Every finding on record at Dumont Center for Rehabilitation and Nursing Care

Based on observation, record review, and interviews conducted during the Recertification and Abbreviated (iQIES Complaint 646935) Survey, the facility failed to ensure that residents' comprehensive care plans were reviewed and revised by the interdisciplinary team periodically and after each comprehensive and quarterly review assessments. Additionally, the facility failed to ensure that a quarterly care plan meeting was held for each resident. This was evident for three (3) (Residents #35, #209 and #149) of 36 total sampled residents. Specifically, 1.) Resident #35's Abuse care plan was not reviewed and revised after each assessment, 2.) Resident #209, who had orders for intravenous hydration, had no care plan to address the intravenous fluid therapy, and 3.) Resident #149' quarterly care plan meeting was not held, as a result the resident was not able participate in the review and revision of their comprehensive care plan. The findings include: The facility policy and procedure titled Care Plan dated 11/06/2018 documented the comprehensive care plan will be reviewed and evaluated quarterly, annually, and when there is a significant change in the resident's condition, in conjunction with the Minimum Data Set Assessment. 1. Resident #35 had diagnoses of Paranoid Personality Disorder (distrust and suspicion of others), Major Depressive Disorder (persistent feelings of sadness or loss of interest), and Chronic Obstructive Pulmonary Disease (breathing is difficult due to air flow obstruction). The Quarterly Minimum Data Set assessment (a resident assessment tool) dated 11/13/2025 documented Resident #35 had intact cognition and required supervision to moderate assist with activities of daily living, bed mobility, manual wheelchair use, and ambulation. A Comprehensive Care Plan for abuse was established for Resident #35 on12/25/2023 and was last revised on 02/19/2024. There was no documented evidence that the Abuse Care Plan was evaluated or revised after 02/19/2024. On 01/22/2026 at 3:05 PM, Social Worker #1 was interviewed and stated that the abuse care plan must be updated quarterly and periodically if there is an occurrence. They stated they are not sure how the abused care plan was not updated after 02/19/2024. On 01/22/2026 at 3:27 PM, the Director of Social Services was interviewed and stated their department is responsible for evaluating and updating Resident #35's abuse care plan. The Director of Social Service stated they have a consultant who audits the care plans but recently the consultant was filling in for a social worker who was on vacation. 2. Resident #209 was admitted to the facility with diagnoses that included Seizure Disorder, Hypothyroidism, and Malignant Neoplasm of Brain. The admission Minimum Data Set, dated [DATE] documented moderately impaired cognition. A nurse's progress note dated 03/14/2025 at 12:40 PM documented that Resident #209 was weak and had poor oral intake. The resident was seen by the physician and ordered intravenous hydration. A physician's order dated 03/14/2025 included 0.45% Sodium Chloride Intravenous Solution at 50 cubic centimeter per hour every shift for hydration. The Medication Administration Record for March 2025 revealed 0.45% Sodium Chloride Intravenous Solution was administered from 03/14/2025 at 3:30PM shift to 03/17/2025 at 7:30 AM shift. There was no documented evidence that Resident #209's comprehensive care plan was reviewed and revised to reflect Resident #209's intravenous fluid therapy. On 01/22/2026 at 9:45 AM, the Director of Nursing stated the unit manager is responsible for revising and updating the care plans. 3. The facility's policy titled Resident Assessment Instrument and Care Planning dated 11/06/2025 documented resident and /or resident's family will be invited to attend the interdisciplinary care plan meeting for comprehensive assessments. Resident #149 was admitted to the facility with diagnoses that included Diabetes Mellitus and End Stage Renal Disease. The Quarterly Minimum Data Set, dated [DATE] documented that Resident #149 had intact cognition and that resident and the family participated in assessment and goal setting. On 01/15/2026 at 11:10 AM, Resident #149 was interviewed and stated they do not remember being invited or attending a care plan meeting. The Care Plan Meeting Schedule documented that Resident #149 was scheduled for a care conference on 12/09/2025 and 12/11/2025. However, there was no documented evidence in Resident #149's medical record that a care plan meeting was held. On 01/23/2026 at 9:52 AM, Social Worker #2 was interviewed and stated they were the social worker assigned to Resident #149 and was responsible for scheduling the care plan meeting. They stated that the resident had a care plan meeting scheduled for 12/09/2025 and 12/11/2025 but the meeting was not held because they did not realize that it was supposed to be a quarterly meeting. On 01/23/2026 at 11:59 AM, the Minimum Data Set Coordinator was interviewed and stated that Resident #149's last quarterly assessment was on 11/26/2025. They stated that the assessment schedule was sent by their department, but it is the social worker's responsibility to schedule the meeting. On 01/23/2026 at 12:46 PM, the Social Worker Director was interviewed and stated that Resident #149's care plan meeting may not have officially taken place, but they are in contact with the family if there are any concerns. On 01/23/2026 at 2:27 PM, the Director of Nursing was interviewed and stated that the Minimum Data Set department schedules the care plan meetings, and the Social Worker invites the residents and families. The Director of Nursing stated they were not aware that Resident#149's care plan meeting was not held as scheduled. 10 NYCRR 415.11(c)(2) (i-iii)

Based on observation, record review, and interviews, the facility failed to ensure that sufficient nursing staff were available to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, the facility reported short staffing on weekends confirmed by a review of the Daily Staffing and the Payroll Based Journal Staffing Data Report, and interviews with the Resident Council and other residents and representatives.The findings include but are not limited to:The undated document titled Nursing Par/Minimum Daily Staffing documented a staffing plan by shift and unit with par levels as follows:Day shift by unit:1st floor: 2 Registered Nurses/Licensed Practical Nurses and 5 Certified Nursing Assistants2 North: 1 Licensed Practical Nurse and 3.5 Certified Nursing Assistants2 South: 1 Licensed Practical Nurse and 3.5 Certified Nursing Assistants3 North: 1 Licensed Practical Nurse and 4 Certified Nursing Assistants3 South: 1 Licensed Practical Nurse and 4 Certified Nursing Assistants4 North: 1 Registered Nurse/Licensed Practical Nurse and 3 Certified Nursing Assistants4 South: 2 Registered Nurses/Licensed Practical Nurses and 3 Certified Nursing AssistantsDay shift total: 9 Nurses and 26 Certified Nursing Assistants Evening shift by unit:1st floor: 2 Registered Nurses/Licensed Practical Nurses and 4 Certified Nursing Assistants2 North: 1 Licensed Practical Nurse and 2.5 Certified Nursing Assistants2 South: 1 Licensed Practical Nurse and 2.5 Certified Nursing Assistants3 North: 1 Licensed Practical Nurse and 3 Certified Nursing Assistants3 South: 1 Licensed Practical Nurse and 3 Certified Nursing Assistants4 North: 1 Registered Nurse/Licensed Practical Nurse and 3 Certified Nursing Assistants4 South: 2 Registered Nurses/Licensed Practical Nurses and 3 Certified Nursing AssistantsDay shift total: 9 Nurses and 21 Certified Nursing Assistants Night shift by unit:1st floor: 1 Registered Nurse/Licensed Practical Nurse and 3 Certified Nursing Assistants2 North: 1 Licensed Practical Nurse and 1.5 Certified Nursing Assistants2 South: 1 Licensed Practical Nurse and 1.5 Certified Nursing Assistants3 North: 1 Licensed Practical Nurse and 2 Certified Nursing Assistants3 South: 1 Licensed Practical Nurse and 2 Certified Nursing Assistants4 North: 1 Registered Nurse/Licensed Practical Nurse and 2 Certified Nursing Assistants4 South: 2 Registered Nurses/Licensed Practical Nurses and 2 Certified Nursing AssistantsDay shift total: 8 Nurses and 14 Certified Nursing Assistants Total staffing for 24-hour period: 26 Nurses and 61 Certified Nursing AssistantsReview of the actual weekend facility staffing schedule from 07/01/2025-09/30/2025 documented the following:On 07/05/2025 on the 7 AM-3 PM shift, there was a shortage of 1 Certified Nursing Assistant on the 2nd floor, 1 Certified Nursing Assistant on the 3rd floor, and 1 Certified Nursing Assistant on 4 South. On 07/05/2025 on the 3 PM-11 PM shift, there was a shortage of 1 Certified Nursing Assistant on the 3rd floor. On 07/05/2025 on the 11 PM-7 AM shift, there was a shortage of 1 Certified Nursing Assistant on 4 South and 1 Certified Nursing Assistant on 4 North.On 07/06/2025 on the 7 AM-3 PM shift, there was a shortage of 1 Certified Nursing Assistant on 2 North, 1 Certified Nursing Assistant on 2 South, and 1 Certified Nursing Assistant on 4 North.On 07/12/2025 on the 11 PM-7 AM shift, there was a shortage of 1 Certified Nursing Assistant on 3 North.On 07/13/2025 on the 7 AM-3 PM shift, there was a shortage of 1 Certified Nursing Assistant on the 2nd floor. On 07/13/2025 on the 11 PM-7 AM shift, there was a shortage of 1 Certified Nursing Assistant on 3 South and 1 Certified Nursing Assistant on 4 North.On 07/19/2025 on the 7 AM-3 PM shift, there was a shortage of 1 Certified Nursing Assistant on 2 South, and 1 Certified Nursing Assistant on 3 South. On 07/19/2025 on the 11 PM-7 AM shift, there was a shortage of 1 Certified Nursing Assistant and 1 Nurse on 4 South.On 07/20/2025 on the 7 AM-3PM shift, there was a shortage of 2 Certified Nursing Assistants on the 1st floor, 1 Certified Nursing Assistant on the 2nd floor, 1 Certified Nursing Assistant on 3 South, and 1 Certified Nursing Assistant on 4 North. On 07/20/2025 on the 3 PM-11PM shift, there was a shortage of 1 Certified Nursing Assistant.On 07/26/2025 on the 7 AM-3 PM shift, there was a shortage of 1 Certified Nursing Assistant. On 07/26/2025 on the 11 PM-7 AM shift, there was a shortage of 1 Certified Nursing Assistant on 4 South.On 07/27/2025 on the 7 AM-3 PM shift, there was a shortage of 1 Certified Nursing Assistant on the 2nd floor, 1 Certified Nursing Assistant on 3 South, and 1 Certified Nursing Assistant on 4 North. On 07/27/2025 on the 11 PM-7 AM shift, there was a shortage of 1 Certified Nursing Assistant on 3 South and 1 Certified Nursing Assistant on 4 North.On 08/02/2025 on the 11 PM-7 AM shift, there was a shortage of 1 Certified Nursing Assistant on 4 South.On 08/03/2025 on the 7 AM-3 PM shift, there was a shortage of 1 Certified Nursing Assistant on 3 South and 1 Certified Nursing Assistant on 4 North. On 08/03/2025 on the 3 PM-11 PM shift, there was a shortage of 1 Certified Nursing Assistant on the 1st floor.On 08/09/2025 on the 7 AM-3 PM shift, there was a shortage of 1 Certified Nursing Assistant on 3 South.On 08/10/2025 on the 7 AM-3 PM shift, there was a shortage of 1 Certified Nursing Assistant on the 1st floor, 2 Certified Nursing Assistants on the 2nd floor, 1 Certified Nursing Assistant on 3 North, 1 Certified Nursing Assistant on 3 South, and 1 Certified Nursing Assistant on 4 North. On 08/10/2025 on the 3 PM-11 PM shift, there was a shortage of 1 Certified Nursing Assistant on 4 North. On 08/10/2025 on the 11 PM-7 AM shift, there was a shortage of 1 Certified Nursing Assistant and 1 Nurse on 4 North.On 08/16/2025 on the 7 AM-3 PM shift, there was a shortage of 1 Certified Nursing Assistant on the 2nd floor, 1 Certified Nursing Assistant on 3 South, and 1 Certified Nursing Assistant on 4 South. On 08/16/2025 on the 3 PM-11 PM shift, there was a shortage of 1 Certified Nursing Assistant on 4 South. On 08/16/2025 on the 11 PM-7 AM shift, there was a shortage of 1 Certified Nursing Assistant on the 2nd floor, and 1 Certified Nursing Assistant and 1 Nurse on 4 South.On 08/17/2025 on the 7 AM-3 PM shift, there was a shortage of 1 Certified Nursing Assistant on the 2nd floor. On 08/17/2025 on the 3 PM-11 PM shift, there was a shortage of 1 Certified Nursing Assistant on 4 North. On 08/17/2025 on the 11 PM-7 AM shift, there was a shortage of 1 Certified Nursing Assistant on 3 South, and 1 Certified Nursing Assistant on 4 South.On 08/23/2025 on the 7 AM-3 PM shift, there was a shortage of 1 Certified Nursing Assistant on the 2nd floor, and 1 Certified Nursing Assistant on 3 South.On 08/24/2025 on the 7 AM-3 PM shift, there was a shortage of 1 Certified Nursing Assistant on the 2nd floor. On 08/24/2025 on the 11 PM-7 AM shift, there was a shortage of 1 Certified Nursing Assistant on 4 North, and 1 Nurse on 4 South.On 08/30/2025 on the 7 AM-3 PM shift, there was a shortage of 1 Certified Nursing Assistant on 3 South, and 1 Certified Nursing Assistant on 4 North. On 08/30/2025 on the 3 PM-11 PM shift, there was a shortage of 1 Certified Nursing Assistant on the 1st floor, 1 Certified Nursing Assistant on 2 South, 1 Certified Nursing Assistant on 4 North, and 1 Certified Nursing Assistant on 4 South. On 08/30/2025 on the 11 PM-7 AM shift, there was a shortage of 1 Certified Nursing Assisted on 3 North, 1 Certified Nursing Assistant on 4 North, and 1 Nurse on 4 South.On 08/31/2025 on the 7 AM-3 PM shift, there was a shortage of 1 Certified Nursing Assistant on the 2nd floor, and 1 Certified Nursing Assistant on 3 South. On 08/31/2025 on the 3 PM-11 PM shift, there was a shortage of 1 Certified Nursing Assistant on 4 South.On 09/06/2025 on the 7 AM-3 PM shift, there was a shortage of 1 Certified Nursing Assistant on 3 South. On 09/06/2025 on the 3 PM-11 PM shift, there was a shortage of 1 Certified Nursing Assistant on the 2nd floor.On 09/07/2025 on the 7 AM-3 PM shift, there was a shortage of 1 Certified Nursing Assistant on the 2nd floor, 1 Certified Nursing Assistant on 3 North, and 1 Certified Nursing Assistant on 4 South. On 09/07/2025 on the 11 PM-7 AM shift, there was a shortage of 1 Certified Nursing Assistant on 4 North.On 09/13/2025 on the 7 AM-3 PM shift, there was a shortage of 1 Certified Nursing Assistant on 3 South. On 09/13/2025 on the 3 PM-11 PM shift, there was a shortage of 1 Certified Nursing Assistant on 4 South. On 09/13/2025 on the 11 PM-7 AM shift, there was a shortage of 1 Certified Nursing Assistant on 4 South.On 09/14/2025 on the 7 AM-3 PM shift, there was a shortage of 1 Certified Nursing Assistant on 3 South. On 09/14/2025 on the 11 PM-7 AM shift, there was a shortage of 1 Nurse on 4 South.On 09/21/2025 on the 7 AM-3 PM shift, there was a shortage of 1 Certified Nursing Assistant on the 1st floor, 1 Certified Nursing Assistant on the 2nd floor, 2 Certified Nursing Assistants on 3 North, and 1 Certified Nursing Assistant on 4 North. On 09/21/2025 on the 11 PM-7 AM shift, there was a shortage of 1 Certified Nursing Assistant on 3 North.On 09/27/2025 on the 7 AM-3 PM shift, there was a shortage of 1 Certified Nursing Assistant on 3 North. On 09/27/2025 on the 3 PM-11 PM shift, there was a shortage of 1 Certified Nursing Assistant on 4 North. On 09/27/2025 on the 11 PM-7 AM shift, there was a shortage of 1 Certified Nursing Assistant on 3 South, and 1 Nurse on 4 South.On 09/28/2025 on the 7 AM-3 PM shift, there was a shortage of 1 Certified Nursing Assistant on the 1st floor, 1 Certified Nursing Assistant on the 2nd floor, 1 Certified Nursing Assistant on 3 South, and 1 Certified Nursing Assistant on 4 North. On 09/28/2025 on the 7 AM-3 PM shift, there was a shortage of 1 Certified Nursing Assistant on 4 South. Review of the actual weekend facility staffing schedule from 01/15/2026-01/23/2026 documented the following:On 01/15/2026 on the 7 AM-3 PM shift, there was a shortage of 1 Certified Nursing Assistant on the 1st floor, 1 Certified Nursing Assistant on the 2nd floor, 1 Certified Nursing Assistant on 3 South, and 1 Certified Nursing Assistant on 4 North.On 01/16/2026 on the 11 PM-7 AM shift, there was a shortage of 1 Certified Nursing Assistant on 4 North.On 01/17/2026 on the 7 AM-3 PM shift, there was a shortage of 1 Certified Nursing Assistant on the 2nd floor, and 1 Certified Nursing Assistant on 3 South. On 01/17/2026 on the 3 PM-11 PM shift, there was a shortage of 1 Certified Nursing Assistant on 4 North. On 01/17/2026 on the 11 PM-7 AM shift, there was a shortage of 1 Certified Nursing Assistant on 3 North.On 01/18/2026 on the 7 AM-3 PM shift, there was a shortage of 2 Certified Nursing Assistants on the 2nd floor, 1 Certified Nursing Assistant on 3 North, 1 Certified Nursing Assistant on 3 South, 1 Certified Nursing Assistant on 4 North, and 1 Nurse on 4 South. On 01/18/2026 on the 3 PM-11 PM shift, there was a shortage of 1 Certified Nursing Assistant on 4 North, and 1 Certified Nursing Assistant on 4 South. On 01/18/2026 on the 11 PM-7 AM shift, there was a shortage of 1 Nurse on 4 South.On 01/19/2026 on the 11 PM-7 AM shift, there was a shortage of 1 Certified Nursing Assistant on 4 North.On 01/20/2026 on the 7 AM-3 PM shift, there was a shortage of 1 Certified Nursing Assistant on the 1st floor, 1 Certified Nursing Assistant on the 2nd floor, and 1 Certified Nursing Assistant on 4 North. On 01/20/2026 on the 3 PM-11 PM shift, there was a shortage of 1 Certified Nursing Assistant on the 2nd floor and 1 Certified Nursing Assistant on 3 South. On 01/20/2026 on the 11 PM-7 AM shift, there was a shortage of 1 Certified Assistant on 4 North.On 01/15/2026 at 10:06 AM, an interview was conducted with Resident #198 who stated they have been waiting an hour for staff to come and assist with dressing. Resident #198 was observed in bed, wearing a gown. Resident #198 further stated this happens often due to short staffing and they are waiting average time of one hour. On 01/15/2026 at 01:26 PM, Resident #42's representative was interviewed and stated that the facility was short staffed, resulting in Resident #42's activity of daily living needs not being consistently met.On 01/15/2026 at 10:28 AM, Resident #60 was interviewed and stated that they experience extended wait times after ringing their call bell for assistance.On 01/16/2026 at 10:46 AM, Resident #132's representative was interviewed and stated that staffing was worse on the weekends and affected how frequently Resident #132 received incontinence care or was checked in on for needs such as water.On 01/16/2026 at 10:06 AM, Resident #198 was interviewed and stated that it typically took an hour to receive assistance getting dressed in the morning after notifying staff that they needed assistance.On 01/20/2026 at 11:04 AM, a meeting with 6 (six) residents from the Resident Council was held. During this meeting, 3 (three) residents (Residents #172, 179, 180) stated that staffing in the facility is a concern, and that staff regularly respond to call bells, state that they will return to provide assistance, and then never return to provide the assistance requested.On 01/23/2026 at 09:59 AM, Certified Nursing Assistant #3 was interviewed and stated that the facility experienced more staff callouts on weekends and holidays. Certified Nursing Assistant #3 stated that they were not aware of the facility offering any incentive to pick up extra shifts.On 01/23/2026 at 11:40 AM, Certified Nursing Assistant #2 was interviewed and stated that they had been employed at the facility for over 10 years. Certified Nursing Assistant #2 stated that staffing is significantly worse on the weekends due to increased callouts and the facility not having enough people to call as backups after someone calls out.On 01/23/2026 at 12:32 PM, the Staffing Coordinator was interviewed and stated that they are responsible for scheduling Nurses and Certified Nursing Assistants in the facility. The Staffing Coordinator stated that they did not know what the difference was between the Par and Minimum numbers listed on the undated document titled Nursing Par/Minimum Daily Staffing, but that the par number was what they used to create their schedule. The Staffing Coordinator further stated that the facility experienced difficulties with staff turnover and a difficulty of finding staff to work full time schedules. The Staffing Coordinator stated that the facility offers financial incentives to staff when they are below their minimum staffing level, but not below their par level.On 01/23/2026 at 12:59 PM, the Director of Nursing was interviewed and stated that the undated document titled Nursing Par/Minimum Daily Staffing lists the par level for each unit, which reflects the number of staff needed to provide the best quality care to meet resident needs. The Director of Nursing stated that the document also reflects the minimum level for each unit, which reflects the number of staff needed to keep residents safe after staff callouts. The Director of Nursing stated that the facilities uses the par level to determine their staffing needs when scheduling staff. The Director of Nursing further stated that the facility offered financial incentives to staff to fill callouts. Additionally, the Director of Nursing stated that they did not believe that there was a staffing problem in the facility and was unaware of resident concerns related to staffing.On 01/23/2026 at 12:51 PM, the Administrator was interviewed and stated that the facility is consistently working on improving staffing levels.10 NYCRR 415.13(a)(1)(i-iii)

