Every finding on record at Glendale Home-Schdy Cnty Dept Social Services

Based on record review and interviews conducted during survey, the facility failed to ensure each resident received adequate supervision to prevent accidents for one (Resident # 3) of three residents reviewed. Specifically, Resident #3 who was at high risk for falls and at risk for bleeding, fell out of bed with no injury on 05/25/2023, while care was provided by one Certified Nurse Aide per care planned interventions. The facility failed to (a.) reassess the resident's risk for falls, (b.) assess the resident for safe bed mobility with one staff, and (c.) implement new interventions to mitigate the risk of an accident. A fall risk assessment was completed on 06/06/2023 with the resident scoring a higher risk for falls than previously assessed, without documented evidence the facility assessed the resident for safe bed mobility and/or new interventions to mitigate the risk of an accident. Subsequently, on 06/19/2023, Resident #3 fell out of bed while care was being provided by one Certified Nurse Aide and was assessed with minor injuries. On 06/21/2023, the resident had a change in condition and was sent to the hospital where they were diagnosed with pelvis fractures (broken bones in the area of the body located between the hips) multiple pseudoaneurysms (contained rupture of an artery) that required embolization (procedure that stops blood flow to a specific blood vessel) of the right pudendal artery (passes through the pelvis). This resulted in actual harm to Resident #3 that was not Immediate Jeopardy.Findings include: The Policy and Procedure titled Falls Protocol, dated 07/22/2016, documented steps to be taken with all falls. The Registered Nurse/Licensed Practical Nurse would complete the Incident and Accident report and would document in the medical record identifying incident, assessment, and treatment rendered. The Policy and Procedure titled, Incident and Accident Reporting, dated 06/2022, documented Incident and Accident reports would be reviewed by the Interdisciplinary Team during the Interdisciplinary Team meeting. The facility administrator was responsible for ensuring implementation of individualized interventions to prevent reoccurrence. A nursing assessment would be completed for all incidents by the Registered Nurse Supervisor/Charge Nurse/Registered Nurse On-Call. A Registered Nurse Assessment was required for all observed and unobserved falls prior to the resident being moved. Major injury included bone fractures. When indicated, immediate intervention/action would be taken at the time of the incident to keep the resident in the safest environment and would be noted on the Incident/Accident Form under the Nursing Review section, in the Progress Notes, and on the Certified Nurse Aide Nursing Instructions. Immediate action(s) would be reviewed by the Interdisciplinary Team and evaluated and/or altered if indicated. The resident's Care Plan and the Certified Nurse Aide Nursing Instructions would be updated by the Team at that time. Resident #3: Resident #3 was admitted to the facility with the diagnoses of congestive heart failure (a chronic, progressive condition where the heart muscle is too weak or stiff to pump blood efficiently, causing fluid to build up in the lungs and body), multiple sclerosis (body's immune system attacks the protective covering of the nerve cells of the brain), and history of falling. The Minimum Data Set (a resident assessment tool) dated 04/28/2023, documented the resident had severe cognitive impairment, usually made themselves understood, and usually understands others. The resident was assessed as totally dependent on staff for bed mobility (how the resident moved to and from lying position, turned side to side, and positioned body while in bed or alternate sleep furniture). The Comprehensive Care Plan for At Risk for Falls due to impaired mobility with an effective date of 12/20/2016, use of narcotics for pain control, and diagnosis of multiple sclerosis, the resident would be free from injury from falls. Interventions included resident belongings within reach, call light in reach, monitor resident to ensure positioned in middle of the bed, and position resident in center of bed. The Comprehensive Care Plan for Anticoagulation Therapy: Medication Use, effective 12/20/2016, documented the resident received Eliquis (blood thinner, anticoagulant). Interventions included avoid bumping and handle resident gently when providing hands on care. Care Plan for ADLs (Activities of Daily Living): All Tasks, effective 05/10/2018, documented the resident required assistance with Activities of Daily Living and bed mobility. Interventions included staff to provide Activities of Daily Living assistance according to Nurse Instructions/Certified Nurse Aide care card. Resident Nursing Instructions (resident care instructions used by the Certified Nurse Aide) dated 05/01/2023 to 10/31/2023, documented one person physical assist for bed mobility effective 08/07/2014. A Fall Risk assessment dated [DATE] documented the resident had no falls in the past three months. The fall risk score was 12, high risk. The Incident/Accident Form for Resident #3 dated 05/25/2023 at 11:30 AM, documented an observed fall. There were no injuries. Resident Statement documented they objected to giving a statement. Identification of Root Cause/Contributing Factors documented the resident was last observed in bed during care and rolled on side. There was no documented evidence of a review by the Registered Nurse section per the facility's policy for Incident and Accident Reporting, with immediate care and actions taken to keep the resident safe and prevent reoccurrence. Some of the handwritten documentation on the incident/Accident Form was illegible and the facility was asked to provide clarification: An attestation dated 11/17/2025 by Assistant Director of Nursing #1, documented the Incident/Accident Form dated 05/25/2023 at 11:30 AM, was completed by Registered Nurse #3. Registered Nurse #3 was called into Resident #3's room at 11:30 AM. The resident was lying on the floor with a pillow under their head. Certified Nurse Aide #1 reported the resident rolled out of bed when they turned around to get more linen. Staff education was given to the certified nurse aide. Education provided to Certified Nurse Aide #1 was inconsistent with what was documented on the Incident/Accident Form dated 05/25/2023: Incident and accident Form dated 05/25/203 documented the resident rolled out of bed when Certified Nurse Aide #1 turned around to get more linen. On Site Education for Certified Nurse Aide #1 dated 05/25/2023 for an Incident/Accident occurrence on 05/25/2023, documented a verbal education for positioning resident - roll resident toward Certified Nurse Aide #1. Certified Nurse Aide #1 stated they would roll the resident toward them and not away from them. There was no documented evidence of education that addressed the aide turning around to get more linen. A Medical Progress Note dated 05/25/2023 at 8:18 PM by Nurse Practitioner #1, documented the resident was seen for follow up and a fall out of bed this morning, 05/25/2023.The resident reportedly rolled out of bed during care and denied hitting their head. The plan was to keep bed in the lowest position and anticipate needs. There was no evidence of any injury. There was no documented evidence of Interdisciplinary Team review of the fall or a fall risk assessment by nursing following the fall.Review of Physical/Occupational Therapy evaluations did not document any evaluation/treatment for safe bed mobility in May 2023.The Comprehensive Care Plan for At Risk for Falls was updated as follows:On 05/25/2023: at 11:30 AM Licensed Practical Nurse reported the resident rolled out of bed. The resident denied pain/discomfort and no redness or bruising was noted. Resident denied hitting their head. On 05/26/2023: a care plan intervention for staff education was added. There was no documented evidence regarding the details of education provided and there was no documented evidence of other new interventions to prevent falls.A Fall Risk assessment dated [DATE] documented one to two falls in the past three months. The fall risk score was 14, high risk.Review of the Care Plan for At Risk for Falls did not document any new interventions were implemented to mitigate the risk of an accident.The Incident/Accident Form for Resident #3 dated 06/19/2023 at 10:05 PM, documented an observed fall. Certified Nurse Aide #2 was providing care and rolled the resident away from them and the resident slid off the bed. The bed was about two feet off the ground. The resident was lying on the floor with their head against the closet. Injuries documented a one (1) centimeter abrasion on the left knee and a three (3) centimeter long by 0.3-centimeter-wide abrasion on the right upper back. Major injury documented pending x-ray results in the AM (morning). Nursing Review section, immediate care provided documented registered nurse assessment. Resident had two small abrasions to upper right back. Range of motion to arms/legs WNL (within normal limits). Denied pain. Resident was lifted to bed using a mechanical lift. X-rays of the neck, right arm, and right shoulder were ordered. Identification of Root Cause/Contributing Factors documented Certified Nurse Aide #2 was doing care in bed in the resident's room at 10:05 PM. Other contributing factors: Certified Nurse Aide rolled the resident away from them and they slid off the bed onto the floor.The Facility Witness Interview Statement form dated 06/19/2023 by Certified Nurse Aide #2, documented they cleaned the front of the resident and when they turned the resident away from them to clean the back of them, the resident slid off the bed and fell next to their closet. Certified Nurse Aide #2 documented the pads were very slippery/thin which could have been one of the reasons the resident had fallen and to prevent this from happening they would get help from another aide and would turn the resident toward them. A Nursing Progress Note dated 06/19/2023 at 10:40 PM by Registered Nurse #4, documented that at 10:05 PM, the licensed practical nurse called to say the resident was on the floor. Registered Nurse #4 reported to the room and per the certified nurse aide, they were performing care in bed and when they rolled the resident away from them, they slid off the bed. The bed was above waist height, and the resident was lying on their back on the floor. The resident was assessed with two (2) small abrasions to upper right back that measured three (3) centimeters long by 0.3 centimeters wide. No other obvious injury was noted. The physician was notified and ordered x-rays to right arm, right shoulder and neck.The Comprehensive Care Plan for At Risk for Falls was updated as follows:On 06/19/2023: witnessed fall. Rolled out of bed during care with certified nurse aide. A new care plan intervention was added for two person assist with bed mobility and hygiene.The Interdisciplinary Team Review form dated 06/20/2023 for the fall on 06/19/2023, documented two person assist for bed mobility and care. The Interdisciplinary Team concluded the accident was unavoidable.A Medical Progress Note dated 06/20/2023 at 4:14 PM by Nurse Practitioner #1, documented they saw the resident on 06/20/2023 after rolling out of bed. The resident reportedly rolled onto the floor and their upper denture was cracked. The resident had no complaints, no signs of distress, or pain. No acute fractures were noted on x-rays. Would discuss possible intervention of upper side rails with Therapy/Nursing versus two person assist for care.A Nursing Progress Note dated 06/21/2023 at 6:39 AM by Licensed Practical Nurse #2, documented the aide reported the resident was not at baseline during first rounds. Writer went into the room and noticed the resident had some wheezing and was not responding. They were not answering basic questions and pupils were non-reactive. Registered Nurse supervisor was notified for an assessment. The physician was notified and ordered Lasix (water pill used to treat fluid retention), duo neb (an inhalation solution used to open airways and reduce inflammation), and Ceftriaxone (broad-spectrum antibiotic) that were given with little effect. The resident's spouse was notified and requested the resident be sent to the hospital. Resident was currently at the hospital.A Nursing Progress Note dated 06/21/2023 at 6:00 PM by Registered Nurse #3, documented the resident was admitted (to the hospital) with a pelvic fracture.A Medical Progress Note dated 06/21/2023 at 6:17 PM by Nurse Practitioner #1, documented they were notified on 06/20/2023 during the evening the resident had hypoxia (low level of oxygen in body tissues) and lethargy (a decrease in consciousness). Ordered extra dose of Torsemide (used help treat fluid retention) and cardiology follow up for the morning of 06/21/2023. The resident's condition deteriorated, and they were transferred to the Emergency Department. The resident was found to have a pelvic fracture per nursing report and would be kept for pain management and observation for bleeding.The Hospital History and Physical Reports, History of Present Illness dated 06/21/2023, documented the patient (Resident #3) came from the nursing home after they rolled out of bed while being changed. A computed tomography (CT scan, a non-invasive procedure that uses rotating X-rays and computer technology to create detailed, cross-sectional images of bones, organs, and tissues) of the abdomen and pelvis showed fractures of the right pubic bone with extension into the superior to inferior pubic rami (pelvis fracture) with active hemorrhage (ongoing, acute loss of blood from damaged vessels due to trauma, posing immediate risks of shock, organ failure, and death) and pseudoaneurysm formation(a collection of blood that forms outside an artery wall, typically caused by injury, and is contained by surrounding tissue). The Hospital Interventional Radiology Angiography (radiographic visualization of blood vessels after injection of a radiopaque substance) Consult dated 06/21/2023, documented a pre/post procedure diagnosis of pelvic trauma. Indication for the procedure was pelvic bleeding. Pelvic angiography demonstrated multiple pseudoaneurysms arising from the right internal pudendal artery. Embolization was performed until vessel occlusion was achieved.During an interview on 04/15/2026 at 11:36 AM, Registered Nurse #3 stated that falls were discussed during morning meeting by the Interdisciplinary Team and they would come up with new interventions to prevent falls. Resident #3 was dependent on staff for all care needs. They recalled Resident #3 fall on 05/25/2023 and they could not explain why there were no new interventions implemented. They did not recall any injury. A resident was usually assessed by Physical/Occupational Therapy following a fall. They stated they could not determine on 05/25/2023 if the aide rolled the resident or they turned away to get linen when the resident rolled off the bed. Immediate education was provided to the aide. They reviewed the electronic medical record and stated there was no fall assessment dated [DATE] and no evaluation by therapy following the fall on 05/25/2023. They stated there was an in-service for nursing staff related to turning and positioning safely following the fall. On 06/19/2023, when the resident fell out of bed while care was being provided by one staff per the care plan, they fractured their pelvis. The Interdisciplinary Team reviewed the fall, changed the resident to a two person assist for bed mobility and care, and updated the care plan. During an interview on 04/15/2026 at 3:48 PM, Director of Nursing #1 stated the Interdisciplinary Team attended the morning meeting and falls were discussed along with interventions to prevent further accidents. When Resident #3 rolled out of bed while the Certified Nurse Aide was providing care on 05/25/2023, the only intervention was immediate education for the aide for safe turning and positioning of a resident. They could not explain why there were no other interventions after the resident fell out of bed on 05/25/2023 and stated an evaluation by therapy would have been a good intervention. Additionally, nursing could have immediately made the resident a two person assist for bed mobility after the fall on 05/25/2023. They stated that after they educated the aide, education was provided to all nursing staff related to safe turning and positioning. During an interview on 04/21/2026 at 12:16 PM, Medical Director #1 stated they were not directly involved with the day-to-day operations of the facility that was managed by the Administrator and Director of Nursing. They attended quarterly Quality Assurance and Performance Improvement meetings and falls were discussed. They stated it would have been the responsibility of the nurse manager and nursing staff to implement interventions to prevent accidents.On 04/21/2026 at 4:07 PM, the surveyor attempted to interview Certified Nurse Aides #1 and #2, who no longer worked at the facility. The contact phone numbers were no longer in service.During an interview on 04/30/2026 at 12:19 PM, Director of Rehabilitation #1 stated the Interdisciplinary Team included staff from Physical and Occupational Therapy. They stated for the most part, a resident received an evaluation by therapy following a fall unless something precluded the evaluation.During an interview on 04/30/2026 at 1:34 PM, Administrator #1 stated they attended the morning meetings. Falls, and Incident and Accidents were discussed at the meeting. The Interdisciplinary Team attended the meeting, and they would talk about interventions to prevent recurrence during the meeting. They did not recall Resident #3 falls. 10 New York Code of Rules and Regulations 415.12(h)(2)

