Every finding on record at Daleview Care Center

Based on observations, record review, and interviews during survey the facility failed to ensure that pain management was provided to each resident consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. This was identified for one (Resident #148) of one resident reviewed for pain management. Specifically, Resident #148 was admitted to the facility with chronic bilateral elbow pain; however, there was no pain medication ordered. In addition, when the resident reported sever pain rating of 8 out of a scale of 0-10 (a scale used to measure pain intensity, where 0 equals no pain and 10 represents the worst imaginable pain) to a Registered Nurse Supervisor, the resident did not receive pain medication for more than two hours.The findings include:The facility policy titled Pain Assessment, dated September 2025, documented pain is difficult to define because of multidimensional aspects. All residents admitted for care management will be assessed for pain. This assessment is done on admission, readmission, quarterly, annually, and with any significant change in the resident's condition. The physician and licensed nurse assess for pain management; the physician prescribes appropriate medications and dosage; the physician/licensed nurse review medication regimen, monitor increase/decrease and change in medication; and the licensed nurse assesses the medications for effectiveness in management of pain, dosage, and administration intervals.Resident #148 was admitted with diagnoses including cerebrovascular accident, Parkinson's disease, and radiculopathy lumbar region (a condition caused by compression or irritation of spinal nerve roots in the lower back, leading to radiating pain, numbness, or weakness in the legs). The 05/03/2026 Minimum Data Set assessment documented a Brief Interview for Mental Status score of 9, indicating the resident had moderate cognitive impairment; and there was no pain indicated.A Comprehensive Care Plan effective 04/29/2026 titled Pain Management, documented Alteration in comfort: pain related to (undefined); interventions included administering medications as ordered by physician and discuss with resident pain management. There were no further updates or notes.The Nursing admission assessment dated [DATE] documented that the resident had mild joint pain with activities and exhibited facial grimaces; the pain was described as a dull ache with grimacing and verbal complaints; the pain intensity was one (1) out of a scale of five (5), indicating mild pain.The Physician History and Physical dated 04/28/2026 documented no pain related to a surgical site; there was no line item related to pain at a non-surgical site.An Occupational Therapy assessment dated [DATE] documented the resident had pain that interfered with functional activity to bilateral elbows and right knee; nursing was made aware.A review of the medical record revealed no documented assessment of the pain identified by Occupational Therapy.The physician orders dated 04/29/2026 documented cleanse right and left elbows with normal saline, apply skin prep, and cover with dry dressing for Stage 1 pressure ulcers.A review of the medical record revealed that there was no pain medication ordered upon the resident's admission on [DATE] until 05/05/2026. During an observation on 05/05/2026 at 8:45 AM, Resident #148 was in bed. Registered Nurse Supervisor #5 was present at the bedside. The resident was complaining of pain in both elbows. The resident did not have the ordered dressings on the elbows. The resident stated the pain was 8 (severe) out of a scale of 10 when asked by the nurse to rate the pain. Registered Nurse Supervisor #5 stated they would call the physician regarding a pain medication. Registered Nurse Supervisor #5 did not address the missing dressings on the elbows, how long the resident has had pain, was there any incident that caused the pain, or what makes it feel better or worse, and the type of pain.During an observation on 05/05/2026 at 10:47 AM, Resident #148 was in their room in a wheelchair. The resident stated they still have pain in their elbows; it feels like when you hit your funny bone, but all the time, both elbows, There was no dressing present on either elbow.During an interview on 05/05/2026 at 10:52 AM Registered Nurse Supervisor #5 stated the resident did not have an order for the pain medication; but the physician assistant was alerted, and they are waiting for them to assess the resident. Pain medication was not given right away because the physician assistant wanted to see the resident first because this was a new pain complaint.A physician's order dated 05/05/2026 at 11:30 AM documented Tylenol 325 milligram tablet, give two tablets (650 milligram) by oral route now for one dose. The Tylenol was administered to Resident #148 at 11:18 AM on 05/05/2026, after approximately two hours after the resident had complaint of pain level of 8 out of 10 on the pain scale indicating severe pain.A progress note written by Physician Assistant #3 on 05/05/2026 at 8:35 PM documented patient was seen today for chronic bilateral upper extremity pain. The resident reported persistent nagging pain in bilateral elbows and shoulders since a fall several months ago. The pain level was rated to be 4 out of 10 on the pain scale. There were no signs of associated swelling, redness, or skin changes. The Plan: Chronic bilateral upper extremity pain, likely musculoskeletal in nature given the chronicity and absence of any acute findings. There were no signs of an acute injury or inflammation upon examination. Initiate intravenous acetaminophen (Tylenol) 1,000 milligram every 8 hours for improved pain control. Monitor response to therapy. Consider further evaluation if pain persists or worsens.A physician's order dated 05/05/2026 documented Ofirmev 1,000 milligrams/100 milliliter (acetaminophen) intravenous solution, infuse 100 milliliters (1,000 milligrams) by intravenous route three times a day for five days.During an interview on 05/07/2026 at 9:36 AM, Physician Assistant #3 stated Registered Nurse Supervisor #5 called them about Resident #148's elbow pain. Physician Assistant #3 stated they directed the nurse to give oral Tylenol until they saw the resident. Physician Assistant #3 stated they saw the resident at about 10:30 AM-11:00 AM on 05/05/2026. The resident reported a nagging pain in both elbows for quite a long time and intravenous acetaminophen was ordered as it provides much better pain control than the oral Tylenol.During an interview on 05/07/2026 at 10:24 AM, the Director of Nursing Services stated if a resident has pain, something should be done immediately for the pain. The nurse should get a STAT (immediate) order for pain medication until the doctor can see the resident.During an interview on 05/07/2026 at 10:51 AM, Registered Nurse #8 (the admission nurse) stated they completed the admission assessment for Resident #148, and a pain medication should have been ordered because the resident did complain of pain upon admission and were not sure why the pain medications were not ordered. Registered Nurse #8 stated they think another nurse (could not recall name) was handling the medication orders as part of the admission process.During an interview on 05/07/2026 at 11:05 AM, Occupational Therapist #1 stated they conducted the initial occupational therapy assessment for Resident #148 on 04/29/2026 and the resident did complain of pain during the assessment. Occupational Therapist #1 stated they notified the nursing staff about the resident's pain but were unable to recall who they had notified. During an interview on 05/07/2026 at 11:32 AM, Physician #2 stated they were not sure if the nurses had notified them about Resident #148's complaint of pain. If they were notified, they would have ordered the as needed Tylenol for pain control. A resident with pain level of 8 out of 10 on the pain scale should be medicated with pain medication as soon as possible. 10 New York Code Rules and Regulations 415.12

Based on observations, record review, and interviews during the survey, the facility failed to ensure it maintained an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infections. This was identified for one (Resident #43) of two residents reviewed for skin conditions and for one (1) (Unit 2 medication cart) of three (3) medication carts reviewed during the medication storage and labeling task. Specifically, 1) during the wound care observation for Resident #43, Licensed Practical Nurse #6 did not sanitize the overbed table before placing the wound care supplies on top of the table. Additionally, Licensed Practical Nurse #6 did not sanitize their hands after removing the dirty dressings from the foot wounds and prior to applying the clean treatments. 2) Licensed Practical Nurse #1 did not use an Environmental Protection Agency (EPA) approved cleaning agent to sanitize the glucometer (a handheld device used to measure the concentration of sugars in the blood) machine after using the machine for each resident.The findings include: The facility policy titled Rehabilitation Nursing: Dressing-Non-Sterile, dated 12/12/2025, documented nursing staff will use a clean dressing technique to apply dressings which will provide a therapeutic environment for wounds that do not require sterile handling. Steps in the process for the licensed nurse include preparing a clean field and preparing necessary equipment that will be needed for dressing change using aseptic (to prevent contamination and the spread of pathogens) technique; washing hands, putting on gloves, removing old dressings, disposing old dressings in garbage, removing gloves and washing hands; placing clean gloves on, cleansing the wound, and then discarding gloves and washing hands before putting on new gloves and applying the ordered treatment. The facility policy and procedure titled, Blood Glucose Measurement Using a Glucose Testing System last revised on 12/01/2025 documented that Licensed Nursing staff may perform a measurement of the resident's blood glucose using a Glucose Testing system that includes glucose test strips, lancets, alcohol swab, germicidal wipes, gloves, and sharp container with instruction to clean and disinfect the Blood Glucose Machine with a germicidal wipes. 1) Resident #43 was admitted with diagnoses including diabetes mellitus, peripheral vascular disease, and cerebrovascular accident. The 04/16/2026 admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 10, indicating the resident had moderate cognitive impairment, and the resident had diabetic ulcers. A Comprehensive Care Plan effective 04/13/2026 titled Skin Integrity: Presence of Skin Breakdown Right Heel Diabetic Foot Ulcer; interventions included to monitor signs and symptoms of infection and apply local treatments as ordered by the physician. A Comprehensive Care Plan effective 04/13/2026 titled Skin Integrity, Presence of Skin Breakdown, left 5th tow diabetic foot ulcer. Interventions included to monitor signs and symptoms of infection and apply local treatments as ordered by the physician. A physician's order dated 04/13/2026 documented cleanse left 5th toe diabetic foot ulcer with normal saline, apply betadine, cover with dry dressing. A physician's order dated 04/27/2026 documented right heel diabetic foot ulcer, cleanse with normal saline, apply skin prep, and cover with dry dressing. A wound consultation dated 04/27/2026 documented the right heel diabetic foot ulcer was resolved. The area remains tender. Cleanse with normal saline apply skin prep and cover with dry dressing. Left 5th toe diabetic foot ulcer, 0.4 centimeters by 0.4 centimeters by 0.1 centimeters; cleanse with normal saline, apply betadine, and cover with dry dressing. The resident remains at increased risk for wound deterioration due to immobility and underlying medical comorbidities. Comprehensive wound care plan implemented offloading, protective measures, and close monitoring for progression or infection. During Resident #43's wound care treatment observation, performed by Licensed Practical Nurse #6 on 05/06/2026 at 11:05 AM, Licensed Practical Nurse #6 set up the wound care supplies in the resident's room on the resident's overbed table by placing the supplies on a small paper towel. Some of the supplies did not fit on the paper towel and were directly touching the table. The nurse did not clean the table or set up a clean field that covered the table. Adjacent to the wound care supplies there was a television remote control and a compression knee sleeve on the table. Licensed Practical Nurse #6 set up a barrier under the resident's feet and then removed the right heel dressing and left toe dressings. The resident then rested their feet on the barrier; after removing the dressings, the nurse put on clean gloves but did not wash hands. Licensed Practical Nurse #6 cleansed the right heel with normal saline and then the resident's heel came to rest on the barrier. The nurse then applied the skin prep and the dry dressing to the heel wound without changing gloves or sanitizing their hands. Licensed Practical Nurse #6 stated they should have set up a clean field on the overbed table before placing the wound care supplies on top of the table and would get another staff member to assist them with the wound care and would restart the wound care. During an interview on 05/07/2026 at 8:02 AM, Registered Nurse #6 (the wound care nurse) stated the nurses should change gloves and wash hands after cleaning the wound; should have cleaned the overbed table to prepare a clean field. Registered Nurse #6 stated that Licensed practical Nuse #6 should have gotten assistance when performing the wound care. During an interview on 05/07/2026 at 8:18 AM, the Nursing Educator stated when performing wound care the nurses need to set up a clean field because the table may not be clean and a dirty table compromises the cleanliness of the supplies and increases the potential for infection. The nurses must sanitize hands and change gloves after each step of the wound care process During an interview on 05/07/2026 at 8:30 AM, the Infection Preventionist/Assistant Director of Nursing stated the nurses cannot wash their hands enough; the table should be sanitized with a barrier; after cleansing a wound and removing old dressings, the nurse must change gloves and wash hands before applying the new dressing/treatment. During an interview on 05/07/2026 at 10:19 AM, the Director of Nursing Services stated the nurses must sanitize hands and change gloves after each step of the wound care treatment process; and they must sanitize the overbed table and set up a clean field for wound care supplies. 2)A review of the blood glucose machine cleaning and disinfecting manual documented the meter should be cleaned and disinfected after use on each resident. The disinfection procedure is needed to prevent the transmission of blood-borne pathogens. A variety of the most used Environmental Protection Agency (EPA) registered wipes were tested and approved for cleaning and disinfecting the blood glucose monitoring system. A review of the facility's Material Safety Data Sheet (MSDS) for Instant Hand Sanitizing wipes revealed that the product cleanses and sanitizes hands. Instant Hand Sanitizing wipes is a flammable solid and can cause serious eye damage. A review of the facility's Material Safety Data Sheet (MSDS) for alcohol prep pads revealed that the product contains 70 percent isopropyl alcohol (a colorless, flammable, chemical compound used as disinfectant). The alcohol prep pads are for antiseptic purposes and used for preparation of skin prior to injection. A review of the facility's Material Safety Data Sheet (MSDS) for Germicidal wipes revealed that the product is used as a disinfectant for hard, non-porous surfaces (substances or areas that do not allow liquids, air, or bacteria to pass through or be absorbed because they lack pores). During an observation for the medication storage and labeling task on 05/04/2026 at 1:07 PM, Licensed Practical Nurse #1 stated they use the alcohol prep pads to wipe the glucometer machine between each resident. Licensed Practical Nurse #1 stated they also use the instant hand sanitizing wipes after wiping the glucometer machine with the alcohol prep pad. Licensed Practical Nurse #1 demonstrated how they clean the glucometer using two alcohol prep pad and instant hand sanitizing wipes. During an interview on 05/04/2026 at 1:12 PM, Licensed Practical Nurse #1, Medication Nurse stated that the alcohol prep pads, and the instant hand wipes were readily available on their cart to clean the glucometer. Licensed Practical Nurse #1 stated that the nurses were not allowed to keep the Environmental Protection Agency (EPA) approved germicidal wipes with the purple top on their medication carts. Licensed Practical Nurse #1 stated that the Environmental Protection Agency (EPA) approved germicidal wipes are kept at the nurses' station. Licensed Practical Nurse #1 stated that the glucometer test strips used for collecting blood on the machine use only a small amount of blood and the blood do not even touch the glucometer machine. Licensed Practical Nurse#1 stated they thought using the alcohol prep pads and the instant hand wipes was sufficient to clean the glucometer. During an interview on 05/04/2026 at 2:01 PM, Registered Nurse #1, the unit manager, stated that glucometer machine should be cleaned with an Environmental Protection Agency (EPA) approved germicidal wipes after each resident use. Registered Nurse#1 stated that Licensed Practical Nurse #1 should have cleansed the glucometer with the Environmental Protection Agency (EPA) approved germicidal wipes and not the alcohol pads and hand wipes. During an interview on 05/05/2026 at 8:50 AM, the Nursing Educator stated that Licensed Practical Nurse #1 should not have used the alcohol prep pads and hand wipes to clean the glucometer machine. The Nursing Educator stated that alcohol prep pads and handwipes are not effective cleaning agents for glucometers. The Nursing Educator stated that the facility protocol for cleaning the glucometer is with the Environmental Protection Agency (EPA) approved germicidal wipes to eliminate any blood borne pathogen. During an interview on 05/05/2026 at 11:26 AM, the Infection Preventionist stated that the facility uses the Environmental Protection Agency (EPA) approved germicidal wipes to clean the glucometers. The Infection Preventionist stated that the Environmental Protection Agency (EPA) approved germicidal wipes are accessible to all nurses and are kept on the nurses' station only medications should be stored in the medication carts. The Environmental Protection Agency (EPA) approved germicidal wipes are considered cleaning agents and not medications. During an interview on 05/07/2026 at 9:56 AM, the Director of Nursing Services stated that the glucometer machine must be cleaned with the Environmental Protection Agency (EPA) approved germicidal wipes, after each resident use. The Director of Nursing Services stated that it is not appropriate that Licensed Practical Nurse #1 used alcohol prep pads and hand wipes to clean the glucometer machine. The Director of Nursing Services stated that the facility was guided by their pharmacy consultant that Environmental Protection Agency (EPA) approved germicidal wipes should not be kept in the medication cart due to possible spillage and contact with other medications. 10 New York Code Rules Regulations 415.19(a) (1-3)

