Every finding on record at Epic Rehabilitation And Nursing At White Plains

Based on observations and interviews the facility failed to ensure that food was stored in accordance with professional standards for safe food handling and storage practice. Specifically, food items stored in the walk-in freezer, walk-in refrigerator, nutritional refrigerator, cook's freezer and dry storage room were observed open to air, undated, and/or without expiration dates.The findings include:The Policy for Food Storage dated 10/7/2024, documented food should be dated as it is placed on the shelves. Date marking to indicate the date or day by which ready-to-eat, potentially hazardous food should be consumed, sold, or discarded will be visible on all high-risk food. If expiration date is on the box and not on the individual item, the item must be stored in or with the original box.During the initial kitchen tour on 5/18/2026 at 9:09 AM, conducted with the Food Service Director, observation of the Nutritional Refrigerator revealed a package of pasteurized processed American cheese that was not labeled with an expiration date.During an observation of the walk-in refrigerator on 5/18/2026 at 9:11AM, an opened gallon of whole milk was without a date that indicated when the container was opened.During an observation of the walk-in freezer on 5/18/2026 at 9:17AM, an opened bag of [NAME] Farms Seasoned Diced Potatoes was exposed to air. A package of frozen waffles wrapped in plastic was without the original packaging and without an expiration date. A five-pound bag of mild cheddar cheese was not within its original packaging and was without an expiration date.Observation of the cook's freezer revealed a box of boneless pork loin partially wrapped in plastic with a large open area exposed to the air. Additionally, a ten-pound box of tilapia fillets was open to air.Observation of the dry storage room on 5/18/2026 at 9:23 AM revealed a bag of penne pasta without a date indicating when the bag was opened. Two one-gallon bottles of white vinegar were open and did not have dates to indicate when they had been opened.During an interview on 5/18/2026 at 9:27 AM, the Food Service Director stated food items identified during the initial kitchen tour were not properly labeled and/or protected from exposure to air. The Food Service Director discarded the food products without opening dates, expiration dates, and foods that were open to air. The Food Service Director stated they were responsible for storage and labeling of food products in the kitchen and stated all items must be labeled upon opening with both the dates opened and expiration date.10 New York Code Rules Regulations 415.14 (h)

Based on observation, interview, and record review the facility failed to ensure residents had the right to a dignified experience for three (3) of four (4) residents (Residents #45, #118 and #145) reviewed for dignity. Specifically, 1) Licensed Practical Nurse # 10 was observed standing over Residents #118 and #145, who were seated at opposite ends of the dining table, while assisting them with eating. Additionally, Licensed Practical Nurse #10 provided other residents water and set up assistance while assisting Resident #118 and Resident #145 with eating and 2) Certified Nurse Aide #9 referred to Resident #45 as a feeder in the presence of other residents during the 05/18/2026 lunch service. The findings include:The facility policy titled Quality of Life-Dignity, written 07/2019, documented staff shall always speak respectfully to residents, including addressing the resident by their name of choice and not labeling or referring to the resident by their room number, diagnosis, or care needs.The facility policy titled Assisting Residents with Meals, written 07/2019, documented residents who cannot feed themselves will be fed with attention to safety, comfort and dignity. For example, not standing over residents while assisting with meals, keeping interactions with other staff to a minimum while assisting residents with meals, and avoiding the use of labels when referring to residents (e.g., feeders). 1) During an observation on 05/18/2026 at 12:58 PM, Licensed Practical Nurse #10 was standing while they assisted Residents #118 and #145 with eating. Residents #118 and #145 were seated at opposite ends of the dining table and being assisted by Licensed Practical Nurse #10 who was walking around the table to assist the two residents. In addition, Licensed Practical Nurse #10 provided water to other residents and provided set up assistance in between assisting Resident #118 and Resident #145 with eating. During interviews on 05/18/2026 at 1:10 PM and 05/20/2026 at 11:09 AM, Licensed Practical Nurse #10 stated they were aware they were standing while assisting Resident #118 and Resident #145 during the lunch service and assisting other residents. They stated the unit was short one nurse for the shift and there were only two certified nurse aides available to assist in the dining room. They stated there were four (4) residents who required assistance with eating in addition to the other residents who required set-up assistance or had other requests. Licensed Practical Nurse #10 stated they should have asked management for help. They stated they should not assist two residents with eating who were seated at opposite ends of the dining room table and should not have been standing while assisting them with eating. Licensed Practical Nurse #10 stated assisting other residents in the dining room between assisting Resident #118 and Resident #145 caused delays and potentially cold food being served to both residents. 2). During an observation on 05/18/2026 at 12:47 PM, Certified Nurse Aide #9 referred to Resident #45 as a feeder when they responded to a question asked by by Certified Nurse Aide #11. There were approximately fifteen residents in the dining room at the time and five (5) residents within the immediate area. During interviews on 05/18/2026 at 12:47 PM and 05/22/2026 at 11:41 AM, Certified Nurse Aide #9 stated they were removing Resident #45's tray because they were a feeder and no longer needed to have the completed tray in front of them. They stated they should not have referred to Resident #45 as a feeder and should have used needs assistance with eating instead. During an interview on 05/20/2026 at 11:06 AM, Licensed Practical Nurse Unit Manager #10 stated residents should never be referred to as feeders. They stated staff should refer to residents by their name or use needing assistance with eating to maintain dignity. During an interview on 05/26/2026 at 1:54 PM, the Director of Nursing stated staff are expected to address residents by their names and the term feeders should never be used. They stated staff should be seated at eye level with residents during dining. 10 New York Code Rules Regulations 415.5

Based on record review and interview conducted during the survey, the facility failed to ensure Minimum Data Set assessments were completed and/or submitted timely for eight (8) of 8 residents reviewed for Minimum Data Set Resident assessments (Residents # 38, #53, #69, #77, #85, #112, #126, and #13). The findings included:The 4/24/2026 Minimum Data Set Completion facility policy documented that all residents will be assessed initially on admission utilizing the resident assessment instrument which incorporates the minimum data set and care area assessment. Subsequent assessments will be completed for quarterly assessment no later than 92 days after the Assessment Reference Date of the Significant Change in Status Assessment or Significant Correction to the Prior Comprehensive Assessment and the next comprehensive assessment will be scheduled within 366 days after the Assessment Reference Date of the Significant Change in Status Assessment or Significant Correction to the Prior Comprehensive Assessment. The Minimum Data Set Coordinator assigns the staff to complete the specific sections of the Minimum Data Set. All Minimum Data Set assessments are maintained electronically with electronic signatures. Certification: the regulation requires the Registered Nurse coordinator to certify that the assessment is complete. The Minimum Data Set Assessor/ Coordinator responsibilities included submitting completed assessments to the Quality Improvement and Evaluation System.On 05/26/2026 at 3:30 PM, review of the Resident Minimum Data Set (MDS 3.0) Summaries in the electronic health record with the Minimum Data Set Coordinator and Minimum Data Set Director for the following residents documented the following:Resident #38's admission assessment reference date of 10/10/2025 was submitted on 11/02/2025,Resident #38's quarterly assessment reference date of 1/10/2026 was submitted on 2/08/2026,Resident #38's quarterly assessment reference date of 4/12/2026 was submitted on 5/17/2026,Resident #53's significant change assessment reference date of 1/13/2025 was submitted on 2/10/2025,Resident #53's quarterly assessment reference date of 4/16/2026 was submitted on 5/17/2026,Resident #69's admission assessment reference date of 1/14/2026 was submitted on 2/08/2026,Resident #69's quarterly assessment reference date of 4/16/2026 was submitted on 5/17/2026,Resident #77's quarterly assessment reference date of 4/12/2026 was submitted on 5/17/2026,Resident #85's annual assessment reference date of 12/27/2024 was completed on 1/20/2025 and submitted on 1/26/2025,Resident #85's quarterly assessment reference date of 1/13/2026 was submitted on 2/26/2026,Resident #85's quarterly assessment reference date of 4/15/2026 was submitted on 5/17/2026,Resident #112's quarterly assessment reference date of 4/08/2026 was submitted on 5/17/2026,Resident #126's annual assessment reference date of 11/08/2024 was completed on 11/26/2024,Resident #126's quarterly assessment reference date of 4/11/2026 was submitted on 5/17/2026,Resident #13's 5-day scheduled assessment reference date of 4/17/2026 was submitted on 5/17/2026. On 05/26/2026 at 3:38 PM, the Minimum Data Set Coordinator stated their responsibility was to ensure that all departments complete and sign off on their sections of the assessments. They stated that for Resident #85, on 12/27/2024, dietary did not complete Section K timely and for Resident #126's annual assessment dated [DATE], Sections A and O were not signed off timely by themselves. On 05/26/2026 at 3:40 PM, the Minimum Data Set Director stated they were responsible for submitting the assessments to the Centers for Medicare and Medicaid Services when they populated to the Minimum Data Set dashboard, however sometimes they did not submit the assessments timely.10 New York Code Rules Regulations 415.11