Based on observation, record review, and interviews, the facility failed to ensure that food was served at an appetizing temperature during meal service. This was evident for two (2) of six (6) units observed during Dining Observation. Specifically, foods served during lunch meal service were not maintained at palatable and appetizing temperatures. The findings are:The facility's policy and procedure titled Food Temperatures reviewed 01/2026 documented all hot food items must be served to the resident at the temperature of at least 140 degrees Fahrenheit at the time of resident received the food.The Meal Delivery Schedule Sheet dated 12/07/2025 documented lunch for Unit 1 was served at 11:55 AM and Unit 2 North was served at 12:10 PM.On 01/20/2026 at 11:38 AM, Test trays were requested for 1st floor and 2nd floor. On 01/20/2026 at 11:50 AM, Food truck was delivered to 1st floor, and staff distributed meal trays to residents in the rooms until 12:10 PM.On 01/20/2026 at 12:10 PM, Test trays were conducted with Food Service Director on 1st floor. It revealed the following for Regular Diet Tray: baked potatoes at 110 degrees Fahrenheit, turkey chili at 105 degrees Fahrenheit, green beans at 90 degrees Fahrenheit. Puree Diet Tray: mashed potato at 130 degrees Fahrenheit, puree green beans at 125 degrees Fahrenheit, puree turkey at 122 degrees Fahrenheit. On 01/20/2026 at 12:15 PM, Food truck arrived on 2nd floor and staff delivered meal trays to residents in the rooms until 12:39 PM. On 01/20/2026 at 12:39 PM, Test trays were conducted with Food Service Director on 2nd floor and revealed the following for Puree Diet Tray: puree green beans at 125 degrees Fahrenheit, puree turkey at 124 degrees Fahrenheit, mashed potato at 130 degrees Fahrenheit. Regular Diet Tray: baked potato at 123 degrees Fahrenheit, green beans at 116 degrees Fahrenheit, turkey chili with beans at 122 degrees Fahrenheit. On 01/21/2026 at 12:35 PM, the Food Service Director was interviewed and stated that hot foods should be served above 140 degrees Fahrenheit for hot foods to be palatable. The Food Service Director acknowledged that hot foods were not maintained at the appropriate temperature range for hot foods served on 01/20/2026. The Food Service Director stated food temperature issues were brought up in the past and was addressed by replacing the equipment and conducting temperature audit every month. There were no further issues reported since then, so they were not aware of this issue.On 01/21/2026 at 2:30 PM, the Administrator was interviewed and stated that they will assess the meal service process and find the solution to ensure residents are served hot foods.10 NYCRR 415.14(d)(1)(2)

Based on observation, record review, and interviews, the facility failed to ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident for two (2) (Residents #1 and #213) of four (4) residents reviewed for Pressure Ulcer/Injury out of 36 total sampled residents. Specifically, Registered Nurses #8 and #9 failed to practice hand hygiene during wound care and Registered Nurse #9 removed unused wound dressing supplies from Resident #213's room and placed them back in the treatment cart. The findings are: The facility's undated Dressing/Treatment/Wound Care Observation process documented the nurse will promote healing of the wound by using clean/aseptic technique and the prescribed treatment. 1. Resident #1 had diagnoses of Stage 3 Pressure Ulcer (bed sore) of left buttocks, Diabetes Mellitus (a disease of inadequate control of blood levels of glucose), and Dementia (a decline in mental ability). The Quarterly Minimum Data Set assessment (a resident assessment tool) dated 12/25/2025 documented Resident #1 had severely impaired cognition and Stage 3 pressure ulcers. The physician's order dated 11/26/2025 documented cleanse wound on left buttocks with normal saline, pat dry, apply calcium alginate on wound bed, and cover with gauze island with border daily. On 01/23/2026 at 10:25 AM, wound care observation was conducted for Resident #1 with Registered Nurse #8. Registered Nurse #8 washed their hands, donned gloves, then removed Resident #1's soiled dressing from the wound on their left buttocks. Registered Nurse #8 removed gloves, performed hand hygiene, donned gloves, and proceeded to clean the wound. Registered Nurse #8 then removed gloves and without performing hand hygiene, donned gloves and then applied the treatment and placed the clean dressing on the wound. Registered Nurse #8 then removed their gloves and performed hand hygiene. On 01/23/2026 at 10:32 AM, Registered Nurse #8 was interviewed and stated the wound care process is to change gloves after cleansing the wound, apply the treatment, and clean dressing, and then remove gloves and wash hands. On 01/23/2026 at 10:57 AM, Registered Nurse #4 who is the Supervisor was interviewed and stated that Registered Nurse #8 should have performed hand hygiene after cleaning the wound. On 01/23/2026 at 12:02 PM, the Director of Nursing was interviewed and stated that nurses are instructed to perform hand hygiene after cleaning the wound. 2. Resident #213 was admitted to the facility with diagnoses that included Arthritis, Non-Alzheimer's Dementia and Pressure Ulcers. The admission Minimum Data Set, dated [DATE] documented that Resident #213 had severely impaired cognition, had two (2) Stage 3 pressure ulcers, and two (2) arterial wounds. The Physician's Order dated 01/14/2026 documented treatment orders for Santyl External Ointment 250 unit/gm: Apply to Right Back Day Shift between 07:30AM and 03:29PM, right upper back, clean with normal saline, pat peri wound dry, apply Santyl nickel thick on wound bed, cover with gauze island with border. The Physician's Order dated 01/14/2026 documented Santyl External Ointment 250 unit/gm: Apply to Right Hip, Day Shift between 07:30AM and 03:29PM, right upper hip, clean with normal saline, pat peri wound dry, apply Santyl nickel thick on wound bed, cover with gauze island with border. On 01/23/2026 at 10:55 AM, a wound care observation was performed with Registered Nurse #9. Registered Nurse #9 entered Resident# 213's room and with the assistance of Certified Nursing Assistant #8 positioned Resident#213 on their left side. Registered Nurse #9 then took out a packet of loose gauze from the treatment cart, a small bottle of normal saline solution, a drape, box of gloves, 3 cotton swabs, and a tube of Santyl with Resident #213's name on it, a bordered gauze, and a small medication cup. Certified Nursing Assistant then removed some personalized items from Resident#213's bedside table, and Registered Nurse #9 then placed the drape on the bedside table, then placed the items from the treatment cart on the drape. Registered Nurse #9 washed their hands and donned a pair of gloves. Registered Nurse #9 took some loose gauze and placed them on the drape in 4 bundles and poured some normal saline solution on the gauze. Registered Nurse #9 then proceeded to clean Resident #213's Right hip wound, changed their gloves and applied the ointment, covered the wound, and changed their gloves. Registered Nurse #9 then proceeded to Resident#213's wound on the right upper back. Registered Nurse #213 removed the dressing, then proceeded to clean the wound and then applied the treatment to the wound, covered the wound, and removed their gloves. The Registered Nurse failed to perform hand hygiene in between glove changes. Registered Nurse #9 then washed their hands, took the remainder of the gauze packet, the box of gloves, and Resident #213's ointment, and placed it back in the treatment cart. On 1/23/2026 at 11:30 AM, immediately following the observation, Registered Nurse#9 was interviewed and stated they were taught to change their gloves before touching the residents and during dressing changes. Registered Nurse #9 also stated that they can use a hand sanitizer before changing the dressing and changing gloves. On 01/23/2026 at 2:33 PM, the Director of Nursing was interviewed and stated that the nurses received in-service education on wound care and performing hand hygiene in between glove changes. The Director of Nursing also stated that the nurses are not supposed to put back any supplies that were taken from the treatment cart and placed in the resident's room. 10 NYCRR 415.19(b)(4)

