Every finding on record at Ghent Rehabilitation & Nursing Center

Based on observation, interview, record review, and review of facility policy, the facility failed to employ sufficient, qualified, and competent dietary support personnel to ensure meals were prepared and served on time according to established meal schedules, and to ensure food preparation was performed by qualified staff. Findings include: Review of the facility posted meal times indicate the meals will be served at 7:30 AM, 11:30 AM, and 4:30 PM Observations of Unit 2 for lunch service revealed the following: During an observation on 07/15/2026 at 12:34 PM, staff observed passing trays out to residents in the in-unit dining areas. During an observation on 07/16/2026 at 1:37 PM, staff observed passing lunch meal trays to residents in the in-unit dining areas. During an observation on 07/17/2026 at 12:36 PM, lunch meal trays were not observed on the unit and residents were waiting in the in-unit dining areas. During an observation on 07/20/2026 at 12:46 PM, lunch meal trays were not observed on the unit and residents were waiting in the dining area. The tray cart was observed to be brought to the unit at 1:16 PM. Staff began passing lunch meal trays at 1:18 PM to residents. At 1:20 PM. During an observation on 07/21/2026 at 1:30 PM, lunch trays were being delivered. During observations on 7/15/2026, 7/16/2026 and 7/17/2026 between 4:00pm and 5:00pm Administrator #1 was in the kitchen assisting with Dinner prep and service. During an interview with three out of three anonymous residents on 07/15/2026 at 12:34 PM on unit two, residents stated they were upset about waiting a long time for lunch. They stated that lunch meals are always late and that today's lunch mealtime is early compared to what time they are typically served. During an interview on 07/16/2026 at 9:52 AM, Family Member #1 stated that residents typically wait until 2:00 PM for lunch and 6:00 PM through 7:00 PM for dinner on unit two. During interview with Administrator #1 on 7/16/2026 at 1:30 PM, stated that they have been helping out in the kitchen cooking for dinner service since the last Food Service Director went out on medical leave which had been about 2 weeks. Administrator #1 stated they are in the process of trying to find a permanent solution but are still working on plans at this time. 42 CFR S 483.60(a)(3) Sufficient Support Personnel

Based on observation, record review and interviews during the recertification survey, the facility did not ensure that food was stored, prepared, distributed, or served following professional standards for food service safety in the central kitchen. Specifically, skim milk cartons were found past expiration dates and finished temperature logs were unable to be provided. The Findings include: During inspection in the central kitchen on 7/15/2026 the following items were found to be out of compliance with New York State food safety regulations: At 11:00AM 2 crates of skim chocolate milk with 7/9/2026 expiration date and 1 crate of skim chocolate milk with 7/14/2026 expiration date were identified in the walk in refrigerator At 11:05AM 1 bag of food without label or date and 1 plastic container without label or date. At 11:15AM Temperature logs for food were unable to be provided when requested from dietary staff. At 12:30PM temperature logs were requested from Administrator #1 At 2:30PM temperature logs were provided for 7/13/2026- 7/15/2026. Administrator #1 was unable to locate any previous temperature logs by end of survey During interview, on 7/15/2026 at 11:15AM, Dietary Staff #1 stated they were unaware of the expired milk and proceeded to remove the milk from the walk-in. During interview on 7/16/2026 at 10:00am, Administrator #1 stated hey would reach out to the prior Food Service director and see if they could provide information as to where the temperature logs could be found. 10 New York Codes, Rules, and Regulations 415.14(h)

Based on observation and interviews conducted during the survey, The facility did not maintain all mechanical, electrical, and patient care equipment in a safe operating condition. Specifically, the dishwasher was not functioning as intended. The Findings include: During observations on 7/15/2026 at 11:00 AM the dishwashing machine was identified to be set for high temperature rinse and the final rinse temperature did not exceed 120 degrees Fahrenheit. The dishwashing machine was also leaking from the pressure relief valve during final wash cycles. The sink sanitizer dispenser mixing device on the three bay sink was also identified to be leaking constantly throughout the survey. When these items were brought to the attention of Administrator #1 they instructed Director of Environmental facilities #1 to contact the service company. During an interview on 7/16/2026 at 2:00pm, with Administrator #1, it was stated that they were unaware the systems were not working and will make sure the repair company is there and everything is addressed. New York Codes, Rules, and Regulations Title 10 S415.5(e)(1)(2)

Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for 3 (100 Unit Cart B; 200 Unit Cart A; 300 Unit Cart A) of 3 medication carts, and 1 (100 Unit) of 2 medication rooms reviewed. Specifically, (a.) One expired Lispro insulin pen, two expired bottle of eye drops and 1 expired bottle of fluticasone nasal spray; (b.) 6 inhalers with no open or expiration dates; (c.) 3 Lantus insulin pens with no expiration dates. (d.) The 100 Unit medication room narcotic box on the left, the outside lock was left open. The Findings Include: The facility's Policy and Procedure titled Storage - Labeling Maintenance of Medications revised 11/2025, documented Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. All medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations. Controlled substance medications must be kept in a double locked cabinet attached to a permanently affixed wall. 11. Medications with shortened expiration dates (i.e. Insulin's, injections, ophthalmic drops, etcetera) must be dated when opened. See Recommended Minimum Storage Parameters for specific information. 12. Medication must be checked regularly for expiration dates and deterioration. Expired medications are removed from use and returned to the Pharmacy. 13. Medications no longer in use are returned to the Pharmacy and are destroyed or credited where applicable in accordance with State and Federal regulations. During an observation on 07/15/2026 at 12:45 PM, the 100 Unit Medication Room, left narcotic box outside lock was left open. Licensed Practical Nurse # stated they were going to notify maintenance after lunch that the outside lock was broken. During an observation on 07/22/2026 at 10:16 AM, 300 Unit Cart A contained 1 expired Lispro insulin pen, 1 Basaglar insulin kwik pen with no expiration date; 4 albuterol inhalers and 1 budesonide inhaler with no open or expiration dates. During an interview on 07/22/2026 at 10:30 AM Licensed Practical Nurse # 1 stated they were unaware of shortened expiration dates for any medications. They stated this was not reviewed during orientation. During an observation on 07/22/2026 at 10:40 AM, Unit 200 Cart A contained 3 Lantus Kwik Pens with no open or expiration dates. 1 bottle of Visine eye drops had an expiration date of 3/20/2026; 1 bottle of tobramycin eye drops had no open or expiration date, 1 bottle of fluticasone nasal spray was opened 4/3/2026 expiration date of 7/3/2026, and 1 Symbicort inhaler with no open or expiration date. During an interview on 07/22/2026 at 10:40 AM, Licensed Practical Nurse #4 stated they were unaware that certain medications had shortened expiration dates after opening. During an observation on 07/22/2026 at 11:00 AM, Unit 100 Cart B contained 1 Incuse Ellipta inhaler with no open or expiration date. During an interview on 07/22/2026 at 11:00 AM, Licensed Practical Nurse #5 stated they were unaware that inhales had shortened expiration dates. They also stated they had been working at the facility for several years and oriented new nurses. During an interview on 7/20/2026 at 1:30 PM, Assistant Director of Nursing #1 and Director of Nursing #1 stated new hire nurses attend general orientation then they are paired with a nurse on the floor to complete nurse checklist. The checklist includes a medication administration exam and an observation of medication pass. It is the responsibility of the medication nurse to ensure the medication cart is clean and orderly and medications are dated. 10 New York Codes, Rules, and Regulations 415.18(d)

Based on observation, record review, and interviews conducted during a survey, the facility did not ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature. Specifically, (a) for Resident #31, food was not served at an appetizing temperature during a lunch meal on 07/21/2026 and stated that food was cold; (b) for Residents #37, #50, and #3, food was not served at an appetizing temperature and/or palatable; and (c) six anonymous residents during a resident council meeting on 07/16/2026 stated the food was not that good, often cold, and was undercooked.Findings include: Facility Policy titled, Food and Nutrition Services, last reviewed on 12/01/2026, documented that each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the Food Service Manager/Designee so that a new food tray can be issued. Facility Policy titled, Reheating Foods, revised on 04/2026, documented that employees will reheat food in a manner that complies with safe food handling practices. To take temperatures, a clean, rinsed, sanitized, and air-dried thermometer numerically scaled and accurate to plus or minus two degrees Fahrenheit is needed. A thermometer will be available for use as needed on the unit for reheating of food. Resident #31 Resident #31 was admitted to the facility with the diagnoses of osteoarthritis of the left hip (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), congestive heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), and hypokalemia (deficiency of potassium in the bloodstream). The Minimum Data Set (an assessment tool) dated 06/25/2026, documented the resident understood others, was able to be understood, and was cognitively intact. During an observation on 07/21/2026 at 1:30 PM, Resident #31's lunch meal was delivered and contained the following items with temperatures measured as follows: Apple juice was 66.7 degrees Fahrenheit, whole milk was 61.7 degrees Fahrenheit, blushing pears were 67.4 degrees Fahrenheit, tuna salad sandwich was 65.4 degrees Fahrenheit, and Shepard's pie was 104 degrees Fahrenheit. After tasting the food and drinks, the temperature of the entree was lukewarm to slightly cool and tasted bland; the apple juice, milk, and tuna fish sandwich were room temperature to slightly cool. During an interview on 07/20/2026 at 9:46 AM, Resident #31 stated the beef stew last night was cold. During an interview on 07/21/2026 at 9:19 AM, Resident #31 stated that if the temperatures of the food were very undesirable, they may not eat the food. For example, they received buttered zucchini in the past, and it was cold, so they did not eat it. Resident #37 Resident #37 was admitted to the facility with diagnoses of type two diabetes (a chronic condition that happens when a person has persistently high blood sugar levels), major depressive disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life), and severe protein-calorie malnutrition (a condition caused by inadequate intake or absorption of protein and calories). The Minimum Data Set, dated [DATE], documented the resident understood others, was able to be understood, and was cognitively intact. During an interview on 07/15/2026 at 10:37 AM, Resident #37 stated the food is not appealing, and hot foods are not hot. Resident #50 Resident #50 was admitted to the facility with diagnoses of hypertension (high blood pressure), diabetes mellitus (a chronic condition that happens when a person has persistently high blood sugar levels), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest). The Minimum Data Set, dated [DATE], documented the resident understood others, was able to be understood, and had moderate cognitive impairment. During an interview on 07/15/2026 at 11:34 AM, Resident #50 stated the food is cold and some of the meat is hard. Resident #50 receives ground meat, so it is easier for them to chew per their request. Resident #3 Resident #3 was admitted to the facility with diagnoses of heart failure (a condition in which the heart muscle cannot pump enough blood to meet the body's need for blood and oxygen), type two diabetes (a chronic condition that happens when a person has persistently high blood sugar levels), and protein-calorie malnutrition (a condition caused by inadequate intake or absorption of protein and calories). The Minimum Data Set, dated [DATE], documented the resident understood others, was able to be understood, and was cognitively intact. During an interview on 07/22/2026 at 9:40 AM, Resident #3 stated the food at the facility is always cold. Resident #3 stated they have to ask for a sandwich or for more food at dinner time because they are still hungry after eating the dinner meal. During a surveyor-led resident council meeting on 07/16/2026 at 10:05 AM, six out of six residents stated and agreed that the food was not that good, often cold, and were served undercooked burgers at times. During an interview on 07/21/2026 at 10:19 AM, Certified Nursing Aide #3 stated they would call the kitchen for a new tray if a resident complained about undesirable food temperatures. During an interview on 07/22/2026 at 10:35 AM, Certified Nursing Aide #5 stated the only food complaints they receive from residents are about the food being cold. Certified Nursing Aide #5 stated they would heat the food up in the microwave if a resident had complaints about food being cold. They do not take temperatures of the food after microwaving the meal. Certified Nursing Aide #5 stated it is not often that they have to re-heat a meal in the microwave. They stated that most residents who complain about undesirable food temperatures will still eat the cold food and do not ask for it to be re-heated. During an interview on 07/21/2026 at 10:50 AM, Clinical Nutrition Director #1 stated residents had complaints about food being lukewarm. Clinical Nutrition Director #1 stated that ideally, if food was being re-heated, Certified Nursing Aides should take temperatures of the food. They stated if residents are not happy with meal temperatures, staff will provide residents with a new tray. 10 New York Code of Rules and Regulations 415.14(d)(1)(2)

Based on observation, record review, and interviews conducted during a survey, the facility did not ensure that meals were provided at regular times in accordance with resident needs, preferences, requests, and plan of care. Specifically, (a) lunch service was observed to be later than the scheduled mealtime on unit two on 07/15/2026, 07/16/2026, 07/17/2026, 07/20/2026, and 07/21/2026 and (b) six anonymous residents during a resident council meeting on 07/16/2026, stated concerns about the lateness of meals. Findings include: Facility Policy titled, Food and Nutrition Services, last reviewed on 12/01/2026, documented that each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. The policy documented that meals are scheduled at regular times to assure that each resident receives at least three meals per day. Mealtimes are posted in facility common areas. Three documents titled, Food Committee Meeting and Food Committee Minutes, dated 04/15/2026, 05/27/2026, and 06/22/2026 were reviewed. The document dated 04/15/2026, documented that starting on 04/20/2026, new mealtimes will be in effect at 7:30 AM, 11:30 AM, and 5:30 PM. The document included that residents stated acceptance and agreement with the new schedule with no concerns voiced. The document dated 05/27/2026, documented that residents reported that some meals are not being served timely and mostly occur on the weekends. Staff adjusting to new mealtimes and re-education to be provided. The document dated 06/22/2026, documented that a resident stated lunch arrived on unit two on Sunday at approximately 1:30 PM. An idea was provided by a staff member to switch up scheduling, so whomever is serving lunch is not the cook for dinner to free up time for quicker meal distribution. Document titled, Main Dining Room Nurse, dated 04/27/26 through 05/01/2026 located in the main dining room, documented to arrive by 7:25 AM, 11:25 AM, and 5:15 PM. The document included sections for breakfast, lunch, and dinner with names of staff members for the specific mealtime. Undated document titled, [NAME] Rehabilitation and Nursing Mealtimes, documented the facility mealtimes at 7:30 AM, 11:30 AM, and 4:30 PM. During an observation on 07/15/2026 at 12:34 PM on unit two, staff observed passing trays out to residents in the in-unit dining areas. During an observation on 07/16/2026 at 1:07 PM on unit two, the tray carts were not on the unit and residents were waiting in the in-unit dining areas for their lunch meals. At 1:19 PM, lunch meal trays were not observed on unit two and residents continued to wait. At 1:37 PM, staff observed passing lunch meal trays to residents in the in-unit dining areas. During an observation on 07/17/2026 at 12:36 PM on unit two, lunch meal trays were not observed on the unit and residents were waiting in the in-unit dining areas. During an observation on 07/20/2026 at 12:46 PM on unit two, lunch meal trays were not observed on the unit and residents were waiting in the dining area. The tray cart was observed to be brought to the unit at 1:16 PM. Staff began passing lunch meal trays at 1:18 PM to residents. At 1:20 PM, Resident #28 stated the food was cold. During an observation on 07/21/2026 at 1:30 PM, Certified Nursing Aide #4 was observed walking towards Resident #31's room to deliver their lunch meal tray to their room. However, surveyor used that meal tray as a test tray. During an interview on 07/15/2026 at 10:37 AM, Resident #37 stated breakfast is scheduled at 8:30 AM and they sometimes get it around 9:30 AM. Lunch is supposed to be served from 11:30 AM through 12:00 PM and on some days, they are not being served until 1:30 PM. Resident #37 stated that snacks are offered at the facility and they get one each night. During an interview with three out of three anonymous residents on 07/15/2026 at 12:34 PM on unit two, residents stated they were upset about waiting a long time for lunch. They stated that lunch meals are always late and that today's lunch mealtime is early compared to what time they are typically served. During an interview on 07/16/2026 at 9:52 AM, Family Member #1 stated that residents typically wait until 2:00 PM for lunch and 6:00 PM through 7:00 PM for dinner on unit two. Family Member #1 stated that staff will take residents to the in-unit dining areas on unit two and residents will be sitting there for one and a half hours waiting for their meals. During a surveyor-led resident council meeting on 07/16/2026 at 10:05 AM, six out of six residents stated and agreed that meals are served late, specifically breakfast and lunch. They stated meals should be served at 7:30 AM, 11:30 AM, and 5:30 PM. They receive breakfast at 8:30 AM and lunch at 12:30 through 1:30 PM. The residents stated that meals are one hour late or sometimes more. During an interview on 07/20/2026 at 9:46 AM, Resident #31 stated that lunch was served from 12:15 PM to 12:30 PM on 07/19/2026. During an interview on 07/20/2026 at 1:25 PM, Resident #18 stated there was a movie activity today at 1:30 PM that they will miss because they did not receive their lunch meal tray yet at the time of interview. During an interview on 07/21/2026 at 9:19 AM, Resident #31 stated that lunch was late on 07/20/2026 and was not served until after 1:30 PM. They stated that mealtimes are not consistent. During an interview on 07/20/2026 at 12:58 PM, Certified Nursing Aide #2 stated that lunch should have been delivered to unit two earlier today. They stated the scheduled mealtimes are as follows: breakfast at 8:00 AM, lunch can be harder to determine what time staff will come with the trays, but should be 11:30 AM, and dinner at 5:30 PM. During an interview on 07/21/2026 at 10:19 AM, Certified Nursing Aide #3 stated the scheduled mealtimes are as follows: breakfast around 8:00 AM to 8:30 AM, lunch at 11:30 AM, and dinner at 5:00 PM to 5:30 PM. They stated that the times meals come to unit two sometimes vary between 30 minutes. Certified Nursing Aide #3 stated there was a recent change in mealtimes around March or May 2026. During an interview on 07/22/2026 at 10:35 AM, Certified Nursing Aide #5 stated mealtimes vary every day on unit two because of the lack of staff in the kitchen. They stated that breakfast is typically served at 8:30 AM and the latest lunch is served is 12:30 PM. Certified Nursing Aide #5 stated there have been times when breakfast and lunch were served later than the stated times, but that does not happen often. During an interview on 07/21/2026 at 10:50 AM, Clinical Nutrition Director #1 stated the scheduled mealtimes are as follows: breakfast at 7:30 AM, lunch at 11:30 AM, and dinner at 5:30 PM. They stated there was a recent change in mealtimes because they realized they were out of compliance with hours between the evening meal and the breakfast meal. They stated meals typically come to the unit as follows: morning usually arrives at 7:30 AM, lunch has been late and tray carts are coming to the last unit, unit two, around 1:30 PM, and dinner is on the unit at 5:30 PM with the latest being around 6:15 PM on unit two. Clinical Nutrition Director #1 stated they received complaints about the timing of meals. The residents voted on wanting mealtimes to be changed and residents agreed to the new mealtimes. Clinical Nutrition Director #1 stated that residents are unhappy that meals are coming later than the newly agreed mealtimes. During an interview on 07/22/2026 at 10:43 AM, Director of Nursing #1 stated that the scheduled mealtimes are as follows: 7:30 AM, 11:30 AM, and 16:30 PM. They stated that around the last month, there were complaints about the meal timing. During an interview on 07/22/2026 at 10:49 AM, Administrator #1 stated that mealtimes are as follows: 7:30 AM, 11:30 AM, and 4:30 PM. They stated the facility made an adjustment to mealtimes around one month ago. Administrator #1 stated that it is still challenging for staff to adjust to the new mealtimes. They stated that staffing issues caused delays with starting to serve meals in the main dining area. The goal is to open the main dining rooms to fix the complaints about food temperatures once the new kitchen staff are trained. Administrator #1 stated that when the main dining area was open, they never had complaints about food temperatures. 10 New York Code of Rules and Regulations 415.14(f)(1)(2)(3)(4)

Based on observation, record review, and staff interview conducted during the survey, the facility failed to implement and maintain an effective infection prevention and control program, by failing to ensure Contact Precautions were implemented and maintained for one resident (Resident #28) with a draining wound. Specifically, on 07/17/2026 Resident #28 who was on Contact Precautions, was observed seated in a wheelchair at a table in the dining area with another resident while the resident's wound dressing was visibly leaking drainage. Staff were observed in the area, and no redirection or interventions attempted to address the situation. The surveyor informed the Infection Preventionist who spoke with the resident, the resident was cooperative and headed back to their room for a dressing change to be performed. This deficient practice created potential for transmission of infectious organisms to residents, staff, and visitors. Findings include: The Facility's Policy and Procedure titled Isolation- Categories of Transmission Based Precautions last updated 7/2025, documented Contact Precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. The individual on contact precautions will be placed in a private room if possible. If a private room is not available, the Infection Preventionist will assess various risks associated with other resident placement options. When transporting individuals with skin lesions, excretions, secretions, or drainage that is difficult to contain, contact precautions will be taken during resident transport to minimize the risk of transmission. Resident #28 is a [AGE] year-old, admitted to the facility with diagnosis of Schizophrenia (chronic mental health illness), Cerebral Infarct (type of stroke caused by sudden interruption of blood flow), Atrial Fibrillation (a heart rhythm disorder). The Minimum Data Set (an assessment tool) dated 6/26/2026 documented the resident is cognitively intact, makes self-understood and understands others. The Physician's Orders dated 07/02/2026 documented an order for contact precautions every shift for MRSA (Methicillin Resistant Staphylococcus Aureus) (a type of bacteria that causes skin infections and is resistant to many antibiotics) of the bilateral lower extremity. The Comprehensive Care Plan was reviewed and documented the resident was on contact precautions with an initiation date of 7/17/2026. The care plan lacked a focus and intervention. The Infection Care Plan undated documented the resident has an infection of the bilateral lower extremity wounds/cellulitis, interventions included (6/18/2026) administer antibiotics per medical doctor orders, maintain universal precautions with providing resident care. The at Risk For Skin Impairment Care Plan documented maintain contact precautions (07/02/2026). The At Risk for Skin Issues Care Plan dated 6/13/2026 documented bilateral lower extremity cellulitis with antibiotic therapy. During a resident observation on 7/17/2026 Resident #28 was observed to be seated at a table with a peer, the resident's right leg was observed to have drainage leaking from it. Staff were observed in the area and no attempts were made to redirect the resident back to their room. The Infection Preventionist was notified by the surveyor, observed the resident and stated they should not be out of their room because the drainage is leaking from the bandage. The resident was easily redirected back to their room. During interview 07/20/2026 12:18 PM Infection Preventionist nurse they stated residents on contact precautions can come out of their room if the affected area is covered and not draining. They further stated, Resident # 28 wound was draining, therefore they should not have come out of their room and that was the reason for being on contact precautions. The Infection Preventionist stated the resident would refuse to stay in his room. During an interview on 07/21/2026 3:17 PM the Director of Nursing stated when a resident is on contact precautions they can come out of their room if the affected area is covered. If there was no drainage, then the resident can come out of their room. If there is drainage coming out of the dressing the resident would have to stay in their room. 10 New York Codes, Rules, and Regulations 415.19