Based on record review and interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for two (2) of three (3) residents (Resident #112 and #182) reviewed for change in condition. Specifically, 1) Resident #112 received their daily 9 AM medications at approximately 2:30 PM on 04/13/2026 including the medications Isosorbide Mononitrate and Valsartan (blood pressure pills) for hypertension, Torsemide (water pill) for congestive heart failure, Trelegy Ellipta (inhaler) and Albuterol nebulizer medicine for asthma and 2)for Resident #182 with a history of urinary tract infection and reported complaints of urinary tract symptoms, urine was not collected timely for urinalysis/culture as per the 11/29/2024 physician order. Additionally, there was no documented evidence that the physician was notified when staff were unable to collect the urine on 11/29/2024 and 11/30/2024.The findings include: The July 2019 Policy for Medication Administration Schedule documented that medications shall be administered according to established schedules. Medications are administered according to the following routine schedule: ordered time: daily medications are given at 9:00AM. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified. The policy titled Catheterization, Intermittent, Female Resident documents to notify the physician of any abnormalities and report other information according to professional standards of practice. 1) Resident #112 had diagnoses including asthma, congestive heart failure, and hypertension. The 04/08/2026 quarterly Minimum Date Set (assessment tool) documented Resident #112 had severely impaired cognition. The Physician Order dated 12/27/2024 documented Valsartan 160 milligram tablet, give 1 tablet by oral route daily for hypertension, Isosorbide Mononitrate extended release 60 milligram, give 1 tablet by oral route daily for hypertension, and Trelegy Ellipta 200 microgram-62.5 microgram-25 microgram powder for inhalation, inhale 1 puff once daily for mild intermittent asthma. The Physician Order dated 10/02/2025 documented Albuterol sulfate 2.5 milligram/3 milliliters (0.083%) solution for nebulization, inhale 3 milliliters (2.5 milligram) by inhalation route four times per day for exercise induced bronchospasm. 10/05/2025 Torsemide 20 milligram, give one tablet by oral route once daily for congestive heart failure, The Care Plan for Asthma last updated 03/04/2026 documented promote compliance with medication regimen. The Care Plan for congestive heart failure last updated 03/04/2026 documented an intervention to administer medications per physician orders. The Care Plan for hypertension last updated 03/04/2026 documented notify the provider with elevated blood pressure. The Care Plan for Nebulizer Use/infection control Care Plan last updated 03/05/2026 documented administer nebulized medications as prescribed. The Care Plan for medication last updated 03/09/2026 documented administer medications per Physician/ Nurse Practitioner The April 2026 Medication Administration Record documented Resident #112's 9 AM medications were not administered on 04/13/2026 at 9 AM as ordered. Symbols *^ documented by Licensed Practical Nurse #1 indicated 'not administered' per the Medication Administration Record Legend. The 04/13/2026 Medication Incident Form documented drug omissions including Valsartan, Albuterol, Trelegy Ellipta, Torsemide, and Isosorbide ordered to be administered at 9:00 AM were not given on 04/13/2026. The 04/13/2026 at 2:27 PM Monitoring Tab documented Resident #112's blood pressure was 188/84. The 04/14/26 at 5:31 PM Nurse Practitioner #1 note documented date of service 04/13/26. Resident #112 was seen today for medication review, elevated blood pressure. They were notified at 1:28 PM by Licensed Practical Nurse #1 that Resident #112 did not receive their 9:00 AM medications of Albuterol, Valsartan, Trelegy, Isosorbide. Medications were reviewed by this writer. Seen for elevated blood pressure. Systolic Blood Pressure 188 on 04/13/26 at 2:27 PM. On 05/20/2026 at 12:52 PM during an interview and review of their written statement regarding Resident #112's medication omissions on 04/13/2026, Licensed Practical Nurse # 1 stated they did not administer Resident #112's 9 AM medications as ordered although they were aware that they should have done so. They stated they did not make the nurse manager aware or ask for help. They stated they gave Resident #112 their missed medications around 2:15 PM. On 05/21/2016 at 10:56 AM during an interview, Licensed Practical Nurse Unit Manager #2 stated that medications scheduled for 9AM should be administered between 8AM and 10AM. They stated that the assigned nurse was responsible to assure that the residents received their medications as ordered. They stated that Licensed Practical Nurse #1 should have notified them if they needed help to complete their medication administration as ordered. On 05/21/2026 at 10:40 during an interview, the Assistant Director of Nursing stated that between 1:00 to 1:30 PM on 04/13/2026, they were notified by Resident #112's family that Resident #112 did not receive their 9 AM medications. They stated that Nurse Practitioner #1 was made aware and one-time orders were given to administer the medications and investigation was started regarding the medication omissions. They stated that medications which are ordered to be administered at 9 AM should be administered between 8 AM and 10 AM. They stated it was their expectation that nurses administer medications as ordered. They stated the assigned nurse was responsible for ensuring residents received their medications as ordered. They stated Licensed Practical Nurse Unit Manager #2 was on the unit that day and Licensed Practical Nurse #1 should have notified them if they needed help to complete their medication administration as ordered. They further stated that Licensed Practical Nurse #1 had their cell phone number and could have called them for assistance if Licensed Practical Nurse Unit Manager #2. 2) Resident # 182 had a diagnosis of hypertension, chronic atrial fibrillation and hyperlipidemia. The Physician Progress Note dated 11/27/2024 at 3:49 PM documented hospital work-up: Daughter notes increased lower abdomen pressure. Urinalysis positive in emergency room. Status post Merrem (antibiotic to treat serious bacterial infection). . The Care Plan for incontinence dated 11/27/2024 documented monitor for signs and symptoms of cystitis such as dysuria, urgency, fever, change in mentation and burning n urination and notify the medical doctor and optimize hydration. The Nursing Progress note written by Infection Preventionist/Staff Educator dated 11/29/2024 at 10:45 AM writer received call from Resident #182's daughter, vocalizing resident complaints of burning in vaginal area. Case discussed with the unit manager and physician. Resident was seen by the physician at bedside with new orders given for urinalysis and culture/sensitivity and to start Pyridium 200 milligram three times daily times two (2) days. Start Pyridium after urinalysis and culture/sensitivity collection. The Physician Order dated 11/29/2024 at 10:51 AM documented urinalysis and culture/sensitivity, may straight catheter as needed. The Physician Progress Note dated 11/29/2024 at 1:02 PM documented urinary tract infection. Commence Pyridium 200 milligrams every 8 hours times two (2) days. Urinalysis and culture/sensitivity. The Physician Order dated 11/29/ 2024 at 5:00 PM documented Pyridium 200 milligram one (1) tablet three (3) times daily x two (2) days for dysuria. The 11/2024 and 12/2024 Medication Administration Record documented Pyridium was administered as per physician order. The Nursing Progress Note dated 11/29/ 2024 at 9:53 PM documented that Resident #182 started on Pyridium 200 milligram related to dysuria. Resident #182 noted with blood in their brief. Registered Nurse Supervisor #50 and Physician # 23 notified. Monitor for another episode. Resident #182 is scheduled for urine collection for urinalysis and urine culture. Resident #182 is incontinent. Unable to obtain urine specimen, writer endorsed to next shift. The Nursing Progress Note dated 12/1/2024 at 9:08 AM documented Resident #182 remains without episodes of hematuria so far this shift. Continues Pyridium three (3) times a day for management of urinary discomfort as per daughter. Resident #182 denies urinary burning currently. Reminded Resident #182 of urine specimen collection and to call for staff to assist with specimen collection. The Nursing Progress Note dated 12/1/2024 at 11:07 PM documented Resident #182 is alert and responsive. Urine was collected for urinalysis and culture and stored in the 3rd floor refrigerator, pending collection. Continue to monitor. There was no documented evidence to indicate that urine was collected as per the 11/29/2024 physician order prior to 12/01/2024. There was no documented evidence that the physician was notified when staff were unable to collect the urine on 11/29/2024 and 11/30/2024. The Nurse Practitioner Progress Note dated 12/02/2024 at 10:31 PM documented labs: urinalysis with microscopy positive. The Physician Order dated 12/02/2024 documented Pyridium 100mg twice daily x two (2) days for dysuria. The 12/2024 Medication Administration Record documented Pyridium 100mg was administered as per physician order on 12/02/2024, 12/03/2024 and 12/04/2024. The Physician Progress Note dated 12/04/2024 at 2:17 PM documented proteus mirabilis (bacteria) greater than 100K. The admission Minimum Data Set (assessment tool) dated 12/03/2024 documented Resident #182 had moderate cognitive impairment, was incontinent of bowel and bladder and required substantial/maximal assistance with toileting hygiene. During an interview on 5/26/2026 at 1:00 PM the Medical Director stated if urine needed to be collected on a Friday, they would usually put in a stat order. They stated if the resident was symptomatic, they would follow up on the status of the urine. Additionally, they stated four (4) days was not a reasonable amount of time to wait on collection of urinalysis and urine culture. They stated this case was an outlier. During an interview on 5/26/2026 at 1:25 PM the Director of Nursing stated if the resident was symptomatic, the urine should have gone out quicker. 10 New York Code Rules Regulations 415.12

Based on observation, record review and interviews, the facility failed to ensure that residents consistently received necessary treatment and services to prevent and promote healing of pressure ulcers for three (3) of six (6) residents (Residents #s 81, 33 and 55) reviewed for pressure ulcers. Specifically, 1) heel offloading was not implemented as per physician order for Resident #81 with documented pressure ulcers to both heels, 2) heel offloading was not implemented as per physician order for Resident #33 who was assessed to be at risk for pressure ulcers, and 3) the use of heel booties was not implemented as per physician orders for Resident #55 who was assessed to be at risk for pressure ulcers and had observed redness to both heels.The findings include:1)Resident #81 was admitted to the facility with diagnoses including pressure ulcer of sacral region, stage 3, encounter for surgical aftercare following surgery on the circulatory system, and cerebrovascular accident. The 3/25/2026 admission Minimum Data Set Assessment (a resident assessment tool) documented Resident #81 was cognitively intact, independent with sit to lying and lying to sitting on side of bed, at risk for developing pressure ulcers, had one (1) full thickness tissue loss pressure ulcer and two (2) unstageable pressure ulcers due to coverage of wound bed by slough or eschar and received pressure ulcer care, pressure reducing device for the chair and bed.The Physician Order dated 3/18/2026 documented heels off bed, every shift.The Care Plan for wound left heel and wound right heel dated 3/18/2026 documented frequent position changes and offloading of pressure points, use heel booties during bedtime and maintain offloaded heels.The Physician Order dated 5/8/2026 documented to provide strict offloading to the left heel, no shoe, use of leg elevator, and heel boot always while in the chair, every shift The May 2026 Treatment Administration Record documented heels off bed and strict offloading to the left heel.During observations on 5/18/2026 at 10:06 AM and 11:01 AM, and 5/22/2026 at 9:56 AM, Resident #81 was lying in bed with both heels resting directly on the mattress. The heels were not off loaded.During observation on 5/19/2026 at 9:37 AM, Resident #81 was in bed with both heels resting directly on a pillow surface. The heels were not offloaded. During an interview on 5/22/2026 at 9:59 AM, Certified Nurse Aide #15 stated they provided care for Resident #81 almost daily and were aware that Resident #81 had pressure ulcers on both heels. Certified Nurse Aide #15 stated Resident #81 was supposed to offload both heels with a pillow while in bed. Certified Nurse Aide #15 stated that the pillow should be positioned under Resident #81's calves so the heels would be completely free from pressure while lying down. Certified Nurse Aide #15 stated they could not locate the pillow used for offloading. Certified Nurse Aide #15 stated that at times, when arriving for the 7AM shift, Resident #81 did not have a pillow positioned under their calves. Certified Nurse Aide #15 stated they did not always remind Resident #81 about offloading their heels because Resident #81 was able to independently transfer between the bed and wheelchair. Certified Nurse Aide #15 stated it would be the responsibility of the night shift staff to ensure a pillow was in place while Resident #81 was in bed overnight.During an interview on 5/22/2026 at 10:23 AM, Licensed Practical Nurse #16 stated that Resident #81 had pressure ulcers on both heels and physician orders directing staff to offload Resident #81's heels while in bed. Licensed Practical Nurse #16 explained offloading meant removing all pressure from a resident's heels while lying in bed. Licensed Practical Nurse #16 entered Resident #81's room and observed Resident #81 lying in bed with both heels resting directly on the mattress. Licensed Practical Nurse #16 asked Resident #81 where the pillow was located, and Resident #81 pointed to a chair in the room where the pillow was observed. Licensed Practical Nurse #16 stated all nurses and certified nurse aides were responsible for ensuring a pillow remained under Resident #81's calves and for reminding Resident #81 about the importance of keeping pressure off their heels. Licensed Practical Nurse #16 stated that although the pillow had been under Resident #81's calves earlier in the morning, staff had not continued monitoring after Resident #81 woke up and moved independently between the bed and wheelchair several times. 2) Resident #33's diagnoses included unspecified folate deficiency anemia, benign prostatic hyperplasia with lower urinary tract symptoms, and cerebral infarction due to thrombosis of other cerebral artery. The quarterly /five (5) day scheduled Minimum Data Set, dated [DATE] documented Resident #33 had moderate cognitive impairment, no rejection of care, required substantial/maximal assistance with showering and hygiene, and was at risk for pressure ulcers. The Physician Order dated 04/17/2026 documented heels off bed.There was no documented evidence in the comprehensive Care Plan to address heel offloading. During observations on 05/18/2026 at 10:35 AM, 05/19/2026 at 11:36 AM, and 05/20/2026 at 9:05 AM, Resident #33's bilateral heels were resting on their mattress and were not offloaded.During an observation and interview on 05/20/26 at 9:15 AM, Certified Nurse Aide #13 stated Resident #33's feet were not offloaded, and they were not aware that Resident #33 had a physician order to offload heels. During an interview on 05/20/2026 at 10:15 AM, Licensed Practical Nurse Unit Manager #10 stated they were not aware if certified nurse aide staff were offloading Resident #33's heels. Upon review of Certified Nurse Aide Task Record on the electronic medical record, Licensed Practical Nurse Unit Manager #10 stated there was no task which directed heel offloading of Resident #33's heels. They stated a certified nurse aide task should have been added once the physician order was placed. They stated they should have ensured completion of documenting the task. 3.Resident #55's diagnoses included toxic megacolon (distended colon), Ogilvie syndrome (colon paralysis) and Alzheimer's disease. The 04/04/2026 quarterly Minimum Data Set documented Resident #55 had moderate cognitive impairment, no rejection of care, had bilateral impairment lower extremities, was dependent for activities of daily living, bed mobility and transfers, and was at risk for pressure ulcers.The Physician Order dated 04/16/2026 documented heel booties to be applied to relieve pressure every shift. The Care Plan for potential for skin breakdown last updated 05/09/2026 documented heel booties to be applied to relieve pressure every shift. During an observation on 05/18/2026 at 11:10 AM, Resident #55 was in bed on their back with their bilateral bare feet on the mattress. The were no heel booties in place. During observations on 05/18/2026 at 3:45 PM, 05/19/2026 at 11:58 AM, and 05/20/2026 at 9:39 AM, Resident #55 was resting in their Geri chair with their bilateral, bare heels resting on the Geri chair. There were no heel booties in place. During a brief interview and observation on 05/19/2026 at 11:58 AM, Resident #55's representative stated Resident #55's heels were positioned on the Geri chair, and they did not have heel booties on. During an interview and observation on 05/20/2026 at 10:43 AM, Certified Nurse Aide #14 stated Resident #55 did not have heel booties in place and their bilateral heels were not offloaded. Resident #55's bilateral heels had redness. Certified Nurse Aide #14 stated they were unaware if there was a certified nurse aide task to apply heel booties on the electronic medical record. During an observation and interview on 05/2026 at 10:55 AM, Licensed Practical Nurse Unit Manager #10 stated Resident #55 did not have heel booties in place, bilateral bare heels were not offloaded, and bilateral lateral heel redness was observed. Upon review of the electronic medical record, they stated Resident #55 had an order for heel booties to relieve pressure every shift. They stated Resident #55 wore heel booties at night and should wear them during the day as well. Licensed Practical Nurse Unit Manager #10 stated a task was present for heel bootie application to prevent pressure. Heel booties were in Resident #55's closet.During an interview on 05/26/2026 at 2:00 PM, the Director of Nursing stated physician orders for offloading heels or applying heel booties should be followed by facility staff for all residents. 10 New York Code Rules Regulations 415.12 (c) (2)