Based on observation, record review, and interviews conducted during the Recertification and Abbreviated Survey (iQIES Incident 646938), the facility failed to ensure that the resident or their representative participated in all aspects of person-centered care planning. This was evident for one (1) (Resident #211) of two (2) residents reviewed for care planning out of 36 total sampled residents. Specifically, Resident #211's representative was not afforded the opportunity to participate in the resident's care planning process. The facility's policy titled Resident Assessment Instrument and Care Planning Process dated 11/06/2025 stated resident and /or resident's family will be invited to attend the interdisciplinary care plan meeting for comprehensive assessments.Resident #211 was admitted to the facility with diagnoses that included Schizophrenia, Diabetes Mellitus, and Seizure Disorder.The quarterly Minimum Data Set assessment dated [DATE] documented that Resident #211 was cognitively intact. The admission Minimum Data Set assessment dated [DATE] documented that Resident #211 felt it was very important for their family or friends to be involved in discussions about their care. On 07/01/2025, the Resident Manager of a group home that Resident #211 resided in prior to admission reported that the facility was refusing to discuss Resident #211's care with them or any other representative from the group home (Incident 646938).On 01/21/2026 at 11:12 AM, the Resident Manager from the group home that Resident #211 resided in was interviewed and stated that the group home acted as a representative for Resident #211. The Resident Manager stated that one of the contacts that the facility had for the Resident #211 was outdated as the person listed had retired and their phone was disconnected. The Resident Manager stated that the other contacts for Resident #211 were a Registered Nurse who worked at the group home, and the Executive Director from the group home. The Resident Manager stated that no one from the group home was invited to Resident #211's care plan meetings or involved in their care, despite wanting to be involved.On 01/23/2026 at 11:48 AM, the Executive Director from the group home who was listed as one of Resident #211's contact was interviewed and stated they would like to attend Resident #211's care plan meetings but was had not received an invitation from the facility. On 01/20/2026 at 10:04 AM, the Assistant Director of Nursing was interviewed and stated that a nurse on the evening shift had notified them on an unknown date that someone from Resident #211's group home had called the facility requesting information about Resident #211's care, but because they were not the group home employee listed on the resident's face sheet, they were not provided with information. The Assistant Director of Nursing stated that the Social Worker is typically the person who updates the list of contacts who can receive resident health information, and that they were not sure if the Social Worker was made aware of the group home's request for information. The Assistant Director of Nursing further stated that they did not personally communicate with Resident #211's representatives during the duration of their stay in the facility.On 01/20/2026 at 10:54 AM, Registered Nurse #4 was interviewed and stated that they were a Nurse Manager on Resident #211's unit. Registered Nurse #4 stated that they had not communicated with Resident #211's representatives during Resident #211's stay in the facility. They further stated that the Social Worker was responsible for inviting representatives to care plan meetings.On 01/21/2026 at 11:57 AM, Social Worker #1 was interviewed and stated that they are responsible for inviting residents and their representatives to care plan meetings. Social Worker #1 stated that resident representatives are only invited to initial, significant change, and discharge care plan meetings. Social Worker #1 stated that resident representatives are not invited to quarterly care plan meetings, and that if the resident refuses to attend, the Interdisciplinary Team meets without the resident or representative. Social Worker #1 stated that Resident #211's representatives was invited to and attended their discharge meeting but was unable to provide documented evidence that Resident #211's representatives were invited to Resident #211's initial or quarterly care plan meetings.On 01/22/2026 at 10:06 AM, the Director of Social Services was interviewed and stated that Social Worker #1 is responsible for inviting resident representatives to initial, significant change, and discharge care plan meetings. The Director of Social Services stated that representatives are not invited to quarterly care plan meetings, and that instead, information is shared with representatives when they come to visit residents on the unit. The Director of Social Services further stated that they were not aware that Resident #211's representatives wanted to be involved in their care plan meetings.On 01/23/2026 at 01:02 PM, the Director of Nursing was interviewed and stated that they were not aware that Resident #211's representatives felt like they were not being involved in their care planning. The Director of Nursing stated that they had not personally communicated with Resident #211's representatives during the duration of the resident's stay at the facility.10 NYCRR 415.11(c)(2) (i-iii)

Based on record review, and interviews during the Recertification and Abbreviated (2680670) Survey, the facility did not ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the New York State Department of Health. This was evident for one (1) (Resident #35) of two (2) residents reviewed for Dignity out of 36 total sampled residents. Specifically, the Ombudsman reported to the Director of Nursing that Resident #35 alleged that a Nurse Practitioner verbally abused them. The incident was not reported to the New York State Department of Health.Cross Reference F610 Investigate/Prevent/Correct Alleged Violation The findings include: The undated facility's policy titled Patient / Resident Abuse documented it was the policy of the facility to initiate a report when there is an incident of or suspicion of physical abuse, sexual abuse, mistreatment or neglect of a resident(s), to the Office of Health Systems Management in accordance with New York State Public Health Law Section 2803d. The purpose of the policy was to be in compliance with the New York State Patient Abuse Reporting Law. The facility's policy titled Investigation protocol for Resident Abuse Cases dated 02/2005 documented that the staff nurse will initiate an incident report and will inform the supervisor. The supervisor will initiate investigation of the incident and will inform the Director of Nursing if there is a potential for abuse. The Director of Nursing will immediately review the case and determine if an initial investigation is needed and will inform the Administrator if it is a potential case of abuse. The Administrator will discuss with the Director of Nursing on the conclusion of internal investigation or the need to call the Department of Health. If the Department of health must be called, it must be done within 5 working days. Resident #35 had diagnoses of Paranoid Personality Disorder (distrust and suspicion of others), Major Depressive Disorder (persistent feelings of sadness or loss of interest), and Chronic Obstructive Pulmonary Disease (breathing is difficult due to air flow obstruction). The Quarterly Minimum Data Set assessment (a resident assessment tool) dated 11/13/2025 documented Resident #35 had intact cognition and required supervision to moderate assist with activities of daily living, bed mobility, manual wheelchair use, and ambulation.The Resident Occurrence Report Statement completed by Nurse Practitioner #1 dated 01/05/2026 documented they went to give Resident #35 a copy of their recent laboratory reports with Registered Nurse #4 who is the supervisor. Resident #35 was yelling and would not sign that they received a copy of their recent laboratory results. Resident #35 would not let them explain the results and was verbally abusive and disrespectful throughout the encounter on 12/26/2025.The Resident Occurrence Report Statement from Registered Nurse #4 who was the supervisor dated 01/05/2026 documented they accompanied Nurse Practitioner #1 to deliver requested laboratory results to Resident #35. After knocking and entering the room, Resident #35 became agitated stating they were woken up from their nap. Nurse Practitioner #1 apologized and began to explain the details of the laboratory results when Resident #35 interrupted and became verbally abusive towards Nurse Practitioner #1 and would not allow them to finish explaining the laboratory results. Resident #35 then yelled at Nurse Practitioner #1 to leave their room. Nurse Practitioner #1 asked Resident #35 to sign their copy for documentation that they received their request, but they refused. Resident #35 continued yelling at Registered Nurse #4 and Nurse Practitioner #1 to leave their room. The date of the counter was on 12/26/2025.There was no documented evidence Resident #35's allegation of abuse was reported to the New York State Department of Health.On 01/15/2026 at 12:16 PM, Resident #35 was interviewed and stated Nurse Practitioner #1 is bad that they scream and yell at them.On 01/23/2026 at 12:07 PM, the Director of Nursing was interviewed and stated the Long-Term Care Ombudsman came to the facility on [DATE], the same day that Nurse Practitioner #1 and Registered Nurse #4 statements were gathered. The Ombudsman informed them that Resident #35 reported that Nurse Practitioner #1 was verbally abusive to them. The Director of Nursing stated that the abuse allegation was not reported to the Department of Health or investigated thoroughly because Registered Nurse #4 witnessed the encounter and Resident #35 tends to confabulate. The Director of Nursing also stated they concluded there was no evidence that Nurse Practitioner #1 was abusive to Resident #1 and instead it was actually the resident who was abusive to the Nurse Practitioner. On 01/23/2026 at 2:22 PM, the Administrator was interviewed and stated an allegation of verbal abuse must be fully investigated and is mandated to be reported to the Department of Health. 10 NYCRR 415.4(b)(2)

Based on observation, record review, and interviews conducted during the Recertification and Abbreviated Survey (iQIES Complaint 2680670), the facility failed to ensure that all alleged violations involving abuse were thoroughly investigated. This was evident for one (1) (Resident #35) of two (2) residents reviewed for dignity out of 35 total sampled residents. Specifically, on 01/05/2026, the facility received a report from the Ombudsman stating that Resident #35 alleged that Nurse Practitioner #1 verbally abused them. The facility failed to maintain evidence that the alleged violation of verbal abuse was thoroughly investigated. Cross Reference F609 Reporting of Alleged Violations The findings include:The facility's policy titled Investigation protocol for Resident Abuse Cases dated 02/2005 documented that the staff nurse will initiate an incident report and will inform the supervisor. The supervisor will initiate investigation of the incident and will inform the Director of Nursing if there is a potential for abuse. The Director of Nursing will immediately review the case and determine if an initial investigation is needed and will inform the Administrator if it is a potential case of abuse. The Administrator will discuss with the Director of Nursing on the conclusion of internal investigation or the need to call the Department of Health. If the Department of health must be called, it must be done within 5 working days. Resident #35 had diagnoses of Paranoid Personality Disorder (distrust and suspicion of others), Major Depressive Disorder (persistent feelings of sadness or loss of interest), and Chronic Obstructive Pulmonary Disease (breathing is difficult due to air flow obstruction).The Quarterly Minimum Data Set assessment (a resident assessment tool) dated 11/13/2025 documented Resident #35 had intact cognition and required supervision to moderate assist with activities of daily living, bed mobility, manual wheelchair use, and ambulation. The Resident Occurrence Report Statement from Nurse Practitioner #1 dated 01/05/2026 documented they went to give Resident #35 a copy of their recent laboratory reports with Registered Nurse #4 who is the supervisor. Resident #35 was yelling and would not sign that they received a copy of their recent laboratory results. Resident #35 would not let them explain results and was verbally abusive and disrespectful throughout the encounter on 12/26/2025.The Resident Occurrence Report Statement from Registered Nurse #4 who is the supervisor dated 01/05/2026 documented they accompanied Nurse Practitioner #1 to deliver requested laboratory results to Resident #35. After knocking and entering the room, Resident #35 became agitated stating they were woken up from their nap. Nurse Practitioner #1 apologized and began to explain the details of the laboratory results when Resident #35 interrupted and became verbally abusive towards Nurse Practitioner #1 and would not allow them to finish explaining the laboratory results. Resident #35 then yelled at Nurse Practitioner #1 to leave their room. Nurse practitioner #1 asked Resident #35 to sign their copy for documentation that they received their request, but they refused. Resident #35 continued yelling at Registered Nurse #4 and Nurse Practitioner #1 to leave their room. The date of the counter was on 12/26/2025.The facility only collected written statements from Nurse Practitioner #1 and Registered Nurse #4. The investigation did not include interviews and/or statements from Resident #35 who was the alleged victim, other residents on the unit, or other staff who might have potentially witnessed the alleged incident, and / or interactions or relationship between Nurse Practitioner #1 and other residents. The facility failed to present any conclusion and appropriate corrective action, if the allegation was verified, On 01/15/2026 at 12:16 PM, Resident #35 was interviewed and stated Nurse Practitioner #1 is bad, and yells and scream at them. On 01/23/2026 at 12:07 PM, the Director of Nursing was interviewed and stated the Ombudsman notified them on 01/05/2026 that Resident #35 reported that Nurse Practitioner #1 verbally abused them. The Director stated that statements were gathered from Nurse Practitioner #1 and Registered Nurse #4. The Director of Nursing stated that Registered Nurse #4 witnessed the encounter, and that Resident #35 tends to confabulate. The Director of Nursing stated they concluded there was no evidence of abuse and it was actually Resident #1 who was abusive to the Nurse Practitioner. On 01/23/2026 at 2:22 PM, the Administrator was interviewed and stated that an allegation of verbal abuse must be fully investigated. 10 NYCRR 415.4