Based on observation, record review, and interviews conducted during survey, the facility did not ensure each resident was treated with respect, dignity and care in an environment and manner that promotes maintenance or enhancement of their quality of life. Specifically, during dining observations on 07/15/2026 and 07/20/2026, plastic utensils and/or plastic dishware were provided to residents on one of three units during the lunch meal. Findings include: Facility Policy titled, Maintaining Resident Respect and Dignity, revised on 02/27/2025, documented that the mission of the facility is to provide loving care to all residents in a timely manner that bespeaks dignity, respect, compassion, sensitivity, and concern. Areas of focus included: Maximizing the dining experience. The policy documented that a large portion of one's day is spent in dining and interactions during mealtime can be meaningful to individual residents. Best practice for maintaining a dignified dining experience may include promoting resident independence and dignity in dining (such as avoidance of day-to-day use of plastic cutlery and paper/plastic dishware, bibs instead of napkins, dining room conducive to pleasant dining, aides not yelling). During a dining observation during the lunch meal on 07/15/2026 at 1:01 PM, all resident trays on unit two had plastic spoons and/or plastic knives on their lunch trays. The residents were provided metal forks on their lunch tray. During a dining observation during the lunch meal on 07/20/2026 at 01:20 PM, Residents #55, #28, and #16 were observed to have plastic, non-reusable cups with plastic covers on them for their drinks. During an interview on 07/15/2026 at 12:48 PM, Resident #18 stated they receive plastic spoons occasionally. Resident #18 stated that they feel terrible getting plastic utensils and that plastic utensils are hard to eat with. During an interview on 07/21/2026 at 09:19 AM, Resident #31 stated they prefer metal utensils because they are easier to handle and cut food with. They would also prefer reusable cups. During an interview on 07/20/2026 at 12:58 PM, Certified Nurse Aide #2 stated they knew the kitchen was missing mugs and utensils. Certified Nurse Aide #2 stated that they have seen plastic utensils on trays recently. They were unsure of the date or time when plastic utensils were served. Certified Nursing Aide #2 stated that residents may have plastic utensils because of missing utensils. During an interview on 07/21/2026 at 10:19 AM, Certified Nurse Aide #3 stated they would know if a resident was care planned to receive plastic utensils or cups because it would be on their meal ticket and in the Kardex (an electronic system that contains directions for providing resident-specific care). During an interview on 07/21/2026 at 10:50 AM, Clinical Nutrition Director #1 stated that if residents received plastic utensils or dishware that it would be in the residents' care plan. Clinical Nutrition Director #1 stated that the reasons residents may receive plastic utensils are for safety precautions, some residents prefer plastic utensils, or the facility ran out of utensils and dishware. Clinical Nutrition Director #1 stated that the facility ran out of metal spoons last week. They purchased more metal spoons and were no longer using plastic spoons. Clinical Nutrition Director #1 stated that they thought they had enough metal knives. They stated the facility ran out of reusable dishwasher safe cups because of them being thrown out. During last week, the kitchen used plastic cups. The facility placed an order for the dishwasher safe cups at the end of last week. Clinical Nutrition Director #1 stated they did not think plastic utensils and plastic non-reusable cups should be served to residents if it is not ordered or care planned. They stated that plastic utensils could be difficult for residents to use and may cause residents to need more assistance with meals. Clinical Nutrition Director #1 stated that plastic utensils and dishware was a dignity issue and utensils being broken off while eating can also be an issue. During an interview on 07/22/2026 at 10:43 AM, Director of Nursing #1 stated residents would receive plastic utensils or plastic cups for behaviors, droplet precautions, personal preference, and if the dishwasher or sanitizer was not working properly. During an interview on 07/22/2026 at 10:49 AM, Administrator #1 stated residents typically only receive plastic utensils or dishware if they were care planned for them. If plastic utensils or dishware were not care planned, they tried not to give residents plastic. Administrator #1 stated that they are constantly ordering reusable cups and silverware because residents may keep them or they were getting thrown out. If the facility ran out of reusable cups and silverware, the facility would use plastic. Administrator #1 stated that they ran out of reusable cups and metal spoons on 07/13/2026. Administrator #1 stated that they purchased metal spoons, forks, and knives on 07/18/2026; on 07/20/2026, they were told by dietary that they ran out of metal knives. 10 New York Code of Rules and Regulations 415.5(a)

Based on observation, interview, and record review conducted during survey, the facility failed to ensure the resident and/or resident representative were notified of a change for one resident, Resident #111. Specifically, Resident #111 and their resident representative were not notified when one of their pain medications was discontinued, then restarted two days later as needed. The findings include: The facility policy titled Change in Status Notification revised 11/2025, documented the resident's attending physician, or designee and responsible party would be notified by the nurse manager, nursing supervisor/designee when: 1.) there was an incident or accident involving the resident; 2.) there was a sudden or unexpected change or deterioration in the resident's physical, mental, or psychosocial/emotional status; and 3.) any situation which required a change in the resident' s plan of care, medication or treatment regimen. Resident #111 Resident #111 was admitted to the facility with diagnoses of osteonecrosis (the death of bone tissue caused by a loss of blood supply), furuncle of buttock (a painful, pus-filled skin infection that starts deep in a hair follicle on the rear), and congestive heart failure (a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs). The Minimum Data Set (an assessment tool) dated 06/19/2026, documented the resident was cognitively intact, could be understood, and could understand others. During an interview on 07/15/2026 at 12:12 PM, Resident #111 stated they were in a lot of pain. They stated they could not eat when they were in pain at times. They stated their left leg was a bad leg. They further stated they sometimes received Tylenol which did not do anything. During an interview on 07/17/2026 at 12:36 PM, Resident #111 stated they were trying not to think about the pain. Resident #111 stated they could not get any other pills for the pain but did not know why. They stated their left leg had pain because they did not have a hip and they were waiting for surgery. During an interview on 07/21/2026 at 9:44 AM, Resident #111 stated they had a bad night and were in a lot of pain. They stated they received some Tylenol, but they were not aware of any other as-needed pain medications available to them. They stated they were aware that they had received tramadol before but were not sure what it was for. Review of Resident #111's Medication Administration Record for July 2026, documented: A physician order dated 06/05/2026, tramadol tablet 50 milligram, give 1 tablet by mouth 4 times a day for chronic pain to hip. Order was discontinued on 07/14/2026 at 12:16 PM. A physician order dated 07/16/2026, documented tramadol tablet 50 milligrams, give 1 tablet by mouth every 6 hours as needed for moderate to severe pain for 14 days. There was no documented evidence that Resident #111 and/or their resident representative was notified that the resident's scheduled tramadol was discontinued on 07/14/2026 and as-needed tramadol started on 07/16/2026. During an interview on 07/21/2026 at 10:05 AM, Licensed Practical Nurse #1 stated they were not sure why Resident #111's scheduled tramadol was discontinued and a day later they started as needed tramadol. They stated maybe their pain was not as bad as it was. They also stated that when it was scheduled sometimes the resident would not need it. Licensed Practical Nurse #1 stated residents or their representative should be made aware when there were medication changes and provided an explanation as to why the medication was changed. During an interview on 07/21/2026 at 10:39 AM, Registered Nurse #2 stated Resident #111 had pain. They stated the resident had both scheduled pain medications and as-needed pain medications. Registered Nurse #2 stated they were not sure why Resident #111's scheduled tramadol was discontinued. They stated maybe it was discontinued related to the resident's constipation or maybe it was not on her discharge summary when the resident returned from the hospital. Registered Nurse #2 stated normally the resident or family would be notified if there was a change in a resident's pain medication either by nursing or the provider. During an interview on 07/22/2026 at 10:45 AM, Registered Nurse #1 stated they were not sure why Resident #111's tramadol was discontinued. They stated the resident was always in pain. They stated now the resident's tramadol was as needed. Registered Nurse #2 stated if they noticed a resident had a new order, they usually reiterated it to the resident, just in case. During an interview on 07/22/2026 at 12:43 PM, Registered Nurse #2 stated they spoke with the Medical Provider and were informed that Resident #111's scheduled tramadol was discontinued on 07/14/2026 related to the resident having a possible ileus (a medical condition where the intestines stop working correctly, without physical blockage). They stated the resident went to the hospital, came back, and a nurse that knew Resident #111 was previously on Tramadol contacted the Medical Provider on 07/16/2026 and the Medical Provider said the resident should be on as-needed tramadol and put the order in. They stated the Medical Provider talked with the resident about discontinuing the tramadol and said it should be in their note. Registered Nurse #2 stated the resident was now aware the tramadol was available as-needed and had been asking for it. During an interview on 07/22/2026 at 12:36 PM, Director of Nursing #1 stated the Nurse Practitioner discontinued Resident #111's scheduled tramadol on 07/14/2026 and the as needed tramadol was started on 07/16/2026. They stated they thought it was discontinued because the resident had a possible obstruction and was sent to the hospital. They stated Resident #111's son was very involved in their care and knew everything that went on with the resident. They stated Resident #111's son was notified of their change in condition and hospital transfer, but there was no documentation about them being notified of resident's medication change. 10 New York Code Rules and Regulation 415.3(f)(2)(ii)(c)

Based on record review and interviews conducted during a survey, the facility failed to ensure Comprehensive Care Plans were reviewed and revised by the interdisciplinary team after each assessment based on changing goals, preferences, and needs of the resident and in response to current interventions for two (Resident #'s 103 and 110) of 29 reviewed. Specifically, (a.) Resident #103's Comprehensive Care Plan for Falls was not reviewed or revised after they sustained a fall on 05/28/2026; and (b.) Resident #118's Comprehensive Care Plan for Advanced Directives was not revised after their code status changed. The findings include: The facility policy titled Comprehensive Care Planning revised 11/2026, documented the interdisciplinary team would review and revise the care plan quarterly following Minimum Data Set (MDS) completion, with significant change, return following hospital admission, annually, and as needed. Resident #103 Resident #103 was admitted to the facility with diagnosis of unspecified dementia (a decline in mental ability severe enough to interfere with daily life, encompassing core impacts on memory, thinking, and behavior); peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel), and chronic obstructive pulmonary disease (a long-term lung condition that makes airflow hard and breathing difficulty). The Minimum Data Set (an assessment tool) dated 06/23/2026, documented the resident had severe cognitive impairment, was sometimes understood by others, and sometimes understood others. An incident report dated 05/28/2026, documented Resident #103 had an observed fall at the nurse's station. The Comprehensive Care Plan for Falls dated 07/17/2026, documented Resident #103 was at risk for falls related to unsteady gait, impaired judgement, and frequent attempts to self-transfer without assistance. There was no documented evidence that Resident #103's Comprehensive Care Plan for Falls was reviewed or revised after the resident fell on [DATE]. During an interview on 07/21/2026 at 11:26 AM, Director of Nursing #1 stated that Resident #103 had frequent falls and after each fall the care plan was updated. Resident #118 Resident #118 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), acute respiratory failure and acute kidney failure (the sudden loss of kidney function that happens over hours or days, causing dangerous wastes to build up in the blood). The Minimum Data Set, dated [DATE], documented the resident had moderate cognitive impairment, could be understood, could understand others, and had an indwelling catheter. A progress note dated 07/17/2026 at 08:51 PM, documented Resident #118 returned from the hospital. The resident's Medical Orders for Life Sustaining Treatment (MOLST) was updated to reflect a Do Not Necessitate (DNR) order. The Comprehensive Care Plan for Advanced Directives dated 06/11/2026, documented Resident #118 wishes for advanced directives were full code. The documented goal indicated Resident #118's wishes would be honored. Review of Resident #118's Comprehensive Care Plan on 07/22/2026, revealed the resident's advanced directives care plan had not been updated to reflect their change in code status. 10 New York Codes, Rules, and Regulations 415.11(c)(2)(i-iii)

Based on observation, interview, and record review conducted during a survey, the facility failed to ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well being for one (Resident #107) of one resident reviewed. Specifically, Resident #107 was provided with and/or offered minimal activities from 07/01/2026 to 07/22/2026 and they were observed in bed with the door closed, no stimulation with a one-to-one sitter on 07/15/2026, 07/16/2026 and 07/20/2026. Additionally, concerns were identified that there were minimal activities offered to residents that resided on both rehab unit and the memory care unit.The findings include:The facility policy titled Activity Program revised 03/2025, documented activity programs were designed to promote residents' well-being, independence, and quality of life through a comprehensive resident-centered approach. Activities are individualized based on each resident's assessment, preferences, interests, abilities, cultural and religious background, and life experiences, and include both group and one-to-one opportunities available seven days a week, including evenings, weekends, and holidays. Activities are intended to support physical, cognitive, emotional, and social well-being, foster self-esteem, comfort, pleasure, creativity, education, success, and independence, and are not limited to those provided by the activities department. Resident #107 was admitted to the facility with diagnoses of dementia (a group of conditions that cause a progressive decline in cognitive abilities), schizoaffective disorder (mental health condition that combines symptoms of schizophrenia with mood disorders), and depression (a mental health condition characterized by persistent sadness, loss of interest, and other symptoms that significantly impair daily life). The Minimum Data Set (a resident assessment tool) dated 04/23/2026, documented the resident was usually understood by others, usually understood others, and had severe cognitive impairment.Resident #107's Comprehensive Care Plan for Activities, documented the resident was dependent on staff for engagement and benefited from individualized and independent activities tailored to their abilities and preferences. Some interventions included: (1.) activity staff would coordinate with nursing staff during Resident #107's one-to-one sessions to ensure they were engaged and content with their leisure activities; (2.) provide Resident #107 with one-to-one support for socialization and stimulation; (3.) provide the resident with the activities calendar/notify the resident of any changes to the calendar of activities and give them verbal reminders often; (4.) Resident #107 favored activities that did not require intense cognitive effort, they enjoyed engaging in straightforward, organized activities like music program, sensory groups, and physical exercises; and (5.) Resident #107 would be provided with sensory tools like stress balls and soft objects to squeeze and grasp.Review of the July 2026 documentation of activities for Resident #107 revealed the resident only participated in six one-to-one programs and eight self-directed activities out of 22 days.During observations on 07/15/2026, 07/16/2026 and 07/20/2026, Resident #107 was observed in their room with the door closed with one-to-one staff member present. There was no television, radio, or other activity being provided.During observations made from 07/15/2026 to 07/21/2026 of the memory care unit, the activity offered consisted of staff/residents seated in the common resident area watching retro television shows throughout the day.During an interview on 07/16/2026, Family Member #1 stated staff did not really talk with residents. They just plopped them down in front of the television. During an interview on 07/21/2026 at 9:58 AM, Certified Nurse Aide #1 stated activities were rarely offered to residents on the rehab unit. They stated the residents were bored. They stated some of the residents had been there a while and needed long-term care.During an interview on 07/21/2026 at 1:21 PM, Registered Nurse #4 stated there was no designated activity aide for the memory care unit.During an interview on 7/21/2026 at 1:45 PM, Activities Director #1 stated the activities offered on the memory care unit varied from day to day. They had a small department. They stated activities were offered on the units and provided in the activity room, including coloring, cards, and television as a few examples. Group activities were provided on the memory care unit and sometimes unit staff would facilitate the activity, such as balloon volleyball, morning stretch class, and singalong. Activities Director #1 stated they were short staffed with only four staff in total including the weekends. They stated they had two staff per day, with three on Wednesday and had no dedicated activity staff for the memory care unit. Activities Director #1 stated Resident #107 would sometimes attend a group program but liked to move around. They stated the resident received most activity in their room.Activities Director #1 stated when resident #107 attended group activities they were often disruptive. They stated the activities team provided one-to-one activity including sensory room/sensory program for memory care residents who were unable to attend group sessions. 10 New York Codes, Rules, and Regulations 415.5(f)(1)h

Based on observation, interview and record review conducted during the survey, the facility failed to ensure that it provided respiratory care consistent with professional standards of practice for three (Resident #s 1, 71, 116) of four residents reviewed for Respiratory Care, in addition oxygen was not available when ordered for one (Resident # 116) of three residents, and conflicting orders were not reconciled before care was provided for one (Resident # 71) of three residents. Specifically, Resident #116 was ordered by the physician to be administered three liters of oxygen, when the surveyor observed the resident on 07/15/2026 at 12:28 PM to be short of breath and their portable oxygen tank was empty. During an observation on 07/16/2026, Resident #1 was administered oxygen at a liter flow rate greater than the current physician's order. Additionally, on 07/20/2026, Resident # 116 and Resident # 71 were observed to be administered oxygen at a liter flow rate different than the physician order. Resident #71 had three conflicting orders for oxygen administration that had not been clarified. These failures placed residents at risk for inadequate and inappropriate oxygen delivery. The findings include: The policy titled Administration of Oxygen last reviewed 07/24/2025, documented that a registered nurse, licensed nurse or respiratory therapist may start, stop or adjust oxygen order with a medical doctor order. Resident #116: Resident #116 has primary diagnosis Parkinson's Disease (progressive neurological disorder that impairs movement and balance), Vascular Dementia (decline in memory caused by reduced blood flow to the brain), and Pneumonia. The Quarterly Minimum Data Set (a resident assessment tool) dated 05/7/2026 documented the resident with moderate cognitive impairment, makes self-understood and usually understands others. The Pleural Effusion/Viral Pneumonia Comprehensive Care Plan dated 07/16/2026 documented to give medication as ordered. The Oxygen Therapy Comprehensive Care Plan dated 07/20/2026 documented Resident # 116 had two liters of oxygen as needed related to pneumonia. Interventions included monitor for signs and symptoms of respiratory distress and report to medical doctor as needed, oxygen settings; oxygen via nasal cannula at two liters as needed The Physician's Order dated 07/10/2026 documented oxygen at two liters per minute via nasal cannula for shortness of breath as needed. The Medication Administration Record dated July, 2026 documented; monitor oxygen tank level every two hours for oxygen monitoring start date of 07/15/2026 6:00 PM. During an observation on 07/15/2026 at 12:28 PM Resident # 116 was observed sitting upright in a wheelchair in their room. The resident was wearing a nasal cannula attached to a portable oxygen tank on the back of their wheelchair. The resident was visibly short of breath and the oxygen tank was observed to be empty. The surveyor immediately alerted Registered Nurse #2 to the resident's condition and empty oxygen tank. Registered Nurse #2 verified the resident was short of breath and the oxygen tank was empty and stated they would get one. Several minutes later Registered Nurse #3 entered the residents room, confirmed he was short of breath and measured the resident's oxygen saturation was 86. They stated they were not sure if that is normal or not. Registered Nurse #3 then applied oxygen via the concentrator at two liters per minute at 12:40 PM. Registered Nurse #3 stated they would have to check the residents chart and see if that was normal for the resident. The resident's oxygen saturation was rechecked and read 88-89 percent. Registered Nurse #3 then stated they are still unsure if that is normal for the resident. During an observation on 07/20/2026 at 9:55 AM Resident #116 was observed with Registered Nurse #3 in their room, sitting in their wheelchair. The oxygen was applied via nasal cannula running at three liters per minute. Per Registered Nurse #3, they stated the oxygen flow rate was not set properly; it should be set at two liters. The registered nurse adjusted the flow rate to two liters. Resident #71 Resident #71 was admitted to the facility with Acute and Chronic Respiratory Failure with Hypoxia (sudden worsening of chronic respiratory failure that results in inadequate oxygen levels), Acute and Chronic Respiratory Failure with Hypercapnia (sudden worsening of chronic respiratory failure in which the lungs cannot adequately exchange gases resulting in elevated carbon dioxide levels), and Chronic Obstructive Pulmonary Disease (progressive lung disease that limits airflow, making it difficult to breathe). The Minimum Date Set dated 07/17/2026 documented the resident was cognitively intact. The active Physician's Orders were reviewed and revealed three active orders for oxygen. The active Physician's order dated 03/30/2026 documented an order for oxygen at four liters per minute via nasal cannula continuous. The active Physician's order dated 03/30/2026 documented oxygen continuous at three liters per minute via nasal cannula, please document in progress notes if on room air. The active Physician's order dated 03/30/2026 oxygen as needed at three liters per minute via concentrator to keep oxygen saturation above 92% as needed for oxygen use. The Respiratory Risk Comprehensive Care Plan dated 05/28/2023 documented the resident at risk due to chronic obstructive pulmonary disease and chronic respiratory failure diagnosis. The Pulmonary Consult dated 03/17/2026 documented resident continue all medications, stay on oxygen at three liters. On 07/16/2026 at 9:10 AM Resident #71 was observed in the hallway in a wheelchair, the oxygen tank was noted to be empty. Resident #1 Resident #1 had primary diagnosis of Acute Respiratory Failure with Hypoxia (sudden inability of the respiratory system to maintain adequate oxygenation), Acute on Chronic Congestive Heart Failure (sudden worsening of an existing heart failure condition, resulting in the hearts inability to pump blood effectively), Type 2 Diabetes Mellitus (disease in which the body does not produce enough insulin). The Minimum Data Set, dated [DATE] documented the resident had moderate cognitive impairment, able to make self-understood and usually understands others and required oxygen therapy. The Physicians Orders dated 06/22/2026 documented oxygen continuous at two liters per minute via nasal cannula every shift. The Medical Progress Note dated 06/22/2026 documented the resident with a recent hospitalization 06/13-06/18/2026. Review of systems documented; Oxygen flow rate two liters per minute. During an observation on 07/16/2026 8:31 AM Resident #1 was observed sleeping in bed with a nasal cannula in place. Oxygen concentrator was observed to be running at 3.5 liters per minute. During an observation on 07/20/2026 at 9:45 AM Resident #1's oxygen concentrator was observed at 3.5 liters/minute. During an observation on 07/21/2026 at 8:00 AM Resident #1 was observed in bed with her nasal cannula in place and oxygen running from the concentrator. The concentrator was noted to be set at three liters. During an interview on 07/21/2026 at 8:50 AM, Registered Nurse #3 stated they were unsure if they adjusted the resident's oxygen flow rate back to two liters yesterday when it was brought to their attention by the surveyor. They stated the doctors order was for two liters. During an interview on 07/21/2026 at 3:17 PM, Director of Nursing #1 stated the resident oxygen should have been set as the order stated. The floor nurses and unit manager were to have checked it. 10 New York Codes, Rules, and Regulations 415.12(k)(6)