Based on record review and interviews conducted during a survey, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice for three (3) (Resident #s 3, 2, and 7) of 4 residents reviewed. Specifically, (a.) (1.) Resident #3's pressure ulcer on the left heel had inconsistent wound staging (performed to indicate the characteristics and extent of tissue injury) from 8/03/2023 to 9/22/2023, (2.) a pressure ulcer on the right heel had treatment orders and did not have any weekly wound assessments, and (3.) a pressure ulcer on the back of the lower left leg had a treatment order and did not have weekly wound assessments, (b.) (1.) Resident #2's pressure ulcer on the coccyx identified on 10/11/2023, did not have weekly wound assessments when the wound was being treated from 10/11/2023 to 12/31/2023; (2.) did not ensure placement of an air mattress from 10/17/2023 to 12/31/2023, to prevent worsening of the coccyx wound, and (c.) For Resident #7, alternate arrangements were not made for daily wound treatment and weekly wound assessment of a pressure ulcer on the sacrum and left heel on 4/09/2026, when the resident was scheduled to be out of the facility for an appointment on the day the designated in-house wound care provider completed wound rounds. Findings include: The Policy and Procedure titled, Wound/Pressure Ulcer Policy, revised 4/18/2023 and 1/2025, documented the nurse would describe and document/report a full assessment of the pressure sore including location, stage, length, width and depth, presence of exudates (drainage that seeps out of a wound) or necrotic tissue (dead or devitalized non-viable tissue which impedes would healing), pain assessment, current treatments, support surfaces and all active diagnoses. The physician would assist staff to identify the type (for example, arterial or stasis (caused by vein problems) and characteristics of an ulcer and would order pertinent wound treatments, including pressure reduction surfaces. The physician would evaluate and or be notified of changes and or progress of wound healing especially for those with complicated, extensive, or poor-healing wounds. Resident #3: Resident #3 was readmitted to the facility with diagnoses of multiple sclerosis (body's immune system attacks the protective covering of the nerve cells of the brain), diabetes (body does make enough insulin or it well as it should to remove sugar from the bloodstream), and pressure ulcer of unspecified site and stage. The Minimum Data Set (an assessment tool) dated 8/4/2023, documented the resident had severe cognitive impairment, sometimes made themselves understood, and sometimes understood others. The resident was assessed as having two (2) 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 dead tissue) pressure injuries that presented as deep tissue injury (intact skin with localized area of persistent deep red, maroon, purple discoloration due to damage of underlying soft tissue). The Comprehensive Care Plan for Skin Integrity: Presence of Skin Breakdown, effective 7/5/2023, documented the resident had a deep tissue injury (results from intense and/or prolonged pressure and may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss) on the right heel. On 8/03/2023, the care plan was updated and documented the resident now had a deep tissue injury to the right heel. There was no documentation of the pressure ulcer on the left heel. On 9/07/2023, the care plan was updated and documented a new treatment for the left heel. Interventions included assessing the characteristics of ulcer daily during treatment care and document findings weekly, refer for follow up with the Wound Care Team, perform wound care rounds weekly, and maintain turning and positioning schedule every 2 (two) hours as recommended. Findings for the pressure ulcer on the left heel: The Nursing - Pressure Ulcer/Injury Monitoring record documented an unstageable, deep tissue injury on the left heel was identified on 8/03/2023 at 5:16 PM and measured four (4) centimeters long by four (4) centimeters wide by zero (0) centimeters depth. The wound was closed and there was no drainage or odor. Color was purple. The anatomical drawing was inconsistent with the assessment data and indicated the wound was on the right heel. The Nursing Progress Note dated 8/06/2023 at 10:46 AM by Licensed Practical Nurse #3, documented the left heel was noted to have a broken, blister like area. Reported to the supervisor and was to be addressed by the physician when available. The resident denied pain or discomfort to the area. There was no evidence of assessment of the wound dated 8/06/2023 by a Registered Nurse or qualified person when the wound had changed on 8/06/2023. The Medical Progress Note dated 8/07/2023 at 1:02 PM by Nurse Practitioner #1, documented they were notified of a blister on the left heel. The left heel had two (2) blisters noted, one that was approximately two (2) centimeters and intact, and the other approximately one (1) centimeter and appeared ruptured. Continue to apply skin prep (sterile liquid that provides a skin-protectant film). Review of the Nursing - Pressure Ulcer/Injury Monitoring record for the left heel wound dated August 2023, documented inconsistent wound staging: On 8/10/2023 at 12:47 PM, the left heel wound continued to be staged as a deep tissue injury, when it was documented on 8/06/2023 and 8/07/2023, that the wound had opened. Additionally, the assessment did not indicate there were two (2) wounds as was noted on 8/07/2023. On 8/18/2023 at 11:40 AM, 8/24/2023 at 11:41 AM, and 8/31/2023 at 3:33 PM, the left heel wound continued to be staged as a deep tissue injury and the assessment did not indicate there were two (2) wounds. The Nursing Progress Note dated 9/07/2023 at 11:07 AM, documented the left heel was assessed by Registered Nurse #3, secondary to bloody drainage. Nursing Progress Note dated 9/07/2023 at 11:09 AM by Registered Nurse #3, documented a new treatment for the left heel. The Nursing - Pressure Ulcer/Injury Monitoring record for the left heel wound dated 9/07/2023 at 11:59 AM, documented one (1) wound was assessed and documented the stage of the wound as unable to determine. The Medical Progress Note dated 9/11/2023 at 1:54 PM by Nurse Practitioner #1, documented a chief complaint of left heel wound. The wound had increased in size. The resident had no complaints of pain and no signs of distress. Assessment documented pressure ulcer of left heel, unstageable. Pressure ulcer of skin with full thickness skin loss. Plan documented decline in ruptured blister to left heel, area had enlarged, had purulent (foul, unpleasant) odor, and necrotic tissue (dead tissue). The Nursing - Pressure Ulcer/Injury Monitoring record for the left heel wound dated September 2023, documented inconsistent wound staging:On 9/15/2023 at 2:24 PM, the left heel wound was staged as a deep tissue injury and was improved which was inconsistent with findings noted on 9/11/2023, when it was assessed as an unstageable pressure ulcer and the wound had declined. On 9/22/2023 at 12:42 PM, the left heel wound documented the stage of the wound as unable to determine. Findings for the pressure ulcer on the right heel: Review of the Nursing - Pressure Ulcer/Injury Monitoring report for August 2023, did not document an assessment of the deep tissue injury on the right heel, identified on 8/03/2023 per the comprehensive care plan. There was no documented evidence of Nursing Progress Notes dated 8/03/2023. Review of Physician's Orders report documented: A treatment order for the right heel dated 8/10/2023 to apply skin prep two (2) times a day at 7:00 AM - 3:00 PM and 3:00 PM - 11:00 PM. The order was entered by Director of Nursing #1. A treatment order for the right heel dated 8/14/2023 for the right heel to apply zinc and cover with bordered gauze. Change daily and as needed. The order was entered by Registered Nurse #3. The Medical Progress Note dated 8/19/2023 at 7:00 PM by Nurse Practitioner #1, documented the resident had an open area to the right heel. No complaints of pain in the area. Heel boots to promote elevation. There was no description of the extent of the injury to the right heel and no measurements of the wound. Review of the Nursing - Pressure Ulcer/Injury Monitoring report for August and September 2023, did not document any weekly assessments of the pressure ulcer on the right heel. Findings for the pressure ulcer on the back of the lower left leg: The Nursing Progress Note dated 9/10/2023 at 12:30 PM by Registered Nurse #5, documented a new unstageable pressure ulcer was found on the back of the lower left leg that measured three (3) centimeters long by three (3) centimeters wide. Review of the Nursing - Pressure Ulcer/Injury Monitoring report for September 2023, did not document an assessment dated [DATE] of the pressure ulcer on the back of the lower left leg. Review of Physician's Orders report documented:A medication/treatment order dated 9/11/2023 for a pressure ulcer of unspecified site and unspecified stage for Collagenase Clostridium Histolyticum 250 unit/gram topical ointment (used to remove damaged tissue from chronic skin ulcers), apply to area on left dorsal (back) shin twice a day at 7:00 AM - 3:00 PM and 3:00 PM - 11:00 PM. The order was entered by Registered Nurse #3 and was renewed on 9/19/2023. Review of the Nursing - Pressure Ulcer/Injury Monitoring report for September 2023, did not document any weekly assessment of the pressure ulcer on the back of the lower left leg. Resident #2: Resident #2 was admitted to the facility with diagnoses of multiple fractures of left ribs, pressure ulcer of left buttock stage 2 (partial-thickness loss of skin that presents as a shallow ulcer or may present as an intact or open/ruptured blister), and diabetes without complications ( a chronic condition that happens when a person has persistently high blood sugar levels). The Minimum Data Set, dated [DATE], documented the resident was cognitively intact, was able to make themselves understood and understood others. The Comprehensive Care Plan for Skin Integrity: Presence of Skin Breakdown effective 11/22/2023, documented the resident had skin breakdown. The location was not documented. Interventions documented perform wound care rounds weekly. The Comprehensive Care Plan for Skin Integrity: Presence of Skin Breakdown effective 12/30/2023, documented the resident had skin breakdown located on the coccyx/buttocks related to moisture and shearing (when two layers of tissue slide past each other in opposite directions). Interventions included assess characteristics of ulcer daily during treatment care and document findings weekly. The Nursing - Pressure Ulcer/Injury Monitoring record dated 10/11/2023 by Registered Nurse #8, documented a stage two (2) pressure ulcer on the coccyx (tailbone) identified on 10/11/2023 at 9:51 PM. The wound measured one (1) centimeter long by four tenths (0.4) centimeter wide by one tenth (0.1) centimeter deep. Treatment was betadine (topical antiseptic). There were no additional assessments documented on the Nursing - Pressure Ulcer/Injury Monitoring record when the coccyx wound continued to be treated: The Medical Progress Note dated 10/17/2023 at 9:02 AM by Nurse Practitioner #2, documented the resident was seen on 10/17/2023 at the request of nursing for an open area on the coccyx that measured approximately one (1) centimeter long by approximately one (1 )centimeter wide by one tenth ( 0.1) centimeter deep. Present treatment with betadine. Diagnosis, Assessment, and Plan documented pressure injury of sacral region, stage two (2), coccyx. Cleanse with normal saline, apply scant amount of hydrogel (wound gel), cover with Optifoam (dressing). Air mattress to bed. There was no documented evidence of an order for the air mattress. The Physician's Orders report documented the following treatment orders for the coccyx: 10/11/2023 Betadine BID (twice daily) to coccyx pressure injury, every day at 7:00 AM - 3:00 PM and 3:00 PM - 11:00 PM. 10/14/2023 Coccyx treatment, cleanse with sterile normal saline (isotonic solution of salt and water), pat dry and apply thin layer of hydrogel (wound gel) and cover with Optifoam Gentle (dressing). 11/8/2023 Coccyx treatment, cleanse with sterile normal saline, pat dry and apply thin layer of hydrogel (wound gel) and cover with Optifoam Gentle (dressing), every 3 days and PRN (as needed). 12/27/2023 Dressing change to coccyx once daily and as needed, cleanse with normal saline solution, pat dry and apply wound gel to wound base and cover with border foam (dressing). Every day at 7:00 AM - 3:00 PM. Review of the Treatment Administration Record documented the coccyx wound was treated per physician order from 10/11/2023 to 12/31/2023. Resident #7: Resident #7 was admitted to the facility with diagnoses of osteomyelitis (infection in a bone) of vertebra (spine), sacral and sacrococcygeal region (lower spine), multiple sclerosis, and diabetes. The Minimum Data Set, dated [DATE], documented the resident was cognitively intact, was able to make themselves understood, and understood others. The resident was assessed with one (1) stage 4 (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone in the ulcer) that was present upon admission. The Comprehensive Care Plan for Skin Integrity: Presence of Skin Breakdown - Left Heel, Coccyx, Surgical Site RLE (right lower extremity), effective 4/06/2026 documented interventions which included: assess characteristics of ulcer daily during treatment care and document findings weekly, refer for follow up with the Wound Care team, perform wound care rounds weekly, apply local treatments as ordered by the physician. Notes documented the resident was seen on wound rounds on 4/16/2026. The Physician's Orders report documented:3/26/2026 Coccyx pressure injury stage four (4) cleanse with Dakins (strong topical antiseptic widely used to clean infected wounds, and ulcers), then cleanse with normal saline. Apply collagen particle (wound dressing), pack with silver alginate (antimicrobial wound dressing) gently once daily and as needed, then cover. Every day at 7:00 AM - 3:00 PM. 3/26/2026 Left heel: apply betadine WTM (wet to moist) once daily and as needed. Every day at 7:00 AM - 3:00 PM. The Nursing Progress Note dated 4/9/2026 at 3:19 PM by Licensed Practical Nurse #4 documented the resident had been leave of absence all shift. The Nursing Progress Note dated 4/9/2026 at 5:37 PM by Registered Nurse #6, documented the resident returned from the hospital status post aortogram (test that allows the physician to map out a patient's arteries) and angiogram (diagnostic procedure that uses imaging and injected contrast (dye) to show how the blood flows through the blood vessels) left leg. The Treatment Administration Record dated April 2026, did not document wound treatment for the pressure ulcer on the coccyx and left heel on 4/09/2026. The Wound Care assessment dated [DATE] and 4/16/2026 by inhouse Wound Care Provider #1, documented a wound assessment for a stage four (4) pressure ulcer on the sacrum and an unstageable pressure ulcer on the left heel that were present on admission. There was no documented evidence of a weekly wound assessment dated [DATE]. During an interview on 11/14/2025 at 3:27 PM, Licensed Practical Nurse #5 stated they had different people doing wound care, including the former Assistant Director of Nursing #2, when Resident #2 was in the facility. They recalled that Resident #2 did have wounds and reviewed the notes in the electronic medical record during interview. They further stated Assistant Director of Nursing #2 would come to the unit once a week for wound rounds. They stated Assistant Director of Nursing #2 did not have good notes about the wounds and there were no details about the wound bed or drainage. They further stated Registered Nurse #8 did the initial assessment of Resident #2's wound on 10/11/2023; Registered Nurse #7 was responsible for the unit and did not always have good follow through with the weekly wound assessments. They further stated the facility now had a wound care specialist who came into the facility once (1) a week. They stated that if they identified a wound, they would have a Registered Nurse immediately assess the wound. They stated Registered Nurse #4 would now do the initial wound assessments on the unit and sets up the wound care. They stated that in December 2023, Director of Nursing #1 was doing the wound rounds and there were no detailed notes from them about the wounds. They stated that ultimately, Director of Nursing #1 made the final decision for ordering an air mattress for a resident; If there was an order for an air mattress, there would be a treatment order for the nurse to check the functioning of the mattress. During an interview on 11/14/2025 at 4:28 PM, Registered Nurse #4 stated the following: There was an initial assessment of Resident #2's coccyx wound on 10/11/2023. There should be weekly assessments of the wound thereafter. The resident did have a hospitalization in October 2023 and returned on 11/8/2023. They stated they wrote a note about the wound on 11/8/2023 but did not do an assessment of it. There was no contract for wound care in 2023, and they would leave the skin assessments for the unit manager to do. A specialty mattress was typically ordered for a resident with a stage 3 wound or higher and would be approved by Director of Nursing #1. They reviewed Resident #2's wound assessment records and stated there were no other assessments of the coccyx wound after Registered Nurse #8 did the initial assessment on 10/11/2023. During an interview on 4/15/2026 at 1:16 PM, Registered Nurse #7 stated Resident #7 had a pressure ulcer on the sacrum and left heel. Wound Care Provider #1 came into the facility every Thursday to assess wounds. On 4/9/2026, Resident #7 was out of the facility for an angiogram and there was no wound care note because Wound Care Provider #1 would come around 8:30 AM and Resident #7 had already left for the appointment. Resident #7 returned to the facility at 5:37 PM. They stated Registered Nurse #6 was the supervisor and would have been responsible for assessing the resident's wounds on 4/09/2026. Wound care was usually done during the assessment. During an interview on 4/15/2026 at 11:36 AM, Registered Nurse #3 stated pressure ulcers were to be assessed weekly, and any changes made to wound treatments were done at that time. They could not recall if there was a wound care team when Resident #3 was in the facility and stated they now had an in-house wound care provider that was doing the weekly assessments. During an interview on 4/15/2026 at 3:48 PM Director of Nursing #1 stated there was no wound care team when Resident #s 2 and 3 were in the facility. Director of Nursing #1 was doing the weekly wound assessment in the interim until the in-house Wound Care Provider #1 started coming to the facility. They recalled Resident #3 having a wound on their left heel and did not recall a wound on the right heel or back of left leg. A deep tissue injury was not open, and an unstageable pressure ulcer was open and usually covered with eschar (dead or devitalized tissue). If a pressure ulcer was documented as UTD (unable to determine) on assessment, it should have been documented as unstageable. They recalled Resident #3's left heel wound was dark, black. The anatomical drawing dated 8/03/2023, that indicated a pressure ulcer on the right heel, was documented incorrectly and should have been the left heel. They were not aware of Resident #2's pressure ulcer on the coccyx or the need for an air mattress and stated they were not always made aware of every pressure ulcer. Resident #7 was out of the facility on 4/9/2026, when the in-house wound care provider was doing wound rounds. Resident #7 came back to the facility late on 4/09/2026. Registered Nurse #7 was responsible for the unit and should have completed the wound assessment on 4/10/2026. During an interview on 4/21/2026 at 12:16 PM, Medical Director #1 stated Registered Nurse #3 and Director of Nursing #1 would have been responsible for ensuring weekly wound assessments for Resident #3. Ultimately, Nursing Administration was responsible for ensuring daily wound treatments and weekly wound assessments were completed for all residents. During an interview on 4/30/2026 at 1:34 PM, Administrator #1 stated the facility currently had an in-house wound care provider who came to the facility once a week. When Administrator #1 was made aware of Resident #7 not having a wound assessment on 4/9/2026, they had a discussion with nursing staff about the importance of the weekly wound assessments. 10 New York Code of Rules and Regulations 415.12(c)(2)

