Every finding on record at Eddy Heritage House Nursing and Rehabilitation CTR

Based on observations, interviews, and record reviews conducted during the abbreviated survey (#2665815), the facility failed to ensure residents' right to be free from neglect for one (1) of five (5) residents reviewed. (Resident #1). Specifically, on [DATE] at 2:00 PM, the facility identified that Resident #1 received four (4) incorrect doses of morphine sulfate (a strong opioid analgesic used to treat moderate to severe pain) totaling 80 milligrams over a 12-hour timeframe. This resulted in the resident becoming lethargic and unresponsive with unstable vital signs including blood pressure and oxygen saturation. The facility failed to provide interventions to reverse the effects of the medication despite the family inquiry to Narcan (also known as naloxone, a medication used to reverse or reduce the effects of opioids). The resident expired on [DATE] at 6:20 AM. This resulted in Substandard Quality of Care that was Immediate Jeopardy that resulted in the death of Resident #1, with the likelihood of serious injury, harm, impairment, or death adverse outcomes occurring to all 108 residents in the facility.This is evidenced by: Cross Reference to F-760: Residents Are Free of Significant Med Errors The facility policy titled ' Abuse Prevention and Investigation Policy, effective [DATE], documented residents had the right to be free from verbal, sexual, physical, and mental abuse, neglect, mistreatment, corporal punishment, involuntary seclusion, exploitation, and misappropriation of property. Under Investigation/Identification, the policy documented the resident should be assessed, and any necessary care and treatment provided. Neglect was defined as failure to provide timely, consistent, safe, adequate and appropriate services, treatment and care necessary to avoid physical harm, mental anguish, or mental illness such as nutrition, medication, therapies, sanitary clothing and surroundings and activities of daily living. For example: facility failure to implement an effective communication system across all shifts for communicating necessary care needs, information between staff, practitioners, and resident representatives. The facility policy titled Management of Opioid Overdose (Naloxone administration), effective date [DATE], documented an opioid overdose needed urgent medical attention. Naloxone should be administered to anyone who presented with signs of opioid overdose. Under procedure it was documented: a.) evaluate for signs of opioid overdose, which included unconsciousness or inability to awaken, slow or shallow breathing or difficulty breathing such as chocking sounds or a gurgling/snoring noise from a person who cannot be awakened, fingernails or lips turning blue/purple; b.) if an opioid overdose was suspected, stimulate the person, call the person's name, if that did not work to vigorously grind knuckles into the sternum or run knuckles on the person's upper lip, continue to monitor the person, including breathing and alertness, and try to keep the person awake and alert; c.) if the person did not respond, provide rescue breathing if the person was not breathing on their own, d.) administer naloxone per manufacturer recommendation. The facility policy, Medication Errors and reporting, dated [DATE], documented medication events included transcription errors. The purpose of the policy was to ensure prompt identification, reporting, documentation, investigation and correction of all medication events (including errors and near misses) to protect resident safety and comply with regularity requirements. The procedure read: 1. assess the resident to ensure safety; 2.) notify the Nurse Manager and/or nursing supervisor immediately. Any potentially reportable error, per New York State would be escalated to the Medical Director, Director of Nursing and the Executive Director; 3.) the Nurse Manager/supervisor would notify the provider immediately and would obtain direction regarding necessary resident monitoring, duration of monitoring and expected follow up communications; 4.) notify pharmacy for any dispensing errors; 5.) notify the resident and/or the designated representative about the error and follow up plan 6.) document nature of the event, individuals notified, actions taken, order received, resident's response to the event and mentoring plan in the resident progress notes. Results of continued monitoring, assessments and communications would also be documented. Record review revealed Resident #1 was admitted to the facility on [DATE] for five (5) days of respite care (a short-term, substitute care for a person who requires assistance by a caregiver. Respite care provides temporary relief for primary caregivers, giving the caregiver a break for rest, errands, or personal time, preventing caregiver burnout, and ensuring the care recipient is still looked after in a setting able to provide appropriate care) with diagnoses of senile degeneration of the brain (an outdated term for dementia, a general decline in cognitive function that is not a normal part of aging), end-stage renal disease (the final stage of chronic kidney disease, occurring when kidneys fail to filter waste and toxins from the blood), and atrial fibrillation (an irregular and often very rapid heart rhythm). The Brief Interview for Mental Status dated [DATE] documented the resident was rarely understood. Resident #1 was not in the facility long enough to receive a complete Minimum Data Set (a resident assessment tool). A Home Hospice Note dated [DATE] at 8:30 AM by Registered Nurse #6 documented Resident #1 was receiving acetaminophen, tramadol, and diclofenac gel as needed in their home prior to facility admission for five (5) days of respite care. Resident #1 denied pain throughout their visit and medications were reviewed with Health Care Proxy #1 with good understanding. It was further documented that Registered Nurse #6 called the facility at the completion of their visit with Resident #1 and gave report to Registered Nurse #7. There was no documented evidence that Resident #1 had received morphine sulfate in their home prior to facility respite admission. The Medication Administration Record for [DATE] documented Resident #1 received 20 milligrams of morphine sulfate four (4) times over a 12-hour period ([DATE] at 2:00 AM, 6:00 AM, 10:00 AM, and 2:00 PM). The order was discontinued on [DATE], after the facility staff identified Resident #1 received four (4) incorrect doses of morphine sulfate totaling 80 milligrams. During an interview on [DATE] at 1:02 PM, Registered Nurse #6 stated they visited with Resident #1 at their home on the morning of [DATE], prior to Resident #1's admission to the facility for respite care. They stated Resident #1 was at their baseline. They were alert, drowsy, vitals were stable, heart rate was low, but was not in distress, and could answer basic yes/no questions. Registered Nurse #6 stated that Resident #1 had a comfort pack, which included comfort medications, anxiety medications, and pain medications. They further stated that Resident #1 had an order for morphine sulfate five (5) milligrams by mouth every four (4) hours as needed but had never taken it. Registered Nurse #6 stated they had given report to the hospice nurse for the facility and a facility registered nurse (did not recall name) with the resident's vital signs, diagnoses and mentation. Registered Nurse #6 stated they did not discuss the resident's comfort pack or pain medication during their report. During an interview on [DATE] at 2:23 PM, Registered Nurse #2 stated they were a Hospice provider at the facility. They stated they saw Resident #1 for a skilled nursing visit on [DATE] upon their admission for respite care. Registered Nurse #2 stated they verbally reviewed the resident's medications with Registered Nurse #1, including morphine 5 milligrams every 4 hours as was ordered on the record in the electronic charting system used by Hospice group. They stated they had received report from the community hospice nurse but did not discuss Resident #1's medications. On [DATE], Registered Nurse #1 transcribed three (3) out of the five (5) morphine Sulfate orders incorrectly for Resident #1 and completed a first check to ensure accuracy. Registered Nurse #3 did a second check of the medication orders for accuracy and signed off on the orders. There was no documented evidence that a third check was completed by any staff. During an interview on [DATE] at 10:40 AM, Registered Nurse #4 stated they assisted Registered Nurse #1 in identifying the correct concentration of morphine sulfate from a drop-down menu but did not enter the order or witness the order being entered. They stated on [DATE], Licensed Practical Nurse #1 came to them to question the morphine sulfate order. They stated this was when they discovered that there was no third signature to confirm the order was correct through the facility's triple check system. Registered Nurse #4 stated they immediately discontinued the order, informed Physician #1 of the error, and received a new corrected order for morphine, which was entered into the system. When they left for the day around 3:45 PM, they stated Resident #1 was stable, their blood pressure was good, and no apnea was observed. Registered Nurse #4 stated they did not call Director of Nursing #2 or Administrator #1, contacting the Physician #1 was their first priority. On [DATE] at 2:00 PM, after the medication error was identified, there was no documented evidence that Physician #1 was notified of the error, just an order signed by Physician #1 for a corrected morphine dose. There was no documented evidence that Physician #1 gave further instructions on how to care for Resident #1 after the medication error was identified, nor were there physician notes or assessments that documented four (4) incorrect doses of morphine were administered. Resident #1's vital signs on admission on [DATE] at 2:57 PM were documented as blood pressure: 161/71, temperature: 97.9 degrees, heartrate: 51 beats per minute, respirations: 20 breaths per minute, oxygen saturation: 93 percent on room air. On [DATE] at 10:28 PM, Resident #1's temperature was recorded as 97.1 degrees. On [DATE] at 6:50 PM, a nursing progress note documented Resident #1's oxygen saturation was 89 percent and the resident was on three (3) liters of oxygen.Physician #1 ordered oxygen therapy every two (2) to four (4) liters per minute as needed for shortness of breath on [DATE] at 12:27 PM. There was no documented evidence that any further vital signs were taken, or assessment completed, for Resident #1 on [DATE] after the medication error was discovered. A nursing progress note dated [DATE] at 3:36 AM, documented at 2:30 AM, nurse was called to unit to assess change in resident condition. Resident #1's blood pressure was recorded as 94/39, respirations: 28-32 breaths per minute, and oxygen saturation was 65 percent on three (3) liters of oxygen. No heart rate was documented. There was no documented evidence that any further vital signs were taken for Resident #1 on [DATE] prior to their death at 6:20 AM. There was no documented evidence that the facility monitored Resident #1's condition, assessed their decline, provided necessary treatment, responded to respiratory depression, coordinated with hospice, or ensured physician oversight after the medication error was identified.There was no documented evidence of nursing notes from [DATE] at 9:32 AM to [DATE] at 6:44 PM indicating that Resident #1 was monitored, assessed, or in any way treated for the overdosing of morphine nor was there any notation that Resident #1 received incorrect doses of morphine during that time. A nursing progress note dated [DATE] at 6:48 PM, written by Registered Nurse # 9, documented Resident #1 was at the facility for respite, was on home hospice, and was actively dying. It further documented that they called hospice to inform them of the situation and a Hospice Registered Nurse was sent to the facility to assess the resident and speak to the family. A Health Status note dated [DATE] at 3:36 AM by Licensed Practical Nurse #4, documented that they were called to the unit for a change in resident condition, and an attempt to contact Hospice was made but contact number on the chart was not in service. A Health Status note dated [DATE] at 4:57 AM by Licensed Practical Nurse #4, documented that Hospice was notified of the change in Resident #1's condition. There was no documented evidence that hospice was notified of the medication error. During an interview on [DATE] at 12:12 PM, Health Care Proxy #2 stated Resident #1 had not received any medications prior to their admission to the facility. They stated they left the facility around 2:00 PM on [DATE] and returned around 4:00 PM on [DATE]. They stated Resident #1 was sleeping soundly enough to be snoring and they were unable to wake him. Health Care Proxy #2 stated they asked unnamed staff if Resident #1 had been like that all day and the unnamed staff reportedly stated yes. An unnamed doctor spoke to Health Care Proxy #2 and mentioned the resident had received morphine, but it was a low dose. The unnamed doctor reportedly stated to Health Care Proxy #2 that Narcan (naloxone - a medication used to reverse or reduce the effects of opioids) was not safe to use and Health Care Proxy #2 was advised to let Resident #1 sleep it off. They left the facility after 7:00 PM and were called back to the facility on [DATE] at 4:00 AM because Resident #1 was dying. They were at Resident #1's bedside when they were pronounced deceased at 6:20 AM. There was no documented evidence that the resident representative was notified of the medication error until [DATE]. During an interview on [DATE] at 10:05 AM, Director of Nursing #2 stated they were largely unaware of the situation. They stated, they recalled seeing Resident #1 one time and the resident was sleeping at the time. They stated they did not recall receiving a call from the facility the night the resident passed. They further stated any conversation they had would have been documented in the Electronic Medical Record. During an interview on [DATE] at 12:08 PM, Director of Nursing #1 stated they were off when the incident occurred. They heard about the medication error when they returned. They stated the facility had a triple check system, when an order was put in, it would be checked for three (3) shifts after for accuracy. When asked if that practice was in place when Resident #1 was admitted or a new practice put in place as a result of this incident, Director of Nursing #1 stated that it was in place before the incident occurred. When asked why there was a lack of response documented by all staff involved, Director of Nursing #1 stated that Resident #1 was on hospice. During an interview on [DATE] at 12:34 PM, Administrator #1 stated they were not in the facility when the medication error occurred. To the best of their knowledge, there was a transcription error that went through to resident orders. The orders from hospice were confusing. The day after Resident #1 was admitted , one of the nurses questioned the order. The unit manager looked at it and stated that it was a transcription error. Then it was brought to Administrator #1. The nurse that made the original transcription order was educated and given a solitary area to do admission work. They had a message from Resident #1's family when they returned to work. They stated they met in person with the family on [DATE] to review what happened. Administrator #1 stated that they were very transparent with Resident #1's family. Administrator #1 stated that Director of Nurse #2 started the investigation, but Administrator #1 had to finish it. Administrator #1 stated that Medical Director #1 discussed the medical details and Narcan administration with Resident #1's family and that Administrator #1 was not part of that conversation. During an interview on [DATE] at 2:04 PM, Medical Director #1 stated the resident was admitted to the facility for respite care. They stated they were contacted on [DATE] at 3:00 AM and were informed that Resident #1 had received 20 milligrams of morphine sulfate every 4 hours for four (4) doses, 80 milligrams total, and they stated it was a significant medication error. Medical Director #1 state the family was not communicated with right away. They had a meeting with the family at a later time to discuss what occurred. Medical Director #1 stated Narcan was discussed, but they were not directly involved with the resident. They stated Director of Nursing #2 was at bedside with the daughter, Narcan was discussed, and the decision was that Resident #1 was comfortable and on hospice. The facility was notified of the Immediate Jeopardy on [DATE] at 5:28 PM. The facility's Immediate Jeopardy Removal Plan dated [DATE] at 10:20 PM was accepted. The Immediate Jeopardy was removed on [DATE] at 1:00 PM. Based on observation, interview and record review conducted on [DATE], [DATE], [DATE], and [DATE], the facility's corrective actions were fully implemented effective [DATE] at 1:00 PM and included the following: Hospice contact information will be posted in each nursing unit and will be included on the face sheet for residents actively on Hospice by [DATE]. On each of the 3 (three) resident units, the contact for Community Hospice was visible at accessible locations such as a nursing station. The facility had 3 (three) residents enrolled in Hospice services on [DATE] and in each of the three resident's electronic medical records and hard(paper) charts, the contact number for Community Hospice was visible and accessible under contacts on the residents' face sheets. Medication error reporting policy was updated on [DATE] to include a statement that requires the Physician/Nurse Practitioner, upon notification of medication error, to provide direction for monitoring, duration of monitoring and expected follow up communication. The policy also states that documentation will include nature of the incident, nature of the event, individuals notified (including family and hospice as applicable), actions taken, orders received, results of continued monitoring, assessments and communication. Completed [DATE]. Observed to be true [DATE], effective date [DATE] by review of the revised policy supplied to surveyors.All on-call Physicians and Nurse Practitioners (for dates [DATE]-[DATE]) were in serviced by the Chief Medical Officer #1 regarding high-risk medications and review of electronic ordering for safe dosing. The remaining Physicians and Nurse Practitioners were in serviced on [DATE]. All nursing including agency staff will be educated by nursing educator/designee prior to start of shift on the updated Medication Error Reporting policy, which includes directions on provider and family notification as well as resident monitoring and documentation requirements was completed on [DATE]. Education Sign-In Sheets titled Transcription- Triple Check- Medication Reconsolidation, Transfer report - hand off sheet, Neglect related to Resident Monitoring - Education sign-in sheets documented 39 out of 39 in house nurses and 13 agency nurses educated. 13 Agency nurses left to educate if they return to the facility. During an interview with Director of Nursing #1 on [DATE] at 12:18 PM, surveyor identified 1 (one) in house nurse Registered Nurse #11 was not educated prior to their shift on [DATE] and was actively working on their shift. Registered Nurse #11 was educated on [DATE] at 12:43 PM. Compare transcribed orders with original provider order for accuracy. Checks will be completed and documented in the paper chart for the next two consecutive shifts. All nursing staff (including agency staff) will receive education by the nurse educator, supervision or designee prior to start of shift regarding medication reconciliation, medication transcription, triple check and safe medication administration practices. Education sign-in sheets documented 39 out of 39 in house nurses and 13 agency nurses educated. 13 Agency nurses left to educate if they return to the facility. Education sign in sheet titled, Transcription- triple check-medication reconsolidation, transfer repot- hand off sheet, Neglect related to resident monitoring, documented 39 out of 39 in-house nurses and 13 agency nurses were in-serviced regarding on the abuse/neglect and mistreatment policy with a special focus on potential neglect related to medication errors and lack of monitoring, assessment and documentation related to change in condition. There are 13 agency nurses left to educate if they return to work at the facility. 10 New York Codes, Rules, and Regulations 415.4(b)(I)(i)