Based on observation, record review and interviews during survey, the facility failed to ensure nursing staff had the specific competencies and skills necessary to care for residents' needs as identified through resident assessments for three (Resident # 29, 35 and 116) of six residents reviewed. Specifically, (a.) when Resident #116 experienced respiratory distress on 07/15/2026, Registered Nurse #2 noted the resident's oxygen saturation was at 86 percent and could not identify if this was a change in the resident's condition. (b.) Licenses Practical Nurse #3 and Registered Nurse #4 were unaware of manufacturer of proper insulin pen administration instructions to prime pen before use to ensure correct dosage. The findings include: Regulation 483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies, and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in plan of care. 483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident are plans ad responding to resident's needs. The facility's Policy and Procedure titled Administration of Medications - General, revised 3/2025 documented: Medications are administered in a safe and timely manner, and as prescribed. Procedure: 2. The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 6. Medications errors are documented, reported, and reviewed by the Quality Assurance Performance Improvement committee to inform process changes and the need for additional staff training. Resident #116 was admitted to the facility with a diagnosis of Parkinson's Disease (progressive neurological disorder that impairs movement and balance), Vascular Dementia (decline in memory caused by reduced blood flow to the brain), and Pneumonia (a lung infection that causes the tiny air sacs to fill with fluid or pus, making it hard to breathe). The Minimum Data Set (an assessment tool) dated 05/07/2026, documented the resident had moderate cognitive impairment and sometimes could be understood, and could understand others. During an observation on 07/15/2026 at 12:28 PM, Resident # 116 was observed sitting upright in a wheelchair in their room. The resident was wearing a nasal cannula attached to a portable oxygen tank on the back of their wheelchair. The resident was visibly short of breath, and the oxygen tank was observed to be empty. The surveyor immediately alerted Registered Nurse #2 to the resident's condition and empty oxygen tank. Registered Nurse #2 verified the resident was short of breath and the oxygen tank was empty and stated they would get another tank. Several minutes later Registered Nurse #3 entered the resident's room, confirmed the resident was short of breath and measured the resident's oxygen saturation at 86 percent. They stated they were not sure if that was within normal limits. At 12:40 PM, Registered Nurse #3 applied oxygen via the concentrator at two liters per minute. Registered Nurse #3 stated they would have to check the resident's chart and see if that was normal for the resident. The resident's oxygen saturation was rechecked and read 88-89 percent. Registered Nurse #3 stated they were still unsure if that was normal for the resident. During an interview with Director of Nursing #1 on 07/21/2026 at 3:17 PM, they stated the resident's oxygen should have been set as the order stated. The floor nurses and unit manager were to have checked it. Resident #29 was admitted to the facility with diagnosis of Cerebral Palsy (a group of lifelong conditions that affect movement, balance, and posture due to damage to the developing brain); Diabetes Type 2 (a chronic medical condition where blood sugar levels are too high because the body cannot make enough insulin or use it properly), and left spastic hemiplegia (a condition causing muscle stiffness (spasticity) and weakness on one side of the body). The Minimum Data Set (an assessment tool) dated 6/13/2026, documented the resident had mild cognately impairment and sometimes could be understood, and could understand others. The Medication Administration Record for Resident #29 documented NovoLog FlexPen Subcutaneous Solution Pen-injector 100 unit/milliliter, Inject 8 unit subcutaneously three times a day. Record review of manufacturer instructions for use of Novolog KwikPen revealed to prime the pen prior to each use by facing needle toward the sky, turning dial to 2 units, flicking the pen to remove air bubbles, depressing plunger so reading returned to zero units, and observing insulin at needle tip. This was to ensure proper dose was administered. During a medication administration observation on 07/20/2026 at 1:01 PM, Licensed Practical Nurse #3 administered Novolog 8 units via pen-injector to resident #29. Licensed Practical Nurse #3 did not prime the pen-injector prior to administration. During an interview on 7/20/2026 at 1:05 PM, Licensed Practical Nurse #3 stated they were unaware that insulin pen-injector or (Kwik-Pen) should be primed prior to administration. They had never primed in the past as no one ever told them they should do so. They stated new hire orientation consisted of general orientation then paired with a nurse preceptor on the floor to complete checklist. It was never mentioned that insulin pen-injectors should be primed. During an interview on 7/20/2026 at 1:10 PM, Registered Nurse #2 stated they were not aware that insulin pen-injectors should be primed prior to administration. During an interview on 7/20/2026 at 1:25 PM, Director of Nursing #1 verbalized steps to administration of insulin via pen-injector. During an interview on 7/20/2026 at 1:30 PM, Assistant Director of Nursing #1 and Director of Nursing #1 stated new hire nurses attend general orientation then they would be paired with a nurse on the floor to complete nurse checklist. The annual competencies consisted of setting up a room with a skills to complete. Administration of insulin was not included in skills competencies. 10 New York Code of Rules and Regulations 415.26(c)(1)(iv)

Based on observations, record review and interviews conducted during a survey, the facility did not ensure a medication error rate of no greater than 5% during a medication administration observation when 25 of 27 opportunities of error were observed (96.3%) for 5 of 5 residents (Resident #29, 35, 04, 106 and 107). Specifically, Licensed Practical Nurse #3 administered an insulin injection to Resident #29 without priming injection prior to administration. Licensed Practical Nurse #2 mixed Potassium Chloride powder in applesauce instead of water as ordered; and of the 27 medication observations, 25 were scheduled at 8:00 AM but given after 10:00 AM. The findings include: The facility's Policy and Procedure titled Administration of Medications - General, revised 03/2025 documented: Medications are administered in a safe and timely manner, and as prescribed. PROCEDURE: 2. The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions. 3. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication administration times are determined by resident need and benefit, not staff convenience. 6. Medications errors are documented, reported, and reviewed by the QAPI committee to inform process changes and the need for additional staff training. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Resident #29 was admitted to the facility with diagnosis of Cerebral Palsy (a group of lifelong conditions that affect movement, balance, and posture due to damage to the developing brain); Diabetes Type 2 (a chronic medical condition where blood sugar levels are too high because the body cannot make enough insulin or use it properly), and left spastic hemiplegia (a condition causing muscle stiffness (spasticity) and weakness on one side of the body). The Minimum Data Set (an assessment tool) dated 06/13/2026, documented the resident had mild cognately impairment and sometimes could be understood, and could understand others. Resident #35 was admitted to the facility with diagnosis of Chronic Obstructive Pulmonary Disease (a long-term lung condition that damages the airways, blocks airflow, and makes it hard to breathe); Unspecified Dementia (a decline in memory, thinking abilities, and behavior that interferes with daily life), and Major Depressive Disorder (disorder defined by persistent sadness, low energy, and loss of interest in activities). The Minimum Data Set (an assessment tool) dated 06/04/2026, documented the resident was cognately impaired and sometimes could be understood, and could understand others. Resident #04 was admitted to the facility with diagnosis of Unspecified Dementia (a decline in memory, thinking abilities, and behavior that interferes with daily life); Atrial Fibrillation (a heart rhythm disorder where the upper chambers of the heart beat irregularly and fast); Unspecified Psychosis (a temporary medical label used when a person shows signs of losing touch with reality, such as hallucinations, delusions, or confused thinking). The Minimum Data Set (an assessment tool) dated 05/07/2026, documented the resident was cognately impaired and sometimes could be understood, and could understand others. Resident #106 was admitted to the facility with diagnosis of Cerebral Vascular Disease (a group of conditions that affect the blood vessels and blood flow in the brain, leading to problems like stroke; Aphasia (a language disorder that affects a person's ability to speak, understand speech, read, and write); and Anxiety Disorder (a mental health condition that causes intense, excessive, and ongoing worry and fear about everyday situations). The Minimum Data Set (an assessment tool) dated 05/15/2026, documented the resident was cognately impaired and sometimes could be understood, and could understand others. Resident #107 was admitted to the facility with diagnosis of Dementia (a decline in memory, thinking abilities, and behavior that interferes with daily life); Major Depressive Disorder; (disorder defined by persistent sadness, low energy, and loss of interest in activities); and Seizures (a sudden, uncontrolled burst of electrical activity in the brain that can change a person's movement, behavior, feelings, or awareness. The Minimum Data Set (an assessment tool) dated 04/23/2026, documented the resident was cognately impaired and sometimes could be understood, and could understand others. During a medication administration observation on 07/20/2026 at 10:30 AM, Licensed Practical Nurse #2 mixed a potassium chloride 20 milliequivalent packet with other crushed medications to administer to resident #35. The Medication Administration Order documented give potassium chloride 20 milliequivalent packet with 2-4 ounces of water. During a medication administration observation on 07/20/2026 at 1:01 PM, Licensed Practical Nurse #3 administered Novolog 8 units via pen-injector to resident #29. Licensed Practical Nurse #3 did not prime the pen-injector prior to administration. The Medication Administration Record for resident #29 documented NovoLog FlexPen Subcutaneous Solution Pen-injector 100 unit/milliliter, Inject 8 unit subcutaneously three times a day. During a medication administration observation on 07/20/2026 between 10:00 AM and 10:30 AM, Licensed Practical Nurse #2 administered the following medications ordered for 8:00AM: Resident #107: Loratadine Tablet 10 milligram; Sertraline HCl Oral Capsule 200 milligram; Sodium Chloride Oral Tablet 1 gram; Vitamin D3 Capsule 1.25 milligram; Ativan Oral Tablet 1 milligram; Resident #106: Eliquis 5 milligrams; Rosuvastatin 5 milligrams; Thiamin 100 milligram; Claritin 10 milligram; and Vitamin d 1000 microgram was omitted. Resident #4: Amlodipine 5 milligram; Eliquis 2.5 milligrams; Iron sulfate 325 milligram; Losartan 25 milligram; Metoprolol 25 milligram; Sertraline 50 milligram; Folic Acid 1 milligram; Memantine 5 milligram; Saccromyce 250 milligram. Resident #35: Baclofen 5 milligram; Citalopram 10 milligram; Potassium Chloride 20 milliequivalent; Budesonide Inhaler 160/4.5 microgram. During a medication administration observation on 07/20/2026 at 10:30 AM, Resident #35 had special instructions to crush medication. However, there were no physician's order to crush medication. During an interview on 07/20/2026 at 10:30 AM, Licensed Practical Nurse #2 stated they were late with 08:00AM medication pass because they were the only nurse for forty residents, and they were in the dining room with residents who required assistance with breakfast. Licensed Practical Nurse #2 also stated originally there were two nurses assigned to the unit. One of the nurses was pulled early on to go to another floor. They stated the 100/dementia unit is often left with only one nurse for forty residents who are diagnosed with dementia and behaviors. Licensed Practical Nurse #2 stated they notified their unit manager that they were late with medications. Licensed Practical Nurse #2 stated they were not aware that they were not to mix Potassium Chloride powder packet with applesauce. Going forward they will follow instructions per Medication Administration Record. During an interview on 07/20/2026 at 10:10 AM, Registered Nurse #4 stated they were unaware that the medication pass was running over two hours late. They acknowledged only one nurse was assigned for forty residents, who they had observed in the dining area assisting with meals earlier. When asked what steps should you take when medications are administered late. Registered Nurse #4 stated they were just back from vacation and getting sorted out. During an interview on 07/20/2026 at 10:40 AM, Director of Nursing #1 acknowledged there was one nurse for forty residents on the dementia unit, and they had pulled one of the nurses originally assigned because another unit had a nurse that was not strong working alone. They stated all of their nurses can ask for help, and they were not aware Licensed Practical Nurse #2 needed help. Director of Nursing #1 stated Registered Nurse #4 is the unit manager who is just back from vacation but normally would assist. During an interview on 07/20/2026 at 10:40 AM, Director of Nursing #1 was unable to locate physician orders to crush medications on resident #35, or any other resident with instructions to crush medications. They stated an order to crush medications should be obtained before entering special instructions to crush medications. During an interview on 07/20/2026 at 10:40 AM, Assistant Director of Nursing #1 stated they determine if a resident should have their medications crushed by reviewing their diet and how the resident best takes their medications. Surveyor prompted Assistant Director of Nursing #1 that an order must be obtained to crush medications. During an interview on 07/20/2026 at 1:05 PM, Licensed Practical Nurse #3 stated they were unaware that insulin pen-injector or (Kwik-Pen) should be primed prior to administration. They had never primed the pen in the past and no one ever told them they should do so. They stated new hire orientation consisted of general orientation then paired with a nurse preceptor on the floor to complete checklist. It was never mentioned that insulin pen-injectors should be primed. During an interview on 07/20/2026 at 1:10 PM, Registered Nurse #2 stated they were not aware that insulin pen-injectors should be primed prior to administration. During an interview on 07/20/2026 at 1:25 PM, Director of Nursing #1 verbalized steps to administration of insulin via pen-injector. When asked how to prime pen and how much insulin to prime with, the Director of Nursing #1 paused for several moments before responding. During an interview on 07/20/2026 at 1:30 PM, Assistant Director of Nursing #1 and Director of Nursing #1 stated new hire nurses attend general orientation then they are paired with a nurse on the floor to complete nursing checklist. The annual competencies consist of setting up a room with a skill(s) to complete. Administration of insulin is not included in skills competencies. 10 New York Codes, Rules, and Regulations 415.12(m)(1)

Based on observation, record review, and interviews conducted during a survey, the facility failed to ensure it developed and prepared menus to meet resident choices including their nutritional, religious, cultural, and ethnic needs for four (Resident #'s 16, 18, 13, and 111) of four residents reviewed. Specifically, residents did not receive food and/or condiments as listed on their meal tickets for two observed meals on 07/15/2026 and 07/21/2026. Findings include: Facility Policy titled, Food and Nutrition Services, reviewed on 12/01/2026, documented that each resident was provided with a nourishing, palatable, well-balanced diet that met their daily nutritional and special dietary needs, taking into consideration the preferences of each resident. The policy documented that the food and nutrition services staff would inspect food trays to ensure that the correct meal was provided to each resident, the food appeared palatable and attractive, and it was served at a safe and appetizing temperature. If an incorrect meal was provided to a resident, or a meal did not appear palatable, nursing staff would report it to the Food Service Manager/Designee so that a new food tray could be issued. Resident #16 Resident #16 was admitted to the facility with diagnoses of dysphagia (difficulty in swallowing), hypertension (high blood pressure), and chronic obstructive pulmonary disease (narrowing of airways in the lungs making it difficult to breathe). The Minimum Data Set (an assessment tool) dated 06/29/2026, documented the resident understood others, was able to be understood, and was cognitively intact. During an observation on 07/15/2026 at 12:40 PM, Resident #16's meal ticket included salt, sugar, pepper, apple juice, iced tea, butterscotch pudding, smothered steak with onions, broccoli, and buttered pasta. Resident #16's meal tray was missing salt, pepper, sugar, and they were served mashed potatoes with gravy instead of the buttered pasta that was listed on their meal ticket. Resident #18 Resident #18 was admitted to the facility with diagnoses of stage three chronic kidney disease (moderate kidney damage, where the kidneys are less able to filter waste and toxins from the blood), severe protein-calorie malnutrition (a condition caused by inadequate intake or absorption of protein and calories), and gastroesophageal reflux disease without esophagitis (chronic condition where stomach acid flows back into the esophagus). The Minimum Data Set, dated [DATE], documented the resident understood others, was able to be understood, and was cognitively intact. During an observation on 07/15/2026 at 12:48 PM, Resident #18's meal ticket included yogurt, Mrs. Dash, iced tea (lemon if available), ice in a glass, diet soda, butterscotch pudding, ground seafood alfredo, ground broccoli, and buttered pasta. Resident #18's meal tray was missing Mrs. Dash. Resident #18 was served pineapples and not butterscotch pudding. Resident #31 Resident #31 was admitted to the facility with the diagnoses of osteoarthritis of the left hip (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), congestive heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), and hypokalemia (deficiency of potassium in the bloodstream). The Minimum Data Set, dated [DATE], documented the resident understood others, was able to be understood, and was cognitively intact. During an observation on 07/21/2026 at 1:30 PM, Resident #31's lunch meal was delivered and contained the following: apple juice, whole milk, blushing, tuna salad, and Shepard's pie. The lunch meal tray was missing the following items that were on the meal ticket: salt, pepper, hot tea, and corn. During an interview on 07/21/2026 at 2:00 PM, Resident #31 stated that they typically did not get salt and pepper on their meal trays even though it was on their meal tickets. During an interview on 07/21/2026 at 1:34 PM, Certified Nursing Aide #4 observed surveyor conducting Resident #31's test tray and reviewed Resident #31's meal ticket. Certified Nursing Aide #4 stated the items that were identified as missing from Resident #31's meal tray should have been provided. Resident #111 Resident #111 was admitted to the facility with diagnoses of moderate protein-calorie malnutrition (a condition caused by inadequate intake or absorption of protein and calories), chronic obstructive pulmonary disease (narrowing of airways in the lungs making it difficult to breathe), and chronic congestive heart failure (condition where the heart muscle is weakened and cannot pump blood effectively). The Minimum Data Set, dated [DATE], documented the resident understood others, was able to be understood, and was cognitively intact. During an observation on 07/15/2026 at 12:51 PM, Resident #111's meal ticket included apple juice, water, butterscotch pudding, smothered steak, broccoli, and buttered pasta. Resident #111 was served mashed potatoes with gravy instead of pasta and applesauce instead of butterscotch pudding. During an interview on 07/21/2026 at 10:50 AM, Clinical Nutrition Director #1 stated they met with residents at admission, care conferences, and quarterly and annual assessments where they updated preferences. They stated they also utilized a nutrition management system where they could customize what residents received. Clinical Nutrition Director #1 stated the nutrition management system was where they updated residents' likes, dislikes, and allergies. 10 New York Codes, Rules, and Regulation 415.14(c)(1-3)

Based on observation, record review, and interviews during the survey, the facility failed to ensure the resident's environment remained free of accident hazards as is possible. This was identified for one (Resident #1) of 20 residents reviewed. Specifically, Resident #1 was injured from their bed's installation hardware (bolt for a bed rail, which is an adjustable metal or rigid plastic bar that attach to the bed) that protruded beyond its frame. On 05/22/2026, Resident #1 sustained a cut to their right lower leg from the hardware on the bed while Registered Nurse #1 assisted the resident into bed. Resident #1 required hospitalization and 16 staples. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy. The findings include: The facility policy and procedure titled, Resident Safety and Accident Prevention, reviewed 01/2026, documented that the facility is committed to providing a safe and supportive environment for all residents by implementing a structured, proactive accident prevention program. It further documented that the facility routinely evaluates all resident-accessible areas for potential hazards and promptly implements corrective actions as necessary to reduce risk. All staff receive training on accident prevention strategies, resident-specific needs, and safe response protocols. The effectiveness of safety interventions is reviewed routinely and as needed following any incident, and adjustments are made accordingly.Resident #1 was admitted to the facility with diagnoses of myotonic muscular dystrophy (a genetic disorder that causes progressive muscle weakness and shrinking); peripheral vascular disease (a slow, progressive circulation disorder characterized by narrowing, blockage, or spasms in blood vessels outside the heart and brain); and Type 2 diabetes mellitus (when the body cannot use insulin correctly and sugar builds up in the blood). The Minimum Data Set (a resident assessment tool) dated 06/03/2026, documented that they could understand and be understood by others, and were cognitively intact. Record review of the facility's Investigative Report dated 06/01/2026 documented the following: On 05/22/2026, Resident #1 was lying in their bed when Registered Nurse #1 entered the room around 7:30 AM with medications and fluids. Upon assisting Resident #1 to a sitting position with their legs at bedside dangling over the edge, Resident #1 bumped their right calf on the side of the bed. Bleeding began to occur. Registered Nurse #1 assessed the wound and applied a dressing to the site. Due to the extent of the bleeding, the on-call medical doctor was notified. Resident #1 was sent to the hospital per the medical doctor's order regarding a laceration to the right posterior calf, where they received 16 staples to the site. Resident #1 also required a brief hospital stay for an unrelated diagnosis of aspiration pneumonia. Maintenance Director #1 was made aware of the incident and evaluated the mechanics and was able to safely remove the bolts. Upon meeting with the Interdisciplinary Team, it was determined that the best course of action would be to remove lower bolts from all facility beds to prevent further injury. Maintenance Director #1 reviewed the stability of the bed without the bolt and confirmed safety. They removed lower bolts from Resident #1's bed and as a precaution from all 119 other beds within the facility to prevent recurrence.The Hospital Discharge summary dated [DATE] documented Resident #1 had a significant history of diabetes and peripheral vascular disease; resident was recently admitted following a right leg laceration sustained at a skilled nursing facility; staples were placed on 05/22/2026 by the emergency department.During an observation and interview on 06/12/2026 beginning at 1:30 PM, Resident #1 stated they had 16 staples in their leg. While a nurse transferred them, their leg was cut on the screw at the end of the bed. The bleeding was profuse, and the nurse called the doctor. They were sent to the hospital. Resident #1 stated they asked the nurse to take it easy, but the nurse was in a rush and abruptly moved them from the top of the bed to the bottom, causing their leg to be ripped by the screw on the bed. Resident #1 stated they did not think it was intentional and wished that Registered Nurse #1 had listened to them. There were bolts noted at the foot of Resident #1's bed. Resident #1 pointed to the bolt/screw and stated the bolt was what cut their leg. The resident was adamant that the bolt/screw was never removed. During an interview on 06/12/2026 at 1:50 PM, Maintenance Director #1 demonstrated on a vacant bed what the screw/bolt looks like when installed and is how it is delivered from the manufacturer. The screw/bolt was identical to what was currently in Resident #1's room. Maintenance Director #1 stated they were under the impression that their assistant had removed the bolts/screw. They stated Maintenance Assistant #1 is on medical leave at this time. During an interview on 06/12/2026 at 2:05 PM, Assistant Director of Nursing #1, Unit Manager #1, and Administrator #1 all stated they thought the bolts were removed. Assistant Director of Nursing #1 stated that Maintenance Assistant #1 brought them a box of screws. Assistant Director of Nursing #1 stated they did not go and check to ensure Resident #1's bed bolts were removed or ensure all of the facility bed bolts were removed as documented in the facility investigation. During an interview on 06/13/2026 at 12:20 PM, Registered Nurse #1 stated they were called to assess Resident #1 due to a change in condition and were attempting to hydrate Resident #1. Resident #1 was lying in bed in a semi upright position. They stated they assisted the resident to the edge of the bed in a seated position. They stated Resident #1 yelled out stop and pulled back; as the resident pulled back, the weight of their body pulled their lower extremities, catching onto the bed where there was a bolt. Registered Nurse #1 stated the dressing on the resident's right lower extremity had significant blood seeping through. They assessed, applied pressure dressing then notified the physician. The resident was sent to the hospital. During an observation on 06/13/2026 at 10:30 AM in facility rooms 210, 223, 224, 225, 227 and 228, there were bolts noted in the foot of the beds.During an interview on 06/13/2026 at 11:30 AM, Director of Maintenance #1 stated they were at the facility until 9:00 PM the previous night (06/12/2026), removing all the bolts from the lower portion of beds. They were unable to finish all of them and returned this morning to complete. They were in the process of finishing and must have missed a few. Maintenance Director #1 stated they had just completed removing all bolts from the lower portion of the beds in the entire facility. During an observation on 06/13/2026 at 11:40 AM, in facility rooms 210, 223, 224, 225, 227 and 228, the bed bolts were noted as removed. 10 New York Codes, Rules, and Regulations 415.12(h)(1)