Based on observation, record review, and interviews conducted during the Recertification and Abbreviated (iQIES Complaint 646935) survey, the facility failed to ensure that services provided met professional standards of quality. This was evident for one (1) (Resident #209) of four (4) residents reviewed for Discharge out of 36 total sampled residents. Specifically, Resident #209, who had no discharge order for intravenous therapy, was discharged home with an intravenous access device left in place. In addition, the resident was given discharge medications that belong to a different resident. Cross Reference: F694 Parenteral/Intravenous Fluids The findings are:The facility's policy and procedure titled Day of Discharge Protocol and Procedure dated 03/18/2025 documented that the licensed nurses are responsible for verifying discharge medications. The policy documented that medications being sent home must be verified by two (2) nurses for accuracy. The licensed nurse must remove all medical appliances as per physician's order prior to discharge, for instance intravenous line. Resident #209 was admitted to the facility with diagnoses include Seizure Disorder, Hypothyroidism and Malignant Neoplasm of Brain.The admission Minimum Data Set, dated [DATE] documented moderately impaired cognition.A physician's order dated 03/14/2025 documented Midline via IV national and 0.45% Sodium Chloride Intravenous Solution at 50 cubic centimeter per hour every shift at 7:30AM, 3:30PM, 11:30PM for nine (9) doses for hydration. The order was discontinued on 03/17/2025. Registered Nurse #13's note dated 03/17/2025 at 11:21 AM documented Resident #209 was discharged home with medication taken. Registered Nurse #12's note dated 03/17/2025 at 12:46 PM documented Resident #209 was discharged home with discharge medications. The Interdisciplinary Discharge summary dated [DATE] documented information related to Resident #209's care needs after discharge. There was no discharge plan or care instructions related to intravenous access device.The Occurrence Report Investigation dated 03/18/2025 documented on 03/18/2025, the facility received a call from a Hospice Nurse stating that Resident #209 was discharged home with an intravenous access device still in place and a blister pack of medication that did not belong to Resident #209. The Director of Nursing interviewed the unit staff and found that on 03/17/2025, Registered Nurse #13 was notified that Resident #209's transportation was waiting for the resident. Registered Nurse #13 disconnected Resident #209's intravenous line, without removing the intravenous access device. Resident #209 was also given discharge medications which included a blister pack that belonged to another resident. Registered Nurse Manager #12 visited Resident #209's home to retrieve another resident's blister pack of medication and removed Resident #209's intravenous device. Registered Nurse #13 and Registered Nurse #12 were no longer working at the facility, and were unable to be interviewedOn 01/22/2026 at 9:45 AM, the Director of Nursing was interviewed and stated they received a call from a Hospice Nurse on 03/18/2025 reporting that Resident #209 was discharged home with intravenous device access and a blister pack that did not belong to Resident #209. The Director of Nursing stated that Registered Nurse #13 and Registered Nurse #12 processed Resident #209's discharged on 03/17/2025. the Registered Nurses were interviewed and discovered that resident's intravenous line was disconnected but the access device was not removed. Registered Nurse Manager #12 was instructed to visit the Resident #209's home. Registered Nurse Manager #12 removed Resident #209's intravenous access device and another resident's blister pack was recovered and was returned to the facility. 10 NYCRR 415.11(c)(3)(i)

Based on observation, record review, and interviews, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice, and comprehensive person-centered care plan. This was evident for one (1) (Resident #163) of five (5) residents reviewed for Unnecessary Medications out of 36 total sampled residents. Specifically, Resident #163, who had a diagnosis of Diabetes Mellitus, had a physician's order to notify the physician when resident's finger stick blood sugar (method of drawing drops of blood from the finger for testing the blood glucose level) result is less than 60 milligrams per deciliter or more than 351 milligrams per deciliter. There was no documented evidence that the physician was notified when Resident #163's finger stick blood sugar was higher than 351 milligrams per deciliter on multiple occasions.The findings are: The facility's undated policy titled Diabetes Management documented that the physician must be notified by the nurse according to the parameters as specified in the blood sugar orders. The nurse manager must audit the medical records of diabetic residents prior to renewal date to ensure all required care has been rendered and review any trends or changes needed with the physician. Resident #163 was admitted to the facility on [DATE] with diagnoses of Diabetes Mellitus and Hypertension. The admission Minimum Data Set, dated [DATE] documented resident was cognitively intact.The Diabetes Mellitus Care Plan initiated on 11/06/2025 and was revised on12/25/2025 documented Resident #163 had Type 2 Diabetes Mellitus. Interventions included to administer medication, provide diet as ordered, monitor sign symptoms of hyper/hypoglycemia (restlessness, neuro alteration, vital signs and weakness, insomnia) and glucose three times daily before meals. A physician's order dated 11/19/2025 and was renewed on 01/14/2026 documented Humalog Kwik Pen Subcutaneous Solution 100 unit per milliliter, to inject as per sliding scale subcutaneously three times daily before meals for Type 2 Diabetes Mellitus; and glucose monitoring three times daily before meals.If Blood Sugar < 60 then call Medical Doctor Initiate Hypoglycemic Protocol. If Blood Sugar 180-200 = dose 2 units. If Blood Sugar 201-250 = dose 4 units. If Blood Sugar 251-300 = dose 6 units. If Blood Sugar 301-350 = dose 8 units. If Blood Sugar 351 > 400 = dose 10 units call Medical Doctor. If Blood Sugar > 400, call Medical Doctor.The Medication Administration Records from 11/19/2025 to 01/23/2026 documented the following finger stick blood sugar results: On 12/21/2025 at 5:00 PM, 390 milligrams per deciliterOn 01/03/2026 at 5:00 PM, 400 milligrams per deciliter.On 01/04/2026 at 5:00 PM, 427 milligrams per deciliter. On 01/18/2026 at 5:00 PM, 355 milligrams per deciliter.A review of the nurses' and medical progress notes from 11/19/2025 through 01/23/2026 showed no documentation that the physician was notified when Resident #163's finger stick blood sugar level were above 351 milligrams per deciliter.On 01/23/2026 at 2:15 PM Licensed Practical Nurse #3 was interviewed and stated that they call the physician when Resident #163's finger stick testing showed elevated blood sugar levels. Licensed Practical Nurse #3 stated they did not document the call in the progress notes. On 01/23/2026 at 2:38 PM, Licensed Practical Nurse #4 was interviewed and stated they would have followed the order and would have notified the physician if Resident #163's finger stick test showed elevated blood sugar level. Licensed Practical Nurse #4 could not recall every episode and could not explain why they did not document the call in the progress note. On 01/23/2026 at 11:15 AM, Registered Nurse #3 stated the unit nurse who administers the medication also perform blood sugar checks and administers insulin in accordance with the order. They stated physicians are notified when blood sugar level is too low or high and that nurses must document this in the progress notes along with the doctor's instructions. Registered Nurse #3 stated they could not explain why nurses did not document this in Resident #163's medical record. On 01/23/2026 at 10:17 AM, Nurse Practitioner #1 was interviewed and stated they are notified when a resident's blood sugar level is too low or too high. However, Nurse Practitioner #1 could not recall if they were notified of Resident #163's elevated blood sugar levels. On 01/23/2026 at 12:59 PM, Physician #1 was interviewed and stated they should be notified if diabetic residents blood sugar was too low or too high so they can assess the resident. Physician #1 stated they do not recall getting any information about elevated blood sugar level for Resident #163. On 01/23/2026 at 1:14 PM, the Director of Nursing was interviewed and stated nurses must follow the insulin order per sliding scale and notify the physician in accordance with the parameter. They stated that nurses are responsible for calling the physicians as instructed if the blood sugar is too high, depending on the ordered parameters. 10 NYCRR 415.12

Based on observation, record review, and interviews, the facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complications of enteral feeding. This was evident for one (1) (Resident #12) of 27 residents reviewed for medication administration task. Specifically, Registered Nurse #6 did not appropriately verify placement of gastrostomy tube prior to administering medications and enteral feeding.The findings include:The facility policy titled Medication Administration: Enteral dated 01/06/2016 documented verify tube position by placing stethoscope over patient's epigastric region and inject 20-30cc of air into the tube while listening for whooshing sound or aspirate for stomach contents.Resident # 12 had diagnoses of Gastrostomy (surgically created stomach opening for tube feeding), Anoxic (deprived of oxygen) Brain Damage, and Down Syndrome (born with an extra chromosome which changes the body and brain's development).The Quarterly Minimum Data Set assessment (a resident assessment tool) dated 11/22/2025 documented that Resident #12 had a feeding tube.A physician's order dated 10/21/2025 documented a tube feeding administration order of Jevity 1.2 to be administered at a rate of 70 milliliters per hour for 16 hours. The formula amount per feeding is 1120 milliliters.During medication administration observation conducted on 01/16/2026 at 11:08 AM, Registered Nurse #6 checked the placement of the gastrostomy tube by introducing air and auscultating with a stethoscope and stated a whooshing sound was heard.On 01/16/2025 at 11:10 AM, Registered Nurse #6 was interviewed and stated they were instructed either to aspirate for stomach contents or listen for a whooshing sound using a stethoscope in order to ensure tube placement in the stomach.On 01/20/2026 at 2:56 PM, Registered Nurse #7 who was the supervisor was interviewed and stated the process to ensure tube placement in the stomach is to aspirate for stomach contents. The medications should be held if the amount is over 100 milliliters or there is no stomach contents aspirated, and the physician should be notified.On 01/23/2026 at 11:52 AM, the Director of Nursing was interviewed and stated they were unaware that staff should no longer be verifying tube placement by auscultation but instead they should verify placement by checking gastric contents. The Director of Nursing also stated they updated the policy on enteral medication administration last week and completed in-services for nursing staff on the revised policy.10 NYCRR 415.12(g)(2)

Based on observation, record review, and interviews conducted during the Recertification and Abbreviated (iQIES Complaint 646935) and Recertification survey, the facility failed to ensure that parenteral fluids were administered consistent with professional standards of practice. This was evident for one (1) of four (4) residents (Resident #209) reviewed for Discharge out of 36 total sampled residents. Specifically, Resident #209 did not receive appropriate care and services for their prescribed intravenous therapy. Medical records lacked ongoing monitoring of the resident's intravenous access device. The findings are:The facility's policy and procedure titled Intravenous Administration dated 12/01/2025 documented: 1) verify provider order: confirm medication/fluid, dose, volume, rate and frequency, review resident allergies. 2) prepare supplies 3) label intravenous bag, date/label intravenous tubing 4) set up intravenous/flow controller 5) start infusion 6) monitor infusion 7) discontinue intravenous: confirm with medical doctor that intravenous line is no longer needed, remove catheter, apply dressing and document removal, site condition.The facility's policy and procedure titled Intravenous Line Management and Dressing Change dated 11/12/2024 documented peripheral intravenous line is to provide proper care and maintenance to prevent external infection. Orders must be placed for all intravenous lines to include monitoring, monitoring every shift for sign, symptom of infection/infiltration, change dressing change 24 hours after insertion then every 7 days until removed or soiled. Tubing changes every 3 days during night shift.Resident #209 was admitted to the facility with diagnoses include Seizure Disorder, Hypothyroidism and Malignant Neoplasm of Brain. The admission Minimum Data Set, dated [DATE] documented moderately impaired cognition.The Physician Note dated 03/02/2025 documented Resident #209 noted bradycardia and to administer 0.9% Sodium Chloride intravenous at 75 cubic centimeter per hour for three doses to support hemodynamic stability.The Nursing Note dated 03/02/2025 at 5:54 PM documented Peripheral line order confirmation #189536. There was no documentation in resident's medical record of the date/time, site assessment, resident's tolerance and verification of the intravenous insertion. The Physician Order initiated 03/02/2025, discontinued 03/04/2025 documented 0.9% Sodium Chloride Intravenous Solution at 75 cubic centimeter per hour intravenously every shift for three (3) doses for hydration.The Medication Administration Record for 0.9% Sodium Chloride Intravenous Solution documented two (2) administrations recorded on 03/02/2025 during 11:30PM to 7:30AM shift and on 03/03/2025 from 3:30PM to 11:30PM shift.There was no documented evidence that an administration or assessment of the intravenous therapy was conducted on 03/03/2025 during 7:30AM to 3:30PM shift.In addition, there was no documented evidence that Resident #209 was evaluated to determine if intravenous access device should be maintained or removed upon completing intravenous fluid therapy on 03/03/2025.The Nursing Note dated 03/04/2025 at 8:09 PM documented peripheral intravenous line at left hand was dislodged and bleeding noted. Line removed, cleaned and dressing applied.The Nursing Note dated 03/14/2025 documented Resident #209 plan to start 0.45% Sodium Chloride for hydration. Author tried to insert it twice, unsuccessful. Ordered IV National Resident's family was called and updated.The Physician Order initiated 03/14/2025 discontinued 03/17/2025 documented Midline via IV national and 0.45% Sodium Chloride Intravenous Solution at 50 cubic centimeter per hour every shift for 9 doses for hydration.There was no documentation of the midline placement to include date/time, site assessment, resident's tolerance and verification of the device insertion.The Nursing Note dated 03/14/2025 at 11:39 PM documented Resident #209 started intravenous fluid 0.45% Sodium Chloride for hydration.The Physician Note dated 03/15/2025 documented Resident #209 seen for hypernatremia, continue intravenous 0.45% Sodium Chloride for gradual correction of Sodium levels. Monitor closely for sign/symptom of fluid overload.The Medication Administration Record for March 2025 revealed 0.45% Sodium Chloride Intravenous Solution was administered from 03/14/2025 at 3:30PM to 11:30PM shift to 03/17/2025 at 7:30AM to 3:30PM shift.Review of the Nursing Notes from 03/15/2025 to 03/17/2025 revealed nursing assessment and monitoring were not consistently documented. Nursing Note dated 03/15/2025 at 12:35PM documented peripheral intravenous line in the left arm. The Nursing Notes dated 03/15/2025 at 8:24 PM, dated 03/16/2025 at 8:59 PM documented peripheral line in the left hand. The Nursing Notes dated 03/16/2025 at 6:37 AM, dated 03/16/2025 at 3:25 PM and dated 03/17/2025 at 6:34 AM documented midline on the left upper arm.On 01/20/2026 at 9:56 AM, Registered Nurse #10 was interviewed and stated that Resident #209 had peripheral line placed on left hand for intravenous therapy as per reviewing the record. Resident #209 received the infusion continuously for three shifts. Nurses are responsible for monitoring infusion and assessing the intravenous site every shift. Registered Nurse #10 stated they cannot locate the midline placement documentation for intravenous therapy and could not explain why there was no documentation in the medical record.On 01/23/2026 at 10:19 AM, Nurse Practitioner #1 was interviewed and stated that the provider assesses and determine the resident's need for intravenous therapy. Once it is determined, the intravenous is ordered and placed intravenous access device either via peripheral or midline. If intravenous order is to be infused continuously then the order is written with type of fluid, rate, duration. The duration is written in the electronic medical record as 3 doses = 3 shifts = 24 hours. Nurse Practitioner stated they have been ordering in this way and were not aware of any issues. Nurse Practitioner stated once resident completed the intravenous infusion, provider should be notified. They stated that the provider will re-evaluate/determine the next treatment plan or will have the intravenous access device removed.On 01/22/2026 at 9:45 AM, Director of Nursing stated Resident #209 was noted bradycardia and started intravenous therapy for hydration from 03/02/2025 to 03/03/2025. Resident #209 had another intravenous therapy ordered from 03/14/2025 to 03/17/2025 after laboratory results showed elevated sodium level. They stated that a Registered Nurse attempted to insert the peripheral line but was unsuccessful so an order for midline placement was made which was inserted by an intravenous vendor. The Director of Nursing stated there was no documentation found in the medical record that showed that intravenous access placement was made on 03/02/2025 and on 03/14/2025. The Director of Nursing stated intravenous placement, or insertion must be documented and along with an ongoing assessment of the site infusion. 10 NYCRR 415.12 (k)(2)