Based on observation, record review, and interviews, the facility failed to ensure an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections was implemented for one (1) of five (5) residents (Resident #7) reviewed for infection control. Specifically, enhanced barrier precautions were not implemented as per physician order for Resident #7 when Certified Nurse Aide #19 was observed turning and repositioning, feeding, and changing a soiled gown and Licensed Practical Nurse #16 was observed providing pressure ulcer wound care and repositioning assistance without wearing an isolation gown.The findings include:The Policy and Procedure titled Enhanced Barrier Precautions dated 4/2024, documented enhanced barrier precautions is primarily intended to apply to care that occurs within a resident's room where high-contact resident care activities including but were not limited to dressing, assisting with transfers and mobility, providing hygiene and wound care. Enhanced barrier precautions required wearing disposable gloves and an isolation gown prior to high contact activity. Hand hygiene should be performed before and after each resident contact and after removing Personal Protective Equipment.Resident #7 was admitted to the facility with diagnoses including Parkinson's disease, pressure ulcer of right hip, stage four (4), diabetes mellitus.The 3/14/2026 Annual Minimum Data Set (an assessment tool) documented that Resident #7 had intact cognition, required substantial assistance with eating, personal hygiene, and was dependent on staff assistance for lying to sit on side of bed and sitting to lying. Resident #7 was at risk of developing pressure ulcers and had one (1) full thickness tissue loss with exposed muscle pressure ulcer. The resident received pressure ulcer care.The 4/25/2024 physician order documented enhanced barrier precautions to be maintained every shift. The 4/25/2024 Comprehensive Care Plan for Enhanced Barrier Precautions documented enhanced barrier precautions will be implemented during high-contact resident care activities when caring for residents with wounds. High-contact resident care activities include dressing, bathing or showering, transferring, and providing hygiene. Enhanced barrier precautions require gown and glove use for residents with any wound that requires dressings. Signage will be placed for enhanced barrier precautions on the resident's door.During an observation on 5/19/2026 at 12:51 PM, Enhanced Barrier Precautions signage was observed posted on Resident #7's door and a personal protective equipment cart was observed outside the resident's room. Resident #7 was observed lying in bed. Certified Nurse Aide #19 entered Resident #7's room carrying Resident #7's lunch tray, placed the tray next to Resident #7's bed, and applied gloves. The surveyor observed Certified Nurse Aide #19 assisting Resident #7 to sit on the side of the bed while standing in close contact with Resident #7. While they were assisting, Certified Nurse Aide #19's uniform was observed making contact with Resident #7's bed linen and Resident #7's gown. Certified Nurse Aide #19 then assisted Resident #7 with feeding. Food was observed spilling onto Resident #7's gown. Certified Nurse Aide #19 was observed changing Resident #7's soiled gown during which Resident #7's gown was observed making contact with Certified Nurse Aide #19's uniform. During the same observation, Resident #7's roommate requested assistance. Certified Nurse Aide #19 was observed assisting Resident #7's roommate without changing their gloves. Certified Nurse Aide #19 touched the roommate's belongings, the roommate's right forearm, wheelchair handles, wheelchair arm support, and the privacy curtain. Certified Nurse Aide #19 was observed exiting the room, without performing hand hygiene.During an interview on 5/19/2026 at 1:31 PM, Certified Nurse Aide #19 stated Resident #7 required assistance with personal care, repositioning, and feeding. Certified Nurse Aide #19 stated they had assisted Resident #7 with positioning before lunch, feeding during lunch, and changing the resident's soiled gown afterward. Certified Nurse Aide #19 stated Enhanced Barrier Precautions required staff to wear gloves and gowns while providing personal care to residents. Certified Nurse Aide #19 stated they usually wore both gloves and a gown when assisting residents on Enhanced Barrier Precautions but forgot to put on the isolation gown on that day.During an observation on 5/21/2026 at 11:01 AM, Resident #7 was observed lying in bed with Enhanced Barrier Precautions signage posted on the resident's door and personal protective equipment cart outside the room. The surveyor observed Licensed Practical Nurse #16 apply gloves and enter the room to provide wound care. Licensed Practical Nurse #16 set up wound care supplies and turned Resident #7 from right to left side. During care, the licensed practical nurse's uniform was observed making contact with Resident #7's leg. During wound care, Licensed Practical Nurse #16 went to the bathroom to wash hands and touched the privacy curtain while moving through the room. After completing wound care, Licensed Practical Nurse #16 repositioned Resident #7 in bed and rearranged the disposable under pad, which made contact the licensed practical nurse's uniform. Upon exiting the room, Licensed Practical Nurse #16 stated they forgot Resident #7 was on Enhanced Barrier Precautions. Licensed Practical Nurse #16 stated residents on Enhanced Barrier Precautions requiring high-contact resident care activities such as wound care, required staff to wear both a gown and gloves.During an interview on 5/26/2026 at 10:50 AM, the Staff Educator/ Infection Control Preventionist stated they were responsible for staff education, including infection control education for nurses and certified nurse aides. The Staff Educator/ Infection Control Preventionist stated staff received education regarding infection prevention and control practices, including Enhanced Barrier Precautions, hand hygiene, and appropriate use of personal protective equipment. The Staff Educator/ Infection Control Preventionist stated staff were expected to follow the precaution signage posted outside residents' rooms. 10 New York Code Rules Regulations 415.19(a) (1-3)

Based on observation, record review and interview the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain personal hygiene for one (1) of five (5) residents (Resident #33) reviewed for activities of daily living. Specifically, on multiple occasions from 05/18/2026-05/19/2026 Resident #33 was observed unkempt, unshaven and wearing the same clothing. The findings included:The Policy for activities of daily living dated 07/2019, documented residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene.Resident #33's diagnoses included unspecified folate deficiency anemia, benign prostatic hyperplasia with lower urinary tract symptoms, and cerebral infarction. The Care Plan for activities of daily living dated 04/18/2026 documented provide necessary adaptive equipment/assistive devices to optimize self-sufficiency and provide privacy with individualized, safe parameters.The Care Plan for activities of daily living/rehabilitation dated 04/18/2026 documented extensive assistance.The 04/27/2026 quarterly /five (5) day Minimum Data Set (a resident assessment tool) documented Resident #33 had moderate cognitive impairment, no rejection of cares, required substantial/maximal assistance with showering and hygiene, and was at risk for pressure ulcers. The current Certified Nurse Aide Task instructions documented bathing Monday and Thursday during the 3:00 PM to 11:00 PM shift and provide substantial/maximal assistance x one (1) with personal hygiene: general hygiene/upper and lower body dressing: all shifts daily.The April and May 2026 Certified Nurse Aide Accountability Record documented Resident #33 was showered on 04/23/2026, 05/17/2026 and 05/18/2026/not shaved, and showered and shaved 04/27/206 and 04/30/2026.During observations and interviews on 05/18/2026 at 10:35 AM and 3:51 PM, Resident #33 was in bed wearing a grey pajama shirt and a black hoodie sweater. Resident #33 was unshaven with substantial stubble. Resident #33 stated they were not showered and had not been showered in for a long time. Resident #33 stated a male aide told them they would shave them earlier in the day but did not return. During observations on 05/19/2026 at 11:36 AM and 05/20/2026 at 9:05 AM, Resident #33 was in bed unshaven with substantial stubble, wearing a grey pajama shirt and black hoodie sweater. Resident #33 stated they had not received cares or a shower.During an interview and observation on 05/20/2026 at 9:15 AM, Certified Nurse Aide #13 stated Resident #33 was assisted to the bathroom earlier in shift and was scheduled for showers Tuesdays and Fridays during the 3:00 PM to 11:00 PM shift. They stated Resident #33 should be shaved on shower days and they had not observed that Resident #33 was shaved over the last five (5) days. They stated they were aware Resident #33 needed to be shaved and did not do so due to waiting to see if the 3:00 PM to 11:00 PM shift would complete the task. They stated they change Resident #33's clothing daily and were unaware that Resident #33 had been in same clothing for the last 3 days. Certified Nurse Aide #13 stated they placed a white t-shirt on Resident #33 on 05/19/2026 and maybe Resident #33 changed back into grey pajama shirt independently. Certified Nurse Aide #13 stated Resident #33 was unshaven and should have been shaved. They stated they did not know when Resident #33 was last showered. During an interview on 05/20/2026 at 10:15 AM, Licensed Practical Nurse Unit Manager #10 stated Resident #33 was hesitant for care at times but would eventually comply with encouragement. They stated Resident #33 should have had their clothing changed and a shave over the last three days. They stated they round the unit continuously/supervise staff and should have been more diligent in observing Resident #33. During an interview on 05/20/2026 at 4:35 PM, Certified Nurse Aide #18 stated they worked with Resident #33 on 05/18/2026 and did not shower the resident. They stated they asked Resident #33 two times if they would like a shower and they refused. They stated they should have documented the refusal. They stated they reported the refusal to the unit nurse. They stated the last time they showered and shaved Resident #33 was 04/17/2026. 10 New York Code Rules Regulations 415.12 (a)(3)