Based on observation and staff interview during the recertification survey dated 08/28/23 through 09/01/23, the facility did not provide effective housekeeping and maintenance services for three (3) of 3 resident units and the core area. Specifically, on Unit #1, the floor was soiled with dirt in corners and next to walls in the corridors, dining rooms, nurse station, and resident room #s 101, 105, 109, 111, 118, 121, and 122; the windows were soiled with air borne debris and water stains in resident room #s 101, 105, 109, 111, and #122; the corridor wall outside the nurse aide room was soiled with drip marks, the walls were scraped in the room [ROOM NUMBER] restroom, the paint was chipped on the door frame to room [ROOM NUMBER], and wallpaper was peeling in the foyer old tub room; and the laminate on the nurse station enclosure walls was chipped. On Unit #2, the floor was soiled with dirt in corners and next to walls in the corridors, dining rooms, nurse station, and resident room #s 208, 212, 227; the windows soiled with air borne debris and water stains in the dining rooms and resident room #s 208, 212, and #227; drip marks were found on the wall by the 2-A smoke barrier doors; the walls were scraped in the 2-C corridor and in the nurse station area; and the laminate on the nurse station enclosure walls was chipped. On Unit #3, the floor was soiled with dirt in corners and next to walls in the dining rooms, nurse station, and resident room #s 304, 318, 324, 325, and #328; the windows were soiled with air borne debris and water stains in the dining rooms and resident room #s 304, 318, 324, 325, and #328; the paint was chipped on one wall in resident room [ROOM NUMBER]; and the vinyl wall covering was bubbling out in the 3-C shower room. In the Core Area, the floor was soiled with dirt in corners and next to walls in the Physical Therapy Department restroom; a 3-foot section of wallpaper in the dining room was ripped; the floor was soiled with dirt in corners and next to walls in the physical therapy room; the windows surrounding the Middle Courtyard were soiled with air borne debris and water stains; and the corridor wallpaper was peeling outside the physical therapy room. This is evidenced as follows: Unit #1 During observations on 08/28/23 at 11:50 AM, the corridor floors were soiled with dirt in corners and next to walls. During observations on 08/31/23 at 3:49 PM, the floor was soiled with dirt in corners and next to walls in the corridors, dining rooms, nurse station, and resident room #s 101, 105, 109, 111, 118, 121, and and #122. The windowswere soiled with air borne debris and water stains in resident room #s 101, 105, 109, 111, and #122. The corridor wall outside the nurse aide room was soiled with drip marks, the walls were scraped in the room [ROOM NUMBER] restroom, the paint was chipped on the door frame to room [ROOM NUMBER], and wallpaper was peeling in the foyer old tub room. The laminate on the nurse station enclosure walls was chipped. Unit #2 During observations on 08/28/23 at 11:50 AM, the corridor floors were soiled with dirt in corners and next to walls, and drip marks were found on the wall by the 2-A smoke barrier doors. During observations on 08/31/23 at 3:49 PM, the floor was soiled with dirt in corners and next to walls in the corridors, dining rooms, nurse station, and resident room #s 208, 212, and #227. The windows were soiled with air borne debris and water stains in the dining rooms and resident room #s 208, 212, 227; drip marks were found on the wall by the 2-A smoke barrier doors; and the walls were scraped in the 2-C corridor and in the nurse station area. The laminate on the nurse station enclosure walls was chipped. Unit #3 During observations on 08/31/23 at 3:49 PM, the floor was soiled with dirt in corners and next to walls in dining rooms, nurse station, and resident room #s 304, 318, 324, 325, and #328. The windows soiled with air borne debris and water stains in the dining rooms and resident room #s 304, 318, 324, 325, and #328. The paint was chipped on one wall in resident room [ROOM NUMBER], and the vinyl wall covering was bubbling out in the 3-C shower room. Core Area During observations on 08/28/23 at 11:50 AM, the floor was soiled with dirt in corners and next to walls in the Physical Therapy Department restroom, and a 3-foot section of wallpaper in the dining room was ripped. During observations on 08/31/23 at 3:49 PM, the floor was soiled with dirt in corners and next to walls in the Physical Therapy room. The windows surrounding the Middle Courtyard were soiled with air borne debris and water stains, and the corridor wallpaper was peeling outside the physical therapy room. Record Review The document titled Maintenance of Floors dated 11/01/20, documented that floors are to be kept clean and that environmental rounds will be conducted to ensure cleanliness. This document is silent on requiring or inspecting floors for cleanliness in corners and along walls. Interviews During an interview on 08/28/23 at 12:04 PM, the Director of Environmental Services stated that 3 new housekeepers have been hired, the floor cleaner employee is currently on medical leave, and work on stripping the floor on Unit #1 was started last Saturday (08/26/23). During an interview on 09/01/23 at 2:06 PM, the Administrator stated that the facility is aware of the cleaning items found, but due to a changeover in housekeeping staff, the facility has not been able to keep to the expected high standard. The Administrator stated that the new housekeeping staff are being trained and will be supervised to keep the floors clean, and the Maintenance Department will be power washing the windows this fall. The Administrator stated that staff should have reported the maintenance issues found during survey and will be re-educated to do so. The Administrator stated that the Director of Environmental Services will be directed to repair the doors and walls where in disrepair (scraped walls and doors, peeling wallpaper, laminate bubbling out) and clean the identified areas. 483.10(i)(3); 10 NYCRR 415.5(h)(4)

Based on record review, observation, and interview during the recertification survey conducted 8/28/2023-9/1/2023, the facility did not provide food and drink that were prepared by methods that conserved flavor, and appearance, were palatable and at a safe and appetizing temperature, for 4 of five test trays. Specifically, food and beverages served to the residents on the units were served at suboptimal temperatures, unappetizing in appearance and were not palatable. This was evidenced by: Food Council done separately from Resident Council documented the following concerns: - 5/17/2023 meeting documented the following: All residents attending stated food was not as warm as they would have liked, no cold cereal was provided as stated on meal slips, milk was sour, ice cream sandwiches were soft, toast too hard, too many egg dishes for breakfast, would like more meat, facility out of sugar substitutes that need to be available for therapeutic diets, out of Nepro (liquid supplement) needed for therapeutic diets, desert presentation is poor, an alternative to cart/heating ideas and passing of trays is needed. - 6/20/2023 meeting documented the following: Residents complaining about cold food. Food Service Director (FSD) explained plate warmers needed repairs. A document provided by the facility titled Food and Nutrition Services, undated and unsigned documented the following: - Policy: Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. - Procedure: 1. The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. 2. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. 3. If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the FSM so that a new food tray can be issued. During an observation on 08/31/23 at 12:31 PM on Unit 3, the first food cart arrived and service to residents began immediately. The last tray was served from the cart and the test tray was provided at 12:42 PM. On all observed trays on Unit 3, the beverage, macaroni salad, and apple pie were served in disposable plastic cups. The test tray temperatures were taken, and all items served were tasted. The results were as follows: - Macaroni salad was 53.8 F (degrees Fahrenheit), was cool to touch, and tasted bitter - Apple pie was 69.6 F, was room temperature, was mushy, was sweet and tasty - Milk was 50.5 F, cool - Red beverage was 64.2 F, tepid and unidentifiable - Carrots were 119.3 F, lukewarm and bland - Cheeseburger was 120.2 F, slightly warm, plain (served without condiments) the bottom bun was soggy and inedible. The second cart arrived on the Unit 3 at 12:47 PM, with the last tray served at 1:00 PM when the test tray was taken from the cart. The test tray temperatures were taken, and all items served were tasted. The results were as follows: - Macaroni salad was 54.9 F, cool to touch, and tasted bitter - Apple pie was 71.8 F, room temperature, mushy, and was sweet and tasty - Milk was 54.8 F, cool - Red beverage was 66.2 F, tepid and unidentifiable - Carrots were 119.3 F, lukewarm and tasted bland. - Cheeseburger was 121.1 F, slightly warm, plain (served without condiments), and the bottom bun was soggy and inedible. During an observation on 08/31/23 at 12:31 PM on Unit 1, the food cart arrived. The last tray was served from the cart and the test tray was provided at 12:52 PM. On all observed trays on Unit 3, the beverage, macaroni salad, and apple pie were served in disposable plastic cups. The test tray temperatures were taken, and all items served were tasted. The results were as follows: - Macaroni salad was 65.5 F, cool to touch, dry in appearance and tasted bitter - Apple pie was 69.1 F, cool, mushy, and was flavorful - Soda- 63.9 F lukewarm, diet soda - Red beverage was 66.6 F, lukewarm and unidentifiable - Carrots were 92.03 F, cold and bland - Cheeseburger was 91.2 F, cold, bland and the bun was soggy. During an observation on 08/31/23 at 12:45 PM on Unit 2, the first food cart arrived and service to residents began immediately. A test tray was not provided as requested. On all observed trays on Unit 2, the beverage, macaroni salad, and apple pie were served in disposable plastic cups. The second cart arrived on Unit 2 at 1:01 PM, and the last tray was served at 1:17 PM, A test tray was not provided. The test tray was delivered directly from the kitchen at 1:23 PM. The test tray temperatures were taken, and all items served were tasted. The results were as follows: - Macaroni salad was 64.9 F, cool to touch, and tasted sour. - Apple pie was 72.6 F, room temperature, mushy, was sweet, crust was flaky on top. - Milk was 62.8 F, cool but not cold. - Red beverage was 67.2 F, lukewarm, and unidentifiable (maybe Kool Aid) - Carrots were 110.3 F, overcooked, watery, lukewarm and bland - Cheeseburger was 114.2 F, slightly warm, plain (served without condiments), and the bottom bun was soggy. During an interview on 08/28/23 at 11:21 AM, Resident #36 stated their spouse had to bring in food from outside. The resident stated that the food served here smells and tastes bad. During an interview on 08/28/23 at 12:28 PM, Resident #28 stated the food was not worth the wait and is usually cold. During an interview on 08/28/23 at 12:29 PM, Resident #89 stated the food was not usually identifiable and was always cold. During an interview 08/31/2023 at 01:28 PM. Certified Nursing Assistant (CNA #2) stated the food is always cold and frequently late. Some residents order out and don't eat the food if it looks bad or is cold. If there is enough staff, we can ask for another tray, but they are short staffed in the kitchen and getting a new tray isn't possible most days. During an interview on 8/31/2023 at 1:45 PM, the Licensed Practical Nurse (LPN #1) stated the residents biggest complaint is the food being cold. They have addressed it with the facility management but nothing changes. The residents don't have a choice to either eat it or be hungry. During an interview on 8/31/2023 at 2:58 PM, the FSD, stated menus are adjusted at times because the food delivery arrives, and items are frozen and there isn't enough time for meal prep. Residents' complaints about food are being addressed but with line staff in the kitchen changing all the time, education on how to plate prep has been hard. Residents are complaining about cold food and that is a challenge. During an interview on 08/31/23 at 03:51 PM, the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) stated the residents had been complaining about the quality of the food for a long time. Difficulty with getting line staff to understand how to plate the food had been an ongoing issue. The FSD was recently hired, and education has been ongoing with staff but nothing has resolved the complaints of hot food being served cold and cold foods being served warm. Meals are getting out late and the concerns are ongoing. During an interview on 09/01/23 at 02:47 PM, the facility Administrator stated they were aware of resident complaints regarding the food being cold. They have reviewed the organization of the kitchen, and education on how to get the foods prepped and sent out quicker have been done. Education has been provided but that has not corrected the issue. 10 NYCRR 415.14 (d)(1)(2)

Based on observation and interviews during the recertification survey dated 08/28/23 through 09/01/23, the facility did not ensure food was stored, prepared, distributed or served in accordance with professional standards for food service safety for two (2) of 3 resident unit kitchenettes and the main kitchen. Specifically, in the main kitchen, the microwave oven, can openers and holders, sheet pan racks, plate warmer, shelving, stove drip pans, roll-in refrigerator, fire extinguishers, floor behind cooking equipment, and dishwashing area floor in corners and along the walls were soiled with food particles, food drips, and/or a black build-up; the pantry restroom fixtures were soiled with human residue or soap stains; the pantry restroom floor and walls were soiled with dirt particles along the walls and in corners. In both the Unit #1 kitchenette and Unit #2 kitchenette, the microwave ovens, refrigerators, cabinets, and floors next to walls and in corners were soiled with food particles, food drips, and/or dirt. This is evidenced as follows: During observations on 08/28/23 at 10:58 AM, in the main kitchen, the microwave oven, can openers and holders, sheet pan racks, plate warmer, shelving, stove drip pans, roll-in refrigerator, fire extinguishers, floor behind cooking equipment, and dishwashing area floor in corners and along the walls were soiled with food particles, food drips, and/or a black build-up; the pantry restroom fixtures were soiled with a residue; the pantry restroom floor and walls were soiled with dirt particles along the walls and in corners. In both the Unit #1 kitchenette and Unit #2 kitchenette, the microwave ovens, refrigerators, cabinets, and floors next to walls and in corners were soiled with food particles, food drips, and/or dirt. During an interview on 08/31/23 at 3:08 PM, the Food Service Director stated that it was known that the kitchen needs cleaning, and there has been a lack of follow-up regarding the cleaning items found, but there is a process in place (cleaning schedule) that needs to be better followed. The Food Service Director stated that the maintenance department will be contacted to replace the kitchen door, refrigerator door gasket, and broken coving tiles. During an interview on 08/31/23 at 3:30 PM, the Administrator stated that do to a lack of proper oversight, the housekeepers should have but have not been keeping the kitchenettes including the refrigerators clean and been keeping the pantry restroom clean. The Administrator stated that the housekeepers will be re-educated on these responsibilities, and the soiled items found in the kitchen will be discussed with the Food Service Director. The Administrator stated that the facility, having a lot of new staff in housekeeping, maintenance, and dietary, is in the process of bringing each of these areas to a high standard. 10 NYCRR 415.14(h)

Based on observation, record review, and staff interviews during the recertification survey dated 08/28/23 through 09/01/23, the facility did not ensure foods brought to residents by family and other visitors was in accordance with adopted regulations in one (1) of 2 kitchenettes. Specifically, in the Unit #2 kitchenette refrigerator 3 packages of deli-sliced cold cuts were labeled with a resident's name and dated 7/17, 7/22, and 8/16; one package of deli-sliced cold cuts was labeled with a resident name with a date that was not discernable; restaurant meatballs that were not labeled with the resident name or date; and restaurant pizza that was not labeled with the resident name or date. This is evidenced was evidenced by: During observations on 08/28/23 at 10:58 AM, in the Unit #2 kitchenette refrigerator 3 packages of deli-sliced cold cuts labeled with resident name) and dated 7/17, 7/22, and 8/16; one package of deli-sliced cold cuts was labeled with a resident name with a date that was not discernable; restaurant meatballs that were not labeled with the resident name or date; and restaurant pizza that was not labeled with the resident name or date. The document titled Storage & Labeling of Food Brought in by Family/Visitors dated 09/2019, documented that food brought into the facility by family or visitors is to be labeled (by staff) with the resident name and the date the item(s) was brought into the facility and housekeeping staff will discard the food after 48 hours. During an interview on 08/31/23 at 10:29 AM, the Director of Environmental Services stated that the Dietary Department was responsible for discarding the outdated food brought into the facility for residents and did not realize, when asked, that per facility policy, housekeepers are responsible for discarding outdated food. During an interview on 08/31/23 at 12:56 PM, the Food Service Director stated that nurses are responsible for discarding outdated food that is brought into the facility by family or visitors and that the dietary department is not involved with food brought to residents. During an interview on 08/31/23 at 3:10 PM, the Administrator stated that there had been a lot of staff turnover in housekeeping, and so being, all staff were verbally instructed to throw out outdated food. The Administrator stated that the new housekeeping staff should have been discarding outdated food but are yet not fully aware of this responsibility, but they will now be educated.

