Every finding on record at Crown Heights Center for Nursing and Rehabilitatio

Based on record review and interviews conducted during an abbreviated survey (2699587), the facility failed to ensure the designated resident's representative was notified of changes in the resident's condition. This was evident for one (1) of six (6) residents sampled (Resident #1). Specifically, on 12/06/2025 at 5:00 PM Occupational Therapist Assistant #1 documented they saw Resident #1 sliding from the wheelchair to the floor. There is no documented evidence that the facility notified Resident 1's representative that Resident #1 was seen sliding out of the wheelchair to the floor.The findings are:The Facility's Policy on Notification of Changes dated on 12/2024, documented it is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate (hereafter designated as the physician). The resident and/or their representatives will be educated about treatment options and supported to make an informed choice about care preferences when there are multiple care options available. All pertinent information will be made available to the provider by the facility staff. Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative, and the resident's physician, to ensure best outcomes of care for the resident.Resident #1 was admitted to the facility with diagnoses including constipation, chronic pain syndrome, and history of falling.Minimum Data Set (a resident assessment tool) dated 11/22/2025, documented Resident #1 had moderately impaired cognition.There was no documented evidence that Resident #1's representative was notified on 12/06/2025 that Resident #1 was observed sliding from their wheelchair to the floor.During an interview on 12/30/2025 at 9:28 AM, Registered Nurse Supervisor #2 stated during body assessment of Resident #1 there were no visible injury, trauma, or skin changes. Registered Nursing Supervisor #2 stated the medical doctor or Resident #1's representative was not informed that Resident #1 slide out of the wheelchair to the floor on 12/06/2025.During an interview on 12/29/2025 at 1:42 PM, Director of Nursing stated Registered Nurse Supervisor #2 must notify the medical doctor and Resident #1's family representative when Resident #1 slide out of the wheelchair to the floor on 12/06/2025.10 NYCRR 415.3(e)(2)(ii)(b)

Based on observation, record review and interview during an Abbreviated Complaint Survey (Complaint # 2699587), the facility failed to ensure resident's care plan was reviewed and revised by the interdisciplinary team after each assessment. This was evident for one (1) out of six (6) residents sampled (Resident #1). Specifically, on 12/06/2025 at 5:00 PM Occupational Therapist Assistant #1 documented they saw Resident #1 sliding from the wheelchair to the floor. Registered Nurse Supervisor #2 was notified on 12/06/2025. There was no documented evidence that Resident #1's care plan was reviewed and revised with new interventions after Resident #1 slide from the wheelchair to the floor on 12/06/2025. The findings include:The facility policy titled Care Plan Comprehensive dated 12/2024, documented an Individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Also care plans are revised as changes in the resident's condition dictate. Care plans are reviewed at least quarterly.Resident #1 was admitted to the facility with diagnoses including constipation, chronic pain syndrome, and history of falling.Minimum Data Set (a resident assessment tool) dated 11/22/2025, documented Resident #1 had moderately impaired cognition.Resident #1's care plan for actual fall dated 08/29/2025, with interventions including keeping personal items within the reach, neuro checks, physical therapy and routine rounding. There is no documented evidence that the care plan was updated after Resident #1 slide out of the wheelchair to the floor on 12/06/2025. There was no documented evidence that a team meeting was done to discuss the sliding out of the wheelchair.On 12/06/2025 at 5:10 PM, Occupational Therapist Assistant #1 documented on the facility's statement form, Resident #1 was seen sliding off their wheelchair. Occupational Therapist Assistant #1 reported the incident to the Licensed Practical Nurse #1.During an interview on 12/30/2025 at 11:09 AM, Occupational Therapist Assistant #1 stated on 12/06/2025 at 5:10 PM, as they were getting off the elevator on the 3rd floor on 12/06/2025 and saw Resident #1 sliding off their wheelchair on to the floor. Occupational Therapist Assistant #1 stated Resident #1 got up by themself and sat on the wheelchair, then slide off the wheelchair again to the floor. Occupational Therapist Assistant #1 stated Licensed Practical Nurse #1 was informed and stayed with Resident #1.During an interview on 12/30/2025 at 9:28 AM, Registered Nurse Supervisor #2 stated on 12/06/2025 during the 7:00 AM - 7:00 PM shift they received notification from Licensed Practical Nurse #1 that Resident #1 slide from the wheelchair to the floor. Registered Nurse Supervisor #2 stated Resident #1 said they did not fall. Registered Nursing Supervisor #2 stated they performed a full body assessment and there were no injuries, no trauma, and Resident #1 denied any pain. Registered Nurse Supervisor #2 stated they did not document Resident #1 sliding from the wheelchair to the floor. Registered Nurse Supervisor #2 stated they did not updated Resident #1's care plan on 12/06/2025.During an interview on 12/29/2025 at 1:42 PM, Director of Nursing stated they were not aware that Resident #1 slide out of the wheelchair to the floor on 12/06/2025. Director of Nursing stated Registered Nurse Supervisor #2, who was working on the shift at that time should have done a full body assessment. Director of Nursing stated Registered Nurse Supervisor #2 should have done an incident report and update the care plan with new interventions.10 NYCRR 415.11

Based on observation, record review and interview during an Abbreviated Complaint Survey (Complaint # 2699587), the facility failed to ensure Resident #1 received treatment and care in accordance with professional standards of practice. This was evident for one (1) of six (6) residents sampled (Resident #1). Specifically, on 12/19/2025 License Practical Nurse #2 administered a stool softener to Resident #1 without a physician's order for the stool softener. License Practical Nurse #2 did not document the administration of the stool softener to Resident #1. The findings include:The facility policy titled Administering Oral Medication dated 12/2024, documented the purpose of this procedure is to provide guidelines for the safe administration of oral medications. Verify, that there is a physician's medication order for this procedure.Resident #1 admitted to the facility with diagnoses included constipation, chronic pain syndrome, and history of falling.Minimum Data Set (a resident assessment tool) dated 11/22/2025 documented Resident #1 had moderately impaired cognition.Resident #1's care plan for bowel incontinent with interventions including check resident every two (2) hours and assist with toileting as needed, observe pattern of incontinence, and initiate toileting schedule if indicated.A nursing progress note dated 12/19/2025 at 11:11 AM, written by Licensed Practical Nurse #1 documented Resident #1 asked for stool softener and the medication was given and tolerated well.Review of the physician's order dated from 12/01/2025 to 12/29/2025 revealed no physician's order for any stool softener.The Emergency Department note dated 12/19/2025, documented Resident #1 presented to the emergency department from the facility for constipation. Resident #1 has intermittent cramping and abdominal pain. Resident #1 reported they had no bowel movement in 3 days. Resident #1 was given medication at the facility and had a bowel movement right before coming to the emergency department. In the emergency department while being evaluated, Resident #1 had a large bowel movement, after the bowel movement Resident #1 stated they felt better and denied any further abdominal pain. There was no bowel obstruction.During an interview on 12/29/2025 at 9:50 AM, Resident #1 stated they went to the hospital on [DATE] because they were constipated. Resident #1 stated they informed Licensed Practical Nurse #2 and was given some medication for the constipation. Resident #1 stated they were still having pain; the medication did not work so they called 911 and went to the hospital. Resident #1 stated at the hospital they have a large bowel movement, felt better and went back to the facility on the same day.During an interview on 12/30/2025 at 9:43 AM Licensed Practical Nurse #2 stated on 12/19/2025 at 11: 11AM, Resident #1 asked them for something to move their bowel. Licensed Practical Nurse #2 stated they give Resident #1 two tablets for constipation. Licensed Practical Nurse #2 stated there was no physician's order for the medication.During an interview on 12/29/2025 1:58 PM, Medical Doctor #1 stated they review Resident #1's medical record and noted when Resident #1 was admitted to the facility on [DATE] Resident #1 was on bowel regiment for 30 days. Medical Doctor #1 stated after the 0 days medication was completed, there were no further complaints of constipation. Medical Doctor #1 stated there were no call requesting an order for a stool softener for Resident #1 on 12/19/2025.During an interview on 12/30/2025 at 2:14 PM, Administrator stated Licensed Practical Nurse #2 should have contacted Resident #1's medical doctor, explained the symptoms and request the order for a stool softener. The Administrator acknowledged Licensed Practical Nurse #2 administered a stool softener to Resident #1 without a physician's order.10 NYCRR 415.12

Based on observation, record review and interview during Abbreviated Complaint Survey (Complaint #2699587), the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents. This was evident for one (1) out of six (6) residents sampled (Resident #1). Specifically, Resident #1 was a high risk for falls, the physician's order dated 11/11/2025 documented Resident #1 may be out of bed to standard wheelchair with bilateral elevating leg rests and with manual transfer of one (1) person. On 12/06/2025 at 5:00 PM, Occupational Therapist Assistant #1 documented Resident #1 was seen sliding from the wheelchair to the floor. There is no documented evidence on the Documentation Survey Report or on the Resident Nursing Instruction form instructing staff members on how to supervise Resident #1 to prevent fall.The findings include:The facility policy titled Fall Risk assessment dated 12/2024, documented the nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls. Also, the attending physician and nursing staff will evaluate the resident's vital signs, assess the resident for medical conditions (such as those that cause dizziness or vertigo) or sensory impairments (such as decreased vision and peripheral neuropathy) that may predispose to falls.Resident #1 was admitted to the facility with diagnoses included constipation, chronic pain syndrome, and history of falling.Minimum Data Set (a resident assessment tool) dated 11/22/2025, documented Resident #1 had moderately impaired cognition.A physician's order dated 11/11/2025, documented Resident #1 may be out of bed to standard wheelchair with bilateral elevating leg rest and with partial to moderate assistance during manual transfer by one (1) person.There was no documented evidence on the Documentation Survey Report or on the Resident Nursing Instructions form with instructions on how to supervise Resident #1 to prevent falls.On 12/06/2025 at 5:10 PM, Occupational Therapist Assistant #1 observed Resident #1 sliding off their wheelchair. Occupational Therapist Assistant #1 reported the incident to Licensed Practical Nurse #1 and wrote a statement.There is no documented evidence that a body assessment was done, and medical doctor or the family was notified. There is no documented facility's investigation of Resident #1 sliding out of a wheelchair to the floor.During an interview on 12/29/2025 at 9:50 AM, Resident #1 stated they did not fall. Resident #1 reported they dropped something on the floor and tried to pick it up when Occupational Therapist Assistant #1 saw them on the floor.During an interview on 12/30/2025 at 11:09 AM, Occupational Therapist Assistant #1 stated on 12/06/2025 at 5:10 PM, as they were getting off the elevator on the 3rd floor, they saw Resident #1 sliding off their wheelchair. Occupational Therapist Assistant #1 stated Resident #1 got up by themself, sit on the wheelchair then slide off again. Occupational Therapist Assistant #1 stated they informed Licensed Practical Nurse #1, who stayed with Resident #1. Occupational Therapist Assistant #1 then went in search of Registered Nurse Supervisor #2 and did not find them. Occupational Therapist Assistant #1 stated they wrote a statement and leave it at the nursing station.During an interview on 12/30/2025 at 9:28 AM, Registered Nurse Supervisor #2 stated on 12/06/2025 (not sure of time), they were informed by Licensed Practical Nurse #1 that Occupational Therapist Assistant #1 reported on the third floor, Resident #1 slide out of the wheelchair on to the floor. Registered Nurse Supervisor #2 stated Resident #1 was asked what happened, and Resident #1 reported that they did not fall. Registered Nursing Supervisor #2 stated they performed body assessment on Resident #1 but did not document the fall assessment because there was no trauma, no injuries or skin changes. Registered Nursing Supervisor #2 stated they did not informed the medical doctor about the fall by sliding out of the wheelchair.During an interview on 12/29/2025 at 1:42 PM, Director of Nursing stated they were not aware that Resident #1 had a fall by sliding out of the wheelchair on 12/06/2025. Director of Nursing acknoleged that Registered Nurse Supervisor #2 should have initiated an incident report, collected statements from the staff members and reported the fall to the medical doctor and resident's family representative.10NYCRR415.12(h)(1)

Based on observation, record review and interview during Abbreviated Complaint Survey (Complaint #2699587), the facility failed to ensure that medical records were maintained in accordance with accepted professional standards and practices and were accurately documented. This was evident for one (1) out of six (6) residents sampled (Resident #1). Specifically, on 12/06/2025 at 5:00 PM Occupational Therapist Assistant #1 documented they saw Resident #1 sliding from the wheelchair to the floor. There was no nursing or medical doctor's documentation in Resident #1's medical record indicating that Resident #1 was assessed after Resident #1 slide out of the wheelchair to the floor on 12/6/2025.The findings are:The facility policy titled Charting and Documentation dated 01/2026 documented all services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. Also documented all incidents, accidents, or changes in the resident's condition must be recorded.Resident #1 admitted to the facility with diagnoses included constipation, chronic pain syndrome, and history of falling.Minimum Data Set (a resident assessment tool) dated 11/22/2025 documented Resident #1 had moderately impaired cognition.During review of medical records from 12/01/2025 through 12/30/2025, there were no documented evidence that Resident #1 was assessed after slided out of a wheelchair to the floor.During an interview on 12/30/2025 at 9:28 AM, Registered Nurse Supervisor #2 stated on 12/06/2025 (not sure of time) they were informed Resident #1 slide out of the wheelchair to the floor. Resident #1 said that they did not fall. Registered Nurse Supervisor #2 stated they did not write any progress note in Resident #1's medical record.During an interview on 12/29/2025 at 1:42 PM Director of Nursing stated Registered Nurse Supervisor #2 was working at the time. Director of Nursing stated Registered Nurse Supervisor #2 should have written a nursing progress note in Resident #1 medical record. 10 NYCRR 415.22(a)(1-4)

Based on observation, record review, and interview conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure the residents' right to a safe, clean, comfortable, and homelike environment was maintained. Specifically multiple observations were made of resident rooms were observed with wood furniture scratched veneer, missing key holes, missing handles to dressers or wall cabinets, bedside tables were observed with missing paint on the lower leg areas. 2.) resident rooms were observed with mismatched paint, holes in dry wall and duct tape on the floor, missing tile and/or grimy tile. 3.) resident's wheelchair was observed with torn cushion and enteral feeding pumps and poles on 2 East and 2 [NAME] unit was observed with cream-colored stains on the pump and pole bottoms. 4). the whirlpool tub was noted to be dirty with discarded items inside and unit shared bathrooms were observed with discolored damaged or missing tiles. 4.) the step leading to the trash dumpster was noted to be rusty with hole in metal stairs on the left side of the steps. 5). the wall behind in the 2nd floor dining room refrigerator and false pantry was observed with holes in back wall area. This was evident in 5 out of 6 units observed (2 East, 2 West, 3 East, 3 [NAME] and 4 West). The findings are: The facility's policy titled Cleaning and Disinfecting Resident Care Items and Equipment reviewed December 2024 documented resident shared equipment including shared items and durable medical equipment shall be cleaned and disinfected according to the current Centers of Disease Control recommendations for disinfection and the Occupational Safety Health Administration Bloodborne Pathogens Standard. Durable medical equipment such as enteral feeding pumps, intravenous poles shall be cleaned after usage on the Environment Protection Agency registered antimicrobial list recommended by public health authorities. Medical storage equipment such as medication/treatment carts, cardiopulmonary resuscitation carts shall be cleaned when visibly soiled and on as needed basis. The facility policy titled 7 Step Cleaning Progress reviewed August 2024 documented rooms the policy is to establish an efficient cleaning process and maintain a sanitary physical environment. Rooms will be cleaned thoroughly cleaned monthly or as needed. The following was observed during multiple observations conducted from 12/12/2024 to 12/19/2024. a.) Kitchen observations on 12/12/2024 from 09:21 AM - 10:58 AM, 12/16/2024 at 04:29 PM and 12/18/24 01:13 PM, include leaking kitchen kettle, cracked tile on the floor and missing tile. There is a gap in the wall edge by refrigerator #3 by wall mixer, cracked tile around the drain by the kettle and prep area, cracked tile by the stove partially replaced. The metal shelf of the kitchen holding washed dishes has grease residue on the metal shelves. Cracked corners on the resident fiberglass meal trays. Cracked floor and baseboard tiles in the dish room. Cracked floor tile under freezer #2. Cracked tile by prep station thawing sink opposite refrigerator #1. Visible hole under the sink pipe in the kitchen dish room. During an interview on 12/17/2024 at 11:28 AM, Dietary Aide # 7 stated, the kitchen tiles have been broken and maintenance comes to fix them when water comes up from floor drain areas. During an interview on 12/17/2024 at 10:32 AM, Dietary Aide # 4 stated, the leaking cooking kettle makes a puddle on the floor. There was a puddle in the kitchen at least 1-time last week after it rained heavy, and maintenance came to take care of it. b). On 12/17/24 at 10:29 AM, during kitchen trash disposal task with Dietary Aide # 4 the metal walking stairs leading to the bottom of the facility trash compactor were observed to be damaged. There was stored wheelchair parts visible under stairs area. On 12/19/2024 at 12:44 PM main floor staff dining lounge past the kitchen on lobby floor noted with black colored droppings under sink, food stain in freezer and bottom drawer noted with light brown colored food stain on the bottom of the lower drawers. c.)2nd Floor shared dining room by the elevator was observed from 12/12/2024 to 12/19/2024 with no radiator cover, metal exposed under mounted wall television area and the ice machine vent was dusty. There was a noticeable hole in the wall behind the refrigerator with a gap in between the refrigerator and the false pantry. 2nd Floor -2 East unit - on 12/12/2024 at 3:09PM and 12/17/2024 at 03:14PM, 12/17/2024 at 3:35PM - 3:37PM, the following was observed room [ROOM NUMBER]E-209 enteral feeding pump with dried cream-colored stains back of the pump. room [ROOM NUMBER]E - 206 has 6 strip of duct tape on floor holding tile down. The trash can by A bed is covered with a brown colored stain on the outside. 2 East- fan by room [ROOM NUMBER]E-222 noted to be dusty and has a white ribbon inside the fan and stamped with sticker inspected 8/20/2024. Metal fan by room [ROOM NUMBER]E-211 and 2E-215 dusty on outside with stamped inspected 7/16/2024. 2nd Floor on 12/12/2024 at 12/12/2024 at 04:46 PM, 12/17/2024 at 03:14 PM and 12/17/2024 at 03:40 PM, Elevator # 1- left and right lower edge damage to dry wall. Elevator # 2nd number elevator left lower edge and right side exposing dry wall covered with duct tape. Elevator # 3 has damage to dry wall on the 1/3 on left and 1/4 right side. 2 East -room [ROOM NUMBER] - 4 pieces of black duct tape holding floor tiles. 2 East shower room [ROOM NUMBER]/17/24 03:17 PM to 03:20PM, there was a gap in tile under sink in shower opposite nurses' station in 3 areas, shower drain with brown colored debris around hole in the drain cover. Large shower chair with rusty wheels. Large bathtub was dusty. The large bathtub contained the following a gray colored commode, pair of discarded vinyl gloves, empty bucket, brown colored debris on tub jets. Hoyer canvas blue wrap by the arms trap areas noted to be dusty on the fabric. d.) 2 [NAME] unit - room [ROOM NUMBER] P - on 12/12/2024 02:45 PM, 12/16/2024 at 10:38 AM and 12/17/2024 at 03:00 PM, the call light box on the wall was noted hanging from the wall over the resident's headboard on 12/12/2024.) On 12/12/2024 at 02:49 PM, 12/16/2024 at 02:53 PM, 12/17/2024 02:57 PM and 12/18/2024 07:57 AM, room [ROOM NUMBER] P enteral feeding pump noted with cream-colored stains on the pump back area and pole noted with cream-colored stains on the bottom of the pole and the resident's floor. Air conditioning/heater unit damaged on left side by window bottom, unit is dusty with grey colored dust, dried leaves in adjustment knob. On 12/12/24 02:58 PM, 12/13/24 09:35 AM, the following was observed. room [ROOM NUMBER] wall divider by sink with chipped wood and air conditioning/heater unit dusty and unit crash cart with dusty bottom area. Medication Cart in the nurse's station observed with dust. room [ROOM NUMBER] enteral feeding pole with cream colored feeding on bottom dried and on enteral feeding pump front and back area. Air conditioning/heater unit dried leaves, gray colored dust in vent area. 2 [NAME] bathroom- tub with stains in tub, plastic cup on right side of seat, white towel, belt with white colored dust, shower chair for larger residents with brown colored stain on bottom area, cracked tile under sink on left edge approximately 1 3/4 x 1/2 inch. Bottom wheels for larger shower chair with rust on all 6 wheels. Wound Care treatment cart for 2 [NAME] on - 12/18/24 09:41 AM empty sharps container noted with cream colored tape affixed to the right side of the sharps container holder horizontally to keep it closed. Environment 2 West- 12/12/24 11:46 AM 2 [NAME] Hoyer lift dusty plastic foot pad and missing paint on both Hoyer leg area. 2 [NAME] Medication room on 12/16/2024 at 10:05 AM veneer on cabinet door labeled pill crusher and thermometer had ripped veneer on upper cabinet middle left door. During an interview on 12/18/2024 at 08:29 AM, the Housekeeper #1 stated, when they clean the bedside table, they scrape down the table and mop it to get the floor clean. They are not sure who they report to if the table bottom is crusty or missing paint. This is where the residents eat, and residents put their feet on, and you want it to be comfortable. e.) 3rd East and 3 [NAME] units were observed from 12/13/2024 from 11:02 AM - 12:54 PM to 12/18/2024 at 08:16AM - 03:29PM: 3 East findings room [ROOM NUMBER] - 2 tier bed side drawers scratched, missing keyhole, damaged and missing dry wall and hole in wall and missing dry wall. Water stain on ceiling tiles, bedside table missing paint on bottom base, holes at the baseboard for the B bed below the window. 3 East-318 dusty air conditioning/heater unit, cracked wall tile. room [ROOM NUMBER] Air conditioning/heater unit dusty, bedside tables missing paint on the bottom, cracked dry wall by door edge, scratched paint on air conditioning/heater. Bed A- 3 tier bedside table with missing top handle. Wall closet door missing right handle. Bed B - 2 tier dresser draw scratched veneer. room [ROOM NUMBER] - peeling paint on the wall opposite resident bed. room [ROOM NUMBER] Damaged dry wall and spoon in Air conditioner and heater unit. room [ROOM NUMBER] 2 tier dresser drawer with scratched brown colored veneer, missing keyhole, air conditioner/heater dusty wall edge, bedside table missing paint at bottom, missing tile on bottom edge of sink wall and 2 chipped tiles at sink edge, shower with rusty metal pipe, wall with missing paint above soap dish, bathroom tile in bathroom with brown colored edges. On 12/13/24 at 12:47 PM and 12/18/24 03:38 PM, room [ROOM NUMBER] - air conditioner/heater dusty and dresser drawers with scratched veneer. room [ROOM NUMBER] - dresser draw veneer scratched and missing paint on bedside table, fall matt with cracked edge. Exposed dry wall on sink edge and on bottom of wall. Missing key holes on 2 tier dressers with scratched veneer and air-conditioned dusty top and windowsill and grimy corners. room [ROOM NUMBER]- air conditioner/heater with paper and dried leaves in unit, missing key lock on the wall cabinet for A bed, sink drain left edge on wall brown in color pipe with brown grime on pipe, chipped dry wall on left side of wall edge below the sink and vital signs machine with dirty bottom foot pedals. room [ROOM NUMBER] the 2 tier dresser draw missing key lock, missing veneer on bottom edge scratched wood, 2 holes on wall where mount for electronics on floor. room [ROOM NUMBER] - 3 tier dresser right edge chipped, scratched veneer and mounted hand sanitizer dispenser not fully even with the wall. room [ROOM NUMBER] - bedside table missing paint, accordion bathroom door slat broken on lower edge, closet missing lock on left sided and tied closed with a broken metal hanger. Air conditioning unit dried leaves in unit and dusty grate. Wall with mismatched paint with dry wall patch by window under light by sink left and damaged dry wall on lower edged in room. room [ROOM NUMBER] hand sanitizer dispensed on wall not fully mounted to the wall screws visible on the right upper and lower side. room [ROOM NUMBER]- bedside table missing paint for A bed, footboard missing veneer and wood pulp exposed. There were 20 missing -1-inch tiles on handwashing sink edge. Air conditioned/heater unit dusty window, 2 tier dresser scratched veneer, damaged dry wall scratched on blue paint and right lower edge by sink. On 12/17/2024 at 03:07 PM, the 3 [NAME] bathroom was observed with multiple missing tiles on the floor of the bathroom and a 4 x 4 hole in wall. 3 [NAME] tub with clear plastic cup, cracker wrapper, vinyl glove, temperature probe machine and roach wing inside tub. Commode seat with dried brown stain on the right outer edge and left inner edge, rust on the legs, missing tile on the back wall of the commode and broken tile at hand washing sink. On 12/17/2024 at 03:29 PM, the 3 East pantry was observed and there were small black colored droppings under the microwave left draw, white colored water stain on the ice machine and there was a metal ladle spoon in the draw below the microwave. During an interview on 12/18/2024 at 03:00 PM, the Maintenance technician stated, when they do rounds three times during their shift to visually see any written or unwritten concerns. Observe walls that need to be painted if they are damaged and if the sheet rock needs to be put back in place. They paint as needed but can't say the last time painting was done on their unit, and they informed the Director of Maintenance that they need matching paint for units and replacement doors for resident bathrooms and some were ordered. Radiator cleaning is done quarterly, and it was done a month ago. When they encounter missing tile, they try to replace them and as soon as they identify a concern, and they prioritize their workload. They took two beside tables down last week to repair and if it can't be repaired, we get new bedside tables. We try to do all repairs in the shop downstairs. They have noticed the bedside tables are scratched up and we switch up the bedside table and want to renovate. Residents are here long term or short term, and we are providing comfort and care, visual stability in relation to the presentation of the room that creates environment for comfort and relaxation for resident. During an interview on 12/18/2024 at 03:47 PM, 3 [NAME] Licensed Practical Nurse # 1 stated, they have never seen tub cleaned and the tub is broken, and we do not use it. The tub contained a plastic cup cracker wrapping glove, roach wing and plastic temperature probe. Cleaned sometime this month and not sure when the tub was last cleaned. They do not clean the bottom of the medication cart. We don't use the commode. The medication carts are very old and if we try to clean them it is hard, and housekeeping used to wash. The last time they were washed was 2- 3 years ago. The unit needs to be homelike residents live here and this is the staff second home and what we like for us we like for them. f.) 4 [NAME] unit on 12/17/2024 from 12:26 PM - 4:13 PM - Nursing Station on 4 [NAME] peeling paint at nurses' station and opposite side of elevators. room [ROOM NUMBER]- mismatched paint, missing dry wall paint opposite nurse's station to right of unit door entrance from hallway. room [ROOM NUMBER]- 5 tier cart with cracked left edge, dusty edge on cart at bottom edge with oxygen tank. room [ROOM NUMBER]- bedside table missing paint. On 12/17/2024 at 12:52 PM -12:54 PM Room W403-bedside table missing pain on the bottom, Room W408- bedside table with chipped left edge. room [ROOM NUMBER]- bedside tale missing paint on bottom and room [ROOM NUMBER]- bedside table missing paint. 12/17/24 at 12:26 PM, room [ROOM NUMBER] wall outside room missing green paint has dry wall on wall area. On 12/17/2024 at 12:34 PM and 12/17/2024 04:09 PM, 12/18/2024 at 08:25 AM, the 4 [NAME] dining room - bedside table missing paint, all 4 - air conditioner and heater units are dusty and once opposite refrigerator contained a puzzle piece inside. Wheelchair with missing 1/4 of black right arm and left arm ripped with exposed fabric for resident sitting in the dining room. Rusty metal cart in day room/dining room. Wheelchair missing black veneer in some areas exposing white underneath approximately 2 inches for resident sitting in the dining room. On 12/18/2024 at 08:20 AM, room [ROOM NUMBER] and 409 bedside table missing paint, room [ROOM NUMBER]- brown crusty colored cream-colored stain on bottom of bedside table, room [ROOM NUMBER], room [ROOM NUMBER]- bedside table missing paint. room [ROOM NUMBER]- bedside table missing paint, dining room bedside table missing paint. On 12/19/24 at 10:56 AM, room [ROOM NUMBER] - sitting chair noted with tear in veneer in room. On On 12/18/24 at 3:57 PM, the 4 [NAME] unit tub noted with broken tile 4 total by the soiled storage area. During an interview on 12/17/2024 at 12:57 PM. Licensed Practical Nurse # 2 stated, each unit has a blood pressure cuff that is cleaned between every resident. They are not sure how often the bottom of the blood pressure cuff machine is cleaned, and they noticed it was dusty. The blood pressure machine is brought to resident's rooms, and you don't want to introduce dirty items into their environment, and it needs to be cleaned to keep functioning properly. For the rooms with dry wall that has not been painted the facility is in process of painting and replacing furniture piece by piece. During an interview on 12/17/2024 at 01:20 PM, Registered Nurse #5 stated, they look at resident's rooms while they observe the certified nursing assistants during care. The beside tables observed for excess items that may need to be thrown out. Certified nursing assistants wipe draws, remove items and throw items as needed out. The dresser drawers are cleaned for resident safety and hoarding will invite unwanted guests. This is the resident's home, we want it to be more homelike, make it look clean and have furniture to look like home. During an interview on 12/18/2024 at 02:51 PM, Maintenance Worker #2 stated, there are no concerns they are aware of for bedside tables on the 4th floor. They throw out bedside tables and there is renovation on the 4th floor and there are old tables on the 4th floor. We clean the radiators daily and we installed new covers on them this month. During an interview on 12/18/2024 at 03:14 PM, the Director of Maintenance stated, they do rounds daily, look at the maintenance book, make sure any environmental concerns are addressed by maintenance. The 2nd floor metal wall plate comes off due to wheelchairs hitting the wall. They are not sure when the refrigerator and wall unit was installed. 2 [NAME] room [ROOM NUMBER] stated they are reinstalling and working on the wall. Quarterly air conditioning/heater cleaning done, and it was last done in September. The damaged wall by the elevator damaged due to wheelchairs hitting it. The building is in the process of remodeling, and they have spare tables and they have placed an order for additional tables for the building. If there are any issues with the bedside tables, it will be in the maintenance logbook. They stated room [ROOM NUMBER] East 302 closet handle will be replaced. The room needs to be homelike for the residents to be comfortable, to be treated with respect, better environment for resident. Painting is done if needed. I do rounds to see what areas need to be painted and we do the painting. We look for safety issues, stained or missing tiles, environmental concerns and for resident safety. During an interview on 12/19/2024 at 01:18 PM, the Assistant Director of Nursing/Infection Preventionist stated, that the following units have had work done over the past 2 years- 2 East, 2 [NAME] and 4 East and work in in progress on 4 [NAME] unit. They do weekly rounds of the kitchen to look for cleanliness and they are not aware of any environmental concerns, and nothing reported to then for the kitchen in the year. 10 NYCRR 415.5(h)(2)