Based on observation, record review, and interviews, the facility failed to ensure that needed services, care, and equipment were provided to ensure that a resident with limited range of motion and mobility maintained or improved function based on the resident's clinical condition for one (1) of five (5) residents (Resident #55) reviewed for position and mobility. Specifically, the use of a left-hand palm guard was not implemented as per physician order and the comprehensive care plan for Resident #55.The findings included:A policy for Contracture Prevention and Management last reviewed 01/2024, documented Nursing and Rehabilitation Departments will work in conjunction to apply preventative measures such as range of motion, positioning, and splinting to prevent and manage contractures in the resident population. Resident #55's diagnoses included toxic megacolon (distended colon), Ogilvie syndrome (colon paralysis) and Alzheimer's disease. The 04/04/2026 Quarterly Minimum Data Set (a resident assessment tool) documented Resident #55 had moderate cognitive impairment, no rejection of care, had bilateral impairment to their lower extremities and was dependent for activities of daily living, bed mobility and transfers.The Physician Order dated 04/16/2026 documented left palmer guard splint for up to six (6) hours or as tolerated to decrease risk of contractures.The Activities of Daily Living Function/Rehabilitation care plan, 'updated 05/09/2026 documented interventions including left palm guard splint for up to six (6) hours or as tolerated to decrease risk for contractures. The Care Plan for contracture last updated 05/09/2026 documented interventions including left palmer guard splint for up to six (6) hours or as tolerated to decrease risk of contractures.During observations on 05/18/2026 at 3:45 PM, 05/19/2026 at 11:58 AM, and 05/20/2026 at 9:39 AM, Resident #55 was in their Geri chair in the day room without the left-hand palm guard device in place. Resident #55's left hand was contracted. During a brief interview on 05/19/2026 at 11:58 AM, Resident #55's representative stated they did not recall observing Resident #55 with a left-hand palm guard device in place during visits. During an observation and interview on 05/20/2026 at 10:43 AM, Certified Nurse Aide #14 stated they assist Resident #55 with activity of daily living. They stated Resident #55 did not have a left-hand palm guard to be placed, and Resident #55 did not have contractures. During an observation of Resident #55 with Certified Nurse Aide #14, they stated Resident #55 did not have a left-hand palm guard in place.During an observation and interview on 05/20/2026 at 10:55 AM, Licensed Practical Nurse Unit Manager #10 stated Resident #55 did not have a left-hand palm guard in place. Upon review of the electronic medical record, they stated Resident #55 had a physician order for a left-hand palm guard device to be worn six (6) hours a day. They stated they remembered Resident #55 having a blue palm device in the past. They stated that Resident #55 did not have a refusal of care/device care plan in place. During a review of the Certified Nurse Accountability Task Sheet, Licensed Practical Nurse Unit Manager #10 stated a task for a left-hand palm guard was not present and should have been entered when the physician order was placed. During an observation of Resident #55's room, Licensed Practical Nurse Unit Manager #10 was unable to locate a left-hand palm guard device. During an interview on 05/22/2026 at 10:07 AM, the Director of Rehabilitation stated Resident #55 had a physician order and care plan intervention for a left-hand palm guard splint. They stated they were not aware whether Resident #55 was wearing the device daily for six (6) hours as prescribed and stated that the Rehabilitation Department was not notified that Resident #55 required a replacement device. During an interview on 05/26/2026 at 2:11 PM, the Director of Nursing stated resident contracture prevention devices should be applied daily as per the physician order and resident care plan. They stated replacement devices can be obtained by contacting the Rehabilitation Department. 10 New York Code Rules and Regulations 415.12(e)(2)

Based on record review and interviews, the facility failed to ensure they implemented interventions correctly and consistently including adequate supervision consistent with the Resident's needs, goals, care plan, and physician's orders to prevent accidents for one (1) of five (5) residents (Resident #112) reviewed for accidents. Specifically, there was no documented evidence that every one-hour monitoring when in bed was implemented as per physician order prior to an 8/25/2025 fall, no documented evidence that Resident #112 was always kept in a supervised area when awake as per comprehensive care plan prior to an 8/31/2025 fall, and no documented evidence that Resident #112 was out of bed to their wheelchair on the 11:00 PM to 7:00 AM shift as per comprehensive care plan prior to a 03/27/2026 fall. Additionally, the Director of Nursing did not investigate whether or not interventions were consistently implemented to prevent falls. The findings included: The Policy for Falls-Clinical Protocol dated 7/2019 documented, the physician will help identify individuals with a history of falls and risk factors for falling. The staff and physicians will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions based on assessment of the nature or category of falling, until falling reduces or stops or until the reason is identified for its continuation. The staff and physicians will monitor and document the individual's response to interventions intended to reduce falls or the consequences of falling. Resident #112 had diagnoses that included asthma, heart failure, and non-Alzheimer's dementia.The Physician Order dated 12/27/2024 documented monitor Resident #112 every hour when in bed, which populated to the Medication Administration Record.The 7/06/2025 annual Minimum Data Set (assessment tool) documented Resident #112 was cognitively impaired and had 2 or more falls with no injury since admission or prior assessment. Resident #112 required supervision with rolling in bed, sitting to standing, chair to bed and toilet transfers, and with ambulation 50 feet, and was dependent with locomotion in their wheelchair.The Care Plan for falls updated on 7/21/2025 documented keep Resident #112 in supervised area when awake, close monitoring when asleep.The 8/11/2025 Briggs Fall Risk Evaluation documented total score of 20, High Risk!The 8/25/2025 Incident & Accident Report documented Resident #112 had an unwitnessed fall and was observed by staff lying on the floor mat next to their bed on 8/25/2025 at 10PM. The statement written by Licensed Practical Nurse #3 documented they last provided care to Resident #112 at 8:15 PM. The statement written by Certified Nurse Aide #5 documented they last provided care to Resident #112 at 7:30 PM and did not document the last time they saw Resident #112 prior to the incidentThe August 2025 Medication Administration Record documented by Licensed Practical Nurse #3 indicated Resident #112 was monitored every hour when in bed during the 3:00 PM-11:00 PM shift on 8/25/2025.The 8/25/2025 Briggs Fall Risk Evaluation documented total score of 24, High Risk.The 8/31/2025 Incident/Accident Report documented Resident #112 had an unwitnessed fall and was observed by staff lying on their right side on the floor by their wheelchair in their room on 8/31/2025 at 6AM. Resident #112 stated they fell and hit their head. The statement documented by Registered Nurse #4 documented that Resident #112 was brought in their wheelchair to the nursing station area by Certified Nurse Aide #6, at 5:50 AM, and Resident #112 wheeled themselves back to their room and fell.The Care Plan for falls was updated on documented 1/1/2026, ensure Resident #112 is out of bed to their wheelchair on the 11PM to 7AM shift.The 1/06/2026 quarterly Minimum Data Set documented Resident #112 was cognitively impaired and had 2 or more falls with no injury since admission or prior assessment. Resident #112 required supervision with rolling in bed, sitting to standing, chair to bed and toilet transfers, and with ambulation 50 feet, and was dependent with locomotion in their wheelchair.The 3/13/2026 Briggs Fall Risk Evaluation documented total score of 18, High Risk.The 3/27/2026 Incident/Accident Report documented Resident #112 had an unwitnessed fall and was observed by staff on the floor by their bed on 3/27/2026 at 7:40 AM. There was no documented evidence as to the reason Resident #112 was not out of bed to their wheelchair on the 11PM to 7AM shift and in a supervised area.On 5/21/2026 at 12:58 PM during an interview the Director of Nursing stated that Licensed Practical Nurse #3 signed the Medication Administration Record documenting they monitored Resident #112 every hour, however Licensed Practical Nurse #3 documented in their written statement that they last saw Resident #112 at 8:15 PM which was one hour and 45 minutes prior to Resident #112's fall at 10PM. They stated they had not investigated whether or not the intervention to monitor Resident #112 every hour had been implemented.On 05/21/2026 at 5:45 PM during an interview Licensed Practical Nurse #3 stated they last provided care to Resident #112 on 08/25/2025 at 8:15 PM when they administered their nebulizer treatment per their handwritten statement. They stated they were responsible to monitor Resident #112 every hour per the physician order, but they had to administer medications to other residents down the hall. They stated their handwritten statement was accurate.On 05/21/2026 at 3:51 PM during an interview Registered Nurse #4 stated that Resident #112 was brought to the nurse's station on 08/31/2025 by Certified Nurse Aide #6 to be supervised for safety, however Resident #112 wheeled themself to their room without staff observing them. They stated they were administering medications at that time. They stated they gave clear verbal instructions and a written assignment sheet to the Certified Nurse Aides as to which residents needed to be taken out of bed on their shift and stated that the Certified Nurse Aides were responsible to monitor those residents for safety.On 05/21/2026 at 4:13 PM during interview Certified Nurse Aide #6 stated the nurse, and certified nurse aides should take turns supervising residents for safety.On 05/21/2026 at 4:32 PM during interview the Director of Nursing stated their expectation was that the staff use a team approach to supervise residents. They stated staff should not have left Resident #112 unsupervised. They stated staff was responsible for supervising Resident #112 when they were out of bed. They stated they did not investigate how Resident #112 was able to get to their room unattended, while they should have been supervised by staff.On 05/21/2026 at 5:34 PM during a follow-up interview regarding Resident #112's 8/31/2026 fall, the Director of Nursing stated there were no documented instructions as to how the staff should monitor Resident #112 for supervision / safety.On 05/21/2026 at 5:34 PM during an interview, the Director of Nursing stated Resident #112 should have been assisted out of bed on the 11PM to 7AM shift for supervision on 3/27/2026. They stated they did not know why Resident #112 was in bed at 7:40 AM on 3/27/2026. They stated that on 1/01/2026 the care plan intervention documented to assist Resident #112 out of bed on the 11PM to 7AM shift, however on 3/27/2026 there was no documentation as to the reason why Resident #112 was still in bed after 7AM. The Director of Nursing stated the intervention to assist Resident #112 out of bed for supervision was not populated to the Medication Administration Record and it was not documented in the Resident Nursing Instructions for the Certified Nurse Aides. The Director of Nursing stated they did not investigate the reason that Resident #112 was in bed at 7:40 AM.On 05/22/2026 at 8:32 AM during interview regarding Resident #112's fall on 3/27/2026, Certified Nurse Aide #7 stated they had worked the overnight shift from 3/26/2026 to 3/27/2026. They stated they were aware to get Resident #112 out of bed at around 6:30 AM and bring them to the seating area outside the nursing station for supervision and they were aware they were responsible to supervise Resident #112 while the resident was at the nursing station. They stated they did not remember if they had assisted Resident #112 out of bed on that date and stated they had not been asked to write a statement.On 05/22/2026 at 9AM during an interview with Registered Nurse #8 regarding Resident #112's fall on 3/27/2026, they stated they had worked the overnight shift from 3/26/2026 to 3/27/2026. They stated they were aware that Resident #112 should be assisted to get out of bed at around 6:30 AM on night shift. Registered Nurse #8 stated they would have written a note if Resident #112 had refused to get out of bed on the night shift. They stated they did not know why Resident #112 was in bed after 7AM on 3/27/2026, and they had not been asked to write a statement.On 05/22/2026 at 1:35 PM interview with Licensed Practical Nurse Unit Manager #2 regarding Resident #112's fall on 3/27/2026, they stated Resident #112 was sleeping when they rounded on the unit at 7:15 AM. They stated the 1/01/2026 care plan intervention documented ensure Resident #112 was out of bed to wheelchair on 11PM to 7AM shift. They stated they did not know why the 3/27/2026 Incident / Accident Report did not include documentation regarding Resident #112 being in bed at 7:40 AM.10 New York Code Rules Regulation 415.12(h)(2)