Based on record review and interviews conducted during a survey, the facility failed to provide pain management consistent with professional standards of practice and the comprehensive person-centered care plan for one (1) (Resident #3) of three (3) residents review. Specifically, for Resident #3, the facility did not have evidence of an assessment of the resident's pain, when there was a new physician order dated 9/23/2023 for Tramadol (narcotic pain medication) and the resident was already receiving Acetaminophen (helps treat mild to moderate pain) Extra Strength 1000 milligrams, every eight (8) hours. Findings include: Resident #3: Resident #3 was admitted to the facility with diagnoses of multiple sclerosis (body's immune system attacks the protective covering of the nerve cells of the brain), diabetes (body does make enough insulin or it well as it should to remove sugar from the bloodstream), and pressure ulcer(localized area of skin and tissue damage caused by prolonged, unrelieved pressure, friction, or shear forces) of unspecified site and stage. The Minimum Data Set (an assessment tool) dated 8/04/2023, documented the resident had severe cognitive impairment, sometimes made themselves understood, and sometimes understood others. The Policy and Procedure titled, Pain Management Protocol, revised 3/22/2023, documented the protocol would assist staff to recognize, evaluate, and treat relief of pain, according to the specific plan of care. Pain would be monitored and documented by the medication nurses in the electronic medical record using the pain scales before and after pain medication. Follow up in the electronic medical record should occur within one hour of administration supported by a progress note reflecting administration and effect for each dose administered. The Comprehensive Care Plan for Pain Management last revised 8/08/2023, documented the resident had pain related to diagnoses that included neuropathy (damage of the nerves outside the brain and spinal cord), Multiple Sclerosis, and spinal stenosis (space inside the backbone is too small and can put pressure on the spinal cord and nerves). It documented the care plan was reviewed and there were no issues with pain management this quarter. Interventions included on-going assessment of the resident's pain with emphasis on the onset, location, description, intensity of pain and alleviating and aggravating factors and administer medications as ordered by the physician. The Physician's Orders report dated 5/01/2023 to 10/31/2023, documented an order renewal dated 9/19/2023 for Acetaminophen Extra Strength 500 milligram tablet, give two (2) tablets by oral route every eight (8) hours). Original order date was 6/28/2023. The Physician's Orders report dated 5/01/2023 to 10/31/2023, documented an order dated 9/23/2023 for Tramadol 50 milligram tablet, give 0.5 tablet (25 milligram) by oral route three (3) times per day as needed for unspecified pain. Mmaximum daily dose 75 milligrams. Start date 9/23/2023. There was no documented evidence of an assessment or that the physician was notified of the resident's pain and the need for additional pain medication. Review of the Medication Administration Record and Nursing Progress Notes dated September 2023, documented: The Medication Administration Record dated 9/23/2023 at 2:54 PM, documented Tramadol 25 milligram was administered by Registered Nurse #2, who was a Licensed Practical Nurse at the time. The Nursing Progress Note dated 9/23/2023 at 3:04 PM, documented Tramadol 25 milligram was given to the resident. There was no documentation of the description and location of the pain. The Medication Administration Record dated 9/24/2023 at 12:53 AM, documented Tramadol 25 milligram was administered. The Nursing Progress Note dated 9/24/2023 at 3:23 AM, documented Tramadol 25 milligram was given for pain with positive effect. There was no documentation of the description and location of the pain. The Medication Administration Report dated 9/25/2023 at 12:21 AM, documented Tramadol 25 milligram was administered. The Nursing Progress Note dated 9/25/2023 at 5:55 AM, documented Tramadol 25 milligram was given for pain with positive effect. There was no documentation of the description and location of the pain. During an interview on 4/15/2026 at 3:48 PM, Director of Nursing #1 stated Resident #3 should have had an assessment of their pain on 9/23/2023 prior to calling the on-call provider about the pain. The assessment and call to the provider should have been documented in the electronic medical record. During an interview on 4/21/2026 at 12:16 PM, Medical Director #1 stated nursing staff probably called the on-call provider because the resident complained of pain. Nursing staff usually wrote a note in the electronic medical record when they had to call a provider and would document details about the reason for the call and any orders received. During an interview on 4/21/2026 at 3:46 PM, Registered Nurse #2 stated they were a Licensed Practical Nurse on 9/23/2023 and did not recall the order for the Tramadol or the need for the medication. They would not have given the Tramadol without talking to the supervisor first because it was a narcotic pain medication. The supervisor would have had to call the provider to get the order. They stated they probably did not write a note because they relied on the supervisor to document the call to the provider and the order received. 10 New York Code of Rules and Regulations 415.12