Based on observation, record review and staff interview during the Recertification /Complaint survey (NY00334742) conducted between 12/12/2024 and 12/19/2024, the facility did not ensure that all alleged violations involving abuse and injury of unknown origin were reported immediately to the New York State Department of Health, but not later than 2 hours after the alleged abuse and injury were observed. Specifically, (1) an injury of unknown origin found on resident #251's forehead was not reported; (2) Resident-Resident physical abuse resulting to injury involving 3 residents was not reported (Residents #214, #268, and #589); and (3) Injury of unkown origin found on Resident #24's toes was not reported. This was evident for one of three residents investigated for complaints and 4 out of 4 residents reviewed for Accidents out of 38 sampled residents. The findings are: The facility's policy and procedure titled Accident and Incident Report dated 07/2024, documented that As soon as possible, but no later than 24 hours post occurrence, complete the Accident/Incident Report. Fill in all spaces on the form, giving an exact description of the circumstances surrounding the accident or incident; Interview staff assigned to the care of the resident, and/or all staff assigned to the nursing unit on which resident resides; The Administrator, after discussion with the Director of Nursing, will reach a final decision if the accident is reportable to the Department of Health. The facility's policy and procedure titled Abuse, Neglect, Exploitation, and mistreatment of residents dated 03/2016, last revised 07/2024 documented that All reports of alleged resident abuse, neglect, mistreatment, exploitation, or misappropriation of resident property will be responded to immediately as outlined in the facility's policies and procedures. There is no documented evidence of the reporting time frame to the New York State Department of Health. 1). Resident #251 was admitted to the facility 01/27/2024, with diagnoses that included Alzheimer's disease, Non-Alzheimer's Dementia, Seizure disorder. The Quarterly Minimum Data Set, dated dated dated [DATE] documented that Resident #251 had severe impairment in cognition, and impairment on both sides of lower and upper extremities. The Minimum Data Set also documented that the resident requires Substantial/maximal assistance/total dependent of staff for most activities of daily living. Minimum Data Set documented that Resident had no behavioral symptoms directed towards others. The Comprehensive Care Plan for Behavior dated 2/21/2024, last updated 8/11/24, documented that Resident #251 has a behavior problem, agitated when redirected by staff, and can be potentially physically aggressive (towards staff) related to unspecified dementia. With goals including Resident will receive redirection with less aggression based on the medication adjustment. Interventions included: - Administer medications as ordered; Monitor/document for side effects and effectiveness; Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by; Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. The Comprehensive Care Plan for Fall dated 1/27/24, last updated 11/11/24, documented that Resident #251 is at High risk for falls related to Deconditioning, Gait/balance problems, altered mental status, Dementia, Alzheimer's disease, generalized muscle weakness 2/22/2024 Possible witnessed fall; with the goals including Resident will be free of falls while in the facility through the review date; Will not sustain serious injury through the review date; will have decreased opportunity for falls and falls related injuries through the review date. Interventions included: - Monitor for changes in cognitive function; Provide reality orientation for periods of increased confusion; Needs prompt response to all requests for assistance; Frequent monitoring while in bed. Intake Number NY00334742 dated 03/01/24 documented that complainant reported that they received a call from the facility that Resident fell on [DATE]; The family visited Resident on 2/25/24 and noted that the right eye was completely closed, and a knot noted on resident's forehead. Complainant reported that they were not receiving a consistent explanation on when the resident was last seen or how resident fell . Complainant stated that the staff are dismissive towards their request for a meeting with the staff. On 12/12/24 at 11:32 AM, Resident #251's family (Complainant) was interviewed and stated that they received the call that resident fell and hit the head, when resident was visited the mark noticed on the resident head and face seemed as if resident got punched in the face; statement by the staff is not consistent, and they refused to play the camera to view resident's movement prior incident. Family stated they requested clarification from the staff to rule out that resident was not attacked or punched by somebody because resident has Alzheimer's behavior and could not state how the injury occurred but there was no positive response received from the facility. Progress note Nursing dated 2/22/2024 08:40 documented: Report received that Resident #251 was bleeding from forehead. Upon assessment, resident sustained a dollar coin size hematoma to the forehead which was oozing [NAME] red blood. Nurse Practitioner notified and requested to evaluate the resident. There is no documented evidence of how Resident #251 sustained the injury in the resident's chart. Progress note Physician dated 2/22/2024 11:38 documented requests to see Resident #251 with swelling on right forehead; seen and examined at the bedside. Physician documented that on 2/22/24, nurse reported that resident has swelling on right forehead 7 cm x 7 cm.; resident could not mention what happened. Progress note Therapy-Communication with Rehab dated 2/22/2024 documented that Resident noted with large hematoma to right forehead with observed frank blood. Resident remarked of discomfort to touch; unable to recount sequence of events leading to fall, however, Resident did state that they fell from the bed. Nursing staff stated it was an unwitnessed fall noting that Resident was observed with swelling to right forehead this morning. There is no documented evidence in the progress notes by all the interdisciplinary team members that the injury sustained by Resident #251 was known or witnessed by any staff. As per the Facility's Accident/Incident Report reviewed dated 2/22/2024, Certified Nursing Assistant #4's statement documented that they were gathering supplies when they saw Resident #251 walked into room [ROOM NUMBER]; they went to redirect the resident and observed a bump on the resident's head. Resident Incident Report completed by the Shift Supervisor on 2/22/24 documented that Resident was observed at 7:20 am 2/22/2024 with unwitnessed bump on right forehead, the incident was unwitnessed, resident was walking in the hallway and was observed with a bump to the right forehead, resident unable to detail the incident. Pressure dressing applied. Accident/Incident Investigation Summary dated 2/26/24 documented that Resident observed with bump on right forehead. Resident unable to state what happened; right forehead oozing [NAME] red blood. No change in Level of consciousness; Seen by Medical Doctor, ordered to transfer to emergency room for Cat Scan. The Summary conclusion is The investigation has revealed that there is no cause to believe any alleged resident abuse, mistreatment or neglect has occurred. There is no documented evidence in the Accident/Incident investigation summary that revealed that the injury observed on the resident's forehead was witnessed, or to show that the source of the injury was known. On 12/16/24 at 12:20 PM, an interview was conducted with Certified Nursing Assistant #5. Certified Nursing Assistant #5 stated that they were assigned to Resident #251 on 2/22/24 7 am to 3 pm shift, when they made rounds on the assumption of duty, Resident #251 was not observed in the room, and they went to gather their supplies for the day; one of the staff on the unit reported that they observed Resident #251 with a bump on the forehead when they went to re-direct the resident from wandering into another room. On 12/17/2024 at 3:03 pm, Certified Nursing Assistant #4 was interviewed and stated that when they were in the hallway trying to get their supplies, saw resident #251 going to room [ROOM NUMBER], the lady's room, they went to re-direct the resident and saw the bump on the forehead. Certified Nursing Assistant #4 stated that they could not recollect how the incident really happened. On 12/16/24 at 12:34 PM, an interview was conducted with the Registered Nurse Supervisor #3. Registered Nurse Supervisor #3 stated that they worked as the unit Manager when Resident #251 was observed with a bump with bleeding on the forehead by the Certified Nursing Assistant, pressure dressing was applied, and the Nurse Practitioner was called to assess the resident. Registered Nurse stated that the incident was reported to the Assistant Director of Nurse that is responsible for reporting to the Department of Health. On 12/17/24 at 12:35 PM, Registered Nurse Supervisor #1 was interviewed and stated that all residents are closely monitored, 2 staff are stationed at both ends of the hallway to observe the residents' movements on each side of the hallway. Registered Nurse Supervisor #1 further stated that if Resident #251's injury had occurred in the hallway, it could have been captured by the staff on hallway. Registered Nurse Supervisor #1 stated that they cannot explained why the resident's injury was not captured by the staff. On 12/16/24 at 12:51 PM, the Assistant Director of Nursing was interviewed and stated that they were not in the building yet when the incident occurred that morning, they were notified by the Unit Manager that resident was walking in the hall-way as usual and they observed a bump with blood on the resident head, resident was unable to state how it happened, and none of the staff stated they did not know how it happened, the assigned Certified Nursing Assistant reported that Resident was in bed when they were making round and no bump was noted during round. Assistant Director of Nursing also stated that the bump was noted when the resident got up walking on the unit, and the camera could not be viewed to see how the resident got the injury. On 12/16/24 at 01:07 PM, the Director of Nursing was interviewed and stated that the Interdisciplinary Team committee met to discuss the Resident's Incidents and deemed the incident was not reportable. Director of Nursing stated that nobody was there when the incident happened, but because resident has behavior of wandering. they thought resident could have bumped the head on the bed or on something on the unit. Director of Nursing stated that the incident was not reported based on the outcome of the investigation. On 12/16/24 at 02:40 PM, the Nurse Practitioner was interviewed and stated that they were notified by nursing that Resident #251 had unwitnessed injury on the forehead and would be sent to the hospital for Cat scan to make sure there was no fracture sustained from the injury that was observed on 2/2/2024. Nurse Practitioner stated that they don't do reporting and is not sure if the injury should be reported to the Department of health or not. On 12/17/24 at 08:54 AM, the Occupational Therapist was interviewed and stated that Rehab was informed to assess Resident #251 for possible unwitnessed fall on 2/22/2024, resident was assessed and observed with coagulated blood on the forehead, resident was unable to explain what happened; Occupational Therapist stated that Resident #251 had already been sent to the hospital for Cat scan to rule out fracture, and the nursing was still investigating what happened at that time; Occupational Therapy stated that it was not cleared how the incident occurred and could not explained why the incident was not reported to the Department of Health. On 12/17/24 at 09:16 AM, Rehab Director was interviewed and stated that they have a team that always follow up for incident/accident of fall. Rehab Director stated that resident's incident was not cleared if it was a fall or accident, resident was not in Occupational Therapy at that time of the incident, but they followed up with the Assistant Director of Nursing as a member of fall committee, and it was reported that resident might have bumped head on the wall. The Director of Rehab stated that they believe the incident should have been reported to the Department of Health since there was no clear indication of how resident sustained the injury. Director of Rehab stated that they were not aware that the incident was not reported. On 12/17/24 at 02:29 PM, Medical Doctor was interviewed and stated that they were called to assess Resident #251 after the unwitnessed injury on the forehead with bleeding; Resident was seen about 9:00 am and noted with hematoma, resident was not able to state how it happened and staff could not say how it occurred, resident was sent to the hospital for Cat scan to rule out fracture and internal bleeding. The Doctor stated that they were the on-call physician when the incident occurred, and they did not know that the incident was not reported to the Department of health. On 12/17/24 at 02:47 PM, the Administrator was interviewed and stated that they are aware that Resident #251 was noted with a bump on the head, when they reviewed the Incident investigation at the morning report, they believed that the incident might have happened when the resident was wandering around the unit because resident has behavior of wandering. The Administrator stated that they thought a staff saw the resident bumping head on the wall when they were trying to re-direct the resident, but they were not so sure of what exactly happened and could not recollect very well how the staff had documented the incident. There was no documented evidence that any staff saw the resident bumping head on the wall; and the facility failed to report the incident to the Department of Health as injury of unknown origin. 41709 2). Resident #214 was admitted to the facility with diagnoses which included Vascular Dementia, Hypertension and Diabetes. The Quarterly Minimum Data Set 3.0 assessment dated [DATE] documented Resident was moderately cognitively impaired in cognition and had no behavioral symptoms towards others. Nursing behavior progress notes dated 10/6/2024, documented resident was noted displaying signs of aggression towards other residents while sitting in the dining room. Resident removed from dining room. Resident responded well to re-direction and escorted back to their room. Plan of care is ongoing. Resident #268 was admitted to the facility with diagnoses which included Cerebral Infarction, Opioid Dependence and Pain. The Quarterly Minimum Data Set 3.0 assessment dated [DATE] documented resident had moderately severely impaired in cognition and had no behavior symptoms towards others. The facility Accident Incident report documented the occurrence happened at approximately 10:50 AM on 10/06/2024 and documented Resident #268 was engaged in a physical altercation, and was pushed to the floor by another resident causing a bump to the back of resident head. The report further documented Resident #268 was unresponsive for 45 seconds, lying on their back on the floor. The Accident Incident report identified Resident #214 as the aggressor who pushed Resident #268 causing resident to hit back of their head. Resident #589 was admitted to facility with diagnosis including Dementia, Hypertension and Chronic Obstructive Pulmonary Disease. The Quarterly Minimum Data Set 3.0 assessment dated [DATE] documented Resident had moderately severely impaired in cognition and had no behavior symptoms towards others. The facility Accident Incident report documented the occurrence happened at approximately 10:50 AM on 10/06/2024 and documented resident was pushed to the floor causing a bump with redness to the back of the head. The report further identified Resident #214 as the resident who pushed Resident #589 to the floor. Resident #268 and Resident #589 were transferred to the hospital for evaluation. There was no documented evidence that an incident report or Resident #214 who was the aggressor, was included in the investigation. There was no documented evidence that this incident was reported to the New York State Department of Health. On 12/19/24 at 02:12 PM, Licensed Practical Nurse #5 was interviewed and stated, while walking past the dining area, they saw Resident #214 push Resident #268 causing resident to be unconsciousness for 45 seconds, and saw Resident #214 pushed Resident #589 to the floor causing a bump to the back of resident head in the dining area. Licensed Practical Nurse #5 stated, immediately called the front desk to call a STAT and all the supervisors responded. Licensed Practical Nurse #5 stated Resident #268 and Resident #589 were transferred to the hospital for evaluation. On 12/19/24 01:10 PM Assistant Director of Nursing #2 was interviewed and stated, is responsible for summarizing the incident reports to rule out abuse, and is aware any allegation of abuse must be reported to The Department of Health within two hours. Assistant Director of Nursing #2 stated did investigate the incident and was aware Resident #214 was the aggressor. Assistant Director of Nursing #2 stated, worked with the Director of Nursing to review incidents to see if it rises to the level of reporting to The Department of Health. Assistant Director of Nursing #2 stated after the review of the incident it was too late to report, and therefore the incident was not reported. On 12/19/24 at 02:26 PM, an interview was completed with The Director of Nursing. The Director of Nursing stated was aware of the incident on arrival to work the next day. The Director of Nursing stated upon review saw the incident report for residnet #214 was not completed, and did informed the supervisor to complete the report. The Director of Nursing stated when reviewing the whole incident at the time did not believe there was abuse, because all the residents involved did not have a history of aggressive behavior, and were all cognitively impaired and meant no harm. The Director of Nursing stated this incident was not reportable because two of the residents went to the hospital and the Computed Tomography Scan was negative, and all residents involved had no history of this behavior. The Director of Nursing also stated they are aware of the regulations to report any allegations af abuse immediately but not later than two hours after the incident occurs. The Directof of Nursing added this incident did not rise to the level of reporting to the Department of Health. 44864 3). Resident #24 was admitted to the facility with diagnoses that include Anxiety Disorder, Bipolar Disorder and Schizophrenia. The Quarterly Minimum Data Set, dated dated dated [DATE] documented resident's cognition as severely impaired, Brief Interview of Mental Status of (BIMS)1, no behavioral symptoms, independent with bed mobility, supervision for eating, toilet use and transfers. The Minimum Data Set also documented Resident #24 is frequently incontinent of urine and always incontinent of bowel, no pain, takes an antipsychotic and an antianxiety medication and no alarm used. The Quarterly Minimum Data Set, dated dated dated [DATE] documented resident's cognition as severely impaired, BIMS1, physical behavioral symptoms, behavior of this type occurred 1 - days, independent with bed mobility, supervision for eating, toilet use and transfers. The Minimum Data Set also documented Resident #24 is frequently incontinent of urine and bowel, no pain, takes an antipsychotic, and no alarm used. The Comprehensive Care Plan focus created 10/30/22, last revised 08/2124, documented Resident #24 is placed on secured unit due to Psychological and Behavioral problems. Goals include avoid injury to staff or visitors, and to redirect residents' behavior so no staff, resident or visitor is injured, and that Resident/representative will be satisfied with placement on secured unit, review date 2/19/24. Target date 03/24/25. Interventions include to review resident's behavioral symptoms periodically to evaluate continued benefit of remaining on a secured unit and monitor resident for any changes in mood and behavior and report to Medical Doctor/Nursing. The Comprehensive Care Plan focus created 5/19/23 documented Resident #24 has a potential to be physically aggressive, last revised 09/19/2124, grabbing and reaching for others, related to Dementia, poor impulse control. Goals include Resident #24 will not harm self or others through the review date, 9/19/24. Interventions include communication to analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. The Comprehensive Care Plan focus created on 09/18/24, documented Resident #24 has an alteration in musculoskeletal status related to a fracture of proximal phalanx of right lesser toe. Goals include will remain free of pain or at a level of discomfort acceptable through the review date, 11/10/24. Interventions include give analgesics as ordered by Physician. monitor and document for side effects and effectiveness. A Nurse's Note dated 9/14/24 documented resident was very aggressive and combative during this tour towards residents and staff. All medication was administered. The resident was redirected several times, A Nurse's Note dated 9/15/24 documented Staff informed that Resident #24 was bleeding from their right foot. Resident #24 was found sitting in their room with their right foot on the radiator. Upon assessment, resident noted to have laceration on her 3rd, 4th, and 5th metatarsal. Pressure applied to stop the bleeding immediately. Telehealth called and informed about the same. After assessment, the doctor instructed to send Resident #24 to the hospital for further evaluation. Emergency Medical Services arrived and took resident to the hospital. The facility incident report dated 9/15/2024 documented that Resident #24 was found sitting on a chair with their right foot on the radiator in the resident's room. Resident found to have laceration on the 3rd, 4th, and 5th metatarsal. The incident report documented in Part B section of the investigation, that resident assessed for bleeding, observed in the room with their right foot elevated on the radiator, and that Resident #24 unable to state what happened. Radiator was checked for sharp edges and was reported to maintenance. Resident transferred to the emergency room for further evaluation. Resident #24 returned with a diagnosis of fracture of proximal phalanx toe, right. foot closed. A review of the hospital's discharge summary dated 9/16/24, revealed that Resident #24 was evaluated for wound to right foot. The discharge summary documented that evaluation of patient with laceration to plantar aspect, X-Ray consistent with fracture. A diagnosis of closed physeal fracture of proximal phalanx of lesser toe of right foot, with the result documented a minimally displaced extra articular fracture of the right third and 4th proximal phalangeal [NAME] shaft junctions in unchanged alignment. Interventions documented included orthopedic surgery, laceration repair done by them, outpatient follow up. A nurse's note dated 9/17/24 documented post hospital visit: Resident seen this am with dressing to right foot, On Assessment, it was observed that Resident #24 had a small laceration under the 4th toe, no other laceration noted, no bleeding noted, dressing left dry and intact. I was reported via ER visit That Resident sustained, laceration to foot and closed physeal fracture of proximal phalanx of lesser great toe of right foot, and that Resident #24 has a follow up appointment on 9/24/2024. An Orthopedic surgery clinic note dated 09/24/24 documented wound was washed out and closed by Orthopedics in the emergency department on 09/16/24. Physical exam included right lower extremity, sutures c/d/l, no wound dehiscence with 3cm laceration at plantar aspect of 4th toe proximal phalanx, no tendon visualized, 1.5cm laceration at plantar aspect of 3rd toe proximal phalanx, no tendon visualized, 0.5cm superficial abrasion to plantar aspect of 2nd toe proximal phalanx. No purulent from either wound, no gross contamination. Documented X-ray of right toes, foot, ankle, fracture of 3rd and 4th toe proximal phalanx, presence of calcaneus ORIF. X-ray of right. toes, foot, ankle: fracture of 3rd and 4th toe proximal phalanx, presence of previous calcaneus ORIF hardware. Record review and staff interviews did not reveal any documented evidence that the injury of unknown origin dated 9/15/24 was reported to the New York State Department of Health. On 12/19/24 at 12:32 PM, Registered Nurse #1 was interviewed and stated that they were the Supervisor for that unit, the day the incident occurred in the afternoon, around 3:15pm. Registered Nurse #1 stated that the Staff on the unit called them to assess Resident#24 who was bleeding from a cut of 3of Resident's #24 toes, on the plantar of the right foot. Registered Nurse #1 observed that the resident had their foot on top of the radiator and there was some bleeding observed, and that they, (Registered Nurse #1) saw that the radiator had some sharp edges. Registered Nurse #1 stated that Resident #24 was barefooted at the time and that the Resident #24 was unable to state what happened. Registered Nurse #1 also stated that they did not see any blood on the radiator and that they could not tell exactly how Resident #24's foot could get on top of the radiator. Registered Nurse #1 stated that when they came to assess Resident #24, who was sitting in a chair, in the room, and their foot was on the radiator. Registered Nurse #1 stated that here was a video telehealth done and the Licensed Practitioner ordered to transfer the resident to the hospital. Registered Nurse #1 stated that they would normally tell the Assistant Director of Nursing, but that day, the Assistant Director of Nursing was already in the building for some time. Registered Nurse #1 stated that they placed a request for the maintenance to check the radiator at the time, and they came and fixed it. On 12/19/24 at 01:11 PM, the Maintenance Director was interviewed and stated that they usually do their rounds, and that they check the log books on the units, to ensure outstanding work orders are completed, and does weekly rounds on the units to ensure that safety is maintained. The Maintenance Director stated that was the log request to check on the radiator in the room where the accident occurred with Resident #24, did not reveal that there were not any sharp objects that resulted in Resident #24' s safety. The Maintenance Director stated that they just put a cover on the radiator since nursing requested it, but The Maintenance Director examined it the next day when the request was made and found no sharp edges. On 12/19/24 at 01:33 PM, Certified Nursing Assistant #10 was interviewed and stated that the housekeeper called them into the Resident #24's room when they observed that there was smeared blood on the floor, and on Resident #24's right foot. Certified Nursing Assistant #10 stated that they went and called the nurse. Certified Nursing Assistant #10 also stated that they were not assigned to Resident #24 at that time but recalled that Resident#24 would walk about and go to the bathroom by themselves. On 12/19/24at 01:36 PM, Maintenance Worker#3was interviewed and stated that they worked on 09 /16/24 and that they went to check the maintenance logbook, since they check the logbook daily. Maintenance Worker #3 stated that they went to see the radiator in Resident #24's room and in their estimation, the radiator was fine, and that they did not observe any sharp edges to the radiator. Maintenance Worker #3 stated that they signed off that the radiator check was completed, and notified the Maintenance Director that everything was fine. The Maintenance Worker #3 stated that the Maintenance Director asked them to put a cover on the thermostat and then they placed the thermostat on top of the cover. On 12/19/24 at 01:54 PM, Certified Nursing Assistant #11 was interviewed and stated that they were assigned to the resident on the unit on 09/15/24 on the 7-3 shift. Certified Nursing Assistant #11stated that when the accident occurred, they were on lunch, and that prior to going for lunch, they gave Resident #24 a shower, and dressed them and left Resident #24 sitting in their room, in their wheelchair. Certified Nursing Assistant #11 stated that Resident #24 can wheel themselves, walks about in their room and would use the bathroom by themselves, and usually wears nonskid socks. Certified Nursing Assistant #11 stated that Resident #24 was getting up and acting up and running in and out of rooms, and that the Staff would redirect Resident #24 and get them to calm down. On 12/19/24 at 02:00 PM, Housekeeper #2 was interviewed and stated that they are the regular Housekeeper on the 3West unit. Housekeeper #2 stated that they do not recall if there was blood or that they notified the Staff of the Resident #24's condition. On 12/19/24 at 02:31 PM, Licensed Practical Nurse #4 was interviewed and stated that they were the Nurse on duty on 09/15/24 at the time the accident occurred. Licensed Practical Nurse #4 stated that The Certified Nursing Assistant called them to the room, and they put the resident to sit down on the chair. Licensed Practical Nurse #4 stated that that there was a gash under Resident #24's right toe, and that they (Resident #24) were unable to state what happened, Resident #24 was only saying that that they were bleeding. Licensed Practical Nurse #4 stated that they only assumed that Resident #24 probably climbed on the radiator, since there was no other explanation. On 12/19/24 at 03:23 PM, the Administrator was interviewed and said that anytime that there is any injury, they instruct Maintenance to inspect units and the equipment. The Administrator also stated that the maintenance did not find anything wrong with the radiators when it was checked by the Maintenance Director. The Administrator also said that they were aware of the incident, but it could not have been from any sharp edges on the radiator. On 12/19/24 at 03:23 PM, The Director of Nursing was interviewed and stated that they did not report the incident because it was understood the resident had a laceration from the radiator. The Director of Nursing also stated that they are aware of the reporting protocols but did not think that this incident needed to be reported, since the nursing Staff knew what caused the injury. 10 NYCRR 415.4(b)(2)