Based on record review and interview during an abbreviated survey (Case #NY 095), the facility did not ensure that a resident with a pressure ulcer received the necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #2) of 3 residents reviewed. Specifically, for Resident #2, who was assessed as at risk for pressure ulcer development and had 2 pressure injuries (PIs) on their left foot on admission, the facility did not ensure that it recognized, assessed, and addressed an open area on the right buttock that was observed by the Physical Therapy Assistant (PTA) on [DATE] and reported to a licensed practical nurse (LPN). The facility did not ensure the Physician Assistant (PA) #1 was notified of the open area until [DATE] and did not ensure the assessment of the wound was accurate when the wound was assessed by the PA #1 as community acquired (acquired outside the facility) moisture associated skin damage (MASD). Additionally, the facility did not ensure that interventions were implemented and monitored for effectiveness, and for potential changes in the skin condition. On [DATE], a new wound on the resident's left buttock was assessed as MASD, and did not include documentation for the clinical basis for the determination that the wound was not pressure-related when the wound had the characteristics of a PI. The resident died on [DATE] from septic shock secondary to Proteus bacteremia (bacteria that causes wound infection spread into the bloodstream). This resulted in actual harm that was not immediate jeopardy. This is evidenced by: Resident #2: Resident #2 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated [DATE], documented the resident was cognitively intact. The resident required extensive assistance of two for bed mobility, transfers, and toileting. The MDS documented the resident was at risk for developing pressure ulcers and had 2 pressure injuries (PIs) present upon admission. The Policy and Procedure (P&P) titled Pressure Injury Prevention & Management /Wound Rounds effective ,d+[DATE], documented residents with existing pressure ulcers would be evaluated and managed in accordance with the facility's established clinical practice guidelines. The P&P documented several preventive interventions that included turning and positioning schedule when in bed; maintaining adequate hydration and assist with meals as needed; and skin observation on a shift-to-shift basis. When a resident had an actual pressure injury identified, the nurse in conjunction with the Comprehensive Care Plan (CCP) Team would complete the following: Review and revise the preventive care plan interventions, implement a care plan for the actual ulcer, conduct periodic evaluation of the care plan interventions with additional revision as appropriate; and if the pressure ulcer was facility acquired, a Pressure Ulcer Investigation Report would be completed. Nurse responsibilities documented notification to the physician and obtaining an appropriate treatment order; administering the treatment as ordered; preventing infection; notification to the resident's family/designated representative; the MDS coordinator; and the Dietician; and documenting a comprehensive nurse's note on actions taken. RN Manager/designee responsibilities documented to monitor and assess healing/deterioration minimally on a weekly basis during wound rounds; prevent infection; and communicate changes in the PI to the physician so that appropriate revision could be implemented related to the plan of care. Charge Nurse/licensed nurse responsibilities documented to administer treatments as ordered; assess dressing of PI site on a shift-to-shift basis if dressing change was scheduled; report all changes in the pressure ulcer; and monitor the certified nursing assistants (CNAs) implementation of established plan of care on a shift-to-shift basis. CNA responsibilities documented to report any change in the resident's skin condition to the nurse during shift skin inspection; provide care as outlined on the CNA Accountability Record and Resident Profile Sheet (ex. turn and position resident per schedule and assist with nutritional intake). The Physician/NP responsibilities documented conduct periodic evaluation of the PI on an ongoing basis until it was healed and address factors that make the development of a pressure ulcer unavoidable. Review of the Admission Note dated [DATE] at 1:00 AM, written by the physician/Medical Director (MD), documented that there was a fairly large quarter sized superficial wound on the sole of the resident's left foot. The Admission Note documented there were no other wounds. Review of the Nursing Comprehensive Assessment of the Skin dated [DATE], documented the Braden Scale for Predicting Pressure Score Risk (standardized tool for assessment of pressure ulcer risk) was 16 (at risk). Review of the Comprehensive Care Plan (CCP) initiated on [DATE], documented the resident was at risk for impairment to skin integrity related to fragile skin. The resident was admitted with two unstageable PIs on the left foot with the goal that the resident would maintain or develop clean and intact skin. The CCP documented an intervention for nursing staff to turn and position the resident every two hours as needed and as tolerated. The Skin/Wound Note dated [DATE] at 12:36 PM, written by the PA #1, documented an assessment and plan for unstageable PIs on the resident's left foot. The note did not include documentation of any other wounds. The Therapy Note dated [DATE] at 1:44 PM, written by the Physical Therapy Assistant (PTA) #1, documented that during PT (physical therapy) that morning, while assisting Resident #2 to the toilet they saw a large open area on the resident's buttocks that was draining. The pad beneath the resident had blood-stained drainage. The cart nurse (LPN) was brought into the room to examine the resident and the nurse applied cream. The PTA #1 documented that the finding was a decline from last Friday when the skin was red but intact and the CNAs stated that the redness at that time was already known to Nursing staff. An email dated [DATE] at 3:26 PM, from the Director of Admissions to the State surveyor, documented that the facility did not complete an Accident/Incident (A&I) report for the area found on [DATE], because it was considered MASD, and the facility did not do A&Is for that. Review of the Nurse's Notes (N/N), Medication Review Report (MRR), and the Treatment Administration Record (TAR) dated [DATE] and [DATE], did not include documentation of an assessment, or an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Skin/Wound Note dated [DATE] at 12:25 PM, written by the PA #1, documented the following assessment of a right buttock wound: The wound was community acquired MASD and measured 5.5 cm x 1.9 cm x 0.2 cm. The wound bed was 40% granulation (pink-red moist tissue that fills an open wound when it starts to heal), 20% dark purple, and dermis (percentage not noted). There was no drainage and no odor. The treatment plan documented [MEDICATION(S)] Cream (works by stopping the growth of bacteria that may infect an open wound) for wound treatment to be done every shift and interventions to continue repositioning; turning; heel booties; air mattress; keep areas clean were documented. Review of the CCP for revisions on or after [DATE], did not include documentation of a care plan for the right buttock wound with measurable objectives and interventions for healing, prevention of infection, and the preventions of new wounds. Review of the Quarterly MDS Section M; Skin Conditions dated [DATE], documented there were other skin problems that included MASD. Review of the Skin/Wound Note dated [DATE] at 11:48 AM, written by the PA #1, documented the following assessment of the right buttock wound: The wound measured 6.8 cm x 7.2 cm x 0.4 cm. The wound bed was 100% eschar (dead or devitalized tissue that may appear scab-like) and had no drainage and no odor. The treatment plan documented the wound was to be treated with Hydrogel (wound gel that rehydrates necrotic tissue) and DPD (dry protective dressing) and interventions remained the same. There was no documented evidence of the clinical basis for the determination that the wound was not pressure-related when it was characteristic of a PI; the progression of the wound towards healing; and a pain assessment. The wound was not staged. Review of the Skin/Wound Note dated [DATE] at 9:50 AM, written by PA #1, documented the following assessment of the right buttock wound: -The wound measured 7.6 cm x 8.2 cm x 0.3 cm. The wound bed was 10% dermis and 90% granulation and had no drainage and no odor. The treatment plan documented no changes to the wound treatment and/or interventions. There was no documented evidence of the clinical basis for the determination that the wound was not pressure-related when it was characteristic of a PI; the progression of the wound towards healing; and a pain assessment. The wound was not staged. Review of the Skin/Wound Note dated [DATE] at 5:40 PM, written by the PA ID, documented the following assessment of the right buttock wound and a new wound on the left buttock that was not previously identified by Nursing staff: -The right buttock wound measured 5.7 cm x 4.7 cm x 0.3 cm. The wound bed was 100% eschar and had drainage that was not described, and odor. The wound was debrided (dead/devitalized tissue was removed). The condition of the peri-wound was not documented, and the wound was not staged. The treatment plan documented the treatment was debridement and wet to dry dressing with Dakin's solution (bactericidal antiseptic; diluted bleach) and interventions that were unchanged from [DATE]. -A nosocomial (facility acquired) wound on the left buttock that measured 3.4 cm x 1.8 cm x 0.2 cm. The wound bed was 20% slough and 80 % granulation and had drainage that was not described and no odor. The condition of the peri-wound was not documented, and the wound was not staged. The treatment plan documented treatment with Santyl ointment (helps to break up and remove dead skin and tissue). The PA's assessment did not include documentation for the clinical basis for the determination that the wounds were not pressure-related when it was characteristic of a PI; the progression of the right buttock wound towards healing; and a pain assessment. Review of the CCP for revisions on or after [DATE], did not include documentation of a care plan for the right and left buttock wounds with measurable objectives and interventions for healing, prevention of infection, and the preventions of new wounds. Review of the Nurse Practitioner (NP) Note dated [DATE] at 11:02 PM, written by NP #1, documented that they spoke to the nurse regarding the resident groaning and stating that they could not take the pain. NP #1 documented that the nurse reported the resident had draining wounds and had not been eating or drinking. NP #1 ordered narcotic pain medication to be given every 6 hours as needed for pain; one-liter normal saline (intravenous (IV) fluid) 100/ml an hour; and a CBC and CMP laboratory test. There was no documented evidence that NP #1 assessed the resident or the resident's wounds. Review of the Nurse's Note dated [DATE] at 1:25 AM by LPN #3, documented that they spoke to NP #1 about the resident and received orders for narcotic pain medication, IV fluid, and laboratory tests to be drawn in the AM. Review of the COMS- Skin Only Evaluation dated [DATE] at 10:54 AM by the former Director of Nursing (DON) #4, documented that the resident's skin was pale in color, was fragile, and had decreased skin turgor (elasticity; the ability of the skin to change shape and return to normal). DON #4 documented that the nurse noted blisters on both lower legs. PA #1 was notified, and the areas would remain open to air. The physician and PA were to be updated with any changes. The resident's vital signs were not documented. Review of the Skin/Wound Note dated [DATE] at 12:02 PM by Licensed Practical Nurse Manager (LPNM) #1, documented that while doing the resident's wound care they observed new skin discoloration and open areas on the resident's lower extremities. LPNM #1 documented the resident was currently on a turn and position plan, an air mattress was present, and the resident was unable to turn and position themselves. The wound care provider (PA #1) was notified of the observations. The resident was given pain medication at 9:22 AM, and continued moaning, facial grimacing and was very tense with movement. The resident was alert, awake, and aware of their surroundings. LPNM #1 documented that the resident's vital signs were below baseline but did not document them in the note or elsewhere in the medical record. MD #1 was informed of the resident's condition and the resident was sent to the hospital. Review of the COMS - Skin Only Evaluation dated [DATE] at 12:05 PM, written by DON #4, documented the resident's skin was pale in color, mucous membranes were moist with exudate, skin was fragile and had decreased skin turgor. There were opened blisters with clear drainage on both lower legs that were painful. DON #4 documented that the nurse noted opened blisters and the resident complained of pain to legs. The wound PA #1 and MD #1 were notified and ordered to send the resident to the emergency room (ER) for further evaluation. Review of the Hospital Emergency Department (ED) MD Progress Notes dated [DATE] by the physician (DO), documented the resident arrived at 11:47 AM with a chief complaint of [CONDITION(S)] (low blood pressure) and a stage 4 tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) ulcer on their back. The triage impression documented [CONDITION(S)] suspect and the resident's condition in the ED was critical condition. The resident's general appearance was toxic, and the resident was moaning with pain. The resident's back was examined and there was a large 10 cm stage 4 sacral decubitus ulcer with mild surrounding [CONDITION(S)] (redness of the skin). The resident's lower extremities were pale; cool to the touch; with multiple pressure ulcers; and no [CONDITION(S)]. Blood pressure was noted to be 50-,d+[DATE] (normal ,d+[DATE]) and the resident was intermittently confused. The resident was admitted with severe [CONDITION(S)] (develops when the infection causes organ damage) with septic shock (a severe complication of [CONDITION(S)] that can include very low blood pressure, an altered mental state, and organ dysfunction), diarrhea, [CONDITION(S)] (extremely low potassium levels in the blood), acute kidney failure and sacral decubiti. The note also documented that a CT of the chest, abdomen and pelvis was done. There was a large sized sacral decubitus ulcer measuring 10 cm in SI (international system of units) dimension overlying the right lateral aspect of the sacrum. The Hospital Discharge Summary dated [DATE], documented the resident was pronounced dead on the [DATE] at 9:00 PM. The resident's immediate cause of death documented septic shock secondary to Proteus bacteremia likely from the resident's underlying large sacral decubitus ulcer. During an interview on [DATE] at 9:34 AM, the PTA #1 stated that the facility's policy was to report any open areas on the resident's skin to the cart nurse (LPN) #2. The PTA #1 stated that in their role, they were responsible for maintaining the resident's skin integrity and the resident's positioning. The PTA #1 stated that they identified a change in the resident's skin and reported it. The PTA #1 stated that if they wrote that the nurse examined the resident and applied cream, then they had witnessed the nurse applying barrier cream. The PTA #1 stated that the nurse might not have had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The PTA #1 could not recall the nurse's name. The PTA #1 stated that they wrote their note in detail to draw more attention to it because the cart nurses were generally busy and did not know what was going on with the resident at every moment. The PTA #1 stated that the Therapy Department spent a lot of time with the residents and was able to identify changes. The PTA #1 stated that Resident #2 had severe arthritis that made horrific sounds through their hips and knees. The PTA #1 stated that the resident had a tremendous amount of pain and sat most of the time. The PTA #1 stated that there would be inconsistent documentation of turning and positioning because it did not exist and no one was walking around to ensure that it was done. During an interview an interview on [DATE] at 8:52 AM, Resident #2's representative/family member (REP) stated that the resident was being seen by the podiatrist for a nickel-size sore on their foot. The REP stated that the resident did not have any sores on their buttocks prior to admission to the facility. The REP stated that during that time, visitation was limited and said that the resident mentioned that they had a wound on their buttocks. The REP stated that the facility did not give them a lot of information about the resident's condition and/or the wounds. The REP stated that when the LPN Manager (LPNM) #1 called to get consent for the debridement of the wound on the buttock on [DATE], they stated, You do know they have a sore on their buttocks? The REP then stated that later that evening, a male nurse called and asked permission to get IV fluids and narcotic pain medication. The REP stated that the nurse said they felt like the resident had failure to thrive and told the REP that the resident was not eating and was in pain. The REP stated that on [DATE], LPNM #1 called to say the resident was being transferred to the ED because they thought something vascular was happening. During an interview on [DATE] at 1:22 PM, LPNM #1 stated that they were the nurse manager after RNM #4 no longer worked there. LPNM #1 stated that if a change in the resident's skin was reported to the cart nurse (LPN), the Registered Nurse Supervisor (RNS) should have been called immediately. LPNM #1 stated that LPNs were not allowed to do assessments and said even a tiny red dot or small area could turn into a big giant thing the next day. LPNM #1 stated that the facility had issues with Nursing staff not signing for treatments and/or interventions. LPNM #1 stated that they recalled sending Resident #2 to the hospital. LPNM #1 stated that on [DATE], the resident had more than one wound located on either side of both lower legs, that were not there on [DATE], and the resident looked sick. LPNM #1 stated that they did not recall if they documented the resident's vital signs in the electronic medical record (EMR). LPNM #1 stated the wounds looked like pressure ulcers. During an interview on [DATE] at 1:54 PM, NP #1 stated that they no longer worked at the facility and did not recall Resident #2. NP #1 stated that they did not get involved in the assessment and management of the wounds. NP #1 stated that their focus was on residents' medical needs and the PA was responsible for wound management. NP #1 stated that they would sometimes take a picture of a wound and would send it to the PA. NP #1 stated that wound management was not their expertise and said wound assessments should include measuring and staging the wound because there were different treatments for the different stages; and assessing drainage and odor for signs of infection. NP #1 stated that all assessment findings should then be documented. During an interview on [DATE] at 1:46 PM, LPN #4 stated that they no longer worked at the facility but recalled the resident. LPN #4 stated that no one was following the rules, they would never get a full report about any resident and felt like they were walking blind half the time during their assignment. LPN #4 stated that wound rounds were done on Wednesday and if there were any issues with wounds on any other day, the wounds did not get assessed until then. LPN #4 stated that the RNs were not assessing wounds. During an interview on [DATE] at 2:47 PM, LPN #3 stated that PA #1 was the main person for wound assessments and came to the facility on ce a week on Wednesday for wound rounds. LPN #3 stated that LPNM #1 was the acting unit manager. LPN #3 stated that when the resident complained of right/left buttock pain, they would have looked at the resident's skin to see if there were any changes and would have called NP #1. LPN #3 stated that the weekly skin checks were done on the resident's shower day and said they would document any skin changes in a note. During an interview on [DATE] at 3:22 PM, LPN #2 stated that they no longer worked at the facility. LPN #2 stated that there was a delay in the assessment of Resident #2's right buttock wound because the PA did all the wound assessments and was only there once a week. LPN #2 stated there was no unit manager at that time and said RN #4 had stepped down as unit manager in April of 2021. LPN #2 stated that if the wound was reported to them, they would have reported to NP #1 because they were in the facility almost daily. LPN #2 stated that they would have covered the wound and then let the PA look at it during wound rounds. LPN #2 stated that when PA #1 did come for wound rounds, they were literally in and out. LPN #2 stated that they had to nag PA #1 about bad smelling wounds; would tell PA #1 that something was not right with a wound, but PA #1 would not listen. LPN #2 stated that they would tell NP #1 about things that were going south with the wounds; it smelled like something dead and NP #1 would order bloodwork and antibiotics if necessary. During interview on [DATE] at 4:13 PM, CNA #2 stated that they were familiar with Resident #2. CNA #2 stated that PA #1would come in once a week on Wednesday to wound care on the residents. CNA #2 stated that the resident had a wound and their buttocks hurt really bad. CNA #2 stated that PA #1 ended up [MEDICATION(S)] it and explained that they took the dead skin off. CNA #2 stated that afterwards, it was a big hole about the size of CNA #2's fist, that was about 3 to 4 inches wide. During interview on [DATE] at 11:34 AM, the PA #1 stated that their assessments of Resident #2's wound were 100% correct and stated that the stage of the wounds should have been documented. The PA #1 stated that they knew what to write but did not and stated that sometimes there were outside influences that told them how to document. The PA #1 stated that the nurses were not assessing the resident's wounds and stated that they were only documenting what the PA told them to document. The PA #1 stated that the right and left buttock wounds were never MASD. The PA #1 stated they should have documented the following assessments of the wounds: -On [DATE], the right buttock wound was a stage 2 (partial-thickness loss of skin with exposed dermis (second layer of skin), presenting as a shallow open ulcer) PI. -On [DATE], the right buttock wound had progressed to an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough (moist dead tissue) or eschar (hard or soft dead tissue that is scab-like) PI. -On [DATE], the right buttock wound was an unstageable PI. -On [DATE], the right buttock wound was an unstageable PI and then after debridement it was a stage 4 (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer) PI. -On [DATE], the left buttock wound was a stage 4 PI. During an interview on [DATE] at 11:08 AM, the physician/Medical Director (MD) stated that they had no professional relationship with the wound care PA #1. The MD stated that the facility had to rely on a wound care solution and said PA #1 was contracted to provide wound care services. The MD stated that they were aware wounds were happening in the facility and said they did not consult with the PA #1 about the resident's wounds. The MD stated that they were in charge of facility operations and at the end of the day had to answer for the resident's care. The MD stated that what happened to Resident #2 was a sentinel event and stated that the resident came in from the hospital with wounds; was not 100% nourished; had weight loss; difficulty with mobility; had skin integrity issue and was at risk for wounds. The MD stated that they did not have the resident's status directly communicated to them until the resident was sent out to the hospital. The MD stated that they did a cursory review of the medical record and stated they saw multiple notes from NP #1 but there was really only one note from Nursing staff and that was when the resident was sent out on [DATE]. The MD stated that the resident had lost 8 pounds, which would have been impactful on wound healing and the development of new wounds. The MD stated that if they were informed sooner, they would have been able to see how the wounds were unfolding and would have been able to make medical decisions accordingly. The MD stated that the documentation by Nursing staff to communicate changes in the buttock wounds was not there. The MD stated that the facility had deep-seated problems that they had to resolve. The MD stated that as the Medical Director they have tried to influence change by bringing attention to the issues and bringing it up at QAPI with administration. The MD stated that the facility had to make corrections so that it does not lead to these sentinel events. During an interview on [DATE] at 12:14 PM, RN Manager (RNM) #4 stated that they no longer worked in the facility. RNM #4 stated that they were the unit manager of the resident's unit for three weeks in [DATE]. RNM #4 stated that after they left the unit, LPN #2 was the interim unit manager and then LPNM #1 was the acting nurse manager. RNM #4 stated that there was no communication whatsoever on the unit and had no idea what was going on. RNM #4 stated that the MD did not want to be notified of the wounds and stated they were told to contact the PA #1. RNM #4 stated that the MD and PA only came into facility on Wednesday. RNM #4 stated that they looked at the wounds when the PA #1 did their assessment and wrote notes the way that the PA #1 wanted RNM #4 to write them. RNM #4 stated that they were told to write MASD and RNM #4's understanding was that was what the PA #1 was told to do. RNM #4 stated that it was a corporate policy that they had to document a certain way. RNM #4 stated that infection prevention was done by doing wound treatments every day and updating the doctor with the condition of the wound. RNM #4 stated that they were very busy every day with helping to feed residents or passing medications and stated that they were not ensuring that wound treatments were being done. RNM #4 stated that sometimes the nurses would pass the wound treatments onto the next shift and stated that did nothing for the twice daily wound treatments. During an interview on [DATE] at 12:03 PM, the Corporate Administrator (ADMIN #2) stated that the wound care PA was contracted to provide weekly wound care to the residents and was not responsible for the residents' medical care. The ADMIN #2 stated that NP #1 and the MD, who was also the Medical Director, was responsible for the medical care of the residents. The ADMIN #2 stated that when the LPN became aware that Resident #2 had a wound on their right buttock, they should have reported to the Registered Nurse (RN). The ADMIN #2 stated that the RN should have notified NP #1 and not the PA #1, because the NP was in the facility every day and could have initiated a treatment right away, whereas, the PA #1 was only there once a week, and it could take up to a week for them to treat the wound and by then it's too late. The ADMIN #2 stated that the RN would also initiate a pressure ulcer investigation for the weekly skin team to review and then they would get the MD involved. The ADMIN #2 stated that the Director of Nursing (DON) was responsible for implementing the nursing P&Ps and stated that there was a communication breakdown with some of the previous DONs. The ADMIN #2 stated the MD was responsible for providing oversight of the care provided by NP #1 and stated that MD was responsible for the resident's overall care and for overseeing that the care was being provided to meet the resident's needs. The ADMIN #2 stated that the MD had access to the EMR (electronic medical record) and should have been monitoring the care that was being provided to the resident and the resident's response to the care. The ADMIN #2 stated that if nursing had a concern with the care being provided by the MD, it would be communicated to the DON, and then to the Administrator, and then to the Regional Medical Director, who provided oversight for the MD. 10 NYCRR 415.12(c)(1)

Based on record review and interview during an abbreviated survey (Case # NY 332), the facility did not ensure that residents were free of any significant medication errors for 1 (Resident # 3) of 3 residents reviewed. Specifically, for Resident #3 who had chronic [CONDITION(S)], the facility did not ensure the resident received [MEDICATION(S)] for treating/preventing blood clots from 1/12/2022 to 1/17/2022, when the order for the medication was entered incorrectly as one-time only by the provider. Subsequently, on 1/18/2022, the resident had a change in mental status and was sent to the hospital where they were diagnosed with stroke due to [CONDITION(S)] (formation of a blood clot) and required medical and surgical interventions. This resulted in actual harm that is not immediate jeopardy. This is evidenced by: Resident #3: Resident #3 was readmitted to the facility with cerebral infarction (stroke) due to [CONDITION(S)] of left cerebellar artery, chronic [CONDITION(S)] (quivering or irregular heartbeat that can lead to blood clots and stroke) and [CONDITION(S)] (PVD). The Minimum Data Set (MDS - an assessment tool) dated 1/1/2022, documented the resident was cognitively intact. The Policy and Procedure P&P titled Anticoagulant Therapy effective 12/21/2021, documented that it was the policy of the facility to monitor any resident that received anticoagulant therapy by evaluating pertinent laboratory values when indicated. The P&P documented that anticoagulant therapy was indicated for the prophylaxis (prevention) and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Anticoagulant medications would be scheduled for administration on the evening shift or as specified by the MD (physician). Residents who were started on [MEDICATION(S)] ([MEDICATION(S)]) would have a baseline INR (International Normalized Ratio; used to determine the [MEDICATION(S)] dosage; typical target range is 2 to 3) prior to starting therapy, an MD order stating the dose and frequency of the laboratory tests for monitoring. A [MEDICATION(S)] Flow Sheet (CFS) would be initiated upon initial order for [MEDICATION(S)]. The Nurse Manager (NM)/designee was responsible for ensuring that lab values were communicated to the resident's MD and that the therapy was adjusted and warranted; would document on the CFS the following: date, current dose, PT/INR results, MD notified/action taken (including dose change), date of the next PT/INR, and nurse signature. Review of the Hospital History and Physical Report for date of admission 12/25/2021, documented that the resident had a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's medications included [MEDICATION(S)]. The Hospital Discharge Summary dated 12/29/2021, documented discharge medications that included [MEDICATION(S)] 3.5 mg daily. Review of the Comprehensive Care Plan (CCP) for anticoagulant therapy related to [CONDITION(S)], last revised 1/10/2022, documented to administer anticoagulant medications as ordered by the physician; monitor for side effects and effectiveness every shift; laboratory tests as ordered and report abnormal results to the physician. Review of the Lab Results Report dated 1/1/2022 for collection date 12/31/2021, documented the INR was 1.4. The unsigned [MEDICATION(S)] Flow Sheet (CFS) dated 12/31/2021, documented the INR was 1.4 and the Nurse Practitioner (NP) #1 was notified. The follow up INR test was to be done on 1/7/2022. Review of the Medication Review Report (MRR) and the Medication Administration Report (MAR) documented the nurse signed that the [MEDICATION(S)] 4.5 mg was given from 1/1/2022 to 1/6/2022, per physician order. Review of the Admission Note dated 1/5/2022 by Medical Doctor (MD) #1, documented that the assessment and plan for [CONDITION(S)] was for the resident to continue to receive [MEDICATION(S)] and would check the INR weekly, and the goal was for an INR of 2 to 3. The Laboratory Results History Report dated 1/7/2022, documented the INR was 1.5. Review of the unsigned CFS dated 1/7/2022, documented the current dose of [MEDICATION(S)] was 4.5 mg daily. The INR was 1.5 and Nurse Practitioner (NP) #1 was notified. The follow up INR was to be done on 1/14/2022. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The late Nurse Practitioner Note dated 1/16/2022 at 10:22 AM, written by NP #1 for the date of service 1/11/2022, documented a chief complaint of [CONDITION(S)]/[MEDICATION(S)]/low INR. NP #1 documented the INR result for today was 1.5, on 4.5 mg of [MEDICATION(S)] and that they increased [MEDICATION(S)] to 5 mg and would repeat the INR on Friday (1/14/2022). The assessment and plan documented NP #1 increased the [MEDICATION(S)] to 5 mg and the goal was to maintain an INR between 2 and 3 and check it weekly. Review of the MRR documented an order dated 1/11/2022, for [MEDICATION(S)] 5 mg to be given one time only for anticoagulation. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MRR did not document a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The Laboratory Results History Report dated 1/14/2022, documented the INR was 1.5. Review of the MRR, MAR, and CFS dated 1/14/2022, documented the following: -The MRR did not document an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . -The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . -The unsigned CFS dated 1/14/2022, documented the current dose of [MEDICATION(S)] was 5 mg daily. The CFS documented the INR was 1.5 and NP #1 was notified. The follow up INR test was to be done on 1/21/2022. Review of the MRR did not document an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nurse's Note dated 1/18/2022 at 10:09 AM, written by Licensed Practical Nurse Manager (LPNM) #1, documented that they were informed by the Occupational Therapist (OT) that the resident was not at baseline. When LPNM #1 went to see the resident, the resident was groggy; seemed confused; was not answering at baseline; and was slow to react. The resident started to rub their chest and acknowledged they were having chest pain. The former Director of Nursing (DON) #2 was called to assess the resident. The DON and NP agreed to send the resident to the hospital for evaluation. The Nurse's Note dated 1/18/2022 at 3:54 PM, written by the DON #2, documented that they received a call from the hospital. The resident was being transferred to another hospital for [CONDITION(S)] (stroke) management. The resident was noted to have TPA (tissue [MEDICATION(S)] activator; administered to stroke patients to break up a blood clot and restore blood flow); right-sided facial drooping and right arm flaccidity (lacking muscle tone). The Hospital Neurosurgery Consultation Note dated 1/18/2022 at 4:05 PM, documented the resident received TPA at 2:15 PM at the sending hospital and transferred to this hospital for possible thrombectomy (surgery to remove a blood clot from a blood vessel). The resident was reportedly on [MEDICATION(S)] per chart review, but it was unclear if they had been taking it. The impression and plan documented the resident who was presenting with [CONDITION(S)] (a complex language and communication disorder that can occur after a stroke) and right-sided weakness, was found to have a LM1 occlusion (left middle cerebral artery (MCA) blockage) after TPA at the sending hospital. Based on the imaging and clinical exam, a decision was made to take the resident emergently for diagnostic tests and possible left MCA thrombectomy. The Hospital Discharge Order dated 1/27/2022, documented the resident's condition was stable to discharge to the nursing facility. The Discharge Plan documented the resident was hospitalized for left hemispheric stroke due to [CONDITION(S)] not on anticoagulation; status post [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/31/2022 at 2:53 PM, Resident #3 stated that they had a stroke, and they were doing fine. Resident #3 stated that they had limited use of their right side and could not move that well. Resident #3 stated that they had to have surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 6/2/2022 at 1:36 PM, NP #1 stated they no longer worked at the facility. NP #1 stated that they would enter their own orders into the electronic medical record (EMR) and the Licensed Professional Nurse (LPN) would verify them. NP #1 stated that on 1/11/2022, they increased the [MEDICATION(S)] to 5 mg and entered an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . NP #1 stated they were following the protocol. NP #1 stated that on 1/14/2022, they were in the facility and checked for the INR result, but it was not available. NP #1 stated that the results were supposed to be streamed in from the lab. NP #1 stated that they checked for the result throughout the day, but it was still not available. Later, they learned that there was a problem with the Lab sending out the results, and they faxed the results to the wrong facility. NP #1 stated that Nursing staff did not call them with the result, and said they were out sick on 1/17/2022 and 1/18/2022. NP #1 stated that staff should have called the physician (MD), in their absence. NP #1 stated that Nursing staff had a binder with printed lab order sheets and when labs were drawn on Friday, they were supposed to look for the INR results and call the provider. NP #1 stated that it was nursing 101. NP #1 stated that they entered the order incorrectly as a one day only and said the [MEDICATION(S)] was to be increased to 5 mg daily. NP #1 stated that a licensed nurse was supposed to verify the order, and if there was a problem with the order, they were supposed to get clarification. NP #1 stated that the next check was for the Unit Manager to document on the CFS; the amount of [MEDICATION(S)] that the resident was supposed to get and when the next INR was. NP #1 stated that they did not expect the [MEDICATION(S)] to be given one time only and said the LPN confirmed it without questioning it. NP #1 stated that the resident needed [MEDICATION(S)] because they had [CONDITION(S)] and could have a clot or an embolism. NP #1 stated that the potential was always there, and there was higher risk if they did not have the medication. NP #1 stated they would generally sit with the LPN Manager (LPNM) #1, would enter the orders and then LPNM #1 would verify them. During an interview on 9/28/2022 at 1:22 PM, LPNM #1 stated that they no longer worked at the facility. LPNM #1 stated that NP #1 would enter their orders into the electronic medical record (EMR) and then would tell the nurse that they entered it. LPNM #1 stated that NP #1 would sit with LPNM #1 and would enter orders and then LPNM #1 would confirm them. LPNM #1 stated that nurses could verify orders. LPNM #1 stated that NP #1 was not very familiar with entering orders. LPNM #1 stated that with [MEDICATION(S)] orders, the nurse always needs to check the INR result first before they administer it. LPNM #1 stated that the nurse should always question a one-time only [MEDICATION(S)] order. LPNM #1 stated that they were the nurse who sent the resident to the hospital. During an interview on 10/7/2022 at 11:08 AM, the MD/Medical Director (MD) stated that they were told that the repeat INR was done but was not reported, and the [MEDICATION(S)] was on hold until the result came in. The surveyor told the MD that the [MEDICATION(S)] order was entered as a one-time only order and that the resident did not receive the medication from 1/12/2022 to 1/17/2022, and subsequently had a stroke on 1/18/2022. The MD stated that [MEDICATION(S)] was a type of medication that was at high risk for medication errors, and that was why they tried to get residents to take alternative anticoagulants. 10 NYCRR 415.12(m)(2)