Based on record reviews and interviews conducted during the survey, the facility failed to maintain and account for all controlled substances in accordance with professional standards of practice. Specifically, the narcotic count record signature sheet for three (3) of five (5) units were incomplete. Findings include: A review of narcotic count record book for unit Mohawk Trail side A cart documented blank spaces for Off going nurse did not sign for 04/20/2026 at 03:00 PM A review of narcotic count record book for unit Mohawk Trail side B cart documented blank spaces for On coming nurse did not have documented evidence of signature for 04/15/2026 at 03:00 PM Off going nurse did not have documented evidence of signature for 04/15/2026 at 11:00 PM A review of narcotic count record book for unit Union Station side B cart documented blank spaces for Off going nurse did not have documented evidence of signature for 04/07/2026 at 03:00 PM On coming nurse did not have documented evidence of signature for 04/15/2026 at 07:00 AM Off going nurse did not have documented evidence of signature for 04/15/2026 at 03:00 PM Off going nurse did not have documented evidence of signature for 04/16/2026 at 03:00 PM On coming nurse did not have documented evidence of signature for 04/17/2026 at 03:00 PM Off going nurse did not have documented evidence of signature for 04/17/2026 at 11:00 PM On coming nurse did not have documented evidence of signature for 04/20/2026 at 03:00 PM Off going nurse did not have documented evidence of signature for 04/20/2026 at 11:00 PM Off going nurse did not have documented evidence of signature for 04/21/2026 at 03:00 PM On coming nurse did not have documented evidence of signature for 04/22/2026 at03:00 PM Off going nurse did not have documented evidence of signature for 04/22/2026 at 11:00 PM A review of narcotic count record book for unit Union Station side A documented blank spaces for On coming nurse did not have documented evidence of signature for 04/23/2026 at 07:00 AM A review of narcotic count record book for unit Dutch Hollow side B documented bland spaces for Oncoming nurse did not have documented evidence of signature for 04/20/2026 at 03:00 PM Off going nurse did not have documented evidence of signature for 04/20/2026 at 11:00 PM A review of the policy titled Controlled Substances dated 04/2025 stated Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. Both individuals sign the designated controlled substance record. During an interview on 4/24/2026 at 9:47 AM, Licensed Practical Nurse #2 stated the narcotic book should be signed when nurses complete the narcotic count and hand-off of keys at the beginning and end of every shift. 10 New York Codes Rules and Regulations 415.22(a)(1-4)

Based on observation and interview during the survey, the facility failed to ensure that food was stored, prepared, distributed, or served following professional standards for food service safety in the main kitchen and in 2 (two) of 5 (five) kitchenettes/nourishment stations. Specifically, proper dating of open items was not followed, and expired food items were found stored ready for use in the refrigerators and freezers. Findings include: Policy titled, Food Safety Policies and Standards revised 05/31/2025 documented refrigerated, ready to eat TCS (Time/Temperature Control for Safety) food prepared and held in a food establishment for more than 24 hours must be clearly marked with a use by/discard date. Food that is required to be date marked must be discarded if it is in a container or package that does not bear a date or date mark. Commercially packaged, ready-to-eat TCS foods must be clearly marked at the time the original container is opened and used within 7 days but cannot exceed the manufacturer's use by date. During inspection of the main kitchen and kitchenettes on 4/20/2026 at 10:12 AM the following items were found to be out of compliance with New York State food safety regulations: The following items were found to be opened without dates the items were opened on the packaging in the main kitchen: Refrigerator 1 (one) A bottle of chocolate syrup A bag of donuts Freezer off of (behind) Refrigerator 1 (one) A bag of hashbrown patties A bag of breakfast frittatas A bag of chicken and vegetable dumplings A bag of breakfast sausage patties The following item was found past its use by date in Refrigerator 2 (two) in the main kitchen: A bag of cut up potatoes with a use by date of 4/07/2026 marked on the packaging. Observations on unit kitchenettes/ nourishment stations noted the following: Dutch Hollow: In the nourishment station, food from home for a resident was dated 4/14/2026, two items of soup for a resident were dated 4/13/2026 and on item of soup for the same resident was dated 4/15/2026, food for a resident was in an undated paper bag, hot dogs for a resident with a sell by date of 2/25/2026, one slice of cheese for a resident was dated 3/30/2026. Also, in a cabinet there was a plate of tortilla chips that was not dated or labeled, covered with another paper plate. [NAME] Crossing: Kitchenette refrigerator contained bagels in an opened plastic bag that was undated. During a follow up visit to the Main Kitchen on 4/21/2026 at 12:48 PM, the back wall freezer contained an open bag of gluten free chicken nuggets that was not labeled with the date the bag was opened. During an interview on 4/20/26 at 11:01 AM and 4/23/2026 at 10:45 AM, Food Service Director #1 stated when an employee opened a food item, it was the employee's responsibility to date the packaging with the date the item was opened. All open items should have the date they were opened written on them. The undated items found during this tour were being discarded as the date the items were opened was unknown. When food items were brought from outside the facility for residents, they were kept in the kitchenettes on the unit or in the refrigerators in the main kitchen. The items were labeled with the resident's name, room number and date it was brought in. Items could be kept for up to three days. It was the kitchen staff's responsibility to check every shift for food that was past its use by date. If items past their use by date were found, they were discarded. 10 New York Codes, Rules, and Regulations 415.14(h)

Based on observation, record review, and interview conducted during the survey, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (2) (Resident #'s 28 and 137) of four (4) residents reviewed for infection control practices. Specifically, 1.) Certified Nurse Aide # 1 failed to utilize Enhanced Barrier Precautions during resident care, increasing the risk of cross- contamination. 2.) Licensed Practical Nurse #3, while administering medications via gastrostomy tube (a tube placed into the stomach to provide nutrition) failed to maintain aseptic technique by placing the medication cup and supplies for the gastrostomy tube directly on the Resident's bedside table. In addition, the nurse dropped the cup full of crushed medication and proceeded to administer the medications without discarding and repreparing the dose. These deficient practices placed the residents at risk for potential infection and compromised care delivery. Findings include: The Facility's Policy and Procedure titled Infection Prevention and Control Program dated 12/2024, documented the purpose of surveillance of infections was to guide appropriate interventions, and prevent future infections. The Facility's Policy and Procedure titled Administering Medications revised date of 03/2023; documented staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Resident #28 Resident #28 was admitted to the facility with diagnoses of Alzheimer's Disease (a brain disorder that primarily affects memory, thinking,and behavior) Angina (chest pain) and nonthrombocytopenic purpura (purple or red skin discoloration due to bleeding under the skin that occurs without a decrease in platelet count). The Minimum Data Set (an assessment tool) dated 02/06/2026 documented the resident had severe cognitive impairment, frequent urinary incontinence, required partial/moderate assistance with toilet transfer and substantial/maximal assistance with toileting hygiene. The Active Physician's Orders documented an order for Enhanced Barrier Precautions. The Interdisciplinary Team Progress Notes dated 04/1/2026 - 04/21/2026 were reviewed and documented on 04/09/2026 the resident was seen by the medical provider for a urinary tract infection. The medical record documented a resident history of Extended-spectrum beta-lactamases (ESBL) (a type of antibiotic- resistant bacteria causing infection that is harder to treat and more easily spread in healthcare settings). During an observation on 4/20/2026 at 10:40 AM, Resident # 28 and Certified Nurse Aide #1 were exiting the bathroom located in the resident's room. The bathroom trash or bagged items had no isolation gowns in it. Certified Nurse Aide #1 stated they had just assisted Resident #28 with toileting. Certified Nurse Aide #1 stated they did not know that the resident was on Enhanced Barrier Precautions or why, but they would ask the nurse. An Enhanced Barrier Precaution sign was present outside the room. During an interview on 04/24/2026 at 9:57 AM, Infection Preventionist #1, they stated Resident #28 remained on Enhanced Barrier Precautions for colonized Extended-spectrum beta-lactamases. They stated the Certified Nurse Aide toileting a resident should be wearing a gown and gloves. Certified Nurse Aides knew which residents were on Enhanced Barrier Precautions by a sign outside the resident's room, the sign alerted them the resident is on Enhanced Barrier Precautions. Resident #137 Resident #137 was admitted to the facility with a diagnoses of congestive heart failure (heart muscle is unable to pump enough blood to meet the body's needs) , hypertension and Gastrostomy status (artificial opening into the stomach to allow for direct delivery of nutrition, fluids or medications). The Minimum data set dated [DATE] documented, the resident was understood and was able to understand others with intact cognitive function. During an observation on 04/23/2026 at 11:35 AM, Licensed Practical Nurse #3 was observed to place Resident #137's medication cup and equipment to flush the gastronomy tube on their bedside table without a barrier. Licensed Practical Nurse #3 was observed to pick up the medication cup from the bedside table with medication inside and drop it on the floor. They then picked the cup up from the floor and administered the medication to Resident #137. 10 New York Codes, Rules, and Regulations 415.19