Based on observation, record review and staff interview during the Recertification/Complaint survey (NY00334742) conducted between 12/12/2024 and 12/19/2024, the facility did not ensure that all allegations of abuse and injury of unknown origin were thoroughly investigated. Specifically, (1) Injury of unknown origin observed on Resident #251 was not thoroughly investigated and (2). Resident-to-resident altercation involving Residents #214, #268 and #589 was not thoroughly investigated. This was evident for 1 of 3 complaint investigations and for 3 of 3 residents reviewed for Accidents out of 38 total sampled residents. The findings are: The facility policy and procedure titled Abuse Prevention and Reporting with revision date December 2024 documented Physical Abuse includes, but not limited to hitting, slapping, punching, biting, and kicking. The policy documented facility will report alleged violations related to mistreatment, exploitation, neglect, or abuse including injuries of unknown origin source and misappropriation of resident property and report the results of all investigation to proper authorities within specific timeframe. The policy further documented will ensure that all alleged violations are reported immediately, but not later than two hours after the alleged allegation is made, if the events that cause the allegation involve abuse or results in serious bodily injury or not later than 24 hours. 1. Resident #251 was admitted to the facility 01/27/2024, with diagnoses that included Alzheimer's disease, Non-Alzheimer's Dementia, Seizure disorder. The Quarterly Minimum Data Set, dated dated dated [DATE] documented that Resident #251 had severe impairment in cognition, and impairment on both sides of lower and upper extremities. The Minimum Data Set also documented that the resident requires Substantial/maximal assistance/total dependent of staff for most activities of daily living. Minimum Data Set documented that Resident had no behavioral symptoms directed towards others. The Comprehensive Care Plan for Behavior dated 2/21/2024, last updated 8/11/24, documented that Resident #251 has a behavior problem, agitated when redirected by staff, and can be potentially physically aggressive (towards staff) related to unspecified dementia. With goals including Resident will receive redirection with less aggression based on the medication adjustment. Interventions included: - Administer medications as ordered; Monitor/document for side effects and effectiveness; Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by; Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. The Comprehensive Care Plan for Fall dated 1/27/24, last updated 11/11/24, documented that Resident #251 is at High risk for falls related to Deconditioning, Gait/balance problems, altered mental status, Dementia, Alzheimer's disease, generalized muscle weakness 2/22/2024 Possible witnessed fall. Goals included: - Resident will be free of falls while in the facility through the review date; Will not sustain serious injury through the review date; will have decreased opportunity for falls and falls related injuries through the review date. Interventions included: - Monitor for changes in cognitive function; Provide reality orientation for periods of increased confusion; Assist with toileting as needed; Needs prompt response to all requests for assistance; Assist with toileting upon awakening, before/after the meals and at bedtime; Frequent monitoring while in bed. Intake Number NY00334742 dated 03/01/24 documented that complainant reported that they received a call from the facility that Resident fell on [DATE]; The family visited Resident on 2/25/24 and noted that the right eye was completely closed, and a knot noted on resident's forehead. Complainant reported that they were not receiving a consistent explanation on when the resident was last seen or how resident fell . Complainant stated that the staff are dismissive towards their request for a meeting with the staff. On 12/12/24 at 11:32 AM, Resident #251's family (Complainant) was interviewed and stated that they received the call that resident fell and hit the head, when resident was visited the mark noticed on the resident head and face seemed as if resident got punched in the face; statement by the staff is not consistent, and they refused to play the camera to view resident's movement prior incident. Family stated they requested clarification from the staff to rule out that resident was not attacked or punched by somebody because resident has Alzheimer's behavior and could not state how the injury occurred but there was no positive response received from the facility. On 12/12/24 at 10:02 AM, Resident #251 was observed in bed being fed by a staff, resident is unable to answer any question due to cognition impairment. Progress note Nursing dated 2/19/2024 15:43 documented that Resident slept most of this shift; was woken at intervals for meals; woke at the end of the shift and was seated in the wheelchair in the Day Room. Progress note Nursing -Behavior Note dated 2/21/2024 16:08 documented that Resident was observed alert with confusion, very agitated and difficult to redirect, was constantly going to other residents' rooms. When staff redirected the resident back to the room, he got agitated, and attempted to be physically aggressive. Monitoring ongoing. Progress note Nursing dated 2/22/2024 08:40 documented: Report received that Resident #251 was bleeding from forehead. Upon assessment, resident sustained a dollar coin size hematoma to the forehead which was oozing [NAME] red blood. Nurse Practitioner notified and requested to evaluate the resident. There is no documented evidence of how Resident #251 sustained the injury in the resident's chart. Progress note Nursing dated 2/22/2024 10:41 documented that Resident #251 was alert and verbally responsive with period of confusion, left unit at 9:58 am with Emergency Service for Cat Scan due to hematoma on right side of the forehead. Progress note Communication with Rehab dated 2/22/2024 11:200 documented Referral for Occupational, Physical, Speech therapies; Reason for Referral: possible unwitnessed Fall. Progress note Physician dated 2/22/2024 11:38 documented requests to see Resident #251 with swelling on right forehead; seen and examined at the bedside. Physician documented that on 2/22/24, nurse reported that resident has swelling on right forehead 7 cm x 7 cm.; resident could not mention what happened. Assessment: - Unspecified Injury of head; Plan: Will order Cat Scan of head without contrast. Progress note Therapy-Communication with Rehab dated 2/22/2024 15:04 documented Reason for Referral: status post fall; Resident assessed status post fall on unit. Resident noted with large hematoma to right forehead with observed frank blood. Resident remarked of discomfort to touch; unable to recount sequence of events leading to fall, however, Resident did state that they fell from the bed. Resident is Alert and oriented x 1 and is an unreliable historian. Nursing staff stated it was an unwitnessed fall noting that Resident was observed with swelling to right forehead this morning. There is no documented evidence in the progress notes by all the interdisciplinary team members that the injury sustained by Resident #251 was known or witnessed by any staff. As per the Facility's Accident/Incident Report reviewed dated 2/22/2024, Certified Nursing Assistant #4's statement documented that they were gathering supplies when they saw Resident #251 walked into room [ROOM NUMBER]; they went to redirect the resident and observed a bump on the resident's head. Resident Incident Report completed by the Shift Supervisor on 2/22/24 documented that Resident was observed at 7:20 am 2/22/2024 with unwitnessed bump on right forehead, the incident was unwitnessed, resident was walking in the hallway and was observed with a bump to the right forehead, resident unable to detail the incident. Pressure dressing applied, and Nurse Practitioner notified at 8:30 am. Accident/Incident Investigation Summary dated 2/26/24 documented that Resident observed with bump on right forehead. Resident unable to state what happened; right forehead oozing [NAME] red blood. No change in Level of consciousness; Seen by Medical Doctor, ordered to transfer to emergency room for Cat Scan. Returned with negative results. Rehab referral, neuro checks in place. Staff rounding; Fall safety precautions maintained. The Summary conclusion is The investigation has revealed that there is no cause to believe any alleged resident abuse, mistreatment or neglect has occurred. There is no documented evidence in the Accident/Incident investigation summary that revealed that the injury observed on the resident's forehead was witnessed, or to show that the source of the injury was known. There was no documented evidence that an interview was conducted with the staff assigned to the care of Resident #251 and/or all staff assigned to the unit on which the resident resides to clarify the statements written by the staff that the injury sustained was unwitnessed. On 12/16/24 at 12:20 PM, an interview was conducted with Certified Nursing Assistant #5. Certified Nursing Assistant #5 stated that they were assigned to Resident #251 on 2/22/24 7 am to 3 pm shift, when they made rounds on the assumption of duty, Resident #251 was already out of the room, and they went to gather their supplies for the day; one of the staff on the unit reported that they observed Resident #251 with a bump on the forehead when they went to re-direct the resident from wandering into another room and the staff reported to the nurse in charge. Certified Nursing Assistant #5 stated that they cannot recall the name of the staff that saw Resident #251 first or the name of the nurse reported to. On 12/17/2024 at 3:03 pm, Certified Nursing Assistant #4 was interviewed and stated that when they were in the hallway trying to get their supplies, saw resident #251 going to room [ROOM NUMBER], the lady's room, they went to re-direct the resident and saw the bump on the forehead. Certified Nursing Assistant #4 stated that they could not recollect how the incident really happened. On 12/16/24 at 12:34 PM, an interview was conducted with the Registered Nurse Supervisor #3. Registered Nurse Supervisor #3 stated that they worked as the unit Manager when Resident #251 was observed with a bump with bleeding on the forehead by the Certified Nursing Assistant, pressure dressing was applied, and the Nurse Practitioner was called to assess the resident. Registered Nurse stated that the incident was reported to the Assistant Director of Nurse that is responsible for reporting to the Department of Health. Registered Nurse Supervisor #3 further stated that Resident #251 has the habit of wandering in the hall-way, be attempting to fix things, will get up from the wheel chair unassisted and walked around, Registered Nurse Supervisor stated that resident was observed with the unwitnessed injury by the Certified Nursing Assistant that was re-directing the resident on that day, and they did not know how the resident got the injury. On 12/16/24 at 12:51 PM, the Assistant Director of Nursing was interviewed and stated that they were not in the building yet when the incident occurred that morning, as per the Unit Manager, resident was walking in the hall-way as usual and they observed a bump with blood on the resident head, resident was unable to state how it happened, and none of the staff stated they did not know how it happened, the assigned Certified Nursing Assistant reported that Resident was in bed when they were making round and no bump was noted during round. Assistant Director of Nursing also stated that the bump was noted when the resident got up walking on the unit, and the camera could not be viewed to see how the resident got the injury. On 12/16/24 at 01:07 PM, the Director of Nursing was interviewed and stated that the Interdisciplinary Team committee met to discuss the Resident's Incidents and deemed the incident was not reportable. Director of Nursing stated that nobody was there when the incident happened, but because resident has behavior of wandering. they thought resident could have bumped the head on the bed or on something on the unit. Director of Nursing stated that the incident was not reported based on the outcome of the investigation. On 12/16/24 at 02:40 PM, the Nurse Practitioner was interviewed and stated that they were notified by nursing that Resident #251 had unwitnessed injury on the forehead and would be sent to the hospital for Cat scan to make sure there was no fracture sustained from the injury that was observed on 2/2/2024. On 12/17/24 at 08:54 AM, the Occupational Therapist was interviewed and stated that Rehab was informed to assess Resident #251 for possible unwitnessed fall on 2/22/2024, resident was assessed and observed with coagulated blood on the forehead, resident was unable to explain what happened; Occupational Therapist stated that Resident #251 had already been sent to the hospital for Cat scan to rule out fracture, and the nursing was still investigating what happened at that time; Occupational Therapy stated that it was not cleared how the incident occurred. On 12/17/24 at 09:16 AM, Rehab Director was interviewed and stated that they have a team that always follow up for incident/accident of fall. Rehab Director stated that resident's incident was not cleared if it was a fall or accident, resident was not in Occupational Therapy at that time of the incident, but they followed up with the Assistant Director of Nursing as a member of fall committee, and it was reported that resident might have bumped head on the wall. On 12/17/24 at 02:29 PM, Medical Doctor was interviewed and stated that they were called to assess Resident #251 after the unwitnessed injury on the forehead with bleeding; Resident was seen about 9:00 am and noted with hematoma, resident was not able to state how it happened and staff could not say how it occurred, resident was sent to the hospital for Cat scan to rule out fracture and internal bleeding. The Doctor stated that they were the on-call physician when the incident occurred. On 12/17/24 at 02:47 PM, the Administrator was interviewed and stated that they are aware that Resident #251 was noted with a bump on the head, when they reviewed the Incident investigation at the morning report, they believed that the incident might have happened when the resident was wandering around the unit because resident has behavior of wandering. The Administrator stated that they thought a staff saw the resident bumping head on the wall when they were trying to re-direct the resident, but they were not so sure of what exactly happened and could not recollect very well how the staff had documented the incident. There was no documented evidence of the rationale discussed to reach a final decision that the Accident/Incident was not reportable. 41709 2) Resident #214 was admitted to the facility with diagnoses which included Vascular Dementia, Hypertension and Diabetes. The Quarterly Minimum Data Set 3.0 assessment dated [DATE] documented Resident #214 had moderately cognitively impaired in cognition and had no behavioral symptoms towards others. Nursing behavior progress notes dated 10/6/2024 at 14:51 documented resident was noted displaying signs of aggression towards other residents while sitting in the dining room. Resident removed from dining room. Resident responded well to re-direction and escorted back to his room. Plan of care is ongoing. The facility did not complete an accident/incident report for Resident #214, and the resident was not included in the facility investigation. Resident #268 was admitted to the facility with diagnoses which included Cerebral Infarction, Opioid Dependence and Pain. The Quarterly Minimum Data Set 3.0 assessment dated [DATE] documented Resident #268 had moderately severely impaired in cognition and had no behavior symptoms towards others. The facility Accident Incident report documented the occurrence happened at approximately 10:50 AM on 10/06/2024 and documented Resident # 268 was engaged in a physical altercation and was pushed to the floor by another resident causing a bump to the back of resident head. The report further documented Resident # 268 was unresponsive lying on their back on the floor and had a bump to the back of the head which was bleeding. The Accident Incident report identified Resident #214 as the aggressor pushing Resident #268 causing resident to hit the back of head which was bleeding/ Medical progress notes dated 10/6/2024 at documented resident is being seen today for Fall. Resident was involved in an altercation with another resident at facility. During the incident, resident was pushed to the ground and was reportedly unresponsive for approximately 45 seconds. Unknown if direct head trauma, no contusion, no laceration. Plan for Immediate evaluation in the emergency department is recommended due to the reported episode of unresponsiveness. Resident #589 was admitted to facility with diagnosis including Dementia, Hypertension and Chronic Obstructive Pulmonary Disease. The Quarterly Minimum Data Set 3.0 assessment dated [DATE] documented Resident #268 had moderately severely impaired in cognition and had no behavior symptoms towards others. The facility Accident Incident report documented the occurrence happened at approximately 10:50 AM on 10/06/2024 and documented Resident #589 was pushed to the floor, causing resident to hit their head causing a bump with redness. The report further identified Resident #214 as the resident who pushed Resident #589 to the floor. Resident #268 and Resident #589 were transferred to the hospital on 10/6/2024 for evaluation. Both residents received Computer Tomography scan with negative results. The facility provided no documented evidence that an incident report or an investigation report was completed to include Resident #214, who was identified as the aggressor. On 12/19/24 at 02:12 PM, Licensed Practical Nurse #5 was interviewed and stated while walking past the dining area they saw Resident #214 push resident #268, and hit resident #589 in the dining area. Licensed Practical Nurse #5 stated, they immediately called the front desk and called a STAT and all the supervisors responded. Resident #268 and Resident #589 were transferred to the hospital for evaluation. Licensed Practical Nurse #5 stated, Resident #214 was the aggressor in this incident. On 12/19/24 01:10 PM Assistant Director of Nursing #2 was interviewed and stated, they are responsible for summarizing the incident report to rule out abuse. Assistant Director of Nursing #2 did investigate the incident and was aware Resident #214 was the aggressor. Assistant Director of Nursing #2 stated, they worked with the Director of Nursing to review incidents to see if it rises to the level of reporting to The Department of Health. Assistant Director of Nursing #2 stated after the review of the incident it was too late to report, therefore the incident was not reported. Assistant Director of Nursing #2 stated the Nursing Supervisor was given a time to come and complete the incident report for Resident #214 but it was never completed despite giving a deadline. Assistant Director of Nursing #2 stated, they concluded the investigation because all the residents involved have no history of this behavior and are cognitively impaired. On 12/19/24 at 02:26 PM, The Director of Nursing was interviewed and stated, they were called the night of the incident. When they come in the next day, they noticed not all the incident reports were completed. Director of Nursing stated, I did inform the supervisor to complete the report, but it was never completed. The Director of Nursing stated, when looking at the whole incident was not thinking of abuse because all the residents involved did not have a history of aggressive behaviors, they were cognitively impaired and meant no harm. The Director of Nursing stated, this incident was not reportable because two of the residents went to the hospital and the Computed Tomography scan for both was negative. The Director of Nursing gave no reason why Resident #214's incident report was not completed. They are looking at the whole incident as a fall rather than an altercation with residents. The Director of Nursing stated the Supervisor was asked to complete the incident report for Resident #214, but it was not completed. The residents fall care plans were all updated for the incident. On 12/20/24 at 11:46 AM, Registered Nurse #6 was interviewed via telephone and stated, they were the Supervisor on duty at time of the incident. Registered Nurse #6 stated they were called to the unit and arrived to see Resident #268 and Resident #589 at the nurse's station. They were told the residents were sitting in the dining area when the incident occurred. Registered Nurse #6 stated, I did not complete an incident report or get statements from Resident #214 because the resident was already mentioned in Resident #268 and Resident #589 incident reports. Registered Nurse #6 stated the Director of Nursing and Assistant Director of Nursing #2 were made aware by phone email. Registered Nurse #6 stated, they do not recall speaking to The Director of Nursing or the Assistant Director of Nursing #2 at the time of incident. Registered Nurse #6 stated the incident was not abuse because all the residents involved were cognitively impaired with Dementia. Registered Nurse #6 also stated none of the residents have a history of behavior in the past and added they do not recall being told by Assistant Director of Nursing #2 or Director of Nursing to complete an incident report for Resident #214. 10 NYCRR 415.4(b)(3)