Based on record reviews and interviews conducted during the abbreviated survey (#2665815), the facility failed to ensure residents were free from significant medication errors for one (1) of five (5) residents reviewed (Resident #1). Specifically, the facility administered four (4) incorrect doses of morphine sulfate (a strong opioid analgesic used to treat moderate to severe pain), totaling 80 milligrams over a 12-hour period. This resulted in Substandard Quality of Care that was Immediate Jeopardy and resulted in the death of Resident #1, with the likelihood of serious injury, harm, impairment, or death to all 108 residents in the facility.This is evidenced by:Cross reference to F-600: Free from Abuse and Neglect.The facility policy and procedure titled Medication Administration dated [DATE], documented that each resident would receive medications according to the provider orders and accepted professional standards. The nurse was responsible for having knowledge of the therapeutic effects, contraindications, side effects, and drug interactions of medications given. New medications or changing in dosing would be documented in the progress notes. The facility policy titled Medication Errors and Reporting dated [DATE], documented medication events included transcription errors. The purpose of the policy was to ensure prompt identification, reporting, documentation, investigation and correction of all medication events (including errors and near misses) to protect resident safety and comply with regularity requirements. The procedure read: 1.) assess the resident to ensure safety; 2.) notify the Nurse Manager and/or nursing supervisor immediately. Any potentially reportable error, per New York State would be escalated to the Medical Director, Director of Nursing and the Executive Director; 3.) the Nurse Manager/supervisor would notify the provider immediately and would obtain direction regarding necessary resident monitoring, duration of monitoring and expected follow up communications; 4.) notify pharmacy for any dispensing errors; 5.) notify the resident and/or the designated representative about the error and follow up plan 6.) document nature of the event, individuals notified, actions taken, order received, resident's response to the event and mentoring plan in the resident progress notes. Results of continued monitoring, assessments and communications would also be documented.Record review revealed Resident #1 was admitted to the facility on [DATE] for five (5) days of respite care (a short-term, substitute care for a person who requires assistance by a caregiver. Respite care provides temporary relief for primary caregivers, giving the caregiver a break for rest, errands, or personal time, preventing caregiver burnout, and ensuring the care recipient is still looked after in a setting able to provide appropriate care) through [DATE] with diagnoses of senile degeneration of the brain (an outdated term for dementia, a general decline in cognitive function that is not a normal part of aging), end-stage renal disease (the final stage of chronic kidney disease, occurring when kidneys fail to filter waste and toxins from the blood), and atrial fibrillation (an irregular and often very rapid heart rhythm). The Brief Interview for Mental Status dated [DATE] documented the resident was rarely understood. Resident #1 was not in the facility long enough to receive a complete Minimum Data Set (a resident assessment tool).Resident #1's admission order to the facility from hospice read morphine 100 milligrams per five (5) milliliter concentrated solution, take five (5) milligrams by mouth every four (4) hours for indications of pain and/or shortness of breath. A Home Hospice Note dated [DATE] at 8:30 AM by Registered Nurse #6, documented Resident #1 was receiving acetaminophen, tramadol, and diclofenac gel as needed in their home prior to admission. There was no documented evidence that Resident #1 had received morphine sulfate in their home prior to facility respite admission. A Hospice Note dated [DATE] at 1:59 PM documented Registered Nurse #2 verbally reviewed the morphine order with Registered Nurse #1 and the dose was 5 milligrams every four (4) hours. The note documented Resident #1 was drowsy with no complaints of pain upon admission to the facility. An order dated [DATE] at 6:07 PM documented morphine sulfate (concentrate) oral solution 100 milligrams per five (5) milliliters, give one (1) milliliter every four (4) hours for pain. The dose per administration was 20 milligrams per one (1) milliliter. The Medication Administration Record for [DATE], documented Resident #1 received 20 milligrams of morphine sulfate four (4) times over a 12-hour period ([DATE] at 2:00 AM, 6:00 AM, 10:00 AM, and 2:00 PM). The order was discontinued later in the afternoon of [DATE].During an interview on [DATE] at 10:19 AM, Health Care Proxy #1 stated Resident #1 was not receiving morphine sulfate at home. They stated the home hospice nurse, Registered Nurse #6, saw Resident #1 at home just prior to admission to the facility and stated the resident was stable for a respite stay.During an interview on [DATE] at 12:12 PM, Health Care Proxy #2 stated Resident #1 had not received any medications prior to their admission to the facility. They stated they left the facility around 2:00 PM on [DATE] and returned around 4:00 PM on [DATE]. They stated Resident #1 was sleeping soundly enough to be snoring and they were unable to wake them. Health Care Proxy #2 stated they asked unnamed staff if Resident #1 had been like that all day and the unnamed staff reportedly stated yes. An unnamed doctor spoke to Health Care Proxy #2 and mentioned the resident had received morphine, but it was a low dose. The unnamed doctor reportedly stated to Health Care Proxy #2 that Narcan (also known as naloxone, a medication used to reverse or reduce the effects of opioids) was not safe to use and Health Care Proxy #2 was advised to let Resident #1 sleep it off. Health Care Proxy #2 stated they left the facility after 7:00 PM on [DATE] and were called back to the facility on [DATE] at 4:00 AM because Resident #1 was dying. Upon arrival, Health Care Proxy #2 again asked if Resident #1 should receive Narcan. Unnamed facility staff told them that Narcan would be ineffective at that time. They further stated they were at Resident #1's bedside when they were pronounced deceased at 6:20 AM.During an interview on [DATE] at 1:02 PM, Registered Nurse #6 stated they visited with Resident #1 at their home on the morning of [DATE], prior to Resident #1's admission to the facility for respite care. They stated Resident #1 was at their baseline. They were alert, drowsy, vitals were stable, heart rate was low, but was not in distress, and could answer basic yes/no questions. Registered Nurse #6 stated that Resident #1 had a comfort pack, which included comfort medications, anxiety medications, and pain medications. They further stated that Resident #1 had an order for morphine sulfate 5 five) milligrams by mouth every 4 (four) hours as needed but had never taken it. Registered Nurse #6 stated they had given report to the hospice nurse for the facility and a facility registered nurse (did not recall name) with the resident's vital signs, diagnoses and mentation. Registered Nurse #6 stated they did not discuss the resident's comfort pack or pain medication during their report. During an interview on [DATE] at 1:56 PM, Registered Nurse #3 stated they performed the second check on ordered medications for Resident #1, but they did not remember the orders in specific. They stated that this transcription error should have been caught.During an interview on [DATE] at 2:23 PM, Registered Nurse #2 stated they were a Hospice provider at the facility. They stated they saw Resident #1 for a skilled nursing visit on [DATE] upon their admission for respite care. Registered Nurse #2 stated they verbally reviewed the resident's medications with Registered Nurse #1, including morphine five (5) milligrams every four (4) hours. Registered Nurse #2 stated that was what was ordered on the record in the electronic charting system used by the Hospice service provider that rendered services for the facility. They stated they had received report from the Community Hospice Nurse but did not discuss medications. During an interview on [DATE] at 9:21 AM, Registered Nurse #1 stated they had looked at the orders upon the resident's admission and reviewed them with Health Care Proxy #2 who stated they were correct. They stated that they entered the orders into the electronic medical record and instead of entering 0.25 milliliters they entered one (1) milliliter which equaled 20 milligrams of morphine sulfate instead of five) milligrams. During an interview on [DATE] at 10:45 AM, Licensed Practical Nurse #1 stated they questioned the morphine dose after they had given Resident #1's fourth dose, which was the second dose Licensed Practical Nurse #1's administered to Resident #1 on their shift at 2:00 PM on [DATE]. Licensed Practical Nurse #1 stated at that time, they grabbed their drug book, looked it up, and brought it to Registered Nurse #4's attention.During an interview on [DATE] at 10:40 AM, Registered Nurse #4 stated they assisted Registered Nurse #1 in identifying the correct concentration of morphine sulfate from a drop-down menu but did not enter the order or witness the order being entered. They stated on [DATE], Licensed Practical Nurse #1 came to them to question the morphine sulfate order. Registered Nurse #4 stated they immediately discontinued the order, informed Physician #1 of the error, and received a new correct order for morphine, which was entered into the system at 3:42 PM.During an interview on [DATE] at 11:14 AM, Pharmacist Supervisor #1 stated the facility was contacted on [DATE] to clarify a dosage of morphine sulfate for Resident #1 and the dosage was clarified as 100 milligrams per 5 milliliters, give 5 milliliters every 4 hours with Registered Nurse #3 on [DATE] at 6:29 PM. They clarified the order again with Registered Nurse #3 at 7:36 PM. When a new order was received on [DATE], they clarified the order with Physician #1 at 4:15 PM. During an interview on [DATE] at 11:54 AM, Physician #1 stated they gave verbal orders for morphine sulfate. They did not realize the issue with the concentration of morphine sulfate in the order until [DATE] when it was brought to their attention by Registered Nurse #4. They stated they had signed the original orders but may not have read them carefully to notice a high dose of morphine was ordered.During an interview on [DATE] at 12:08 PM, Director of Nursing #1 stated they were off when the incident occurred. They heard about the incident upon their return and had educated the nurse that was involved in the transcription error. They stated the facility had a triple check system; when an order was put in, it was checked for three (3) shifts after, which was in place before the incident occurred. During an interview on [DATE] at 1:49 PM, Licensed Practical Nurse #2 stated they were Resident #1's medication nurse for the overnight shift starting [DATE]. They stated they recalled giving the resident the medication. They stated they were not involved in the three (3)-check system and assumed the order was correct. They stated they did not question the dosage of morphine sulfate because the resident was on hospice. They stated they administered 20 milligrams of morphine on [DATE] at 2:00 AM and 6:00 AM as ordered. During an interview on [DATE] at 12:34 PM, Administrator #1 stated they were not in the facility when the medication error occurred. To the best of their knowledge there was a transcription error that went through to resident orders. The orders from hospice were confusing. It was started as a scheduled dose when it should have been as needed. The day after Resident #1 was admitted , one of the nurses questioned the order. The unit manager looked at it and stated that it was a transcription error. Then it was brought to Administrator #1. The nurse that made the original transcription order was educated and given a solitary area to do admission work. They had a message from Resident #1's family when they returned to work. They stated they met in person with the family on [DATE] to review what happened. Administrator #1 stated that they were very transparent with Resident #1's family. Administrator #1 stated that Director of Nurse #2 started the investigation, but Administrator #1 had to finish it. Administrator #1 stated that Medical Director #1 discussed the medical details and Narcan administration with Resident #1's family and that Administrator #1 was not part of that conversation.During an interview on [DATE] at 2:04 PM, Medical Director #1 stated the resident was admitted for respite care. They were offsite but spoke to Physician #1. They stated they were contacted on [DATE] at 3:00 AM and informed that Resident #1 received 20 milligrams of morphine sulfate every four (4) hours for four (4) doses, 80 milligrams total, and they stated it was a significant medication error. Medical Director #1 stated they had a meeting with the family after the resident expired to discuss what happened. Medical Director #1 stated that Narcan would not have been effective at 4 AM when the family asked for it. When asked if Narcan would have been effective at 4 PM when the family asked for it the first time, Medical Director #1 stated that there were some risks in giving Narcan and that because the resident was comfortable and sleeping, the family and Physician #1 decided not to administer Narcan to Resident #1.The facility was notified of the Immediate Jeopardy on [DATE] at 5:28 PM. The facility's Immediate Jeopardy Removal Plan dated [DATE] at 10:20 PM was accepted. The Immediate Jeopardy was removed on [DATE] at 2:47 PM. *************************************************************************************Based on observations, interviews and record review conducted on [DATE], [DATE], [DATE], and [DATE], the facility's corrective actions were fully implemented effective [DATE] at 2:47 PM and included the following: 35 narcotic orders were reviewed for ongoing appropriateness and safety by Medical Director #1 on [DATE]. No corrections were required. 51 narcotic orders were reviewed for ongoing appropriateness and safety on [DATE]. One (1) order of four (4) written by Physician #1 was found to have an error that could have negatively impacted a Resident. Immediate education was provided to Physician #1 and Licensed Practical Nurse #1, and the order was amended by Chief Nursing Officer #1 and Medical Director #1 immediately. All active medication orders were reviewed between [DATE] and [DATE] by the consultant pharmacists and medical director for ongoing appropriateness and safety. Administrator #1 worked with electronic ordering system creators to enable a feature to run reports that reflected ordering errors for closer daily monitoring. All on-call physicians and nurse practitioners (for dates [DATE] -[DATE]) were in serviced by the Medical Director #1 regarding high-risk medications and review of electronic ordering for safe dosing. The remaining physicians and nurse practitioners were inserviced on [DATE]. 'Transcription of Orders' policy was developed on [DATE] to include information regarding medication reconciliation as well as the triple check process. Compared transcribed orders with original provider order for accuracy. Checks were completed and documented in the paper chart for the next two (2) consecutive shifts. All nursing including agency staff will be educated by nursing educator/designee prior to start of shift on the updated Medication Error Reporting policy, which includes directions on provider and family notification as well as resident monitoring and documentation requirements was completed on [DATE]. Education Sign-In Sheets titled Transcription- Triple Check- Medication Reconsolidation, Transfer report - hand off sheet, Neglect related to Resident Monitoring - Education sign-in sheets documented 39 out of 39 in house nurses and 13 agency nurses educated. 13 Agency nurses left to educate if they return to the facility. Record review completed on [DATE] at 5:20 PM, documented a verbal order was entered directly into the electronic medical record. No order was placed in the chart for nursing staff to start the triple check process. During an interview on [DATE] at 5:45 PM, Chief Nursing Officer #1 stated that the medication nurse was educated on [DATE] around 5:30 PM regarding an end date needed for the order and printing orders to place in the chart to begin the triple check process. They further stated that Medical Director #1, and/or Administrator #1 and/or Chief Nursing Officer #1 would check orders from the previous day starting on [DATE]. They stated Nurse Managers were responsible for completing audits on triple check and would bring audit results to Quality Assurance monthly meetings. On [DATE] at 2:47 PM, surveyors verified the facility conducted a daily 24-hour look back on all new medication orders by Director of Nursing #1 or designee. Interviews with all parties responsible for these barrier checks showed they were aware of their required responsibilities. 10 New York Codes, Rules, and Regulations 415.12(m)(2)