Based on observation, record review, and interviews the facility failed to ensure that a resident received necessary respiratory care in accordance with professional standards of practice. This was evident for one (1) (Resident #109) of three (3) residents reviewed for respiratory care out of 36 total sampled residents. Specifically, Resident #109 was observed receiving oxygen via nasal cannula without a physician's order. The findings include:The facility policy titled Oxygen Policy effective 08/2023 documented providers must issue an order that includes: flow rate, delivery method, and frequency.Resident #159 had diagnoses of Respiratory Failure with Hypoxia (lungs can't get enough oxygen into the blood) and Chronic Obstructive Pulmonary Disease (breathing is difficult due to air flow obstruction).The Annual Minimum Data Set assessment (a resident assessment tool) dated 12/08/2025 documented Resident #109 had severely impaired cognition and did not receive oxygen therapy.On 01/15/2026 at 10:24 AM, Resident #109 was observed with Oxygen in use at 1.5 liters per minute via nasal canula. A review of the physician's order as of 01/15/2025 revealed no attending practitioner's orders and indication for oxygen use.On 01/22/2026 at 5:32 PM, Attending Physician #1 was interviewed and stated the house physician informed them that Resident #109 needed oxygen, and they could not recall the date. Attending Physician #1 also stated an order for oxygen should have been placed since Resident #109 still required oxygen after a few hours of administration. Attending Physician #1 was unable to explain why an order for oxygen was not placed in Resident #109's electronic medical record until 01/20/2026.On 01/23/2026 at 9:51 AM, Licensed Practical Nurse #2 was interviewed and stated sometimes Resident #109 is administered oxygen when they are short of breath. Licensed Practical Nurse #2 also stated they have observed Resident #109 receiving Oxygen prior to 01/15/2026.On 01/23/2026 at 11:07 AM, Registered Nurse #4 who is the supervisor was interviewed and stated they did an audit and realized the oxygen order was missing from Resident #109's medical record. Registered Nurse #4 also stated it was an oversight, there must have been a glitch where the order was dropped, and they recently had the doctor replace the order.On 01/23/2026 at 11:56 AM, the Director of Nursing was interviewed and stated if a nurse observes a resident having difficulty breathing, they can start oxygen at two (2) Liters, and the supervisor would inform the physician. The physician would then assess the resident and place an order for oxygen if needed.10 NYCRR 415.12(k)(6)

Based on observation, record review, and interviews, the facility failed to ensure that a resident requiring oral/dental care was promptly referred for dental evaluation and care. This was evident for one (1) (Resident #133) of one (1) resident reviewed for dental out 36 total sampled residents. Specifically, Resident #133 was observed with missing dental caps, and stated on interview that they have not been evaluated by a dentist since being admitted in 03/2025. The findings are:The facility policy titled Dental Services, effective 12/06/2008, documented that it is the policy of the facility that all residents will receive dental services to maintain their highest practicable level of well-being. The facility will be responsible for assisting the residents in obtaining routine dental services.Resident #133 was admitted on [DATE] with diagnoses that included Cancer, and Seizures.On 01/15/2026 at 12:05 PM, Resident#133 was interviewed and stated they have been having difficulty with their dental caps and that they have not seen a dentist since being admitted .On 01/22/2026 at 10:43 AM, Resident #133 was observed lying in bed, watching television. Resident#133 stated they were finally seen by the dentist yesterday. They stated they have been complaining of the loose teeth and dental caps and the water drooling from their mouth.The admission Minimum Data Set, dated [DATE] documented that resident's cognition as intact and that resident had no broken or loosely fitting dentures, no discomfort or difficulty chewing, and obvious or likely cavities or broken natural teeth.A nursing admission assessment note dated 03/31/2025 documented that resident had missing upper and lower tooth caps and that resident had oral pain. The Comprehensive Care Plan Titled Dental documented that Resident #133 had their own dentition, some teeth missing. A Speech Therapy evaluation note dated 04/01/2025 documented that the resident seen for clinical bedside swallow evaluation and was noted with four (4) loose upper caps that makes it difficult to chew certain foods. Resident noted with oral dysphagia most likely due to poor dentition which suspected to impact resident's ability to masticate regular texture solids adequately /safely.There was no documented evidence in the electronic medical record that Resident #133 had been evaluated by the dentist nor was offered dental services since admission on [DATE].On 01/20/2026 at 1:52 PM, the Director of Nursing was interviewed and stated that the Resident#133 was not seen by the Dentist because Resident#133 said that they were last seen in January 2025 by their own dentist. 10 NYCRR 415.17 (a-d)

Based on observation, record review, and interviews, the facility failed to ensure garbage and refuse were disposed of properly. This was evident during the Kitchen Observation task. Specifically, the facility's waste dumpster was not kept closed when not in use on multiple occasions which exposed garbage and refuse and had the potential to attract pests. The findings are:The facility's policy and procedure titled Garbage Disposal and Removal dated 11/05/2024 documented all garbage and refuse containers are provided with fitting lids or covers and must be kept covered when or not in continuous use. Garbage and refuse containing food waste will be stored in a manner that is inaccessible to pests. On 01/15/2026 at 3:02 PM, outside garbage compactor/dumpster were observed with door opened and exposing full of garbage contained inside of the compactor. On 01/20/2026 at 9:30 AM, and on 01/21/2026 from 10:12 AM to 12:14 PM, outside garbage compactor/dumpster was observed with door left open. On 01/21/2026 at 12:29 PM, Dietary Worker #1 and Food Service Director were observed removing garbage from the kitchen to the compactor located outside of the building. The compactor was observed left open. Dietary Worker #1 removed the garbage from garbage bin and tossed in the compactor. Dietary Worker #1 did not close the compactor door after use, and the door was observed left open. On 01/21/2026 at 12:35 PM, Dietary Worker #1 stated they were not aware that the garbage compactor needed to be closed. On 01/21/2026 at 12:55 PM, Food Service Director was interviewed and stated they did not know why compactor door was left open. It should have been closed after use and kept closed to prevent exposing garbage to the surrounding environment. Food Service Director stated they will need to address this issue with staff and provide education to ensure they are compliant. 01/23/2026 at 2:01 PM, Housekeeping/Maintenance Director was interviewed and stated the compactor should have been closed after each use and kept closed. Housekeeping/Maintenance Director stated they are even checking the compactor twice a week for any holes or damage to prevent any leakage or odor that could be attracting animals and pests. Housekeeping/Maintenance Director further stated they have started to provide staff in-service already to rectify this issue. 01/21/2026 at 2:30 PM, Administrator was interviewed and stated they were made aware of this issue, so they have started to provide in-service to staff. 10 NYCRR 415.14(h)

Based on observation and interviews conducted during the recertification survey from 4/24/24 to 5/1/24, the facility did not maintain a safe, clean, comfortable and home-like environment for 1 of 1 resident's rooms (Resident #44/Unit 3North room [ROOM NUMBER]) reviewed for environment. Specifically, Resident #44 was in their room and a maintenance staff was repairing the flooring in their room with glue and there was an odor observed. On 4/24/24 at 2:08 PM Resident # 44 was observed lying in bed in their room while maintenance staff was repairing the flooring in their room. The bed was pushed diagonal to access the flooring that the maintenance staff was attempted to reglue, and the glue had an odor. On 4/25/24 at 2:10 PM Licensed Practical Nurse, Staff # 7, was asked if the resident should be in the room while repairs are being done in the room and Staff #7 stated the resident should not be in the room, but resident had an episode of emesis, so they did not want to remove them from room. 04/25/24 02:11 PM, Maintenance Worker, Staff #6, was asked if a resident should be in the room while doing repairs the worker stated the glue is non odorous. When asked if they informed the nursing staff, they would be repairing floor in Resident #44 room, they stated no. On 4/25/24 at 2:13 PM, Registered Nurse Unit Manager, Staff #5 stated if maintenance is doing repairs in the resident's room, the resident should not be in the room. Registered Nurse Unit Manager stated the resident should have been removed but resident was not feeling well today. Registered Nurse Unit Manager stated they were not informed maintenance was going to repair the floor. On 4/25/24 at 2:20 PM, Maintenance Director was asked if residents should be in the room during repairs and they stated no unless there was a special circumstance. This writer asked specifically about repairing the flooring, and they stated, absolutely not. On 4/26/24 at 8:55 AM, Administrator stated that they were made aware this writer observed maintenance staff repairing flooring while resident was in the room. Administrator stated this was not the policy and that they absolutely do not do repairs while a resident is in the room. Administrator stated the maintenance staff was written up as a result. 10 NYCRR 415.29(j)(1)

Based on observations, record review and interview during the recertification and abbreviated surveys (NY00333316), the facility did not ensure that all alleged violations involving abuse and neglect were reported within 2 hours to New York State Department of Health (NYSDOH) for 1 of 2 residents reviewed for abuse. Specifically, Resident #94's family informed the facility of an allegation of sexual abuse on 2/10/24 and facility reported to New York State Department of Health (NYSDOH) on 2/11/24. Findings include: Resident #94 was admitted to facility with diagnoses including diabetes, muscle weakness, difficulty walking, and a displaced comminuted fracture of shaft of right femur. The Admission Minimum Data Set (MDS, an assessment tool) dated 1/31/24 documented Resident #94 had moderately impaired cognition and no behavioral symptoms. Facility Accident/Incident investigation dated 2/10/24 documented that a family member of Resident #94 called the Nursing Supervisor on 2/10/24 around 4 PM, and reported that Resident #94 told them they were molested. Resident #94 stated a man entered their room and and sexually assaulted them at midnight. Resident #94 was unable to describe what staff looked like or what they were wearing. The family and police were notified, the police came and the family member declined sending Resident #94 to the hospital. Review of the incident submission report revealed the incident was reported to the New York Department of Health on 2/11/24 at 11:21 AM. When interviewed on 4/30/24 at 12:04 PM, the Director of Nursing stated they called Administrator specifically to review incident and whether it needed to be reported right away as they were not working that day. The Director of Nursing stated the Administrator informed them they looked at the guidelines and because there was no injury or harm, they could report it within 24 hours. When interviewed on 5/01/24 at 1:43 PM, the Administrator stated they reviewed the incident, and did not feel it was harm and did not need to report with 2 hours and could be done in 24 hours. They stated it only needed to be reported in 2 hours if there was harm. 10NYCRR 415.4 (b)(2)(3)

Based on record review and interviews conducted during the recertification survey from 4/24/24 through 5/1/24, the facility did not ensure a Minimum Data Set Discharge Assessment was completed and transmitted for 1 of 2 residents (Resident #150) reviewed for discharge. Specifically, Resident #150 was discharged from the facility on 2/16/24 and the Minimum Data Set Discharge Assessment had not been done at time of survey. The findings include: The facility policy and procedure titled Resident Assessment Instrument issued 10/1/2023, documented the Resident Assessment Instrument (RAI) is used, in accordance with specified format and timeframe's, in conducting comprehensive assessments. In addition, the assessment coordinator is responsible for ensuring the Interdisciplinary Team complete timely residents' assessments and reviews in accordance with CMS RAI Version 3.0 Manual, Chapter 2 assessment schedules: 1. Admission within 14 days of residents' admission to the facility. 2. Quarterly review at least 92 days. 3. Residents' discharge within 14 days after discharge date . The Minimum Data Set (MDS) records of the following resident were reviewed and revealed that a Quarterly assessment were not completed within the Assessment Reference Date (ARD) plus 14 days or 92 days from the last Quarterly Assessment. Resident #150 was admitted to the facility on [DATE] with diagnoses including asthma, glaucoma, and hyperlipidemia. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact and received physical and occupational therapy. A nursing progress note dated 2/16/24 at 10:52 AM documented the resident was discharged to home and left the facility with their spouse. Further review of Resident #150's electronic medical record revealed the Minimum Data Set Discharge Assessment was incomplete and was not submitted. On 4/30/24 at 2:39 PM, during an interview Staff #14 ( Minimum Data Set coordinator) stated Resident #150's Comprehensive Minimum Data Set 5 day assessment was completed on 12/1/23 that was the last assessment done. They reviewed the record and stated they missed completing the Minimum Data Set Discharge Assessment. On 5/1/24 at 10:59 AM, an interview the Director of Nursing stated they were unaware Resident #150 Minimum Data Set Discharge Assessment was not completed and the Minimum Data Set (MDS) department was a separate department from nursing. 10 NYCRR 415.11(a)

Based on observation, record review, and interviews during a recertification survey (4/24/2024-5/1/2024), the facility did not ensure each resident received care, consistent with professional standards of practice, to prevent pressure ulcers for 1 of 13 (Resident #8) residents reviewed for pressure ulcers. Specifically, Resident #8 had care plan interventions and physicians order recommendations to offload heels with heel booties while in bed; however, the resident was observed in bed with their heels resting directly on the mattress and there was no pillow on the mattress for the resident's feet. Findings include: Resident #8 was admitted to the facility on [DATE] with diagnoses including Non-Alzheimer's Dementia, muscle weakness, and schizophrenia. The 3/20/24 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) of 3, indicating the resident had severe cognitive deficit. The MDS documented the resident was at risk for pressure ulcers. A Pressure Ulcer Care Plan created on 10/23/16 documented a goal that the resident will not develop ulcers for 3 months. Interventions updated 1/18/23 documented bilateral heel booties in bed. There was no documentation in the care plan that the resident refused to have their heels offloaded. There was no documented evidence of refusal to wear heel booties. The April 2024 Certified Nursing Assistant Instructions documented to offload the resident's bilateral heels with booties while they are in bed. The resident was observed in bed on 4/24/24 at 10:28 AM, 4/25/24 at 11:10 AM, 4/26/24 at 9:06 AM and 4/30/24 at 10:08 AM. The resident's feet were not being supported by any pillows and their heels were not offloaded from bed with bilateral heel booties. During an interview on 4/30/24 at 10:44 AM, Certified Nurse Assistant (Staff #8) stated to their knowledge the resident was not using heel booties. Stated they were not aware resident was to wear heel booties. Stated they have not seen the heel booties on resident while in bed and have not had to remove them when doing care. During an interview on 4/30/24 at 10:49 AM, Licensed Practical Nurse (Staff #7) was asked if the resident was supposed to wear heel booties. Staff #7 stated, the resident did not have an order for heel booties. Staff #7 was asked how they are informed when a new order is added, they stated it is added to the 24-hour report and then nursing will carry out the order. Staff #7 stated they were not sure not sure if they were off and missed the report that day. 10 NYCRR 415.12(c)(2)