Based on record review and interview during a survey, the facility failed to ensure a resident received a written notice, including the reason for the change, before a room change. In addition, the resident was not provided with the opportunity to disagree and or decline the decision to change rooms. This was evident for one (1) of one (1) residents (#43) reviewed. Specifically, Resident #43 was verbally informed of a room change because it was alleged that a roommate was assisting Resident #43 with activities of daily living. Findings include:The facility's Policy and Procedures titled Room Changes dated 10/29/2024, documented 2. Residents must receive at least 30 days' notice before any planned room change, except in emergency situations where immediate action is required. The interdisciplinary care team, in consultation with the resident and their representative, should determine the necessity and appropriateness of the room change. The notice should include the reason for the change and the new room assignment. 3. Resident Consultation: Residents and their representatives must be consulted about the proposed room change. Residents have the right to refuse the change if it is for the convenience of staff or if the new room is outside a distinct part of the nursing home. The facility's Policy and Procedure titled Resident Rights Revised: 1/2025, documented Glendale Home is committed to upholding the dignity, autonomy, and well-being of each resident. We recognize that residents have the right to be treated with respect and to participate in decisions regarding their care. This policy is designed to ensure that these rights are protected and that residents are informed of their entitlements. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence; right to share a room with their roommate of choice when practicable, both residents live in the same facility and both residents agree. Resident #43 was admitted to the facility with diagnosis of Cerebral Ischemia (a condition that occurs when there isn't enough blood flow to the brain to meet metabolic demand), Anxiety (excessive, persistent, and uncontrollable fear or worry that disrupts daily life), and Depression (a serious medical illness characterized by persistent sadness, loss of interest in activities, and reduced energy). The Minimum Data Set (an assessment tool) dated 09/11/2024, documented they could be understood, understand others, and was cognitively intact. Resident # 129 was admitted to the facility with a diagnosis of Anemia (a blood condition where you lack enough healthy red blood cells to carry sufficient oxygen to your body's tissues), Anxiety (excessive, persistent, and uncontrollable fear or worry that disrupts daily life), and Depression (a serious medical illness characterized by persistent sadness, loss of interest in activities, and reduced energy). The Minimum Data Set (an assessment tool) dated 08/16/2024, documented they could be understood, understand others, and was cognitively intact. Social Worker Progress note dated 07/24/2025 at 02:45 PM, documented they met with Resident #43 today to discuss the importance of maintaining appropriate boundaries regarding personal care. Resident #43 was reminded that their roommate should not be providing or assisting with any aspects of care, including physical assistance or hygiene tasks. This was to ensure that both resident and roommate maintain safety. Resident #43 was receptive to the conversation and expressed understanding. They verbalized agreement and stated that they would refrain from asking or accepting help from their roommate going forward. Social Worker progress note dated 08/07/2025 at 09:06 AM documented Room change today due to safety concerns related to Resident #43's non-compliance with seeking physical assistance with care from their roommate. Social Worker progress note dated 08/10/2025 at 10:54 PM, documented Resident #43 continued to stated they miss Resident #129. Resident was encouraged to enjoy their corner room view and reminded they were able to visit their old roommate and did visit for a short period then returned to their room much calmer. One on one (1:1) emotional support was documented as rendered as well with good effect. During an interview on 11/10/2025 at 9:45 AM, Resident #43 stated Resident #129 was my friend two (2) doors down, because Resident #129 helped so much they separated them. Resident was observed to be tearful about having to change rooms and separate from Resident #43. Resident #43 stated that when they needed a nursing aide, they would not come, and that Resident #129 helped them get their shoes on and get something from their closet. During an interview on 11/10/2025 at 9:30 AM, Resident #129 stated they moved their roommate, Resident #43, because they said their was helping them. They stated that they never asked them about the move and just separated them. Resident #129 stated they were somewhat helping but never lifted Resident #43. They further stated that if Resident #43 asked them to get something out of the closet, they would help. During an interview on 11/10/2025 at 11:00 AM, Resident Representative #1 stated they were never made aware that their parent moved from one room to another. They stated they found out about it from their parent who called them distraught after the move. The Social Worker or Nurse Manager never discussed the move with them at all to date. During an interview on 11/20/2025 at 10:20 AM, Registered Nurse #6 stated Residents #43 and #129 were separated because they had both been educated that Resident #129 was not to assist Resident #43 for safety purposes. Resident #129 helped Resident #43 get dressed by putting on their pants and shoes. Resident #129 was witnessed pushing Resident #43 in their wheelchair. The Social Worker notified families of the move, but not sure when that took place. When asked Registered Nurse #6 what interventions were placed prior to separating the two (2) residents, they replied they were warned previously that they would be separated if Resident #129 continued to assist Resident #43. During an interview on 11/10/2025 at 10:45 AM, Director of Social Work #1 stated they had no idea about the move and that another Social Worker covered Resident #43. They further stated that when a resident was moved, generally there would be a meeting with family. If a resident objected to the move, they would not move them. During an interview on 11/10/2025 at 10:59 AM, Director of Nursing #1 stated they were not aware of the move. They further stated all moves were discussed during the facility's daily morning meeting. If a resident does not want to change rooms, they will not move them. 10 New York Codes, Rules, and Regulations 415.5(e)(2)

Based on record review and interviews conducted during a survey, the facility did not ensure it consulted with the resident's physician and notified the resident's representative when there was a significant change in the resident's physical status for two (2) (Resident #s 16 and 207) of four (4) residents reviewed. Specifically, (a.) Resident #16 family representative were not made aware of resident's change in condition and that resident received intravenous fluids. (b.) Resident #207 was assessed at pain level 10/10, the physician ordered medication adjustments and was not notified that the pain medication was ineffective. Findings include:The Facility's Policy and Procedure Title, Notification of Families, revised 2/28/2016, documented, Protocol: Notification process when acute or significant changes occur that affect the resident's mental, physical, or psychological status. Glendale nursing staff will inform residents/primary contact or legal representative via phone numbers provided before leaving a message when the following occurs: 1. Accident involving injury. 2. Significant change(s) in resident physical, mental, psychological status, such as life-threatening conditions, clinical complications, changes in mental status. 3. Significant alteration in treatment, labs, X-rays. 4. Decision to transfer/discharge resident to hospital, emergency room or other facility. 5. Notification of roommate change, or room/unit change. Key Points: Non-emergent changes where residents are not expected to be transferred out of the facility family notification can be made between 8 AM -9 PM. Supervisors are responsible for notification process. In lieu of the family member/legal representative being unavailable such as vacation, out of town and alternate representative with contact information should be provided. The Facility's Policy and Procedure titled Change of Condition, reviewed 2/2025, documented the facility monitors residents for changes in physical, mental, functional, and psychosocial status and responds in a timely manner consistent with the resident's clinical needs, provider orders, and recognized standards of nursing practice. The goal is to identify potential changes, provide appropriate evaluation. Guidelines: Observation & Awareness. Staff observe residents during routine care and interactions. Any potential change is communicated to the licensed nurse for further clinical assessment. Nursing Assessment: The licensed nurse evaluates the resident as indicated, using nursing judgment and available assessment tools. Assessment may include review of vital signs, pain, behavior, mobility, elimination, intake, skin, cognition, or other relevant clinical indicators. Provider Notification: The resident's practitioner is notified when, in the nurse's clinical judgment, the change warrants. Notification content includes: *Description of change *Assessment findings *Interventions attempted (if any) *Resident response. The practitioner provides direction for further evaluation or treatment, which is carried out as ordered. Resident #16 was admitted to the facility with diagnoses of fracture of shaft of left fibula (break in thin bone outer side of the leg), displaced bicondylar fracture of left tibia (injury where you break your bone and damage the cartilage on top of your tibia), and essential primary hypertension (most common type of high blood pressure). The Minimum Data Set (an assessment tool) dated 03/15/2026, documented that the resident could be understood, understand others, and was severely cognitively impaired. Provider order 03/18/2026 at 3:41 PM by Physician Assistant #1, documented an order for sodium chloride 0.9 percent intravenous solution instill 50 milliliters by intravenous route every hour times one (1) liter. Nursing Progress note by Registered Nurse #2, documented on 3/18/2026 at 3:42 PM Clysis (sodium chloride 0.9 percent) started at 50 milliliter an hour for hydration. There was no documented evidence of family notification. Nursing Progress note by Registered Nurse #2, documented on 3/18/2026 at 3:50 PM, resident had refused Clysis (sodium chloride 0.9 percent), provider was notified. There was no documented evidence of family notification. Late Entry Provider visit on 03/18/2026 documented Physician Assistant #1, documented an order for Clysis (sodium chloride 0.9 percent), intravenous 1 (one) liter. There was no documented evidence of family notification. During an interview on 04/20/2026 at 3:28 PM, Family Member #1 stated they were not notified of changes on a consistent basis. They stated they came into the facility in March 2026 and an intravenous bag of hydration fluids were hung at the resident's bedside. They were not made aware that the provider had ordered intravenous fluids. They did not feel the fluids were necessary and were not in agreement with the new orders. During an interview on 04/24/2026 at 1:40 PM, Staff Development Coordinator #1 stated they were interim unit manager for the unit starting about one (1) week ago. They notified family members of all changes with residents including change of conditions and medication changes.Resident #207 was admitted to the facility with diagnosis of Coronary Artery Disease (a common heart condition where plaque builds up in the arteries, restricting blood flow to the heart muscle); Peripheral Vascular Disease (a slow and progressive disorder of the blood vessels), and Chronic Obstructive Pulmonary Disease (COPD - a progressive, long-term lung disease that causes obstructed airflow, making it difficult to breathe). The Minimum Data Set, dated [DATE], documented they could be understood, understand others, and was cognitively intact. Nursing progress note dated 07/14/2024 at 04:47 PM, documented Registered Nurse #1 Spoke with Nurse Practitioner #1 regarding Resident #207's uncontrolled pain of 10 on 10. Nurse Practitioner #1 ordered Gabapentin (pain medication) 300 milligrams three times a day starting 7/15/2024, one (1) dose of Gabapentin to be given now at dinner time and one (1) dose be given at 9:00 PM. Nurse Practitioner #1 also ordered Hydrocodone as needed, dose to be given at 5:00 PM as the dose was due at 6:00 PM, then, give as needed Hydrocodone dose every 4 (four) hours on the hour for pain control.Nursing progress note dated 7/14/2024 at 9:46 PM documented Resident had a significant decline over the last two (2) days. Resident was not eating, drinking minimally, and was sleeping the entirety of 3:00 PM to 11:00 PM shift. Resident was able to be roused easily, to take medications, but then returned to sleeping. Resident had continued complaints of 10 out of 10 pain in their left foot despite medication adjustment, earlier in this shift. During an interview on 11/05/2025 at 2:25 PM, Nurse Practitioner #1 stated Resident #207 was not their patient and they were covering the shift. They further stated they adjusted medication to address complaint of pain 10 out of 10. Nurse Practitioner #1 stated if pain was not controlled it was the expectation that nurse/supervisor should call the provider back with a re-assessment for further direction. They should include vital signs, change in mental status, history each time to make decision on what to do next. 10 New York Code of Rules and Regulations 415.3(e)(2)(ii)(c)

Based on observations and interviews conducted during survey the facility did not ensure residents' personal property were free from loss or theft for one (1) of one (1) residents reviewed. Specifically, Resident #43 reported they did not receive their laundry back in a timely manner and also five (5) nightgowns were not returned. Findings include: CMS regulations (specifically 42 CFR S483.10(e)(2)) guarantee nursing home residents the right to retain and use personal possessions, including clothing and furnishings, as space permits. Facilities must respect personal property, ensure a homelike environment, and protect belongings from theft, provided they do not infringe on the health, safety, or rights of others. The facility's Policy and Procedure titled Resident Rights Revised: 1/2025, documented Glendale Home is committed to upholding the dignity, autonomy, and well-being of each resident. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: Retain and use personal possessions to the maximum extent that space and safety permit. Resident #43 was admitted to the facility with diagnosis of Cerebral Ischemia (a condition that occurs when there isn't enough blood flow to the brain to meet metabolic demand), Anxiety (excessive, persistent, and uncontrollable fear or worry that disrupts daily life), and Depression (a serious medical illness characterized by persistent sadness, loss of interest in activities, and reduced energy). The Minimum Data Set (an assessment tool) dated 09/11/2024, documented they could be understood, understand others, and was cognitively intact. During an interview on 04/27/2026 at 11:41 AM, Resident #43 stated the facility does her laundry and they had not gotten back some blue and pink nightgowns. At first it was 3 and now it is up to 5 nightgowns that have not been returned to them. Resident stated they now have no nightgowns. Resident stated they have told several staff about the missing nightgowns. During an interview on 04/27/2026 at 11:53 AM, Registered Nurse #6 stated resident #43 had never reported any missing laundry to them. Registered Nurse #6 later stated the resident did have two (2) new nightgowns delivered over the weekend that were in process of labeling. They were unaware of where the other three (3) nightgowns were. They stated that when they are notified of missing items the item is searched for and if not found they will complete a missing item communication email and ultimately the items will be replaced if not found. During an interview on 04/27/2026 at 12:13 PM, Resident Representative #1 stated they had sent three (3) new nightgowns to the facility via amazon last week because their mother had no nightgowns. They stated resident often has laundry items missing and to ensure that their mother is not upset they send in replacement nightgowns. They had not reported the missing laundry to anyone as this is an ongoing issue. During an interview on 04/27/2026 at 12:21 PM, Director of Social Work #1 stated if the resident reportes missing personal items the items are tracked by the social work department. If the item is not found the item will be replaced. During an interview on 4/2/2026 at 12:35PM, Administrator #1 stated an email communication is sent out for any resident missing laundry or personal items. The item is looked for in laundry, kitchen, etc. and if unable to locate the item, the item will be replaced. 10 NYCRR: 415.29, 415.29(d), 415.29(j)(1)