Based on observations, interviews, and record review conducted during an abbreviated survey (Case #2665815), the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for four (4) (Resident #'s 10, 11, 12, and 13) of four (4) residents reviewed for medication administration. Specifically, the resident's medications were administered late across various units and their medical providers were not notified. This is evidenced by: The Facility Policy titled Medication Administration effective date 12/21/2025, documented it was the policy of the facility that each patient/resident/elder would receive medications according to provider orders and accepted professional standards. Times entered into the electronic medication administration record are used to organize the nursing workflow and do not reflect times ordered by the medical staff. Red alerts highlighted in the electronic medication administration record do not reflect late medications. The nurse was responsible for having knowledge for the therapeutic effects, contraindications, side effects and drug interactions of medications given. Resident #10 Resident #10 was admitted to the facility with diagnoses of fracture of left radius (when the radius bone on the arm breaks near the wrist), unspecified dementia (a group of conditions that cause a progressive decline in cognitive abilities), and hypertensive crises (when blood pressure is 180/120 or higher). The Minimum Data Set, dated [DATE], documented the resident had moderate cognitive impairments, could be understood, and could understand others. A physician order dated 10/14/2025, read Lidocaine External Patch 4 percent, apply to lower back topically 1 (one) time a day for pain and remove per schedule. A physician order dated 10/13/2025, read Metoprolol Succinate extended release 24 hour 100 milligrams, give 1 (one) tablet by mouth for hypertension, hold for systolic blood pressure (pressure in the arteries when the heart contracts and pumps blood out, representing the maximum pressure during a heartbeat. It is the top (first) number in a blood pressure reading) less than 100 or heart rate less than 55. Resident #10's Medication Administration Record for November documented Lidocaine External Patch 4% was scheduled to be administered within one (1) hour before or one (1) hour after 8:00 AM. Resident #10's Medication Administration Record for November documented Metoprolol Succinate was scheduled to be administered within one (1) hour before or one (1) hour after 9:00 AM. During an observation on 11/24/2025 at 10:34 AM, Licensed Practical Nurse #9 was observed pulling Resident #10's medications for their medication pass. Their medications included Lidocaine Patch 4 percent, Ensure Plus, Tylenol 500 milligrams 2 (two) tablets, Metoprolol 100 milligrams, Zoloft 25 milligrams, Calcitonin Nasal Solution, and Apixaban 2.5 milligrams. During an interview on 11/24/2025 at 10:34 AM, Licensed Practical Nurse #9 stated they would need to call the doctor about late medications. They stated morning medications were typically administered late. Licensed Practical Nurse #9 stated it was a heavy medication pass on the unit, the system had shut down briefly earlier in the day, and there were residents that needed to go out for appointments. Licensed Practical Nurse #9 further stated they still had four more residents to give medications to. Resident # 11 Resident #11 was admitted to the facility with diagnoses of idiopathic peripheral autonomic neuropathy (nerve damage that affects the autonomic nervous system that control involuntary bodily functions such as heart rate, digestion, and breathing), anxiety disorder (mental health condition characterized by excessive fear or anxiety that interferes with daily activities), and hypertension (also known as high blood pressure,condition where the force of blood against the artery walls is consistently too high). The Minimum Data Set, dated [DATE], documented the resident was cognitively intact, could be understood, and could understand others. A physician order dated 9/23/2023 read Buspirone Hydrochloride oral tablet 15 milligrams, give 1 (one) tablet by mouth 3 (three) times a day for anxiety. A physician order dated 10/17/2025 read Procardia XL tablet extended release 24 hour 60 milligram, give 1 (one) tablet by mouth one time a day for hypertension. Resident #11's Medication Administration Record for November documented Buspirone was scheduled to be administered within one (1) hour before or one (1) hour after 8:00 AM. Resident #11's Medication Administration Record for November documented Procardia XL was scheduled to be administered within one (1) hour before or one (1) hour after 9:00 AM. During an observation on 11/24/2025 at 10:30 AM, Licensed Practical Nurse #10 was observed administering Resident 11's medications. Their medications included Buspirone 15 milligrams, Calcium 600 milligrams, Methenamine Hippurate I gram, Omeprazole 20 milligrams, hydrochlorothiazide 12.5 milligrams, Metamucil packet, Procardia ER 60 milligrams, Duloxetine HCI 30 milligrams, Vitamin C, Vitamin D, Magnesium Oxide, Aspirin 81 milligrams, Ferrous Sulfate 325 milligrams, Colace 100 milligrams, Saline Spray and Artificial Tears. During an interview on 11/24/2025 at 10:37 AM, Licensed Practical Nurse #10 stated they were having computer issues, which was why the medications were late. They further stated they should call the doctor. Resident #12 Resident #12 was admitted to the facility with diagnoses of acute on chronic diastolic (congestive) heart failure (a sudden worsening of symptoms of a pre-existing condition of weakened heart muscles), acute respiratory failure (lungs cannot release enough oxygen into the blood), and atherosclerotic heart disease (a hardening of your arteries from plaque building up gradually inside them). The Minimum Data Set, dated [DATE], documented the resident was cognately intact, could be understood, and could understand others. A physician order dated 11/24/2025 read Bumetanide Oral tablet 2 (two) milligrams, given 1 (one) tablet by mouth 2 (two) times a day for fluid overload, hold for systolic blood pressure less than 100. Resident #12's Medication Administration Record for November documented Bumetanide was scheduled to be administered within one (1) hour before or one (1) hour after 9:00 AM. During an observation on 11/24/2025 at 10:53 AM, Licensed Practical Nurse #1 was observed administering Resident #12's medications. Resident #12 questioned Licensed Practical Nurse #1 as to why their medication were given at all different times. The resident's medication included Bumetanide 2 milligrams, Lovenox 70 microgram, Magnesium Oxide, Multivitamin, and Potassium 20 milliequivalent. During an interview on 11/24/2025 at 10:53 AM, Licensed Practical Nurse #1 stated Resident #12 was the last resident to receive their medications. They stated they would have tried to administer the resident's medication earlier, but the resident was going to a family meeting. Licensed Practical Nurse #1 further stated they would need to call the medical provider regarding the medications being administered late. During an interview on 11/26/2025 at 9:37 AM, Licensed Practical Nurse #1 stated they verbally told the unnamed physician that the morning medications were given late. They stated they forgot to document the communication in the electronic medical record. There was no documented evidence that a medical provider was notified that Resident # 10, 11, 12, or 13's medications were administered late on 11/24/2025. During an interview on 11/26/2026 at 9:49 AM, Licensed Practical Nurse #3 stated nurses should call the supervisor when medications were late. They stated they do not have many regular nurses and rely heavily on agency nurses. Licensed Practical Nurse #3 stated the medication pass was very heavy and nurses got behind. They stated nursing staff would tell the medical provider if a medication was late but may forget to document it. They further stated they believed if they had more consistent staff, there would be less issues. During an interview on 11/26/2025 at 9:40 AM, Registered Nurse #4 stated that nurses are supposed to notify the medical provider when medications are administered late for further instruction and the communication should be documented in the electronic medical record. They further stated the medication pass was very heavy on the fourth floor and there were many interruptions such as activities or therapy. 10 New York Codes, Rules, and Regulations 415.12

Based on interviews and record review conducted during an abbreviated survey (Case #2665815), the facility did not ensure that all alleged violations involving neglect were reported immediately, but not later than 2 (two) hours after the allegation was made, if the event that caused the allegation resulted in serious bodily injury to the Administrator and to the State Survey Agency in accordance with State Law for one (1) (Resident #1) of 1 resident reviewed. Specifically, Resident #1 was involved in a serious adverse event / medication error that resulted in their death on [DATE]. The event was not reported to the New York State Department of Health. This is evidenced by: Cross reference to F-600: Free from Abuse and Neglect. Cross reference to F-760: Residents Are Free of Significant Med Errors. The Facility Policy titled Medication Errors and Reporting effective [DATE], documented the facility maintained a nonpunitive reporting culture, which encouraged all staff to report medication events immediately. All events must be documented, investigated and reviewed regularly to improve systems and reduce future errors. Medication events included transcription errors. It further documented that any reportable error, per New York State (refer to: Reporting Serious Adverse Events to New York State Department of Health Policy) would be escalated to the Medical Director, Director of Nursing, and the Executive Director. The Facility Policy titled Reporting Serious Adverse Events to NYS DOH effective [DATE], documented the purpose and the scope was to ensure timely and accurate reporting of serious adverse events in compliance with New York Department of Health regulations and federal requirements. It was documented that a medication or treatment error that resulted in harm was considered a reportable serious adverse event and required reporting to the New York State Department of Health. It was also documented to document all details in the resident's medical record. Resident #1 was admitted on [DATE] for respite care. The resident received four (4) incorrect doses of morphine sulfate totaling eighty (80) milligrams over a twelve (12) hour period on [DATE]. This resulted in the resident becoming lethargic and unresponsive with unstable vital signs including blood pressure and oxygen saturation. The facility failed to provide interventions to reverse the effects of the medication despite the family inquiry to Narcan (also known as naloxone, a medication used to reverse or reduce the effects of opioids). The resident expired on [DATE] at 6:20 AM. An undated Medication Event Investigation documented, on [DATE] it was discovered that Resident #1's morphine sulfate order had been transcribed in error by milliliters and not milligrams. The order continued until [DATE] at 2:00 PM, when the medication nurse questioned the order. There was no documented evidence that the serious adverse event or medication error involving Resident #1 was reported to the New York State Department of Health. During an interview on [DATE] at 11:20 AM, Administrator #1 stated that they did not feel that Resident #1's passing was caused by the morphine sulfate administration. They stated Executive Director #1 and Medical Director #1 did not connect the morphine administration to Resident #1's death when Administrator #1 reached out to them regarding the incident. When asked if Administrator #1 reported incidents to the New York State Department of Health without speaking to Executive Director #1 or Medical Director #1, Administrator #1 stated that in this particular case, they felt like they needed guidance and was advised to not report it. 10 New York Codes, Rules, and Regulations 483.12 (c) (1)