Based on observations, interviews, and record review during the survey, the facility failed to maintain medical records that are complete and accurately documented. This was identified for one (1) (Resident #28) of three (3) residents reviewed for catheter. Specifically, Resident #28's contact precautions were discontinued on 04/21/2026; however, the resident's medical record was not updated to reflect discontinuation of the contact precautions in Resident #28's electronic medical record (EMR).The findings include: The facility's policy titled Charting and Documentation dated 09/2025 documented all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Resident #28 was admitted with diagnoses including neurogenic bladder (disrupts communication between the brain and bladder causing poor bladder control), diabetes (high blood sugar), and hemiplegia (total or partial loss of movement on one side of the body). A significant change in status Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated that Resident #28 had intact cognition. The Minimum Data Set (MDS) documented that Resident #28 had an indwelling catheter (a flexible tube inserted into the bladder to drain urine) and was on isolation or quarantine for active infectious disease while a resident. A Comprehensive Care Plan (CCP) titled, Contact Isolation Precautions dated 03/12/2026 documented interventions including maintaining contact isolation, applying contact isolation equipment upon entry to the room and discussing with the resident and the resident's family the importance of handwashing. A Physician's Order dated 03/21/2026 renewed on 04/27/2026 documented Contact Isolation for Vancomycin-Resistant Enterococci (bacteria that developed resistance to vancomycin, an antibiotic to treat infection), Klebsiella (bacteria found in human intestines and environment transmitted through person-to-person contact) and Pseudomonas (a highly resistive bacteria to many antibiotics) in the wound. During an observation on 05/04/2026 at 10:20 AM, Resident #28 was in their room lying in bed. An Enhanced Barrier Precaution (EBP) signage was posted outside Resident #28's door. Resident #28 did not have a contact isolation signage outside their door. During an observation on 05/04/2026 at 1:23 PM, Resident #28 was in their room lying in bed. An Enhanced Barrier Precaution signage was posted outside the door. Resident #28 did not have contact signage outside the door. During an observation on 05/05/2026 at 8:05 AM, Resident #28 was in their room. An Enhanced Barrier Precaution signage was posted outside the door. Resident #28 did not have contact signage outside the door. During an interview on 05/05/2026 at 11:26 AM, the Infection Preventionist stated that Resident #28 should have a signage for contact isolation precautions outside their (Resident #28) room. The Infection Preventionist stated that there are wandering residents who must have taken the signage down. A review of Resident #28's medical progress note dated 04/21/2026 did not document to discontinue the contact isolation precautions for Resident #28. A review of Resident #28's Electronic Medical Record revealed no documented evidence that the contact isolation was discontinued until 05/05/2026. During an interview on 05/06/2026 at 8:52 AM, Registered Nurse #1, Unit Manager stated that Resident #28's contact isolation precautions order was discontinued on 04/21/2026 when Physician Assistant#1 discontinued the intravenous antibiotic for Resident #28. Registered Nurse #1 stated that they received a verbal order from Physician Assistant #1 to discontinue the contact isolation precautions. Registered Nurse #1 stated that they took down the signage but forgot to discontinue the order, notify the infection preventionist, and write a nursing progress note. During an interview on 05/06/2026 at 9:30 AM, Physician Assistant #1 stated that they discontinued the intravenous antibiotic order on 04/21/2026 for Resident #28 and told Registered Nurse #1 to discontinue the contact isolation precautions order for Resident #28. Physician Assistant #1 stated they should have documented in the medical progress note and should have written an order to discontinue the contact isolation precautions for Resident #28. During an interview on 05/07/2026 at 10:08 AM, the Director of Nursing Services stated that nurses can take verbal orders, but they are expected to document and update any changes in the medical record. 10 New York Code Rules and Regulations 415.22(a) (1-4)

Based on observations, record review and staff interviews, the facility failed to ensure that all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles. This was identified for one (1) (unit 3) of three (3) units observed during the initial tour and for one (1) (medication cart for Unit 2) of three (3) medication carts reviewed during the medication storage and labeling task. Specifically, 1) Unit Three (3) shower room had unlabeled cream on the ledge in the shower room. 2) Unit Two (2) medication cart was observed with an insulin pen, and an eye drop bottle without a date to indicate when the medications were first opened to determine when the medications should be discarded.The findings include:The facility policy and procedure titled, Medications: Storage and Handling last revised on 12/12/2025 documented that medications and biologicals are stored in locked compartments under proper temperature controls and only authorized personnel have access to the keys. Medications and biologicals past their expiration dates are removed from storage and usage and properly disposed of after such date.1) During an observation on 05/04/2026 at 10:46 AM, an unlabeled open tube of one (1) percent Hydrocortisone cream (a topical steroid), was observed in the Unit three (3) shower room.During an interview on 05/04/2026 at 10:35 AM, Licensed Practical Nurse #4, the charge nurse stated that no medication should be left in the shower rooms. Licensed Practical Nurse #4 stated they did not know who had left the unlabeled Hydrocortisone (topical steroid) one (1) percent tube in the shower room. Licensed Practical Nurse #4 stated that medications including the treatment creams should be stored in the medication or treatment carts.2) During an observation on Unit two (2) on 05/04/2026 at 1:12 PM, the medication cart was observed with an undated, opened Lantus Solostar insulin pen (a long-acting insulin medication used to control high blood sugars in adults and children with diabetes) and a bottle of an undated, opened latanoprost solution eye drops (a prescription medication used to reduce high pressure inside the eye).During an interview on 05/04/2026 at 1:16 PM, Licensed Practical Nurse #1, the medication nurse, stated they were not aware of the Lantus insulin pen and latanoprost eye drops were missing the opened date. Licensed Practical Nurse #1 stated that both the medications were administered during the 3:00 PM-11:00 PM shift. Licensed Practical Nurse #1 stated that the opened date should have been written on the insulin pen and the eye drop bottle to determine when the medications should be discarded. Licensed Practical Nurse #1stated they were not sure after how many days the insulin pen or the eye drop medication be discarded after the first opened date.During an interview on 05/04/2026 at 2:01 PM, Registered Nurse #1, the unit manager stated that to identify the discard date, the Lantus insulin pen and latanoprost eye drops should have been labeled with an opened date indicating when the medications were first opened. Registered Nurse #1 stated the insulin must be discarded 28 days after the opened date.During an interview on 05/05/2026 at 10:25 AM, the Pharmacist stated that the Lantus insulin pen must be discarded 28 days after opening. The Pharmacist stated that the Latanoprost eye drops must be discarded 42 days after opening. The Pharmacist stated that the medications should be discarded after the expiration date.During an interview on 05/06/2026 at 9:40 AM, Licensed Practical Nurse #3, Medication Nurse for 3:00-11:00 PM stated that they could not recall how they missed the Lantus insulin pen and latanoprost not having an opening date. Licensed Practical Nurse #3 stated that they are aware that Lantus insulin pen should be discarded 28 days after it is first opened. Licensed Practical Nurse #3 stated they were not aware that the latanoprost eye drops had an expiration day after the medication bottle was first opened.During an interview on 05/07/2026 at 10:14 AM, the Director of Nursing Services stated that nurses should always document the opened date on medication bottles or pens that have a certain expiration date including insulins and eye drops. The Director of Nursing Services stated that all medications should be properly labeled and locked in the medication or treatment carts.10NYCRR 415.18(e) (1-4)

Based on observation, record review and interviews during the survey the facility failed to ensure it provided pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for one (Resident #146) of five (5) residents observed during the medication administration task. Specifically, during the medication administration observation for Resident#146, Licensed Practical Nurse #5 crushed an extended-release (designed to slowly release the medication) potassium chloride tablet. The blister pack for the extended-release potassium chloride tablet had a direction sticker that read do not crush.The findings include:The facility policy titled Medication Administration: General Policies and Practices, dated 12/01/2025, documented prior to administering medications, the staff nurse: reads the order carefully in its entirety, noting the name, dosage, route, and time of administration, making certain the dosages, frequency and schedules correspond with the physician's orders in the electronic medical record; reads the label before removing medication from the cart, before pouring the medication, and before placing the medication back in the drawer; reviews the electronic medication administration record for accuracy after medications have been prepared; and carefully checks the accuracy of the resident's screen.Resident # 146 was admitted with diagnoses including cancer, diabetes mellitus, and osteomyelitis (bone infection). The 05/06/2026 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 13, indicating the resident was cognitively intact.A physician's order dated 04/30/2026 documented may crush appropriate medications, unless contraindicated, to facilitate administration.A physician's order dated 04/30/2026 documented potassium chloride extended release, 10 milliequivalent tablet, give one tablet by oral route once daily at 9:00 AM, for a diagnosis of hypokalemia (low potassium).During the medication administration observation for Resident#146 on 05/05/2026 at 8:17 AM, Licensed Practical Nurse #5 crushed the extended-release potassium-chloride tablet, mixed the medication in apple sauce, and administered the medication to the resident.During an interview on 05/05/2026 at 9:45 AM, Licensed Practical Nurse #5 and the surveyor observed the potassium chloride blister pack. The label documented: give tablet by oral route once daily, do not crush, whole tablet may be dissolved in four ounces of water prior to administration (allow two minutes to dissolve). There was an additional yellow sticker placed on the blister pack documenting Do Not Crush. Licensed Practical Nurse #5 stated they did not realize the medication label documented that the medication should not be crushed and that they should not have crushed the medication tablet.During an interview on 05/05/2026 at 11:45 AM, Pharmacist #1 stated the extended-release potassium chloride tablet was created to reduce the potential for gastrointestinal pain because with potassium chloride there is the potential for gut lining irritation; therefore, the extended-release potassium chloride tablets should not be crushed.During an interview on 05/06/2026 at 8:45 AM, Nursing Educator #1 stated the nurse should never crush an extended-release medication; this is part of the seven rights of medication administration (right medication, right resident, right dose, right time, right route, right reason, right documentation).During an interview on 05/07/2026 at 10:08 AM, the Director of Nursing Services stated the nurse must read the label on the blister pack prior to medication administration and follow the facility policy to appropriately and safely administer medications to the residents.10 New York Code Rules and Regulation 415.18(b)(1)(2)(3)