Based on observation, record review and interview the facility did not ensure each resident received necessary respiratory care in accordance with professional standards of practice for one (1) of two (2) residents (Resident # 10) reviewed for respiratory care. Specifically, Resident #10 with a physician order for oxygen administration via nasal cannula at two (2) to three (3) liters per minute as needed was administered continuous oxygen at two (2) and/or four (4) liters per minute. Additionally, there was no documented evidence in the administration record to indicate Resident #10 was receiving oxygen. The findings include: The Policy for oxygen administration revised 1/2026 documented the purpose was to provide guidelines for safe oxygen administration. Preparation includes verifying that there is a physician's order, review physician's order or facility protocol for oxygen administration. Oxygen therapy is administered by way of oxygen mask, nasal cannula, and/or nasal catheter. Before administering oxygen, and while the resident is receiving oxygen therapy, assess for signs and symptoms of cyanosis ( blue tone to the skin and mucous membrane); signs and symptoms of hypoxia ( rapid breathing, rapid pulse rate, restlessness, confusion); signs and symptoms of oxygen toxicity ( tracheal irritation, difficulty breathing, or slow, shallow, rate of breathing). Check the tubing connected to the oxygen cylinder to assure that it is free of kinks, turn on the oxygen, place the appropriate oxygen device on the resident (mask, nasal cannula and/or nasal catheter), adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. After completing the oxygen setup or adjustment, the following information should be recorded in resident's medical record: the rate of oxygen flow, route and rationale, the frequency and duration of the treatment, the reason for prn administration, how the resident tolerated the procedure.Resident #10 was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, dementia, and anxiety disorder.The 1/28/2026 Minimum Data Set Quarterly assessment (an assessment tool) documented Resident #10 had severely impaired cognition and was not administered oxygen.The 4/21/2026 physician order documented Oxygen two (2) to three (3) liters per minute as needed via nasal cannula. The 4/22/2026 'Oxygen Therapy' care plan documented follow medical management regimen, oxygen per physician's order, maintain head of bed at 30-45 degrees or as tolerated by resident.The 4/23/2026 Minimum Data Set Significant change assessment (an assessment tool) documented Resident #10 had severe cognitive impairment and was not administered oxygen.On 05/18/2026 at 10:57 AM, Resident #10 was observed with oxygen being administered via nasal cannula at four (4) liters per minute.On 05/19/2026 at 11:48 AM, Resident #10's portable oxygen tank dial was set at two (2) liters per minuteOn 05/21/2026 at 11:37 AM and at 11:40AM, Resident #10 was observed in their room in their wheelchair with oxygen administered via nasal cannula at two (2) liters per minute. On 05/26/2026 at 8:47AM and 12:11PM, Resident #10 was observed awake, in their wheelchair with oxygen administered via nasal cannula at two (2) liters per minute.There was no documented evidence in the April 2026 and May 2026 Medication Administration Records and Treatment Administration Records to indicate oxygen was being administered.During an interview on 05/26/2026 at 12:18PM, the Nurse Educator/Infection Control Preventionist stated the unit nurses were responsible for checking residents on oxygen to make sure they received the correct oxygen per physician's order. The Nurse Educator/Infection Control Preventionist stated the order for Resident #10 was not acceptable as it was written because the order should be specific to two (2) or three (3) liters, but not two (2) to three (3) liters. The Nurse Educator/Infection Control Preventionist was unable to state how the nurses would determine whether the resident would need two (2) liters of oxygen or three (3) liters of oxygen.During an interview with Licensed Practical Nurse #12 on 05/26/2026 at 1:55 PM, stated administration of oxygen was to be signed and documented in the Medication Administration Record or in the Treatment Administration Record at the end of their shift. Licensed Practical Nurse #12 stated the physician's oxygen order for Resident #10 was not written clearly. The order should have documented to administer either two (2) or three (3) liters of oxygen.During an interview on 05/26/2026 at 4:07 PM, the Medical Director stated they are familiar with Resident #10 and their care. They confirmed that the 4/21/2026 oxygen order documented to administer two (2) to three (3) liters of oxygen as needed which they stated was not clear because the nurses would not know whether to administer two (2) liters or three (3) liters of oxygen. The Medical Director stated the oxygen order should have been written to administer two (2) liters because Resident #10 had Chronic Obstructive Pulmonary Disease. The Medical Director confirmed there was no parameter for the as needed oxygen and stated the order should have a documented parameter to administer oxygen below a specific oxygen saturation level, but there was none. The Medical Director stated that Resident #10 should be on continuous oxygen because Resident #10 was not able to determine if they needed oxygen or not. New York Code Rules Regulations 415.12 (k) (6)

Based on record reviews and interviews during an abbreviated survey (2686442) the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for one (1) out of three (3) residents (Resident #1) reviewed for consultations. Specifically, Resident #1 had a gastroenterology consult on 08/07/2025 and was recommended to start on the Linzess (a medication for chronic constipation). Licensed Practical Nurse #1 received Resident #1 at the facility following the consultation and documented there were no recommendations. There was no documented evidence that Resident #1 was ever ordered the Linzess (a medication for chronic constipation).The findings are:The facility Orders for Consultants policy dated 07/2019 documented the Attending Physician shall ultimately be responsible for accepting and applying consultation recommendations and orders. All residents who have a consultation will have the consultation report reviewed by the nurse manager/supervisor within 24 to 72 hours of receipt of any recommendations. The Attending Physician/Nurse Practitioner will be notified of any recommendations within 24 hours for review and any orders.Resident #1 admitted to the facility 12/10/2024 with diagnoses including but not limited to Dementia, Schizoaffective disorder and Constipation.A Quarterly Minimum Data Set, dated [DATE] documented Resident #1 was cognitively intact. The resident had impairment on both sides to the upper and lower extremities and used a wheelchair for locomotion. The resident was dependent for eating, toileting, bed mobility and transfers. The resident was always incontinent of bladder and bowel. Review of a constipation risk/bowel management care plan last revised 11/15/2025 documented Resident #1 was at risk due to their impaired physical mobility and age related decreased intestinal motility. The resident had a history of stool impaction and takes senna, docusate sodium, lactulose, and MiraLAX, as well as needed orders for milk of magnesia, Dulcolax suppository, and fleet enema, for treatment of constipation. Interventions listed included administer medication as per Physician's order, monitor bowel elimination daily, monitor efficacy of current bowel regimen, optimize fiber and hydration intake and promote mobility within the resident's capabilities.Review of a gastrointestinal consult done 08/07/2025 documented Resident #1 had a sigmoidoscopy on 12/2024 due to their history of chronic constipation and stercoral colitis with rectal impaction. Resident #1 had been on lactulose in conjunction with the Fleets enema and Dulcolax, while the resident does move their bowels and has been quite distended but no pain. Further review of the gastrointestinal consult revealed the resident received a new order to start Linzess (a medication for chronic constipation) 145 mcg/day to see if it Is more helpful. Resident #1 would be returning to the office in a few months to assess efficacy and if not helping can go back to their original regimen with Linzess (a medication for chronic constipation) added.Review of Resident #1's Physician order and medication administration record revealed they were never ordered to start on Linzess (a medication for chronic constipation).Review of Licensed Practical Nurse #1's progress note dated 08/07/2025 at 7:17 PM documented Resident #1 returned to the facility at 5:00 PM from an appointment accompanied by the certified nurse aide. Documented no recommendations received from the Gastroenterologist and next appointment scheduled for 12/13/2025, Tuesday, at 04:00 PM.During an interview on 12/12/2025 at 01:15 PM the Director of Nursing stated they could not locate the gastroenterologist consult in Resident #1's chart and had to call the Physician's order to obtain it. The Director of Nursing stated the consultation is supposed to be filed in the resident's chart after it is reviewed and addressed by nursing and medical.During a telephone interview on 12/16/2025 at 11:36 AM Licensed Practical Nurse #1 stated when the resident returns from the appointment, they then check the consultation documentation and if there are recommendations they are reviewed with the provider. Licensed Practical Nurse #1 stated the recommendations are documented in a nursing progress note and they would also leave a copy of the consultation for the unit manager to review and be aware. Licensed Practical Nurse #1 stated if there are no recommendations or new orders then the consultation sheet is filed in the resident's chart. Licensed Practical Nurse #1 stated they do not recall what they documented regarding Resident #1's consultation appointment and if there are no new orders then they usually file the documents as there is nothing new on them. Licensed Practical Nurse #1 stated they usually receive the consultation document which is one sheet and they do not recall seeing any orders on Resident #1's consultation sheet or they would have picked up the orders. Licensed Practical Nurse #1 stated the orders would be listed on the consultation document, but it could be that the information was not on the consultation document. Licensed Practical Nurse #1 stated they do not recall if they filed the consultation sheet, but they are usually very efficient with this.During a telephone interview on 12/16/2025 at 01:21 PM Nurse Practitioner #2 stated they recall Resident #1, and the resident always had an issue with constipation they do not recall seeing the consultation documentation from the appointment and they review the documentation when the residents return with them. Nurse Practitioner #2 stated if they had seen the consultation documentation then the order would have been put in. During an interview on 12/16/2025 at 1:48 PM the Assistant Director of Nursing stated they were covering the 5th floor as the unit manager around September 2025 until recently. The Assistant Director of Nursing stated when a resident returns to the facility from a consultation appointment the floor nurse will review the recommendations with the Physician, and if the recommendations are approved then the orders are entered into the resident's record. The Assistant Director of Nursing stated they do not recall receiving a consultation document from Resident #1's appointment and if they had left the facility for the day then they should have reviewed the documentation the following day. The Assistant Director of Nursing stated they do not recall if they reviewed the consultation documentation the next day or not, but they would expect the consultation paperwork would return documenting if there were recommendations or not. The Assistant Director of Nursing stated if a resident returned without documentation from a consultation appointment that would have prompted them to call the office regarding the documentation. The Assistant Director of Nursing stated this should also prompt the nurse to follow up regarding the consultation documentation. During an interview on 12/16/2025 at 10:54 AM the Director of Nursing stated the residents are sent out to appointments with an Epic consultation form, medication list and a face sheet. The Director of Nursing stated when the resident returns to the facility the accepting nurse will review the consult and inform medical of any recommendations and then medical will let them know if it is approved or not. The Director of Nursing stated if there are new orders then the nurse will leave the documentation in the Physicians binder on the unit, and the next day the Physician will review the documentation on rounds. The Director of Nursing stated they could not locate the consultation form, and it could be misfiled but it is supposed to be placed in the chart after it is addressed by the nurse and medical.NYCRR 415.12

