) consult was done in the hospital and recommended the resident be seen as an outpatient. The Minimum Data Set (MDS) assessment, dated 4/17/2014, documented the resident's cognitive status was severely impaired. The resident was rarely understood, had a suprapubic catheter, and required total assistance for personal hygiene. The nurse practitioner (NP) progress note, dated 5/13/2014, documented the resident had no consults for the review period. The nursing progress notes dated 6/3 - 6/28/2014 documented the resident's suprapubic catheter was plugged, was unable to be flushed, and was changed 8 times by an RN. The nursing progress notes dated 7/1 - 7/27/2014 documented the resident's suprapubic catheter was plugged, was unable to be flushed, and was changed 5 times by an RN. The nursing progress notes dated 8/1 - 8/31/2014 documented the resident's suprapubic catheter was plugged, was unable to be flushed, and was changed 6 times by an RN. From 4/15/2014 through 8/20/2014, there was no documentation of physician's orders [REDACTED]. On 8/20/2014, the nurse practitioner ordered a urology consult to rule out a fistula. The nursing progress note, dated 9/1/2014 at 5:21 AM, documented the resident's suprapubic catheter was "protruding out through vaginal area with balloon still inflated." The resident was sent to the hospital for evaluation. The nursing progress note, dated 9/1/2014 at 10:53 AM, documented the resident returned from the hospital. The suprapubic catheter was changed, and a computerized tomography (CT) scan was done that showed no fistula between the bladder and vagina. The NP progress note, dated 9/4/2014, documented the resident's suprapubic catheter was changed in the emergency room . "They were directed not to put it in quite as far." The nursing progress notes dated 9/14 - 9/28/2014 documented the resident's suprapubic catheter was plugged, unable to be flushed, and was changed 6 times by an RN. During an interview on 10/8/2014 at 3:45 PM, the physician, stated he was was aware the resident's suprapubic catheter came out through the urethra on one occasion. He stated it was a rare occurrence, and he was not aware of the second time. The physician stated he thought the resident's suprapubic catheter was changed monthly or as recommended by the urologist. He stated if the catheter needed to be changed more often, he expected to be notified to determine the underlying cause. On 10/8/2014 at 4:15 PM, during an interview with the nurse practitioner (NP), she stated the last time the resident had an issue with the suprapubic catheter, was when the catheter tip was protruding out the urethra, and the resident was sent to the hospital. She stated the suprapubic catheter was usually changed once a month, or when there was a problem. She stated if the catheter consistently needed changing, she expected to be notified, and would have consulted urology to determine the underlying cause. During an interview on 10/8/2014 at 5:00 PM, the physician stated the resident should not have needed such frequent suprapubic catheter changes, and he should have been notified. On 10/9/2014 at 2:45 PM, during an interview with the Director of Nursing (DON), she stated she was aware the resident's suprapubic catheter was changed "fairly frequently." She stated the physician should have been updated, and was she unsure if he was aware how often the resident's suprapubic catheter needed to be changed. She stated the physician should have been notified to see if something could have been done differently. 10NYCRR 415.12(d)(2)