Based on observations, record review and staff interviews during survey, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team to reflect each resident's preferences and status after each assessment. This was identified for one (1) (Resident #117) of three (3) residents reviewed for skin conditions. Specifically, Resident # 117 had a physician order for compression socks for both legs in the morning and remove at bedtime. Resident #117's care plan did not include the use of ace bandage (an elastic compression wraps designed to reduce swelling) on both legs during the day and remove at night for chronic venous insufficiency (a condition when the leg vein valves are damaged or weakened).The findings include:The facility's policy and procedure titled, Care Plans last revised on 12/2025 documented that all residents will have a plan of care review initially and then no less than every 90 days. Problem statements, goals and interventions will be reviewed, discussed and dated at the time with revisions made as necessary. Criteria for determining a change in status once identified should be reviewed prior to changing the status assessment. Consideration of a change in status should be documented in the residents' record with decision making rationale included.Resident #117 was admitted with diagnoses including, cellulitis (a bacterial infection characterized by swollen, red, hot and painful skin), diabetes (high blood sugar levels) and chronic venous insufficiency (a condition when the leg vein valves are damaged or weakened). The Annual Minimum Data Set (MDS) assessment dated [DATE] documented Resident #117 had a Brief Interview for Mental Status (BIMS) score of five (5) which indicated that Resident #117 had severe cognitive impairment. The Annual Minimum Data Set documented an active diagnosis of peripheral vascular disease.A Comprehensive Care Plan (CCP) titled, Skin Integrity: Presence of Skin Breakdown Left lower leg dated 01/07/2026 documented interventions including applying local treatment as ordered by the Physician and monitoring for signs and symptoms of infection.A Physician's Order dated 04/06/2026 documented the use of compression socks in both legs in the morning and remove at bedtime.A review of the electronic medical record revealed that the comprehensive care plan was not revised to indicate the use of the compression socks as per the physician's orders.During an observation on 05/04/2026 at 10:28 AM, Resident #117 was in their room sitting on their wheelchair with ace wraps on both the lower extremities.During an observation on 05/05/2026 at 8:15 AM, Resident #117 was sitting in their wheelchair with ace wraps on both the lower extremities.During an interview on 05/06/2026 at 8:42 AM, Registered Nurse #1, Charge Nurse stated that Resident #117 had a Physician's order for the use of the ace wraps. Registered Nurse #1 stated that the ace wrap was not included as an intervention on the resident's comprehensive care plan because Resident #117 had a chronic cardiac condition. Registered Nurse #1 stated they should have included the use of the ace wrap as an intervention on Resident #117's comprehensive care plan.A Comprehensive Care Plan (CCP) titled Chronic Venous Insufficiency dated 05/06/2026 had intervention including applying ace wraps on bilateral lower extremity daily at 9:00 AM and remove daily at 9:00 PM. During an interview on 05/07/2026 at 10:11 AM, the Director of Nursing Services stated that the ace wraps should have been included in Resident #117's comprehensive care plan. The Director of Nursing Services stated that Nurses should be aware that care plans are updated with any changes because the care plan reflects the total care of the resident.10 New York Code Rules and Regulations 415.11(c)(2)(iii)

Based on observations, record review, and interviews during the survey, the facility failed to ensure it implemented a comprehensive person-centered care plan that includes measurable objectives and time frames to meet each resident's medical and nursing needs that are identified in the comprehensive assessment. This was identified for one (1) (Resident #43) of two (2) residents reviewed for skin conditions. Specifically, Resident #42 had a physician's order to offload heels at all times. On multiple occasions while the resident was in bed, the resident's heels were directly in contact with a pillow and were not being offloaded.The findings include:Resident #43 was admitted with diagnoses including diabetes mellitus, peripheral vascular disease, and cerebrovascular accident. The 04/16/2026 admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 10, indicating the resident had moderate cognitive impairment. The resident had a diabetic ulcer and was at risk for pressure ulcer development. The resident required partial/moderate assistance for bed mobility; had no behaviors; and no documented non-compliance.The Braden scale (a scale for determining risk for pressure ulcer development) dated 04/10/2026 documented a score of 14, indicating the resident was at moderate risk for pressure ulcer development.A Comprehensive Care Plan effective 04/13/2026 titled Skin Integrity: Presence of Skin Breakdown Right Heel Diabetic Foot Ulcer documented interventions including monitor for signs and symptoms of infection and apply local treatments as ordered by the physician.A physician's order dated 04/20/2026 documented to offload the heels at all times.A physician's order dated 04/27/2026 documented right heel diabetic foot ulcer, cleanse with normal saline, apply skin prep (applied to create a protective barrier against adhesives, body fluids, and friction), and cover with dry dressing.A wound consult dated 04/27/2026 documented the right heel diabetic foot ulcer was resolved, the area remained tender. Recommendations were to cleanse with normal saline, apply skin prep and cover with dry dressing. Offload the heels at all times. The resident remained at increased risk for wound deterioration due to immobility and underlying medical comorbidities.During an observation on 05/04/2026 at 10:00 AM, Resident #43 was in bed. The resident was wearing socks and there was no sheet covering the resident's lower legs. The resident's heels were resting directly on a pillow and were not offloaded.During an observation on 05/05/2026 at 08:00 AM, Resident #43 was sleeping in bed. The resident had socks on and there was no sheet covering the lower legs. The resident's heels were directly resting on a pillow and were not offloaded.During an observation with Registered Nurse Unit Manager #5 on 05/05/2026 at 08:45 AM, Resident #43 was sleeping in bed. Registered Nurse Unit Manager #5 stated when the heels are resting on a pillow, it is considered offloading. Registered Nurse Unit Manager #5 did not re-adjust the pillow to offload the heels.During an observation on 05/06/2026 at 08:35 AM, Resident #43 was in bed. The resident had socks on and there was no sheet covering the lower legs. The resident's heels were resting directly on a pillow and were not offloaded.During an interview on 05/06/2026 at 08:45 AM, the Nursing Educator stated offloading heels means no pressure on heels. The heels should not be touching any surface including the pillows. During an interview on 05/07/2026 at 07:58 AM, Wound Care Physician #1 stated offloading heels means the heels are off the surface. The pillow must be placed under the lower legs to keep the heels off the bed or the pillow.During an interview on 05/07/2026 at 10:19 AM, the Director of Nursing Services stated offloading heels implies that the heels are not touching anything. The staff should be repositioning and readjusting the pillow to ensure the heels are offloaded. 10 New York Code Rules and Regulations 415.11(c)(1)

Based on observation, record review, and interviews during the survey, the facility failed to ensure each resident has the right to be free from chemical restraints not required to treat the resident's medical symptoms. This was identified for one (Resident #1) of five (5) residents reviewed for Unnecessary Medications. Specifically, Resident #1 with diagnosis of major depressive disorder was seen by a psychiatrist on 03/31/2026 who provided a recommendation to reduce the resident's quetiapine (an antipsychotic) dosage from 100 milligrams twice a day to 25 milligrams twice a day for seven days and then discontinue the medication. The facility did not respond to the psychiatry consultation until 05/06/2026, when the facility lowered the dosage as per the psychiatrist recommendation.The findings include:The facility's policy titled Psychotropic Medications, dated 12/01/2025, documented after medications are ordered for a resident, the staff and practitioner shall seek an appropriate dose and duration for each medication that also minimizes the risk of adverse consequences. Residents who use psychotropic medications, including antipsychotics, shall receive gradual dose reductions and behavioral interventions unless clinically contraindicated, to discontinue these drugs. The physician and staff will identify target symptoms/behaviors for which a resident is receiving various medications. The staff will monitor for improvement in these target symptoms/behaviors and provide the physician with that information. The staff and practitioners will consider tapering of medications as one approach to finding an optimal dose or determining whether continued use of medication benefits the residents.Resident #1 was admitted with diagnoses including diabetes mellitus, Parkinson's disease, and major depressive disorder. The 03/22/2026 admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 0, indicating the resident had severe cognitive impairment; and that the resident was taking an antipsychotic medication and there was an indication for it. The resident had no behaviors; mood indicators included little interest in doing things, feeling or appearing down or depressed, sleeping too much or trouble falling or staying asleep, and feeling tired or having little energy for past 7-11 days.A physician's order dated 02/27/2026 documented quetiapine 100 milligram tablet, give one tablet by oral route every 12 hours for major depressive order. This order was discontinued on 03/01/2026.A medical progress note dated 03/01/2026 written by the medical director documented Chief Medical Officer review, psychoactive medications, depression, psychosis, pending psychiatry for clarification (gradual dose reduction consideration).A physician's order dated 03/01/2026 documented quetiapine 100 milligram tablet, give one tablet by oral route every 12 hours for major depressive order, recurrent, severe with psychiatric symptoms.A review of the medical record indicated the resident went to the hospital on [DATE] and was re-admitted on [DATE].A physician's order dated 03/15/2026 documented quetiapine 100 milligram tablet, give one tablet by oral route two times a day at 9:00 AM and 5:00 PM for major depressive disorder, recurrent, severe with psychiatric symptoms. This order was discontinued on 05/04/2026.A medical progress note dated 03/16/2026 documented resident seen for lethargy, fatigue and hypotension. Under assessment/plan: for hypotension and lethargy-start intravenous normal saline for three days; for major depression/intellectual disability- Seroquel and Remeron (for depression), ropinirole (for Parkinson's); [provide] supportive care and psychiatry follow-up.A psychiatry consult dated 03/31/2026 documented that the resident has intellectual disability/developmental delay and is a poor historian. The resident was re-hospitalized on [DATE] due to unresponsive episode and was found to have atrial fibrillation with rapid ventricular response. The resident lived with family who could no longer care for the resident. The resident had behaviors and was difficult to wean off the quetiapine due to delirium from pneumonia, and quetiapine was used by an outside provider for severe depression. There were no psychosis or mania concerns, no suicidal or homicidal ideation, no hallucinations. History of delirium can complicate weaning of quetiapine and would recommend use of Lexapro while wean off is being ensued. Recommendations to start Lexapro 5 milligram by mouth for one week and then 10 milligram every day onwards and to lower Seroquel to 25 milligrams by mouth twice a day for one week and then stop.A physician order dated 04/09/2026 documented psychiatric consultation and follow up as needed.During an observation on 05/04/2026 at 10:55 AM, Resident #1 was observed in the day room during a recreation program. The resident's head was resting on the table, and the resident appeared to be sleeping. An attempt was made by the surveyor to speak to the resident, but the resident looked at the surveyor and put their head back on the table.A physician's order dated 05/04/2026 documented quetiapine 50 milligram tablet, give one tablet by oral route two times a day at 9:00 AM and 5:00 PM for major depressive disorder, recurrent, severe with psychiatric symptoms. This order was discontinued on 05/06/2026.A psychiatry consulted dated 05/06/2026 documented a recommendation to further lower Seroquel to 25 milligrams twice a day for one week and then stop (consistent with the psychiatry consult dated 03/31/2026).A physician's order dated 05/06/2026 documented quetiapine 25 milligram tablet, give one tablet by oral route every 12 hours at 9:00 AM and 9:00 PM for major depressive disorder, recurrent, severe with psychiatric symptoms for one week.On 05/06/2026 at 10:00 AM the Social Worker Director approached the surveyor and stated normally the psychiatry consultation reports were stored in the progress notes section. The psychiatry consultation dated 03/31/2026 was misfiled and was erroneously stored in the wrong section of the electronic medical record and they found it today (05/06/2026).During an interview on 05/06/2026 at 1:27 PM, Physician Assistant #1 stated that normally the psychiatry consultation reports are kept in the progress notes; being that the consultation was stored in wrong section of the electronic medical record, it may have been missed. Physician Assistant #1 stated when they came in 05/04/2026, they noticed that a gradual dose reduction had not been done for Resident #1 and that is why they lowered the quetiapine dosage to 50 milligrams twice a day. A review of the medical record indicated that Physician Assistant #1 saw Resident #1 a total of thirteen (13) times from 03/31/2026 to 05/04/2026. Each of the progress notes documented major depression/intellectual disability-Seroquel, Remeron, ropinirole, supportive care, psychiatry follow up. During an interview on 05/06/2026 at 1:42 PM, Psychiatrist #1 stated they had no idea why the consultation report was stored in the documents section of the electronic medical record and not in the progress notes section. There should be a trial to eliminate the quetiapine for Resident #1 to determine if the resident can live without quetiapine. Psychiatrist #1 stated that for people who are intellectually disabled it is always best to try to lower the dose because there may not be a true psychotic condition or diagnosis. During an interview on 05/06/2026 at 1:45 PM, Primary Physician #1 stated the physician assistant changed the quetiapine to 50 milligrams twice a day on 05/04/2026 because they did not see the psychiatry consult; if the physician assistant saw the consult, they would have changed the dosage to 25 milligrams twice a day as per the consult. The quetiapine was further lowered today to 25 milligrams twice a day as per the consults dated 3/31/2026 and 05/06/2026.A review of the medical record indicated no documentation of quetiapine gradual dose reduction until 05/04/2026; however, the recommendations made by the psychiatrist on 3/31/2026 to decrease quetiapine dosage to 25 milligrams twice a day for one week and then discontinue, were not implemented until 05/06/2026.During an observation on 05/07/2026 at 8:32 AM, Resident #1 was observed in the hallway in their wheelchair. The resident was awake, alert, and responsive to simple questions like how are you?During an interview on 05/07/2026 at 10:10 AM, the Director of Nursing Services stated the doctors know they are supposed to put their notes in the progress notes section of the electronic medical record. The primary doctor is expected to address the recommendations made by the consultants; however, the psychiatry consult dated 03/31/2026 was stored in the wrong section in the electronic medical record therefore, the primary physician did not see the psychiatry consult and did not address the recommendations made by the Psychiatrist. 10 New York State Code Rules and Regulations 415.4(a)(1)