Based on record reviews and interviews conducted during the abbreviated survey (Case #2665815), the facility did not ensure equal access to quality care regardless of diagnosis for (1) (Resident #1) of one (1) resident reviewed. Specifically, staff did not question, assess, or respond to a significant medication error because Resident #1 was receiving hospice services. Licensed Practical Nurse #2 stated they did not question medication that they dispensed to Resident #1 because the resident was on hospice. This compromised Resident #1's right to dignity, self-determination, and access to medically appropriate care. This is evidenced by: Cross reference to F-600: Free from Abuse and Neglect. Cross reference to F-760: Residents Are Free of Significant Med Errors. The Policy and Procedure titled Resident Rights, dated 5/28/2024 documented that the facility would ensure residents had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Further documented was that the facility must protect and promote the rights of the resident. The facility must provide equal access to quality care regardless of diagnosis, severity, condition, or payment source. The resident had the right to choose activities, schedules, healthcare and providers of healthcare consistent with his or her interests, assessments, and plan of care. Record review revealed Resident #1 was admitted to the facility on [DATE] for five (5) days of respite care (a short-term, substitute care for a person who requires assistance by a caregiver. Respite care provides temporary relief for primary caregivers, giving the caregiver a break for rest, errands, or personal time, preventing caregiver burnout, and ensuring the care recipient is still looked after in a setting able to provide appropriate care) through 10/31/2025 with diagnoses of senile degeneration of the brain (an outdated term for dementia, a general decline in cognitive function that is not a normal part of aging), end-stage renal disease (the final stage of chronic kidney disease, occurring when kidneys fail to filter waste and toxins from the blood), and atrial fibrillation (an irregular and often very rapid heart rhythm). The Brief Interview for Mental Status dated 10/08/2025 documented the resident was rarely understood. Resident #1 was not in the facility long enough to receive a complete Minimum Data Set (a resident assessment tool). Resident #1's admission order to the facility from hospice read morphine 100 milligrams per five (5) milliliter concentrated solution, take five (5) milligrams by mouth every four (4) hours for indications of pain and/or shortness of breath. A Home Hospice Note dated 10/08/2025 at 8:30 AM by Registered Nurse #6, documented Resident #1 was receiving acetaminophen, tramadol, and diclofenac gel as needed in their home prior to admission. There was no documented evidence that Resident #1 had received morphine sulfate in their home prior to facility respite admission. During an interview on 11/17/2025 at 10:19 AM, Health Care Proxy #1 stated Resident #1 was not receiving morphine sulfate at home. They stated the home hospice nurse, Registered Nurse #6, saw Resident #1 at home just prior to admission to the facility and stated the resident was stable for a respite stay. During an interview on 11/18/2025 at 12:12 PM, Health Care Proxy #2 stated Resident #1 had not received any medications prior to their admission to the facility. During an interview on 11/19/2025 at 1:49 PM, Licensed Practical Nurse #2 stated they were Resident #1's medication nurse for the overnight shift starting 10/08/2025. They recalled giving the resident the ordered morphine sulfate. They stated they assumed the order was correct and did not question the dosage of morphine sulfate because the resident was on hospice. They stated they administered 20 milligrams of morphine on 10/09/2025 at 2:00 AM and 6:00 AM as ordered. During an interview on 11/18/2025 at 10:45 AM, Licensed Practical Nurse #1 stated that the dose seemed excessive, however because Resident #1 was on hospice, they did not question it prior to giving the medication. Licensed Practical Nurse #1 stated they questioned the morphine dose after they had given the second dose on their shift at 2:00 PM on 10/09/2025. During an interview on 11/19/2025 at 10:40 AM, Registered Nurse #4 stated on 10/09/2025, Licensed Practical Nurse #1 came to them to question the morphine sulfate order, and that when they left for the day around 3:45 PM, they stated Resident #1 was stable and because Resident #1 was a hospice patient, the goal was to be comfortable, which they believed the resident to be. During an interview on 11/18/2025 at 12:12 PM, Health Care Proxy #2 stated Resident #1 had not received any medications prior to their admission to the facility. They stated they left the facility around 2:00 PM on 10/08/2025 and returned around 4:00 PM on 10/09/2025. They stated Resident #1 was sleeping soundly enough to be snoring and they were unable to wake them. Health Care Proxy #2 stated they asked unnamed staff if Resident #1 had been like that all day and the unnamed staff reportedly stated yes. An unnamed doctor spoke to Health Care Proxy #2 and mentioned the resident had received morphine, but it was a low dose. The unnamed doctor reportedly stated to Health Care Proxy #2 that Narcan (also known as naloxone, a medication used to reverse or reduce the effects of opioids) was not safe to use and Health Care Proxy #2 was advised to let Resident #1 sleep it off. Health Care Proxy #2 stated they left the facility after 7:00 PM on 10/09/2025 and were called back to the facility on [DATE] at 4:00 AM because Resident #1 was dying. Upon arrival, Health Care Proxy #2 again asked if Resident #1 should receive Narcan. Unnamed facility staff told them that Narcan would be ineffective at that time. 10 New York Codes, Rules, and Regulations 483.10 (c)(2) and 483.25 (d)

Based on interviews and record review conducted during the abbreviated survey (Complaint #2665818), the facility did not ensure that hospice or the resident representative/emergency contact was notified of a significant medication error for 1 (one) (Resident #1) of 5 (five) residents reviewed. Specifically, Resident #1 experienced a significant medication error on 10/09/2025, and there was no documented evidence that hospice was notified, and the resident's representative was not made aware until 10/28/2025. This is evidenced by: Cross reference to F-600: Free from Abuse and Neglect. Cross reference to F-760: Residents Are Free of Significant Med Errors. The document Service Agreement by and between [Hospice Vendor #1] and [Facility] dated 10/24/2027, documented promptly upon admission of a hospice patient, who has not been residing in a nursing home, to the Nursing Facility and consent of the Hospice Patient (or his/her Authorized Representative), Hospice would furnish nursing with a copy of the then-current hospice plan of care. Hospice and nursing facility agreed to immediately notify each other of any identified change in the condition of a residential hospice patient which required supplementation, modification or alteration of the Plan of Care, including but not limited to changes in medications or the ordering of clinical laboratory testing or other services. The policy Resident Rights effective date 5/28/2024, documented Under Notification of Change that the facility must immediately notify the resident, physician, and/or the resident's representative when there was an accident that resulted in injury, a significant change in the resident's health status, or a need to alter treatment significantly, including a need to change a current treatment, in addition to discontinuing a current treatment or commencing a new treatment. The policy Medication Errors and reporting dated 10/10/2021, documented medication events included transcription errors. The purpose of the policy was to ensure prompt identification, reporting, documentation, investigation and correction of all medication events (including errors and near misses) to protect resident safety and comply with regularity requirements. It was further documented that the family and/or the designated representative would be notified about the error and follow up plan. Resident #1 was admitted on [DATE] for respite care. The resident received four (4) incorrect doses of morphine sulfate totaling eighty (80) milligrams over a twelve (12) hour period on 10/09/2025. There was no documented evidence that hospice was notified of the medication error that Resident #1 received. There was no documented evidence that the resident's representative was notified of the medication error until 10/28/2025, as evidenced by a progress note entered by Medical Director #1 documenting a meeting with the resident's representatives to review the events surrounding the resident's passing. During an interview on 11/19/2025 at 11:40 AM, Registered Nurse #4 stated on 10/09/2025 Licensed Practical Nurse #1 informed them that the morphine dosage was likely wrong and they checked it. Registered Nurse #1 stated they immediately discontinued the order, informed Physician #1 of the error, and received a new correct order for morphine, which was entered into the system. They further stated, the did not notify Director of Nursing #1 or Administration, contacting the doctor was their first priority. During an interview on 11/19/2025 at 12: 34 PM, Administrator #1 stated they were not in the facility when the incident occurred. They had a received a voicemail from the resident representative when they returned to work. They stated the resident representative had reached out to Director of Nursing #2, but Director of Nursing #2 did not return their call. Administrator #1 stated they met in person with the family on 10/28/2025. During an interview on 11/19/2025 at 2:04 PM, Medical Director #1 stated the family was not communicated immediately about the medication error. 10 New York Codes, Rules, and Regulations 415.3(f)(2)(ii)(d)

Based on observations, interviews, and record reviews conducted during the abbreviated survey (Case # 2668815), the facility did not ensure that a resident's drug regimen was free from unnecessary medications for 1 (one) of 5 (five) residents reviewed (Resident #1). Specifically, the facility administered morphine sulfate (strong opioid used to treat moderate to severe pain) as a routine, standing medication despite no documented clinical evidence of pain or shortness or breath, exposing Resident #1 to unnecessary risk of adverse drug effects including over-sedation and respiratory depression. This is evidenced by: Cross reference to F-600: Free from Abuse and Neglect. Cross reference to F-760: Residents Are Free of Significant Med Errors. The Policy and Procedure titled Medication Administration, dated 12/21/2023 stated each resident will receive medications according to the provider orders and accepted professional standards and the nurse is responsible for having knowledge of the therapeutic effects, contraindications, side effects, and drug interactions of medications needed. The Policy and Procedure titled Clinical Documentation dated 12/01/2022 documented that resident's medical records reflect an ongoing account of the following, including but not limited to: 1) Findings of assessment and reassessment, 20 Identification of problems, 3) Treatment goals, plan of care and revisions to plan of care, 4) Care, treatment and services provided, 5) Resident's response to care, treatment, and services provided, 6) Resident's progress toward the achieved goals/outcomes, 7) Resident's declination of treatment, 8) Education of residents on risks/benefits of treatment and refusal of treatment including information about available alternatives, 9) Discharge plan, and 10) Notification of attending physician and family of all of the above. Record review revealed Resident #1 was admitted to the facility on [DATE] for five (5) days of respite care (a short-term, substitute care for a person who requires assistance by a caregiver. Respite care provides temporary relief for primary caregivers, giving the caregiver a break for rest, errands, or personal time, preventing caregiver burnout, and ensuring the care recipient is still looked after in a setting able to provide appropriate care) with diagnoses of senile degeneration of the brain (an outdated term for dementia, a general decline in cognitive function that is not a normal part of aging), end-stage renal disease (the final stage of chronic kidney disease, occurring when kidneys fail to filter waste and toxins from the blood), and atrial fibrillation (an irregular and often very rapid heart rhythm). The Brief Interview for Mental Status dated 10/08/2025 documented the resident was rarely understood. Resident #1 was not in the facility long enough to receive a complete Minimum Data Set (a resident assessment tool). A Home Hospice visit note on 10/08/2025 at 8:30 AM, by Registered Nurse #6 documented Resident #1 was noted to be taking Tylenol and Tramadol (opioid pain medication used to treat moderate to severe pain) 1 (one) time a day (mainly at bedtime), and Diclofenac gel (topical medication used to relive pain and inflammation) 2 (two) to 4 (four) times a day. Morphine Sulfate was available to Resident #1 as part of the comfort pack provided by hospice but Resident #1 had not yet used it at home, nor did they have pain at time of visit. Registered Nurse #6 called facility at completion of visit in the home and spoke with receiving nurse to give report. A late entry Hospice note on 10/10/2025 at 4:06 PM, by Registered Nurse #2 documented that on the visit on 10/08/2025 at 2:05 PM they reviewed the Morphine Sulfate dosage with Registered Nurse #1. The Medication Administration Recorded for October 2025, documented Resident #1 received the order for Morphine Sulfate (concentrate) oral solution 100 milligram per milliliter, give 1 milliliter by mouth every 4 hours for pain on 10/09/2025 at 2:00 AM, 6:00 AM, 10:00 AM, and 2:00 PM. Documented pain level for each morphine administration was 0 (zero). There was no documented evidence of resident pain requiring morphine sulfate. During an interview on 11/18/2025 at 10:45 AM, Licensed Practical Nurse #1 stated it should have been caught as an excessive dose. 10 New York Codes, Rules, and Regulations 415.12(I)(1)