Based on observations, record review and interviews during the recertification survey conducted from 4/24/2023 to 5/1/2024 the facility did not ensure that they store, prepare, distribute, and serve food in accordance with professional standards for food service. Specifically, sanitary conditions were not maintained in the main kitchen area. In the dishwasher area, the blue cup racks, which the kitchen staff claimed as clean racks were stored on the floor then later were picked up and combined with other clean racks for further use. The findings are: The facility policy and procedures titled Storage of Utensils, Trays, Racks to prevent contamination documented that clean equipment, racks and utensils will be stored in a clean, dry location in a way that protects them from contamination by splashes and dust. During the initial tour of the kitchen observation on 4/24/24 at 10:02 AM the Dietary Aide was loading blue cup racks on the cart next to dry and clean area of the dishwasher and moved them away. Next, the Dietary Aide picked up two blue cup racks from the floor, which were stored under the dishwasher transporter and combined them with other racks that were taken from the top of transporter and moved them away. During an interview on 4/24/24 at 10:02 AM the Director of Dietary Service stated that the Dietary Aide was loading clean blue cup racks from the top of dishwasher on the cart for further use. The surveyor asked the Director of Dietary Service if it was correct to combine the clean racks and the one that were picked up from the floor for further use. The Director of Dietary Service stated that it was not the correct action. The clean racks were contaminated and cannot be used. 10 NYCRR 415.14(h)

REVISED 6/26/24 IDR Based on observations, record review and interviews during a recertification survey from 4/24/24-5/1/24, the facility did not ensure that an infection prevention plan was implemented for identifying, tracking, and monitoring infections, communicable diseases, and outbreaks. Specifically, 1) Clostridium Difficile infections were not documented on the infection line list at readmission from the hospital for 1 of 3 Residents (Resident #101) until 5 days later, 2) measures to prevent the spread of Clostridium Difficile were not implemented to include a private room, and 3) Resident #113's ventilator tubing was not changed within parameters and was 5 days past due. The findings are: The facility undated policy for Infection Control, documented personnel must be aware of and alert to problems and potential infection control problems throughout the facility and protect residents from infection with constant surveillance of the environment and all who enter it. The Centers for Disease and Prevention guidance titled, 'How Can CDI (Clostridium Difficile) be prevented in hospitals and other Healthcare Settings?' Documented: use Contact Precautions with known or suspected Clostridium Difficile and place these residents in private rooms. If private rooms are not available, they can be placed in rooms (cohorted) with other CDI patients. The facility policy Clostridium Difficile, dated 5/2009, documented a private room is indicated. Residents with C. difficile may be cohorted. 1. Resident #101 had diagnoses of sepsis, major depressive disorder, and atrial fibrillation. The Minimum Data Set, (an assessment tool) dated 4/3/24 documented the resident did not have cognitive impairment, was hearing impaired and needed assistance from staff for activities of daily living. Resident #101 was ventilator dependent and was readmitted from the hospital on 4/21/24 after treatment for sepsis secondary to Clostridium Difficile. Resident #101's physician orders dated 4/21/24 document contact precautions for Clostridium Difficile for 10 days and Vancomycin (antibiotic) oral suspension via gastrostomy tube every 6 hours for 40 doses. An observation was made on 4/25/24 at 02:02 PM on the 4th floor unit. Resident #101 was in their room with Resident #27 (roommate) who was also ventilator dependent, and all curtains were pushed back. A review of Resident #27's medical record revealed a diagnoses of respiratory failure and ventilator dependence. Resident #27's Minimum Data Set, dated dated dated [DATE] documented the resident was dependent on staff for all care and was incontinent of bowel and bladder. There was no documented evidence of active Clostridium Difficile infection. During an interview on 4/25/24 at 02:00 PM, Staff #17 (Registered Nurse) stated Resident #101 returned from the hospital with Clostridium Difficile infection and was placed back in the same room they were in before going to the hospital. Staff #17 stated they did not know how the decision was made to keep Resident #101 in the same room with Resident #27 who did not have Clostridium Difficile. During an interview on 4/26/24 at 1:15 PM, the Infection Preventionist was asked for their line list for all residents with Clostridium Difficile. They stated there were no active cases in the building. The Infection Preventionist looked in the computer and named three residents who had been the last cases and Resident #101 was not one of them. They stated in morning report they usually found out about infections and residents that have been started on antibiotics and that was how they started tracking infections. The Infection Preventionist stated when Resident #101 was readmitted , they were not aware the resident had Clostridium Difficile and the resident received antibiotics for 5 days before they had knowledge about it. They stated they were not aware that a private room was indicated to prevent the spread of infection. During an interview on 4/26/24 at 2:35 PM, Physician #2 stated they performed the readmission assessment from the hospital for Resident #101 and were aware of the resident's Clostridium Difficile infection at morning report the day after readmission. They stated they were aware of the indication for a private room and did not think about it at the time and should have put Resident #101 in a private room. During a second interview with the Infection Preventionist on 5/1/24 at 12:00 PM, they stated they were informed by the unit managers about Resident #101 having Clostridium Difficile infection at morning report but forgot about it and that was why the infection tracking had not been started. 2. The facility policy and procedures titled Infection Prevention and Control program documented the following policies and procedures are designed to control and reduce the risk of nosocomial infections due to respiratory care equipment and procedures. Disposable ventilator circuits will be changed and dated every 2 weeks and when visibly soiled or mechanically malfunctioning. Resident #113 was admitted to the facility with diagnoses including persistent vegetative state, and acute and chronic respiratory failure. The Quarterly Minimum Data Set, dated dated dated [DATE] documented the resident had severely impaired cognition and was dependent with functional abilities. The physician order dated 4/3/24 documented ventilator settings as AC Mode: VT 450, respiratory rate 16 FIO2 40%, PEEP +5 and to monitor log vent parameters every 6 hours. During observations on 4/24/24 at 12:51 PM and 4/25/24 at 9:46 AM the ventilator circuit was observed dated 4/5/24. During an interview on 4/25/24 at 9:46 AM Director of Respiratory stated per policy they changed ventilator tubing every two weeks. The Director of Respiratory observed the tubing and stated it was dated 4/5/24 and should have been changed on 4/19/24. 10 NYCRR 415.19(b)(1) 49255

Based on observations, record reviews, and interviews conducted during an abbreviated survey the facility failed to comply with the requirements relating to maintaining written policies and procedures for resident ' s advance directives for 5 (Resident #1, #2, #3, #4, #5) of 50 residents who had full codes. Specifically, Resident #1 who ' s family had requested to have Cardiopulmonary Resuscitation (CPR) did not have current signed physician orders [REDACTED]. For Residents #2, #3, #4, and #5 who requested CPR did not have care plans and were not identified, accodring to facility policy and procedures. The facility lacked documentation that resident ' s wishes were discussed, initiated, and implemented for Advanced Directives. Additionally, the facility did not have a system to routinely check wristbands, the DNR list, and failed to ensure that staff were educated to the facility policies on Advanced Directives and identification of residents CPR/DNR status. This resulted in actual harm to Resident #1 when CPR was not initiated and the potential for serious harm that is Immediate Jeopardy for residents ' health and safety. Complaint Number: NY 720 This was evidenced by, but not limited to the following: Cross References: F 309- Provide Care for Highest Well-Being -scope and severity-L F 490- Administration- scope and severity-L F 501-Medial Director- scope and severity-L F 250- Social Worker-scope and severity - L Review of the undated facility Policy and Procedure titled " Advanced Directives " at the time of incident which was not dated or signed by Medical Director, Administrator or Director of Nursing (DON) revealed that admissions department provided residents, families and surrogates, the "NYS Department of Health ' s DNR Order pamphlet. Social services discusses DNR with family or surrogates during the initial assessment period, and at the time of significant change and quarterly and annually for all others. All discussions are documented in clinical record. Social Services/Nursing notifies Physician if resident/ family member requests a DNR order or revocation of current orders. DNR order is documented in care plan. Nursing notes, DNR orders, are faxed order to pharmacy. Charts are labeled with DNR stickers and wristbands are placed on the residents. Physician reviews and renews DNR orders at least monthly or upon order renewal. Review of the undated facility Policy and Procedure titled " Cardiopulmonary Resuscitation (CPR) documents that CPR will be performed on all residents unless a DNR order exists. Staff who are certified in Basic Life Support (BLS) will perform CPR. The first trained staff arriving on the scene will initiate CPR. " Procedure for CPR, nurse will check the name band and chart to determine if resident is a full code, determine unresponsiveness, if resident does not respond call out for help and provide a location, note the time and do not leave the resident alone, when help arrives notify operator and call a code blue. " The Supervisor directs activities during the emergency. " Provide appropriate treatment to resident until the resident is transferred to the hospital. " Resident #1 was a [AGE] year old male who was originally admitted to the facility [DATE] and readmitted from the hospital on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set (MDS); a resident assessment tool dated [DATE] documented resident #1 cognitive status as being severely impaired. Review of Physician order [REDACTED]. Therefore, according to facility policy and procedure the resident was considered a full code. Review of Interdisciplinary progress notes dated for [DATE] did not include written documentation regarding resident ' s right for Advanced Directives. Furthermore, there was no documentation that a bracelet was placed on the resident. Review of the last social service note dated [DATE] revealed in " January of 2015 during a family meeting regarding implementation of advanced directives the resident ' s cousin and first contact expressed that she did not want a DNR for the resident. " She further expressed, " staff should do whatever is necessary to save the life of the resident. " There was no further documentation that advanced directives were reviewed again with the family after [DATE] meeting. There was no social services note specifying residents or family ' s wishes for Advanced Directives on readmission of [DATE]. On [DATE] at 4:00 PM a review of the video surveillance tape dated [DATE] at 3:10 PM, revealed the actions of CNA#1 went into resident's room at 3:11 PM and came out at 3:25 PM with dirty linens, LPN#1, and RNS#1 went to residents room at 3:25PM, all of which moved in a non-emergent way. Physican is seen going into room at 3:45PM. Physician came out of room went to desk and reviewed resident's chart that RNS#1 handed her. At no time was RNS#1 or LPN#1 observed to look for a list or in residents chart to check the residents Advanced Directives before giving the record to the physician. Review of the facility investigation dated [DATE] documents that on [DATE] Resident #1 was observed with decreased alertness by his assigned Certified Nursing Assistant (CNA) who informed the Licensed Practical Nurse (LPN #1) who found the resident without a pulse and blood pressure, she then left the resident to alert the Registered Nurse Supervisor (RNS #1). RNS #1 and LPN #1 both went to resident and found him without a blood pressure, pulse or respirations. RNS #1 and LPN #1 left resident to alert the physician. RNS#1 was interviewed on [DATE] at 11AM. He stated that LPN# 1 came to the desk and alerted him that resident had expired. He then went to the room where he observed the resident with fixed pupils and was cold to touch. He states he then went to notify the physician. He did not recall if the resident was wearing a bracelet and states that he had never been oriented to the facility policy and procedures for Advanced Directives or CPR. Review of RN Supervisor Orientation Form dated [DATE] and [DATE] for RNS#1 reveals that orientation for DNR/DNI (Do Not Intubate) Process, was not dated, reviewed or performed until after the incident on [DATE]. Review of RN Supervisor Orientation Form for RNS#2 documented orientation dates on [DATE] and [DATE], the DNR/DNI (Do Not Intubate) Process, was not dated, reviewed or performed. On [DATE] interviews between 12:00 PM and 5:30 PM were conducted with 4 staff RNs revealed that as of [DATE] residents who have a DNR status are now supposed to be wearing yellow bracelets, have a yellow strip on the spine of their charts, and a yellow name plate on their door. All 4 staff RNs stated that the yellow bracelets were not used before the [DATE] incident, and added that some residents had bracelets that " may " have had yellow dots identifying if resident had a DNR. RN# 4, 5 and 6 stated that there was a list at the nurses' desk with residents names who have DNR orders. RN# 4 and 6 stated that the list which was presented on [DATE] was an outdated DNR list and they were unaware of how often the list is updated by social work. All 4 RNs stated that they do not recall ever having an in-service or orientation that covered Advanced Directives or the CPR policy and procedure until this week went they started using the yellow bands. On [DATE], 8 LPNs interviewed between 10:30 AM and 5:30 PM revealed that LPN # 1, 2, 3, 4, 5, and 6 would use the list at nurse ' s station to determine if resident had a DNR. LPN #2, 5 and 8 stated that residents had yellow dots on bracelets to identify DNR status and if there were no dots or bracelets they would check the list and chart. LPN#1 and 7 stated that the facility never had bracelets to identify resident CPR status, and added most residents do not wear bracelets at all. LPN #1 and 3 stated they would call and wait for supervisor to start CPR, LPN # 2, 7 and 8 stated that they would initiate CPR if they found an unresponsive resident. All 8 LPNs stated that they did not recall ever having an in-service or orientation that covered Advanced Directives or the CPR policy and procedure until recently when facility started using the yellow bands. On [DATE] Social Worker #1 was interviewed at 2:40 PM and stated that all residents require a care plan for advanced directives. She was unable to give an explanation as to why some residents did not have a care plan in place as the policy states. She stated that social workers are responsible for keeping the DNR lists current and they are not checked daily, and there was no method for monitoring the list or documentation that list were updated and checked. The admissions coordinator and staff are notified verbally in a " Huddle Meeting " (morning meetings) of new admissions that have DNR status and social workers will add the name to list, all other departments are notified verbally but are not given DNR lists. On [DATE] Social Worker #2 was interviewed at 3:00 PM and stated he is responsible for getting advanced directives, care plans for advanced directives and lists that go to nursing stations of residents who have DNR. He added that he was not sure if his assigned residents care plans were updated with current Advanced Directive information. On [DATE] at 3:40PM the staffing coordinator was interviewed and stated that she has not been checking if the nursing staff have current BLS certification for CPR when she does the scheduling of staff and added that she will start doing that today. She further states that she does not have or maintain a list of current BLS certified nurses and does not know who does that. During an interview on [DATE] at 12:06 PM the Assistant Director of Nursing stated that she does most of the orientations and in service education and did not cover Advance Directives or CPR policy and procedures during the orientations, but did go over code blue. She did not teach staff that residents DNR status is identified by yellow dots on bracelets and yellow dots on charts. But since [DATE] she is in-servicing staff on the new policy and procedure for the identification of residents Advanced Directives and CPR which includes yellow bracelets, yellow name for medical records and room door. During an interview with the Director of Nursing on [DATE] at 12:55 PM she stated that LPN#1 was terminated from facility after her investigation because it was felt that LPN#1 should have initiated CPR immediately. After this incident she felt that the facility needed a 3 point identification system to better identify residents with Advanced Directives. DON did not know the system for checking accuracy for the DNR list her staff use for identification of residents with DNRs and stated social workers are responsible for the list. She was not aware that facility policy and procedures for advanced directives and CPR were not being taught during orientation or in-service, and thought the original policy and procedure documented residents who have DNRs have yellow dots on chart and wristbands. She was also not aware that the staffing coordinator did not schedule staff without assuring that a current BLS certified licensed staff was available on all shifts, and did not have or maintain a list of current BLS certified staff. During an interview with the Administrator on [DATE] at 1:30PM he stated he was aware on [DATE] that the DON developed a new policy and procedure and on [DATE] they began training staff. He was not aware that facility policy and procedures for advanced directives and CPR were not being taught during orientation or in-service. The staffing coordinator did not schedule staff without assuring that a current BLS certified licensed staff was available on all shifts or that list of current BLS certified staff was available. The administrator also thought the original policy and procedure documented residents who have DNRs have yellow dots on chart and wristbands. On [DATE] LPN #1 was interviewed at 1:45 PM. She stated that she did not initiate CPR because she did not get direction from RNS#1, who stood at the door and never put a hand on the resident, "LPN ' S are supposed to take direction from the RN supervisors for a code blue." She stated that she has been at the facility for a long time and never knew about the yellow dots on wristbands and what it meant, the only way she knew how to check a resident DNR status is the list at nurses station or the chart. LPN# 1 states not many residents wear wristbands and she didn't check if Resident#1 had a wrist band. Review of residents comprehensive care plan for advanced directives for Residents #2, #3, #4, and #5 reveals: Resident #2, with team review dated [DATE], [DATE] and [DATE] documented resident problem/need as resident did not have advanced directives due to refusing. Interventions included yellow indicator on chart/name band. On [DATE] the care plan evaluation documented, " residents family refuses to execute advanced directives, family provided with MOLST and did not complete it. When asked, son stated that he will review with family. " Resident #3 who was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive care plan (CCP) dated [DATE] with a date of [DATE] written over [DATE], documented resident had a Medical Orders for Life-Sustaining Treatment (MOLST). The care plan did not and does not specify if resident has a DNR or is a full code. Interventions on the care plan included yellow indicator chart /name band from [DATE] original date of care plan. Review of residents MOLST revealed that family did not sign a DNR order until [DATE] and physician signed MOLST for DNR [DATE]. There was no order for a DNR for resident until [DATE] however the resident was identified as having a DNR since admission of [DATE]. Resident #4, date of initial care plan of [DATE] and team review of [DATE], [DATE] and [DATE] documented residents problem/need as health care proxy. The interventions included yellow indicator placed on chart/name band. Resident #5, date of initial care plan [DATE], with team review dated [DATE], [DATE], [DATE] and [DATE] documented resident problem/need as MOLST. Intervention included yellow indicator on chart/name band. Evaluation of plan dated, [DATE], [DATE], [DATE], all documented "resident MOLST continues to be honored" , and on [DATE] evaluated documented, " this review residents advanced directive MOLST and DNR continues to be honored proceed with plan of care. The immediacy was removed on [DATE], which was concurrent with the investigation exit, as the facility had implemented the following interventions: The facility contracted with experienced consultants to assist in addressing the issues identified by the Department of Health. The Medical Director, Administrator and Director of Nursing reviewed, revised and implemented a revised policy to address Advanced Directives for Cardiopulmonary Resuscitation and Do Not Resuscitate. Residents DNR list was updated and is now scheduled to be updated daily for changes( room changes, transfers to hospital, new admissions, readmissions, DNRs rescinded or requests by resident or family. A current list of all certified nurses Basic Cardiac Life Support (BCLS) was compiled and in place for use with staffing needs. Upon admission/readmission of residents social worker will discuss the plan of advanced directives and an Advanced Directive Care Plan shall be put into place immediately. In event of social worker unable their designee/ Registered Nurse Supervisor, who will ascertain DNR status, communicate with MD, and identifiers will be put into place immediately. An audit tool was created to monitor compliance with all DNR identifiers, which included monitoring of existence of Advanced Directives Care plans for all residents. Immediate DNR/CPR education was included in mandatory in-services. Education will be ongoing and conducted for all staff and new hire orientations. Immediate adult CPR certification and recertification had begun for all nursing, and CNAs. CPR classes were being provided by facility and continues until all nurses and CNAs are CPR certified. All new hires will be required to have a valid CPR certification status to assure that the schedule consist of nursing personnel have current CPR certification. An audit tool was created to monitor the compliance with tracking of valid CPR certifications and will be conducted weekly for 3 months by the DON and or ADON. The facility provided evidence that 100% of the nursing department staff were educated and in-serviced on the new P&Ps and protocols. A plan was placed for future interventions including QA reviews for monitoring of residents CPR status and compliance with the education, training and identification of residents Advanced Directives. 10NYCRR 415.26