Based on observations, record review, and interviews during the Recertification Survey initiated on 2/24/2025 and completed on 2/28/2025, the facility did not ensure it maintained an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #283) of one resident reviewed for Respiratory Infection. Specifically, Resident #283 was readmitted to the facility on [DATE] from the hospital with a diagnosis of Influenza. The resident was placed on Contact and Droplet Precautions. During two separate observations, [NAME] #1 and [NAME] #2 were cleaning the resident's room without wearing appropriate Personal Protective Equipment. [NAME] #1 put on the Personal Protective Equipment after the observation and then exited the room without removing the Personal Protective Equipment to retrieve a garbage pail from the hallway. The finding is: The facility's policy titled Infection Control-Droplet Precautions, effective 10/30/2023, documented droplet precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Infectious agents for which droplet precautions are indicated include Influenza virus. The facility's policy titled Infection Control-Contact Precautions, effective 10/30/2023 documented that contact precautions are intended to prevent transmission of infectious agents that are spread by direct or indirect contact with the patient or the patient's environment. Healthcare personnel wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient environment. Putting on the Personal Protective Equipment upon room entry and discarding before exiting the room is done to contain pathogens. Resident #283 was admitted to the facility with diagnoses of Muscle Wasting and Atrophy (muscle shrinkage), Diabetes Mellitus, and Major Depressive Disorder. The Minimum Data Set assessment was not available due to the resident's recent admission to the facility. The Nursing Admission assessment dated [DATE] documented the resident was oriented to person, place, and time. A review of nursing progress notes revealed the resident was transferred to the hospital on 2/17/2025 due to low hemoglobin and was readmitted to the facility on [DATE] with a positive diagnosis of Influenza. A Comprehensive Care Plan titled, Isolation Precautions for Influenza A, effective 2/20/2025, documented resident has an active infection requiring isolation precautions. The goal was for staff to prevent the spread of infection. The intervention included to maintain an isolation cart outside of the resident's room and to maintain Contact Precautions. The care plan did not include Droplet Precautions. A Physician's order dated 2/24/2025 documented Contact/Droplet precautions until (Influenza) symptoms resolve. During an observation on 2/24/2025 at 10:26 AM, Resident #283 was lying in bed in their room. A pink sign outside the resident's room documented: Isolation, Droplet/Contact Precautions, Staff and Providers must clean their hands when entering and exiting, wear a gown, an N95 Respirator (facemask acceptable if an N95 not available); eye protection, and gloves. [NAME] #1 was observed inside the resident's room not wearing a gown, eye protection, or an N95 mask and was sweeping the floor and moving furniture around. [NAME] #1 was wearing a surgical mask and gloves. [NAME] #1 stated they knew they were supposed to wear all appropriate Personal Protective Equipment and were not able to state why they were not wearing the appropriate Personal Protective Equipment. The porter then sanitized their hands, put on a gown, gloves, an N95 mask, and eye shield, and re-entered the room. After continuing to sweep the room, the porter exited the room with all the Personal Protective Equipment still on, including the gloves, and retrieved a garbage pail that was outside of Resident #283's room across the hallway. During an interview on 2/24/2025 at 2:17 PM, Operations Manager #1 stated the porters are supposed to follow the instructions on the isolation precautions sign at the doorway; they are supposed to wear full Personal Protective Equipment for Contact and Droplet rooms and then remove the Personal Protective Equipment before leaving the room. During an interview on 2/26/2025 at 8:02 AM, the Assistant Director of Nursing/Infection Preventionist #1 stated [NAME] #1 was expected to follow the directions on the isolation precaution sign. Assistant Director of Nursing/Infection Preventionist #1 stated the resident should have been placed on Contact and Droplet precautions on 2/20/2025 when the resident was readmitted and a Physician's order for Contact and Droplet Precautions should have been obtained on 2/20/2025 and the care plan should have also included the Droplet Precautions. Assistant Director of Nursing/Infection Preventionist #1 stated this was an oversight. During an interview on 2/27/2025 at 10:06 AM, the Director of Nursing Services stated the staff are expected to follow the isolation precaution directions provided on the signage. During an observation on 2/27/2025 at 11:57 AM, [NAME] #2 was observed inside Resident #283's room cleaning while the resident was in bed. The isolation Contact and Droplet signage was still at the doorway. The porter was wearing gloves, a gown, and a surgical mask, but no N95 mask and no eye protection. The surveyor brought the signage to the attention of the porter, who then reached out of the room to the isolation cart, which was placed in the hallway outside of the resident's room, wearing the same gloves, and took out a face shield from the isolation cart and put on the face shield. 10 NYC RR 415.19(a)(1-3)

Based on observation, record review, and staff interviews during the Recertification Survey initiated on 2/24/2025 and completed on 2/28/2025, the facility did not ensure that drugs and biologicals were stored in a locked compartment. This was identified for one (Resident #1) of four residents reviewed for Accident Hazards. Specifically, Resident #1 was observed with an Albuterol inhaler (medication used to treat difficulty breathing) on top of their bed and there was no nursing staff in the vicinity. There was no Physician's order for Albuterol inhaler and the resident was not assessed to self-administer their medication. The finding is: The facility's policy titled Medications: Storage and Handling last revised on 12/12/2024, documented medications are stored according to procedures established in compliance with State and Federal regulations. Medications and biologicals are stored in locked compartments under proper temperature controls, and only authorized personnel have access to the keys. Residents participating in a self-administration program are to have a locked medication cabinet in their room. Resident #1 was admitted with diagnoses including Chronic Obstructive Pulmonary Disorder, Malignant Neoplasm (Cancer) of the lung, and Emphysema (chronic lung disease that permanently damages the lungs' air sacs). The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 3, which indicated that Resident #1 had severe cognitive impairment. The Minimum Data Set assessment documented Resident #1 had shortness of breath when lying flat. A review of Resident #1's electronic medical record revealed no Physician Orders for an Albuterol 90 microgram inhaler. A Physician's Order dated 12/27/2024 documented Breo Ellipta (an inhaler that treats asthma and Chronic Obstructive Pulmonary Disease) 100 micrograms per 25 micrograms dose powder by inhalation of puff by oral route once daily. A Comprehensive Care Plan titled Respiratory Disorder: Chronic Obstructive Pulmonary Disorder dated 9/26/2024, documented interventions including to administer medications and oxygen therapy as per the Physician's Orders. During an observation on 2/24/2025 at 10:29 AM, Resident #1 was sitting in a wheelchair in their room. An unlabeled Albuterol 90 micrograms inhaler was observed on top of Resident #1's bed with an expiration date of 3/6/2025. There was no nurse in the room or within the vicinity of Resident #1's room. Resident #1 stated they did not remember where the inhaler came from and that they used that inhaler all the time. During an interview on 2/24/2025 at 10:43 AM, Licensed Practical Nurse #2 stated Resident #1 did not have an order for an Albuterol inhaler. Licensed Practical Nurse #2 stated Resident #1 had an order for a Breo-Ellipta inhaler that the Nurses administer once a day. Licensed Practical Nurse #2 stated the resident is confused and they had never seen Resident #1 use the Albuterol inhaler. During an interview on 2/24/2025 at 1:41 PM, Registered Nurse#1, the Unit Manager, stated they had never seen Resident #1 use the Albuterol inhaler. Registered Nurse #1 stated Resident #1 had confusion and would not be able to self-administer the medication. Registered Nurse #1 stated they did not know how Resident #1 obtained the inhaler medication. During an interview on 2/27/2025 at 10:33 AM, the Director of Nursing Services stated Resident #1 should not have had any medications without the nurse's supervision. The Director of Nursing Services stated Nurses should be aware of any unsecured medications. 10 NYCRR 415.18(e)(1-4)

Based on observation, record review, and interviews during the Recertification Survey initiated on 2/24/2025 and completed on 2/28/2025 the facility did not ensure each resident was free of any significant medication errors. This was identified for one (Resident #284) of six residents observed during medication administration. Specifically, Resident #284 had a do not crush physician's order for Metoprolol extended-release medication tablet (a blood pressure medication). During the medication administration observation, Licensed Practical Nurse #5 crushed and administered the Metoprolol extended-release medication tablet to Resident #284. The finding is: The facility's policy titled Medication Administration: General Policies and Practices, effective 11/12/2024, documented that prior to administering any medication the staff nurse reads the order in its entirety carefully, noting the name, dosage, route, and time of administration, making certain that the dosages, frequency, and schedules correspond with the physician's order; reads the medication label before pouring the medication; reviews the electronic medication record for accuracy after all medications for a specific resident have been prepared. The policy did not specifically address extended-release medications or crushing medications. Resident #284 was admitted with diagnoses including Joint Replacement Surgery, Diabetes Mellitus, and Hypertensive Heart Disease. The Minimum Data Set assessment was not available because the resident was recently admitted to the facility. The Nursing Admission assessment dated [DATE] documented the resident was oriented to person, place, and time. A Physician's order dated 2/17/2025 documented Metoprolol Succinate Extended Release (ER) 25-milligram tablet, extended-release 24 hours, by oral route once daily at 9:00 AM; Do Not Crush or Chew, for diagnosis of Essential Hypertension. The accessdata.fda.gov website for Metoprolol Succinate extended-release tablets documented that the Metoprolol Succinate extended-release tablets are scored and can be divided; however, the whole or half tablet should be swallowed whole and not chewed or crushed. A Physician's order dated 2/18/2025 documented a regular-consistency diet. During a medication administration observation on 2/25/2025 at 8:18 AM, Licensed Practical Nurse #5 prepared Resident #284's medications. Licensed Practical Nurse #5 crushed and mixed each of the following medications individually in apple sauce, and administered the medications to the resident: -Finasteride 5 milligrams for enlarged prostate, -Entresto 24 milligrams-26 milligrams for Heart Failure, -Metoprolol Succinate Extended Release 25 milligrams for Hypertension, -Furosemide 20 milligrams for Hypertension, -Aspirin 81 milligrams for Coronary Artery Disease and, During an interview on 2/25/2025 at 9:00 AM, Licensed Practical Nurse #5 reviewed the physician's order for the extended-release Metoprolol Succinate, which the nurse had crushed and administered to the resident. The order documented Do Not Crush. Licensed Practical Nurse stated the medication blister pack label did not indicate to not crush, therefore they crushed the extended-release Metoprolol Succinate medication. Licensed Practical Nurse #5 questioned the surveyor Was I not supposed to crush the Metoprolol? A review of Licensed Practical Nurse #5's Medication Pass Audit Tool (competency), dated 10/22/2024, revealed the nurse passed the medication pass technique assessment under the category. The audit tool included that products suitable for crushing were crushed (enteric-coated, sustained release and sublingual products are not to be crushed). During an interview on 2/26/2025 at 8:50 AM, the Medical Director (the resident's Primary Physician) stated Licensed Practical Nurse #5 should not have crushed the Metoprolol Succinate Extended-Release tablet because crushing an extended-release tablet releases all the medication at once and creates the possibility of a drop in blood pressure. During an interview on 2/26/2025 at 10:46 AM, Pharmacist #1 stated crushing the extended-release medication releases all the medication at once. Crushing the medication disrupts the medication release mechanism because the medication in the extended-release tablet is formulated to be released throughout the day. There could be side effects from crushing the medication like low blood pressure. Monitoring of the resident's blood pressure would be needed if the extended-release medication was crushed. During an interview on 2/27/2025 at 9:13 AM, Registered Nurse #2, the unit manager, stated nurses are not supposed to crush extended-release medications; this is a part of their education. If a nurse crushes an extended-release medication, they have to reach out to the doctor for further direction. During an interview on 2/27/2025 at 10:06 AM, the Director of Nursing Services stated an extended-release medication should not be crushed. If the nurse crushed the extended-release medication, they have to reach out to the doctor on how to proceed and the resident should be closely monitored for the next 24 hours. The progress note dated 2/25/2025 documented Resident #284'2 blood pressure was obtained on 2/25/2025 at 12:54 PM due to the resident having blood in the urine. The blood pressure was 124/57 millimeters of Mercury (normal range 120/80). There was no documentation regarding monitoring the residents related to administering a crushed extended-release Metoprolol Succinate medication. 10 NYCRR 415.12(m)(2)