Based on observations and staff interviews conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards of food service safety. Specifically, 1) staff was observed not wearing beard guard on multiple occasions or hair restraints appropriately in the kitchen. 2) the dry storage room was observed with an open box of beverage and food thickener was observed opened on two occasions and was noted with a paper cup in the open box while on the shelf. This was observed during the Kitchen facility task. The findings are: The facility's dietary policy and procedure titled Food Preparation and Handling revised 12/16/2024 documented all food will be prepared and handled using safe and sanitary methods. All staff will avoid bare hand contact with ready to eat food, as well as wear single use gloves and use serving utensils. This policy does not mention any uniform requirements in relation to food handling. The facility's dietary policy and procedure titled Sanitation Inspection and Checklist revised 12/16/2024 documented a basic sanitation inspection is completed at least monthly and a quarterly food safety and sanitation audit is conducted in the kitchen. The Food Service Director or designee will complete the Basic Sanitation inspection at least monthly. The Food Service Director or designee will complete the Food Safety and Sanitation Audit at least quarterly. All items not meeting standards will be followed up on, including in-service of staff as warranted. On 12/12/2024 from 9:21 AM to 10:10 AM, the initial observation of the kitchen was conducted with the Food Service Director. It was observed that the Food Service Director was not wearing a hair net when giving the surveyor the initial tour of the kitchen. It was observed that the Contracted Pest Control person onsite in the kitchen wearing a hat with no beard restraint with a noticeable beard as they went about their job. The Pest Control person left before they could be interviewed by the surveyor. On 12/12/2024 at 10:34 AM, Dietary Aide #4 was observed in the kitchen without a beard net. Dietary Aide # 10 was observed dropping off carts into the kitchen. During an interview on 12/12/2024 at 10:35 AM, Dietary Aide #10 stated that they have to take the beard net off when they are outside and they have to put it back on when they get in the kitchen and they were delivering carts from the unit to the kitchen, On 12/16/2024 at 04:29 PM to 04:42 PM, Dietary Aide # 2 was observed on the dinner tray line without a beard net scooping lentil soup with a ladle into cups and scooping gravy with a ladle onto mashed potatoes on a resident tray. Dietary Aide # 3 was observed getting an open pan of cheese pizza slices and placing it on the line and they were not wearing a beard net and had a noticeable beard and mustache present. During an interview on 12/16/2024 at 04:44 PM, Dietary Aide # 2 stated, that they took off their beard net when they stepped out of the kitchen to use the bathroom and they forgot to put it back on. They did not wear a beard net also because it hurts their ears, and they did not notice it was off. They should wear the beard net because hair can fall into the food. During an interview on 12/16/2024 at 04:45 PM, Dietary Aide #3 stated, they have a full beard, and they should wear a beard guard and anything can fall off their beard and into the residents food. On 12/17/2024 at 10:27 AM-10:36 AM, Dietary Aide # 4 was observed taking out the trash and then bringing back the empty can into the kitchen. They were wearing a beard net that was covering their chin but that had a visible mustache. During an interview on 12/17/2024 at 10:32 AM, Dietary Aide # 4, stated they should wear a beard net before they get in the kitchen, and they are available at the front door to the kitchen. They should wear it so no hair gets in the food. On 12/17/2024 at 11:39 AM, Dietary Aide #5 was observed without a beard guard walking through the kitchen with a visible beard present. During an interview on 12/17/2024 at 11:40 AM, Dietary Aide #5, stated they forgot to grab a beard net on the way into the kitchen. They should wear a beard net to protect hair from falling anywhere. During an interview on 12/19/2024 at 12:53 PM, the Dietary Supervisor, stated that staff should wear hair net, apron, beard guards as part of standard precautions when they are in the kitchen and especially when they are on the tray line. During an interview on 12/19/2024 at 01:00 PM, the Director of Food Services, stated staff should wear the following equipment in the kitchen gloves, aprons, bear nets, hair nets and mask if they have not gotten their flu shot. Hair nets and beard nets should be worn because hair can fall in food and the elderly immune systems are weak. Staff can get hair net and beard guard when they are coming in from the door. They did not notice that they were not wearing a hair net. During an interview on 12/19/2024 at 01:17 PM, the Assistant Director of Nursing/Infection Preventionist stated, they do weekly rounds of the kitchen, and they observe for cleanliness and if staff are wearing beard guards, hair nets and that food items are not left open or uncovered. 2. On 12/12/2024 at 09:55 AM, the dry storage room was observed. An open 25 pound box of instant food beverage thickening powder in a torn plastic bag was resting on the bottom shelf to the left wall of the door entrance. The box was labeled with order # 2009449 00093 and dated 8/5/2024 by the food service vendor. There was visible dust on the shelf above the box. On 12/17/2024 at 11:10 AM, the dry storage room was observed again and the 25 pound box of instant food beverage thickening powder resting on the bottom shelf to the left wall of the door entrance with a tear in the plastic bag. There was a paper cup observed in the torn plastic bag in the box. The box was labeled with order # 2009449 00093 and dated 8/5/2024 by the food service vendor. During an interview on 12/17/2024 at 11:13 AM, Dietary Aide # 4 was interviewed and stated, they look at the dry storage room two times a week and they also look at the expiration dates on the food boxes and look at food boxes that are opened. They do not know who tore the bag for the instant food beverage thickener and it should not be like that. They dust the shelves once a month. If the shelf is clean and the food should be covered so no dust material goes on the food product. During an interview on 12/17/2024 at 11:18 AM, the Director of Food Services stated that they look at the boxes in the dry storage every day and the last time they looked at the boxes was this past Monday. The thickener has to be in a container, and it should not be like that. The opened disposable cup should not be in there and there should be a measuring cup used instead. It should not be in an open box since anything can fall in there and it is ready to eat food and it is supposed to be covered and in a container. 10 NYCRR 415.14(h)

Based on observation, record review, and interview conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure that the Minimum Data Set 3.0 (MDS) assessment accurately reflected a resident's status. This was evident for 2 (Resident #237 and #436) of 38 total sampled residents. Specifically, the Minimum Data Set 3.0 assessment for Resident #237 did not accurately reflect the resident's preferred activities and the Minimum Data Set 3.0 assessment for Resident #436 did not accurately reflect the resident use of wander guard as alarm. The findings are: The facility policy titled MDS (Minimum Data Set) Guidelines for Completion with undated effective or revised date documented it is the policy of all Allure Facilities to ensure accurate and timely completion of Minimum Data Set for all residents in accordance with Federal and State Operation [NAME]. 1) Resident #237 had diagnoses which included Unspecified dementia, Anxiety disorder, and Depression. The Annual Minimum Data Set assessment dated [DATE] documented Resident #237 was moderately cognitive impairment. The Minimum Data Set assessment also documented it was not very important for Resident # 237 to keep up with the news and to do their favorite activities. It also documented only Resident #237's representative participated in the assessment. The Comprehensive Care Plan related to recreation and leisure preferences initiated 7/29/2023 and last reviewed 9/10/2024 documented one of the goals was Resident #237 will pursue independent activities of their choice. The assessment titled Activities Evaluation dated 3/11/2024 documented it was very important for Resident #237 to keep up with the news and do their favorite activities. On 12/19/2024 at 10:44 AM, the Activities Director was interviewed and stated they did the activity assessment for Resident #237 in Minimum Data Set assessment and Activities Evaluation dated 3/11/2024. The Activities Director also stated it was very important for Resident #237 to keep up with the news and do their favorite activities. The Activities Director stated they were busy and coded by error as not very important for Resident #237 to keep up with news and to do their favorite activities for the activity preference in the Minimum Data Set assessment dated [DATE]. 2) Resident #436 had diagnoses which included Unspecified dementia, Muscle weakness, and Difficulty in walking. The Admission Minimum Data Set assessment dated [DATE] documented Resident #436 was moderately cognitive impairment and had no wandering behavior. The Minimum Data Set assessment also documented no alarms or restraint was used. The Minimum Data Set assessment further documented Resident #436 and representative did not participate in the assessment. Physician ordered wander guard to be placed to Resident #436's right wrist every shift with starting date on 12/1/2024 and the order was discontinued on 12/12/2024. The Comprehensive Care Plan related to elopement risk/wanderer initiated 12/1/2024 and last updated 12/12/2024 documented Resident # 436 had a wander alert at place. The Nursing Notes from 12/2/2024 to 12/11/2024 documented Resident #436 had wander guard placed at right wrist. On 12/19/2024 at 10:24AM, Registered Nurse #2 was interviewed and stated Resident #436 wandered around and tried to leave the facility when they were newly admitted to the facility on [DATE]. Registered Nurse #2 also stated they put on a wander guard for Resident # 436 for safety on 12/1/2024 after obtaining the physician order to do so. Registered Nurse #2 stated Resident #436 did not like to have the wander guard on and tried to remove it. Registered Nurse #2 also stated they transferred Resident #436 to the secure unit at Unit 3W and removed the wander guard on 12/11/2024. On 12/19/2024 at 11:05AM, the Minimum Data Set Assessor was interviewed and stated they interviewed residents and staff, made observations, and reviewed medical record to collect data for Minimum Data Set assessments. The Minimum Data Set Assessor also stated they completed section P - Restraints and Alarms for Resident #436 in Admission Minimum Data Set assessment dated [DATE]. The Minimum Data Set Assessor stated they did not recall if Resident #436 had a wander guard in place when the Minimum Data Set assessment was conducted. The Minimum Data Set Assessor reviewed the medical record and stated Resident #436 did have wander guard in place when they did the Minimum Data Set assessment. The Minimum Data Set Assessor also stated it was an error not to code wander guard as alarm in section P of the assessment. On 12/19/2024 at 11:13AM, the Minimum Data Set Coordinator was interviewed and stated they did not review the accuracy of the Minimum Data Set assessment. The Minimum Data Set Coordinator also stated their responsibility was to make sure the Minimum Data Set assessments were completed and submitted to Centers for Medicare & Medicaid Services in a timely manner. 10 NYCRR 415.11(b)

Based on observation, record review, and interviews conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not provide an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. This was evident for 3 (Residents #219, #237, and #436) of 4 residents reviewed for Activities out of 38 sampled residents. Specifically, Residents #219, #237, and #436 were not provided with activities that met their preferences and interests. The findings are: The facility policy titled Activity Planning with undated effective or revised date documented the Activity Leader records the recreational interests and needs of each resident on the form for that purpose upon admission. It also documented Activity Director plans a varied program of activities to meet the needs and stated preferences of each individual residents. The facility policy titled Activities with undated effective or revised date documented it is the policy of the facility to provide an activities program that is appropriate to the needs and interests of each resident that will encourage self-care, resumption of normal activities, maintenance of optimal self functioning and contact with the environment. 1) Resident #219 had diagnoses which included Other Displaced fracture of second cervical vertebra, Type III traumatic spondylolisthesis of second cervical vertebra, and Alzheimer's disease with late onset. On 12/12/2024 at 10:30 AM, Resident #219 stated they stayed in the room all the time and would like to watch television in the room like when they were back in the community. Resident #219 also stated the television set was removed for maintenance work and was not re-installed back since they moved back to the room for 3 weeks now. Resident #219 further stated they had no activity in the room. There was no television set observed in the room. There was a tablet observed on the bedside table for which Resident #219 stated they did not know how to use it. The Admission Minimum Data Set assessment dated [DATE] documented Resident #219 had no vision/no hearing problems. It also documented it was very important to keep up with the news and to do their favorite activities. It further documented only Resident #219 participated in the assessment. From 12/12/2024 at 10:30 AM to 12/19/24 at 09:10 AM, multiple observations were made of Resident #219 lying in the bed with no ongoing activities in their room. Resident #219 was also observed not being provided or offered alternate activities in their preferred interest. The Comprehensive Care Plan related to recreation and leisure preferences initiated 6/2/2024 and last updated 11/25/2024 documented one of the goals was Resident # 219 will pursue independent activities of their choice and will be provided their preferred activities. The assessment titled Activities Evaluation dated 5/21/2024 documented it was very important for Resident #219 to keep up with the news and do their favorite activities. The Census list documented Resident #219 moved from room [ROOM NUMBER]-B to room [ROOM NUMBER]-A on 12/3/2024. The Census list also documented Resident #219 moved back from room [ROOM NUMBER]-A to room [ROOM NUMBER]-B on 12/5/2024. There was no documented evidence that a resident centered activity program that incorporated Resident #219's interests which is integral to maintaining and/or improving a resident's physical, mental, and psychosocial well-being, and independence, was implemented after 12/5/2024. On 12/19/2024 at 09:13 AM, Certified Nursing Assistant #3 was interviewed and stated Resident #219 was cognitively intact, did not refuse care, and stayed in the bed most of time. Certified Nursing Assistant #3 stated Resident #219 had a television in the room before the maintenance department did the work in the room like 2 weeks ago. Certified Nursing Assistant #3 further stated the maintenance department had not installed the television back yet, since Resident #219 moved back to their original room in 406-B. Certified Nursing Assistant #3 stated Resident #219 had no activity in the room. Certified Nursing Assistant #3 also stated, they told recreational staff about no television in Resident #219's room and nothing was done so far. Certified Nursing Assistant #219 further stated, Resident # 219 liked to watch television in their room. On 12/19/2024 at 09:23 AM Activity Leader #1 was interviewed and stated they interviewed the residents and/or their representatives for their preferred activities. Activity Leader #1 also stated Resident #219 liked to watch TV in their room. Activity Leader #1 stated they were aware there was no television in Resident #219's room after the maintenance work was done in the room. Activity Leader #1 also stated they notified the maintenance department to install a television for Resident #219 after Resident #219 moved back to their room on 12/5/2024. Activity Leader #1 further stated nothing was done yet. 2) Resident #237 had diagnoses which included Unspecified dementia, Anxiety disorder, and Depression. On 12/12/2024 at 11:22 AM, Resident #237 was interviewed and stated they stayed in the room most of time, had no activities in the room, and wanted to be able to watch television in the room as before. Resident #237 also stated the staff moved the television set from their room for a while and did not install another one since then. There was no television set observed in the room. There was a tablet observed on the bedside table for which Resident # 237 stated they did not know how to use it. The Annual Minimum Data Set assessment dated [DATE] documented Resident # 237 had no problem in vision and hearing, was moderately cognitive impairment, and was not very important to keep up with the news and to do their favorite activities. It also documented only Resident # 237's representative participated in the assessment. From 12/12/2024 at 11:22 AM to 12/19/24 at 09:03 AM, multiple observations were made of Resident #237 lying in the bed or walking around by their bed with no ongoing activities in their room. Resident #237 was also observed not being provided or offered alternate activities in their preferred interest. The Comprehensive Care Plan related to recreation and leisure preferences initiated 7/29/2023 and last reviewed 9/10/2024 documented one of the goals was Resident # 237 will pursue independent activities of their choice. The assessment titled Activities Evaluation dated 3/11/2024 documented it was very important for Resident # 237 to keep up with the news and do their favorite activities. The Census list documented Resident # 237 stayed in room [ROOM NUMBER]-B since 8/21/2023. There was no documented evidence that a resident centered activity program that incorporated Resident #237's interests which is integral to maintaining and/or improving a resident's physical, mental, and psychosocial well-being, and independence, was implemented after the television set was removed from the room with unknown date. On 12/19/2024 at 09:51 AM, Certified Nursing Assistant #2 was interviewed and stated Resident #237 was alert and able make needs known, stayed in the room most of time, and had no activities in the room. Certified Nursing Assistant #2 also stated there was a tablet in the room for Resident # 237 to listen to music. Certified Nursing Assistant #2 further stated Resident # 237 did not know how to use the tablet. Certified Nursing Assistant #2 stated there was a television set in the room before and did not recall how long ago the television set was removed by the maintenance staff. Certified Nursing Assistant #2 also stated Resident # 237 sat at the bed most of time and had no activities in the room. On 12/19/2024 at 10:08 AM, Recreation Aide was interviewed and stated they interviewed Resident #237 for their preferred activities. Recreation Aide also stated Resident #237 liked to watch television in the room. Recreation Aide stated they provided a tablet to Resident #237 to listen to music and watch videos online. Recreation Aide also stated Resident #237 did not know how to use the tablet. Recreation Aide stated they had no explanation why Resident #237's preferred activities were not provided. 3) Resident #436 had diagnoses which included Unspecified dementia, Muscle weakness, and Difficulty in walking On 12/12/2024 at 11:16 AM, Resident # 436 was observed sitting at bed with no-going activities. Resident #436 was interviewed and stated they liked to watch television in their room, and they had nothing to do in the room all day. There was no television set observed in the room. There was a tablet observed on the bedside table for which Resident #436 stated they did not know how to use it. The Admission Minimum Data Set assessment dated [DATE] documented Resident #436 was moderately cognitive impairment, had no problem of vision or hearing, and it was very important for Resident #436 to keep up with the news and do their favorite activities. It also documented Resident #436 and representative did not participate in the assessment. From 12/12/2024 at 11:16 AM to 12/19/24 at 09:00 AM, multiple observations were made of Resident #436 sitting on, or lying in their bed with no ongoing activities in their room. Resident #436 was also observed not being provided or offered alternate activities in their preferred interest. The Comprehensive Care Plan related to recreation and leisure preferences initiated 12/13/2024 documented Resident #436 stated they enjoyed watching television. One of the interventions documented Resident #436 prefers TV channels of game show, ABC, and NBC. The assessment titled Activities Evaluation dated 12/3/2024 documented it was very important for Resident #436 to keep up with the news and do their favorite activities. The Census list documented Resident #436 stayed in room [ROOM NUMBER]-B since 12/11/2024. There was no documented evidence that a resident centered activity program that incorporated Resident #436's interests which is integral to maintaining and/or improving a resident's physical, mental, and psychosocial well-being, and independence, was implemented after Resident #436 was transferred to room [ROOM NUMBER]-B on 12/11/2024. On 12/19/2024 at 09:43 AM, Certified Nursing Assistant # 1 was interviewed and stated Resident #436 was cognitive intact, did not refuse care, and always stayed in the room. Certified Nursing Assistant # 1 also stated there was no television set in the room since Resident #436 was transferred to the room like 1-2 week(s) ago. Certified Nursing Assistant # 1 further stated Resident #436 had no activities in the room. On 12/19/2024 at 10:02 AM, Recreation Aide was interviewed and stated there was no television set in Resident # 436's room. Recreation Aide also stated they provided a tablet for Resident # 436 to listen to music and watch videos. Recreation Aide further stated Resident #436 did not know how to use the tablet. Recreation Aide stated they called the maintenance department to install the television set for Resident # 436 when Resident # 436 was transferred to the unit. Recreation Aide also stated they did not know why the television set was not installed yet. Recreation Aide had no explanation for not providing preferred activities to Resident # 436. On 12/19/2024 at 10:44 AM, the Activities Director was interviewed and stated the facility provided residents with their preferred activities. The Activities Director also stated the facility provided a television set to every bed. The Activities Director further stated they talked to Maintenance Department to install television sets for residents who liked to watch television. The Activities Director stated they were waiting for the Maintenance Department to install television sets for Resident #219, #237, and 436 and did not know the television sets installation status. On 12/19/2024 at 11:25 AM, the Director of Maintenance was interviewed and stated every resident should have a television set in the room. The Director of Maintenance also stated they removed the television sets from the wall in the rooms 406-B, 310-B, and 304-B for Residents #219, #237, and #436 respectfully due to limited space in the rooms. The Director of Maintenance further stated they planned to install television sets to the ceiling above the foot of bed in the rooms for Residents #219, #237, and #436 respectfully. The Director of Maintenance stated they did not install television sets to the ceiling above the foot of bed immediately after removing television sets from the wall in the rooms 406-B, 310-B, and 304-B for Residents #219, #237, and #436 respectfully. The Director of Maintenance stated they were not able to install television sets to the ceiling above the beds in 406-B, 310-B, and 304-B for Residents #219, #237, and #436 respectfully until they had new television sets delivered to the facility. The Director of Maintenance stated they did not know how long Residents #219, #237, and # 436 had to wait for the new television sets to be installed in their rooms in 406-B, 310-B, and 304-B respectfully. The Director of Maintenance had no explanation why they did not keep the old television sets on the wall in rooms or installed the old television sets to the ceiling above the foot of bed in rooms 406-B, 310-B, and 304-B for Residents #219, #237, and #436 respectfully until the new television sets were delivered to the facility for change. The Director of Maintenance was not able to explain how Residents #219, #237, and #436 were able to have their preferred activity of watching television in their rooms after the television sets were removed from their rooms in 406-B, 310-B, and 304-B. 10 NYCRR 415.5(f)(1)