Based on observation, record review and interview conducted during an abbreviated survey, it was determined for 5 of 50 residents (Residents #1, 2, 3, 4, and 5) reviewed for social services, the facility did not provide medically-related social services to attain or maintain residents' highest practicable physical, mental, and psychosocial well-being. Specifically, social workers lacked care planning, proper identification, discussion and coordination of Advanced Directives for residents. This resulted in actual harm to Resident #1 when CPR was not initiated and the potential for serious harm that is IMMEDIATE JEOPARDY for residents' health and safety. Complaint Number: NY 720 This was evidenced by, but not limited to the following: Cross References: F 309- Provide Care/Service for Highest well Being - scope and severity-L F 155- Resident Rights- scope and severity-L F 490- Administration- scope and severity-L F 501-Medial Director- scope and severity-L Review of the facility Policy and Procedure (P&P) titled "Advanced Directives" at the time of incident which was not dated revealed that admissions provides residents, families and surrogates, the " NYS Department of Health ' s DNR Order pamphlet, requests signatures verify receipt of information and gives information to Social Services. " Social services discusses Do Not Resuscitate (DNR) with residents ' family or surrogates during the initial assessment period, at the time of a significant change and quarterly thereafter for residents on the sub-acute unit; at the time of significant change and annually for all others. All discussions are documented in clinical record. Social Services/Nursing notifies Physician if resident, family or surrogate requests a DNR order or revocations of DNR and includes DNR order in the care plan. Resident #1 was a [AGE] year old male who was originally admitted to the facility [DATE] and readmitted from the hospital on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set (MDS); a resident assessment tool dated [DATE] documented residents cognitive status as being severely impaired. Review of Physician Orders dated [DATE] did not specify or have signed orders for Advanced Directives for resident #1. Therefore, according to facility policy and procedure the resident was considered a full code. Review of Interdisciplinary Notes dated [DATE] through [DATE] revealed no evidence that Advanced Directive wishes were addressed or reviewed with the resident or family after 2 separate admissions from the hospital on [DATE] and [DATE]. Review of the last social service note dated [DATE] revealed in " January of 2015 during a family meeting regarding implementation of advanced directives the resident 's cousin and first contact expressed that she did not want a DNR for the resident. " She further expressed, " staff should do whatever is necessary to save the life of the resident. " There was no further documentation that advanced directives were reviewed again with the family after [DATE] meeting. Resident #2 who was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan (CCP) dated [DATE] with a date of [DATE] written over the [DATE] date, revealed resident had Medical Orders for Life-Sustaining Treatment (MOLST). The care plan did not specify if resident had a DNR. Interventions included but were not limited a yellow indicator chart /name band. Review of residents MOLST revealed that family did not sign a DNR order until [DATE] and physician signed MOLST for DNR [DATE]. There was no order for a DNR for resident until [DATE] however the resident was identified as having a DNR since admission of [DATE]. Resident #3, date of initial care plan of [DATE] and team review of [DATE], [DATE] and [DATE] documented residents problem/need as health care proxy. Interventions included but was not limited to placing a yellow indicator on chart/name band. Resident #4 who was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. Review of the CCP dated [DATE] documented resident had a MOLST. The care plan did not and does not specify if resident has a DNR or if she is a full code. Interventions on the care plan included yellow indicator chart /name band which would indicate resident is a DNR. Residents MOLST for a DNR was not signed by the physician until [DATE]. On [DATE] Social Worker #1 was interviewed at 2:40 PM and stated that all residents require a care plan for advanced directives and was unable to give an explanation as to why some residents did not have a care plan in place as the policy states. She stated that it is the responsibility of social workers to keep the DNR lists current, they are not checked daily, has no method for monitoring, or documentation when they were updated or checked last. She stated that the admissions coordinator and staff are notified verbally in a "Huddle Meeting" (morning meeting) of new admissions that have DNRs and social workers will add the name to the list, all other departments are notified verbally but are not given the DNR lists. On [DATE] Social Worker #2 was interviewed at 3:00 PM and stated that he is responsible for getting advanced directives, doing care plans for advanced directives and putting names on the list that go to nursing stations of residents who have DNR. He added that he was not sure if his assigned residents care plans were updated or if they all have care plans with current Advanced Directive information. 10NYCRR 415.5 (g)