Based on record review and staff interviews during the Recertification Survey initiated on 2/24/2025 and completed on 2/28/2025, the facility did not ensure the Physician documented in the resident's medical record that the irregularity identified by the Pharmacist has been reviewed and what action has been taken to address it. This was identified for two (Resident #121 and Resident #116) of five residents reviewed for Unnecessary Medications. Specifically, Nurse Practitioner #1 disagreed with recommendations provided by the Consultant Pharmacist for Resident # 121 and Resident #116; however, the reason for the disagreement was not documented. The findings are: The facility's undated policy titled, Drug Regimen Review-Monthly documented that the Prescriber/Licensed Designee shall document on the Drug Regimen Review form whether they agree or disagree with the recommendations and provide a brief clinical rationale if no change is to be made. 1) Resident #121 had diagnoses including Atrial Fibrillation and Orthostatic Hypotension (blood pressure drops significantly when a person stands up from a sitting or lying position). The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderately impaired cognition. The Physician's Order dated 10/25/2024 last renewed on 2/9/2025 documented for the resident to receive Fludrocortisone (a steroid medication that helps reduce inflammation and treat adrenal insufficiency) 0.1 milligram tablet - give 1 tablet (0.1 milligrams) by oral route twice daily for Orthostatic Hypotension. The Physician's Order dated 10/25/2024 documented for the resident to receive Midodrine (a medication used to treat low blood pressure) 10-milligram tablet - give 1 tablet by oral route three times per day for Orthostatic Hypotension. The medication was discontinued on 2/4/2025. The Physician's Order dated 2/4/2025 last renewed on 2/9/2025 documented for the resident to receive Midodrine 5 milligram tablet - give 1 tablet by oral route three times per day for Orthostatic Hypotension. The Drug Regimen Review dated 1/28/2025 documented the resident was currently receiving both Midodrine and Fludrocortisone with diagnoses of Orthostatic Hypotension. The Consultant Pharmacist recommended evaluating the need for both medications and considering discontinuing one of the medication orders, if appropriate. The Physician/Prescriber Response made by Nurse Practitioner #1 on 1/31/2025 documented Disagree; however, there was no clinical rationale indicated on the form or in the resident's Electronic Medical Record. 28173 2) Resident #116 had diagnoses including Benign Prostatic Hyperplasia, Insomnia, and Multiple Myeloma. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 2, indicating the resident had severely impaired cognition. The Physician's Order dated 12/12/2024 last renewed on 2/25/2025 documented Haloperidol 1 milligram (an antipsychotic medication) tablet - give 1 tablet by oral route twice daily for Metabolic Encephalopathy. The Physician's Order dated 12/13/2024 last renewed on 2/25/2025 documented Melatonin 5 milligram (a hormone that aids in sleep) tablet - give 1 tablet by oral route once daily at bedtime for Vitamin Deficiency, unspecified, and Melatonin 3 milligram tablet - give 1 tablet by oral route once daily at bedtime for Vitamin deficiency, unspecified. The Physician's Order dated 12/12/2024 last renewed on 2/25/2025 documented Pomalyst 3 milligram (medication to treat Multiple Myeloma) capsule - give 1 capsule (3 milligrams) by oral route once daily for 21 days for Multiple Myeloma in relapse. The Physician's Order dated 12/12/2024 last renewed on 2/25/2025 documented Tamsulosin 0.4 milligram (smooth muscle relaxer) capsule - give 1 capsule (0.4 milligrams) by oral route once daily half an hour following the same meal each day for Benign Prostatic Hyperplasia with lower urinary tract symptoms. The Drug Regimen review dated 1/10/2025 documented: -The resident was currently receiving Haloperidol 1 milligram twice daily for behaviors associated with Dementia. No recent behavior problems were noted. The Consultant Pharmacist recommended evaluating the current dosing and to consider tapering Haldol to 1 milligram daily dosing or documenting the reason for the inability to do so. The Physician/Prescriber Response made by Nurse Practitioner #1 on 1/14/2025 was Disagree; however, no clinical rationale was documented on the form or in the resident's Electronic Medical Record. -The resident was currently receiving both Melatonin 5 milligrams and Melatonin 3 milligrams. The Consultant Pharmacist recommended evaluating the need for two medications in the same drug class and considering discontinuing one order, if appropriate. The Physician/Prescriber Response made by Nurse Practitioner #1 on 1/14/2025 was Disagree; however, no clinical rationale was documented on the form or in the resident's Electronic Medical Record. -The resident was currently receiving Pomalidomide (Pomalyst) once a day for 21 days. Typically dosed cyclically once a day for 21 days of a repeated 28-day cycle. No follow-up cycle is scheduled. The recommendations were to evaluate and consider ordering follow-up cycles to ensure continuity of care, if appropriate. The Physician/Prescriber Response made by Nurse Practitioner #1 on 1/14/2025 was Disagree; however, no clinical rationale was documented on the form or in the resident's Electronic Medical Record. -The resident was currently receiving Tamsulosin (Flomax) 0.4 milligram with an order to crush the medication. This medication should not be crushed, chewed, or opened. The recommendations were to evaluate the continued need. Consider either discontinuing if no longer needed or switching to Silodosin (Rapaflo) 8 milligrams (medication used for enlarged prostate) once daily after dinner which may be opened and the powder sprinkled whole in applesauce, if appropriate. The Physician/Prescriber Response made by Nurse Practitioner #1 on 1/14/2025 was Disagree; however, no clinical rationale was documented on the form or in the resident's Electronic Medical Record. During an interview on 2/26/2025 at 12:00 PM, Nurse Practitioner #1 stated they have been a Nurse Practitioner for only approximately six months. Nurse Practitioner #1 stated they were not aware that they have to write an explanation when they disagree with a Pharmacist's recommendation. Nurse Practitioner #1 stated Primary Physician #1 did not educate them about documenting the rationale for disagreeing with the recommendations made by the Pharmacist. During an interview on 2/26/2025 at 12:45 PM, Primary Physician #1 stated Nurse Practitioner #1 should have written a response when they disagreed with a Pharmacist's recommendations. One can disagree with the recommendations; however, the rationale for disagreement must be documented in the resident's medical record. Primary Physician #1 stated Nurse Practitioner #1 was trained first before they were allowed to work by themselves. 10 NYCRR 415.18(c)(2)

Based on observations, record review, and interviews during the Recertification Survey initiated on 2/24/2025 and completed on 2/28/2025, the facility did not ensure that the staff implemented and provided care and services according to the resident's needs and professional standard of practice for each resident with a feeding tube. This was identified for one (Resident #27) of one resident reviewed for Tube Feeding, specifically, on 2/24/2025 at 11:30 AM and 1:00 PM. Resident #27 was observed receiving enteral tube feeding (a method of providing nutrition directly into the gastrointestinal (GI) tract through a tube); the enteral tube feeding bottle and the water bag was observed hanging on a feeding tube stand without a label including the resident's name and the time the tube feeding was started. The finding is: The facility's policy titled Tube Feedings: Gastrostomy Feedings, last revised on 11/12/2024, documented that Gastrostomy tube feedings will be administered by licensed nursing staff in accordance with written physician orders. To maximize each resident's quality of life, tube feedings will be provided during the evening and overnight hours. Resident #27 was admitted with diagnoses that included Multiple Sclerosis (a disease in which the immune system eats away the protective covering of nerves), Quadriplegia (loss of movement and sensation in all four limbs- arms and legs), and Chronic Obstructive Pulmonary Disorder (COPD). The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #27 had a Brief Interview for Mental Status (BIMS) score of 0. Resident #27 was rarely and was never understood. Resident #27 had severe cognitive impairment. Resident #27 had a swallowing disorder, including holding food in their mouth and cheek. Resident #27 had a feeding tube (nasogastric or abdominal) and received an average fluid intake per day by intravenous or tube feeding. The Comprehensive Care Plan (CCP) titled Tube Feeding, dated 10/17/2024, documented interventions to administer the feeding formula with the required amount of water as prescribed by the Physician. Monitor for signs and symptoms of aspiration precaution. Ensure the head of the bed is elevated at 30-45 degrees or more during feeding and one hour after the feeding. The Physician's order dated 11/9/2024 documented Jevity1.5, 1000 cubic centimeters per 1500 kilocalories per day with a flow rate of 50 milliliters per hour for 20 hours per day. Start the feeding at 5:00 PM. Water Flushes with 250 milliliters of water bolus (single large dose) before and after each feeding using a syringe kit. Automatic water flush of 600 milliliters at 30 milliliters per hour for 20 hours every day at 11:00 PM-7:00 AM shift, 7:00 AM-3:00 PM shift, and 3:00 PM-11:00 PM shift. During an observation on 2/24/2025 at 11:30 AM, Resident #27 was observed receiving enteral tube feeding via a feeding pump. In their room. The enteral feeding bottle and a water bag were observed hanging from the feeding tube stand. The enteral tube feeding bottle and the water bag did not have a label to identify the resident's name, the time feeding was started, and the feeding directions as prescribed by the Physician. In a subsequent observation on 2/24/2025 at 1:00 PM, Resident #27 was observed receiving enteral tube feeding via a feeding pump. In their room. The enteral feeding bottle and a water bag were observed hanging from the feeding tube stand. The enteral tube feeding bottle and the water bag did not have a label to identify the resident's name, the time feeding was started, and the feeding directions as prescribed by the Physician. During an interview on 2/24/2025 at 1:06 PM, Licensed Practical Nurse #1 stated they did not notice that the enteral tube feeding bottle and water bag did not have any label on them. The Licensed Practical Nurse #1 stated that the evening nurse should have labeled both the enteral tube feeding bottle and the water bag. Licensed Practical Nurse #1 stated they also should have checked the enteral tube feeding bottle and water bag for the labels during the morning medication pass. During an interview on 2/24/2025 at 3:03 PM, Licensed Practical Nurse #4, who worked during the 3:00 PM-11:00 PM shift on 2/23/2025, stated they had forgotten to label the enteral tube feeding bottle and the water bag. Licensed Practical Nurse #4 stated they did not have a marker or pen to label the enteral tube feeding bottle and water bag. Licensed Practical Nurse #4 stated that they become busy with the medication pass and had forgotten about labeling the enteral feeding bottle and water bag. During an interview on 2/26/2025 at 2:42 PM, Registered Nurse #1, Unit Manager, stated the enteral tube feeding bottle and water bag should have a label with the resident's name, the time the feeding was started, and instructions about the enteral order by the Physician. During an interview on 2/27/2025 at 10:00 AM, the Director of Nursing Services stated Resident #27's enteral feeding bottle and water bag should have been labeled. The Director of Nursing Services stated that all Nurses on each shift are responsible for ensuring that proper labeling is in place for both enteral feeding bottles and water bags. 10 NYCRR 415.12(g)(2)

Based on observation, record review, and interviews during the Recertification Survey initiated on 2/24/2025 and completed on 2/28/2025, the facility did not ensure that each resident's environment remained free of accident hazards. This was identified for one (Resident #21) of four residents reviewed for Accidents. Specifically, an oxygen E-Cylinder tank (portable oxygen tank) was observed on the right side of Resident #21's bed. The E-Cylinder tank was not secured in a rolling safety stand or a metal rack. The finding is: The facility's policy, titled Oxygen Closet last revised on 9/2024, documented the facility would maintain an adequate supply of oxygen needed for the administration of oxygen. A minimum of two small E-Cylinder tanks will be maintained on each unit for emergency purposes. Oxygen tanks not secured on tank dollies or the E-tank rack, will be secured to the wall with chains. Resident #21 was admitted with diagnoses including Acute Renal Failure with Hypoxia (absence of enough oxygen in the tissues) and Chronic Obstructive Pulmonary Disease (COPD). The Annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 10, indicating Resident #21 had moderate cognitive impairment. Resident #21 had shortness of breath when lying flat. A Physician's Order dated 1/16/2025 documented continuous oxygen therapy to Resident #21 at 2 liters per minute via nasal cannula. The order was discontinued on 1/29/2025. A Comprehensive Care Plan (CCP) titled Respiratory Disorder dated 9/5/2023 documented interventions including elevating the head of the bed at 45 degrees and administering oxygen therapy as per the Physician's Order. During an observation on 2/24/2025 at 10:59 AM, Resident #21 was sitting in their wheelchair receiving oxygen therapy from an oxygen concentrator at 2 liters per minute via nasal cannula. A free-standing E-Cylinder (portable tank) tank was on the side of Resident #21's bed. During an interview on 2/24/2025 at 10:59 AM, Certified Nursing Assistant #1, who was present in the resident's room during the observation, stated they did not notice the oxygen tank on the side of the bed during morning care. Certified Nursing Assistant #1 stated that they did not know who put the tank on the side of the bed. Certified Nursing Assistant #1 stated that the oxygen tank should be in an oxygen caddy or metal rack. During an interview on 2/24/2025 at 11:06 AM, Licensed Practical Nurse #1 stated Resident #21 did not have a Physician's Order for Oxygen treatment. Resident #21's oxygen order was discontinued on 1/29/2025. Licensed Practical Nurse #1 stated that they did not know who left the oxygen tank without the rolling cart in the resident's room. During an interview on 2/24/2025 at 1:46 PM, Registered Nurse #1, Unit Manager, stated Resident #21 did not have a Physician's Order for Oxygen treatment. Resident #21's oxygen order was discontinued on 1/29/2025. Registered Nurse #1 stated that the town had a power outage the day before (2/23/2025), and an oxygen tank must have been brought to Resident #21. Registered Nurse #1 stated that the oxygen tank should have been secured on a rolling cart or caddy. During an interview on 2/27/2025 at 9:00 AM, the Director of Nursing Services stated if a resident is having shortness of breath or an anxiety attack, the facility can start oxygen therapy at a maximum of 2 liters via nasal cannula. The Director of Nursing Services stated that the oxygen tank should have been on a rolling cart or a caddy due to the danger of the oxygen tank falling or exploding if left unsecured. 10 NYCRR 415.12(h)(1)