Based on record review and interviews conducted during the Recertification Survey from 12/13/2024 to 12/19/2024, the facility did not ensure residents received adequate supervision to prevent accidents. This was evident for 1 (Resident #24) of 4 residents reviewed for accidents out of 38 total sampled residents. Specifically, Resident #24, who is cognitively impaired with agitated behaviors, sustained a laceration on right 3rd, 4th and 5th metatarsal resulting in a minimally displaced extra articular fracture of the right third and 4th proximal phalanges. The findings are: The facility's policy and procedure titled Accident and Incident Report dated 07/2024, documented that As soon as possible, but no later than 24 hours post occurrence, complete the Accident/Incident Report. Fill in all spaces on the form, giving an exact description of the circumstances surrounding the accident or incident; Interview staff assigned to the care of the resident, and/or all staff assigned to the nursing unit on which resident resides; The Administrator, after discussion with the Director of Nursing, will reach a final decision if the accident is reportable to the Department of Health. Resident #24 was admitted to the facility with diagnoses that include Anxiety Disorder, Bipolar Disorder and Schizophrenia. The Quarterly Minimum Data Set, dated dated dated [DATE] documented resident's cognition as severely impaired, Brief Interview of Mental Status(BIMS) of 1, no behavioral symptoms, independent with bed mobility, supervision for eating, toilet use and transfers. The Minimum Data Set also documented Resident #24 is frequently incontinent of urine and always incontinent of bowel, no pain, takes an antipsychotic and an antianxiety medication and no alarm used. The Quarterly Minimum Data Set, dated dated dated [DATE] documented resident's cognition as severely impaired, BIMS1, physical behavioral symptoms, behavior of this type occurred 1 - days, independent with bed mobility, supervision for eating, toilet use and transfers. The Minimum Data Set also documented Resident #24 is frequently incontinent of urine and bowel, no pain, takes an antipsychotic, and no alarm used. The Comprehensive Care Plan focus created 10/30/22, last revised 08/2124, documented Resident #24 is placed on secured unit due to Psychological and Behavioral problems. Goals include avoid injury to staff or visitors, and to redirect residents' behavior so no staff, resident or visitor is injured, and that Resident/representative will be satisfied with placement on secured unit, review date 2/19/24. Target date 03/24/25. Interventions include to review resident's behavioral symptoms periodically to evaluate continued benefit of remaining on a secured unit and monitor resident for any changes in mood and behavior and report to Medical Doctor/Nursing. The Comprehensive Care Plan focus created 5/19/23 documented Resident #24 has a potential to be physically aggressive, last revised 09/19/2124, grabbing and reaching for others, related to Dementia, poor impulse control. Goals include Resident #24 will not harm self or others through the review date, 9/19/24. Interventions include communication to analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. The Comprehensive Care Plan focus created on 09/18/24, documented Resident#24 has an alteration in musculoskeletal status related to a fracture of proximal phalanx of right lesser toe. Goals include will remain free of pain or at a level of discomfort acceptable through the review date, 11/10/24. Interventions include give analgesics as ordered by Physician. monitor and document for side effects and effectiveness. A Nurse's Note dated 9/14/24 documented resident was very aggressive and combative during this tour towards residents and staff. All medication was administered. The resident was redirected several times, and s was made aware of behavior. The resident is now lying in bed after several hours of noncompliance. A Nurse's Note dated 9/15/24 documented Staff informed that Resident #24 was bleeding from their right foot. Residen t#24 was found sitting in their room with their right foot on the radiator. Upon assessment, resident noted to have laceration on her 3rd, 4th, and 5th metatarsal. Pressure applied to stop the bleeding immediately. Telehealth called and informed about the same. After assessment, the doctor instructed to send Resident #24 to the hospital for further evaluation. Emergency Medical Services arrived and took resident to the hospital. The facility incident report dated 9/15/2024 documented that Resident #24 was found sitting on a chair with their right foot on the radiator in the resident's room. Resident found to have laceration on the 3rd, 4th, and 5th metatarsal. The incident report documented in Part B section of the investigation, that resident assessed for bleeding, observed in the room with their right foot elevated on the radiator, and that Resident #24 unable to state what happened. Radiator was checked for sharp edges and was reported to maintenance. Resident transferred to the emergency room for further evaluation. Resident #24 returned with a diagnosis of fracture of proximal phalanx toe, right. foot closed. A review of the hospital's discharge summary dated 9/16/24, revealed that Resident #24 was evaluated for wound to right foot. The discharge summary documented that evaluation of patient with laceration to plantar aspect, X-Ray consistent with fracture. A diagnosis of closed physeal fracture of proximal phalanx of lesser toe of right foot, with the result documented a minimally displaced extra articular fracture of the right third and 4th proximal phalangeal [NAME] shaft junctions in unchanged alignment. Interventions documented included orthopedic surgery, laceration repair done by them, outpatient follow up. A Nurse's Note dated 9/17/24 documented post hospital visit: Resident seen this am with dressing to right foot. On Assessment, it was observed that Resident #24 had a small laceration under the 4th toe, no other laceration noted, no bleeding noted, dressing left dry and intact. It was reported via ER visit that Resident sustained, laceration to foot and closed physeal fracture of proximal phalanx of lesser great toe of right foot, and that Resident #24 has a follow up appointment on 9/24/2024. An Orthopedic surgery clinic note dated 09/24/24 documented wound was washed out and closed by Orthopedics in the emergency department on 09/16/24. Physical exam included right lower extremity, sutures c/d/l, no wound dehiscence with 3cm laceration at plantar aspect of 4th toe proximal phalanx, no tendon visualized, 1.5cm laceration at plantar aspect of 3rd toe proximal phalanx, , no tendon visualized, 0.5cm superficial abrasion to plantar aspect of 2nd toe proximal phalanx. No purulent from either wound, no gross contamination. Documented X-ray of right toes, foot, ankle, fracture of 3rd and 4th toe proximal phalanx, presence of calcaneus ORIF. X-ray of right. toes, foot, ankle: fracture of 3rd and 4th toe proximal phalanx, presence of previous calcaneus ORIF hardware. Record review and staff interviews did not reveal that the accident dated 9/15/24 was reported to the New York State Department of Health. On 12/19/24 at 12:32 PM, Registered Nurse #1 was interviewed and stated that they were the Supervisor for that unit, the day the incident occurred in the afternoon, around 3:15PM. Registered Nurse #1 stated that the Staff on the unit called them to assess Resident #24 who was bleeding from a cut on Resident's #24 toes, on the plantar of the right foot. Registered Nurse #1 observed that the resident had their foot on top of the radiator and there was some bleeding observed, and that they, (Registered Nurse #1) saw that the radiator had some sharp edges. Registered Nurse #1 stated that Resident #24 was barefooted at the time and that the Resident #24 was unable to state what happened. Registered Nurse #1 also stated that they did not see any blood on the radiator and that they could not tell exactly how Resident #24's foot could get on top of the radiator. Registered Nurse #1 stated that when they came to assess Resident #24, who was sitting in a chair, in the room, and their foot was on the radiator. Registered Nurse #1 stated that here was a video telehealth done and the Licensed Practitioner ordered to transfer the resident to the hospital. Registered Nurse #1 stated that they would normally tell the Assistant Director of Nursing, but that day, the Assistant Director of Nursing was already in the building for some time. Registered Nurse #1 stated that they placed a request for the maintenance to check the radiator at the time, and they came and fixed it. On 12/19/24 at 01:11 PM, the Maintenance Director was interviewed and stated that they usually do their rounds, and that they check the log books on the units, to ensure outstanding work orders are completed, and does weekly rounds on the units to ensure that safety is maintained. The Maintenance Director stated that was the log request to check on the radiator in the room where the accident occurred with Resident #24, did not reveal that there were not any sharp objects that resulted in Resident #24' s safety. The Maintenance Director stated that they just put a cover on the radiator since nursing requested it, but The Maintenance Director examined it the next day when the request was made and found no sharp edges. On 12/19/24 at 01:33 PM, Certified Nursing Assistant #10 was interviewed and stated that the housekeeper called them into the Resident#24's room when they observed that there was smeared blood on the floor, and on Resident #24's right foot. Certified Nursing Assistant #10 stated that they went and called the nurse. Certified Nursing Assistant #10 also stated that they were not assigned to Resident #24 at that time but recalled that Resident#24 would walk about and go to the bathroom by themselves. On 12/19/24at 01:36 PM, Maintenance Worker#3was interviewed and stated that they worked on 09 /16/24 and that they went to check the maintenance logbook, since they check the logbook daily. Maintenance Worker#3 stated that they went to see the radiator in Resident #24's room and in their estimation, the radiator was fine, and that they did not observe any sharp edges to the radiator. Maintenance Worker #3 stated that they signed off that the radiator check was completed, and notified the Maintenance Director that everything was fine. The Maintenance Worker #3 stated that the Maintenance Director asked them to put a cover on the thermostat and then they placed the thermostat on top of the cover. On 12/19/24 at 01:54 PM, Certified Nursing Assistant #11 was interviewed and stated that they were assigned to the resident on the unit on 09/15/24 on the 7-3 shift. Certified Nursing Assistant #11stated that when the accident occurred, they were on lunch, and that prior to going for lunch, they gave Resident #24 a shower, and dressed them and left Resident #24 sitting in their room, in their wheelchair. Certified Nursing Assistant #11 stated that Resident #24 can wheel themselves, walks about in their room and would use the bathroom by themselves, and usually wears nonskid socks. Certified Nursing Assistant #11 stated that Resident #24 was getting up and acting up and running in and out of rooms, and that the Staff would redirect Resident #24 and get them to calm down. On 12/19/24 at 02:00 PM, Housekeeper #2was interviewed and stated that they are the regular Housekeeper on the 3West unit. Housekeeper #2 stated that they do not recall if there was blood or that they notified the Staff of the Resident #24's condition. On 12/19/24 at 02:31 PM, Licensed Practical Nurse #4 was interviewed and stated that they were the Nurse on duty on 09/15/24 at the time the accident occurred. Licensed Practical Nurse #4 stated that The Certified Nursing Assistant called them to the room, and they put the resident to sit down on the chair. Licensed Practical Nurse #4 stated that that there was a gash under Resident #24's right toe, and that they (Resident #24) were unable to state what happened, Resident #24 was only saying that that they were bleeding. Licensed Practical Nurse #4 stated that they only assumed that Resident #24 probably climbed on the radiator, since there was no other explanation. On 12/19/24 at 03:23 PM, the Administrator was interviewed and said that anytime that there is any injury, they instruct Maintenance to inspect units and the equipment. The Administrator also stated that the maintenance did not find anything wrong with the radiators when it was checked by the Maintenance Director. The Administrator also said that they were aware of the incident, but it could not have been from any sharp edges on the radiator. On 12/19/24 at 03:23 PM, The Director of Nursing was interviewed and stated that they did not report the incident because it was understood the resident had a laceration from the radiator. The Director of Nursing also stated that they are aware of the reporting protocols but did not think that this incident needed to be reported, since the nursing Staff knew what caused the injury. 10 NYCRR 415.12(h)(2)

Based on observation, interview and record review conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure that the physician reviewed the resident's total program of care. This was evident for 1 resident (Resident #71) of 2 residents reviewed for Dialysis, out of 38 sampled residents. Specifically, there were no physician's order for Dialysis and the care and treatment for the monitoring of the Perma Cath on Resident #71, who was on Dialysis. The findings are: The facility's policy titled Medication Order Reconciliation updated 07/24, documented that reconciliation will occur during admissions, discharge, transfers, order changes and routine reviews. The responsibilities include that the nursing staff will verify and update records, the pharmacist will conduct regular reviews and identify potential issues and the Physician will provide clear orders and address discrepancies. The facility's policy titled Hemodialysis, updated 07/24 documented that the purpose of this policy is to provide continuous monitoring of residents with End Stage Renal Disease (ESRD). Resident #71 was admitted to the facility with diagnoses that include End Stage Renal Disease and Coronary Artery Disease. The Admission Minimum Data Set, dated dated dated [DATE] documented resident's cognition as intact, dependent on staff for bed mobility, chair/bed transfers, no toileting attempted, supervision or touching assistance for eating, always incontinent of urine, frequently incontinent of bowel, received scheduled pain medication regimen, on a therapeutic diet, and is on dialysis. The Quarterly Minimum Data Set, dated dated dated [DATE] documented resident's cognition as intact, dependent on staff for bed mobility, chair/bed transfers, no toileting attempted, supervision or touching assistance for eating, always incontinent of urine, frequently incontinent of bowel, received scheduled pain medication regimen, on a therapeutic diet, and no Dialysis. The Physician's orders dated 12/9/24 documented Renal diet, regular texture, thin consistency, fluid Restriction 1500 ml/day: Dietary 720 ml/day, Nursing 780 ml/day. Nursing: 7-3: 300 ml 3-11: 300 ml 11-7: 180 ml and a pitcher by bedside. On 12/16/24 11:15 AM Resident # 71 was observed sitting in their room in their wheelchair, alert and oriented to name. Resident #71 stated that that they will be going to Dialysis today at 1:00PM. There was no documented evidence of physician orders documenting that Resident #71 goes to Dialysis, the frequency of Dialysis, or the monitoring of the permcath for Dialysis. The Comprehensive Care Plan focus documented Resident #71 needs hemodialysis related to End Stage Renal Disease (left chest wall Permcath), created 8/19/2024. Goals include that the resident will have no signs/symptoms of complications from dialysis through the review date, 8/20/24. Interventions include to monitor/document/report as needed any signs/symptoms of infection to access site, redness, swelling, warmth, or drainage. A Nurse's Note dated 12/16/24 documented Resident #71 going on dialysis. Safety precautions active. A Nurse's Note dated 12/13/2024 documented Resident #71 returned from Hemodialysis in stable condition. AV graft site intact dressing clean and dry no sign of bleeding noted. A Nurse's Note dated 12/11/2024 documented Resident #71 was readmitted on [DATE] from the hospital with diagnosis of Anemia, unspecified and other past medical diagnoses of Gout, is dependent on renal dialysis, Resident #71 goes to Hemodialysis on Monday, Wednesday Friday, Renal diet, regular texture, thin consistency. A Physician's Note dated 12/04/2024 documented s patient is seen for follow up, recently readmitted to the facility, End Stage Renal Disease, on maintenance hemodialysis 3 times a week, Patient denies symptoms presently and that patient had dialysis session on hold today secondary to low hemoglobin. The Physician's note also documented that Hemodialysis will be restarted only with hemoglobin greater than 7. On 12/19/24 at 11:19 AM, Certified Nursing Assistant #12 was interviewed and stated that they are the primary Certified Nursing Assistant on the 7-3 shift. Certified Nursing Assistant #12 also stated that Resident #71 needs 2 persons assist for transfers and goes to Dialysis on Monday, Wednesday, and Friday. Certified Nursing Assistant #12 stated that the nurse will give a report of the residents that are on Dialysis. On 12/17/24 at 11:58 AM Registered Nurse Manager #2 was interviewed and stated that when a resident is admitted , the orders are reconciled with Licensed Nurse that admits the resident and with the Registered Nurses. Registered Nurse Manager #2 also stated that it is not necessary for an order in the system, since there is a communications book that lists where the resident goes for Dialysis and the time that they go. Registered Nurse Manager #2 said that the doctor would monitor to see if any labs were done that the doctor would monitor the results. Registered Nurse Manager #2 said that the Staff is aware that Resident #71 is on Dialysis on Mondays, Wednesdays, and Fridays at 1PM. On 12/18/24 at 04:15 PM, the Director of Nursing was interviewed and stated that when a resident is admitted /readmitted , the reconciliation is done with the Registered Nurse Supervisors to ensure that all orders are reconciled. The Director of Nursing also stated that the resident was readmitted on [DATE] and that the order was omitted by error since, the order was there prior to the resident's readmission. The Director of Nursing also stated that the Licensed Nurses are all aware that the orders must be reconciled when there is an admission and a readmission. On 12/19/24 11:25 AM the Medical Doctor was interviewed and stated they are the Licensed Practitioner for any issues with Resident #71. The Medical Doctor also stated that Resident #71 is stable now and that they check the order and the medications. The Medical Doctor stated that they don't know what happened at the time, but Resident #71 had an order previously, and that these orders are reviewed whenever the resident has a complaint or concerns. The Medical Doctor also stated that they review the chart and the orders when they see the resident believed that when Resident #71 was last readmitted , someone missed the order. 10 NYCRR 415.15(b)(2)(iii)

Based on observation, record review, and interviews conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure medications and biologicals were stored in accordance with professional standards of practice. Specifically, 1) Eighteen individual expired Heparin lock flush syringes were stored on medication room on 2 [NAME] and 2 East Units. This was evident for 2 of 6 units (2 [NAME] and 2 East) during the Medication Storage Task. The findings are: 1. The facility policy and procedure titled Medication Storage updated 07/2024 documented the facility safety of resident by proper storage of medications. The facility following state and federal regulations as well as recommendations made by a medications manufacturer or supplier. Medications must be removed and disposed of immediately if they are expired. The Medication room inspections for the facility from July to December 2024 were reviewed and it documented that expired medications were found in subsequent inspections. On 12/16/20204 at 10:05 AM to 11:22 AM, Licensed Practical Nurse # 4 accompanied the surveyor to the Medication Room on 2 West. The following was observed in a cabinet above the counter and in the container on the counter with intravenous fluids contained a total of 3 Heparin flushes. There was 2 Heparin 50 USP unit per 5 ml (10 USP per milliliter) flushes with lot number 314577 expiration date 08/01/2024 and 1 Heparin 50 USP unit per 5 ml (10 USP per milliliter) flushes with lot number flush 314732 expiration date 09/01/2024. There was 1 bag of 1000 milliliter 5 percent intravenous dextrose with lot # Y419277 expiration date October 2024. During an interview on 12/16/2024 at 11:22 AM, Licensed Practical Nurse #4 stated that the Medication Room is stocked once a week and the old dates are placed in the back and the newer dates are pulled forward. Housekeeping found a whole set of normal saline and heparin flushes while cleaning the cupboard in the medication room and put them together and did not throw the items out. They looked at the intravenous supplies on Friday and looked at the items in the medication room draws. Housekeeping found the heparin flushes and we were supposed to go through the medication to see what was still good. If medication expired, they are taken downstairs and they did not notice the intravenous fluid was expired. During an interview on 12/16/2024 at 11:28 AM, Registered Nurse #2 stated they were not sure the last time they looked at the intravenous medication. Usually there are no residents on intravenous fluids. Heparin flushes used for central line flush every shift to prevent blood clots. The intravenous fluids is expired in October 2024. The heparin flushes expired in August 2024 and September 2024. We should not have expired items due to resident safety and facility protocol. We barely use heparin flushes. During an interview on 12/16/2024 at 11:36 AM, Housekeeper #5 stated the medications were at the bottom of the cupboard in the medication room and they did not want to throw them out, so they left it for nursing to sort them out. They clean the medication room two times a week. There was wood in the cupboard that was blocking getting to where the items were found. Licensed Practical Nurse #4 saw the items present after they finished cleaning. On 12/16/2024 at 11:59 AM to 12:04 PM, Licensed Practical Nurse #11 accompanied the surveyor to the medication room on 2 East. There was 6 individually wrapped Heparin 50-unit flushes. There were labeled with lot 314732 and expiration date of 09/01/2024 in a plastic bag in the middle drawer below the counter. During an interview on 12/16/2024 at 12:06 PM, Licensed Practical Nurse #11 stated that they looked in the medication room cabinets today and stated this in not their normal unit and they float. The flushes should not have any expired items in medication room and expired medication are unsafe. During an interview on 12/16/2024 at 12:10 PM, Registered Nurse #10 stated they check the medication room weekly or at least once a month. The last time they looked at the medication room they were not aware the expired medication was there. The last time they looked at the Heparin flushes was in April 2024. The Heparin expired in September 2024 and should be discarded for medication safety and resident safety. It should not be used. The effectiveness of the medication is not the same can be altered or more potent or less potent depending on the medication. During an interview on 12/16/2024 at 12:40 PM, Registered Nurse #7 the Unit Manager stated they look at the medication room daily and they looked at the medication flushes and they take turns with the other unit manager. We are not supposed to have expired medication in the medication room and with expired medication don't know the affect and the manufacturer is not responsible for outdated items used. We have a pharmacy that does monthly reviews. During an interview on 12/19/2024 at 11:45 AM, The Consultant Pharmacist was interviewed and stated each month they do the medication room inspections, and any expired or unlabeled medication are documented in their report. They always email the inspection report, and they are printed right away. The facility should not have expired items on their carts or medication rooms. Heparin flushes should be discarded past their expiration date. During an interview on 12/19/2024 at 01:14 PM, the Assistant Director of Nursing/Infection Preventionist stated they do rounds daily at least 6 times a day and almost hourly. They look at 2 to 3 medication rooms daily and also look at the medication carts. They have not looked at the flushes on the unit. They have looked at the intravenous fluids last week and whatever is expired should be removed from the unit. There should be no expired medication on the units. If medications are expired there can be something wrong with it and it can cause harm to the resident. 10 NYCRR 415.18(e)(1-4)