Based on record review and interviews during an abbreviated survey (2686442) the facility did not ensure the physician reviewed the resident's total program of care, including medications and treatments, at each visit for 1 out of 3 residents (Resident #1) reviewed for consultations. Specifically, Resident #1, who had a known history of chronic constipation, had a gastrointestinal consultation on 08/07/2025 and was ordered to start on the medication Linzess (a medication for chronic constipation). Nurse Practitioner #2 saw Resident #1 on 08/17/2025 and documented they reviewed the consultation services, but there was no documented evidence of the medication being ordered for the resident. The facility also did not have the consultation documentation on the resident's record or available for review.The findings are:The facility Orders for Consultants policy dated 07/2019 documented Attending Physicians shall ultimately be responsible for accepting and applying consultant recommendations and orders. The Attending Physician will consider the appropriateness of the consultant's recommendations relative to the resident's current condition, risk factors, existing medication regimen, etc and as appropriate approve orders based on consultant recommendations. Resident #1 admitted to the facility 12/10/2024 with diagnoses including but not limited to Dementia, Schizoaffective disorder and Constipation.A Quarterly Minimum Data Set, dated [DATE] documented Resident #1 was cognitively intact. The resident had impairment on both sides to the upper and lower extremities and used a wheelchair for locomotion. The resident was dependent for eating, toileting, bed mobility and transfers. The resident was always incontinent of bladder and bowel. Review of a constipation risk/bowel management care plan last revised 11/15/2025 documented Resident #1 was at risk due to their impaired physical mobility and age related decreased intestinal motility. The resident had a history of stool impaction and takes senna, docusate sodium, lactulose, and MiraLAX, as well as needed orders for milk of magnesia, Dulcolax suppository, and fleet enema, for treatment of constipation. Interventions listed included administer medication as per physician's order, monitor bowel elimination daily, monitor efficacy of current bowel regimen, optimize fiber and hydration intake and promote mobility within the resident's capabilities.Review of a gastrointestinal consult done 08/07/2025 documented Resident #1 had a sigmoidoscopy on 12/2024 due to their history of chronic constipation and stercoral colitis with rectal impaction. Resident #1 had been on lactulose in conjunction with the Fleets enema and Dulcolax, while the resident does move their bowels and has been quite distended but no pain. Further review of the gastrointestinal consult revealed the resident received a new order to start Linzess (a medication for chronic constipation) 145 mcg/day, to see if it Is more helpful. Resident #1 would be returning to the office in a few months to assess efficacy and if not helping can go back to their original regimen with Linzess (a medication for chronic constipation) added.Review of Resident #1's Physician orders and medication administration record revealed they were never ordered to start on the medication Linzess (a medication for chronic constipation).The facility did not have the consultation documentation available for review.During an interview on 12/12/2025 at 1:15 PM the Director of Nursing stated they could not locate the gastroenterologist consult in Resident #1's chart and had to call the Physician's order to obtain it. The Director of Nursing stated the consultation is supposed to be filed in the residents' chart after it is reviewed and addressed by nursing and medical.During a telephone interview on 12/16/2025 at 11:36 AM Licensed Practical Nurse #1 stated when the resident returns from the appointment, they then check the consultation documentation and if there are recommendations, then they are reviewed with the provider. Licensed Practical Nurse #1 stated if there are no recommendations or new orders then the consultation sheet is filed in the resident's chart.During a telephone interview on 12/16/2025 at 01:21 PM Nurse Practitioner #2 stated they recall Resident #1 and the resident always had an issue with constipation. Nurse Practitioner #2 stated Resident #1 had a hospitalization and was recommended to follow up with the Gastroenterologist and based on the resident's history and the hospital recommendation they were ordered to follow up. Nurse Practitioner #2 stated that is why Resident #1 went out for the gastrointestinal consultation on 08/07/2025. Nurse Practitioner #2 stated they do not recall any consults recommending Linzess (a medication for chronic constipation) for Resident #1, because with their history they would have definitely followed the recommendation, and it would have been ordered. Nurse Practitioner #2 stated they do not recall seeing the consultation documentation from the appointment and they review the documentation when the residents return with them. Nurse Practitioner #2 stated they sign off on the consultations for the residents and they have a communication book on each unit where the staff will place the consultation documentation for their review, or they will call and review the recommendations with them over the phone. Nurse Practitioner #2 stated if they could not find documentation from a consult in their communication book then they would go back and check the resident's chart to review the consultation. Nurse Practitioner #2 stated they would document about the consultation in their progress note and whenever a resident goes out to a consultation appointment, they write a progress note regarding it. The Surveyor reviewed Nurse Practitioner #2's progress note, dated 08/18/2025 at 02:25 PM, with them which documented Resident #1 was seen on 08/17/2025 and the consultation services were reviewed. Nurse Practitioner #2 stated they do not know, and this could have fallen through the cracks and was a mistake. 10NYCRR 415.15(b)(2)(iii)

Based on observation, interview, and record review conducted during the recertification and abbreviated surveys (NY00329183) from 10/3/2024 to 10/11/2024, the facility did not ensure sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain their highest practicable wellbeing in accordance with the facility assessment. This was evident on 2 (5th Floor and 4th Floor) of 4 resident units. Specifically, 6 of 6 Certified Nursing Assistant personnel files contained no evidence of practical competency in basic nursing skills and activities of daily living, and 4 of 4 licensed nursing personnel files did not contain competency assessments of medication management. The findings are: The Facility assessment dated [DATE] documented every staff member had knowledge competency in abuse, resident rights, identification of condition change. Additional training for all staff included dementia/behavioral management. Nursing has additional training for basic nursing skills, activities of daily living, skin and wound care, and medication management. Competencies were based on current standards of practice, may include return demonstration, observed behavior, and observed ability. Competencies were verified upon orientation, at least annually, and as needed. Please refer to F760 and F761. Upon review of Licensed Practical Nurse #2, Registered Nurse #3, Licensed Practical Nurse #4, and Registered Nurse #6 personnel records, there was no documented evidence medication management and other basic nursing services competencies were performed. Upon review of Certified Nursing Assistant #12, #13, #14, #15, #16, and #17 personnel records, there was no documented evidence competencies related to activities of daily living and basic nursing skills were performed. A sample of the facility Orientation/Annual Inservice information packet provided to new hires and during annual reeducation documented the list of topics staff were to be knowledgeable and proficient. There was no documented evidence medication management, basic nursing skills, activities of daily living, dementia care, or behavioral health and management were part of the orientation or annual inservice package. On 10/11/2024 at 12:40 PM, the Human Resources Director was interviewed and stated the communication between Human Resources and the Nursing department related to disciplinary actions and rule violations has not been ideal. The Human Resources Director became aware of concerns with employee job performance and incidents when the Nursing Department wanted an employee suspended, however, there were other levels of progressive disciplinary action that needed to occur before an employee received a suspension. There were meetings with corporate personnel and the new Director of Nursing was better at communicating with Human Resources. The Human Resources Director stated they were responsible for ensuring new hires provided certain information and were provided with the employee handbook and corporate compliance information. The staff Inservice Educator was removed from that position in 6/2024 and placed back into the position of charge nurse. No one replaced the Inservice Educator for the facility. The Director of Nursing and Human Resources Director attempted to provide staff with their required annual inservice and trainings, but staff reported, if they were not getting paid to complete their inservices, they were not going to complete them. The facility did utilize online web-based trainings; however, the facility was not equipped with computer terminals and/or space for employees to complete inservices while on site at the facility. Behavior management and dementia care were not included in the annual inservices, trainings, and competencies. After 90 days of a new hire working for the facility, a performance evaluation was supposed to be performed by the director of the department. On 10/11/2024 at 1:06 PM, the Assistant Director of Nursing was interviewed and stated they were responsible for the competency evaluations and inservices/trainings for all the units and nursing staff. Certified Nursing Assistant competencies included observing the provision of care, transfers, feeding, and mechanical lift use. Licensed Nurses were observed and evaluated for medication administration, storage of medications, and whether they used the medication carts appropriately. The Assistant Director of Nursing stated they only recall conducting competencies and performance evaluations related to episodic incidents, complaints, and/or concerns. Annual performance evaluations were conducted by the Director of Nursing and the Assistant Director of Nursing stated they were not involved in that process. The Assistant Director of Nursing stated they recall completing approximately 5-10 performance evaluations of new hires within the past 6 months. On 10/10/2024 at 3:42 PM and 10/11/2024 at 01:30 PM, the Director of Nursing was interviewed and stated the system in place to ensure competency evaluations of nursing staff was not the best. Competency evaluations of nursing staff skills and abilities were not consistently being done. Education and inservice was also not consistent with nursing staff. Behavior management and dementia care inservices were initiated for all nursing staff upon incident as of 10/4/2024. The Nursing Administration attempted to ensure competency evaluations were done upon orientation and annually. Nurse managers were responsible for inservicing and educating nursing staff on the units. The Director of Nursing stated inservices, trainings, and competencies were now part of their responsibility since they took on the role in 6/2024. The facility no longer had a Inservice Educator position, and the position was absorbed into the Director of Nursing's responsibilities. On 10/11/2024 at 2:16 PM, the Administrator was interviewed and stated they were unsure whether competencies and performance evaluations were being performed for nursing staff. Competencies and performance evaluations were supposed to be done annually for all employees. The Administrator stated they were responsible for ensuring a system was in place to evaluate the competency and performance of all staff including nursing staff. 10 NYCRR 415.26(c)(1)(iv)

Based on observation, interview, and record review conducted during the recertification and abbreviated (NY00329183) from 10/3/2024 to 10/11/2024, the facility did not ensure a performance review of every nurse aide at least once every 12 months, and regular in-service education based on the outcome of these reviews. This was evident on 1 (5th Floor) of 4 resident units. Specifically, 6 of 6 Certified Nursing Assistant personnel files contained no evidence of performance evaluations and inservice based on the results of performance evaluations. The findings are: The Facility assessment dated [DATE] documented every staff member had knowledge competency in abuse, resident rights, identification of condition change. Additional training for all staff included dementia/behavioral management. Nursing has additional training for basic nursing skills, activities of daily living, skin and wound care, and medication management. Competencies were based on current standards of practice, may include return demonstration, observed behavior, and observed ability. Competencies were verified upon orientation, at least annually, and as needed. The Facility Survey Report dated 10/3/2024 documented each nurse aide was required to receive 6 hours of paid inservice training every 6 months. The list of survey topics since last survey (3/8/2022) documented 9.75 total hours of inservice provided to nurses' aides. Behavioral health care and/or management were not included in the list of inservice topics provided to staff. Upon review of Certified Nursing Assistant #12, #13, #14, #15, #16, and #17 personnel records, there was no documented evidence of annual performance evaluations or of 12-hour annual inservice required to ensure competent skills and abilities. A sample of the facility Orientation/Annual Inservice information packet provided to new hires and during annual reeducation documented the list of topics staff were to be knowledgeable and proficient. There was no documented evidence medication management, basic nursing skills, activities of daily living, dementia care, or behavioral health and management were part of the orientation or annual inservice package. On 10/11/2024 at 12:40 PM, the Human Resources Director was interviewed and stated the communication between Human Resources and the Nursing Department related to disciplinary actions and rule violations had not been ideal. The Human Resources Director became aware of concerns with employee job performance and incidents when the Nursing Department wanted an employee suspended, however, there were other levels of progressive disciplinary action that needed to occur before an employee received a suspension. There were meetings with corporate personnel and the new Director of Nursing was better at communicating with Human Resources. The Human Resources Director stated they were responsible for ensuring new hires provided certain information and were provided with the employee handbook and corporate compliance information. The staff Inservice Educator was removed from that position in 6/2024 and placed back into the position of charge nurse. No one replaced the Inservice Educator for the facility. The Director of Nursing and Human Resources Director attempted to provide staff with their required annual inservice and trainings, but staff reported, if they were not getting paid to complete their inservices, they were not going to complete them. The facility did utilize online web-based trainings; however, the facility was not equipped with computer terminals and/or space for employees to complete inservices while on site at the facility. Behavior management and dementia care were not included in the annual inservices, trainings, and competencies. After 90 days of a new hire working for the facility, a performance evaluation was supposed to be performed by the director of the department. On 10/11/2024 at 1:06 PM, the Assistant Director of Nursing was interviewed and stated they were responsible for the competency evaluations and inservices/trainings for all the units and nursing staff. Certified Nursing Assistant competencies included observing the provision of care, transfers, feeding, and mechanical lift use. Licensed Nurses were observed and evaluated for medication administration, storage of medications, and whether they used the medication carts appropriately. The Assistant Director of Nursing stated they only recalled conducting competencies and performance evaluations related to episodic incidents, complaints, and/or concerns. Annual performance evaluations were conducted by the Director of Nursing and the Assistant Director of Nursing stated they were not involved in that process. The Assistant Director of Nursing stated hey recall completing approximately 5-10 performance evaluations of new hires within the past 6 months. On 10/10/2024 at 3:42 PM and 10/11/2024 at 1:30 PM, the Director of Nursing was interviewed and stated the system in place to ensure competency evaluations of nursing staff was not the best. Competency evaluations of nursing staff skills and abilities were not consistently being done. Education and inservice was also not consistent with nursing staff. Behavior management and dementia care inservices were initiated for all nursing staff upon incident as of 10/4/2024. The Nursing Administration attempted to ensure competency evaluations were done upon orientation and annually. Nurse managers were responsible for inservicing and educating nursing staff on the units. The Director of Nursing stated inservices, trainings, and competencies were now part of their responsibility since they took on the role in 6/2024. The facility no longer had a Inservice Educator position, and the position was absorbed into the Director of Nursing's responsibilities. On 10/11/2024 at 2:16 PM, the Administrator was interviewed and stated they were unsure whether competencies and performance evaluations were being performed for nursing staff. Competencies and performance evaluations were supposed to be done annually for all employees. The Administrator stated they were responsible for ensuring a system was in place to evaluate the competency and performance of all staff including nursing staff. 10 NYCRR 415.26(c)(2)(iii)