Based on record reviews and interviews during a survey, the facility failed to ensure residents were free from unnecessary medications for,(4) four (Residents #55, 97, 13, and #155) of six (6) residents reviewed, Specifically, a) Residents #55 and #97 had as needed psychotropic medications with end dates outside the regulatory limit of 14 days. b) resident #13, did not have documented attempts of gradual dose reduction or documentation that a gradual dose reduction is clinically contraindicated c) Resident #155 did not have an appropriate diagnosis for an antipsychotic medication. Findings include: The policy and procedure titled Psychotropic Medication, reviewed 2/2025, stated as needed orders for psychotropic drugs were limited to 14 days and a gradual dose reduction must be attempted annually, unless clinically contraindicated. Resident #55 Resident #55 was admitted to the facility with the diagnoses of vascular dementia (a progressive decline in thinking skills caused by conditions that block or reduce blood flow to the brain), atrial fibrillation (an arrhythmia where the heart's upper chambers beat chaotically and out of sync with the low chambers, causing a rapid, irregular heartbeat), and major depressive disorder (a serious mental health condition characterized by persistent, severe low mood, loss of interest in activities, and fatigue lasing at least two weeks). The Minimum Data Set (an assessment tool) dated 2/12/2026 documented the resident was usually understood, sometimes understood others, and was severely cognitively impaired. The Physician's order dated 12/29/2025 stated lorazepam (a medication used to treat severe anxiety, anxiety-associated depression, and other conditions) 0.5 milligram tablet by oral route two (2) times for 30 days as needed. The Physician's Order dated 4/13/2026 stated lorazepam 0.5 milligram tablet by oral route every six (6) hours for 30 days as needed. Resident #97 Resident #97 was admitted to the facility with the diagnoses of Alzheimer's disease,(a brain disorder that primarily affects memory, thinking, and behavior), anemia, (a deficiency of healthy red blood cells leading to insufficient oxygen delivery to body tissues), and depression (a mood disorder that causes persistent feeling of sadness and loss of interest in activities once enjoyed). The Minimum Data Set (an assessment tool) dated 11/22/2025 documented the resident was usually understood, could usually understand others, and was severely cognitively impaired. The Physician's Order dated 3/17/2026 stated lorazepam 0.5 milligram tablet by oral route two (2) times per day for 30 days as needed. During an interview on 04/27/2026 at 12:13 PM, Registered Nurse #1 stated the provider ordered the psychotropic medications that way and were entered as ordered. During an interview on 04/27/2026 at 1:40 PM, Medical Director #1 stated psychotropic as needed medications should have a 14-day end date. They stated that in some cases, depending on the diagnoses, the duration may be extended but the reason should be documented. During an interview on 04/27/2026 at 1:47 PM, Physician's Assistant #1 stated the duration for as needed psychotropics should be 14 days. They stated the nurses would enter the order into the system for pharmacy and choose the duration. Resident #13 Resident #13 was admitted to the facility with the diagnoses of hemiplegia(a severe or complete paralysis on one side of the body caused by brain damage) following cerebral infarction (sudden disruption of blood flow to the brain, leading to cell death), generalized anxiety disorder (a mental health condition characterized by persistent, excessive, and uncontrollable worry), and bipolar disorder (a chronic mental health condition characterized by extreme mood swings alternating between intense highs and severe lows). The Minimum Data Set (an assessment tool), dated 2/11/2026 documented the resident was able to be understood, was able to understand others, and was cognitively intact. The Physician's Order dated 03/03/2025 stated aripiprazole (an anti-psychotic medication) 10 milligram by oral route once daily for bipolar disorder. The Physician's Order dated 08/01/2024 stated trazodone 100 milligram by oral route once daily at bedtime for generalized anxiety disorder. The Physician's Order dated 8/13/2025 stated venlafaxine extended release 150 milligram give two (2) capsules (300 milligram) by oral route once daily with food for bipolar disorder. The Follow up Psychiatric Consult dated 8/13/2025 documented a failed gradual dose reduction in March 2025. Medical notes dated 09/01/2025, 12/04/2025, 01/12/2026, 02/08/2026, and 04/05/2026 documented a gradual dose reduction was not attempted and to defer to psychiatric services. During an interview on 04/27/2026 at 12:20 PM, Registered Nurse #3 stated they could not find any documentation of a gradual dose reduction of psychotropic medications for the past year. During an interview on 04/27/2026 at 1:40 PM, Medical Director #1 stated the resident should have psychiatric services involved and a gradual dose reduction should have been attempted per protocol within the past year. They did not know why it was not done. During an interview on 04/28/2026 at 11:22 AM, Nurse Practitioner #1 stated they assumed the resident was being seen by psychiatric services and that a psychiatrist would handle any gradual dose reductions. They were not aware that the resident had not seen psychiatric services since 8/13/2026. 10 New York Codes, Rules, and Regulations 415.4(a)(1)

Based on record reviews and interviews conducted during a survey, the facility failed to timely report an injury of unknown origin to the State Survey Agency immediately, but not later than two (2) hours after the findings of serious bodily injury in accordance with State law through establish procedure for one (1) (Resident #8) of one (1) resident reviewed. Specifically, for Resident #8 a fracture of unknown origin was not reported Findings include: Facility policy titled, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, reviewed 04/2025, documented the facility prohibits abuse, neglect, misappropriation of resident property, and exploitation by anyone including but not limited to staff, family, friends and residents of the facility. The Administrator or Director of Nursing will notify the appropriate State Agency(s) immediately (no later than 2 hours after allegation / identification of allegation) by Agency's designated process after identification of alleged/suspected incident. Resident #8 Resident # 8 was admitted to the facility with a diagnoses of Quadriplegia (paralysis of all four limbs and the torso, typically caused by injury to the cervical spinal cord or brain,) paroxysmal atrial fibrillation (a type of irregular, rapid heart rhythm that begins abruptly and stops on its own,) and Gastro-esophageal reflux disease (a chronic digestive disorder where stomach contents (acid/food) frequently flow back into the esophagus.) The Minimum Data Set (an assessment tool) dated 02/24/2026 documented that they could be understood and understand others and was cognitively intact. Record review of portable diagnostic imaging Results from Mobile Imaging dated 02/12/2026, 12:02 PM documented findings of oblique/spiral fractures of the distal tibial and fibular diaphysis ( a serious lower leg injury caused high energy twisting forces resulting in an angled break). Impression: Acute distal tibial and fibular fractures. Record review of progress note dated 02/12/2026 at 12:59 PM written by Registered Nurse #1 documented mobile imaging faxed result of right lower extremity x-ray. Documentation of notification of Nurse Practitioner #2 and Medical Director #1 of results of portable diagnostic imaging. Documentation of notification of administrator, Director of Nursing and Social Work of result of portable diagnostic imaging. Documentation of notification of Resident #8 of results of portable diagnostic imaging. Recommendation was to send Resident #8 to hospital for treatment. Review of Nursing Home Incident/Accident Investigation Report (Fracture) dated 02/12/2026 at 12:00 PM documented Resident # 8 was being treated for cellulitis of right leg, had been on antibiotic for 7 days. Redness did not resolve. Provider ordered X-ray, which showed a fracture of tibia/fibula (a break of the shinbone). Review of Nursing Home Incident/Accident Investigation Report (Fracture) dated 02/12/2026 at 12:00 PM documented Root Cause Analysis, Primary cause of fracture: Resident alert and oriented, denies being injured or falling. Stated I go all over; it could have happened anywhere. Resident denies injuring himself. Review of statement from Social Worker # 1 dated 02/12/2026 at 01:00 PM documented Mobile Imaging results from an x-ray today showed oblique/spiral fractures of the distal tibial a fibular diaphysis.medial displacement of the distal tibial fracture component. Resident #8 is unable to identify any specific incident that may have resulted in the fractures. During an interview on 04/27/2026 at 11:45 AM, Resident #8 stated they were not sure how they got the injury. They stated they thought they caught the edge of their shoe on the side of the elevator, and it got twisted. They stated they had no concerns for abuse and had no fear of any staff members. During an interview on 04/28/2026 at 08:50 AM, Director of Nursing #1stated that on the morning of 02/12/2026, a nurse noted redness and warmth to the right lower extremity of Resident #8. They were seen by the primary and wound doctor and started on an antibiotic for cellulitis. They were seen by the wound doctor again and they thought it could be osteomyelitis, so an x-ray was ordered. They stated a reportable incident would be one where they suspected abuse or I had no idea how the injury happened. They stated they did not feel like this was reportable after the Interdisciplinary Team met and they met with the resident. They stated they talked to the resident and felt there was no abuse. During an interview on 04/28/2026 at 11:05 AM, Director of Nursing #1 was asked if they were aware of the two-hour reporting window included injuries of unknown origin. They stated they knew but got most of the investigation done on the first day. The doctor reviewed it and determined it was a fracture that the staff could not cause. They stated they did not watch the injury happen. They stated they did not consider it an injury of unknown origin, they felt it was self-inflicted. They stated they all concluded with the Interdisciplinary Team and they felt that the resident did it to themself and so it was not reportable. 10 New York Codes, Rules, and Regulations 415.4(a)(1)

Based on record reviews and interviews during the survey, the facility failed to provide care to dependent residents in accordance with professional standards of practice for two (2) (Resident #s 2 and #201) of five (5) residents reviewed. Specifically, (a.) for Resident #2, staff failed to provide the resident with a shower/bath for the first two weeks after admission and (b.) for Resident #201, staff failed to provide assistance to the bathroom and toilet resident as scheduled. Findings include: Resident #201 Resident #201 was admitted to the facility with diagnoses of displaced intertrochanteric fracture of right femur (a type of broken hip), heart failure (when the heart muscle doesn't pump blood as well as it should), paroxysmal atrial fibrillation (episodes of an irregular heart rhythm). The Minimum Data Set (an assessment tool) dated 07/15/2024, documented that the resident could be understood, understand others, and was cognitively intact. Record Review Care Plan dated 12/20/2023 titled Activities of Daily Living, documented Resident #201 required extensive one assist for transfer, ambulation, and toileting. Care Plan dated 12/20/2023 titled Bowel Evacuation and Maintenance, interventions documented certified nurse assistant was to document bowel elimination every shift. Resident Certified Nurse Aide Documentation titled Toileting dated 07/2024 had no documented evidence of toileting on 07/12/2024 on day shift or night shift, 07/13/2024 evening shift or night shift, 07/14/2024 day shift or night shift, 07/15/2024 night shift, 07/16/2024 day shift, 07/18/2024 night shift, 07/19/2024 day shift or night shift, 07/20/2024 night shift, 07/21/2024 day shift, 07/23/2024 day shift, 07/24/2024 day shift, 07/26/2024 day shift, 07/27/2024 day shift, 07/28/2024 evening shift or night shift and 07/30/2024 night shift. Resident #2 Resident #2 was admitted to the facility with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the non-dominant side ( late-effect weakness or paralysis on the side due to a previous stroke,) essential hypertension (a chronic condition characterized by persistently elevated force of blood against artery walls,) and hypo-osmolality and hyponatremia (a condition where the blood is too diluted). The Minimum Date Set dated 12/26/2023 documented that they could make themselves understood and understand others and was cognitively intact. Record review Care plan dated 12/20/2023 titled Activities of Daily Living: All Tasks. Patient currently is extensive assist of 2 for bed mobility and transfers due to safety concerns. Resident requires assistance with activities of daily living and mobility. Minimum Data Set, dated [DATE] documents resident is substantial/maximal assist for the ability to bathe self, including washing, rinsing and drying self. Care plan dated 12/21/2023 titled Activities of Daily Living: All Tasks, notes documented resident required extensive assist of two (2) for transfers due to safety concerns. Resident Certified Nurse Aide Accountability record titled Bathing dated 12/21/2023 had no documented evidence of bathing/shower on the evening shift, and 12/28/2023 had no documented evidence of bathing/shower completed on the evening shift. Interviews: During an interview on 4/28/2026 at 8:35 AM, Certified Nurse Aide #2 stated there were no instances where they had not been able to give a shower. They stated if they were not able to give a shower, it would be reported to the nurse, and the shower would be rescheduled for the next day. Interview with Licensed Practical Nurse # 4 on Union Station Unit at 08:40 AM on 04/28/2026. They stated, there is no reason for a resident not to get their shower on the scheduled day. Stated if they are short staffed or the Aides need help, the nurses will step in and assist with giving care, including showers if necessary. Stated if they were not able to give a shower, it would be reported to the head nurse and we would ask the next shift to pick it up, If they could not, the shower would be scheduled for the next day. Stated we communicate this by leaving a note with the 24-hour report and we would pass it on in shift-to-shift report. 10 New York Codes, Rules, and Regulations 415.12(f)(1)