Based on observations, record review, and interviews conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure menus were followed. This was evident for 5 residents (Resident # 97, Resident # 156, Resident # 212, Resident # 252 and Resident # 271) observed during the Dining Observation task. Specifically, food items were omitted or substituted, and residents were not informed of the changes. The findings include: The policy and procedure titled, Menu Item Substitutions reviewed 1/12/2024 documented menus will be followed as written unless a substitution is warranted in the event of unavailability of an item, unforeseen event, temporary inability to prepare the item or a special meal. A menu substitution item substitution list shall be maintained on file. Food service staff will consult with the director of food and nutrition services or designee on any needed menu substitutions. All changes to the menu (including the date, menu items substitution, reason for the substitution will be recorded on the menu substitution log. Records of menu items substitutions shall be retained for at least six months or per state and local guidelines. Daily menu items substitutions shall be written on the menu and visible for residents to see. The policy and procedure titled Resident Food Preferences reviewed on 12/2024 documented nutritional assessments will include an evaluation of individual food preferences. The Food Services Department will offer a limited number for food substitutes for individuals who do not want to war the primary meals. The residents clinical record (orders, care plan or other appropriate locations) will document the resident likes and dislikes and special dietary instructions or limitation such as altered food consistency and caloric restrictions. The Dietitian will visit residents periodically to determine if revisions are needed regarding food preferences. The nursing staff will inform the kitchen about resident requests. 1. Resident #97 had diagnoses which included Hypertension, Type 2 Diabetes Mellitus, Hyperlipidemia, Unspecified Dementia, Adult Failure to Thrive, Vitamin Deficiency Unspecified. The Admission Minimum Data Set 3.0 dated 09/27/2024 documented Resident #97 was severely impaired. On 12/12/2024 at 05:40 PM, Resident #97 dinner tray was observed and contained yellow rice, chicken, carrot and green beans and pepper, applesauce and tea. There was no milk on Resident #97, and it was crossed out on the tray. On 12/12/2024 at 05:41 PM, Resident #97 was asked if they like milk and they did not respond. 2. Resident #156 had diagnoses which included Hypertensive Heart Disease with Heart Failure and Hyperlipidemia Unspecified. The Discharge Minimum Data Set Assessment 3.0 dated 06/19/2024 documented Resident #156 was moderately impaired cognition. On 12/12/2024 at 05:06 PM dinner was observed on the 2nd floor. Resident #156 was served a tray which contained chopped chicken, yellow rice, green beans, carrots, red pepper and apple sauce. The had whole milk was crossed out on the tray ticket. 3. Resident #212 had diagnoses of Anemia, Hypertension, Chronic Kidney Disease Stage 3a, Dementia in disease not classified elsewhere, Hyperlipidemia and Vitamin Deficiency Unspecified. The Admission Minimum Data Set 3.0 dated 11/12/2024 documented Resident # 212 was severely cognitively impaired. On 12/12/2024 at 05:11 PM dinner tray was observed on the 2nd floor. Resident # 212 was served a tray which contained chopped chicken, yellow rice, applesauce, 4-ounce milk and soup. The assorted juice was crossed out. 4. Resident #252 was admitted to the facility with diagnoses that included Unspecified Dementia, Gastroesophageal reflux disease without Esophagitis and Hypertension, The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #252 had severely impaired cognition. On 12/12/2024 at 12:09 PM, Resident #252 was served a lunch tray that contained baked fish, white rice (double), peas and carrots (double), mandarin oranges, 4-ounce whole milk. Two cups of tossed salad was crossed out on resident tray ticket. There was no tartar sauce on resident's lunch tray. On 12/21/2024 at 12:10 PM, Resident #252 was asked if they liked salad but did not respond to the surveyor. 5. Resident #271 was admitted to the facility with diagnoses that included Dementia, Hypertension and Diabetes Mellitus. The Admission Minimum Data Set assessment dated [DATE] documented that Resident #271 had severely impaired cognition. On 12/12/2024 at 12:02 PM, Resident #271 was served their lunch tray that contained mandarin orange, milk, white rice, vegetables, coffee. The salad on their tray ticket was crossed out. No substitute was written on the ticket. On 12/12/2024 at 5:08 PM, Resident #271 was served a dinner tray that contained chicken leg, yellow rice, applesauce, and soup. Resident #271 lunch tray ticket included baked chicken, white rice, mandarin orange, whole milk, coffee and the 1 cup of tossed salad was crossed out. On 12/12/2024 at 5:10 PM, Resident #271 was asked if they liked salad and did not respond to the surveyor. Resident #271 requested gravy for their chicken. On 12/12/2024 at 12:02 PM - 12:27 PM, lunch trays were observed Resident #271 tray had mandarin oranges, 4-ounce whole milk, white rice, mixed vegetables and coffee. Salad was crossed out on the tray ticket (no substitute was written on the ticket. Resident #252 tray was observed with baked fish, white rice, peas and carrots, mandarin oranges, 4-ounce whole milk, double white rice, peas and carrots, no tartar sauce on tray and ticket states 2 cups of tossed salad which is crossed out. On 12/12/2024 at 12:03 PM, Resident # 271 requested gravy for their food. The menu substitution slips were reviewed and did not contain any food substitutions for the missing items on the residents trays that included tossed salad, whole milk and tartar sauce. During an interview on 12/12/2024 at 12:23 PM, Certified Nursing Assistant #7, stated that they check the residents trays before the get it. They stated that the Lactaid milk is missing for the resident and family leave a note if milk not there give Ensure and they have a prescribed shake and Ensure from their family member. They let the kitchen know if a food item is missing from the tray so they can send it up. The milk is always here. Pureed broccoli is vegetable, Milk given at breakfast and juice is sent in a container and we pour. During an interview on 12/12/2024 at 05:21 PM, Certified Nursing Assistant #6 was interviewed and stated they checked the resident's trays and there is nothing missing from the trays and some residents don't want soup, so they don't put on the tray. Cross out means they don't have the food item downstairs and residents may get a replacement sometimes put on the menu. On 12/12/2024 at 04:43 PM, Dinner trays were observed. Resident #97 tray was observed with yellow rice, chicken, carrot, green beans and red pepper, applesauce, tea and the milk was crossed out on their ticket. Resident #156 was observed with chopped chicken, yellow rice, green beans, carrots and red pepper and applesauce on tray and the whole milk on their ticket was crossed out. Resident # 212 tray with yellow rice, chopped chicken, apple sauce, 4-ounce milk and soup and ticket had assorted juice crossed out. Resident # 97 tray was observed with yellow rice, chicken, carrot, green beans, bell pepper and applesauce. The milk was crossed out on the tray ticket. Resident #212 tray was observed with yellow rice, chopped chicken, apple sauce, 4-ounce milk, soup on the tray. Assorted juice crossed was out on the tray ticket. During an interview on 12/12/2024 at 05:23 PM, Registered Nurse # 5 stated that they make sure the ticket is correct and they check the trays. When a food item is crossed out it means is not being served with the tray. If a food item is missing tell kitchen staff if bring up oversite or substitute for something else. During an interview on 12/12/2024 at 05:26 PM, Resident #156 stated that they like milk. During an interview on 12/17/2024 at 11:30 AM, Dietary Aide #7 stated if the kitchen did not have an item on the ticket the option is crossed out. They have not noticed that the salad was crossed out. They try to make salad and if the delivery did not come in sometimes there are issues with the delivery. If the item is crossed out did not have item and substitute item. There are flyers done if no dessert. During an interview on 12/17/2024 at 11:33 AM, Dietary Aide #8 stated they make salads when available. No salads were made lately and we do not have any at this time. The last time they made salad was last week and they do not know what happened. I don't think it came in and the Food Service Director said none came in and there is nothing to substitute for the salad. There have been no requests for salad in the last week. During an interview on 12/19/2024 at 02:07 PM, the Director of Food Service stated that they have a substitution book and they send a paper on the floor. They put the paper on the trucks. They are not sure which food substitutions were made but they have the substitution sheets. During an interview on 12/19/2024 at 02:18 PM, the Registered Dietitian was interviewed and stated there have been no menu substitutions since last week that they were consulted on. For menu changes if there is a meal alternative or texture concern or menu substitution, they should be consulted due to the potential for food allergens to ensure the substitution is appropriate for the resident. The menu is designed by a menu planning company, and they will review the menu as needed. 10 NYCRR 415.14(c)(1-3)

Based on observation, record review, and interviews conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure that infection control prevention practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, (1) Certified Nursing Assistant (CNA) #8 was assisting multiple residents to perform hand hygiene in the dining room and did not clean their hands in between residents (2) Licensed Practical Nurse #3 who was observed performing wound care did not ensure infection control practices were maintained during a dressing change. This was evident during Dining Observation and Infection Control tasks. The findings are: The facility policy and procedure titled Hand washing reviewed December 2024 documented hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. Employees must wash their hand for twenty to thirty seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: before and after direct contact with residents, after handling potentially contaminated with blood, body fluids or secretions, after removing gloves. In most situations the preferred method o f and hygiene is with alcohol-based hand rub, if hands are not visibly soiled used alcohol-based hand rub containing 60-95% ethanol or isopropanol for all of the following situation before and after direct contact with residents, before after contact wait a resident intact skin., after contact with objects in the immediate vicinity of the resident and after removing gloves. Hand hygiene is always the final step after removing and disposing of persona protective equipment, The use of gloves does not replace hand washing/hand hygiene. 1. On 12/12/2024 at 11:36 AM to 11:49 AM, the 2nd Floor dining area opposite the elevators was observed. Certified Nursing Assistant # 5 was observed assisting to get residents ready for the lunch meal by handing out hand wipes with their bare hands to the residents. Residents placed the used hand wipes into a plastic bag held by Certified Nursing Assistant #5. Certified Nursing Assistant #5 took a used piece of paper from Resident #271 and assisted them to clean their hands with a hand wipe which was then placed in a plastic bag. Certified Nursing Assistant #5 then gave Resident #35 a hand wipe with their bare hands which after being used was placed in a plastic bag. No hand hygiene was observed between residents. Certified Nursing Assistant #5 assisted a resident to lock their wheelchair at the dining table with their bare hands. Certified Nursing Assistant #5 proceeded to give the resident in the wheelchair a hand wipe with their bare hands to wipe their hands. Certified Nursing Assistant #5 then donned gloves and assisted the resident to clean their hands. Certified Nursing Assistant #5 discarded the used hand wipe. Certified Nursing Assistant #5 then assisted another resident to adjust the paper clothing protector. a Then Certified Nursing Assistant #5 removed their gloves and washed their hands at the sink in the dining room. During an interview on 12/17/2024 at 02:35 PM, Certified Nursing Assistant #5 stated that they did not notice that they did not wash their hands during dining. For infection control they should wash their hands in-between residents. Bacteria can be on your hands, and it can transfer to other residents. 44864 2. Resident # 94 was admitted to the facility with diagnoses that include Stroke, Neurogenic Bladder and Hemiplegia. The facility's policy titled Pressure Ulcers/Skin Breakdown- Clinical Protocol, updated 07/2024, documented that the Physician will authorize orders related to wound treatments, including dressings and applications of topical agents. The facility's policy titled, Enhanced Barrier Precautions, last revised 03/25/24, documented that Enhanced Barrier Precautions, refers to an infection control intervention designed to reduce transmission of multi drug resistant organisms that employ targeted gown and gloves use during high contact resident care activities. The policy further stated that Enhanced Barrier Precautions are indicated for residents including those with wounds, even if the resident is not known to be infected or colonized with multidrug- resistant organisms. The Annual Minimum Data Set, dated dated dated [DATE], documented Resident #94's cognition as severely impaired, resident has a pressure ulcer/injury, is at risk of developing pressure ulcers/injuries, has a Stage 4 pressure ulcer that was present upon admission/entry or reentry and uses pressure reducing device for chair, bed. The Physician's Orders dated 12/10/24 documented Santyl External Ointment 250 unit/gm (Collagenase): apply to the sacrum topically daily for stage 4 ulcer and clean the sacrum with normal saline then apply Santyl ointment, cover with a clean dry dressing. 2.2x1.2cm for 30 days. The Physician's Orders dated 6/8/24 Enhanced Barrier Precaution related to sacral wound. On 12/17/24 at 10:52 AM, Licensed Practical Nurse #3 was observed for wound care to the sacrum, for Resident #94. Licensed Practical Nurse #3 entered Resident #94's room, placed some supplies on the resident's mattress, and washed their hands, and put on a pair of gloves. Licensed Practical Nurse #3 then pulled down Resident #94's trousers, took a drape from the supplies on the bed, and place it under Resident #94's buttocks as they positioned Resident #94 on their side. Licensed Practical Nurse #3 tore open some gauze packets and cleaned the wound and placed the dirty gauze on the bed next to the other supplies. Licensed Practical Nurse #3 then took off their gloves and placed a clean pair of gloves on. Licensed Practical Nurse #3 then place the Santyl ointment (treatment for the wound) on a piece of gauze, covered the dressing, retaped the Resident #94's incontinent briefs and pulled back up Resident #94's trousers. Licensed Practical Nurse #3 then gathered all the discarded garbage in their hands and threw them in a garbage. Licensed Practical Nurse#3 then took off their gloves and washed their hands. At no time was Licensed Practical Nurse #3 wearing a gown. On 12/17/24 at 11:00 AM, immediately after the wound care observation, Licensed Practical Nurse #3 was interviewed and stated that they forgot to wash their hands between glove changes and that they knew that after each glove change, they were taught to wash their hands. Licensed Practical Nurse #3 stated that they were in-serviced on Enhanced Barrier Precautions and that they were supposed to use a gown when they were doing the treatment. On 12/17/24 at 11:30 AM, the Wound Care Coordinator was interviewed and stated, that their role is to do weekly rounds with the wound care provider and do initial assessments on the residents. The Wound Care Coordinator also stated that they do training for the other nurses who are trained on the proper techniques for wound care, including being taught to wash their hands between glove changes. On 12/18/24 at 02:53 PM, the Registered Nurse Manager #4 assigned to Unit 4East was interviewed and stated, that they usually do in-services for the Staff on the units, and that all Staff were educated on Enhanced Barrier Precautions. The Registered Nurse Manager #4 also stated that they observe the wound care nurses who do wound care daily, and that the Registered Nurse Managers do spot checks to ensure compliance on wound care techniques. On 12/18/24 at 04:35 PM, the Director of Nursing was interviewed and stated that all Staff was educated on Enhance Barrier Precautions and that and the Infection Control Preventionist will follow up on ensuring that Infection Control practices are maintained. The Director of Nursing also stated that the Licensed Practical Nurse #3 was educated, and competencies were done on wound care practices when Licensed Practical Nurse #3 was recently hired. 10 NYCRR 415.19 (a)(1-3), (b)(4)

Based on observation, record review and staff interview conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not maintain an effective pest control program so that the facility is free of pests and rodents. This was evident during the environmental observation. Specifically, 1) A live rodent was observe caught in a box trap in the dining room while residents were present. 2) Flies were observed flying on the units during the survey (2 [NAME] and 4 West). This was evident for the Environmental task. The findings include: The facility policy titled Pest Control with a revision date of 05/2024 documented that the facility will maintain an effective pest control program that eradicates and controls common household pests and rodents. The facility maintains a written agreement with a qualified outside pest service to provide comprehensive pest control services on a weekly basis and scheduled basis. Ensure use of appropriate chemicals to control pests, use of a variety of methods in controlling certain seasonal pests (indoor and outdoor methods), external perimeter and outlying buildings or structures. The facility meets with the Pest Control technician on a weekly basis before and after the service to communicate any issues with the building that may need additional treatment and to get a verbal report from the technician on the status of pest control within the building. Written reports are reviewed on a weekly basis from the pest control company outlining steps that have been taken and issues that need to be followed up. These issues are reviewed at morning report with the entire team. During environmental observations on 12/12/2024 from 11:46 AM - 03:40 PM the following was noted on Unit 2 [NAME] . A black fly was observed flying on the unit by the nurse's station and in the hallway by 2 [NAME] -room [ROOM NUMBER]. During an observation on 12/13/2024 at 10:54 AM, a black fly was noted flying in room [ROOM NUMBER] on Unit 2 [NAME] and at the unit nurse's station. During an observation on 12/17/2024 at 10:16 AM, the atrium was observed and there was a door facing the security desk leading to the outside with stored equipment that included floor buffers, 2 recliners, hose, planting pot, planting shovel. There were noticeable roach droppings on the furniture. The bait traps were observed, and one had a date of 10/31/2024 written on top of the white bait paper box. During an observation on 12/17/2024 at 12:54 PM, a black fly was observed flying on Unit 4 [NAME] by the nurse's station. During an interview on 12/17/2024 at 01:09 PM, the Unit Clerk was interviewed and stated the Director of housekeeping deals with traps on the unit. The flies were noticed today on the unit and we are supposed to write a note in pest control book. During an observation on 12/17/2024 at 02:32 PM, a black fly was observed in the hallway on the 2nd floor day room area on Unit 2 West. During an interview on 12/17/2024 at 02:40 PM. Certified Nursing Assistant # 5 stated they may see a rat run on the floor early in the morning randomly in the unit dining room. They see pest control on a monthly basis. Last week they saw a rat running in the dining room at 07:30 AM. There are no resident complaints of roaches and flies. During an observation on 12/18/2024 at 08:16 AM a black fly in the hallway on the 4th floor leading to Unit 4 West. During an interview on 12/18/2024 at 11:16 AM, Resident # 35 stated that they see mice in their room. They are dangerous and they can eat a whole bunch of your body. Some people leave food and tissue paper on the ground and rats eat and they come back for some more food. If mice are here and the kitchen should be full of mice because this is where they have food. During an interview on 12/18/2024 at 11:17 AM, Resident #221 stated that they saw a mouse in their room the night before. During an interview on 12/18/2024 at 02:53 PM, Maintenance Worker #2 stated they have noticed no vermin and no issues on the unit in the past. One time they saw a mouse on the trap in one of their rooms and in the process of cleaning last year and better now. Vermin pose an infection control issue. During an interview on 12/18/2024 at 03:04 PM, the Maintenance technician stated they have seen dead mice while cleaning the radiator 2 weeks ago and they have noticed a dead mice noted in resident room. There are sticky pad traps to check. They log sightings in the pest control book and the exterminator comes two times a week and need additional attention they add additional treatment. During an interview on 12/18/2024 at 03:14 PM, the Director of Maintenance stated they do rounds daily. They look for safety issues, look for signs of vermin penetration and they are here sometimes when the pest control person visits the building. During an observation on 12/19/2024 at 10:50 AM, a black fly was noted on the electric panel in the kitchen by the hand washing sink. During an interview on 12/19/2024 at 01:18 PM, the Infection Preventionist stated they have noticed on the unit an occasional fly especially if food is left out and no mice, flies or roaches were observed. They stated they have not looked at the staff lounge on the main floor. Vermin post a threat of disease and infection, and the infections can be transmitted to the residents. They are updated on pest control issues by the maintenance books and the Director of Housekeeping inform them what is found. 10 NYCRR 415.(5) (h)(1)

Based on observations, interviews, and record review conducted during the Recertification survey from [DATE] to [DATE], the facility did not store food in accordance with professional standards for food service safety. This was evident during kitchen observation. Specifically, expired chocolate cake mix was observed in the kitchen's Dry Storage Room (DSR). The findings are: On [DATE] at 09:29 AM, a tour of kitchen was conducted and the DSR was observed with 2 boxes containing six 5lb boxes of chocolate cake mix on the shelf. The boxes had expiration dates of [DATE] and [DATE]. On [DATE] at 10:30 AM, an interview was conducted with Dietary Aide (DA) who stated they are responsible for the DSR and last rotated items in [DATE]. The DA did not check the chocolate cake mix and the last time they checked it was [DATE]. On [DATE] at 10:34 AM, the Food Service Director (FSD) was interviewed and stated they are responsible for checking dry storage expiration dates. The FSD did not notice the expired cake mix on the DSR shelf. 415.14 (h)

Based on observations, record review, and interviews conducted during a Recertification survey from 10/25/22 to 11/01/22, the facility did not ensure residents' environment was safe, clean, comfortable, and homelike. This was evident for 2 (2 [NAME] and 4 West) out of 6 units. Specifically, 1) Multiple rooms on the 2 [NAME] were observed with air conditioning (AC)/heater units that were dusty, dirty, and in disrepair; and 2) 4 [NAME] resident rooms were observed with dirty toilet bowls that had brown stains, a resident's bathroom without a functioning light above the toilet bowl, a dusty and broken radiator, a stained divider curtain, and a resident's closet door was not completely painted. The findings are: The facility policy titled Preventative Maintenance Program revised 07/2022 documented to ensure the provision of a safe, functional, sanitary, and comfortable environment for resident's staff and the public. 1) From 10/25/2022 at 11:03 AM to 10/31/2022 at 10:30AM, observations of 2 [NAME] resident rooms, 203, 206, 207, 211, 218, 223, and 226 had AC/heater units that were dirty and/or in disrepair with dried dead leaves wedged between the bottom of the vent covering and the bottom portion of the unit, missing and damaged air vent grates, significant dust buildup on the top of the unit and on the vent grates, and missing AC/heater covers. 37787 2) From 10/25/2022 at 11:27 AM to 10/28/22 at 4:28 PM, a tour of 4 [NAME] resident rooms was conducted and the following was observed: room [ROOM NUMBER] had an AC/heater unit noted covered in dust and stained with black and brown [NAME]. The resident's bathroom contained a light that would not turn on and a toilet bowl with black and brown stains spattered onto it. The divider curtains between roommates in 426 had large brown stains throughout the fabric and fruit flies were surrounding the curtain. room [ROOM NUMBER] had a toilet bowl in the resident's bathroom that was stained with black and brown spots. room [ROOM NUMBER] had a brown stained divider curtain hanging in between the resident beds. room [ROOM NUMBER] had a small garbage can without a garbage bag and it had crusty brown dirt caked on it. On 10/28/22 at 4:12 PM, the Director of Housekeeping was interviewed and stated they acknowledge there are brown rusty stains in resident bathrooms. Housekeeping is going to work with Maintenance to remove the stains. On 10/28/2022 at 1:03PM and 5:19 PM, the Director of Maintenance (DOM) was interviewed and stated they look at the AC units quarterly for damage, broken parts and need for cleaning. The last time the units were cleaned was June or July 2022 and the last time they looked at the units was in August 2022. The DOM assesses if the units need to be serviced and if there is any physical damage. There are times the units will have food on them or dust on the radiator. Many of the AC/heater units are missing covers. The DOM uses hot water to clean the AC units and no chemicals. On 10/31/22 at 317 PM, the Administrator was interviewed and stated the building is under renovation and the 4th floor is next. New curtains were ordered for the 4th floor in July 2022 and the facility is expected to receive them in December 2022. 415.12(h)(2)