Based on observation, record review, and interview conducted during the Recertification and Abbreviated Surveys (NY00329183) from 10/03/24 to 10/11/24, the facility did not ensure residents were free of significant medication errors for 2 (Resident #202 and #96) of 9 residents reviewed for Medication Administration. Specifically, 1) Resident #202 was administered Lasix (diuretic) 20 milligrams and Losartan (antihypertensive) 100 milligrams without a physician's order, which resulted in the need for blood pressure monitoring every 30 minutes and intravenous fluids. 2) Resident #96 was about to receive a 4 milligram dose of Tizanidine (muscle relaxant) instead of the physician ordered 2 milligram dose during a medication observation that was stopped by the surveyor. The findings are: The facility policy titled Administering Medications dated 7/2019 documented individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time, and right method(route) of administration before giving the medication. 1) Resident #202 was admitted with diagnoses including but not limited to chronic lower extremity paralysis, colostomy in left upper quadrant, and multiple sclerosis. The 5-day Minimum Data Set assessment dated [DATE] documented Resident #202 had intact cognition and was not receiving a diuretic. There was no documented evidence in the physician's order for the administration of Lasix or Losartan. The 11/29/23 Medications Care Plan documented to minimize potential complications from prescribed medications and administer medications per physicians' orders. The 11/30/23 Investigative Summary documented on 11/30/23, at approximately 8:30 AM, Resident #202 was given the wrong medication. The medication given was Lasix 20 milligrams and Losartan 100 milligrams. Upon investigation and staff interview, it was determined that the nurse gave the resident their roommate's medication in error. The Nurse Practitioner was notified, assessed the resident, and their blood pressure was stable. Intravenous fluids were started at 75 cubic centimeters per hour for one liter for hypotension, and blood pressure monitoring was ordered to be done every 30 minutes for 24 hours. Upon completion of the investigation and staff interview, the nurse was educated on the policy and procedures of medication administration and disciplinary action was taken. The 11/30/23 at 3:01 PM Nursing Progress note by the Assistant Director of Nursing documented Resident #202 experienced an episode of hypotension, the Nurse Practitioner assessed the resident, and gave new orders to administer normal saline, at 75 cubic centimeters per hour, and to monitor the blood pressure every 30 minutes. The 11/30/23 Physicians orders documented Resident #202 was to have their blood pressure monitored every 30 minutes, receive Sodium Chloride 0.9% injection solution infused at 75 cubic centimeters per hour by intravenous route every hour for 12 hours until 1 liter bag was complete, a Urinalysis and Culture done one time, and insert a urinary catheter for urinary retention. During an interview on 10/08/24 01:00 PM, Licensed Practical Nurse #2 stated that on the day of 11/30/23, they administered the wrong medication to Resident #202. They stated they got distracted and mixed it up with the roommate's medications, and did not remember what was happening at the time. Licensed Practical Nurse #2 stated they did not verify the resident prior to administering their medications and made an error., Licensed Practical Nurse #2 stated that they realized they gave Resident #202 the medication after it was too late. During an interview on 10/10/24 at 11:41 AM, the Medical Director stated Lasix would cause an increased urination, lower potassium, and blood pressure, and Losartan could also lower the blood pressure. The Medical Director stated that orders were given for Resident #202 to have their blood pressure monitored and to receive intravenous fluids due to Losartan having a short half-life which can cause hypotension, and because Lasix can cause dehydration from excessive fluid loss. 2) Resident #103 was admitted with diagnoses including hyperlipidemia, major depressive disorder, pain, and paraplegia. The 7/25/24 Quarterly Minimum Data Set documented Resident #103 had intact cognition. The 1/23/24 Medications Care Plan documented to administer medications per physician orders. The physician order dated 10/7/24 documented to administer Tizanidine 2 milligram tablet of at 9:00 AM and 1:00 PM; administer Tizanidine 4 mg tablet at 5:00 PM. On 10/11/24 at 9:35 AM, during a medication administration observation, Licensed Practical Nurse #2 took a 4 milligram tablet of Tizanidine out of a blister pack and placed it inside the medication cup along with the other medication. Licensed Practical Nurse #2 then proceeded to go in the room to administer Resident #103 their medications. Licensed Practical Nurse #2 was stopped before they were able to administer the Tizanidine 4 milligram tablet. Licensed Practical Nurse #2 stated they overlooked the physician order and were going to give the wrong dose of the medication. Licensed Practical Nurse #2 stated that they should have checked the physician orders prior to administering medications, and they made a mistake. During an interview on 10/11/24 at 1:06 PM, the Assistant Director of Nursing stated they performed medication administration competencies with Licensed Practical Nurse #2 and have had continued conversations with Licensed Practical Nurse #2 due to previous medication errors. 10 NYCRR 415.12(m)(2)

Based on observations, record review, and interviews conducted during the Recertification Survey from 10/03/24 to 10/11/24, the facility did not ensure that all drugs and biologicals were stored in accordance with the manufacturer's specifications and professional standard of practice for 2 (Residents #12 and #96) of 8 residents reviewed for Medication Administration; and Medication and Treatment carts were observed unlocked. Specifically, 1.) Resident #12 was found with physicians ordered ipratropium nasal spray and an albuterol sulfate inhaler in their room on their bedside table. 2.) Resident #96 was found with 2 Trelegy inhalers, a Flonase nasal spray, an ipratropium nasal spray, an albuterol sulfate inhaler, and a triamcinolone acetonide ointment, and 3) the 5th Floor Medication Cart and Treatment Carts were left unlocked and open in the hallway accessible to residents, visitors, and unlicensed staff. The findings are: The facility policy titled Storage of Medications dated 7/2019 documented that the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Resident #12 was admitted with the following diagnoses including but not limited to chronic obstructive pulmonary disease, chronic rhinitis, chronic atrial fibrillation, and functional dyspepsia. The 8/10/24 Quarterly Minimum Data Set documented that Resident #12 had intact cognition, had chronic obstructive pulmonary disease, and received 7 days of respiratory therapy. The 5/20/24 Medications Care plan documented to manage and minimize potential complications from prescribed medications. Interventions included administering medications per physicians' orders. Upon review of Care Plans, there were no documented evidence that there was a care plan for Resident #12 to self-administer their medications. The 4/27/24 Physician order documented that Resident #12 was to receive Ipratropium bromide nasal spray and spray 2 sprays by intranasal route 2 times per day for chronic rhinitis. The 8/14/24 Physician order documented that Resident #12 was to receive Albuterol Sulfate aerosol inhaler-inhale 2 puffs by inhalation route two times per day as needed with instructions to rinse mouth with water and spit after each use. On 10/03/24 at 10:05 AM, Resident #12 was observed in their room and the physician ordered ipratropium nasal spray and an albuterol sulfate inhaler were on their bedside table. Resident #12 stated that they used the albuterol twice a day and took it when they needed it and when they got a heavy feeling in their chest. They stated no one monitored them while they used it. Resident #12 stated that after using the albuterol inhaler, they did not rinse their mouth and spit (as per physician's instructions) and stated that they did not need to do that. 2.) Resident #96 was admitted with chronic obstructive pulmonary disease, chronic atrial fibrillation, chronic rhinitis, and shortness of breath. The 9/7/24 Quarterly Minimum Data Set documented that Resident #96 had intact cognition. Had chronic obstructive pulmonary disease, coronary artery disease, and peripheral vascular disease, and received 7 days of respiratory therapy. The 9/19/24 Physician orders documented to administer: - fluticasone propionate nasal spray in each nostril 2 times per day for allergic rhinitis. - ipratropium bromide nasal spray in each nostril by intranasal route 2 times per day for chronic rhinitis - Trelegy Ellipta for inhalation route once daily at the same time each day for asthma with instructions to rinse mouth with water and spit after use. - albuterol sulfate HFA 90 mcg/actuation aerosol inhaler by inhalation route every 4 hours as needed with instructions to leave the inhaler the room and can self-administer. The only medication with instructions to self-administer was the Albuterol, however review of Resident #96's record revealed no assessment or care plan to self-administer any medications. On 10/03/24 at 10:49 AM, Resident #96 was observed in their room with 2 Trelegy inhalers, a Flonase nasal spray, an ipratropium nasal spray, an albuterol sulfate inhaler, and a triamcinolone acetonide ointment at their bedside. Resident #96 was interviewed during the observation and stated they took the Fluticasone when they felt like they needed it. Resident #96 stated they took Trelegy once a day at any time. They could use ipratropium twice a day if they wanted too and when they felt like it, and the other inhalers they could use when they wanted. Resident #96 stated that they used the inhalers whenever they wanted as they were escape inhalers and they were used when their chest felt tight. On 10/04/24 at 08:39 AM, Resident #96 was observed with a Trelegy Inhaler on the dresser. Resident #96 stated that staff in came in the middle of night and took their escape inhaler and was very upset. Resident #96 began to cough, was breathing heavy and appeared to be having a panic attack and stated they need their escape inhaler. Resident #96 stated they did not understand why it was taken out of their room. The 10/6/24 at 9:51 AM Nursing progress note documented Resident #96 wanted to keep albuterol inhaler at bedside to administer as ordered and refused to return it to the nurse. Resident #96 was able to demonstrate proper usage and education was provided, and as per physician, Resident #96 may self-administer medications. During an interview on 10/10/24 at 12:33 PM, Licensed Practical Nurse #1 stated when a resident can self-administer medications, there usually was a physician's order, and that medication should not be left at the bedside with a physician's order to self-administer medications. During an interview on 10/10/24 at 02:15 PM, the Medical Director stated residents should be evaluated by the team to self-administer medications. The Medical Director stated that nurses were responsible to make sure that residents were taking the medications by themselves, and that they would discuss with nurses if a resident could self-administer and would give a verbal order that residents could self-administer. Nurses were responsible for putting the order into the computer and stated that it was in the regulation for the facility to have physician's order for a resident to self-administer their medications. During an interview on 10/10/24 at 03:40 PM, the Director of Nursing stated medications should not be left at resident's bedside unless they had an order to self-administer their medications. They stated that any resident that that wanted to carry and self-administer their own medications must be evaluated by the interdisciplinary team and must have a physician order to self-administer medications. 40686 3) On 10/03/2024 at 12:00 PM, the 5th Floor Medication Cart in the south hallway (lower room numbers) was observed unattended with staff, residents, and visitors passing by. The Medication Cart was unlocked, and all drawers were able to be opened. Several vials of injectable medication and inhalers were observed in the top drawer of the Medication Cart. The 2nd drawer of the Medication Cart contained resident blister packs of medication and a locked narcotics box. On 10/03/2024 at 12:20 PM, Registered Nurse #6 was approached, interviewed, and stated they were usually the night nurse and worked a double to cove someone that called out. They were responsible for the 5th Floor Medication Cart and was finished administering medications to the lower half of the floor. The Medication Cart should never be left unlocked. Registered Nurse #6 was asked to observe the Medication Cart and stated the cart was unlocked and they must have forgotten to lock the cart after administering morning medications. Registered Nurse #6 stated the Medication and Treatment Carts on the floor contain prescribed medication and should not be left open to residents, visitors, or non-licensed nursing staff. On 10/03/2024 at 12:59 PM, the 5th Floor Treatment Cart in front of room [ROOM NUMBER] was observed unlocked with several drawers containing prescribed topical ointments and creams, scissors, bandages, and other treatment items. There were no staff observed near the unlocked cart and residents, staff, and visitors passed by the cart without any supervision. On 10/04/2024 at 10:59 AM, the 5th Floor Treatment Cart was observed stationed against the wall outside of the Dayroom. No staff were observed using or stationed at the Treatment Cart which was observed unlocked and opened in the hallway accessible to residents, public, and other staff. At 11:02 AM, Licensed Practical Nurse #20 was interviewed and stated all resident treatments were done for the morning shift. No one was using the Treatment Cart, and it should be kept locked. Licensed Practical Nurse #20 observed the unlocked Treatment Cart and stated they did not know why the Treatment Cart was left unlocked, but the Treatment Cart should always be kept locked. 10 NYCRR 415.18(e)(1-4)