Based on record review and staff interviews during the Recertification Survey, initiated on 2/24/2025 and completed on 2/28/2025, the facility did not ensure that each resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. This was identified for two (Resident #90 and Resident #237) of three residents reviewed for Pressure Ulcers. Specifically, 1) during a wound care observation of Resident #90's left buttock Stage 2 Pressure ulcer (wound with partial thickness loss of skin) on 2/26/2025, another stage Stage 2 Pressure Ulcer was observed on the right buttock. There was no documented evidence of an assessment or a Physician's order for treatment for the right buttock pressure ulcer. The wound care nurse administered treatment on Resident #90's right buttock wound without any Physician's Order 2) Resident #237 was assessed with a Stage 3 pressure ulcer to the sacrum. There was no documented evidence that Resident #237 was turned and positioned every two hours as required by the comprehensive care plan. Additionally, treatment recommendations made by the Wound Care team were not followed. The finding is: The facility's policy titled Pressure Ulcer Care, last revised on 9/27/2023, documented that Registered Nurses (RN) and Licensed Practical Nurses (LPN) are responsible for identifying the presence of and the risk for skin ulcers, document the presence of skin ulcer, initiate Comprehensive Care Plan (CCP), notify wound care nurse of skin risk and presence of ulcers and notify Physician of skin ulcer and obtain treatment orders. To identify residents at risk for the development of Pressure ulcers and to monitor the condition of the resident's skin, report any skin problem, and/or follow-up treatment. Physician Orders are obtained for wound care treatments. All wound care treatments are to specify the frequency of the treatment as well as the duration of the treatment period. Resident #90 was admitted with diagnoses including Hemiplegia (paralysis or weakness on one side of the body), left non-dominant side, Asthma, and Type 2 Diabetes. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 9, which indicated Resident #90 had moderately impaired cognition. The Quarterly Minimum Data Set (MDS) assessment documented that Resident #90 had an unhealed pressure ulcer, was at risk for developing pressure ulcers and used pressure-reducing devices for chair and bed. A review of the Comprehensive Care Plan (CCP) indicated the resident had multiple pressure ulcers including the left buttock, right heel, right medical foot, right distal foot, and sacrum. The interventions included applying treatment as ordered by the Physician, maintaining turning and positioning every 2 hours as recommended, and monitoring for pain. The Comprehensive Care Plan did not include the presence of a pressure ulcer on the right buttock. A Physician's order dated 2/19/2025 documented treatment orders for the left buttock, sacrum, right heel, and right foot wounds. There was no physician's order for a treatment of the right buttock wound. A Physician's order dated 2/19/2025 documented Medihoney (medication that supports the removal of damaged tissue and aids in wound healing). Apply to the left buttock wound after cleaning with normal saline, and cover with a dry protective dressing. A review of the Wound Care Consultation Note dated 2/19/2025 documented the resident had a left buttock unstageable pressure ulcer; Stage 3 sacral pressure ulcer; Stage 3 right heel pressure ulcer; and a Deep Tissue Injury (purple localized area of discolored intact skin or blood-filled blister) to the right foot with treatment recommendations. The note did not indicate a pressure ulcer to the right buttock area. During a wound care observation dated 2/26/2025 at 10:15 AM, Licensed Practical Nurse#2 removed the dressing on Resident #90's left buttock. Licensed Practical Nurse #2 cleansed the left buttock wound with normal saline and applied Medihoney (medication that supports the removal of damaged tissue and aids in wound healing) as per the Physician's order. Licensed Practical Nurse #2 covered the wound with a dry protective dressing. A dressing was observed on Resident #90's right buttock. Licensed Practical Nurse #2 took off the dressing and a Stage 2 pressure ulcer wound was observed on the right buttock. Licensed Practical Nurse #2 cleansed the right buttock wound with normal saline, applied Medihoney to the right buttock wound, and covered the wound with a dry protective dressing without a Physician's order. During an interview on 2/26/2025 at 10:59 AM, Licensed Practical Nurse #2 stated they got confused when they saw the dressing on Resident #90's right buttock. Licensed Practical Nurse #2 stated they recalled Resident #90 had a wound on the right buttock that had healed. Licensed Practical Nurse #2 stated they did not know that the resident had another pressure ulcer on the right buttock. Licensed Practical Nurse #2 stated they should have checked the Physician's Order before putting the treatment on Resident #90's right buttock. During an interview on 2/26/2025 at 1:45 AM, Registered Nurse #1, Unit Manager, stated the wound on Resident #90's right buttock had reopened on 2/25/2025. Registered Nurse #1 stated the Nurse from the day before (2/25/2025) just put a dry dressing on Resident #90's right buttock but forgot to document their findings and did not communicate with the Unit Supervisor. Registered Nurse #1 stated they became aware of the wound after the wound care observation on 2/26/2025. They started an investigation and found out that the Licensed Practical Nurse #3 from the day before knew about the wound but forgot to tell anyone. Registered Nurse #1 stated that Licensed Practical Nurse #2 should have checked the order first before doing the treatment on the right buttock. Registered Nurse #1 stated that if there were no treatment orders for the right buttock wound, then they (Licensed Practical Nurse #2) should have told the Unit Supervisor. During an interview on 2/27/2025 at 8:30 AM, the Wound Care Nurse stated they were not aware that Resident #90's right buttock wound had reopened. The Wound Care Nurse stated that any skin changes must be reported to the Unit Supervisor. The Wound Care Nurse stated that all wound care treatments need a Physician's Order. During an interview on 2/27/2025 at 9:00 AM, the Wound Care Physician stated they had received a notification from the Wound Care Nurse on 2/26/2027 at 11:51 AM regarding Resident #90's right buttock wound that reopened. The Wound Care Physician stated they had ordered to clean Resident #90's right buttock wound with normal saline and applied Medihoney (medication that supports the removal of damaged tissue and aids in wound healing). During an interview on 2/27/2025 at 10:15 AM, Licensed Practical Nurse #3 stated they had worked as a Medication Nurse on 2/25/2025 and had gotten a report from a Certified Nursing Assistant (CNA) (could not recall who) that Resident #90's right buttock wound had reopened. Licensed Practical Nurse #3 stated that they had checked the wound and put a dry sterile dressing on the area. Licensed Practical Nurse #3 stated they forgot to document and report the wound to the Unit Supervisor. Licensed Practical Nurse #3 stated they should have documented Resident #90's reopened wound in the Progress Note, but they got busy with their medication pass. During an interview on 2/27/2025 at 10:45 AM, the Director of Nursing Services stated that Licensed Practical Nurse #2 should not have administered any treatment without a Physician's Order. The Director of Nursing Services stated the expectation is for the Nurses to be able to communicate any skin changes to their Unit Supervisor. The Director of Nursing Services stated that the Unit supervisor can call the Physician and get an order for any treatment needed by the resident. The Director of Nursing Services stated that they (The Director of Nursing Services) expect the Nurses to document any changes in the resident's skin condition. 34798 2) Resident #237 was admitted with diagnoses including Compression Fracture of First Lumbar Vertebra (Spine), Diabetes Mellitus, and Spinal Stenosis. The 1/22/2025 Admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. The Minimum Data Set assessment documented that the resident had one Stage 2 pressure ulcer present on admission, the resident was at risk for developing pressure ulcers, and the resident was dependent on staff members for bed mobility and turning. The Nursing Admission Assessment, dated 1/16/2025, documented a Braden Score (scale for determining pressure ulcer risk) of 17, indicating the resident was at mild risk for developing pressure ulcers. The assessment documented that the resident's skin was intact. The 1/17/2025 wound care nursing skin assessment documented the resident had a Stage 2 Pressure Ulcer on the Sacrum measuring 3 centimeters in length, 2 centimeters in width, and 0.1 centimeters in depth. The wound appeared red and had no drainage. A Physician's order dated 1/17/2025 documented Silvadene 1 % topical cream, cleansing sacral pressure ulcer with normal saline, applying Silvadene, and covering with dry protective dressing once a day. A Wound Physician visit note dated 1/22/2025 documented sacral Stage 2 present on admission, measuring 0.5 centimeters in length, 0.5 centimeters in width, and 0.1 centimeters in depth. The recommendation was to cleanse with normal saline, apply Silvadene twice a day, and turn and position. A review of the January 2025 Treatment Administration Record revealed that the Silvadene treatment was not changed to twice a day as recommended by the Wound Physician. A Comprehensive Care Plan titled Presence of Skin Breakdown-Sacrum, effective 1/16/2025, had no interventions or notes entered until 1/30/2025. Maintain Turning and Positioning every two hours as recommended was entered on 1/30/2025 by the Assistant Director of Nursing/Wound Care Nurse #1. In addition, the Assistant Director of Nursing/Wound Care Nurse #1 entered the treatment recommendation for Silvadene twice a day into the Care Plan but there was no corresponding Physician order. A Physician's order dated 1/29/2025 documented cleansing the sacral pressure ulcer with normal saline, apply Medihoney, and covering with a dry protective dressing twice a day for the Pressure Ulcer of the Sacral Region. A subsequent visit note by the Wound Physician dated 2/5/2025 documented sacral ulcer Stage 3, 1.5 centimeters in length, 1.2 centimeters in width, and 0.1 centimeters in depth. The wound had scant serous drainage, with 50% slough (dead tissue). Recommendations were to cleanse the wound with Normal Saline, apply Medihoney, cover with gauze, and secure with a bordered gauze; change daily, turn, and position every 2 hours. A review of the February 2025 Treatment Administration Record revealed that the Medihoney treatment was not changed from twice a day to daily treatment as per the Wound Physician's recommendation until 2/19/2025. A review of the Resident Nursing Instructions (care instructions for Certified Nursing Assistants) effective 1/16/2025 revealed an entry on 1/30/2025 by the Assistant Director of Nursing/Wound Care Nurse #1 to Turn and Position every two hours as recommended. Bed mobility, entered by the Registered Nurse Admission Nurse #3, documented bed mobility of partial/moderate assist entered on 1/16/2025 (admission). A review of the Certified Nursing Assistant Accountability Records for January and February 2025 revealed no documented evidence that the resident was turned and positioned every two hours. During an interview on 2/28/2025 at 8:55 AM, Certified Nursing Assistant #2 (7:00 AM-3:00 PM shift) stated the resident was not able to turn and position themselves and required assistance. Certified Nursing Assistant #2 stated they turned the resident to place the resident on a bedpan. During the day shift the resident did not stay in bed and was always out of bed. During an interview on 2/28/2025 at 9:07 AM, Rehabilitation Director #1 stated that initially, the resident was dependent on one person for bed mobility and turning and positioning, and with therapy, the resident's bed mobility status improved and the resident required supervision and touching assistance of one person for rolling. During an interview on 2/28/2025 at 10:00 AM, Certified Nursing Assistant #3 (11:00 PM-7:00 AM shift) stated the resident was very alert and would call staff by using the call bell when they needed something, for instance, water, pain medication, or ask to use the bedpan. Certified Nursing Assistant #3 stated they turned and positioned the resident maybe two times during the night. During an interview on 2/28/2025 at 10:09 AM, Certified Nursing Assistant #4 (3:00 PM-11:00 PM shift) stated the resident was alert. The resident usually went back to bed at 8:00 PM and requested to use the bedpan. Certified Nursing Assistant #4 stated they could not remember if there was a spot in the accountability to document turning and positioning. Being that the resident was alert, they would let me know if they were uncomfortable; the resident was just fine. During an interview on 2/28/2025 at 12:19 PM, Assistant Director of Nursing/Wound Care Nurse #1 stated they could not explain why the turning and positioning every two hours intervention was not in place in the Nursing Care Instructions since the resident's admission and why the turning and positioning intervention was first added on 1/30/2025. Assistant Director of Nursing/Wound Care Nurse #1 stated they did not know where the Certified Nursing Assistants would document the turning and positioning every two hours but said turning. During an interview on 2/28/2025 at 12:30 PM, Registered Nurse Admission Nurse #3 stated during the admission assessment the resident was able to turn and position themselves, therefore turning and positioning was not added to the resident's care profile. Registered Nurse Admission Nurse #3 stated the resident must have deteriorated which is why turning and positioning was added on 1/30/2025. During an interview on 2/28/2025 at 1:35 PM, the Director of Nursing Services stated if the admission nurse did an assessment and turning and positioning was not necessary, then that is why turning and positioning was not put in the care profile initially. It is the facility's general policy that turning and positioning is completed every two hours. The Director of Nursing Services stated stated they were not sure if that is in writing in a policy. 10 NYC RR 415.12(c)(1)(2)

Based on record review and staff interviews during the Recertification Survey initiated on 2/24/2025 and completed on 2/28/2025, the facility did not conduct a comprehensive assessment of a resident not less than once every 12 months while a resident. This was identified for one (Resident #78) of one resident reviewed for the Resident Assessment Task. Specifically, Resident #1's Admission Minimum Data Set assessment was completed on 2/7/2024. The Annual Minimum Data Set (MDS) assessment was completed on 2/10/2025, which was 369 days from the previous comprehensive assessment. Additionally, the Assessment Reference Date for the Annual Minimum Data Set was 1/20/2025 and the assessment was not completed until 21 days after the Assessment Reference date. The finding is: The facility's policy and procedure titled Resident Assessment Instrument (MDS 3.0), last revised on 10/1/2023, documented that the Annual (Comprehensive Assessment) is completed within 366 days of the previous Comprehensive Assessment reference date and within 92 days of the previous Quarterly Assessment reference date. Resident #78 was admitted with diagnoses including Cellulitis (bacterial skin infection) of the Right Lower Limb, Hypertension, and Dysuria (painful or uncomfortable urination). The Annual Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #78 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated Resident #78 had mild cognitive impairment. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented Section Z (Assessment Administration) was not completed until 2/20/2025, 21 days after the assessment reference date. During an interview on 2/25/2025 at 1:51 PM, the Minimum Data Set (MDS) Director stated that Resident #78's Annual Minimum Data Set assessment was just completed and submitted today (2/25/2025) at 1:39 PM. The Minimum Data Set Director stated that the Minimum Data Set should have been completed on 2/3/2025, which was 14 days after the assessment reference date. The Minimum Data Set Director stated they were on vacation at the time the assessment was due, and any Registered Nurse could have completed the Minimum Data Set assessment. During an interview on 2/27/2025 at 8:53 AM, the Director of Nursing Services stated the staff have five days to complete the assigned section of the Minimum Data Set. The Director of Nursing Services stated that the Minimum Data Set Coordinator should ensure that the Minimum Data Set assessment is completed timely. During an interview on 2/27/2025 at 12:19 PM, the Administrator stated all Minimum Data Set assessments should be completed on time. The Administrator stated that a backup Minimum Data Set (MDS) assessor should be in place to ensure the timely completion and transmission of the Minimum Data Set (MDS) assessment. 10 NYCRR 415.11(a)(3)(i)