Based on observation, interviews and record review conducted during an Abbreviated Recertification Survey, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 2 (Resident #250 and Resident #201) of 35 sampled residents. Specifically, (1) Resident #250 had a wander guard in place without a current assessment or physician's order. (2) Resident #201 had a [CONDITION(S)], and there were no wound measurement and description notes for 3 weeks. In addition, the treament record showed omissions for wound care for multiple days. The findings are: 1) The undated facility policy and procedure titled Use of Wander Guard Device documented the Physician's order shall be obtained and documented in medical record. Resident #250 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #250 had severely impaired cognition and no wandering behavior. It also documented that Resident #250 required extensive assistance with 1 person for locomotion on and off unit. It further documented Resident #50 had no physical restraints and no alarms in use. On 10/25/22 at 10:39 AM, 10/26/22 at 09:19 AM, 10/27/22 at 09:46 AM, and other occasions during the survey, Resident #250 was observed on the unit sitting in a wheelchair wearing a wander guard device on the left wrist. The most recent Elopement Risk Score dated 5/22/22 documented the score was 12 and Resident #250 was at risk of elopement. There was no documented evidence that elopement assessment was done after 5/22/22 for Resident #250. The physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence that a physician ordered to use wander guard device after 7/26/2022. The CNA Accountability had the task for Behavior Monitoring & Interventions Check for wander guard placement to right wrist until 7/25/22. The Comprehensive Care Plan (CCP) related to Elopement risk/Wanderer, initiated 7/23/2018 and last reviewed 10/6/2022, documented Resident #250 wandered aimlessly. The CCP included interventions to monitor wander guard to right wrist every shift, document wandering behavior and attempted diversional interventions, and check wander guard device placement every shift. The CCP was not updated when the wander guard was discontinued on 7/26/2022. The current Wander Guard List for the unit provided by RN #1 on 10/28/2022 did not have Resident #250 on the list. The Behavior Notes dated 7/31/22 to 9/14/22 were reviewed after wander guard device order was discontinued. The notes documented that Resident #250 was confused, had behavioral problems, and stated they wanted to go home. There was no documented evidence a wanderguard was placed on the resident or that a physician's order was obtained to use a wander guard device. On 10/28/22 at 10:23 AM, Certified Nursing Assistant (CNA) # 1 was interviewed and stated Resident #250 was confused and often talked about going home to see their spouse. CNA #1 also stated Resident #250 was able to wheel themselves without assistance. CNA #1 stated they saw Resident #250 had wander guard device at left wrist area for long time and they did not know the reason for using it. CNA #1 also stated they were not aware Resident #250 had wander guard device order discontinued. CNA #1 further stated they did the tasks listed on the CNA accountability only and did not ask the nurse for wander guard monitor when it was not listed on the CNA Accountability after July 2022. CNA #1 stated they were not aware Resident #250 had wandering behavior or tried to leave the unit. On 10/28/22 at 10:39 AM, Registered Nurse (RN) #1 was interviewed and stated Resident # 250 was generally confused and tried to leave the unit occasionally before. RN #1 also stated Resident #250 did not have or need a wander guard device because Resident # 250 was not able to propel themselves out of unit in the wheelchair recently. RN #1 further stated the wander guard order was discontinued for Resident #250 already on 7/26/22 and Resident #250 was not on the wander guard list since then. RN #1 stated they made rounds on the unit 2 to 3 times a day to make sure residents were safe and received the care according to care plans. RN #1 also stated they were not aware Resident #250 had wander guard device on their left wrist. RN #1 stated they remembered Resident #250 tried to leave the building after the rehab one time few months ago and was not sure if the staff put the wander guard device back afterward. RN #1 also stated they did not know which staff put the wander guard device back and when the attempted elopement event happened. RN #1 further stated they were not able find any documented evidence about the event in the medical note. RN #1 stated they required the physician order to put the wander guard device on the resident and it should be documented in the medical note. RN #1 also stated they were not able to explain why there was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/28/22 at 11:48 AM, Director of Nursing (DON) was interviewed and stated the staff have to obtain consent from representative and physician order before applying wander guard device to resident and document it in the medical note. The DON also stated they were not aware Resident #250 had a wander guard device on. DON further stated they were not able to explain why there was no documented note about applying the wander guard and no physician's order was obtained before applying it to Resident #250. On 10/28/22 at 01:02 PM, the Attending Physician (MD) was interviewed and stated Resident #250 was generally confused. MD also stated they did not recall ordering a wander guard device or any other alarm for Resident #250 after the order was discontinued in July 2022. MD further stated the staff should follow the facility protocol for using the wander guard device or other surveillance for wandering behavior. 2) The policy and procedure titled Wound care policy, which was not dated, documented that it is the policy of the facility to assess all residents and develop a plan of care that will prevent the development of wounds or provide for the healing of existing wounds. The policy further documented that residents would have skin assessments weekly, and wounds should be assessed during each dressing change. Documentation of all wounds must include size, appearance, and type of wound. The wound care nurse will document regularly on residents with wounds. Resident #201 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #201 had moderately impaired cognition with a Brief Interview of Mental Status (BIMS) score of 12 out of 15 and no behaviors or rejection of care exhibited. Resident #201 required limited to extensive assistance with the help of 1 person for activities of daily living. There was one venous/arterial ulcer present at the time. The Comprehensive Care Plan (CCP) on Peripheral Vascular Disease (PVD) r/t Diabetes was created on 7/13/2018, and last revised on 9/27/2022. It documented the goal of resident's extremities will be free from pain, pallor, rubor, coldness, [CONDITION(S)], and skin [CONDITION(S)] through the review date. Interventions included elevate legs, wound care, good nutrition/hydration. The Comprehensive Care Plan (CCP) Diabetes Mellitus was created 7/13/2018 and last revised 9/27/2022, with interventions that included check all of body for breaks in skin and treat promptly as ordered by doctor. During an interview on 10/25/22 at 11:55 AM, Resident #201 stated they lost their right great toe earlier in the year because the facility did not properly care for a diabetic ulcer on their foot. A Skin/Wound Note dated 1/21/2022 documented Resident #201 was seen for a break in skin integrity on the right great toe. The resident was noted with a diabetic ulcer on the tip of the right great toe. The ulcer measured 0.5 x 1 x 0.3cm with 100% granulation and small amounts of serous drainage. The resident was described as compliant with care. The physician's order dated 1/21/2022 documented to clean the tip of the right great toe with normal saline, then apply [MEDICATION(S)], and cover with a clean dry dressing every day shift for diabetic ulcer. The Treatment Administration Record (TAR) for January and February 2022 documented that wound treatments were not completed on February 3, 4, 5, 6, 11 and 17. There were no nursing or behavior notes documenting the resident had rejected care or was out of the facility during those days. (Per the Assistant Director of Nursing (ADON), Licensed Practical Nurse #2 was assigned to the unit on 2/3/22 and RN Supervisor #2 was assigned to the unit on 2/11/22.) A physician's note dated 2/9/2022 documented that resident complained of pain in big toes. The right and left big toes were described as with dressing. No wound observation or assessment was documented. The plan was to add oral antibiotics ([MEDICATION(S)] 500mg 3 times a day) for 10 days, continue current management and follow Ortho recommendations. A physician's order was placed on 2/9/22 to start [MEDICATION(S)] 500mg PO 3 times a day. A nursing note dated 2/10/22 at 11:06PM documented resident was to start on ABT [MEDICATION(S)] 500 MG PO for toe infection, pending delivery from pharmacy. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's note on 2/14/2022 documented the resident should continue with oral antibiotics to complete 10 days. The right and left big toes were described as with dressing. No wound observation or assessment was documented. There was no documented evidence that the wound was assessed and monitored for progress and response to the treatment between 1/21/22 and 2/16/22. A Wound Note, written by the wound doctor, dated 2/16/22 documented that the diabetic ulcer on the right great toe had a status of deteriorating. The wound now measured 3cm length x 2.8cm width x 1cm depth, area 8.4sq cm. Bone was exposed. No tunneling was observed. Copious amount of purulent drainage noted with mild odor. Pain level 5/10 was reported. Wound margin was thickened, wound bed 76-100% slough, no granulation, no eschar. Recommended X-ray of right foot, ID consult, and continue current treatment. A right foot X-Ray dated 2/16/2022 documented findings consistent with Right great toe [CONDITION(S)] and [CONDITION(S)]. A physician's note dated 2/17/22 documented the resident's wound was not improving. Resident to start IV [MEDICATION(S)] for Right great toe [CONDITION(S)] and [CONDITION(S)], consult ortho, and continue daily wound dressing. A physician's order was placed on 2/16/22 to start IV [MEDICATION(S)] 2gm every 24hrs for 10 days. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A skin/wound Note dated 2/23/2022, written by the Wound Nurse Practitioner, documented the ulcer now involved the right hallux and dorsal right foot measuring 13.5 x 10 x 0.5 cm with 10% granulation, 30% slough, 60% eschar/dry gangrene and small amounts of sero-sanguineous drainage with a mild odor. A small area of bone was exposed. No increased pain was noted. A skin/wound Note dated 2/24/2022 documented the toe was black in appearance and extended past the metatarsal joint, scant drainage noted but odorous. Resident noted to have an appointment regarding emergency surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] A skin/wound Note dated 3/4/2022 documented the resident was post amputation of the right great toe. The resident was seen and assessed by the wound doctor due to the resulting surgical wound on the right hallux. On 10/28/22 at 10:32 AM, LPN #1, the resident's current nurse, was interviewed and stated that Resident #201 is compliant with care. LPN #1 stated stated that the wound care team takes care of wounds. Nurses care for wounds if wound team is not around. On 11/1/22 at 10:48 AM, LPN #2 was interviewed. LPN #2 stated she was not assigned to Resident #201's unit and could not recall providing treatments to the ressident. On 10/28/22 at 10:45 AM an interview was conducted with the Wound Coordinator (WC), who stated they do initial assessment of wounds, documentation, initiation and updating of care plans. The WC stated they do weekly wounds with the Wound Nurse Practitioner (WNP), update orders, and check any new skin breaks. They have an assistant wound nurse (LPN #3) who does some wound treatments, but the floor nurses are primarily responsible for wound care. The WC does frequent assessments as needed. The WC stated Resident #201 has extensive PVD and recurrent diabetic ulcers. The WC stated they were out of the country when Resident #201's lesion worsened, and toe was amputated. On 11/01/22 at 11:37 AM, LPN #3 (wound nurse) was interviewed and stated they do some of the treatments but they don't do wound assessments. The wound coordinator and RN supervisors do wound assessments. We do weekly rounds on Wednesdays with the wound doctor. Wound assessments are done on admission, on any new wounds, and if there are any changes noticed during wound treatments. Resident #201 is a chronic diabetic with vascular problems. Resident #201 heals fast, but things can also get bad fast. On 10/31/22 at 10:04 AM and 11/2/22 at 11:30 AM and interview was conducted with RN Supervisor #2, who stated the wound care team is usually responsible for wound care. There is a wound care nurse assistant who does the treatments if the WC is not around and documents visits in the chart. The nurses on the floor do daily treatments. RN Supervisor #2 stated if the floor nurses notice anything, it is reported to the wound team and a note is written. Staff sign the TAR to document the treatment was done. If there is no signature on the TAR either they did not sign for it or the order was for every other day. RN supervisor #2 stated they began working at the facility in mid February 2022, and they were in training. RN Supervisor #2 stated they did not assess or do any treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] On 11/01/22 at 10:38 AM an interview was conducted with the ADON, who stated that sometimes the facility is short staffed. Looking back at what happened when resident #201's treatments were not documented as completed, it looks like RN supervisors were the only nurses on the floor those days. The supervisors were doing meds as well on those days. When the wound coordinator is on vacation, the wound nurse (LPN #3) oversees wounds. On 10/31/22 at 12:11 PM an interview was conducted with the Director of Nursing, who stated that when the wound care nurse is not available or out on vacation, generally the RN supervisors on the units cover wound care. Resident #201 has a long history of diabetic ulcers that don't heal properly. I know there is a gap on the documentation of his wound care, I cannot say exactly what happened, but I know this wound would not get worse in 4 days. Sometimes nurses will provide care and forget to document it. Resident #201 has not complained to me about their wound care. They complain about many other things. On 10/31/22 at 04:35 PM an interview was conducted with Resident #201's Primary Doctor who stated that wound care is done by the wound team, doctor and nurse. They do rounds 2 times a week. Also, primary doctor and nurse on the floor check on the wounds. On a daily basis, the floor nurse and wound care nurse take care of the wounds, depending on the situation. Resident #201's wound deteriorated over a period of a few weeks. It was not getting better as quick as we would want it. Sugar was 109-120, we were checking that diabetes was controlled. We were using [MEDICATION(S)] w/o rapid improvement. After about a week of treatment, we added antibiotics based on how the wound was observed. Then we switched to IV antibiotics. The Vascular surgeon advised amputation. If I'm on the floor when the dressing change is being done, I will observe the wound, but sometimes the dressing change is already done when I get there. I don't go to the facility every day. I do rely on the floor manager to give me an idea of what the wound looks like. I rely a lot on the nurses' observations. All the interventions were put in place based on observations that the wound was not improving. I agree that documentation was not descriptive. The details are not there. 415.12

Based on interviews and record reviews conducted during an abbreviated survey (NY 238), the facility did not ensure a resident was free from resident to resident abuse. This was evident in 1 of 3 residents sampled (Resident #1). Specifically, on 08/10/2019, Resident #1 took Resident #2's pants and Resident #2 hit Resident #1. Resident #1 sustained an injury to his right eye and was admitted to the hospital on [DATE]. The resident was diagnosed with [REDACTED]. This resulted in actual harm to Resident #1 that is not Immediate Jeopardy (IJ). Findings Include: Review of the Facility's Policy and Procedure on Abuse, Mistreatment and Neglect dated 12/20/2018, documented that the facility will not permit any form of abuse to residents. The purpose of the policy is to ensure that every resident is free from abuse including physical abuse. Resident # 1 (the victim) was initially admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 05/10/2019 documented Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 13/15 indicating intact cognition. Review of the Nurse's Progress Note dated 08/10/2019 documented that Resident #1 grabbed Resident #2's clothes and was hit in the face. An ice pack was applied to the right eye and mouth. Resident #1's eye was swollen with a small amount of bleeding and the resident complained of eye pain. Review of the 08/2019 Medication Administration Record [REDACTED]. Review of the Facility's Overview of the altercation, dated 08/10/2019, revealed that Resident #1 and Resident #2 were roommates (at the time of the incident). Resident #1 took Resident #2's pants from the hamper and Resident #2 hit Resident #1 in the face. Staff intervened and noted that Resident #1 was holding onto Resident #2's pants. Resident #2 admitted to hitting Resident #1 in the face. Resident #1 had swelling to the right eye and mouth. An ice pack was applied and Resident #1 was transferred to the Hospital emergency room for Computed Tomography (CT) scan of the head. Review of the hospital discharge record revealed that Resident #1 was admitted to the hospital from 8/11/2019 to 8/14/2019. The discharge record revealed that Resident #1 had [MEDICATION NAME] trauma to the right eye and complained of eye pain. A Facial CT-scan confirmed Globe Rupture. Resident #1 was given tetanus and antibiotics treatment. Resident #1 underwent eye surgery (date and time not noted). Resident #1 complained of severe pain and was on multiple pain medications. Resident # 2 (the aggressor) was initially admitted to the facility with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented Resident #2 had long/short-term memory impairment. Cognitive Skills for Daily Decision Making noted as Severely Impaired - never/rarely made decisions. Review of the at Risk for Abuse, Neglect and Mistreatment Care Plan for Resident #2 dated 10/16/2018, revealed interventions to make efforts to provide compatible roommate, monitor behavior, mood and to provide early intervention. The behavioral care plan dated 07/15/2019 documented Resident #2 was physically aggressive. The resident attempted to hit a CNA during Activity of Daily Living (ADL) care. Review of the Psychiatric Consult dated 07/17/2019 documented that Resident #2 had history of [MEDICAL CONDITION], behavioral disturbance and Dementia. Resident is loose and has no dangerous idea to self/others in thinking. Disoriented to time. Poor recent memory. Poor insight/judgement. The recommendation was to continue with [MEDICAL CONDITION] medication. Review of the Nursing Note dated 07/15/2019, documented that Resident #2 spend all his time in his room. Resident #2 was interviewed on 08/20/2019 at 12:30 PM and stated that he had a problem with Resident #1. He stated that Resident #1 came at him and that he responded. On inquiry, Resident #2 stated that he hit Resident #1 with his fist. Resident #2 added that he was now more comfortable as he was moved to a single room. Certified Nursing Assistant #1 (CNA #1) was interviewed on 08/20/2019 at 3:10PM and stated that on 08/10/2019, she heard a call for help, and she ran into Resident #1 and Resident #2's room. She observed Resident #2 attempting to get his clothing from Resident #1 who was saying it's mine. Both residents were hitting each other, and she separated them. Resident #1 had a small amount of blood on his face and Resident #2 had blood on his hand. The nurse came and cleaned up both residents and applied an ice pack to Resident #1. Registered Nurse Supervisor #1 (RNS #1) was interviewed on 11/20/2019 at 10:30AM and stated that she was covering the unit at the time of the incident and responded to the call. She stated that Resident #1 had bleeding and swelling to his right eye. She applied an ice pack to Resident #1's face. She stated that she called the Physician and Resident #1 was transferred to hospital. Licensed Practical Nurse #1 (LPN #1) was interviewed on 11/21/2019 at 10:05AM via telephone. She stated that she was the charge nurse on the 3-11PM shift on 08/10/2019. She stated that she worked intermittently on Resident #1 and Resident #2's unit. On 08/10/2019 (does not recall time), she heard CNA #1 screaming and she ran to Resident #1 and Resident #2's room. She observed Resident #1 sitting in his chair and Resident #2 standing at a distance. On inquiry she stated that she did not see the actual physical altercation. However, Resident #1 had blood on his face and eyes. She applied an icepack and obtained Resident #1's vital signs. She stated that she asked Resident #1 to explain what happened and Resident #1 replied, I didn't steal anything which was Resident #1's usual response. She stated that Resident #1 had a bag containing Resident #2's belongings under his arm. Resident #1 kept repeating that Resident #2's clothes belonged to him. The RNS #1 assessed Resident #1 and he was transferred to the hospital via ambulance. She stated that Resident #2 admitted that he hit Resident #1 with his hand. The Director of Nursing Service (DNS) was interviewed on 08/20/2019 at 4:00PM and stated that the LPN #1 called him to the unit and he observed Resident #1 with an icepack to his right eye. Resident #1 was alert, responsive and complaining of pain in his eye. Resident #1 had swelling to his eyelids and redness of the eye. He affirmed that Resident #1 was immediately transferred to the Hospital. 415.4 (b)(1)(i)

Based on staff interviews and record review during an abbreviated survey, the facility did not ensure that the necessary care and services to maintain the highest practicable physical well-being of a resident was provided. This was evidenced by 1 of 17 sampled residents (Resident is #37). Resident #37 was noted with lab results that included a very high potassium level that was not reported to the doctor for 4 days. On the fifth day, the resident presented with numbness to the extremities that was not reported to the physician. The resident was subsequently transferred to the hospital and expired from Cardiopulmonary Arrest (CPA). This resulted in actual harm that is not Immediate Jeopardy. Complaint # NY 537 The finding is: Resident #37 is a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Nursing Admission assessment dated [DATE] documented that the resident was oriented to time, place and person, had clear and distinct speech, and understood verbal communication. The Comprehensive Care Plan for Altered Cardiac Status dated [DATE] identified that the resident had a [DIAGNOSES REDACTED]. A nurse's note dated [DATE] documented that blood was drawn for lab tests in the morning and that the resident had no apparent distress. The lab report generated on [DATE] at 2:12 PM documented that the resident's potassium level was "VH" (very high) at 6.4 mmol/L (normal range: 3.5 - 5.5 mmol/L). The report also documented that the "serum is hemolyzed." The lab's Distribution Information documented that the resident's critical value result was reported to a Registered Nurse (RN) at 3:51 PM on [DATE]. The specific name of the RN was documented in the report. The RN was identified by the surveyor as the evening RN Supervisor (RNS). The review of the nurse's notes and doctor's notes from [DATE] to [DATE] revealed no documentation regarding the very high potassium level. The doctor's progress note dated [DATE] indicated that the Medical Doctor (MD) reviewed the lab result and noted the potassium level from hemolyzed blood. The MD ordered Sequential Multiple Analysis-6 (SMA-6) for the [DIAGNOSES REDACTED]. A nurse's note dated [DATE] at 6 AM documented that the resident complained of numbness of extremities. The note also documented that the nursing supervisor was made aware and "MD to assess." The 24-hour report for the night shift on [DATE] also documented that the resident complained of numbness to the extremities. There was no documented evidence that the MD was notified of the resident's change in condition A nurse's note dated [DATE] at 10 AM documented that the resident complained of difficulty in breathing. The MD evaluated the resident and observed that the resident was unable to move his left upper and left lower extremities. The MD ordered to transfer the resident to the emergency room . A nurse's note dated [DATE], ,[DATE] PM stated that the lab called and notified the facility of the critical values from the lab result. The lab report generated on [DATE] at 1:06 PM confirmed that the potassium level was indicated as "high" at > 8.5 mmol/L, the result drawn from clear specimen. The hospital record dated [DATE] revealed that the resident arrived at the emergency room at 10:30 AM on [DATE] and expired at 1:45 PM due to CPA. An interview with the MD was conducted on [DATE] at 3:30 PM. The MD stated that he did not see the [DATE] lab report until [DATE] when it was on his clip board on the unit. The MD stated that he never got a call from a nurse regarding the critical value. The MD stated that if he got a call right away about the high potassium level from hemolyzed blood, he would have ordered to repeat the lab right away. When he saw the result on [DATE], he only ordered to repeat the lab, because the resident did not have any symptoms of distress at the time. The MD stated that he was never notified by a nurse that the resident complained of numbness during the night shift on [DATE] to [DATE] and there was no note to see the resident. On the morning of [DATE], the resident stopped the MD and asked to be seen because he was not feeling well. The MD observed the resident to be paralyzed on the left arm and leg, and immediately ordered to transfer the resident to the emergency room . The MD stated that the resident expired at the hospital that day and that the high potassium could have led to the [MEDICAL CONDITION]. The MD stated that if he did not see the resident at that time in the morning, the resident would have died in the facility. An interview with the evening Licensed Practical Nurse (LPN) was conducted on [DATE] at 4:45 PM. The LPN stated that if the lab results have critical values, the lab would call the nursing supervisor right away and fax the report to the facility. Then the nursing supervisor calls the MD and lets the charge nurse on the unit know of the lab result and MD's order. The LPN stated that on [DATE], she was not notified by the nursing supervisor of the lab result or any new orders from the MD. The LPN stated that she would have documented about the lab results if she was informed. An interview with the night LPN was conducted on [DATE] at 1:49 PM. When asked about the note she wrote on [DATE], the LPN stated that she is not sure why the resident was having numbness, but "it had to be something the supervisor needed to know." She stated that she does not recall if or how the nursing supervisor responded to her report about the resident. An interview with the evening RNS was conducted on [DATE] at 3:14 PM. The RNS stated that for critical value lab results, the lab will call and report the result to the nursing supervisor, then fax the lab report to the nursing office. Then the nursing supervisor will take the lab report to the unit, call the MD, the MD will give an order, then the charge nurse on the unit will be notified of the lab result and MD's order. The nursing supervisor will document the findings in the chart and the result will also be documented on the 24 hour report. When RNS was asked about the resident's critical value result that was reported to her on [DATE] by the lab, the RNS denied getting the verbal report from the lab. The RNS stated that she would "never ignore critical value report" and that the lab must have spoken to someone else even if her name was documented on their report. She also stated that whenever the lab reports get faxed to the nursing office, the nursing supervisor during that shift is responsible to bring the lab reports to the units. An interview with the Director of Nursing (DON) was conducted on [DATE] at 4:45 PM. The DON stated that the lab will call the nursing supervisor if there is a critical lab value and the result will be faxed to the nursing supervisor's office. Then the nursing supervisor brings the result to the unit, notify the MD, and receive orders. In regards to Resident #37, the DON was unable to explain what happened because she was not the DON in the facility at the time. An interview with the Administrator was conducted on [DATE] at 1:07 PM. The Administrator stated that when a critical value is reported from the lab, the nurse would immediately let the MD know, receive orders from the MD, then document the result. When asked about Resident #37's critical value result and lack of immediate intervention, the Administrator stated that he was not aware of it until the Department of Health began to investigate the case. 415.12