Based on observation, interview, and record review during an abbreviated survey (Complaint #NY 951), the facility did not ensure each resident received adequate supervision to prevent accidents for 1 (Resident #1) of 7 residents reviewed for elopement. Specifically, the facility did not reassess Resident #1 for elopement risk and supervision needs, and did not provide adequate supervision after the resident, who had impaired cognition, attempted to leave the facility through an alarmed egress door on 1/30/21. Additionally, on 1/30/2021, after the alarm on the egress door was silenced, staff did not properly reset the door alarm. On 1/31/21 Resident #1, who was last seen at 4:00 AM, left the facility undetected by staff. At 5:50 AM the resident was found outside. Subsequently, Resident #1 was transferred and admitted to the hospital with a body temperature of 88.4 degrees Fahrenheit. This resulted in actual harm that is not immediate jeopardy. This was evidenced by: Resident #1 was admitted to the facility with diagnoses of dementia, diabetes and [CONDITION(S)]. The Nursing Comprehensive assessment dated [DATE] documented the resident was alert, drowsy and confused, oriented to self, had altered judgement and insight. The undated Policy and Procedure (P&P) for Elopement/Wandering Assessment documented a comprehensive assessment was to be completed at the time of admission, and whenever a change in mental status and behavior was noted that would compromise the health, safety and well-being of the resident was noted. All incidents regarding elopement or near miss for elopement were to be reported on a facility incident report form no later than the end of the shift on which the incident occurred and submitted to the Administrator and Director of Nurses to review. The Facility Investigation dated 2/2/2021 completed and signed by the Corporate Regional Director (CRD) documented that, sometime in the morning on 1/30/21, Licensed Practical Nurse Supervisor (LPNS) #1 was paged to Wing 3 by Registered Nurse (RN) #1 who informed LPNS #1 that Resident #1 had pushed an egress door open and set off the alarm. RN #1 needed LPN #1 to turn off the alarm with a key. LPNS #1 described the way she turned the key in the egress door. It was determined LPNS #1 turned the key to the right which deactivated the alarm. LPN 31 did not ensure the alarm was rearmed as she did not hear the anticipated chirping or see the red flashing light which would have indicated the alarm was on. The Weather Channel website documented the temperature range for the region where the nursing facility was located was: On 1/30/21 the high temperature for the day was 21 F and the low was 0 F. On 1/31/21 the high was 19 F and the low was 14 F. Finding #1: The facility did not reassess Resident #1 for elopement risk and supervision needs after the resident attempted to leave the facility through an alarmed egress door on 1/30/21. The Nursing Comprehensive assessment dated [DATE] at 8:30 PM by Registered Nurse Supervisor (RNS) #2 documented Resident #1 had a history of mental health and behavioral issues. The resident did not have a history of wandering and elopement and was assessed as not being at risk for wandering or elopement. A 24-Hour Shift Report dated 1/30/21 documented the evening shift (2:45 PM to 11:15 PM) was shift number 7 of 9 shifts as a new admission for Resident #1. The resident remained confused and needed rechecking. A Nurses Note dated 1/31/21 at 8:05 AM, written by RNS #1, documented checked on Resident #1 at 5:00 AM and did not see the resident on the bed. RNS #1 and Certified Nurse Aide (CNA) #2 then started looking for the resident in the bathroom and other rooms. They then went to the egress door and saw footprints in the snow. CNA #2 ran outside to look for the resident and RNS #1 went inside to activate the Missing Person process when the resident was not found. Then 911 was called and the DON was notified. At 5:50 AM the police found Resident #1 behind bushes about 100-150 feet away from the building. The resident was then sent to the hospital. RNS #1 also documented that CNA #2 had reported that she had checked on the resident at 4:00 AM and the resident was sleeping. A Nurses Note dated 1/31/21 at 10:50 AM, written by LPN #3, documented she spoke with the hospital personnel who reported Resident #1 had been admitted to the hospital's Intensive Care Unit. A Resident Accident and Incident (A&I) Report dated 1/31/21, completed by Registered Nurse Supervisor (RNS) #1, documented that at 5:00 AM on 1/31/21, Resident #1 was not in bed and was last seen at 4:00 AM by and Certified Nursing Assistant (CNA) #2. RNS #1 and CNA #2 searched the unit and could not find the resident. They checked the egress door and saw footprints in the snow. CNA #2 went outside to try to find the resident, then RNS #1 called 911 and the resident was found by police at 5:50 AM and taken to the hospital by ambulance. Hospital Admission Emergency Department progress notes dated 1/31/21 at 6:00 AM by the Nurse Practitioner (NP), documented Resident #1 was lethargic, cold, shivering blinking his/her eyes but was unresponsive. The resident's body was cold to touch, and his/her arms were stiff and clenched to the chest, and he/she was dressed in a hospital gown and wet socks. The resident's vital signs were documented as: blood pressure (B/P) 172/101 (normal range 90/60 to 120/80), oxygen saturation (O2 sat- measurement of oxygen in the blood, normal range 95 to 100%) was 84%. At 6:08 AM the resident's rectal temperature was 88.4 degrees Fahrenheit (expressed as 88.4F; normal range 97.8F to 99.1F). The resident was warmed with intravenous fluids administered through a fluid warmer, and he/she was covered with a warming blanket. Resident #1 was diagnosed with hypothermia (a low body temperature). Blood work was ordered, and the resident was diagnosed with [CONDITION(S)] (high potassium that can affect heart functioning). An electrocardiogram (EKG) was ordered and the resident was transferred to the hospital's telemetry unit for continuous cardiac monitoring. During an interview on 2/3/21 at 11:50 AM CNA #1 stated Resident #1 frequently wandered on the unit and staff spent a lot of time redirecting the resident. On 1/30/21 Resident #1 opened the egress door on the unit, which was located next to the resident's room. CNA #1 was nearby, heard the alarm and redirected the resident away from the egress door. During an interview on 2/8/21 at 11:15 AM CNA #4 stated on 1/30/21 she heard the door alarm sound and looked up from the nurse's station and saw Resident #1 against the push bar on the egress door. RN #1 and CNA #1 were in the same hallway as Resident #1 and both redirected the resident. CNA #4 stated Resident #1 was a known wanderer and staff had to redirect him/her. During an interview on 2/4/21 at 12:50 PM RN #1 stated she was on duty on 1/30/21 day shift when Resident #1 wandered on the unit and set off the alarm to the egress door next to his/her room and CNA #1 redirected the resident back to his/her room. RN #1 stated she paged LPNS #1 to come to the unit and turn the alarm off. RN #1 stated that it was her responsibility to document the resident's attempt to leave the facility and complete an A&I report, but she thought LPNS #1 would document the incident. RN #1 stated she was busy and did not document or report the incident to anyone else, and she did not know if LPNS #1 had documented or reported the incident. During an interview on 2/3/21 at 3:40 PM RNS #1 stated Resident #1 was known to wander in the facility. On 1/31/21 RNS #1 checked on Resident #1 at 5:00 AM and the resident was not in bed. She asked CNA #2 if she had seen Resident #1, and CNA #2 told her she last saw the resident in bed at 4:00 AM. RNS #1 stated she and CNA #2 checked all the rooms and bathrooms on the unit and did not find Resident #1. They checked the fire door next to the resident's room and noticed footprints in the snow outside. When CNA #2 opened the door, no alarm sounded. RNS #1 stated she was shaken by this and immediately called 911 while CNA #2 searched outside for the resident. 911 told her they would send the police and an ambulance. During an interview on 2/3/21 at 5:00 PM CNA #2 stated she last saw Resident #1 at 4:00 AM on 1/31/21. CNA #2 stated that RNS #1 asked her around 5:00 AM if she had seen Resident #1 and she told RNS #1 she last saw the resident at 4:00 AM. CNA #2 stated they searched the unit and when they could not find the resident, they realized that maybe the resident had gotten out of the building. They went to the fire door and saw footprints in the snow outside. CNA #2 stated the red light that meant the door was alarmed was not flashing, and when she opened the door the alarm did not sound. CNA #2 searched for the resident for a long time following the footprints in the snow and could not find him/her. The police found Resident #1 and an ambulance took Resident #1 to the hospital. During an interview on 2/4/21 at 1:28 PM the Administrator (ADM) stated she had not been notified of Resident #1's attempt to leave the facility on 1/30/21 until after the resident left the building on 1/31/21. When LPNS #1 went to reset the alarm on 1/30/21, she turned the key to the left and locked the door, then she turned it to the right which turned the alarm off. During an interview on 2/8/21 at 1:40 PM LPNS #1 stated that, on 1/30/21, she was paged to Resident #1's unit to turn off the egress door alarm, and when she arrived the alarm had timed out and was no longer sounding. LPNS #1 stated she would normally have documented the incident on the 24-hour report, written a note and completed an A&I, and informed the ADM or Director of Nursing (DON), as well as the NP or Medical Director (MD), but she did not take any of these actions. During an interview on 2/5/21 at 2:20 PM the NP stated that she was not notified about the resident's elopement attempt on 1/30 or the elopement on 1/31/21. During an interview on 2/5/21 at 2:30 PM the MD stated he had not been made aware of Resident #1's attempted to leave the building on 1/30/21 until after the resident had been found outside the building on 1/31/21. The MD stated he was available 24 hours a day, 7 days a week and he should expected staff to notify him if a resident was having a change in condition or behavior. The MD stated he expected that the appropriate assessments would be done to evaluate and make changes in the resident's care if necessary and that early interventions could possibly prevent accidents like this from happening. Finding #2: After the alarm on the egress door was silenced on 1/30/21, LPNS #1 did not properly reset the alarm. The Exit Alarm manual titled Detex dated 5/5/2015, for the alarm on the egress door through which Resident #1 exited on 1/31/21 documented that, to arm the system, staff were to close the door and turn the key to the ON position. A red light would blink twice followed by a green light flashing for the remainder of the arming time (a 15 second default time). After the arming time, the green light would turn off, a siren would chirp, and the red light would flash 3 times. The device would then be properly armed and if the door was opened the alarm would sound and the red light would turn on. The Daily Door Checks Form for the month of 1/2021 documented that all doors were checked Monday through Friday and this was indicated by a box checked off for each door and the date it was checked. During an interview on 2/8/21 at 1:40 PM LPNS #1 stated she was paged to Resident #1's unit to turn off the alarm on the egress door on 1/30/21. The alarm was not sounding when she arrived because it had already timed out, so she turned the key to the left and then again to the right then back to straight position and pulled the key out. She did not recall hearing the chirps or checking for the red flashing light. She thought the door was alarmed. During an observation and interview on 2/3/21 at 11:22 AM the Director of Maintenance (DM) demonstrated the alarm operations of the egress door on Resident #1's unit. The DM showed how to set the lock and alarm by turning the key to the left, then turn the key to the upright position and pull the key out. The DM stated that, to reset the alarm, the light should turn red and staff should listen for 3 chirps. The DM demonstrated that when the key was turned to the right and then to the upright position the red light did not flash and that meant the door was not alarmed. The DM stated that he and the maintenance man (MM) checked the door alarms daily during the week and Supervisors were responsible for checking the door alarms on the weekend. During an interview on 2/3/21 at 11:55 AM the MM stated he checked the alarm on 1/29/21 and it was working correctly. During an interview on 2/3/21 at 1:30 PM the CRD stated she had conducted an investigation on Resident #1's elopement and concluded that on 1/30/21, LPNS #1 was paged to reset the egress door alarm on Resident #1's unit. LPNS #1 demonstrated that she turned the key to the right then straight and pulled the key out which would have deactivated the alarm. The CRD stated the Supervisors checked the door alarms and wander guards on the weekend, but there was no paperwork to log any specified time/shift that the alarmed doors were checked. During an interview on 2/3/21 at 3:40 PM RNS #1 stated that when searching for Resident #1 on 1/31/21, CNA #2 opened the door and no alarm sounded. RNS #1 stated that the Supervisors were responsible for checking the door alarms on the weekend and that she had not yet completed the task when it was discovered Resident #1 had left the building. She also stated the facility did not have a form to document that door alarm checks were completed on the weekend. During an interview on 2/4/21 at 1:28 PM the Administrator (ADM) stated that on 1/30/21 the resident opened the egress door sounding the alarm. LPNS #1 went to reset the alarm on 1/30/21, she turned the key to the left and locked the door, then she turned it to the right which turned the alarm off. 10 NYCRR 415.12(h)(2)