Based on record review and staff interviews during the Recertification Survey initiated on 2/24/2025 and completed on 2/28/2025, the facility did not ensure that all completed Minimum Data Set (MDS) assessments were electronically transmitted to the Center for Medicare and Medicaid Services (CMS) within 14 days of the resident assessment completion. This was identified for one (Resident #78) of one resident reviewed for the Resident Assessment Task. Specifically, Resident #78's Annual Minimum Data Set (MDS) assessment was completed on 2/10/2025; however, the assessment was not electronically submitted to the Center for Medicare and Medicaid Services (CMS) until 2/25/2025, 15 days after the completion date. The finding is: The facility's policy and procedure titled Resident Assessment Instrument (MDS 3.0), last revised on 10/1/2023, documented that the Minimum Data Set (MDS) process requires input from the health care team to complete the designated areas in a timely and accurate fashion in accordance with State and Federal regulations. The Minimum Data Set (MDS) Coordinator is responsible for the electronic transmission process. The transmission will occur as dictated by the Resident Assessment Instrument Manual. Resident #78 was admitted with diagnoses including Cellulitis (bacterial skin infection) of the Right Lower Limb, Hypertension, and Dysuria (painful or uncomfortable urination). The Annual Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #78 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated Resident #78 had mild cognitive impairment. A review of the Minimum Data Set (MDS) 3.0 Nursing Home Validation Report provided by the facility revealed the following: Resident #78's Annual Minimum Data Set (MDS) assessment with the reference date of 1/20/2025 was completed on 2/10/2025; however, the assessment was not electronically submitted to the Center for Medicare and Medicaid Services (CMS) until 2/25/2025, 15 days after the completion date. During an interview on 2/25/2025 at 1:51 PM, the Minimum Data Set (MDS) Director stated Resident #78's Minimum Data Set assessment was transmitted today (2/25/2025) at 1:39 PM. The Minimum Data Set Director stated that the Minimum Data Set assessment should have been transmitted on 2/17/2025. The Minimum Data Set Director stated they were on vacation at the time the assessment was due for transmission and any Registered Nurse could have completed and transmitted the Minimum Data Set assessment. During an interview on 2/27/2025 at 8:53 AM, the Director of Nursing Services stated the staff have five days to complete the assigned section of the Minimum Data Set. The Director of Nursing Services stated that the Minimum Data Set Coordinator should transmit the completed Minimum Data Set assessment timely. During an interview on 2/27/2025 at 12:19 PM, the Administrator stated all Minimum Data Set assessments should be completed and transmitted to the Centers for Medicare and Medicaid Services on time. The Administrator stated that a backup Minimum Data Set (MDS) assessor should be in place to ensure the timeliness of the completion and transmission of the Minimum Data Set (MDS) assessment. 10 NYCRR 415.11(a)(3)(i)

Based on observation, interviews, and record review during an abbreviated survey with complaint # NY00350920, the facility did not ensure that the environment remained secure and free from accident hazards for one (Resident #1) of three residents reviewed for elopement. Specifically, Resident #1 with severe impaired cognition and assessed as an elopement risk exited the facility undetected by staff through an unalarmed south stairwell emergency exit door at 5:55PM. Resident #1 was found by local law enforcement 0.2 miles away from the facility at 6:40PM. The facility staff identified Resident #1 missing at 8PM. There are 12 other residents identified as elopement risk. The findings are: The facility's policy and procedure titled Elopement and Prevention effective 10/1/2005 and revised on 5/15/24 documented that it is the policy of the facility to provide safe and secure environment for all residents. In the event of resident elopement, it is the policy of the facility to implement the policy and procedure immediately to locate the missing resident in a timely manner. The policy will also be used to train and maintain staff awareness of the importance of resident safety and security. The facility's policy and procedure titled Wander Guard with effective date 10/2008 and revised on 11/2023 documented that Licensed staff to monitor residents for need to wear transmitter, based on resident assessment and risk of elopement. Use prior history of and/or observations. Ensure the care plan and the Certified Nursing Assistant accountability sheet reflect transmitter use. Ensure that residents have transmitters in place and that Certified Nursing Assistant or Nurse check for proper placement and signs of skin irritation or discomfort caused by transmitter band. Documents in medical record the placement of the alarm. Certified Nursing Assistant to report observations of wandering residents to the unit manager or supervisor. All attempts by a resident attempting to elope shall be reported immediately to the Unit manager or Supervisor. Resident #1 was admitted to the facility with diagnoses including Fall and neck pain, Acute Rhabdomyolysis, Urinary Tract Infection, Anxiety Disorder with behavioral issues, Vascular Dementia and Metabolic Encephalopathy. The Minimum Data Set, dated dated dated [DATE] identified the Resident #1's cognitive status as severely impaired, with a Brief Interview Mental Status Score of 5. Resident #1 required supervision to total assistance with activities of daily living. The Elopement Risk assessment dated [DATE], documented Resident #1 was at risk for elopement. The Behavior Symptoms: Wandering Care Plan initiated on 8/8/24 documented that Resident #1 was noted with exit seeking behavior, elopement assessment done, and wander guard placed on right hand. Interventions noted in place that included administer medications as ordered by physician. Ensure proper placement of right-hand wander guard and check for any malfunction. Notify MD and refer resident for psychological services as needed. Regularly assess and evaluate risk for elopement. Physician's Orders dated 8/8/24 documented an order for Wander guard - Check every shift for placement and location of device to right hand. Treatment Administration Record (TAR) on 8/8/24 initiated wander guard to right hand and to check for placement every shift. The nurses' documented for 3-11 and 11-7 shifts with their initials. On 8/9/24 the nurses documented for all 3 shifts and on 8/10/24 the nurses documented for the 7-3 and 3-11 shifts. The Certified Nursing Assistant (CNA) Accountability Record dated 8/10/24 showed Certified Nursing Assistant #2 documented a dash (-) for the 3-11 shift. The legend showed the dash (-) represented as Not Documented. The checking for wander guard function was done on 11-7 shift, nurses documented on 8/8/24 and 8/9/24. A facility Investigation Summary dated 8/10/24 documented that on 8/10/24 at 7:30 PM, Licensed Practical Nurse #1 noted that Resident #1 was not in their room and nearby hallway. Licensed Practical Nurse #1 immediately alerted floor staff to search the unit for Resident #1. A head count was conducted. At 8 pm the resident was not located, and the nursing supervisor was informed and announced, Code Orange (missing resident). The staff were assigned to search the entire building, immediate property, and the local community but the search was unsuccessful. Nursing supervisor called 911 to report elopement. At approximately 9 PM, a local law enforcer arrived at the facility and informed the nursing supervisor that Resident #1 was located and was transported to the hospital for evaluation. The nursing supervisor called the hospital and was informed that Resident #1 appeared uninjured and was expected to return to the facility. A review of surveillance cameras conducted on 8/20/2024 revealed that on 8/10/2024 Resident #1 left the dining room at about 5:40 PM. At 5:41 PM Resident #1 was seen entering the opened elevator. Resident exited the elevator in the basement level and walked towards the rear of the building and exited from the first-floor south stairwell emergency exit door into the parking lot at 5:55 PM. Resident #1 is seen walking towards the main street and out of camera range by 5:56PM. The facility is located on a 4-lane high traffic street. There is no documented progress note from the unit nurse on 8/11/2024 regarding an incident. The Nursing Supervisor Nurse's Progress notes dated 8/11/24 documented that they were informed by staff that Resident #1 was missing at approximately 8PM. Initiated unit search, unable to locate resident. Code orange was activated and every resident on the floor was accounted for. Resident #1 was unable to be found in the facility. Police were made aware. The police arrived at the facility and informed the staff that the Resident #1 was at the Hospital for evaluation. Doctor's Progress Notes dated 8/12/24 documented that Resident #1 admitted to the hospital after an elopement incident. Psychiatry Consults dated 8/15/24 documented a Mental Status Exam, Resident #1's mood and affect were normal. No suicidal or homicidal ideation or plans, denied hallucinations, has limited though acceptable memory, cognition, insight, and judgement. No evidence of impulsivity. During an interview with Certified Nursing Assistant #2 on 8/26/24 at 10:43 AM stated that they were assigned to Resident #1 for 3-11 shift on 8/10/24. Resident #1 was assisted to the bathroom before dinner time. At approximately 7:30-7:45 PM they were informed that Resident #1 was missing. Certified Nursing Assistant #2 started the search inside the facility and the neighborhood but was unsuccessful. Certified Nursing Assistant #2 also added that wander guard placement was checked by the nurses every shift and if a resident with wander guard passed by the elevator it sets off the alarm and everyone responds to that alarm. Certified Nursing Assistant #2 also stated that they left the Certified Nursing Assistant accountability record blank when documenting for care provided for Resident #1 for that shift since Resident #1 was not in the building. During an interview with Licensed Practical Nurse #1 on 8/20/2024 at 3:20 PM stated they were working that evening shift and at around 7:30 PM they assisted Resident #1's roommate to bed when they noticed that Resident #1 was not in their bed. Licensed Practical Nurse #1 asked staff about resident #1's whereabouts but they also did not see Resident #1. They called the nursing supervisor and informed them that Resident #1 was missing. Nursing Supervisor alerted all staff and started the search but Resident #1 was not found. Later the nursing supervisor informed the staff that Resident #1 was found by the police. Licensed Practical Nurse #1 stated that they checked Resident #1's wander guard around 3PM when Resident #1 passed by the unit's elevator, and it activated the elevator's alarm. The last time they saw Resident #1 was when they gave them their 5 PM medicine. Licensed Practical Nurse #1 further added that the nurses monitored the hallway while giving the residents medication and the residents who were high risk for elopement stayed in the dining room with one Certified Nursing Assistant watching them. During an interview with Unit Manager on 8/20/24 at 11:40 AM, the Unit manager stated that on 8/8/24 Resident #1 walked and attempted to get on the unit's elevator, an elopement risk assessment was completed, and wander guard was placed on Resident #1's right wrist. They stated that they were not working that day of the incident but received a call around 9PM that Resident #1 had eloped but was found by the police at a convenient store and was brought to the hospital. During an interview and tour with Director of Maintenance on 8/20/24 at 1:45 PM they stated that the first-floor emergency exit door next to the kitchen where Resident #1 exited had no alarm and that door was used by staff and delivery personnel. If the resident with a wander guard attempts to get on the elevator, the elevator locks and alarm goes off until staff placed the code to deactivate it. During an interview with Director of Nursing on 8/20/24 at 2:40 PM they were made aware of the incident around 8:35-8:40 PM that Resident #1 was missing, and an expanded search was done, and law enforcement was called. Resident #1 exited through the side back emergency exit door that was not alarmed. Around 9PM Resident #1 was located by police and was taken to the hospital. Director of Nursing stated that Resident #1's wander guard was found in the dining room and was intact. During an interview with the Administrator on 8/20/24 at 3PM, stated that at 8:35 PM they were informed that Resident #1 was missing, code orange was announced and the search for Resident #1 was started but unsuccessful, then 911 was called. They were on their way to the facility when the Assistant Director of Nursing called and reported that Resident #1 was located by the police and taken to the hospital. 10 NYCRR 415.12(h)(2)