Based on observation, staff interviews and record review during an abbreviated survey the facility placed residents at immediate risk for serious harm or death by failing to develop and implement effective policies & procedures which ensure that staff initiate and provide Cardio-Pulmonary Resuscitation (CPR) in emergent situations; failed to provide the staff with orientation and education for Advanced Directives, CPR and Emergent Situations and failed to ensure that adequate CPR trained staff are present on all shifts. Specifically, Licensed Practical Nurse (LPN) #1 and Registered Nurse Supervisor (RNS) #1 failed to perform CPR to Resident #1 after he was found to be unresponsive. The facility lacked documentation that all staff received orientation and in servicing on the facility policy and procedure for Advanced Directives and CPR. Additionally, the facility did not correlate current CPR certified staff with actual staffing schedules. This resulted in actual harm to resident #1 when CPR was not initiated and the potential for serious harm that is Immediate Jeopardy for residents ' health and safety. Complaint Number: NY 720 This was evidenced by, but not limited to the following: Cross References: F 155- Resident Rights- scope and severity-L F 490- Administration- scope and severity-L F 501-Medial Director- scope and severity-L F 250 -Social Service-scope and serverity-L The findings are: The undated facility Policy and Procedure titled " Cardiopulmonary Resuscitation (CPR) " in place at the time of incident documents that CPR will be performed on all residents unless a DNR order exists. Staff who are certified in Basic Life Support (BLS) will perform CPR. A master list of CPR trained staff will be kept in the nursing office. A preliminary plan of care shall be developed upon the resident admission, to provide basic life support prior to activating the EMS system. " Procedure for CPR, nurse will check the name band and chart to determine if resident is a full code, determine unresponsiveness, if resident does not respond call out for help and provide a location, note the time and do not leave the resident alone, when help arrives notify operator and call a code blue. " The Supervisor directs activities during the emergency. " Provide appropriate treatment to resident until the resident is transferred to the hospital. " The undated Policy and Procedure titled " Advanced Directives " at the time of incident that was not dated or signed reveals that admissions provides residents, families and surrogates, the " NYS Department of Health ' s DNR Order pamphlet. Social services discusses DNR with family or surrogates during the initial assessment period, at the time of significant change and quarterly thereafter on the sub-acute unit; at the time of significant change and annually for all others. All discussions are documented in clinical record. Social Services/Nursing notifies Physician if resident, family or surrogates requests a DNR order or revocation of currents orders and includes DNR order in care plan. Physician reviews admission and readmission pre-existing DNRs. Nursing notes DNR order, faxes order to pharmacy, labels chart with DNR sticker and places wristband on resident. " Resident #1 was a [AGE] year old male who was originally admitted to the facility [DATE] and readmitted from the hospital on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set (MDS); a resident assessment tool dated [DATE] documented the resident's cognitive status as being severely impaired. Review of the facility investigative summary dated [DATE] documented that on [DATE] Resident #1 was observed with decreased alertness by his assigned Certified Nursing Assistant (CNA) and at 3:20 PM after completing cares she noticed resident was not breathing and called LPN #1. LPN #1 found resident without a pulse and blood pressure then left resident to alert RNS #1. At approximately 3:28 PM LPN #1 asked RNS #1 to follow her to residents room because she thought that resident expired. Facility obtained statement from RNS #1 documented, upon seeing the resident his limbs appeared stiff, he was pulseless, and skin appeared extremely pale and cool to touch. The resident ' s mouth was open, eyes were closed. Resident pupils were fixated. Resident did not show any signs of life, immediately notified physician who was on the unit and resident was pronounced dead. Review of Physician order [REDACTED]. Therefore, according to facility policy and procedure the resident was considered a full code. Review of social services note dated [DATE] revealed in " January of 2015 during a family meeting regarding implementation of advanced directives the residents cousin and first contact expressed that she did not want a DNR and expressed, "staff should do whatever is necessary to save the life of the resident." There was no further documentation that advanced directives are reviewed again with the family after the [DATE] meeting. An untimed "Interdisciplinary Progress Note" written by LPN#1 dated [DATE] at 1:30PM, documented, wound rounds done, treatment continues to multiple wounds. At 3:15PM it documented, " called to room [ROOM NUMBER] by nursing staff to evaluate resident not responding to tactile stimuli, on evaluation no blood pressure, no pulse noted. Supervisor notified. " An untimed Interdisciplinary Progress Note dated [DATE], written by RNS #1 documented, " At approximately 3:25PM I was asked by one of the staff to check on a patient who was suspected of being expired. I immediately went to see the resident's, upon entering the residents room he appeared to be stiff, I checked for pulse, no pulse was noted, patient pupil was assessed, pupil was fixated, and his skin was pale and cool to touch. Resident did not show any visible signs of life. Doctor was on the unit, she was notified immediately. " During an interview on [DATE] at 11AM with RNS#1, He states that LPN# 1 came to the desk told him that resident had expired. He states he went to the room where he observed the resident with fixed pupils and was cold to touch so he went to notify the physician. He did not recall if the resident was wearing a bracelet and states that he had never been oriented to the facility policy and procedures for Advanced Directives or CPR. Review of the RN Orientation Form for RNS#1 revealed that orientation for DNR/DNI (Do Not Intubate) Process, was not dated, reviewed or performed until after the incident of [DATE]. Review of Interdisciplinary progress notes for [DATE] did not include written documentation regarding resident ' s right for Advanced Directives. Furthermore, there was no documentation that a bracelet was placed on resident. On [DATE] between 12:00 and 5:30 PM interviews conducted with 4 staff RNs revealed that as of [DATE] residents who have a DNR status are now supposed to be wearing yellow bracelets, have a yellow strip on the spine of their charts, and a yellow name plate on their door. All 4 staff RNs stated that the yellow bracelets were not used before the [DATE] incident, and added that some residents had bracelets that " may " have had yellow dots identifying if resident had a DNR. RN# 4, 5 and 6 stated that there was a list at the nurse ' s desk with residents names who have DNR orders. RN# 4 and 6 stated that the list which was presented on [DATE], "was an outdated DNR list and they were unaware of how often the list is updated by social work." All 4 RNs stated that they do not recall ever having an in-service or orientation that covered Advanced Directives or the CPR policy and procedure until this week went they started using the yellow bands. On [DATE], 8 LPNs interviewed between 10:30 AM and 5:30 PM revealed that LPN # 1, 2, 3, 4, 5, and 6 would use the list at nursing desk to determine if resident had a DNR. LPN #2, 5 and 8 stated that residents had yellow dots on bracelets to identify DNR status and if there were no dots or bracelets they would check the chart. LPN#1 and 7 stated that the facility never had bracelets to identify resident CPR status, and added most residents do not wear bracelets at all. LPN #1 and 3 stated they would call and wait for supervisor to start CPR, LPN # 2, 7 and 8 stated that they would initiate CPR if they found an unresponsive resident. All 8 LPN ' s stated that they did not recall ever having an in-service or orientation that covered Advanced Directives or the CPR policy and procedure until recently when facility started using the yellow bands. On [DATE] Social Worker #1 was interviewed at 2:40 PM and stated that all residents require a care plan for advanced directives and was unable to give an explanation as to why some residents did not have a care plan in place as the policy states. She stated that it is the responsibility of social workers to keep the DNR lists current and they are not checked daily, she has no method for monitoring the list or documentation of when they are updated or checked last. She stated that the admissions coordinator and staff are notified verbally in a " Huddle Meeting " (morning meeting) of new admissions that have DNR ' s and social workers will add the name to the list, all other departments are notified verbally but are not given the DNR lists. On [DATE] Social Worker #2 was interviewed at 3:00 PM and stated he is responsible for getting advanced directives, care plans for advanced directives and lists that go to nursing stations of residents who have DNR. He added that he was not sure if his assigned residents care plans were updated with current Advanced Directive information. On [DATE] at 3:40PM the staffing coordinator was interviewed and stated that she has not been checking if the nursing staff have current BLS certification for CPR when she does the scheduling of staff and added that she will start doing that today. She further states that she does not have or maintain a list of current BLS certified nurses and does not know who does that. On [DATE] the Assistant Director of Nursing stated in interview at 12:06PM that she does most of the orientations and in service education. She stated that she did not cover Advance Directives or CPR policy and procedures during orientations, but did go over code blue. She further states that she did not teach staff that residents DNR status is identified by yellow dots on bracelets and yellow dots on charts. She further states that on [DATE] she started in-servicing staff on the new policy and procedure for the identification of residents Advanced Directives and CPR. On [DATE] the DON stated in interview at 12:55 PM that after this incident she felt that the facility needed a 3 point identification system to better identify residents with Advanced Directives. She states the new policy and procedure was being taught to staff starting [DATE] without approval or input from the Medical Director or Administrator. She stated the Medical Director looked it over on Monday [DATE] but he had not signed it, the Administrator had not seen or approved it because he was away during the incident, but she had been in contact with him by phone. She further states that she was not aware that facility policy and procedures for advanced directives and CPR had not been taught during orientation or inservice, and thought the original policy and procedure documented residents who have DNRs have yellow dots on chart and wristbands. She was also not aware that the staffing coordinator did not schedule staff without assuring that a current BLS certified licensed staff was available on all shifts, and did not have or maintain a list of current BLS certified staff. On [DATE] the Administrator was interviewed at 1:30PM. He states that the DON informed him by phone on [DATE] about the incident. He stated that he was told by the DON that she was doing an investigation of the incident and she would report back to him on [DATE]. He stated that he was aware on [DATE] that the DON developed a new policy and procedure and on [DATE] they were training staff to this new policy that had not been reviewed or approved. He further stated he was not not aware that the staffing coordinator was scheduling staff without assuring current BLS certified licensed were available on all shifts, or that no one maintained a list of current BLS certified staff. He was not aware that Advanced Directives and CPR was not being covered in orientation or in serviced and also stated that he thought the original policy and procedure documented residents who have DNRs have yellow dots on chart and on the wristbands, "I'm sure that the policy and procedure states yellow dots on charts and on bands." On [DATE] LPN #1 was interviewed at 1:45 PM. She stated that she attended wound rounds with the physician and saw resident#1 at about ,[DATE]:30 PM and his condition was stable. At about 3:20 PM two CNAs came to her and reported that resident did not look good. She went to RNS#1 then brought her blood pressure machine with her to the room. She stated, " I could not get a reading, the blood pressure machine was not registering and he had no pulse or respirations, but he felt warm to touch. " She stated that she did not initiate CPR because she did not get direction from RNS#1, "who stood at the door and never put a hand on the resident." She then added, " nurses are supposed to take direction from the RN supervisors for a code blue." " I did not know about dots on braclets, and I don't know if he was wearing one." Hardly none of the residents even wear those wristbands". She stated that the list at the nurse ' s station or the residents chart would have to be checked to determine if resident was a DNR or not. "I've never checked if resident had a wrist band". On [DATE] at 5:40PM the physician was interviewed and stated that a female nurse came out of a room into the hall that day and said to her that a resident died . She went into resident's room with the nurse practioner at about 3:40 PM then asked the nurse if resident had a DNR and she was told no. She then asked the nurse if anyone had done CPR and she was told no. The physician stated at that point starting CPR was futile, and when she questioned the nurse why CPR had not been done the nurse shrugged her shoulders. The physican did not recall the nurses name but was able to give a description. On [DATE] at 4:00 PM a review of the video surveillance tape dated [DATE] at 3:10 PM, revealed the actions of CNA#1 went into residennt room at 3:11 PM and came out at 3:25 PM with dirty linens, LPN#1, and RNS#1 went to residents room at 3:25PM, all of which moved in a non-emergent way. Physican is seen going into room at 3:45PM. Physician came out of room went to desk and reviewed residents chart that RNS#1 handed her. At no time was RNS#1 or LPN#1 observed to look for a list or in residents chart to check the residents Advanced Directives before giving the record to the physician. The immediacy was removed on [DATE], which was concurrent with the investigation exit, as the facility had implemented the following interventions: The facility contracted with experienced consultants to assist in addressing the issues identified by the Department of Health. The Medical Director, Administrator and Director of Nursing reviewed, revised and implemented a revised policy to address Advanced Directives for Cardiopulmonary Resuscitation and Do Not Resuscitate. Residents DNR list was updated and is now scheduled to be updated daily for changes( room changes, transfers to hospital, new admissions, readmissions, DNR ' s rescinded or requests by resident or family. A current list of all certified nurse ' s Basic Cardiac Life Support (BCLS) was compiled and in place for use with staffing needs. Upon admission/readmission of residents social worker will discuss the plan of advanced directives and an Advanced Directive Care Plan shall be put into place immediately. In event of social worker unable their designee/ Registered Nurse Supervisor, who will ascertain DNR status, communicate with MD, and identifiers will be put into place immediately. An audit tool was created to monitor compliance with all DNR identifiers, which included monitoring of existence of Advanced Directives Care plans for all residents. Immediate DNR/CPR education was included in mandatory in-services. Education will be ongoing and conducted for all staff and new hire orientations. Immediate adult CPR certification and recertification had begun for all nursing, and CNAs. CPR classes were being provided by facility and continues until all nurses and CNAs are CPR certified. All new hires will be required to have a valid CPR certification status to assure that the schedule consist of nursing personnel have current CPR certification. An audit tool was created to monitor the compliance with tracking of valid CPR certifications and will be conducted weekly for 3 months by the DON and or ADON. The facility provided evidence that 100% of the nursing department staff were educated and in-serviced on the new P&Ps and protocols. A plan was for future interventions including QA reviews for monitoring of residents CPR status and compliance with the education, training and identification of residents Advanced Directives. 10NYCRR 415.26

Based on observations, record review and staff interviews conducted during an abbreviated survey it was determined that the facility Administrator failed to ensure that the facility operated in a manner which its written policies and procedures were maintained regarding Advanced Directives (Cardiopulmonary Resuscitation, CPR, or Do Not Resuscitate, DNR). Specifically, the facility failed to have a system in place to ensure that physician orders [REDACTED]. Additionally, they did not have a system to ensure CPR certified staff were scheduled on all shifts. This resulted in actual harm that is IMMEDIATE JEOPARDY and Substandard quality of care to resident health and safety. The finding is: Complaint Number: NY 720 This was evidenced by, but not limited to the following: Cross References: F 309- Provide Care/Services for Highest Well Being- scope and severity-L F 155- Resident Rights- scope and severity-L F 250- Social Services - scope and severity-L F 501-Medial Director- scope and severity-L Findings are: During an abbreviated survey a deficiency for Right to Refuse, Formulate Advanced Directives (F 155) F (309) - Quality Assessment & Assurance F (205) - Social Services and F (501)-Medial Director - was cited at an Immediate Jeopardy level. Specifically, resident ' s rights were not consistently being honored in regards to advanced Directives. On [DATE] the Administrator was interviewed at 1:30PM. He states that the DON informed him by phone on [DATE] about the incident. He stated that he was told by the DON that she was doing an investigation of the incident and she would report back to him on [DATE]. He stated that he was aware on [DATE] that the DON developed a new policy and procedure and on [DATE] they were training staff to this new policy that had not been reviewed or approved. He further stated he was not aware that the staffing coordinator was scheduling staff without assuring current BLS certified licensed were available on all shifts, or that no one maintained a list of current BLS certified staff. He was not aware that Advanced Directives and CPR was not being covered in orientation or in serviced and also stated that he thought the original policy and procedure documented residents who have DNRs have yellow dots on chart and on the wristbands, "I'm sure that the policy and procedure states yellow dots on charts and on bands." 10NYCRR 415.26

Based on observations, record review, and staff interviews conducted during an abbreviated survey it was determined that the facility medical director failed to coordinate and implement the facility ' s policies and procedures for residents' Advanced Directives (Cardiopulmonary Resuscitation, CPR, or Do Not Resuscitate, DNR). This resulted in actual harm to Resident #1 and the potential for serious harm that is Immediate Jeopardy to resident health and safety. Complaint Number: NY 720 This was evidenced by, but not limited to the following: Cross References: F 309- Provide Care for Highest Well-Being, -scope and severity-L F 155- Resident Rights, - scope and severity-L F 490- Administration,- scope and severity-L F 250-Social Services,- scope and severity-L The findings are: An interview was conducted with the Medical Director (MD) on [DATE] at 3:30 PM. The MD stated that he did not know who Resident #1 was and is aware of some of the concerns that were found during the investigations regarding the resident care. He is not sure what policies were in effect regarding CPR at the time but has read the new policies and as far as he knew were good. The immediacy was removed on [DATE], which was concurrent with the investigation exit, as the facility had implemented the following interventions: The facility contracted with experienced consultants to assist in addressing the issues identified by the Department of Health. The Medical Director, Administrator and Director of Nursing reviewed, revised and implemented a revised policy to address Advanced Directives for Cardiopulmonary Resuscitation and Do Not Resuscitate. Residents DNR list was updated and is now scheduled to be updated daily for changes( room changes, transfers to hospital, new admissions, readmissions, DNR ' s rescinded or requests by resident or family. A current list of all certified nurse ' s Basic Cardiac Life Support (BCLS) was compiled and in place for use with staffing needs. Upon admission/readmission of residents social worker will discuss the plan of advanced directives and an Advanced Directive Care Plan shall be put into place immediately. In event of social worker unable their designee/ Registered Nurse Supervisor, who will ascertain DNR status, communicate with MD, and identifiers will be put into place immediately. An audit tool was created to monitor compliance with all DNR identifiers, which included monitoring of existence of Advanced Directives Care plans for all residents. Immediate DNR/CPR education was included in mandatory in-services. Education will be ongoing and conducted for all staff and new hire orientations. Immediate adult CPR certification and recertification had begun for all nursing, and CNAs. CPR classes were being provided by facility and continues until all nurses and CNA ' s are CPR certified. All new hires will be required to have a valid CPR certification status to assure that the schedule consist of nursing personnel have current CPR certification. An audit tool was created to monitor the compliance with tracking of valid CPR certifications and will be conducted weekly for 3 months by the DON and or ADON. The facility provided evidence that 100% of the nursing department staff were educated and in-serviced on the new P&Ps and protocols. A plan was for future interventions including QA reviews for monitoring of residents CPR status and compliance with the education, training and identification of residents Advanced Directives. 10 NYCRR 415.15 (a)