Based on record reviews and interviews conducted during the abbreviated survey (Case # 2665815), the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of ar resident (Resident #1). Specifically, the facility lacked oversight in place to use its resources (staff, policies, and communication systems) effectively and efficiently to protect Resident #1. This is evidenced by: Reference is made to deficiencies related to ineffective administration: Please refer to F600 as it pertains to the facility's failure to ensure freedom from neglect. Please refer to F760 as it pertains to the facility's failure to ensure freedom from significant medication errors. Please refer to F550 as it pertains to the facility's failure to ensure resident dignity. Please refer to F609 as it pertains to the facility's failure to ensure adverse events were reported to the State Survey Agency. Please refer to F684 as it pertains to the facility's failure to ensure services provided met professional standards. Please refer to F757 as it pertains to the facility's failure to ensure each resident's drug regimen was free from unnecessary medications without adequate indications. Please refer to F841 as it pertains to the facility's failure to ensure the responsibilities of the Medical Director were completed and accurate. Please refer to F710 as it pertains to the facility's failure to ensure that resident's care was supervised by a Physician. Facility administration leadership failed to provide effective oversight, policy enforcement, and resource allocation to ensure resident safety, resulting in Neglect (F600) and a Significant Medication Error (F760) that contributed to the death of Resident #1. These deficiencies collectively reflect ineffective facility administration and failure to ensure systems were in place to protect resident safety. During an interview on 11/19/2025 at 10:05 AM, Director of Nursing #2 stated they were largely unaware of the circumstances surrounding Resident #1's decline and did not recall being notified at the time of the resident's passing. During an interview on 11/19/2025 at 12:08 PM, Director of Nursing #1 stated that they were not directly involved in the incident investigation and were unaware of any systematic changes implemented following the medication error. They further stated that there was a triple check system that was used to ensure errors like what had occurred didn't happen, and it was in place prior to the incident. During an Interview on 11/19/2025 at 12:34 PM, Administrator #1 stated the medication transcription error could be attributed to confusing hospice orders and staff overstimulation, and stated hat leadership reviewed errors after the incident. They stated as a result of the incident, staff looked at all the errors beginning with those that came from the hospital. They stated Morphine Sulfate transcription error began as a scheduled dose when it should have been written as needed During an interview on 11/19/2025 at 2:04 PM, Medical Director #1 stated the event was a significant medication error and that family communication occurred at a later date. During an interview on 11/26/2025 at 11:20 AM, Administrator #1 stated that they did not feel that Resident #1's passing was caused by the morphine sulfate administration. They stated Executive Director #1 and Medical Director #1 did not connect the morphine administration to Resident #1's death when Administrator #1 reached out to them regarding the incident. When asked if Administrator #1 reported incidents to the New York State Department of Health without speaking to Executive Director #1 or Medical Director #1, Administrator #1 stated that in this particular case, they felt like they needed guidance and was advised to not report it. 10 New York Codes, Rules, and Regulations 483.70(i)

Based on observations, interviews, and record reviews conducted during the abbreviated survey (Case # 2665815) from 11/17/2025 to 11/26/2025, for 1 (one) (Resident #1) of 3 (three) residents reviewed, the facility did not ensure that the Physician provided supervision of medical care. Specifically, Physician #1 signed 5 incorrect orders for morphine concentrate oral liquid resulting in Resident #1 receiving 80 milligrams of morphine over a 12-hour period. Additionally, there was no documented evidence that Physician #1 provided any follow up instructions or care to Resident #1 after the medication administration was discovered. This is evidenced by: Cross reference to F-600: Free from Abuse and Neglect. Cross reference to F-760: Residents Are Free of Significant Med Errors. Record review revealed Resident #1 was admitted to the facility on [DATE] for five (5) days of respite care (a short-term, substitute care for a person who requires assistance by a caregiver. Respite care provides temporary relief for primary caregivers, giving the caregiver a break for rest, errands, or personal time, preventing caregiver burnout, and ensuring the care recipient is still looked after in a setting able to provide appropriate care) under hospice services. Record review of the Medication Administration Record revealed Physician #1 signed multiple morphine sulfate orders within a short timeframe on 10/08/2025 and 10/09/2025, including orders with varying concentrations, volumes, frequencies, and directions, resulting in unclear medication instructions. Signed orders included morphine sulfate concentrate with directions ranging from 5 (five) milliliters every 4 (four) hours, 1 (one) milliliter every 4 (four) hours, 1 (one)-time doses, and subsequent corrections, reflecting inconsistent and inaccurate prescribing. Resident #1's Medication Administration Record for October 2025, documented that Resident #1 had an order for the following: Morphine Sulfate (Concentrate) Oral Solution 100 milligrams per 5 milliliters, may give 0.5 milliliters one time only for pain for 1 day. This order was started on 10/08/2025 at 7:15 PM and discontinued on 10/09/2025 at 3:11 PM. This order was signed by Physician #1. Morphine Sulfate (Concentrate) Oral Solution 100 milligrams per 5 milliliters, give 1 milliliter by mouth every 4 hours for pain. This order was started on 10/08/2025 at 10:00 PM and discontinued on 10/09/2025 at 3:10 PM. This order was signed by Physician #1. Morphine Sulfate (Concentrate) Oral Solution 100 milligrams per 5 milliliters, give 5 milliliters by mouth every 4 hours for pain. This order was started 10/08/2025 at 2 PM and discontinued on 10/08/2025 at 6:07 PM. This order was signed by Physician #1. Morphine Sulfate (Concentrate) Solution 20 milligrams per milliliter, give 1 milliliter by mouth one time only for pain for 2 days may remove from pyxis. This order was started 10/08/2025 at 6:15 PM and discontinued on 10/09/2025 at 3:11 PM. This order was signed by Physician #1. Morphine Sulfate (Concentrate) Solution 20 milligrams per milliliter, give 5 milligrams by mouth every 4 hours for pain/shortness of breath 5 milligrams every 4 hours. This order was started on 10/09/2025 at 4 PM and discontinued on 10/09/2025 at 5:52 PM. This order was signed by Physician #1. Pharmacy records documented multiple contacts with facility staff on 10/08/2025 and 10/09/2025 to clarify the accuracy of the morphine sulfate orders of dosing and concentration. Per pharmacy records received from Pharmacy Vendor #1, the following contacts were made with the facility regarding the multiple morphine orders and the questionable accuracy of the orders: On 10/08/2025 at 4:56pm- Morphine 100 milligrams per 5 milliliter electronic prescription medication order sent into pharmacy for Resident #1 with directions Give 5 milliliter by mouth every 4 hours for pain Quantity: 30 each packages. Clarified directions as a 1 milliliter dose equals 20 milligrams per Registered Nurse #3 per Physician #1 at 6:29 PM by pharmacist. On 10/08/2025 at 6:14 PM- Morphine 20 milligrams per 1 milliliter electronic prescription medication order sent into pharmacy for Resident #1 with directions Give 1 milliliter by mouth one time for pain for 2 days may remove from pyxis Quantity: 3. Quantity clarified per Registered Nurse #3, per Physician #1 at 7:36 PM as 1 milliliter and authorized to use 4 times 5 milligram doses out of Omnicell by pharmacist. On 10/08/2025 at 6:14 PM- Morphine 100 milligrams per 5 milliliters electronic prescription medication order sent into pharmacy for Resident #1 with directions Give 1 milliliter by mouth every 4 hours for pain Quantity:1. Clarified as 1 milliliter per Physician #1 at 7:15 PM by pharmacist. Authorized to use out of Omnicell to Registered Nurse #1 by pharmacist at 7:19 PM. On 10/09/2025 at 3:46 PM- Morphine 20 milligrams per 1 milliliter electronic prescription medication order sent into pharmacy for Resident #1 with directions Give 5 milligrams by mouth every 4 hours for pain/shortness of breath every 4 hours. Quantity clarified as 30 doses per Physician #1 at 4:15 PM by pharmacist. On 10/09/2025 at 6:42 PM Pharmacist recorded an alert in the profile for Resident #1 as Spoke with Director of Nursing #2. Physician #1 sent Morphine 20 milligram syringe in error and it got corrected to 5 milligram dose. Stated they gave Resident #1 4 doses and will Narcan Resident #1 out of pyxis. During an interview on 11/19/2025 at 11:14 AM, Pharmacist Supervisor #1 stated the facility was contacted on 10/08/2025 to clarify an accurate dosage of morphine sulfate for Resident #1 and the dosage was clarified with Registered Nurse #3 on 10/08/2025 at 6:29 PM. They clarified the order again with Registered Nurse #3 at 7:36 PM. When a new order was received on 10/09/2025, they clarified the order with Physician #1 at 4:15 PM. Additionally, there was a request to access the pyxis to obtain Narcan however, according to the records, it was never administered per their records. Records of all contacts with the facility regarding morphine order clarifications were requested and received. During an interview on 11/19/2025 at 11:54 AM, Physician #1 stated they weren't normally the doctor for respite residents, but they were asked to do Resident #1's orders. Physician #1 recalled there was an issue with the concentration of the morphine order. Physician #1 stated that they gave verbal orders for morphine sulfate. The concentration was 20 milligrams, which was higher than normal. Physician #1 didn't realize the issue when they put in the order. Physician #1 stated they did check and sign the order but didn't read it carefully and looked at the milliliter without realizing the concentration would change the dosage. Physician #1 stated that they should have checked it more carefully. Physician #1 further stated that they didn't hear from pharmacy at that time about any issues and after Resident #1 passed, Physician #1 wasn't really involved with any investigation, Medical Director #1 would have more information. During an interview on 11/19/2025 at 2:04 PM, Medical Director #1 stated that after the incident, they had a conversation with Physician #1 with no additional action. They stated that it was a significant medication error, but Physician #1 was a good doctor that made a mistake.10 New York Codes, Rules, and Regulations 415.15(b)(1)(i)(ii)

Based on observation, record review, and interviews conducted during a recertification survey from 2/20/2024 to 2/27/2024, the facility did not ensure drugs and biologicals were labelled and stored in accordance with professional standards of practice. Specifically, (a.) opened medications had no open and/or expiration dates; (b.) controlled substances were not kept secured in a double locked cabinet; (c.) expired medications were present; and (d.) an unlocked medication cart was left unattended. This was evident for 4 out of 6 medication carts reviewed, and for 1 out of 3 medication storage rooms reviewed. This is evidenced by: The facility's Medication Administration Policy and Procedure, effective 12/21/2023, documented the nurse was to carefully check the name, dose, amount of administration and expiration date, and to remain with the unlocked medication cart/cabinet. It further documented that if nurse needed to leave the cart, the cart was to be locked. The Facility's Pharmacy Services and Procedure Manual revised 8/7/2023 documented the facility was to store Schedule II - V Controlled Substances in a separate compartment within the locked medication carts and should have different key or access device. It further documented to store all drugs and biologicals in locked compartments, including storage of Schedule II-V medications separately locked, permanently affixed compartments, permitting only authorized personnel to have access; controlled substances were to be securely stored in a double locked cabinet, affixed to the wall or floor until the beginning of the medication pass; upon completion of the medication pass, controlled substances must be returned to the cabinet. Section 4.8 of the pharmacy manual, regarding the procedure for appropriate labeling of medications, documented medications that were in multiple dose vials (i.e.: insulin) or containers (i.e., bulk liquids) must have had a label indicating the date the container was first opened and the date of expiration. It documented multidose vials of injectable medications would expire 28 days after the date opened, unless otherwise specified by the manufacturer, and medications with expiration dates of month and year only would expire on the last day of the month. Section 15 further documented the facility was to ensure that medications and biologicals for expired, discharged , or hospitalized residents were stored separately, away from use, until destroyed or returned to the provider. A. During an observation on 02/23/2024 at 11:37 AM the 4th floor Medication Cart, East Side a bottle of stock Tylenol had no open date. The expiration date was worn off and was unable to be determined. Additionally, 1 open Basaglar insulin pen had no open or expiration date. During an observation on 2/23/2024 at 12:48 PM, the 4th floor southside medication cart contained the following: 1 bottle of Latanoprost 0.005% eye drops with no open date, dispensed date was 7/24/2023. 1 bottle of refresh tears with no open date; 1 open Levemir insulin pen with no open and no expiration date. 1 tube of Oragel solution with no top cover and no open date. During an interview on 2/23/2024 at 11:40 AM, Licensed Practical Nurse #4 stated they did not label stock medications with open dates. Licensed Practical Nurse #4 was not aware of an Omnicare Pharmacy Grid of Medications with shortened discard dates after opening (a grid that list expiration dates of specific medications). During an interview on 2/23/2024 at 12:48 PM, Licensed Practical Nurse #6 stated the open Oragel solution should have been discarded. During an interview on 2/27/2024 at 10:51 AM, Licensed Practical Nurse #8 stated they were aware they should check expiration dates but didn't check expiration dates on medication bottles in the cart because they had too many medications to administer. Licensed Practical Nurse #8 stated if residents were given expired medications, they did not know side effects, and was not aware of the Omnicare Pharmacy Grid of Medications with shortened discard dates after opening. During an interview on 2/27/2024 at 11:15 AM, Assistant Director of Nursing #1 provided the surveyor with the, Omnicare Pharmacy Grid of Medications with shortened discard dates after opening, and stated the Grid was present on each medication cart for the nursing staff to refer to. During an observation on 2/27/2024 at 11:30 AM, the medication carts on the 3rd floor Southside, 4th floor Eastside and Southside; and 3rd and 4th floor Medication rooms did not have the, Omnicare Pharmacy Grid of Medications with shortened discard dates after opening, posted. B. During an observation on 2/23/2024 at 11:15 AM, the 3rd floor Southside Medication Room narcotic lock box had only one functioning lock. The narcotic lock box was observed to have a broken lock inside while it contained multiple narcotics and an envelope with jewelry. During an observation on 2/23/2024 at 11:20 AM, the 3rd floor Southside Medication Room refrigerator contained a narcotic box with a broken lock. The narcotic box contained the Schedule III controlled substance, dronabinol 5mg. During an interview on 2/23/2024 at 11:15 AM, Licensed Practical Nurse #5 stated they previously informed Nursing Supervisor #1 about broken locks. During an interview on 2/23/2024 at 01:56 PM, Assistant Director of Nursing #1 stated they were unaware of broken locks on 3rd floor Medication Room narcotic boxes. Assistant Director of Nursing #1 stated they would put in a work order immediately. During an observation on 2/26/2024 at 10:00 AM, the locks on the narcotic box in the 3rd floor Medication Room remained broken. C. During an observation on 2/23/2024 at 11:20 AM, the Medication Room refrigerator contained expired medications as follows: - C-Lido/Benadryl/Maalox expired 2/04/2024, - C-Lido/Benadryl/Maalox expired 1/11/2024; - Vancomycin hydrochloride solution expired 1/25/2024. During an interview on 02/27/2024 at 11:12 AM, Registered Nurse Educator #1 stated nursing staff completed annual competencies along with various monthly in-services in-person and the pharmacy conducted semi-annual audits on medication administration. Registered Nurse Educator #1 stated the last audit was Summer 2023, that it was the nursing department's responsibility to check expiration dates of medications, and the responsibility of each nurse assigned to a medication cart to remove expired medications from those carts. D. During an observation on 02/26/2024 at 10:20 AM, the 4th floor Southside Medication cart was left unattended. The cart was unlocked, and the laptop revealed resident Personal Identifiable Information. The nurse assigned to the medication cart was unable to be located. During an interview on 2/26/2024 at 11:00 AM, the Assistant Director of Nursing #1 stated nurse assigned to 4th floor Southside medication cart was an agency nurse that agency staff received one day of shadowing orientation at the facility, and that the agency provided medication administration orientation and training. 10 New York Codes, Rules and Regulations 415.18(d)