Based on observations, record review, and interviews conducted during the Recertification Survey from 10/03/24 to 10/11/24, the facility did not ensure that infection control prevention practices and procedures were maintained by 3 of 4 nurses (Registered Nurse #3 and Licensed Practical Nurse #2 and Licensed Practical Nurse #1) during the medication administration observation. Specifically, 1) Registered Nurse #3 did not practice hand hygiene or sanitize vital signs equipment between residents, and touched a resident's eye lid with the eye dropper during administration. 2) Licensed Practical Nurse #2 did not practice hand hygiene or wipe down the blood pressure cuff prior to doing the resident's blood pressure and before placing it back into the vital signs machine basket. 3) Licensed Practical Nurse #1 was observed preparing Resident #98's medications and their long hair was observed going inside the medication cart, medication cups, and the nebulizer treatment box. Findings include: 1) During a medication administration observation on 10/08/24 at 8:38 AM, Registered Nurse #3 went into the dining room, without sanitizing their hands, to give Resident #80 their medication and take their vital signs. Resident #80 was eating breakfast and Registered Nurse #3 removed the yogurt and attempted to take the resident's blood pressure. Resident #80 was visibly upset, irritated, and yelling they wanted to eat breakfast. Registered Nurse #3 was unable to get the blood pressure, removed the cuff, and did not administer the medications. At 8:42 AM, Registered Nurse #3 went back to the medication cart, without sanitizing their hands or the blood pressure cuff, then proceeded to save Resident #80's medications by putting the 2 cups full of medications on top of each other and placing them in the top of the medication cart. At 8:45 AM, Registered Nurse #3 walked into the Resident #43's room without sanitizing their hands, proceeded to take the resident's temperature and then placed the thermometer on the resident's breakfast tray while they left the room to go get tissue from another resident's room. At 8:51 AM, Registered Nurse #3 was instilling eye drops into Resident #43's eyes. The resident was clinching their eyes shut and Registered Nurse #3 pried the resident's upper eye lid open and touched their eye lid with top of eye drop bottle to instill the eye drops. At 08:56 AM, Registered Nurse #3 left Resident #43's room and placed the thermometer into the vital signs machine basket without sanitizing the thermometer or sanitizing their hands, before proceeding to the next resident. During an interview on 10/09/24 at 3:53 PM, Registered Nurse #3 stated they were supposed to wash and/or sanitize their hands before and after each resident when giving medications and performing vital signs. Registered Nurse #3 stated that when instilling eye drops, the applicator should not touch the resident's eyes and/or eyelids because of infection control and that the proper way to administer eye drops was by instilling the eye drops in the lower lid without touching their eyelids. Registered Nurse #3 stated they should have wiped down the blood pressure cuff between each resident use and the thermometer should have been cleaned and not placed on the breakfast tray. 2) During a medication administration observation on 10/08/24 at 09:03 AM, Licensed Practical Nurse #4 was observed going into Resident #85 room with the vital signs machine and did not sanitize their hands or wipe down the blood pressure cuff prior to entering and exiting Resident #85's room and placed the blood pressure cuff into the vital signs machine basket. During an interview on 10/08/24 at 09:03 AM, Licensed Practical Nurse #4 stated that they are aware of the infection control prevention practices and normally would wipe down the blood pressure cuff and sanitize their hands, and mistakenly forgot to do it. During an interview on 10/11/24 at 01:06 PM, the Assistant Director of Nursing stated that during the medication administration trainings, the nurses were educated on hand hygiene and the importance of sanitizing the vital signs equipment to prevent infections. The Assistant Director of Nursing stated that nurse should not be going from resident to resident administering medications or doing vitals without performing infection control practices. 3) During a medication administration observation on 10/08/24 at 9:18 AM, Licensed Practical Nurse #1 was preparing Resident #98's medications, and their long hair was observed going inside the medication cart, medication cups, and the nebulizer treatment box. When interviewed at that time, Licensed Practical Nurse #1 stated they were aware that their long hair was going into the medication cup (that was filled with medications) and the ipratropium bromide (nebulizer) box. They stated that their hair going into the resident's medication was poor infection control practice. Licensed Practical Nurse #1 stated that they forgot to put their hair up and proceeded to take their hair tie off their wrist and tied their hair up into a bun. 10 NYCRR 415.19

Based on observation, interview, and record review conducted during the recertification survey from 10/3/2024 to 10/11/2024, the facility did not ensure residents were treated with respect and dignity. Specifically, several nursing staff on the Dementia unit were observed without identification badges. The findings are: The facility policy titled Identification Badge dated 1/20/2020 documented all staff were required to wear an identification badge while in the facility. The facility policy titled Quality of Life - Dignity dated 7/2019 documented staff shall keep the resident informed and oriented to their environment. On 10/03/2024 at 12:10 PM, Certified Nursing Assistant #13 was observed walking from the 5th Floor Nursing Station across the resident lounge area and towards the Dayroom. Certified Nursing Assistant #13 was observed without an identification badge and when approached, stated they forgot their badge in their bag. Certified Nursing Assistant #13 turned around towards the Nursing Station and returned wearing an identification badge. Certified Nursing Assistant #15 was observed walking across the resident lounge and towards the Dayroom. After being approached and asked whether they had identification, Certified Nursing Assistant #15 stated they worked for facility and had an identification badge in their bag. Certified Nursing Assistant #15 then asked, Do you want me to go get it? On 10/4/2024 at 2:45 PM, Resident #37's Designated Representative was interviewed and stated staff on the 5th Floor did not consistently wear identification badges which was confusing for the residents because of their cognitive impairments and concerning to the visitors and families in terms of staff accountability and dignity and respect for the residents. On 10/11/2024 at 10:21 AM, Certified Nursing Assistant #16 was observed talking with Certified Nursing Assistant #19 in the 5th Floor Dayroom while 15 residents sat in their wheelchairs either falling asleep or watching television. Neither of the Certified Nursing Assistants interacted with or acknowledged the residents in the Dayroom. Certified Nursing Assistant #16 was approached and observed without an identification badge. Certified Nursing Assistant #16 identified themselves by first name only and stated they were a new employee and was on orientation. On 10/11/2024 at 12:59 PM, the Human Resources Director was interviewed and stated they were on leave from 12/2023 through 3/2024 and the identification badge machine was not functional. An email was sent to all employees to inform them of the various ways they can secure an identification badge and directing them to do so if they did not currently have an identification badge. All new employees were provided with identification badges prior to them working on resident units. On 10/11/2024 at 1:30 PM, the Director of Nursing was interviewed and stated they performed regular rounds of the resident units to observe staff performance. The Director of Nursing stated staff compliance with wearing identification badges was identified as a persistent concern. They stated staff education had not been consistent. On 10/11/2024 at 2:16 PM, the Administrator was interviewed and stated they made regular rounds of the resident units and tried to make sure staff were in compliance with wearing identification badges. 10 NYCRR 415.5(a)

Based on observation, record review, and interviews during the recertification survey conducted from 10/3/24 - 10/10/24, the facility did not ensure residents were informed during their stay of their rights and rules and regulations governing resident conduct and responsibilities. Specifically, the facility did not ensure resident rights were provided or reviewed during monthly Resident Council meetings. Findings include: An undated Policy and Procedure titled Resident Council did not include documentation that a review of residents' rights was conducted at Resident Council meetings. A record review of Resident Council Meeting Minutes dated April 2024 to August 2024 did not include documentation that residents' rights were reviewed. A Resident Council meeting was conducted on 10/4/2024 at 11:00 AM. Eleven members attended, including the President and [NAME] President of Resident Council. Residents stated resident rights were not discussed during resident council meetings. Residents stated they were provided information regarding resident rights upon admission but no further review or notification of updates or changes regarding resident rights concerns had been addressed. During an interview on 10/7/2024 at 1:15 PM the Director of Social Services/Grievance Official stated they were aware of Resident Council meetings and did review minutes of meetings after each meeting with the Director of Activities. They stated resident rights information was provided in admission packets and posted in day rooms on each floor of the facility. They stated that after admission to the facility, resident rights information was available to residents upon request only and they did not provide an annual paper copy to residents. The Director of Social Services also stated resident rights could be discussed with residents in person, at resident council meetings or during care plans meetings, but there was no routine or annual discussion. They stated they were not able to provide documentation that resident rights were reviewed annually with the residents, or that they had been reviewed at the last five Resident Council meetings and/or during care plan meetings. 10 NYCRR 415.3

Based on observations, record review, and interviews conducted during the Recertification Survey from 10/03/24 to 10/11/24, the facility did not ensure the development and implementation of comprehensive person-centered care plans to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being for 1 of 1 resident (Resident #96 ) reviewed for self-administration of medications. Specifically, the facility did not develop a care plan to address Resident #96 carrying and self-administering their albuterol sulfate aerosol inhaler. The findings are: The facility policy titled Care Plans, Comprehensive Person-Centered dated 7/2019 documented the Interdisciplinary Team in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person centered care plan for each resident. The comprehensive, person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Resident #96 was admitted with chronic obstructive pulmonary disease, chronic atrial fibrillation, chronic rhinitis, and shortness of breath. The 9/7/24 Quarterly Minimum Data Set documented Resident #96 had intact cognition and received 7 days of respiratory therapy. The 9/19/24 physicians' orders documented Resident #96 was to receive albuterol sulfate HFA 90 mcg/actuation aerosol inhaler by inhalation route every 4 hours as needed with instructions to leave the inhaler in the room and can self-administer. On 10/03/24 at 10:49 AM, Resident #96 was observed in their room with an albuterol sulfate inhaler and stated they could use the inhaler whenever they wanted, because it was their escape inhaler for the feelings of chest tightness. They stated the inhaler was always at their bedside. There was no documented evidence in the electronic medical record that a Self-Administration of Medication Care Plan was initiated prior to 10/6/24. On 10/10/24 at 03:40 PM, the Director of Nursing stated the registered nurses were responsible for initiating Care Plans and all residents should have care plans to reflect their plan of care. They stated if a resident was assessed to self-administer medications, the care plan should have been initiated immediately after the assessment and approval to self-administer medications. 10 NYCRR 415.11(c)(1)