Based on observation, record review and interviews during a survey, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for ONE (1) (resident #207) of thirty-five (35) residents reviewed. Specifically, on 7/14/2024 at 11:42 AM, Resident #207's daughter called expressing concern and stated resident complained of trouble breathing and pain 10/10. At 4:47 PM the provider was notified of pain 10/10 and adjusted the resident's pain medication. At 9:46 PM, resident #207 was lethargic with no appetite; the provider was not made aware of the change in condition and or persistent pain. On 7/15/2024 at 4:09 PM, Resident #207 was unresponsive, hypotensive and sent to the Emergency Room. Findings include:Resident #207 was admitted to the facility with diagnosis of Coronary Artery Disease (a common heart condition where plaque builds up in the arteries, restricting blood flow to the heart muscle); Peripheral Vascular Disease (a slow and progressive disorder of the blood vessels), and Chronic Obstructive Pulmonary Disease (COPD - a progressive, long-term lung disease that causes obstructed airflow, making it difficult to breathe). The Minimum Data Set (an assessment tool) dated 07/15/2024, documented they could be understood, understand others, and was cognitively intact. The Facility's Policy and Procedure titled Change of Condition reviewed 2/2025, documented The facility monitors residents for changes in physical, mental, functional, and psychosocial status and responds in a timely manner consistent with the resident's clinical needs, provider orders, and recognized standards of nursing practice. The goal is to identify potential changes, provide appropriate evaluation. Guidelines: Observation & Awareness. Staff observe residents during routine care and interactions. Any potential change is communicated to the licensed nurse for further clinical assessment. Nursing Assessment: The licensed nurse evaluates the resident as indicated, using nursing judgment and available assessment tools. Assessment may include review of vital signs, pain, behavior, mobility, elimination, intake, skin, cognition, or other relevant clinical indicators. Provider Notification: The resident's practitioner is notified when, in the nurse's clinical judgment, the change warrants. Notification content includes: *Description of change* Assessment findings* Interventions attempted (if any) *Resident response. The practitioner provides direction for further evaluation or treatment, which is carried out as ordered. The Facility's Policy and Procedure titled Quality of Care Policy reviewed 1/2023 documented, the facility provides care and services to ensure each resident attains or maintains the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and person-centered plan of care. Care is delivered by qualified staff in accordance with physician orders, evidence-based practices, and applicable federal and New York State Department of Health regulations. Changes in resident condition are promptly identified, evaluated, and addressed, with timely care plan updates and referrals as appropriate. Nursing progress note dated 7/4/2024 at 11:42 AM documented, Resident #207's daughter called stating that their father called them and said they were very, very sick. Registered Nurse #5 assessed resident #207. Vital Signs were temperature 98.9, blood pressure 112/64, heart rate 68, respirations 20. The Resident's upper lobe Lung sounds were clear, but they would not cooperate with lower lobe lung assessment. The resident complained of having trouble breathing; the resident was not observed using any accessory muscles to breathe. The resident's oxygen saturation level was 90%, which was within normal limits. The resident refused use of oxygen and refused to have their dressing changed. Registered Nurse #1 updated resident #207's daughter that resident was not in any acute distress, and that they were not dying as they had told both daughter and son earlier. Nursing progress note dated 07/14/2024 at 04:47 PM, documented Registered Nurse #5 Spoke with Nurse Practitioner #1 Nurse Practitioner #1 regarding residentsn#207's uncontrolled pain of 10 on 10. Nurse Practitioner #1 ordered Gabapentin 300 milligrams three times a day starting 7/15/2024, one dose of Gabapentin to be given now at dinner time and one dose be given at 9:00 PM. Nurse Practitioner #1 also ordered Hydrocodone as needed dose be given at 5:00 PM as the dose was due at 6:00pm, then, give as needed Hydrocodone dose every 4 hours on the hour for pain control Nursing progress note dated 7/14/2024 at 9:46PM documented Resident has had a significant decline over the last 2 days. Resident is not eating, drinking minimally, and is sleeping the entirety of 15:00-23:00. Resident is able to be roused easily, to take medications, but then returns to sleeping. Resident had continued complaints of 10/10 pain in their left foot despite medication adjustment, earlier in this shift. Nursing progress note dated 07/15/2024 at 04:09AM documented Resident very lethargic and non-responsive; blood pressure 90/50 heart rate 53 temperature 95.9 blood glucose 194 unable to get an oxygen saturation reading. Nurse Practitioner #1 ordered resident be sent to hospital emergency room. Hospital Discharge summary dated [DATE] documented a diagnosis of Toxic metabolic encephalopathy. The resident had initially presented from nursing home for altered mental status along with lethargy. This is likely in the setting of severe sepsis due to gram-negative pneumonia. The resident's mental status has greatly improved throughout hospitalization after treatment with intravenous antibiotics and as per their daughter is at their baseline mental status. The patient was discharged back to extended care facility. During an interview on 11/5/2025 at 2:25PM, Nurse Practitioner #1 stated Resident #207 is not their patient. They were covering the shift. They adjusted medication to address complaint of pain 10/10. Nurse Practitioner #1 stated if pain was not controlled it is the expectation that nurse/supervisor should call the provider back with a re-assessment for further direction. They should include vital signs, change in mental status, history each time to made decision on what to do next. During an interview on 11/5/2025 at 12:00 PM, Director of Nursing #1 stated Resident #207 was seen by wound care. Once a resident goes to wound care they are no longer followed by the facility for wounds, the wound care center follows them. The Director of Nursing stated they do not recall anything about the wounds on resident #207's feet and was not aware of the change in condition on 7/14/2024-7/15/2024. During an interview on 11/5/2025 at 12:20PM, Registered Nurse #6 stated they do not remember the specifics regarding resident #207 but remember they had issues with their feet. However, when a resident has a change in condition, they would assess the resident for change in baseline, notify provider and document. They stated the documentation for resident #207 should have been better. 10 New York Codes, Rules, and Regulations 415.4 (b)(1)(i)

Based on record reviews and interviews during the survey process, the facility failed to obtain necessary treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. Specifically, for Resident #13, there was no psychiatric service follow-up as ordered by the psychiatrist. Findings include: Resident #13 was admitted to the facility with the diagnoses of hemiplegia(a severe or complete paralysis on one side of the body caused by brain damage) following cerebral infarction (sudden disruption of blood flow to the brain, leading toe cell death), generalized anxiety disorder (a mental health condition characterized by persistent, excessive, and uncontrollable worry), and bipolar disorder (a chronic mental health condition characterized by extreme mood swings alternating between intense highs and severe lows). The Minimum Data Set (an assessment tool) dated 2/11/2026 documented the resident was able to be understood, was able to understand others, and was cognitively intact. The Follow Up Psychiatric Consultation, dated 8/13/2025, documented follow-up in two (2) to three (3) weeks. There was no follow-up scheduled or completed. Medical notes; dated 09/01/2025, 12/04/2025, 01/12/2026, 02/08/2026, 03/09/2026, and 04/05/2026, documented the resident was receiving psychotropic medication and management to be deferred to psychiatric services. During an interview on 4/27/2026 at 1:40 PM, Medical Director #1 stated Resident #13 should have had psychiatric services involved. During an interview on 4/28/2026 at 11:22 AM, Nurse Practitioner #1 stated they assumed the resident was being seen by psychiatric services but did not read any consultations. They stated the nurses would let them know if there were any changes or recommendations made. During an interview on 4/28/2026 at 11:40 AM, Registered Nurse #3 stated the nurses would arrange for follow-up appointments and that they had not made the follow-up appointment; they did not know why the lapse had occurred. 10 New York Codes, Rules, and Regulations 415.12(f)(1)

Based on observation, interview, and record review conducted during a survey, the facility failed to ensure that its medication error rate did not exceed five (5) percent for two (2) (Resident #'s 32 and #57) of eight (8) residents observed during a medication pass for a total of 35 observations. This resulted in a medication error rate of 31.43 percent. Findings Include: The facility's policy and procedure titled Administering Medications revised 03/2023, documented the expiration/beyond use date was to be checked prior to administering a medication. Resident #32 Resident #32 was admitted to the facility with diagnoses of essential primary hypertension (most common type of high blood pressure), herpes viral ocular disease unspecified (group of eye disorders caused by infection with the herpes simplex virus), hyperlipidemia unspecified (excess amount of fats in your blood). The Minimum Data Set (an assessment tool) dated [DATE], documented that the resident could be understood, understand others, and was cognitively intact. Review of the Medication Administration Record dated April 2026 documented Resident #32 had a physician order and received: Propranolol 60 milligram tablet, give two (2) tablets (120 milligrams) by oral route once daily at 9:00 AM. Aspirin 81 milligram tablet delayed release, give one (1) tablet by oral route once daily at 9:00 AM. Losartan 25 milligram tablet, give one (1) tablet by oral route two (2) times per day at 9:00 AM and 8:00 PM. Valacyclovir 1 gram tablet, give one (1) tablet by oral route two (2) times per day at 9:00 AM and 8:00 PM. Myrbetriq 25 milligram tablet extended release, give one (1) tablet by oral route once daily at 9:00 AM. During an observation on [DATE] at 8:33 AM, Licensed Practical Nurse #1 reviewed Resident #32's Medication Administration Record and stated Resident #32 was to receive propranolol 60 milligram tablet two (2) tablets, aspirin 81 milligram tablet delayed release, Losartan 25 milligram tablet, Valacyclovir 1 gram tablet, and Myrbetriq 25 milligram tablet extended release. Licensed Practical Nurse #1 began to prepare the propranolol 60 milligrams, when they were asked to show the surveyor the expiration date of the medication, they had difficulty locating the information on the medication blister card. They then proceeded to prepare the four (4) additional medications without checking the expiration dates of the medications. Medications were administered to Resident #32. Resident #57 Resident #57 was admitted to the facility with diagnoses of multiple sclerosis (autoimmune disorder that affects the brain and spinal cord), ulcer of esophagus with bleeding (hole in the esophagus that causes bleeding), and essential primary hypertension (most common type of high blood pressure). The Minimum Data Set (an assessment tool) dated [DATE], documented that the resident could be understood, understand others, and was cognitively intact. Review of the Medication Administration Record dated [DATE] documented Resident #57 had a physician order and received: Tamsulosin 0.4 milligram capsule, give one (1) capsule once daily one-half hour following the same meal each day at 8:00 AM. Pantoprazole 20 milligram tablet delayed release, give one (1) tablet at 8:00 AM. Baclofen 20 milligram tablet, give one (1) tablet four (4) times per day at 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. Gabapentin 300 milligram capsule, give three (3) capsules (900 milligrams) three (3) times per day at 8:00 AM, 12:00 PM, and 7:00 PM. Metoprolol succinate ER 25 milligram tablet extended release 24 hour, give one (1) tablet once daily at 8:00 AM. During an observation on [DATE] at 8:50 AM, Licensed Practical Nurse #1 reviewed Resident #57's Medication Administration Record, and stated Resident #57 was to receive Tamsulosin 0.4 milligram capsule, Pantoprazole 20 milligram tablet delayed release, Baclofen 20 milligram tablet, Gabapentin 300 milligram capsule three (3) capsules, Metoprolol Succinate ER 25 milligram tablet extended release 24 hour. Licensed Practical Nurse #1 prepared medication for administration without checking expiration dates for any of the five (5) medications administered to Resident #57. Durin an interview on [DATE] at 8:33 AM, Licensed Practical Nurse #1 stated they did not routinely check expiration dates prior to administering medication. The night nurses did a good job at going through the carts ensuring medications were not expired. In general, the expirations dates of individual residents' medications were checked prior to being placed in the medication cart, stock medications were checked prior to being placed in medication room. Occasionally the carts were cleaned out, and expiration dates were checked as well. During an interview on [DATE] at 9:39 AM, Director of Nursing #1 stated they would expect the five (5) rights (right resident, right medication, right dose, right time, and right route) to be completed as well as checking the expiration date prior to administering every medication. After being altered to medication pass being completed without expiration dates being checked, they stated they would follow up with the nurse. 10 New York Codes, Rules, and Regulations 483.45(f)(1)