Based on medical record review and interviews during abbreviated surveys (Case #'s NY 052 and NY 324), the facility did not ensure that each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for two (Resident #'s 1 and #3) of six (6) residents reviewed. Specifically, Resident #1 was to receive a House Ground diet that specifically excluded bread sticks. On [DATE], the resident was served a breadstick with her meal, choked on the breadstick and expired. Resident #3, who had a recent surgical repair of an umbilical hernia, experienced gastro-intestinal symptoms (vomiting) and then [MEDICAL CONDITION] ( lack of oxygen ). There was a delay in treatment when facility staff received a physicians order to send the resident to the emergency room for further evaluation, however did not immediately contact 911. The resident became unresponsive requiring cardio-pulmonary resuscitation. This is a repeat deficiency from a recertification survey dated [DATE]. This resulted in actual harm for Residents #1 and #3 that is not Immediate Jeopardy. This was evidenced by: Resident #1 The resident was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident to have moderate cognitive impairment, and required setup assistance with meals. She was also assessed to require a mechanically altered diet. The undated Policy and Procedure (P&P) for Nursing Responsibilities at Meal Service documented that nursing personnel were responsible for ensuring residents were served the correct diet. Prior to serving a tray, the nurse was to check the menu to assure the correct food was being served to the resident. If there was doubt, the charge nurse was to check the written physician's orders [REDACTED]. The facility Diet Definition dated [DATE], documented that the Ground Diet called for regular bread, and no garlic bread or breadsticks. A History and Physical (H&P) dated [DATE], and signed by the physician, documented that the resident had a history of [REDACTED]. A Nutrition Risk assessment dated [DATE], documented that this resident was ordered to be on a house, ground diet. The Comprehensive Care Plan (CCP) for Mechanically Altered Diet Due to Difficulty Chewing dated [DATE], documented that the resident was to receive a House Ground diet. An undated Resident Profile Details report documented that the resident was to receive a House Ground Diet and listed menu item substitutions for this resident. It documented that when a bread stick was on the menu, the resident was to instead receive one slice of bread with margarine. A physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. The Resident Care Card (used by staff to know what care the resident required) dated [DATE], documented that the resident was to receive a House Ground Diet, and that she required set-up of her meals. The facility Menu for the dinner meal on [DATE], listed a bread stick as one of the items. Also listed as available was bread with margarine. The Meal Ticket for this resident, for the dinner meal on [DATE], did not include bread or a breadstick. An Occurrence Report (OR) dated [DATE] at 5:20 pm, documented that this resident choked and had an airway obstruction, and had expired. In a written statement dated [DATE], a visitor to the facility stated that he was in this resident's room when he heard her coughing. He asked the resident if she was choking and she nodded her head yes. The visitor ran to the nurses station and called down the hall that she was choking. Staff came into the room within a minute or two. In a written statement dated [DATE], CNA (Certified Nursing Assistant) #3 documented that she delivered this resident's meal tray at 5:00 pm on [DATE]. The CNA compared her tray ticket to her food, and the resident had a regular house meal. She cut up one of the manicotti, and the breadstick was whole. The CNA asked the resident if everything was okay, and the resident said it was. The CNA left the room. Approximately five minutes later, a visitor told her this resident was choking. She went to the resident's room and saw that the resident was visibly choking and her face had started to turn blue. The CNA went to get a nurse, and told other staff that the resident was choking. She, another CNA and Licensed Practical Nurse (LPN) #1 ran back to the room. When they arrived at the room, the resident's face, "was bluer, and she was visibly choking and making gurgling noises." The LPN started doing the [MEDICATION NAME] maneuver and told her to call the Registered Nurse Supervisor (RNS) #1. The CNA left the room and notified the RNS, and then returned to the room. When she returned to the room, the resident was still visibly choking and was blue in color. The CNA saw, "some food come out that looked like pieces of moist bread." When the RNS arrived, she asked to have LPN #3 paged to the unit. When LPN #3 arrived, she said the resident, "was gone." The CNA left the room. In a written statement dated [DATE], CNA #1 documented that at 5:15 pm on [DATE], she was assisting residents with meals in the dining room when she was told this resident was choking. Approximately one minute later the CNA arrived in the resident room, and the resident was sitting up and had a bread stick in her hand. LPN #1 got behind the resident and performed the [MEDICATION NAME] maneuver, while the resident was gurgling and spitting. The LPN put her fingers in the resident's mouth and pulled out chunks of food in between doing the [MEDICATION NAME]. The resident stopped drooling and she got more blue in color. RNS #1 arrived in the room and attempted the [MEDICATION NAME] maneuver. RNS #1 then stated that the resident was not breathing, and this CNA left the room. In a written statement dated [DATE], CNA #2 documented that around 5:00 pm on [DATE], she assisting residents with meals in the dining room when she was told this resident was choking. She was told to stay with the residents in the dining room at that time. She was then told that the resident was choking and that they needed help with her. When she entered the room, the resident was "purplish blue" in color and LPN #1 was performing the [MEDICATION NAME] maneuver. She saw the LPN swipe her mouth, but did not see anything come out. RNS #1 arrived in the room and attempted the [MEDICATION NAME] maneuver, and checked the resident's pulse, and listened to her heart with the stethoscope. RNS #1 then stated that the resident was "gone". The CNA left the room. In a written statement dated [DATE], LPN #1 documented that on [DATE] shortly after 5:00 pm, two CNA's notified her that this resident was choking. When she arrived at the room, the resident was slouched forward in bed, was blue and was not responding to voice or touch, and was not breathing. The resident was repositioned in bed so the LPN could perform the [MEDICATION NAME] maneuver. When she started the maneuver, chewed up noodles came up, and the LPN laid the resident on her side to "scoop her mouth". The resident still was not breathing so the [MEDICATION NAME] maneuver was continued. The resident expelled some bread, so her mouth was swept again. The LPN continued the [MEDICATION NAME] maneuver until RNS #1 arrived. RNS #1 attempted the maneuver, and the resident was still blue and was not responding. LPN #2 was paged, and when she arrived the resident had already passed away. In a written statement dated [DATE], RNS #1 documented that on [DATE] at 5:25 pm, she was paged to go to this resident's unit. When she arrived on the unit she was told this resident was choking. When the RNS entered the room, the resident was purplish gray and non-responsive, and LPN #1 was performing the [MEDICATION NAME] maneuver. The RNS put her finger down the resident's mouth and pulled out some unchewed pasta. RNS #1 attempted the [MEDICATION NAME], the laid the resident down and again reached in her mouth and, "got nothing". She listened to the resident's heart beat with a stethoscope, and there was no heart beat. In a written statement dated [DATE], the facility Chef documented that for dinner on [DATE], "everyone" got a breadstick with their ground meal unless they were supposed to have a pureed diet. The facility's investigation summary dated [DATE] at 4:51 pm, documented that this resident had received food that was not according to her diet consistency. The resident was delivered a dinner tray in her room with a food item not consistent with her diet consistency. A visitor saw the resident choking and notified staff. Nursing staff responded and attempted to clear the resident's airway with the [MEDICATION NAME] maneuver, but were unsuccessful, and the resident expired. The Certificate of Death dated [DATE], and signed by the facility physician, documented that the resident had expired due to [MEDICAL CONDITION], which was due to high blood pressure and [MEDICAL CONDITION]. During an interview on [DATE] at 12:05 pm, the Registered Dietician (RD) stated that the facility's definition of a House Diet was regular food and that a House Ground diet was regular food ground up. Additionally, the House Ground diet specifically said ' "no garlic bread and no bread sticks". The RD also stated that because of the consistency of the manicotti, it did not have to be ground up on a ground diet. She also stated that this resident preferred to eat her meals in her room, and she had a hearty appetite. The RD stated that the meal contents were supposed to be checked with the meal ticket by the cook and an aide. When the meal arrived on the unit, the nursing staff serving the tray, was supposed to check the meal on the tray with what was written on the meal ticket. She stated that on the evening on [DATE], the Administrator called her to come to the facility because this resident had choked while eating, and that there had been a breadstick with her meal. The RD stated that because this resident was on a house ground diet, and the diet definition specifically excluded bread sticks, this resident should not have had a bread stick. During an interview on [DATE] at 12:37 pm, RNS #1 stated that on [DATE] she was called to this resident's unit because the resident was choking. When she entered the room, LPN #1 was behind the resident performing the [MEDICATION NAME] maneuver, and the resident was blue/gray/purplish in color and was flaccid. She performed a finger sweep of the resident's mouth and pulled some bread and noodles out. LPN #1 told her she had already pulled bread out of the resident's mouth. The RNS attempted the [MEDICATION NAME] maneuver also, but was not able to clear the resident's airway. After listening to the resident's heart for two minutes and finding no pulse, LPN #2 came in the room and agreed that there was nothing more to do because the resident was a "Do Not Resuscitate". During an interview on [DATE] at 2:08 pm, CNA #3 stated that on [DATE] she had delivered the resident's dinner tray to her in her room. She stated that she checked the contents of the tray with what was on the meal ticket, then set up the tray for the resident. She stated that when she checked the meal ticket, she thought she saw a breadstick on the ticket because that was part of the main meal for that evening. After she had left the room, a visitor came to her and said this resident was choking. She went to the resident's room and the resident was blue and she was definitely choking. She immediately went into the hallway and shouted for help. LPN #1 arrived and began doing the [MEDICATION NAME] maneuver, and slapping the resident on the back. At one point the LPN put her finger in the resident's mouth and pulled out pieces of bread. After a couple minutes, RNS #1 arrived and took over doing the [MEDICATION NAME] maneuver, and slapping the resident on the back. After a couple minutes the RNS and LPN #2 determined the resident had passed away and there was nothing more that could be done. During an interview on [DATE] at 3:28 pm, the Administrator stated that on the evening of [DATE], she was in the building when she learned that this resident had choked and expired. She stated that she immediately began an investigation and determined that this resident had received a breadstick on her dinner tray, which she was not supposed to receive because she was on a ground diet. She stated that based on her findings, she believed the resident had choked on the breadstick. During an interview on [DATE] at 9:50 am, the Physician stated that he was not familiar with this resident prior to [DATE]. On the evening of [DATE], he was in the building when staff reported to him that the resident had "choked and died ." He stated that he did not have proof that the resident had choked, so based on her history he documented on the Certificate of Death that the resident had expired due to [MEDICAL CONDITION], which was due to high blood pressure and [MEDICAL CONDITION]. Resident #3 The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The MDS dated [DATE], assessed the resident to have moderate cognitive impairment. Review of nurse's notes dated [DATE] at 2:30 pm, documented the resident went to the hospital at 9:00 am for laproscopic hernia removal. Additional documentation at 6:22 pm revealed the resident was being admitted with a [DIAGNOSES REDACTED]. The hospital form titled "Patient Discharge Instructions" dated [DATE] documented "in case of emergency contact your doctor immediately or go to the nearest emergency room ". Nurse's notes dated [DATE] at 6:15 pm documented that the resident returned to the facility at 4:25 pm, with abdominal pain 7 out of 10 (pain scale), medicated for pain, abdomen firm, abdominal binder in place with small amount of sanguineous drainage noted at the surgical site. Nurse's notes dated [DATE] at 8:55 am documented that some serosanguinous drainage noted on the abdominal binder; abdomen hard and rounded with bowel sounds in four quadrants. At 2:00 pm it was documented incision line to abdomen dry no redness, resident out of bed propelling in wheelchair. At 9:00 pm it was documented that the resident received pain medication for abdominal pain to the surgical site with effectiveness. Nurse's notes dated [DATE] documented: 2:00 am; resident had two episodes of vomiting green/black fluid, abdomen firm, distended and bowel sounds are present in four quadrants. Sutures intact, physician aware "just keep an eye on him." 5:30 am; the resident had frequent brown emesis ("looks like chocolate milk"). Pulse oximetry 81% (POX oxygen level / normal 90 - 100%), the physician was called and ordered oxygen two liters via nasal cannula; expiratory wheezing noted. 6:30 am; still some nausea, POX 82 on room air, oxygen reapplied, HR 102, still wheezing. 7:10 am; increased respirations, very moist. Temperature 99.9, POX 81, continues to vomit brown liquid, MD aware, N.O. (new order) send resident to the hospital for evaluation and treatment. 7:45; 911 called to transport resident to ER. 8:00 am; went to resident room, noted resident unresponsive-code blue call. 8:00 am; compression started. 8:05 am; the rescue squad arrived. 8:30 am; transported to ER. 1915 (7:15 am) late note. @ 0655-obseved resident was more congested. Called Dr. Davis who said to send him out. The Physician's Interim Orders dated [DATE] documented a T.O. (telephone order); send resident to ER for eval and treatment. This T.O. entry did not include the time of the order. Review of the Patient Care Record (PCR) from the Emergency Medical Services (EMS) dated [DATE] at 8:00 am documented arrived on scene, confusion from staff concerning if EMS was called and for which patient. Heard staff call "Code Blue" (cardio-pulmonary arrest) patient noted in [MEDICAL CONDITION], CPR initiated by staff with chest compressions. While intubating the resident, suctioned for approximately 600 cubic centimeters (cc) of coffee ground like emesis. The resident remained asystole, CPR continued. At 8:08 am an additional EMS ALS (advanced life support) staff arrived, Large amounts of coffee ground like emesis noted in upper airway and suctioned. CPR continued and the resident arrived at the hospital at 8:32 am. Review of the hospital medical record dated [DATE] at 8:41 am documented that the "resident was found unresponsive shortly after complaining that he was nauseous". The resident had recent surgery two days ago for lysis of adhesions. The abdomen was noted to be obese, rounded appearance with scars noted in the surgical site noted in the entire abdomen, soft. The resident is in severe respiratory distress and ventilation was initiated. Under the section titled "History of Present Illness" it was documented that all history was obtained from the EMS and nursing home staff, as the resident is unconscious. The resident reportedly complained of nausea and difficulty breathing this morning and began to vomit coffee ground emesis. Nursing home staff found him five minutes later pulseless, unresponsive and apneic (not breathing). EMS found him asystole, CPR was initiated and the resident was suctioned for one liter (1,000 cc) of coffee ground emesis. Resuscitation continued and the resident was pronounced dead at 10:12 am. Review of a pamphlet titled "Adult Umbilical Hernia Repair" authored by the American College of Surgeons (undated) intended for patient education, documented the following: to contact the surgeon if you have: pain that will not go away, pain that gets worse, a fever of 101 degrees or more, repeated vomiting, swelling, redness or foul smelling drainage, strong or continuous abdominal pain or swelling of the abdomen. Interview with the Registered Nurse Supervisor (RNS) on [DATE] at 2:30 pm who stated on [DATE] it was reported to her from the aide, that the resident was vomiting just after midnight, green/brown in color. The RNS stated she called the physician and reminded him that the resident was one day post-operative, and the physician told her to "keep an on eye on him". The RNS stated the resident continued with more episodes of vomiting, "like chocolate milk". The RNS stated the resident then began with respiratory problems, and wheezing. The RNS stated a second call was placed to the physician around 3:30 am, and he ordered oxygen, a nebulizer breathing treatment and something for nausea. When asked if she reminded the physician that the resident was post-operative, she said "No", I reminded him once, I didn't think I needed to remind him again. When asked if she questioned the physician about contacting the surgeon, she said she had not. The RNS stated the resident's abdomen was distended and firm. She wondered if he aspirated while vomiting, but since he just had surgery, it was probably filled with gas. The RNS stated she should have sent him out. Interview with the resident's physician on [DATE] at 9:00 am who stated that he was called on [DATE] during the night and was unsure what time it was. He stated he was told the resident vomited, but never was told that the resident was repeatedly vomiting. He stated had he been advised of repeated vomiting he would have sent the resident to the emergency room after the first call. Additionally, he stated that even when the facility called to report the [MEDICAL CONDITION], he was again not told that the resident had vomited repeatedly. He stated he would have expected an immediate call back if the treatment he ordered did not work right away, not hours later, as it happened. He stated that there was a delay in the facility calling him back to report further decline in the resident's condition. When asked when he would expect the resident to be transferred to the hospital after giving the order, he stated that there was a delay in the transfer as well, he would have expected 911 called immediately. 10 NYCRR 415.12

Based on staff interviews and record review during standard recertification survey, the facility failed to ensure that new admission residents were free of significant medication errors for 5 (#6, 26, 81, 92, and 123) ) of 29 residents reviewed. The facility failed to ensure that effective systems were in place to obtain newly ordered medications from the pharmacy or the Emergency Medication Box to administer on the day of the admission and failed to notify the physician of the delay in the administration of the ordered medications. In addition the facility failed to identify and investigate medication omissions as medication administration errors. Specifically, Resident #6 was admitted on [DATE] and did not receive [MEDICATION NAME] ([MEDICAL CONDITION] medication), [MEDICATION NAME] (blood sugar control), [MEDICATION NAME] (pain control), Requip (restless leg syndrome), [MEDICATION NAME] (antipsychotic) and [MEDICATION NAME] ([MEDICAL CONDITION]) until the following day 05/28/2014. Resident # 26 was admitted on [DATE] and did not receive [MEDICATION NAME] and [MEDICATION NAME] (both antibiotics) until 05/15/2014, Resident # 81 was admitted on [DATE] and did not receive [MEDICATION NAME] (an antibiotic) and [MEDICATION NAME] (blood pressure) until 06/01/204, Resident # 92 was admitted [DATE] and did not receive [MEDICATION NAME] until 05/24/2014. Resident # 123 was admitted on [DATE] and did not receive [MEDICATION NAME] and Risperidal (antipsychotic) until 06/01/2014. This resulted in no actual harm with the potential for more than minimal harm that is Immediate Jeopardy for resident health and safety and Substandard Quality of Care. This is evidenced by: 1. Resident # 6: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ( a standardized assessment tool, (MDS) dated [DATE] assessed the resident as having severe cognitive impairment for daily decision making. A nurses note dated 05/27/14 at 10:15 am, signed by a Registered Nurse (RN) documented that the resident was admitted to the Nursing home from home. The Physician admission orders [REDACTED]. The Medication Administration Record (MAR) tabled for May of 2014 included lines with arrows written through the administration boxes for 05/27/14 for the following medications and times; [MEDICATION NAME], and Requip at 5 PM, [MEDICATION NAME], and [MEDICATION NAME] at 9 PM, indicating that the medications were not administered to the resident as ordered. The administration boxes for 05/28/14 and beyond did not include lines and arrows, but were open spaces that had initials written in the spaces, indicating the nurse that had administered the medication doses. The undated facility emergency narcotic medication box (EKit) content list, included [MEDICATION NAME] 5mg/325mg as one of the medications that were available to be administered to residents if needed. Review of both the unit and facility 24 hour reports dated 5/27/14, did not include documentation regarding the scheduled medication doses for 5 PM and 9 PM not being available or being omitted for Resident #6. During interview on 06/12/14 at 2:30 pm with the Charge Licensed Practical Nurse (CLPN) #1 who had obtained the admission medication orders from the physician, she stated that she writes the orders on an order sheet which includes a carbon copy to use as the MAR, so that the orders are automatically transcribed to the MAR. The CLPN # 1 stated that she added the administration times, according to the orders. She denied writing a line or arrow through the times for the administration times of 5 PM and 9 PM for 05/27/14. She stated that she usually left them blank and the medication nurses would fill the boxes in when the medications arrived from pharmacy. She added that the nurses were not allowed to sign their initials with a circle to indicate that the medication was not available. She further stated that she did not request an extra pharmacy delivery for the medication because she thought the pharmacy would see the times the medication were ordered to be given and automatically get the medication from the local pharmacy. During interview on 6/12/14 at 3:45pm LPN # 2, the medication nurse on 05/27/14, she stated that the lines and arrows were already written in the administration boxes for the evening doses of 5 PM and 9 PM, when she began the medication administration. She did not give the medications that had lines and arrows written through the boxes for 05/27/14. She did not question it, she assumed that the delay in the start of the medications had been addressed on the day shift. She further stated that she did not think to check the Kit, she thought the supervisor would have done that. During an interview on 06/12/14 at 3:55 pm the Registered Nursing Supervisor (RNS), who worked the evening the resident was admitted , stated that she did not recall being told that there was a problem with obtaining the resident's medication. She assumed that all medications had been taken care of because the resident was admitted so early in the day. She further stated that she was not aware that the administration boxes had lines and arrows written through them and that the resident did not get the ordered medications. The RNS stated that they would usually contact the pharmacy, contact the physician and obtain permission to give the [MEDICATION NAME] from the EKit. The additional medications, not available in an EKit, should have been reviewed by the RNS and the Director of Nursing (DON) to determine if they needed to be given right away. During an interview on 06/16/14 at 8:30 am the Pharmacy Director (PD), she stated that the pharmacy routinely delivered to the facility twice a day; the first one left the pharmacy at 11:00 am and arrived at the facility at approximately 3:00 pm, the second one left their pharmacy between 7 and 8:00 pm and arrived at around 11:00 pm. She stated that it is the nursing homes responsibility to contact the pharmacy to let them know that medications are needed prior to the next routine run, the pharmacy would then contact the local pharmacy to request the medications and delivery. The Registered Nurse Manager (RNM) was interviewed on 06/16/14 at 12:30 pm, she stated that the orders are usually obtained and transcribed by the charge nurses. She briefly checks that all the medications are ordered, she does not check the dates and times of administration or when the medications are scheduled to begin. She did not routinely sign the orders when she checks them. RNM #1 stated that she completed an admit/readmit check list with each admission, the list included to indicate if medications were ordered but, did not include to check that the medications arrived or that they were administered. RNM #1 stated that CLPN #1 should have contacted pharmacy to let them know the medication was needed for the evening medication pass, she was not aware if that had been done. She was also not aware that Resident #6 did not not receive her medications as ordered. She further stated that a notation should have been included on the 24 report sheet that the medications were needed and if the medications were not available the physician should have been notified and that should have been included in the documentation. During interview on 06/16/14 at 1:30 pm the resident's physician stated that he was on vacation when the resident was admitted but, that the resident should have received her evening medications as ordered and that the physician on call should have been contacted when staff realized the medications were not going to be available. 2. Resident #81: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed the resident as having intact cognitive skills for daily decision making. A nursing progress note dated 05/30/14 documented that the resident arrived at the facility at 3:40 pm. An undated physician's orders [REDACTED]. 1:00 pm, and 5:00 pm and [MEDICATION NAME] Suspension 125 mg = 2.5 ml by mouth every 6 hours, scheduled for administration at 6:00 am, 12:00 pm, 6:00 pm, and 12:00 am. The MAR dated 05/30/14 through 05/31/14, included blank administration boxes of [MEDICATION NAME] at 5:00pm on 05/30/14 and a line with an arrow in the administration box for [MEDICATION NAME] at 6:00 pm on 05/30/14. During interview on 06/12/14 at 9:00 am the RNM #3 stated that she was not aware that the resident had not received medications as ordered by the physician. The nurse responsible for the error was fairly new, but should have known to contact the physician get an order to administer the medications when they were received from the pharmacy. RNM # 3 stated that the LPN should have signed the medication orders and indicated that they were telephone orders. During interview on 06/12/14 at 3:15 pm LPN # 3 stated that she reviewed the admission medications with the physician via telephone and wrote the orders. LPN# 3 stated that she signs the orders and writes telephone order indicating they are telephone orders, but must have forgotten to do that this time. LPN #3 did not remember why the medications were not given, she thought they probably were not delivered by the pharmacy. LPN#3 stated that only a supervisor can order a STAT delivery from pharmacy and she could not remember notifying the supervisor. If medications are not available the physician should be called and new orders written on the MAR. LPN #3 was unable to provide documentation of a call to the physician. During interview on 06/12/14 at 3:30 pm RNM # 3 stated that new medication orders are faxed to the pharmacy and it usually takes 4-6 hours for delivery. LPN # 3 could have called the pharmacy for a STAT delivery when the resident was admitted late in the afternoon. LPN #3 should have called the physician when the medications were not available and should have documented the directions given by the physician as an order. On 06/17/14 at 1:00 pm RNM #3 was asked for the facility policy book, she reported that there was not a book on the unit, but there was one in the staffing room and all of the policies are in the computer. When asked, RNM #3 reported that not all staff have access to the computer system. During an interview on 06/17/14 at 2:45 pm LPN #3 stated that she did not remember what the physician told her when she called for directions on 05/30/14 but he always says the same thing, either give the medications when they arrive or hold until the next scheduled dose is due. 3. Resident # 126: The resident was admitted on [DATE] at 4:40 pm with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. The May 2014 MAR documented the above medications with the same times. The [MEDICATION NAME] had an arrow drawn in at the 9:00 pm time up to the 14th. There was an additional arrow drawn through the administration box for the 14th. There were no initials that the 9:00 pm dose was given. The [MEDICATION NAME] had arrows drawn through the 6:00 pm and 12:00 am doses to the 14th. There were additional arrows drawn through the boxes for the14th for those doses. There were no initials that the 6:00 pm and 9:00 pm doses were given. There was no documentation on the MAR why the doses were not given . There was no documented evidence of a physician order [REDACTED]. The only nurses note documented on 05/14/14 was written at 8:45 pm and included that the resident arrived at 4:40 pm from the hospital. This note included her diagnoses, her physical condition and her activities of daily living abilities, in addition to other assessments. There was no documentation of the physician being called for instructions because the medications [MEDICATION NAME] and [MEDICATION NAME] were not available to give at 9:00 pm and at 6:00 pm and 9:00 pm respectively. During interview on 06/17/14 at approximately 9:30 am LPN # 3, who gave medications the evening of 05/14/14, stated she probably did not give the evening medications because they were not in the facility yet. She stated that pharmacy doesn't get medications to the facility until 10:00 pm, even if they STAT it takes a long time to get the medications to us. She stated the RNM for the unit knew about the problems and the facility was working on it. She stated she started in February, and had been off orientation since the beginning of April. The medication problem had been going on since then. She stated she had not received education about what to do if medications were not on time. She stated she that she wrote the arrows in the boxes for the 14th to make it clear when the antibiotics started and when they should end. She stated she thought she called the physician about the antibiotics not being available. She stated she should have written a note. She also stated that [MEDICATION NAME] and [MEDICATION NAME] were not in the emergency kit and that the supervisor was aware that the medications were not in the facility. On 06/16/14 at 1:10 pm the policy titled " Ordering and Receiving Medications From Provider Pharmacy" was provided by the DON. This policy did not include a date. The DON stated she obtained it from the computer. It included under the title Procedures 3) Stat and Emergency Delivery , section a) If needed before the next regular delivery, fax the medication order to the pharmacy immediately upon receipt. Call the Pharmacy to inform the pharmacy of the need for prompt delivery and request delivery within 4 hours. Section b) Timely delivery of new orders is required so that medication administration is not delayed. The emergency kit is used when the resident needs a medication prior to pharmacy delivery. Section 5) New admission orders [REDACTED]. b) the nurse will make a back up call to the pharmacy to validate receipt of the order. If the order will not be received prior to the expected dose administration, the nurse will contact the physician to obtain new direction for medication administration. During interview on 06/16/14 at 4:01 pm the DON stated the process for new admission medications was to look at the discharge summary to obtain the medication orders, write the orders, discuss with the physician to see if he approved, he usually gives the telephone order, then the nurse send the orders to the pharmacy by fax. If it is a new admission the nurse also has to call the pharmacy to see that they received the orders. That nurse who faxes the orders and makes the call should ask the pharmacy if the medications will be here for the next scheduled dose. At that time if the pharmacy realizes medications won't be here on a regular run then they will either send them on a stat run or call the satellite (local) pharmacy. Based on this the medications should be here for the next dose administration. She was not sure when this procedure went into effect. During interview on 06/17/14 at approximately 9:45 am the resident's physician stated the resident should have received the [MEDICATION NAME] and [MEDICATION NAME] on the evening of her admission. He stated he did not remember if he was called about this resident's medication. He stated that this has been an occasional problem for the facility. During interview on 06/17/14 at 10:23 am RMN # 3 stated she was not aware that LPN # 3 did not give the resident her [MEDICATION NAME] and [MEDICATION NAME] the evening of her admission. She stated there was no reason to miss them, those drugs are in the emergency kit (EKit). She stated the process if medications are not available is that the nurse has to call the physician, let him know then he decides what to do, gives an order and the nurse has to document it. The nurse writes the orders on the MAR and should write a nursing note. She stated she was not aware of LPN # 3 not using the correct process for medications so could not correct the problem. She stated she did not know why LPN # 3 put arrows through the boxes for the 14th, it was not their process. RNM # 3 stated the LPN had been preceptored during orientation, but but had not had a performance evaluation since then. Following this interview the Surveyor and RNM # 3 went into the medication room to observe the EKit. There was a list of medications available in the EKit which included the [MEDICATION NAME] 250 mg and the [MEDICATION NAME] 250 mg. During an interview on 06/17/14 at 2:53 pm the Medical Director stated that if medications were not available in the facility to give a resident, his expectation was that the nurse would call the physician, notify the Nursing Supervisor or notify the DON if the Supervisor could not handle the situation. He stated the nurse should not make a decision on medications, the physician needed to make the decision whether the medication could wait to be given when it came in or wait until the morning, or what needed to be done. During interview on 06/17/14 at 3:16 pm the RNS for the evening shift stated nurses let her know if medications are not in the medication cart to give a resident at night. She would see if the medication was in the EKit, call the physician to see what he wanted to do, call the pharmacy. She did not know if LPN # 3 had let her know of the medications not available. She stated she did not know why LPN # 3 did not give the antibiotics from the emergency kit, there should be an order for [REDACTED]. The nurses call the physician, get the order and take medications from the kit themselves. She was not aware that LPN # 3 did not give the evening medications. During a repeat interview on 06/17/14 at 11:46 am the DON was asked what the Nursing Supervisors role was in making sure medications were in the facility to give evenings. She stated their piece is to make sure the nursing assessments were done and to give direction to nurses as to what to do. She stated that a nurse finding that medications were not available should let the Supervisor know and call the physician. She stated the pharmacy was new in December 2013. She stated that at this time there were no written procedures from the pharmacy about what would happen for new medications. She stated they had been talking about problems in the monthly pharmacy meetings. She stated the RNM's do not attend these meetings. She has nurse leadership meetings two times a month that the RNMs and charge nurses attend. These nurses then pass along the information from leadership meetings to the rest of the staff. She stated that staff were made aware to fax medication orders and call the pharmacy and tell them when the next dose is needed by through the leadership meetings. She was asked for documentation of this but did not produce it. On 06/17/14 at approximately 3:00 pm the DON was asked if she would consider the medications not being given the evening of admission a medication error. She stated yes. She was asked to provide the medication error reports for the past 3 months. She brought in 3 reports, none of which were the medications not given the evening of admission. The contract with the pharmacy was requested on 06/17/14. It was provided. The term of agreement was for December 1, 2013 to November 30, 2015. Under 2. Obligations of the Pharmacy 2) pharmacy will deliver products in accordance with the pharmacy's routine delivery schedule. 4) Pharmacy will deliver products on a Stat basis when the contents of the Emergency Kit cannot satisfy the needs of the customer. Under 3. Obligations of the Customer B. Use its best efforts to aggregate, organize and plan daily orders to Pharmacy to minimize the number of Stat orders; including, but not limited to using medications contained in the Emergency Kits in lieu of requesting a Stat order. 10NYCRR415.12(m)(2)