Based on observation, record review, and interviews during the recertification survey from 2/20/2024 to 2/27/2024, the facility did not prepare and serve food in accordance with professional standards for food service safety in 3 (three) of 3 kitchenettes. Specifically, food was not stored to preclude contamination, the kitchenettes were not clean, and the cabinetry in the kitchenettes were not in good repair. This is evidenced by: During observations on 2/20/2024 at 10:44 AM, single-serving packets of beverage thickener were stored under the sink in the Second Floor Unit kitchenette. Cabinets, cupboards, drawers, microwave ovens, and the floor in corners and next to walls were soiled with food particles in the Second Floor Unit kitchenette and the Third Floor Unit kitchenette; the bottom of cabinet under the sink in the Fourth Floor Unit kitchenette was warped and soiled with black particles. In the Second Floor Unit kitchenette, 2 cabinet doors would not close and stay shut when tested , and in the Third Floor Unit kitchenette, one cupboard door was missing a handle. The undated document titled, Daily Cleaning Checklist, was reviewed and documented that the doors to the kitchenette cabinets, cupboards, and drawers and the kitchenette microwave ovens were to be cleaned daily. The undated document titled, Weekly Cleaning Checklist, was reviewed and documented that the insides of the kitchenette cabinets, cupboards, and drawers were to be cleaned weekly. No documented evidence that kitchenette floors were scheduled to be cleaned in corners and next to walls was located for review. There was no documented evidence for review that indicated the facility maintenance department was notified to repair in the kitchenette missing handles, loose doors, or the bottom of any cabinets. During an interview on 2/22/2024 at 2:31 PM, Administrator #1 stated that the kitchenettes would be thoroughly cleaned including the floors in corners and all cabinetry, and that Manager of Facilities #1 would be asked to repair the cabinet doors. 10 New York Codes, Rules, and Regulations 415.14(h) Chapter 1 State Sanitary Code Subpart 14-1

Based on observation, record review, and interviews conducted during a recertification survey from 2/20/2024 to 2/27/2024, the facility did not provide pharmaceutical services including procedures that assured the accurate dispensing and administering of all drugs and biologicals according to professional standards. Specifically, (a.) an administered controlled substance was not signed out on the control substance record when documented in the resident's medical record as administered; and (b.) nursing staff did not verify the correct resident prior to medication administration for 2 (Resident #'s 4 and 76) residents observed for medication administration. This is evidenced by: The facility's Medication Administration Policy and Procedure, effective 12/21/2023, under Procedure: documented the Registered Nurse/Licensed Practical Nurse will 3. Note carefully the name, dose, amount of administration and expiration date. 5. Use pill crusher to crush tablets (per order). 6. Identify the resident/elder by two identifiers (ex, checking the ID bracelet, ID photo in electronic medical record). 7. Administer medication using principles of aseptic clean technique based on route and type of medication being given. (Refer to appropriate procedures for specific administration). A. During an observation on 2/23/2024 at 10:59 AM, the 3rd floor, Southside Medication Cart Narcotic count for Lyrica 150 milligram tablet documented 28 tablets in binder and the medication card count was 27. The reconciliation of Resident #312's narcotic (Lyrica) had a one pill discrepancy. During an interview on 2/23/2024 at 11:00 AM, Licensed Practical Nurse #5 stated Resident # 312 received 1 dose of Lyrica 150 milligrams at 10:00 AM and they did not sign the medication out of the narcotic book. Licensed Practical Nurse #5 stated they should have signed the narcotic out of the binder at the same time it was signed in the electronic medical record. During record review on 2/23/2024 at 11:10 AM, a physician's order was reviewed that documented Resident #312 was to be administered Lyrica 150 milligram tab at 10:00 AM. The resident's electronic Medication Administration Record indicated resident #312 received Lyrica 150 milligram at 10:00 AM. B. During an observation on 2/23/2024 at 8:40 AM, Licensed Practical Nurse #2 entered the rooms of Residents #4 and Resident #76 to complete medication administration. During both medication administrations, Licensed Practical Nurse #2 did not verify each resident's name prior to administration. During an interview on 02/27/2024 at 11:12 AM, Registered Nurse Educator #1 stated nursing staff completed annual competencies along with various monthly in-services in-person and the pharmacy conducted semi-annual audits on medication administration. Registered Nurse Educator #1 indicated the last audit was Summer 2023 and they reviewed the rights of medication administration including the right patient, right medication, right dose, right time, and right route. 10 New York Codes, Rules and Regulations 415.18 (b)(1)(2)(3)

Based on interviews and record reviews conducted during the recertification survey from 2/20/2024 to 2/27/2024, the facility did not ensure prompt efforts were made to respond to grievances and complaints from residents of the facility. Specifically, the facility did not ensure the facility's process for missing property and grievances was followed when the residents reported lost items or filed complaints. Additionally, the residents needed to be appropriately apprised of the progress toward any resolutions made for grievances or missing items. This is evidenced by: Policy and Procedure titled Complaints and Grievances, dated 1/2016, documented that the facility would promptly deal with complaints and recommendations made by residents and their designated representatives. The purpose of this policy was to promptly bring complaints or recommendations to the attention of one individual responsible for addressing and explaining to the resident when a complaint could not be fully resolved. During a record review, grievances provided by the facility from August 2023 through November 2023, contained no documentation of resolutions or responses by the facility. During a record review of filed missing items reports, the facility could not produce any documentation of filled missing items reports by residents or any resolutions to the reports. During an interview on 2/21/2024 at 3:29 PM with the resident council, Residents #22, #92, and #58 stated that they did not get feedback from the facility when making a complaint. They stated that complaints were made to staff on the floor and did not believe they were taken to anyone. When asked if they knew the procedure for filing a complaint or grievance, they stated that they did. During an interview on 2/27/2024 at 10:08 AM, Director of Social Services #1 stated that missing item reports should be kept with social work. They stated the units were to forward the missing items reports to social services for review and then the reports were to be sent to administration. They stated once administration reviewed the forms, they should be returned to social services for follow-up with the residents. They stated that they hardly ever received missing item forms as those forms would be given directly to nursing. They stated social work unit had handled fewer than ten (10) reports in the last month and fewer than twenty (20) within the previous year. They stated if social services were kept in the loop, they follow up with residents and their families. They stated that when speaking with resident families, social work would report to the families what happened initially along with the resolution. They stated social services sometimes made appointments with families for items such as glasses or hearing aids so the family would be aware of where the resident was in the process of receiving a replaced item. During an interview on 2/27/2024 at 10:15 AM, Assistant Director of Nursing #1 stated that missing items were reviewed in the morning meeting. They stated that once filled out, the forms were kept on the floor with the unit manager. They stated that social services got involved in the resolution, possible restitution, and follow-up with residents. When asked how often the staff were educated on the missing items form, they stated all staff were educated on the policy of grievances and missing or misappropriation of items upon hire. When asked if the policy was reviewed during the year, Assistant Director of Nursing #1 stated that they believed it was reviewed only when individuals were hired during orientation. During an interview on 2/27/2024 at 10:23 AM, Registered Nurse #1 stated that blank missing item forms were kept in a filing cabinet. They stated that the filled-out ones did not stay on the unit but were sent to administration. During an interview on 2/27/2024 at 10:28 AM, Registered Nurse #3 stated that they did not have any of the filled-out forms on the unit as they did not keep them on the unit. They stated that the staff on the unit would start the process and if the items were not found, the form was filled out and sent to social work and administration. During an interview on 2/27/2024 at 11:38 AM, Registered Nurse Educator #1 stated that missing items and misappropriation were covered in new hire education but training was more floor-based. Registered Nurse Educator #1 stated staff are taught that missing items must be reported. They stated that when items were reported missing, the manager on the floor should be notified and the missing item report is to be filled out. They stated that the missing items were discussed during the morning meeting. During an interview on 02/27/2024 at 11:47 AM, Administrator #2 stated that social work should be the gatekeeper for investigating grievances and missing items. They stated that the forms should be kept within the social work office while the investigation progressed. Once a resolution has been made, it should be forwarded to the administration. Administrator #2 responded that social work should work with nursing to follow up with the resident when asked who should follow up with the resident. 10 New York Codes, Rules, and Regulations 483.10(j)(4)(ii)

Based on interview and record review during the recertification and abbreviated survey (Case # NY00297663) from 2/20/2024 to 2/27/2024, the facility did not ensure that a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standard of quality care was developed within 48 hours of admission. This was identified for 1 (Resident #107) of 22 residents reviewed. Specifically, Resident #107 was admitted on [DATE] with history of falls and was assessed to be high risk for falls. A baseline care plan was not developed within 48 hours to include at risk for falls with interventions for safety. This is evidenced by: Cross-reference F-689. The facility's policy and procedure titled Falls Management Policy, effective 10/04/2021, documented Procedure: #2: Residents who were at risk for falls would have an individualized care plan developed which identified interventions to reduce fall risk. The facility's policy and procedure titled Interdisciplinary Care Conference and Care Planning, effective 6/27/2023, stated the facility would develop a baseline interdisciplinary, resident centered care plan within 48 hours of admission. The purpose was to promote effective person-centered care, continuity of care, communication among nursing facility staff, increase resident safety and safeguard against adverse events. Resident # 107 was admitted on [DATE] and discharged on [DATE], as a hospice respite short-term stay resident, with the diagnoses of malignant neoplasm (cancer) of right ureter; secondary neoplasm or lung, liver, and intrahepatic bile duct; and severe right hydronephrosis (a backup of urine in the kidney). The Minimum Data Set, dated dated [DATE], documented the resident could understand and could be understood by others and assessed to be of moderate cognitive impairment of daily living. Record review of an admission nursing progress note dated 6/9/2022, indicated Resident #107's family member child stated the resident had 5 (five) falls in the previous 6 (six) months. The note further documented that the resident complained of frequent falls, most related to urinary urgency. An additional admission nursing progress note also dated 6/9/2022 indicated Resident #107 was admitted with a left elbow scab from fall and a left knee scab from recent fall. During record review, the physician assessment and orders dated 6/10/2022, documented the resident was on hospice and presented for respite care. The assessment indicated Resident #107 had need for assistance with personal care/abnormality, mobility gait/difficulty with ambulation, required assistance with activities of daily living. It further documented the resident was to have fall precautions. During record review, the review of Falls Risk Screener/assessment dated [DATE] and revised 6/13/2022, documented Resident #107 was assessed as having a high risk for falls. During record review, Resident #107's care plan was reviewed and indicated it was initiated on 2/21/2024, 20 months after Resident #107 was discharged from the facility. Resident #107 did not have a focus care plan of at risk for falls, but instead documented Safety Awareness deficit related to limited mobility, revised by the Director of Operations #1 on 2/21/2024. During an interview on 2/22/2024 2:02 PM, Assistant Director of Nursing #1 stated Resident #107 was on every 15 minutes checks due to high-risk falls. Assistant Director of Nursing #1 did not provide documentation of every 15 minute checks. On 2/21/2024 the resident's care plan was updated to initiate every thirty-minute checks, and the resident would be free from falls. It was further documented it had been revised by the Director of Operations on 2/21/2024. There was no documentation for review to indicate the facility had developed Resident #107's baseline care plan with fall risk precautions within 48 hours of admissions. 10 New York Codes, Rules and Regulations 415.11