F602 Based on observations, interviews, and record reviews conducted during an abbreviated survey (Case #NY00329271), the facility did not ensure each resident was free from misappropriation of resident property and exploitation for 2 (Resident #1 and Resident #2) of 3 residents reviewed. Specifically, Resident #1 credit cards was fraudulently used, and 30 dollars was taken while a resident in the facility, Resident #2 had 500 dollars taken from their purse. This is evidenced by: A Policy and Procedure (P&P) titled Abuse Prevention dated February 2023 documented the following: procedures were in place for screening and training employees, protection of residents and for the prevention, identification, investigation and reporting of abuse, neglect, mistreatment, and misappropriation of resident property to ensure that the facility was doing all that was within its control to prevent occurrences. The policy defined Misappropriation of Resident Property as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings, or money without the resident's consent. The policy defined Exploitation as the act of taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats or coercion. Resident #1: Resident #1 was admitted with medical dx including Multiple sclerosis, major depressive disorder and muscle wasting and atrophy admitted to the facility 10/27/23. The Admission Minimum Data Set (MDS) dated [DATE] documented resident with a Brief Interview Mental Score (BIMS) of 15 and is understood and understands. Resident requires partial/moderate assistance with personal hygiene and upper body dressing. The Comprehensive care plan dated October 2023 titled dignity and respect document resident will be always treated with dignity respect and consideration. The intervention documented the facility will provide safe clean and comfortable room and surroundings. The Facility Grievance Form dated 12/4/23 documented the following: 1 bank credit card was taken from resident wallet and 32dollars in cash stollen. Charges to different credit card was made on different dates and different times. The investigation/findings documented all staff working from 10/27/23-11/7/23 were interviewed. Resident was referred for psychology services 12/4/23 Reported to Department of Health and county police. There was no documented progress note. The psychology progress note dated 12/6/2023 documented Therapist met with resident and utilized reflective listening and validation. Resident presented as well-groomed, had euthymic affect, and was in a neutral mood. Worked on developing therapeutic rapport with resident. Resident discussed theft incident that occurred with her. Resident processed this and feelings toward this, impacting mood. Resident #2 Resident #2 was admitted with a medical diagnose including Hypertension Anemia, muscle wasting atrophy status post fracture of right femur BIMS of 13, understood and understands. Requires supervision with personal hygiene and dressing. The Facility grievance form dated 12/4/23 documented Resident reported missing money to nursing supervisor on 12/4/23 at 11:15 am. The investigation and findings document Certified Nurses interviewed, Inservice's on misappropriation of resident's property provided to all staff for education purposes. Police investigation initiated and State Agency notified 12/5/23. Emotional support provided-referred to psychological services. The psychology progress note dated 12/5/2023 at 1:47 pm documented therapist met with resident and utilized reflective listening and validation. Resident presented as well-groomed, had euthymic affect, and was in a neutral mood. Resident discussed the theft incident that occurred. Resident processed her feelings about this and how this triggered symptoms. Resident shared feeling better that the person who did this was caught. A social service note dated 12/11/23 at 12:12 PM documents Resident has been seen by psychology for emotional support due to loss of $500. Police report was made with [NAME] County Police Department. The facility did not secure the camera footage. According to the Administrator it was recorded over. The facility did not obtain a copy of the police report. During an interview conducted with Resident #1 on 1/31/23 at 11:48 am who stated the theft occurred between 11/1 and 12/1. Resident #1 states their credit card had a with zero balance and in December they noticed card had an 800-dollar balance. Resident #1 stated when they checked their personal belongings, the credit card, 30 dollars in cash and 100 dollars in postage stamps were missing. Resident #1 reported it to social worker and the facility called the police who responded. Resident #1 stated they were not offered a lock box on admission and was not aware one was available. Resident #1 stated after the theft they were offered and provided a key for the top draw of the nightstand where her personal belongings are now secured. Resident #1 stated the facility did not return the cash, and they are disputing the charges with the bank. Resident #1 stated another resident also had personal property stolen and were aware the facility had some suspects. During an interview on 1/31/24/ at 12:04 Resident #2 states that about a month ago at someone came into her room during the night and took a cosmetic bag that was kept in her pocketbook with 500dollars and left the content of the pocketbook on the bedside table and floor including her husband's wallet. Resident stated they discovered this at 5am and notified the nurse on the unit immediately. The resident stated she was admitted from an assisted living facility where they had a locked box and was not offered a lock box on admission. Resident #2 stated they kept the cash to give the grandchildren when they visit and to order take out. Resident #2 became tearful and stated she can no longer order takeout when they do not like the food and does not have any money to give the grandchildren when they visit. Resident #2 stated the facility notified the police and the staff members that worked the night are not on the unit but have not replaced the money. Certified Nursing Assistant CNA #1 and CNA #2 were not available for an interview, despite multiple attempts. An interview was conducted with the Director of Social Services (DSW) on 1/31/2024 at 2PM who states that 12/4/23 it was reported that resident #1's credit card had been used fraudulently. DSW reported she interviewed all alert residents and no other concerns. The DSW stated she became aware of Resident #2 and notified the police. The DSW reports 2 agency aids were suspected as they worked the unit with resident #2 and have worked with Resident #1 and previously worked with resident #3 who also had missing funds. The DSW stated that the agency was notified not to send them back. The DSW stated resident were not reimbursed for the missing funds because it was the staff that stole the money and the residents wanted to press charges. The DSW stated they did not document any notes related to resident #1 and there are no care plans. The DSW further stated Resident #1 accepted the lock for the top draw personal belongings but Resident #2 declined as they no longer have anything of value to keep. An interview was conducted with the Facility Administrator on 1/31/2024 at 3pmThey stated they became aware of the incident on 12/4/23 with resident #2. The Administrator stated they reviewed camera footage from the overnight shift and observed Certified Nursing assistant #1 enter the resident's room multiple times. The administrator stated there is no camera footage in the room but based on the resident's allegation, time frame and the observation of the hallway camera they concluded the agency CNA would not return and it was reported to the police. During the investigation they identified CNA#1 and CNA#2 have worked with resident #1, 2 and Resident #3 who previously reported missing credit cards and money. The administrator stated she reported the information to the police. The administrator further stated the facility does not replace money. The resolution to the grievance is the CNAs are off the schedule and the police is doing the investigation. The administrator stated all background checks including the state mandated Criminal History Record Check (CHRC) are completed thru the agency. The administrator states that once an employee is made available thru the agency they have been cleared, and they do not review any documents. The Administrator was unable to obtain a completed CHRC from the agency as of 02/15/2024. 10NYCRR 415.4(b)

Based on observation, record review, and interviews during the Recertification Survey initiated on 12/10/2023 and completed on 12/14/2023 the facility did not ensure each resident remained free of significant medication errors. This was identified for three (Resident #29, Resident #95, and Resident #92) of three residents reviewed for significant medication errors. On 12/10/2023 multiple residents received their medications late because the 11:00 PM-7:00 AM shift Licensed Practical Nurse #8 completed the medication administration pass late which then caused Licensed Practical Nurse #5 to administer medications to the residents late on the 7:00 AM-3:00 PM shift. Specifically, 1) Resident #29 received the physician ordered 6:00 AM and 6:30 AM pain medication and Thyroid medication at 8:02 AM, 2) Resident #95 received the physician ordered insulin and blood glucose check at 10:01 AM instead of 7:30 AM and also at 3:12 PM instead of 11:30 AM, and 3) Resident #92 received the physician ordered pain medication and Thyroid medication at 8:05 AM instead of 6:00 AM and also at 3:46 PM instead of 2:00 PM. The findings include, but are not limited to: The 7:00 AM-3:00 PM Licensed Practical Nurse (LPN) (LPN #5) was observed by a medication cart preparing medications to give to residents on 12/10/2023 at 11:40 AM on the 2nd Floor. LPN #5 was interviewed on 12/10/2023 at 11:40 AM and stated that they (LPN #5) were still giving out 9:00 AM medications at 11:40 AM because the 11:00 PM-7:00 AM LPN (LPN #8) had delayed them (LPN #5). LPN #5 stated that LPN #8 was still giving out medications until 9 AM and they (LPN #5) were unable to use the medication cart because LPN #8 was using it. LPN #5 stated that they came in at 7:00 AM but were unable to use the medication cart until 9:00 AM. LPN #5 stated that at 9:00 AM, they (LPN #5) first did the narcotic count, then blood pressure checks, then residents needing insulin with the residents' other medications at the same time, then residents who needed Tylenol, and then they (LPN #5) had to speak with a resident's family because the resident was getting intravenous (IV) fluids and the resident's family had questions. LPN #5 stated that they (LPN #5) were only about halfway through giving out all the 9:00 AM medications. The Administration Documentation Audit Detail Report dated 12/9/2023-12/10/2023 revealed 12 residents received their medications late during the 11:00 PM-7:00 AM shift on 12/10/2023. The Administration Documentation Audit Detail Report dated 12/10/2023 revealed 22 residents received their medications late during the 7:00 AM-3:00 PM shift on 12/10/2023. 1) Resident #29 has diagnoses that include Pain and Hypothyroidism. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 9 which indicated that the resident had moderately impaired cognitive skills for daily decision making. The Physician Order dated 9/15/2023 and last renewed 12/13/2023 documented for the resident to receive Acetaminophen (an analgesic drug used to relieve mild or chronic pain) 325 milligrams (mg) - give 2 tablets (650 mg) by oral route every 6 hours for Pain; Synthroid (a thyroid medication that replaces a hormone produced by your thyroid gland to regulate the body's energy and metabolism) 25 micrograms (mcg) by oral route daily for Hypothyroidism; and Tramadol (an opioid pain medication) 50 mg tablet every 8 hours for Unspecified Abdominal Pain. The Medication Administration Record (MAR) for December 2023 documented that the Acetaminophen, Synthroid, and Tramadol medications were given as ordered on 12/10/2023. The Administration Documentation Audit Detail Report documented on 12/10/2023 that Resident #29 received Acetaminophen and Tramadol at 8:02 AM instead of 6:00 AM and Synthroid at 8:02 AM instead of 6:30 AM. Resident #29 was interviewed on 12/14/2023 at 12:21 PM and stated when they receive their (Resident #29) pain medication late, they (Resident #29) are in pain. Resident #29 stated that they usually ring their call bell to get their medications when the medications are late. Resident #29 stated that they recall a few days ago when they had to wait to receive their Tylenol and Tramadol medications for their pain. Resident #29 stated that they (Resident #29) received their (Resident #29) pain medications late on that day (12/10/2023). The Director of Nursing Services (DNS) was interviewed on 12/14/2023 at 3:22 PM and stated that pain medications should be given timely. The DNS stated that a Nurse should notify their Registered Nurse (RN) Supervisor anytime when they are running late with giving out medications. The DNS stated that the RN Supervisor on the 11:00 PM - 7:00 AM was never made aware when LPN #8 was running late and should have been. The Medical Director was interviewed on 12/14/2023 at 3:35 PM and stated that if pain medications are not given timely, a resident may have discomfort. The Medical Director stated that the result of receiving pain medication late varies for each individual. The Medical Director stated that if the resident was feeling pain, that was what they were feeling. The Medical Director stated that there was no problem receiving Synthroid medication late. 2) Resident #95 has diagnoses that include Muscle Wasting and Atrophy and Type 2 Diabetes Mellitus without Complications. The admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 6 which indicated that the resident had severely impaired cognitive skills for daily decision making. The Physician Order dated 10/2/2023 and last renewed 12/13/2023 documented for the resident to receive Metformin 1,000 milligrams (mg) tablet - give 1 tablet (1000 mg) by oral route 2 times per day with food every day at 5:00 PM and 9:00 AM for Type 2 Diabetes Mellitus. A Physician Order dated 11/14/2023 and last renewed on 12/13/2023 documented to administer Humalog KwikPen (U-100) Insulin 100 unit/milliliter (mL) subcutaneous, inject by subcutaneous route per prescriber's instructions. Insulin dosing requires individualization. Every Day at 11:30 AM; 4:30 PM; 7:30 AM. Protocol: For blood sugar (BS): 70-150=0 Units, 151-200=2 Units, 201-250=4 Units, 251-300=6 Units, 301-350=8 Units, 351-400=10 Units. Call Medical Doctor (MD) for BS less than 70 or greater than 400 for Type 2 Diabetes Mellitus. The Medication Administration Record (MAR) for December 2023 documented the medications were given as ordered on 12/10/2023 and the resident's blood glucose level was 288 and 6 units of Humalog insulin were given at 7:30 AM and the resident's blood glucose level for 11:30 AM was 146 with no insulin given. The Administration Documentation Audit Detail Report documented that on 12/10/2023 the resident received the Humalog insulin and blood glucose check at 10:01 AM instead of 7:30 AM and at 3:12 PM instead of 11:30 AM. Resident #95 was interviewed on 12/14/2023 at 1:56 PM. Resident # 95 stated that it was important to get their insulin before meals. Resident #95 stated that at times the Nurses check their (Resident #95) blood glucose level after a meal and then their (Resident #95) blood glucose level was not accurate. The Director of Nursing Services (DNS) was interviewed on 12/14/2023 at 3:25 PM and stated that Breakfast is served at 7:30 AM. The DNS stated that blood glucose checks should be done before meals and insulin should also be given before meals. The Medical Director was interviewed on 12/14/2023 at 3:41 PM and stated that blood glucose levels should be done before meals. 3) Resident #92 has diagnoses that include Pain and Hypothyroidism. A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 10 which indicated that the resident had moderately impaired cognitive skills for daily decision making. The Physician Order dated 10/15/2023 and last renewed 12/7/2023 documented for the resident to receive Oxycodone (an opioid medication used to treat moderate to severe pain) 5 milligrams (mg) tablet give 1 tablet (5 mg) by oral route every 8 hours for 14 days at 10:00 PM, 2:00 PM, and 6:00 AM for Pain and Synthroid (a thyroid medication that replaces a hormone produced by your thyroid gland to regulate the body's energy and metabolism) 75 micrograms (mcg) daily at 6:00 AM for Hypothyroidism. The Medication Administration Record (MAR) for December 2023 documented that the Oxycodone and Synthroid medications were given as ordered on 12/10/2023. Oxycodone was to be given at 6:00 AM, 2:00 PM, and 10:00 PM and Synthroid at daily at 6:00 AM. The Administration Documentation Audit Detail Report documented that on 12/10/2023 the resident received the Oxycodone and Synthroid medications at 8:05 AM instead of 6:00 AM and 3:46 PM instead of 2:00 PM. Resident #92 was interviewed on 12/14/2023 at 1:58 PM. Resident #92 stated that when they receive their pain medication late, they are in pain. The Director of Nursing Services (DNS) was interviewed on 12/14/2023 at 3:25 PM and stated that the resident's Synthroid medication should have been provided before meals in the morning. The Medical Director was interviewed on 12/14/2023 at 3:35 PM and stated that if pain medications are not given timely, a resident may have discomfort. The Medical Director stated that the result of receiving pain medication late varies for each individual. The Medical Director stated that if the resident was feeling pain, that was what they were feeling. The Medical Director stated that there was no problem receiving Synthroid medication late. The Assistant Director of Nursing Services (ADNS) #2 was interviewed on 12/14/2023 at 3:59 PM and stated that LPN #8 should have notified their Registered Nurse (RN) Supervisor when they (LPN #8) required assistance with medication administration. The 11 PM-7 AM LPN (LPN #8) was interviewed on 12/14/2023 at 3:46 PM and stated that they (LPN #8) were late in giving out medications because they had to help the Certified Nursing Assistants (CNAs) give care to residents and then started the medication pass late. LPN #8 stated that there was also a resident that could not breathe, and they (LPN #8) had to look for an oxygen tank. LPN #8 stated it was their first day working and did not know where to find an oxygen tank in the facility. LPN #8 stated that since it was their (LPN #8) first day working at the facility, they had to learn all the residents and the Electronic Medical Record (EMR) system. LPN #8 stated that they (LPN #8) should have called the RN Supervisor but did not know who to call. LPN #8 stated that by starting the medication pass late, this caused a [NAME] effect that impacted the other Nurse on the following 7:00 AM-3:00 PM shift. LPN #8 stated that they completed their medication pass at 9:00 AM. LPN #8 stated that they (LPN #8) were not aware that they (LPN #8) should have called the RN Supervisor but knew to go through the chain of command. LPN #8 further stated that there was a Charge Nurse on their (LPN #8) shift but they did not want to bother them. 10 NYCRR 415.12(m)(2)