Based on interview and record review the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident during the recertification survey. Specifically: administration was aware of problems in obtaining medications from the pharmacy but did not identify the extent of the problems related to the failure to provide medications timely since April, that nurses were not documenting when the physician was called as per policy; that medication errors were occurring and were reports and investigations were not completed, that the emergency kit was not utilized when possible. Meetings with the pharmacy resulted in a plan of action ( use of a satellite pharmacy) to prevent this from continuing in April. There was no Quality Assurance (QA) monitoring put into place to evaluate the effectiveness of the plan and the problem continued which resulted in Immediate Jeopardy to resident health and safety. This is evidenced by: Reference F 333 - L The facility failed to ensure that staff followed acceptable standards of practice and administered medications in a timely manner as ordered by the physician; failed to ensure medication errors or omissions were identified and reports were filed; they failed to ensure the existing policy for contacting the physician when medications were not available for administration, and failed to utilize the emergency kit when medications were not available. During interview on 6/16/14 at 4:01 pm the Director of Nurses stated she was aware of the problem of obtaining medications in a timely manner to give newly admitted residents on the evening of their admission about a month and a half ago. She stated they have monthly meetings with pharmacy. She stated the solution to the problem was to let nurses know to call the doctor to get orders to hold it, use the emergency kit, what ever the doctor thought appropriate. She stated the STAT run from pharmacy was supposed to help with the problem. She stated they have not been doing a formal audit of whether the nurses are calling the doctor. She stated she was not aware they were not. She stated they can use a local pharmacy to get medications. She stated the regular pharmacy is supposed to take care of obtaining medications from the local pharmacy. She stated there is nothing in writing from the pharmacy about this. She stated there was no QA being done about how often the problem with lack of medications was occurring. On 6/17/14 at approximately 3:00 pm the Don was asked if she would consider the medications not being given the evening of admission a medication error. She stated yes. She was asked to provide the medication error reports for the past 3 months. She brought in 3 reports, none of which were the medications not given the evening of admission. During interview on 6/16/14 at 4:49 pm the Administrator stated they had identified that evening medication not in the facility for administration for new admissions was a problem. She stated they had been talking with the pharmacy and the pharmacy was responsible for getting the medications to the facility for the first dose. She stated that the facility does not call the satellite (local) pharmacy the pharmacy (contracted) does. She stated that the provision of the satellite (local) pharmacy started April 23 rd. She also stated that it was a new procedure to fax the medication orders to the pharmacy and then follow up with a call to them. She stated they thought they were on tract with the medications. She stated that QA was not doing any audits (monitoring) on the medication problem. During telephone interview on 6/17/14 at 2:53 pm the Medical Director stated he had attended pharmacy meetings and was aware of the problems with medications. He stated that they had made arrangements with a local pharmacy and that nursing staff were aware of the satellite pharmacy and the 5:00 pm time frame. He thought it was mentioned that a policy and procedure was in place. He stated he thought he saw a draft policy on ordering and giving medications recently. 10NYCRR415.26

Based on interview and record review the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies which resulted in immediate jeopardy during the recertification survey. Specifically: the facility identified that obtaining medications in a timely manner to be problem but did not identify the extent of the problems related to the failure to provide medications timely. That nurses were not documenting when the physician was called as per policy; reports and investigations were not completed when medications were omitted, that the emergency kit was not utilized when possible. The facility made changes to the medication procurement (instituted a follow up call to the pharmacy to confirm receipt of the orders and to let them know when the first dose of medication was needed) and delivery system ( instituted a local satellite pharmacy) in April. They failed to put a plan into place to evaluate the effectiveness of their plan and the problem continued which resulted in immediate jeopardy at F 333. This resulted in Immediate Jeopardy to Resident health and safety. This is evidenced by; F 333 The facility failed to ensure that staff followed acceptable standards of practice and administered medications in a timely manner as ordered by the physician; failed to ensure medication errors or omissions were identified and reports were filed; they failed to ensure the existing policy for contacting the physician when medications were not available for administration and failed to utilize the emergency kit when medications were not available. During interview on 6/16/14 at 9:51 am the Registered Nurse Manager RNM of Unit 3 stated that Administration was aware of the problem of getting medications for evening doses for newly admitted residents. She stated the problem dated back at least to when they started using this pharmacy. She stated that the solution was to STAT the medication ( obtain from the satellite pharmacy) but that was not any better. She and the Charge Licensed Practical Nurse stated they did not know of any Quality Assurance audits being done on admission medications. During interview on 6/16/14 at 4:01 pm the Director of Nurses stated she was aware of the problem of obtaining medications in a timely manner to give newly admitted residents on the evening of their admission about a month and a half ago. She stated they have monthly meetings with pharmacy. She stated the solution to the problem was to let nurses know to call the doctor to get orders to hold it, use the emergency kit, what ever the doctor thought appropriate. She stated the STAT run from pharmacy was supposed to help with the problem. She stated they have not been doing a formal audit of whether the nurses are calling the doctor. She stated she was not aware they were not. She stated they can use a local pharmacy to get medications. She stated the regular pharmacy is supposed to take care of obtaining medications from the local pharmacy. She stated there is nothing in writing from the pharmacy about this. She stated there was no QAM being done about how often the problem with lack of medications was occurring. On 6/17/14 at approximately 3:00 pm the Don was asked if she would consider the medications not being given the evening of admission a medication error. She stated yes. She was asked to provide the medication error reports for the past 3 months. She brought in 3 reports, none of which were the medications not given the evening of admission. During interview on 6/16/14 at 4:49 pm the Administrator stated they had identified that medication not in the facility for administration for new admissions was a problem. she stated they had been talking with the pharmacy and the pharmacy was responsible for getting the medications to the facility for the first dose. She stated that the facility does not call the satellite (local) pharmacy the pharmacy (contracted) does. She stated that the provision of the satellite (local) pharmacy started April 23 rd. She also stated that it was a new procedure to fax the medication orders to the pharmacy and then follow up with a call to them. She stated they thought they were on tract with the medications. She stated that QAM was not doing any audits (monitoring) on the medication problem. 10 NYCRR 415.27(a-c)

Based on record review and interviews during an abbreviated survey (NY 585) the facility did not ensure that each resident received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (#82) of two residents reviewed. Specifically, the facility did not ensure that a resident who was having increased pain, swelling, and redness to his knee was assessed by a Registered Nurse (RN), that ongoing assessment and documentation was completed after the resident started on antibiotics for an infection to the area, or that the physician was notified when the resident continued to have symptoms of an infection. This resulted in actual harm that was not immediate jeopardy. This is evidenced by: Resident # 82 The resident was admitted to the nursing home on 5/1/14 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident to have no cognitive impairment, and that he is understood and understands. An initial nursing assessment dated [DATE] at 3:35 pm by the Registered Nurse (RN) had no documented evidence of redness, pain, or swelling to the left knee. A nurse ' s note dated 5/7/14 at 6:45 am by the Licensed Practical Nurse (LPN) documented that the resident complained of right stump pain but had no complaints of left knee pain. A nurse ' s note dated 5/7/14 at 7:45 am by the LPN documented that the resident was seen by the MD. A nurse ' s note dated 5/8/14 at 12:30 pm by the LPN documented that the left knee was noted to be swollen, painful, and warm to touch and that the resident had a history of [REDACTED]. It documented that the Medical Doctor (MD) was made aware and a new order was obtained for [MEDICATION NAME] (an antibiotic). A physician's orders [REDACTED]. There is no documented evidence of a Registered Nurse (RN) assessment of the left knee. A nurse's note dated 5/11/14 at 4:00 am by the LPN documented that the resident was medicated with [MEDICATION NAME] (narcotic pain medication) for achiness in both legs. The first nurse's note written by an RN 5/11/14 at 10:00 pm, did not include documented evidence that the left knee was assessed. A nurse's note dated 5/13/14 at 2:00 pm by the RN documented that the resident was medicated for pain that was rated at a ten out of ten (ten being the worst), but did not include documentation of where the pain was located. The note did not include evidence that the left knee was assessed. A nurse's note dated 5/14/14 at 10:00 pm by the LPN documented that the resident received [MEDICATION NAME] at 3:30 pm for ten out of ten rated pain to his left knee. There was no documentation as to what the left knee looked like. A nurse's note dated 5/16/14 at 4:50 am by the LPN documented that the left knee was noted with increased warmth, redness, and was tender to touch. There is no documented evidence in the nurse's notes or on the twenty-four hour supervisor report for this day that the left knee was assessed by an RN. A nurse's note dated 5/16/14 at 10:00 pm by the LPN documented that the resident was medicated with [MEDICATION NAME] at 3:30 pm for left knee pain of six out of ten; 5/17/14 at 1:30 pm for pain seven out of ten. There is no documentation of what the knee looked like. A Medication Administration Record [REDACTED]. The last dose of [MEDICATION NAME] was signed for on 5/17 at 9:00 pm. There is no documented evidence that the left knee was assessed after the completion of the antibiotics on 05/17/2014. Nurse's notes continued to document each shift until 5/19/14 at 10:15 am that the resident was still taking the [MEDICATION NAME]. Nurse ' s notes dated 5/19/14 by the RN at 6:00 pm documented that the resident was medicated for bilateral leg pain (seven out of ten) and 10:00 pm for bilateral leg pain, and that the redness to the left knee continued, that the resident was placed in the physician's book for examination; There is no documented evidence that this information was added to the unit twenty-four hour report book or the twenty-four hour supervisor report. A nurse's note dated 5/20/14 at 5:00 am by the LPN documented that the resident continued to have redness to his left knee, and on 5/21 at 12:40 am the resident was medicated for left knee pain and had gone out of the facility for an appointment with the surgeon to have the sutures removed from the right stump. A surgical consult sheet dated 5/21/14 documented that the resident was complaining of pain, swelling, and redness in the left knee for a couple of days. It documented that a needle aspiration of the left knee over the patella showed frank puss. The resident was sent to the hospital for admission; "Orthopedics called for emergency surgery today." A hospital history and physical dated 5/21/14 documented by the physician that the resident was admitted for an "excision and drainage of a left prepatellar bursa abscess." During an interview on 6/20/14 at 11:20 am the charge LPN #1 stated that she did not usually do patient care and none of the nurse's reported to her that the resident's knee was not improved or getting worse. During an interview on 6/20/14 at 1:48 pm the registered Nurse Supervisor #1 (RNS) who was on when the area was noted with redness, stated she checked his wounds a few days a week but did not document it. She stated that she looked at it after he started the antibiotics and it was a little worse but she did not notify the MD. The RNS further stated that she should have documented when she checked the area and should have notified the MD when the area looked worse. During an interview on 6 /20/14 at 3:00 pm the LPN #2 stated that when he was admitted he had no issues with his left knee but around 6/5/14 the resident ' s son voiced concerns about the resident ' s left knee being slightly red and that he had been on long term antibiotics in the past for [MEDICAL CONDITION], so she reported that to the supervisor. LPN #2 stated that the supervisor went in the room with the resident and assessed the area, and at that time there was no pain, or swelling and but slight redness. She further stated that she did not document this or contact the MD but she should have. During an interview on 6/20/14 at 3:30 pm the Registered Nurse Manager (NM) stated that she did not find out about the resident being on an antibiotic or having a problem with his left knee until 5/9/14 during morning report. She stated that the charge LPN contacted the physician and got an order for [REDACTED]. During an interview on 6/20/14 at 5:00 pm the DON (Director of Nursing) stated that the area should have been assessed by an RN when it was discovered and staff should have documented every shift what the area looked like while on the antibiotics. She further stated that staff should have contacted the MD when there was no improvement after the antibiotics were started. During an interview on 6/20/14 at 10:15 am the resident ' s physician stated that he did not recall being asked to see the resident and that he should have been contacted after forty-eight hours on the medication (antibiotic) if the resident had no improvement or the area worsened. 10 NYCRR 415.12

Based on observation, record review and interview the facility failed to ensure that the resident environment remained as free of accident hazards as possible on three of three units during the extended recertification survey. Specifically: Hot water temperatures were observed to range from 122-132 degrees Fahrenheit at 17 of 19 sinks in resident sleeping rooms and other resident accessible areas. The maintenance department's hot water temperature logs documented temperatures ranging from 121 to 128 degrees Fahrenheit on nine separate days between July 20, 2012 through October 19, 2012. The staff person responsible for taking the water temperatures knew the acceptable limit of 120 degrees Fahrenheit, but was not given specific training on what temperatures should be brought to the Maintenance Director's attention or adjusted. The facility did not have a policy regarding hot water temperatures on site. This had the potential to affect 51 residents with cognitive, sensory and motor skills impairments. This resulted in no actual harm with the potential for serious harm that is Immediate Jeopardy to resident health and safety and is Substandard Quality of Care. The facility reduced the hot water temperature delivered to resident accessible fixtures and notified staff to be aware of the temperature of hot water at this time thereby removing the immediate risk to resident health and safety prior to survey exit. This was evidenced by: During observation of the environment on 10/30/12 at approximately 1:30pm the following water temperatures were taken with the Maintenance Director present in resident rooms and common areas. The Maintenance Director stated he agreed with each temperature taken. Unit 1: Room 101 was 124 degrees and at that time the Maintenance Director stated the water was very hot; Room 109 was 122 degrees; Room 110 was 124-125 degrees; Room 114 was 122-124 degrees; Room 124 was 125-126 degrees; the Shower Room C sink was 123 degrees. Unit 2: Room 201 was 123 degrees; Room 225 was 125 degrees. At this time the Maintenance Director stated he was not aware of these water temperatures and that the water temperatures are taken weekly. Room 214 was 122-124 degrees; Room 205 was 126-128 degrees; Shower Room A sink was 125-126 degrees. Unit 3: Room 306 was 128 degrees; Room 309 was 132 degrees; Shower Room A was 126-128 degrees at the sink; Room 316 was 126-128 degrees; Room 319 was 124 degrees; Room 323 was 126 degrees. The facility Weekly Maintenance Checklist sheets documented under hot water temps that on 7/20/12- Wing 3 was 121 degrees; 7/27/12- Wing 1 was 122 degrees and the core area was 122 degrees; on 8/3/12- Wing 2 was 122 degrees, Wing 3 was 121 degrees; on 8/10/12- Wing 3 was 121 degrees; on 8/31/12- Wing 1 was 121 degrees; on 9/7/12- Wing 1 was 123 degrees, Wing 2 was 122 degrees, Wing 3 was 126 degrees and core (bathrooms in the administration area of the facility) were 127 degrees; on 10/12/12- Wing 3 was 121 degrees, the core area was 123 degrees; and on 10/19/12- Wing 2 was 128 degrees and the core was 122 degrees. The facility identified 51 residents ( 16 on Wing 1, 16 on Wing 2 and 19 on Wing 3) who could independently use the sinks through interviews with Certified Nurse Aides (CNA). The Administrator and Maintenance Director on 10/30/12 at approximately 5:00pm were asked for their policy regarding hot water. They were unable to provide one. On 10/31/12 at approximately 10:00am the Administrator stated there was no hot water policy in the facility and they were obtaining it from corporate. During an interview on 10/30/12 at 3:22pm the maintenance worker responsible for taking the water temperatures stated he checks the temperatures once a week, usually on Friday. He stated he tests the kitchen, and tests the laundry, then does the units. He stated he usually did one room or the the clean utility room. He stated the temperature should be 120 degrees and that it couldn't be above that. He stated he also tested the bathroom up front (core area). He stated he never found a problem on the units, temperatures were always around 120 degrees +/- 1 or 2 degrees. He stated he does not report a temperature of 1 or 2 degrees above 120 degrees. During an interview on 10/31/12 at 8:28am the maintenance worker stated he did not know how to calibrate the thermometer. He was asked what he did when he got the reading of 128 degrees on 10/19/12 and stated he believed he told the Maintenance Director the temperature was high. He did not remember what he said. He stated he was never trained about what to do if acwater temperature was in the range above 120 degrees. During an interview on 10/30/12 at 3:30pm the Maintenance Director provided the Weekly Maintenance Checklist sheets from March to October. He stated he relies on staff to let him know of problems. Then stated he looks at them once a week and stated he was not aware of the elevated temperatures on 10/19/12. At approximately 5:30pm he was again interviewed and stated that at the end of August they replaced the pump circulator that pushes water to the rooms. He stated he did not do any enhanced testing of water temperatures when the pump was installed. He stated the new pump probably pushes more water through the pipes because it is new. He stated he did not have any policies about doing water temperature checks. He was just told by the previous Administrator how to fill out the Weekly Maintenance Checklist, nothing else. During an interview on 10/30/12 at 3:40pm a 3:00pm - 11:00pm CNA # 1 stated that the water in the shower is very hot and the water in the rooms is hot. She stated she has to add cold water. She stated she had filled out a maintenance slip for the hot water, but did not know when. During an interview on 10/30/12 at 3:56pm 3:00pm - 11:00pm CNA # 2 stated that the water in some of the rooms gets very hot but she never reported it. This surveyor and the CNA went into the shower room and ran the hot water in the sink. The surveyor could not leave her finger under the running water. The CNA also put her finger under the water and stated it was very hot. She stated other sinks get that hot. During an interview on 10/30/12 at 4:03pm 3:00pm - 11:00pm CNA # 3 stated that the water in the sinks in resident rooms is extremely hot and that she had reported it on a maintenance slip. She did not know when however. She stated that she has to add cold water. She identified 5 residents who could use their sinks independently without assist from staff. She stated she had seen one resident using the sink to brush her teeth, but did not think that resident always knew cold from hot. She also identified another resident who could use the sink independently who wandered into other resident rooms. During an interview on 10/30/12 at 4:10pm the Activity Aide of Unit 1 was asked to check the water in the sink in the activity room, located on the dementia unit. The surveyor could not hold her finger under the running water. The Activity aide could not hold her finger under it and stated it was too hot. She stated there were two residents who could independently use the sink who spend time in this activity room. She stated if someone did not know better they could burn themselves. During an interview on 10/30/12 at 4:45pm the Administrator and Director of Nurses (DON) stated they were not aware of the water temperatures being above 120 degrees. Neither was aware of the maintenance records showing the elevated water temperatures. Both stated they would expect that if the temperature was above 120 degrees it would be reported to the Maintenance Director. Then the Maintenance Director should let the Administrator know what was done to correct the situation in morning meeting. If he could not correct the problem immediately then he should let nursing know so they could take whatever action was needed. The DON stated none of her staff ever let her know of excessively hot water. The maintenance slips from March 2012 to October 2012 were examined at approximately 5:30pm on 10/30/12 and there were no slips pertaining to excessive hot water temperatures found. The Maintenance Director stated he did not remember seeing such a slip and none were recorded in the master list of request slips. During an interview on 10/31/12 at 8:36am 7:00am -3:00pm CNA # 4 stated she has noticed water was hot in some rooms and that she had let maintenance know by a phone call. She stated it was a while ago and did not remember when it was. She stated there are residents on the unit who could go to the sink and turn the water on independently without staff assist. She thought there were about 10 to 15 such residents. She stated she recently switched to days and it was on evenings when she noticed the hot water. During an interview on 10/31/12 at 8:41am 7:00am -3:00pm CNA # 5 stated she noticed the water in resident rooms was very hot. She stated there were residents who could maneuver the sinks independently but she was not sure how many. She stated she had not seen anyone get burned by the water but if someone left the water run a while they could get burned. She stated she never let anyone know because she always cools the water down. During an interview on 10/31/12 at 10:14am an alert, oriented resident was sitting in the core area at the front of the facility. He stated he did use the bathrooms in this area. He stated he had his choice of three bathrooms. He stated he could not remember if the water in the sinks there was hot but stated a few days ago the water in his room was exceptionally hot and he had to add cold water. He stated he never thought to tell anyone. 10NYCRR 415.12(h)(1)

Based on record review and staff interviews the Quality Assurance(QA) program failed to have a program that readily identified issues that had the potential to cause serious harm to residents during the extended recertification survey. Specifically, the QA Committee failed to ensure that the resident environment remained as free of accident hazards as possible on three of three units. Hot water temperatures were observed to range from 122-132 degrees Fahrenheit at 17 of 19 sinks in resident sleeping rooms and other resident accessible areas. Review of the maintenance department's hot water temperature logs revealed temperatures ranging from 121 to 128 degrees Fahrenheit on nine separate days between July 20 through Oct. 19, 2012. This resulted in no actual harm with the potential for serious harm that is Immediate Jeopardy to resident health and safety. The facility instituted corrective measures to remove the immediate jeopardy to residents prior to survey exit. This was evidenced by: Refer to F323 Accidents. During an interview with the Director of Nurses and Administrator on 10/30/12 at 4:45pm, they stated that they were not sure what the maximum temperature should be, and they were not aware of the water temperature exceeding 120 degrees. Both expected that if the temperature was above 120 degrees it would have been reported to the Maintenance Director, and the issue brought to the morning meetings for further review. During an interview with the Director of Maintenance 10/30/12 at 5:30pm, he stated that a new pump circulator was put in place the end of August. He stated he did not do any enhanced testing of water when this was completed. Additionally he stated that he did not have any policies regarding water temperatures. During an interview on 10/31/12 at 9:45am the DON and Administrator stated the facility had not done quality assurance in the area of monitoring hot water temperatures because they had not been aware of any issues. The DON agreed at the time of this interview that, based on the survey findings, there was the potential for someone to be burned. Additionally, they stated that daily temperatures would be taken and this would be closely monitored. 10NYCRR 415.27(a-c)