Based on record review and interviews during a recertification survey from 2/20/2024 to 2/27/2024, the facility did not ensure Comprehensive Care Plans were reviewed after each assessment and revised based on changing goals, preferences, and needs of the resident and in response to current interventions for 2 (Resident #'s 47 and #257) of 18 residents reviewed. Specifically, for Resident #47, the comprehensive care plan for psychotropic medication was not reviewed/revised with medication changes. For Resident #257, the comprehensive care plan was not updated/revised after intervention for oxygen administration was discontinued. This is evidenced by: The Policy and Procedure titled, Interdisciplinary Care Conference and Care Planning, dated 6/27/2023, documented the facility would develop a comprehensive, resident-centered care plan for each resident based on the individual needs/problems of each resident. Resident #47 Resident #47 was admitted to the facility with the diagnoses of type 2 diabetes mellitus (a group of common endocrine diseases characterized by sustained high blood sugar levels), dementia (a general term describing problems with reasoning, planning, judgment, memory, and other thought processes caused by brain damage from impaired blood flow to the brain) and generalized anxiety disorder (ongoing anxiety that interferes with daily activities). The Minimum Data set (an assessment tool) dated 1/01/2024 documented the resident could understand others and could make themselves understood. The Brief Interview for Mental Status documented the resident's had a moderate cognitive impairment. Review of Resident #47's medical record indicated a physician's order dated 6/29/2023 for olanzapine 5 milligrams by mouth at bedtime for psychosis. Record review indicated Resident #47's 6/29/2023 order for 5 milligrams of olanzapine was discontinued on 7/12/2023. Further review indicated Resident #47 had a physician's order dated 7/12/2023 for olanzapine 2.5 milligrams by mouth one time a day for 2 days for agitation. This order was documented as completed on 7/15/2023. Record review of Resident #47's Comprehensive Care Plan titled, Potential for altered mood as evidenced by a diagnosis of depression, initiated on 7/03/2023, indicated interventions of specific medications, which included olanzapine dated 7/13/2023. Resident #47's depression care plan listed the potential side effects and adverse reactions of taking olanzapine but did not document any further updates or revisions. 48413 Resident #257 Resident #257 was admitted to the facility with the diagnoses of limb amputation, acute respiratory failure with hypoxia (a condition where you do not have enough oxygen in the tissues of the body caused by a disease or injury that affects a person's breathing), and chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems such as emphysema or chronic bronchitis). The Minimum Data Set, dated dated dated [DATE] documented the resident could understand others and could make themselves understood, and had a moderate cognitive impairment. Review of Resident #257's medical record indicated a physician's order dated 2/13/2024 for oxygen to be administered via a nasal cannula as needed. The order indicated staff should notify the medical doctor if an increased flow rate or continued use was needed for shortness of breath. Resident #257's Comprehensive Care Plan titled, Potential impaired breathing related to chronic obstructive pulmonary disease initiated on 2/09/2024, was reviewed and noted listed interventions included the administration of continuous oxygen. The initial intervention dated 2/09/2024, documented the resident to have oxygen as needed. This initial intervention was documented as discontinued. The comprehensive care plan did not document any further updates or revisions. During an interview on 2/23/2024 at 11:46 AM, Registered Nurse #3 stated that care plans must be updated to reflect the resident's status, and that care plans should be reviewed regularly and updated when needed. During an interview on 2/23/2024 at 2:06 PM, Assistant Director of Nursing #1 stated that comprehensive care plans should be updated as changes occur, as well as during comprehensive assessments. The Assistant Director of Nursing #1 stated that if a care plan involved a medication that was discontinued or completed, then the care plan should be resolved and inactivated. They stated that if a medication order was changed from one medication to another, and the comprehensive care plan mentioned specific medications, the comprehensive care plans should also be updated. 10 New York Codes, Rules and Regulations 415.11(c)(2)(i-iii)

Based on records reviewed and interviews during the recertification survey from 2/20/2024 to 2/27/2024, the facility did not ensure each resident's drug/medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for 4 (Residents #91, #29, #24, and #47) of 6 residents reviewed for unnecessary medications. Specifically, for Resident #29, #24, and #47, as-needed psychotropic medication orders did not include stop dates. Additionally, for Resident #91, an order for a preventative antibiotic did not identify indication for usage. This is evidenced by: A facility policy titled Psychotropic Medication Management dated 6/19/2023, documented that regular reviews of psychotropic medications would be conducted to assess their effectiveness, necessity, and any adverse effects. This review would involve interdisciplinary collaboration with discussion for potential gradual dose reduction. A facility policy titled Drug Regimen Reviews dated 5/8/2023, documented that a complete drug regimen review would be completed to identify potential clinically significant medication issues. The policy further documented that the resolution of uses would be documented on the medication reconciliation form or in the progress notes. A facility policy titled Medication Administration dated 12/21/2023, documented that prior to administering medications, both regularly scheduled and as needed, staff were to have read the electronic medication administration record thoroughly, note the name, dose, amount of administration and expiration date. Should a discrepancy be found, the policy stated always check the physician order and notify the Registered Nurse before administering the medication. A facility policy titled Antimicrobial Stewardship Program Policy dated 6/16/2023, documented that the length of antibiotic treatment should comply with current recommendations, or documentation by medical staff should be present in the record as to rationale for longer duration of treatment. Resident #29 Resident #29 was admitted with the diagnoses of bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows, vascular dementia (a general term describing problems with reasoning, planning, judgment, memory, and other thought processes caused by brain damage from impaired blood flow to the brain), and diabetes. The Minimum Data Set (an assessment tool) dated 1/12/2024 documented the resident was able to be understood and could understand others and was severely cognitively impaired. A review of Resident #29's medical record indicated a Physician's Order, dated 2/22/2024, for lorazepam (a psychotropic medication used to treat anxiety) 1 milligram pill to be given 0.5 milligram by mouth every six hours as needed for anxiety. The medication was to start on an as-needed basis on 2/22/2023 but had no end date documented. Resident #24 Resident #24 was admitted with diagnoses of hemiplegia and hemiparesis (paralysis and weakness) following a stroke, dysphagia (difficulty speaking and swallowing), and type 2 diabetes with diabetic neuropathy (a metabolic disease involving inappropriately elevated blood glucose levels which can cause numbness and tingling or pain in the resident's lower extremities). The Minimum Data Set, dated dated dated [DATE] documented the resident was able to be understood and to understand others, and was significantly cognitively impaired. A physician order dated 11/29/2023 at 11:00 AM, documented that Resident #24 was ordered Seroquel Oral Tablet 25mg give 1 tablet by mouth every 24 hours as needed for worsening anxiety. There was no end date included in the order. A Medication Regimen Review dated 12/07/2023 documented that the as-needed Seroquel order required an actionable step from the primary care provider or nursing staff. A Medication Regimen Review dated 2/08/2024 documented that the as-needed Seroquel order could be considered for discontinuation because the medication had not been used in over 60 days. 48744 Resident #47 Resident #47 was admitted with the diagnoses of dementia, generalized anxiety disorder (ongoing anxiety that interferes with daily activities), and type 2 diabetes. The Minimum Data Set, dated dated dated [DATE] documented the resident was able to be understood, could understand others and had a moderate cognitive impairment. Review of Resident #47's medical record indicated a Physician's Order dated 12/15/2023 for quetiapine (psychotropic) 25 milligrams by mouth every 24 hours as needed for psychosis. Record review indicated this order was discontinued on 1/15/2024. Record review indicated Resident #47 had a Physician's Order dated 1/16/2024 for quetiapine 25 milligrams by mouth every 24 hours as needed for psychosis. Record review indicated this order did not include an end date. Record review indicated Resident #47 had a Physician's Order dated 2/8/2024 for lorazepam (anti-anxiety) 1 milligram tablet to be given 1 tablet by mouth every 12 hours as needed for anxiety. Review indicated no end date included with this order. Review of Resident #47's medical record indicated a document titled, Medication Regimen Review, dated 12/18/2023, listed an end date to an as needed order for psychotropic medications (medication that affects a person's mental state) was required with no exceptions. There was no documented physician response. Review of a document titled, Medication Regimen Review, dated 2/9/2024, listed an end date to the as-needed orders for lorazepam and quetiapine was required with no exceptions. Review indicated no documented physician response. In correspondence to the New York State Department of Health on 2/27/2024, Administrator #2 wrote they were unable to locate Medication Regimen Reviews with documentation where the medical provider addressed the aforementioned recommendations. During an interview on 2/23/2024 at 2:06 PM, Assistant Director of Nursing #1 stated all psychotropic medications given as an as-needed medication should have had an end date. They further stated all new psychotropic medications (medication that affects a person's mental state) or new medications in general, should have had a date for re-evaluation. During an interview on 2/26/2024 at 12:42 PM, Medical Doctor #2 stated that as-needed psychotropic medications should have had an end date scheduled for 14 days after the order. They further stated that after 14 days, the medical team would review it and reorder it if the medication was still needed. During an interview on 2/26/2024 at 3:25 PM, Medical Director #1 stated they did tried to limit the use of psychotropic medications on an as-needed basis. They stated there may not be an end date in the order for situational instances, like end-of-life care, or needing an anti-anxiety drug after a family visit. They stated the reason for no end date would need to be noted and the team would have to review them but such notations may not be in the physician's order itself. The Medical Director #1 stated the medical team reviewed psychotropic medications during monthly regulatory visits. Resident #91 Resident #91 was admitted to the facility with the diagnoses of acute and chronic respiratory failure with hypoxia (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe), and pneumonia. The Minimum Data Set, dated dated dated [DATE] documented that the resident was minimally cognitively impaired, able to make themselves understood, to understand others, and needed some assistance to perform activities of daily living. During a record review on 2/21/2024 at 2:01 PM, it was noted that Resident #91 had a medication order for Azithromycin oral tablet (an antibiotic) 250 milligrams, 1 tablet to be given on Monday, Wednesday and Friday. Review of the order indicated the prescribing indication listed was for preventative. During an interview with Assistant Director of Nursing #1, on 02/27/2024 at 10:15 AM, they stated that it was acceptable to have an order for maintenance or preventative antibiotics; however, there needed to be a reason for the antibiotic. They stated as the facility Infection Preventionist, it was their responsibility to review the antibiotics ordered along with the pharmacist consultant sheets to make sure orders were correct and that any prescribed antibiotic had a reason for use. When asked specifically if an order was written for preventative would be acceptable, Assistant Director of Nursing #1 stated the order should be more like for urinary tract infection prevention and should not be for preventative without indication for precise use. During an interview on 02/27/2024 at 03:25 PM, Medical Director #1 stated that sometimes antibiotics were used as preventatives if the resident was significantly compromised or had acquired multiple infections. They further stated that regarding Resident #91's order for antibiotics, Medical Director #1 believed that the order was carried over from a previous hospital stay when the resident's pulmonary doctor had made the recommendation of preventative treatment. During a follow up interview with Medical Director #1 on 02/27/2024 at 01:11 PM, documentation was provided regarding the rationale for the order to continue antibiotic treatment for preventative purposes. When asked if Resident #91's antibiotic order was acceptable as written, Medical Director #1 stated the order should be rewritten to include the illness being tried to prevent. 10 New York Codes, Rule and Regulations 415.18 (c)(2)

Based on observation and interviews during the recertification survey from 2/20/2024 to 2/27/2024, the facility did not dispose of garbage and refuse properly. Specifically, the exterior dumpster was not clean nor in good repair, and the grounds around the dumpster was littered. This is evidenced by: During observations on 2/20/2024 at 10:38 AM of the exterior grounds, the side door to the garbage dumpster had a 3-inch round hole, one side of the dumpster was soiled with black drip marks, and the ground around the dumpster was littered with food refuse. During an interview on 2/20/2024 at 10:41 AM, Food and Nutrition Director #1 stated that litter could have been there for 2 days and that they would ask the Manager of Facilities #1 to contact the dumpster vendor for dumpster cleaning and door repair. During an interview on 2/20/2024 at 1:27 PM, Administrator #2 stated that Manager of Facilities #1 cleaned the area on 2/20/2024 by 11:00 AM, and the dumpster vendor would be contacted. 10 New York Codes, Rules, and Regulations 415.14(h)

Based on observations, record reviews and interviews conducted during the recertification survey from 2/20/2024 to 2/27/2024, the facility did not ensure the development of comprehensive person-centered care plans, that included measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment, for 1 (Resident #70) of 22 residents reviewed for comprehensive care plans. Specifically, for Resident #70, the facility did not ensure a comprehensive care plan was developed to address the medical order for supplemental oxygen use. This is evidenced by: The facility's policy and procedure titled Interdisciplinary Care Conference and Care Planning dated 6/27/2023 documented the facility would develop a comprehensive, resident-centered care plan for each resident based on the individual needs/problems of each resident. Resident #70 Resident #70 was admitted to the facility with the diagnoses of dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), morbid obesity (a complex chronic condition in which a person has a body mass index of 40 or higher), and atrial fibrillation (a type of arrhythmia, or abnormal heartbeat). The Minimum Data Set (an assessment tool) dated 1/23/2023 documented the resident could usually understand and usually be understood by others and was severely cognitively impaired. Record review of Resident #70's physician orders indicated the resident had a physician order dated 12/3/2023 for oxygen via nasal cannula at 2 Liters per minute continuously. Review of Resident #70's Comprehensive Care Plan indicated the resident did not have a care plan to address the use of supplemental oxygen. During an interview on 2/23/2024 at 2:44 PM, Assistant Director of Nursing #1 stated all residents with orders for oxygen should have had a corresponding plan of care. During an interview on 2/27/2024 at 12:00 PM, Registered Nurse #1 stated new orders or identified conditions should have had a care plan to address the problem. During an interview on 2/27/2024 at 12:20 PM, Registered Nurse #3 stated care plans should be initiated when there was a new condition that needed to be addressed. Registered Nurse #3 indicated this would include oxygen orders. 10 New York Codes, Rules and Regulations 415.11(c)(1)