Based on staff interviews and record review during an abbreviated survey, the facility failed to ensure that services provided met professional standards of quality. This was evidenced by 5 out of 10 residents (Residents # 1, 2, 3, 4, 5). Specifically, the nursing staff failed to administer medications as per the physician's orders [REDACTED]. Additionally, the nursing staff failed to notify the physician when significant medications were not administered and ensure that the residents were clinically monitored for adverse reactions. This resulted in no actual harm with the potential for serious harm that is Immediate Jeopardy to resident health and safety. See F 333 K Complaint ID # NY 289, NY 2982 The findings are: According to the New York State Educational Law Article 139, Section 6902, the practice of the profession of nursing includes the executing of medical regimens prescribed by a licensed physician. It further states that " nursing regimen shall be consistent with and shall not vary any existing medical regimen. " Resident #1 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment Version 3.0, dated 10/28/10 documented that the resident is cognitively intact. The resident required one person, limited assistance with bed mobility, dressing and performing personal hygiene. All other Activities of Daily Living required supervision. A physician's orders [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There are three entries located on the back of the MAR indicated not available" or "unavailable." A review of the nursing notes during this time period did not reveal any further information pertaining to the missed medication. The MAR indicated [REDACTED]. The back of the MAR indicated [REDACTED]. A nurse's note, dated 11/16/10 late entry for 11/12/10 documented that the resident did not receive [MEDICATION NAME] due to unavailability on 11/12. The note was written by an LPN. A review of the nursing notes during this time period did not reveal any further information pertaining to the missed medication. A review of the Physician's Progress Notes during this time period did not reveal any indication that the physician was informed of the missed medications. A review of the resident's progress notes did not reveal that the resident was assessed for adverse effects related to the missed doses of [MEDICATION NAME]. There is also no documented evidence that a Medication Error report was completed for the missed does of [MEDICATION NAME]. Resident #1 was interviewed on 11/16/10 at 12:30 PM, the resident stated that he had not been receiving his [MEDICATION NAME] for the past 4-5 days. LPN #2 was interviewed on 11/22/10 at 11:00AM. LPN #2 stated that she worked on 11/10/10 during the 3PM-11 PM shift. She stated that the [MEDICATION NAME] medication was not available so it was not administered to the resident. LPN #2 stated that she was informed that they were waiting for the medication from the pharmacy. LPN #2 stated that she did not inform the physician or supervisor and she did not document the missed [MEDICATION NAME] in the progress notes or on the back of the MAR. LPN #3 was interviewed on 11/22/10 at 4:30PM. The LPN stated that she worked on 11/11/10-11/12/10 during the 3PM-11PM shift. LPN #3 stated that they did not have the [MEDICATION NAME] to administer to the resident. She called the pharmacy and left a message and did not notify anyone else at the facility. LPN #4 was interviewed via telephone on 11/30/10 at 4:00PM. LPN #4 stated that she worked on 11/10/10 - 11/12/10 during the 11PM-7 AM shift. LPN #4 stated that she was responsible for administering 6AM medications on Resident #1's unit. LPN #4 stated that on 11/10/10 -11/12/10, she did not administer the medication because it was not available. She notified the nursing supervisor, but did not notify the physician. RN #1 was interviewed on 11/22/10 at 3:30PM. RN #1 stated that she worked on 11/13/10 during the 3PM-11 PM shift. She stated that the [MEDICATION NAME] was not available and she did not notify the physician because did not know that she was supposed to. She stated that she informed the oncoming shift. RN #1 stated that she did not assess or monitor the resident for adverse reactions to missing the medication. RN #2 was interviewed on 11/23/10 at 10:30AM. RN #2 stated that she worked on 11/13/10 during the 7AM-3 PM shift. She stated that the nurse informed her that the resident did not have any more [MEDICATION NAME]. She stated that she also worked on 11/14/10 on the unit. None of the nurses informed her that the medication had not arrived. When she worked on 11/15/10, she stated that she was the medication nurse. She stated that there was no [MEDICATION NAME] for Resident #1 on 11/15/10. She stated that she did not inform the physician on any of the days she had worked. She did not notify the nursing supervisor because she was told that the nursing supervisor was already aware that the [MEDICATION NAME] was not available. She stated that she did not assess the resident for adverse reactions. RNS #1 was interviewed via telephone on 11/30/10 at 2:15PM. The RNS stated that she worked the 11PM-7AM shift on 11/13/10-11/15/10. The RNS stated that she covered the whole house when she was the only nursing supervisor on duty; otherwise she covered the unit where Resident #1 resided. RNS #1 stated that no one had notified her that Resident #1 had not received his [MEDICATION NAME] medication. RNS #2 was interviewed via telephone on 11/30/10 at 1:45PM. RNS #2 stated that she worked the 3PM-11 PM shift on 11/10/10-11/12/10. RNS #2 stated that she was responsible for covering Resident #1's unit. RNS #2 stated that she was not informed that the Resident #1 missed his [MEDICATION NAME] medication. RNS #3 was interviewed via telephone on 11/30/10 at 2:05PM. The RNS stated that she worked the 3PM-11PM shift on 11/14/10. RNS #3 stated that she was not notified that Resident #1 had missed his [MEDICATION NAME] medication. Physician #1 was interviewed on 11/19/10 at 2:00PM, 11/22/10 at 2:50PM and 11/23/10 at 1:48PM. The Physician stated that the resident was on [MEDICATION NAME] injections due to his history of [MEDICAL CONDITION] and lack of mobility related to obesity. He was not aware that the resident had missed his [MEDICATION NAME]. He stated that none of the nurses informed him that the medication was not available. Physician #1 stated that he should have been informed so that he could have ordered a replacement. He stated that it is considered a standard of care that if a nurse cannot administer a medication the physician must be informed. Resident #2 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The MDS 3.0 assessment dated [DATE] documented that the resident was cognitively intact. The Comprehensive Care Plan (CCP) implemented on 11/03/2010 documented that the resident has a [DIAGNOSES REDACTED]. physician's orders [REDACTED]. The MAR indicated [REDACTED]. The medical record and MAR binder revealed no evidence that Resident #2's blood glucose was monitored during the period of time that the [MEDICATION NAME] was not administered. A nurse's note dated 11/20/10 at 5:30 PM documented that [MEDICATION NAME] was ordered from the pharmacy. The Pharmacist stated that medication will arrive by the next day. A review of the Physician's Progress Notes during this time period did not reveal any indication that the Physician was informed of the missed medications. A review of the resident's progress notes did not reveal that the resident was assessed for adverse effects related to the missed doses of [MEDICATION NAME]. There is also no documented evidence that a Medication Error report was completed for the missed does of [MEDICATION NAME]. RN #3 was interviewed on 11/23/2010 at 2:20PM. RN #3 stated that [MEDICATION NAME] was not available on 11/15/10. She faxed the order to the pharmacy and informed the evening shift. RN #3 did not check the resident's blood sugar level or notify the physician when she was aware of the missed medication. She stated she was not told that she had to do that. RN # 3 stated that no one reported to her that the [MEDICATION NAME] did not arrive from the pharmacy. LPN #5 was interviewed on 11/22/2010 at 10:20 AM. LPN # 5 worked on 11/20/10 during the 7AM-3PM shift. LPN #5 stated that the [MEDICATION NAME] was missed because it was not available. LPN #5 stated that it was a very hectic day that she was not able to tell the RNS that the [MEDICATION NAME] was not given until around 2:00 PM. LPN #5 did not call the physician. LPN #5 stated that the RNS instructed LPN #3 who works in the evening shift to call the physician and see what needed to be done. LPN #5 also stated that she checked Resident #2's blood sugar and it was within normal limits, but there was nowhere to document it on the MAR, so she did not write the result. LPN #3 was interviewed on 11/23/10 at 4:50PM. LPN #3 stated that she noticed that the [MEDICATION NAME] was not there so she informed RNS #3. LPN #3 was able to administer the [MEDICATION NAME] because she borrowed it from another unit, as instructed by RNS #3. LPN #3 stated that she called the pharmacy but the pharmacy staff said that the [MEDICATION NAME] was not due for reorder yet. She did not call the physician. Interviews were conducted with RNS#4 on 11/23/2010 3:00 PM, RNS #5 on 11/26/2010 11:30 AM and RNS #6 on 11/29/2010 1:50 PM. They all stated that they were not informed that Resident #2 was not getting his insulin. RNS #3 was interviewed on 11/23/10 at 4:30PM. She stated that LPN #3 came downstairs to inform her that Resident #2 ' s [MEDICATION NAME] was not available. RNS #3 instructed LPN #3 to take [MEDICATION NAME] from other unit. She stated that [MEDICATION NAME] is a multiple dose vial so it can be borrowed. RNS #3 stated that she sent an order for [REDACTED]. There was no documentation of [MEDICATION NAME] in the logbook. Physician #1 was interviewed on 11/19/10 at 2:00PM, 11/22/10 at 2:50PM and 11/23/10 at 1:48PM. Physician #1 stated that he was never informed that [MEDICATION NAME] was not being given to Resident #2. Physician #1 stated that if a resident is on [MEDICATION NAME], the blood sugar must be monitored at least twice a day for a week if new to the medication and then at least daily thereafter. He stated that it is considered a standard of care that if a nurse cannot administer a medication the physician must be informed. Resident #3 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The MDS 2.0 assessment dated [DATE] identified that the resident had long term memory impairments and considered to have modified independence in cognitive skills for daily decision making. The physician's orders [REDACTED]. The MAR indicated [REDACTED]. The nurse's notes on the back of the MAR indicated not given" because it was "not available." A nurse's note dated 10/18/10 at 4 PM documented that the resident's [MEDICATION NAME] eye drop was finished and an order was faxed to the pharmacy. The pharmacy could not supply the medication because it was before the reorder date, and the insurance will not pay until 10/21/10. A nurse's note dated 10/19/10 at 3 PM documented that the physician was notified that the [MEDICATION NAME] eye drops could not be supplied yet. The physician instructed to wait for the pharmacy to supply it on 10/21/10. A review of the Physician's Progress Notes prior to 10/19/10 did not reveal any indication that the Physician was informed of the missed medications. A review of the resident's progress notes did not reveal that the resident was assessed for adverse effects related to the missed doses of [MEDICATION NAME]. LPN #7 was interviewed on 11/26/10 at 1:45PM. LPN #7 stated that she became aware that the resident's [MEDICATION NAME] ran out on 10/19/10 when the resident reported to her that she missed 8 days of [MEDICATION NAME] in 10/2010. LPN #7 stated that she called the pharmacy in front of the resident to get a refill, but the pharmacy informed her that it could not be refilled because it was before the reorder date. LPN #7 stated that she notified the physician of the unavailable eye drops when she became aware of it. When asked about her circled initial on the MAR indicated [REDACTED]. RNS #7 was interviewed via telephone on 11/30/10 at 1:50PM. RNS #7 stated that she worked on the resident's unit on 3PM-11PM shift from 10/16-10/18/10. She stated that she was not aware that the resident did not receive her medication. Physician #2 was interviewed on 11/26/10 at 1:25 PM. Physician #2 stated that he was not notified of the unavailability of [MEDICATION NAME] until the resident missed 10 days of the eye drops. Physician #2 stated, "I was notified after the fact..." and that this "is not an appropriate action." He stated that he should have been notified immediately when the staff noticed that the medication was not available. Physician #2 stated that if he was notified right away, he would have contacted the ophthalmologist and discussed if an alternate medication can be given. Resident #4 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The MDS 2.0 assessment dated [DATE] documented that the resident had independent cognitive skills for daily decision making with no memory impairments. The Physician order [REDACTED]. The MAR indicated [REDACTED]. The nurse's notes on the back of the MAR indicated not given" because it was "not available." The other 8 missed doses are documented with circled initials with no explaination on the back of the MAR. A review of the Physician's Progress Notes during this time period did not reveal any indication that the Physician was informed of the missed medications. A review of the resident's progress notes did not reveal that the resident was assessed for adverse effects related to the missed doses of [MEDICATION NAME]. LPN #8 was interviewed on 11/29/10 at 11:00 PM. LPN #8 documented that the [MEDICATION NAME] was not available on 11/13/10. She stated that he does not remember anything about [MEDICATION NAME] not being available for Resident #4. Physician#2 was interviewed on 11/26/10 at 4:15 PM. Physician #2 stated that he was never notified of [MEDICATION NAME] not being available and that he was not aware that Resident #4 missed doses of [MEDICATION NAME] in 11/2010. He stated that he should have been notified as soon as the medication was missed. Resident #5 was readmitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A nurse's note dated 11/17/10 documented that the resident is oriented to person, but has little awareness to time and place. The resident requires limited assistance with all areas of Activities of Daily Living (ADL). The CCP for [MEDICAL CONDITION] Drug Use initiated 10/24/10 documented that the resident used Klonopin for agitation and behavior problem. The facility ' s interventions include administering medications as per physician order, providing ongoing assessment of behavior and need for continued treatment, and monitoring signs and symptoms of adverse reactions. The physician's orders [REDACTED]. The MAR indicated [REDACTED]. The nurse's notes on the back of the MAR indicated not given" because it was "not available." The MAR indicated [REDACTED]. The nurse's notes on the back of the MAR indicated not given" because it was "not available." A review of the resident's progress notes did not reveal that the resident was assessed for adverse effects related to the missed doses of Klonopin and/or [MEDICATION NAME]. RNS #3 was interviewed via telephone on 11/30/10 at 2:15PM. RNS #3 worked the 7AM-3PM shift on 11/18/10. RNS #3 stated that no one notified her that Resident #5 had not received Klonopin or [MEDICATION NAME] during the shift. Physician #1 was interviewed on 11/30/10 at 3 PM. Physician #1 stated that he was not aware that the resident had missed doses of Klonopin and [MEDICATION NAME] on 11/16/10-11/18/10. LPN # 4 was interviewed on 11/30/10 at 4 PM. LPN # 4 worked on 11/16/10 - 11/19/10 during the 11PM-7 AM shift. She stated that she did not administer Klonopin to Resident # 5 because it was not available. On 11/16/10 the nurse from the resident's previous unit gave her the resident's "old" Klonopin from a previous admission. LPN #4 signed for it, placed it in the cart's locked box, but did not administer it. She stated that she informed the supervisor that the medication was not available. The facility Policy and Procedure titled "Medications Preparation and Administration" was reviewed. The policy does not identify follow-up for missed doses or significant medication errors. On 11/23/10 at 11:30 AM an interview was conducted with the Acting Director of Nursing (DON). The DON was asked for a copy of a policy regarding missed doses of medication and staff responsibility regarding missed doses. The DON stated that she did not think there was a policy that described that process. The DON stated that if a medication is missed then the physician and pharmacy must be notified. 415.11 (c)(3)(i)

Based on staff interviews and record review during an abbreviated survey, the facility failed to ensure that residents received all physician ordered medication, failed to identify significant medication errors, failed to monitor residents for adverse reactions when significant medications were not administered and failed to notify the physician when significant medications were not administered. This was evidenced by 5 out of 10 sampled residents (Residents # 1, 2, 3, 4, 5). Specifically, Resident #1 was not administered 12 doses of [MEDICATION NAME] (a blood thinner) as ordered by a physician. Resident #2 was not administered 9 doses of [MEDICATION NAME] (insulin) as ordered by a physician. Resident #3 was not administered 16 doses of [MEDICATION NAME] (eye drops for [MEDICAL CONDITION]) as ordered by a physician. Resident # 4 was not administered 10 doses of [MEDICATION NAME] as ordered by a physician. Resident # 5 was not administered 4 doses of Klonopin (for anxiety) as ordered by a physician. This resulted in no actual harm with the potential for serious harm that is Immediate Jeopardy to resident health and safety and Substandard Quality of Care. See F 281 K Complaint ID # NY 289, NY 2982 The findings are: Resident #1 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment Version 3.0, dated 10/28/10 revealed that the resident is cognitively intact. The resident required one person, limited assistance with bed mobility, dressing and performing personal hygiene. All other Activities of Daily Living required supervision. A physician's orders [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There are three entries located on the back of the MAR indicated not available" or "unavailable." A review of the nursing notes during this time period did not reveal any further information pertaining to the missed medication. The MAR indicated [REDACTED]. The back of the MAR indicated [REDACTED]. A nursing note, dated 11/16/10 late entry for 11/12/10 documented hat the resident did not receive [MEDICATION NAME] due to unavailability on 11/12. The note was written by an LPN. A review of the nursing notes during this time period did not reveal any further information pertaining to the missed medication. A review of the resident's progress notes did not reveal that the resident was assessed for adverse effects related to the missed doses of [MEDICATION NAME]. There is also no documented evidence that a Medication Error report was completed for the missed does of [MEDICATION NAME]. Resident #1 was interviewed on 11/16/10 at 12:30 PM, the resident stated that he had not been receiving his [MEDICATION NAME] for the past 4-5 days. RN #1 was interviewed on 11/22/10 at 3:30PM. RN #1 stated that she worked the 3PM-11 PM shift on 11/13/10. She stated that the [MEDICATION NAME] was not available. RN #1 stated that she faxed over a request to the pharmacy, but she did not follow-up regarding the order. LPN #2 was interviewed on 11/22/10 at 11:00AM. LPN #2 stated that she worked on 11/10/10 during the 3PM-11 PM shift. She stated that the [MEDICATION NAME] medication was not available so it was not administered to the resident. LPN #2 stated that she was informed that they were waiting for the medication from the pharmacy. LPN #2 stated that she did not inform the physician or supervisor and she did not document the missed [MEDICATION NAME] in the progress notes or on the back of the MAR. LPN #3 was interviewed on 11/22/10 at 4:30PM. The LPN stated that she worked on 11/11/10-11/12/10 during the 3PM-11PM shift. LPN #3 stated that they did not have the [MEDICATION NAME] to administer to the resident. She called the pharmacy and left a message but did not notify anyone else at the facility. RN #2 was interviewed on 11/23/10 at 10:30AM. RN #2 stated she worked on 11/13/10 during 7AM-3 PM shift. She stated that the nurse informed her that the resident did not have any more [MEDICATION NAME]. RN #2 faxed a request to the pharmacy. She stated that she also worked on 11/14/10 as the RN on the unit, but that none of the nurses informed her that the medication had not arrived. When she worked on 11/15/10, she stated that she administered medications. She stated that there was no [MEDICATION NAME] for Resident #1 on 11/15/10. She stated that she did not inform the physician on any of the days she had worked. Physician #1 was interviewed on 11/19/10 at 2:00PM and on 11/25/10 at 11:30 AM. The Physician stated that he was not aware that the resident had not received [MEDICATION NAME]. Resident #2 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The MDS 3.0 assessment dated [DATE] documented that the resident was cognitively intact. The Comprehensive Care Plan (CCP) implemented on 11/03/2010 documented that the resident has a [DIAGNOSES REDACTED]. physician's orders [REDACTED]. The MAR indicated [REDACTED]. A nurse's note dated 11/20/10 at 5:30 PM documented that [MEDICATION NAME] was ordered from the pharmacy. The Pharmacist stated that medication will arrive by next day. RN #3 was interviewed on 11/23/2010 at 2:20PM. RN #3 stated that [MEDICATION NAME] was not available on 11/15/10. She faxed the order to the pharmacy and informed the evening shift. RN # 3 stated that no one reported to her that the [MEDICATION NAME] did not arrive from the pharmacy. LPN #5 was interviewed on 11/22/10 at 10:20 AM. LPN # 5 worked on 11/20/10 during the 7AM-3 PM shift. LPN #5 stated that the [MEDICATION NAME] was missed because it was not available. She stated that it was a very hectic day and she was not able to tell the RNS that the [MEDICATION NAME] was not given until around 2:00 PM. LPN #3 was interviewed on 11/23/10 at 4:50 PM. LPN #3 stated that she noticed that the [MEDICATION NAME] was not there so she informed the RNS #3. LPN #3 was able to administer the [MEDICATION NAME] because she borrowed from another unit, as instructed by the RNS #3. LPN #3 stated that she called the pharmacy but the pharmacy staff said that the [MEDICATION NAME] was not due for reorder yet. RNS #3 was interviewed on 11/23/10 at 4:30 PM. She stated that LPN #3 came downstairs to inform her that Resident #2's [MEDICATION NAME] was not available. RNS #3 instructed LPN #3 to take [MEDICATION NAME] from another unit. She stated that [MEDICATION NAME] is a multiple dose vial so it can be borrowed. RNS #3 stated that she sent an order for [REDACTED]. There was no documentation of [MEDICATION NAME] in the logbook. Physician #1 was interviewed on 11/23/10 at 11:30AM. Physician #1 stated that he was never informed that the resident missed doses of [MEDICATION NAME]. Resident #3 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 2.0 assessment dated [DATE] identified that the resident had long term memory impairments and considered to have modified independence in cognitive skills for daily decision making. The physician's orders [REDACTED]. The MAR indicated [REDACTED]. The nurse ' s notes on the back of the MAR indicated not given" because it was "not available." A nurse's note dated 10/18/10 at 4 PM documented that the resident's [MEDICATION NAME] eye drop was finished and an order was faxed to the pharmacy. The pharmacy could not supply the medication because it was before the reorder date, and the insurance will not pay until 10/21/10. A nurse's note dated 10/19/10 at 3 PM documented that the physician was notified that the [MEDICATION NAME] eye drops could not be supplied yet. The physician instructed the nurse to wait for the pharmacy to supply it on 10/21/10. LPN #7 was interviewed on 11/26/10 at 1:45PM. LPN #7 stated that she became aware that the resident's [MEDICATION NAME] ran out on 10/19/10 when the resident reported to her that she missed 8 days of [MEDICATION NAME] in 10/2010. LPN #7 stated that she called the pharmacy in front of the resident to get a refill, but the pharmacy informed her that it could not be refilled because it was before the reorder date. LPN #7 stated that she notified the physician of the unavailable eye drops when she became aware of it. When asked about her circled initial on the MAR indicated [REDACTED]. RNS #7 was interviewed via telephone on 11/30/10 at 1:50PM. RNS #7 confirmed that she worked on the resident's unit on 3-11PM shift from 10/16-10/18/10. RNS #7 stated that she was not aware that the resident did not receive her medication. Physician #2 was interviewed on 11/26/10 at 1:25 PM. The Physician stated that he was not notified of the unavailability of [MEDICATION NAME] until the resident missed 10 days of the eye drops. He stated that "I was notified after the fact..." and that this "is not an appropriate action." The Physician stated that he should have been notified immediately when the staff noticed that the medication was not available. Resident #4 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The MDS 2.0 assessment dated [DATE] documented that the resident had independent cognitive skills for daily decision making with no memory impairments. The physician's orders [REDACTED]. The MAR indicated [REDACTED]. The nurse ' s notes on the back of the MAR indicated not given" because it was "not available." LPN #8 was interviewed on 11/29/10 at 11:00 PM. The LPN, who documented that the [MEDICATION NAME] was not available on 11/13/10, stated that he does not remember anything about [MEDICATION NAME] not being available for Resident #4. Physician #2 was interviewed on 11/26/10 at 4:15 PM. Physician #2 stated that he was never notified of [MEDICATION NAME] not being available and that he was not aware that Resident #4 missed doses of [MEDICATION NAME] in 11/2010. Resident #5 was readmitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A nurse's note dated 11/17/10 documented that the resident is oriented to person, but has little awareness to time and place. The resident requires limited assistance with all areas of Activities of Daily Living (ADL). The CCP for [MEDICAL CONDITION] Drug Use initiated 10/24/10 documented that the resident used Klonopin for agitation and behavior problem. The facility's interventions include administering medications as per physician's orders [REDACTED]. The physician's orders [REDACTED]. The MAR indicated [REDACTED]. The nurse ' s notes on the back of the MAR indicated not given" because it was "not available." The MAR indicated [REDACTED]. The nurse's notes on the back of the MAR indicated not given" because it was "not available." RNS #3 was interviewed via telephone on 11/30/10 at 2:15PM. RNS #3 worked the 7AM-3PM shift on 11/18/10. RNS #3 stated that no one notified her that Resident #5 had not received Klonopin or [MEDICATION NAME] during the shift. Physician #1 was interviewed on 11/30/10 at 3 PM. Physician #1 stated that he was not aware that the resident had missed doses of Klonopin and [MEDICATION NAME] on 11/16/10-11/18/10. LPN # 4 was interviewed on 11/30/10 at 4 PM. LPN # 4 worked on 11/16/10 - 11/19/10 during the 11PM-7 AM shift. She stated that she did not administer Klonopin to Resident # 5 because it was not available. On 11/16/10 the nurse from the resident's previous unit gave her the resident's "old" Klonopin from a previous admission. She signed for it, placed it in the cart's locked box, but did not administer it. She stated that she informed the supervisor that the medication was not available. The facility Policy and Procedure titled "Medications Preparation and Administration" was reviewed. The policy does not identify follow-up for missed doses or significant medication errors. The Acting Director of Nursing (DON) was interviewed on 11/23/10 at 11:30 AM. The DON was asked for a copy of a policy regarding missed doses of medication and staff responsibility regarding missed doses. The DON stated that she did not think there was a policy that described that process. She stated that staff are encouraged to review their own MARs for completeness and there are no documented routine checks or QA of medication administration. The DON stated that if a medication is missed then the physician and pharmacy must be notified. The DON stated that the missed medications for Resident #1 and Resident #2 are considered medication errors, but that she did not complete any of the medication error paperwork. 415.12(m) (2)

Based on interviews and record review the Administrator failed to ensure that the facility operated in a manner in which nursing professional standards of practice for medication administration were met. The Administrator failed to have systems in place to ensure that residents were free from significant medication errors, that residents received medications according to physician's orders [REDACTED]. This was evidenced in 5 of 10 sampled residents (Resident #1, 2, 3, 4, and 5). This resulted in no actual harm with the potential for serious harm that is Immediate Jeopardy to resident health and safety. See F281 K and F333 K Complaint ID # NY 289, NY 2982 The findings are: The facility Policy and Procedure titled "Medications Preparation and Administration" was reviewed. The policy does not identify follow-up for missed doses or significant medication errors. An interview was conducted with the Administrator on 11/23/10 at 2:50 PM. The Administrator was asked about the facility ' s policy and procedure regarding when a resident misses a medication. The Administrator stated that the nursing staff should inform the physician right away and call the pharmacy to inquire about the medication. The Administrator stated that the facility policy should provide the nursing staff with the steps to take if a medication is missed. An interview was conducted with the Acting Director of Nursing (DON) on 11/23/10 at 11:30 AM. The DON was asked for a copy of a policy regarding missed doses of medication and staff responsibility regarding missed doses. The DON stated that she did not think there was a policy that described that process. She stated that staff are encouraged to review their own MARs for completeness and there are no documented routine checks or QA (Quality Assurance) of medication administration. The DON stated that if a medication is missed then the physician and pharmacy must be notified. The DON stated that the facility policy is for the medication nurses to follow up with the MD and Pharmacy. An interview with Assistant Administrator (AA) #1 was conducted on 11/24/10 at 10:30AM. AA #1 stated that the recent missed medications resulted from a breakdown in communication among the nursing staff and the pharmacy. The AA stated that it is not clear who is responsible on the unit to take initiative and follow-up when a resident misses a dose of medication. The AA stated that the facility policy states that it is the responsibility of the unit charge nurse on the unit to follow up with the RN Supervisor and the Pharmacy. 415.26