Based on observations, interviews, and record review during a recertification survey from 2/20/2024 to 2/27/2024, the facility did not ensure treatment with respect, dignity, and care for each resident in a manner and in an environment that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality for 2 (Resident #'s 257 and 258) of 22 residents reviewed for privacy and dignity. Specifically, (a.) staff did not knock on Resident #257's door prior to entering and (b.) did not cover the urine collection bag for Resident #258 for treatment reflective of dignified care and respect for the privacy of the residents. This is evidenced by: A. Staff did not knock on resident doors prior to entering: Resident #257 Resident #257 was admitted to the facility on [DATE] with diagnoses including acute chronic systolic (congestive) heart failure (a disease of the heart caused by damage that has developed over time), acute respiratory failure with hypoxia (a condition where you do not have enough oxygen in the tissues of the body caused by a disease or injury that affects a person's breathing), and chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems such as emphysema or chronic bronchitis). The Minimum Data Set (an assessment tool) dated 2/16/2024 assessed that the resident was fully cognitively intact and required assistance to complete activities of daily living. On Unit 4 South between 2/20/2024 and 2/27/2024, during the 7 AM - 3 PM day shift, it was noted that staff entered resident rooms without knocking on 3 of 12 occasions. Specifically: During Observation 1 on 2/20/2024 at 12:36 PM, a staff certified nursing aide entered Resident #257's room without knocking or announcing themselves. During Observation 2 on 2/23/2024 at 12:52 PM, a nurse staffer walked into room [ROOM NUMBER] without knocking or announcing themselves. During Observation 3 on 2/26/2024 at 11:59 AM, staff certified nursing aide entered resident room [ROOM NUMBER] without knocking or announcing themselves. Additional observations on 2/26/2024 at 12:07 PM and 12:14 PM of Certified Nursing Aide entering resident room [ROOM NUMBER] without knocking or announcing themselves. An observation on 2/22/2024 at 12:37 PM noted a sign above the Certified Nursing Aides documentation station reminding all staff that they are in their residents' homes and that they need to be sure of the following: Knock before entering a resident's room. Announce themselves. Let them know why they are there. During an interview on 2/26/2024 at 12:43 PM, Certified Nursing Aide #14 stated that all staff should knock on the residents' doors and announce themselves before entering the residents' rooms. They stated that this was their home, and staff should not just walk into their rooms. They indicated staff were supposed to knock every time they entered a resident's room but sometimes they did not. During an interview on 2/27/2024 at 10:57 PM, Licensed Practical Nurse #10 stated that all individuals were to knock on the door and announce themselves. When asked if there were any incidents in which staff did not need to knock, they stated that all staff should always knock on the door, even if they just left the room. They said that they have witnessed staff not knocking on doors, and they usually had reminded them of the proper procedure for entering a resident room. They stated the resident sat on their collection bags often or had them suspended to their side and should be moved. They stated that they were clipped to the resident's shirt with a safety pin on occasion. Licensed Practical Nurse # 10 stated they were unsure of a plan or documentation to place them in dignity bags. Still, they should be treated like any other urine collection bag. During an interview on 2/27/2024 at 11:14 AM, Registered Nurse #3, stated that staff should knock on the door and announce themselves before entering residents' rooms. They stated that they had not had any residents complain that staff were not knocking or witnessed staff not knocking. They stated that they believed some staff had just entered resident rooms without knocking or announcing as they had yet to develop the muscle memory to perform the task. They stated they had in-service meetings regarding the proper procedure for entering the resident room. They had placed signage on the unit to remind staff of the requirements. B. Staff did not cover the urine collection bag for treatment reflective of dignified care and respect for the privacy of the residents: Resident #258 Resident #258 was admitted to the facility on [DATE] with diagnoses including Malignant Neoplasm of the bladder and prostate (cancer of the bladder and prostate), bilateral nephrostomy (tubes placed in the kidneys to drain urine due to blockage of tubes that drain to the bladder), and Hemiplegia and hemiparesis following cerebral infarction affecting the left side (an injury to the brain caused by a blockage of blood flow resulting in the decreased use of the left side of the body). The Minimum Data Set, dated dated dated [DATE] assessed that the resident was fully cognitively intact and requires assistance to complete activities of daily living. During an observation on 2/20/2024 at 11:45 AM, Resident #258 was sitting in a wheelchair and was being pushed in the hallway by therapy staff. The resident had two urine collection bags on either side of their body, which were uncovered and lying on their lap. During an interview on 2/27/2024 at 11:15 AM, Registered Nurse #3 stated that Resident #258 went to the hospital recently because of pain in the nephrostomy tube area and thought they had an issue with them. They stated that the resident did not have them in support bags, and when they got full, they pulled on the incision site. They stated they had changed residents' drainage schedules to reduce site straining. They stated they were unsure of a specific nephrostomy tube policy as they have had only two individuals with those prior. They stated that the drainage bags should be covered and in bags so as not to have them exposed. They stated that they would cover them or have them tucked under clothing if exposed. 10 New York Codes, Rules and Regulations 415.3 (c)(1)(i)

Based on record review and interviews during an abbreviated survey (Case # NY00316856), the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse, to the Administrator of the facility and to the State Survey Agency for 1 (Resident #1) of 5 residents reviewed. Specifically, an allegation of physical abuse reported by Resident #1 on 5/15/2023 was not reported to the New York State Department of Health after the allegation was made. This is evidenced by: Resident #1: Resident #1 was admitted to the facility with diagnoses of dementia, squamous cell carcinoma (skin cancer), and anemia (condition of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissue). The Minimum Data Set (an assessment tool) dated 5/18/2023, documented the resident could be understood, could understand others, and had intact cognition for decisions of daily living. The facility's Abuse, Prevention and Investigation Policy, dated 7/27/2023, documented a report to the New York State Department of Health must be made immediately, but no later than 2 hours after forming the suspicion that an allegation meets the following criteria: Serious bodily injury occurred and/or there is suspicion that abuse has occurred. The Statement Form dated 5/15/2023 at 7:10 AM signed by Certified Nurse Aide #2 documented Resident #1 reported the staff that got them dressed that morning was rough and mean causing a bruise on their right arm. The Investigation Summary Form dated 5/15/2023 documented the resident reported to two (2) daytime Certified Nurse Aides that the overnight aide was mean and rough and the bruise on their right arm was caused by the aide. The Conclusion documented the facts in this investigation did not support the allegation of abuse. The section of the form titled Department of Health Notification was blank. The form was signed by Administrator #2 on 5/16/2023. A review of ASPEN Complaints/Incidents Tracking System revealed no reports were submitted by the facility regarding the incident that occurred on 5/15/2023. During an interview on 2/15/2023 at 1:52 PM, Assistant Director of Nursing #1 stated it was an allegation of abuse and should have been reported to the Department of Health immediately; and that there was nothing in the file to indicate the incident was reported. During an interview on 2/15/2023 at 2:05 PM, Administrator #1 stated the incident was suspected abuse and should have been reported within two hours. 10 New York Codes, Rules and Regulations 415.4(b)(2)

Based on record review and interviews during an abbreviated survey (NY00292926), the facility did not ensure that each resident received adequate supervision and assistive devices to prevent accidents for 1 (Resident #2) of 2 residents reviewed. Specifically, the facility did not ensure Resident #2, who was visually impaired, was to be served hot beverages in an adaptive cup with a lid to prevent avoidable accidents. The resident was served a hot beverage in a paper cup without a lid and spilled the contents on themselves, resulting in second degree burns on their chest and thigh. This resulted in actual harm that is not immediate jeopardy for Resident #2. The findings include: The Policy and Procedure (P&P) titled Hot Liquids: Risk and Promoting Safety, dated 1/1/21, documented the facility would identify those residents at risk with hot liquids to decrease potential of burns from hot liquid spills. The policy defined hot liquids as temperatures of 140 degrees or greater. Upon admission and as determined by nursing/dietary services, residents were to be screened by Therapy or designee to determine their ability to safely manage hot liquids. Residents assessed to be at risk with hot liquids were communicated to nursing and dietary staff. The procedure included that nursing staff provide appropriate supervision for residents who are considered to be at risk with hot liquids. All staff disciplines were to refer to the resident meal tickets or list of residents at risk with liquids when with assisting with beverage service requested by the resident. Resident #2 was admitted to the facility with diagnoses of dysphagia, anemia, adjustment disorder and unqualified visual loss in both eyes. The Minimum Data Set (MDS; an assessment tool) dated 3/20/22, documented the resident had moderate cognitive impairment for decisions of daily living, could be understood and could usually understand others. The Comprehensive Care Plan (CCP), initiated 3/14/22, included Resident #2 had a potential safety awareness deficit related to limited mobility, being hard of hearing and legally blind. The CCP also included Resident #2 had impaired ability to complete activities of daily living (ADLs) and required assistance with feeding; interventions included all liquids be served for the resident in Kennedy Cups (assistive device for drinking liquids) with lids and the resident needed to be seated upright in a broad chair/ergo chair (chair used for positioning). The situation background assessment recommendation tool (SBAR) (utilized for the resident change in condition tool) note dated 3/19/22 at 2:06 PM, documented the resident spilled hot tea on themselves. The nurse's assessment documented the resident had reddened areas that were thirteen (13) by nine (9) centimeters to the right breast and fourteen (14) by thirty-two (32) centimeters to the right lateral thigh. Small, intact blisters were documented to have formed on the resident's right thigh. The resident was transferred out to the hospital for evaluation. Registered Nurse Supervisor (RNS) #1 nursing progressnote dated 3/19/22 at 2:54 PM, documented at approximately 1:35 PM, Resident #2 called out for a nurse, the writer went to the resident's room and Resident #2 stated they spilled their tea. The RNS #1 documented they removed the resident's clothing and applied a cool compress to the resident's chest. When Resident #2 was further assessed by RNS #1, a reddened area on the right side of her thigh was also found and cool compress applied to that area as well. The RNS #1 documented the resident's physician and family member were notified, and the physician advised to transfer the resident to the hospital for further evaluation. Review of the facility's investigation of the incident documented RNS #1 was summoned to the resident's room by Resident #2 who reported they had spilled hot tea on themselves. The facility conducted staff interviews which revealed the resident had been served hot tea in a paper cup without a lid by a dietary services staff member. The investigation documented the incident happened when the resident asked for a cup of tea and a dietary staff member provided it to the resident in a disposable cup without a lid or handle. The resident spilled the tea on their right breast and thigh. According to the documentation, RNS #1 immediately responded when Resident #2 called out for a nurse. RNS #1 evaluated Resident #2 and applied cool compresses to the reddened skin on right breast and right thigh. RNS #1 notified the on-call physician and received an order for the resident to be transported to the hospital for further evaluation. As a result of the incident, all dietary and nursing staff were provided re-education regarding the process for taking food and beverage temperatures, serving hot beverages, and accessing resident specific care plan information related to the process. Resident #2's CCP was updated 3/19/22 to include the resident had sustained burns from spilling hot liquid on themselves and was at risk for hot beverages. Review of the hospital discharge instructions, dated 3/19/22, documented physician orders were received for treatment of Resident #2's burns. Review of the facility record documented the Interdisciplinary Team met for root cause analysis of the incident on 3/22/22 and the facility developed a performance improvement plan which included re-education of all staff on facility policy and procedure on service of hot beverages and periodic monitoring of adherence to the procedure. A March 2022 Safety Huddle for all units documented the facility procedure for service of hot beverages was reviewed. Certified wound specialist (CWS) #1 note dated 4/8/22 documented the resident had second degree burns that were in-house acquired to their right lateral thigh measured 22.19 centimeters (cm) long and 5.56 cm wide. CWS #1 note dated 4/22/22 documented the resident had a second degree burn that was one month old to their right chest measured 4.33 cm long and 6.79 cm wide. During an interview on 12/8/22 at 2:28 PM, the Director of Dining Services (DDS) #1 said all hot beverage temperatures need to be taken before services, and the temperature logged with the date and time it was taken. They said the dietary staff would prepare hot beverages prior to the meal service and leave the lid off or add ice cubes to the beverage until the temperature came down to around 162 to 164 degrees. They said all dietary staff received education on how to take food and hot beverages temperatures before serving. They said any adaptive equipment required by a resident would be listed on meal tickets during meal service and communicated to dietary staff. They said Resident #2 was served the hot tea outside of meal service time. During an interview on 12/9/22 at 11:20 AM, Dietary Services Staff (DSS)#1 said hot beverages were made prior to meal service to allow for the temperature to cool and to recheck the temperature prior to being served. They said if a resident requested a hot beverage outside of meal service, the beverage temperature would need to be below 164 degrees before it could be served to a resident. They said residents should not be served hot beverages in paper cups. They said they would record the time and the temperature of all beverages served in a temperature log that was located on each unit. During an interview on 12/9/22 at 11:42 AM, The Director of Nursing (DON) #1 said Resident #2 was served hot tea in a paper cup without a lid by a dietary services worker at the facility. They said the facility provided re-education to all staff on serving hot beverages to residents and facility procedures were updated. They said residents should never be served hot beverages in a disposable cup. During an interview on 12/9/22 at 1:42 PM, the Certified Wound Specialist (CWS) #1 said they were contacted to provide a consult to Resident #2's burns sustained from spilling hot tea on themselves. They said Resident #2 sustained second degree burns on their chest and thigh. They said the resident was prescribed burn treatment medications and was followed by the wound team until wounds were resolved. During an interview on 12/16/22 at 11:48 AM, the facility's Medical Director (MD) #1 said Resident #2 was recommended to use a Kennedy Cup with a cap and straw for beverages, however, the resident was served hot tea in a paper cup by a dietary staff member. They said Resident #2 spilled the hot tea on themselves which resulted in second degree burns. They said following the incident the facility took steps to ensure a similar incident did not occur again. They said the facility reviewed all residents to ensure it was indicated in the plan of care when a resident was at risk with hot beverages. F689- Past noncompliance Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement at the time of this survey: The facility conducted a Safety Month Burn Prevention Huddle for all facility units in March 2022 which included the following information: -All hot beverages must have a lid when transporting. -All lids on hot beverages on rooms trays will be removed by nursing staff when the tray is served in the room. -If a beverage or soup is not warm enough, staff are not to reheat in the microwave. Staff must call down to the kitchen for a fresh bowl of soup or new hot beverage. During an observation on 12/9/22 at 12:43 PM, Resident #2 was observed to be seated in their wheelchair in their room with their meal tray on a side table. The resident #2 had a cup of tea that was served in a cup with a secured lid and two handles on their side of the cup. The resident #2 was not eating or drinking. They said the nurse was coming in to provide them with assistance. At 12:49 PM, a nurse arrived at the resident's room and adjusted the resident and began to serve them their meal. 10 NYCRR 415.12(h)(2)