Based on record review and interviews during the recertification and abbreviated survey (Case #NY00277034) on 8/14/2023 through 8/18/2023, the facility did not ensure all alleged violations of abuse, neglect, or mistreatment, including injuries of unknown source were thoroughly investigated for 1 (Resident #425) of 5 residents reviewed. Specifically, for Resident #425, the facility did not ensure that alleged abuse by Certified Nurse Aide (CNA) #5, reported on 6/1/2021 at 4:18 PM, was thoroughly investigated and documented to rule out abuse, mistreatment, or neglect. Also the facility did not ensure the results of all investigations were reported to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident. This is evidenced by: The facility policy titled Freedom from Abuse, Neglect and Exploitation last reviewed 4/28/2022, documented in response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: 1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse, and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. 2) Have evidence that all alleged violations are thoroughly investigated. 3) Prevent further potential abuse, neglect, exploitation, or mistreatment, while the investigation is in progress. 4) Report the results of all investigations to the Administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. Resident #425: Resident #425 was admitted to the facility with diagnosis of vascular dementia, hypertension, restlessness, and agitation. The Minimum Data Set (MDS- an assessment tool) dated 3/16/2021, documented the resident had severe cognitive impairment, usually understood and was sometimes able to make their needs known. A facility Incident and Accident Report dated 6/1/2021 at 5:20 AM, documented Resident #425 kicked a Certified Nurse Aide (CNA) during care and the resident's leg became painful and swollen with inward rotation. The x-ray report dated 6/1/2021 at 6:28 AM, documented a displaced fracture of the right mid to distal femoral shaft. The document titled Investigation Summary dated 6/4/2021 did not include a conclusion that documented the facility's findings or determination of the allegation of abuse, mistreatment or neglect by CNA #5. During an interview on 8/18/2023 at 11:15 AM, the previous Director of Nursing (DON) #2 said they had completed the investigation and determined there was no evidence that CNA #5 had done anything wrong. However, the previous Administrator had suspended CNA #5 indefinitely and to error on the side of caution, they reported the incident to the NYSDOH and the Attorney General. The DON #2 did not know why a conclusion wasn't documented in the investigation summary. When asked what the outcome was, they said the facility was unable to determine what happened. During an interview on 8/18/2023 at 11:20 AM, the DON said they were not the DON at the time of this incident and were not involved in the investigation. Upon review of the investigation on file, the DON said the investigation did not document that the allegation of abuse was thoroughly investigated; without a conclusion summary the investigation was incomplete. 10 NYCRR 415.4(b)(3)

Based on observation, record review and interviews during the recertification survey, the facility did not ensure the development and implementation of comprehensive person-centered care plans, that included measurable objectives and time frames to meet the resident's medical, nursing, mental and psychosocial needs for 3 (Resident #s 77, 135 and #78) of 34 residents reviewed for Comprehensive Care Plans (CCP). Specifically, for Resident #77, the facility did not ensure the CCP included a care plan to address the resident's hearing deficit and use of hearing aids; for Resident #135, the facility did not ensure the CCP included interventions related to the use of a splint. Specifically, for Resident #78 the facility did not ensure a CCP included a care plan to address alterations in urinary elimination to include an indwelling catheter and ongoing infection requiring contact isolation and treatment of that infection. This is evidenced by: Resident #77 Resident #77 was admitted to the facility with the diagnoses of chronic atrial fibrillation, chronic kidney disease and hypoxemia. The Minimum Data Set (MDS - an assessment tool) dated 7/13/23 documented Resident #77 was able to be understood, was able to understand others, had moderate difficulty hearing others and had a moderate cognitive impairment. During an observation on 8/14/23 at 12:31 PM, Resident #77 was noted to be wearing hearing aids in both ears. A Physician's Order dated 6/3/23 documented the staff to check placement of hearing aid every four hours. A Physician's Order dated 4/18/22 documented the resident's hearing aid to be inserted in the morning and removed at hour of sleep. During an interview on 8/17/23 at 10:56 AM, Certified Nursing Assistant (CNA) #2 stated the nurse kept the hearing aids in the medication room on a charger and the nurse would put them in during the morning. CNA #2 stated Resident #77 had their hearing aids in place. During an interview on 8/18/23 at 10:23 AM, Registered Nurse (RN) #2 stated the care plan should correspond with a resident's diagnoses and conditions. The care plans should be monitored and revised as needed. RN #2 stated a resident with a hearing deficit and hearing aids, like Resident #77, should have that care plan in place. During an interview on 8/18/23 at 10:44 AM, the Director of Nursing (DON) stated that every diagnosis should have a care plan, though the diagnoses may be grouped so a resident doesn't have multiple care plans that state the same thing. Any appliances such as splints and hearing aids should be in a care plan. Resident #135 Resident #135 was admitted to the facility with the diagnoses of immunodeficiency, dementia and cerebral ischemia. The Minimum Data Set (MDS - an assessment tool) dated 7/21/23 documented that Resident #135 could be understood, could understand others and had a moderate cognitive impairment. During an observation on 8/15/23 at 10:40 AM, Resident #135 was noted to wearing a splint on their left hand and wrist. The Comprehensive Care Plan (CCP) titled Musculoskeletal - Fracture did not include the use and monitoring of a splint. The CCP titled Activities of Daily Living did not include the use and monitoring of a splint. During an interivew on 8/17/23 at 10:51 AM, Registered Nurse (RN) #2 stated the resident was decent about keeping the splint on but could remove it independently. During an interview on 8/18/23 at 10:25 AM, RN #2 stated the splint should be on the comprehensive care plan. During an interview on 8/18/23 at 10:44 AM, the Director of Nursing (DON) stated that every diagnosis should have a care plan, though the diagnoses may be grouped so a resident doesn't have multiple care plans that state the same thing. Any appliances such as splints and hearing aids should be in a care plan. Resident #78 Resident #78 was admitted to the facility with the diagnoses of Cerebral vascular accident, neurogenic bladder requiring a catheter, and multiple sclerosis. The MDS dated [DATE], documented Resident #78 was able to be understood, was able to understand others, and had intact cognition for daily decision making. During an observation on 8/15/23 at 10:19 AM, Resident #78 was observed in bed. The foley catheter collection bag was hanging at the side of the bed. The resident had a sign outside the room notifying people entering that the resident was on contact precaution. A nursing progress note date 04/03/2023 at 3:12 PM, documented Resident #78 continues contact precautions for MRSA (Methicillin-resistant Staphylococcus aureus, a resistive contagious infection) in the urine. A Nurse Practitioner note dated 4/09/2023 at 9:42 PM, documented urology consultation was completed regarding recurrent symptomatic urinary tract infections with recommendations for suppression therapy with nitrofurantoin or cephalexin nightly and consider foley catheter changes A Physician's Order dated 04/10/2023, documented give nitrofurantoin macrocrystal 50 mg (milligrams), 1 capsule by oral route once daily at bedtime with food for personal history of urinary tract infections. The electronic medication administration record (eMAR) for August 2023 documented the following give nitrofurantoin macrocrystal 50 mg (milligrams), 1 capsule by oral route once daily at bedtime with food for personal history of urinary tract infections. Start date 4/10/2023 A Nurse Practitioner note dated 4/09/2023 at 9:42 PM, documented urology consultation was completed regarding recurrent symptomatic urinary tract infections with recommendations for suppression therapy with nitrofurantoin or cephalexin nightly and consider foley catheter changes The electronic treatment administration record (eTAR) for August 2023 documented the following: Foley Catheter, change every 4 weeks and prn (as needed). Start date 4/10/2023 for diagnosis of Multiple Sclerosis. The CCP titled Alteration in Urinary Elimination did not include care and monitoring of a urinary catheter and medication and care for isolation of the resident on contact isolation. The CCP titled Neuromuscular Disease related to MS did not include loss of bladder function and care and monitoring of a catheter. During an interview on 8/17/23 at 12:06 PM, Certified Nursing Assistant (CNA) #6 stated the resident had an indwelling catheter and was on contact isolation. During an interview on 8/17/2023 at 2:26 PM, Licensed Practical Nurse #2 (LPN) stated the resident had medication for suppression of MRSA. During an interview on 8/17/23 at 10:23 AM, Registered Nurse (RN) #3 stated the care plans are generated by the MDS and the focus of the CCP's was determined by a resident's diagnoses and conditions and care needs. The care plans should be monitored and revised as needed and all diagnoses need to be addressed. After review of the CCP's for Neuromuscular disease and alteration of urinary elimination when the addition of the foley catheter and urinary infection occurred in April 2023, areas of concern requiring goals and interventions had not been addressed in the current CCP's for adequate monitoring. This would need to be addressed. During an interview on 8/18/2023 at 10:45 AM, the DON stated CCP's were an area the facility and nurses needed to focus on. The MDS coordinator had been behind, and an outside company was helping to catch up and this had affected the on time completion of the CCP's. 10 NYCRR 415.11(c)(1)

Based on observation, record review and interviews during the recertification survey, the facility did not ensure care plans were reviewed and revised in a timely manner for 2 (Resident #'s 45, and 78) of 34 residents reviewed for Comprehensive Care Plans (CCP). Specifically, for Resident #45, the facility did not ensure the Comprehensive Care Plan (CCP) for Sensory Deficit (At Risk for Visual Deficit), Musculoskeletal Disorder (Vitamin D Deficiency), and Sleep Pattern Disturbance were reviewed at least quarterly. Specifically, for Resident #78, the facility did not ensure the CCP for Resident #78 for Neuromuscular disease related to Multiple Sclerosis and Altered Urinary Elimination were updated quarterly with goals and interventions as treatment was changed. This is evidenced by: The Policy and Procedure (P&P) titled Baseline Care Plans, Resident Care Plans, dated 11/2022, documented the Interdisciplinary Team (IDT) must review and update each CCP at least quarterly. Resident #45 Resident #45 was admitted to the facility with diagnoses of bipolar disorder, pain, and osteoporosis. The Minimum Data Set (MDS - an assessment tool) dated 3/15/2023, documented the resident was able to make themselves understood, understand others, and moderately cognitively impaired. The CCP, titled: Sensory Deficit (At Risk for Visual Deficit), documented a review date of 06/03/2022; Sleep Pattern Disturbances, documented a review date of 06/10/2022; and Musculoskeletal Disorder (Vitamin D Deficiency), documented a review date of 08/17/2022. During an interview on 08/18/23 at 12:55 PM, the Director of Nursing (DON) stated they were currently covering the [NAME] Crossing (EC) Unit since there was no full-time Nurse Manager there. The Nurse Managers or DON was responsible for reviewing each resident's CCP at least quarterly. The CCP for Resident #45 for Sensory Deficit (At Risk for Visual Deficit) and Sleep Pattern Disturbances had not been reviewed since June 2022, and Musculoskeletal Disorder (Vitamin D Deficiency) had not been reviewed since August 2022. These CCP should have been reviewed quarterly since these dates, they were not sure why this had not been done. Resident #78 Resident #78 was admitted to the facility with the diagnoses of Cerebral Vascular Accident, neurogenic bladder requiring a indwelling catheter, and Multiple Sclerosis (MS). The MDS dated [DATE], documented Resident #78 was able to be understood, was able to understand others, and had intact cognition for daily decision making. The CCP, titled: Altered Urinary Elimination related to UTI with MRSA, did not include medication and other changes that were in place with new orders from 4/10/2023. Neurological Disease, related to Multiple Sclerosis documented the CCP was last reviewed and updated on 2/27/2023. During an interview on 8/16/2023 at 2:24 PM, Registered Nurse Unit Manager (RNUM) #3 stated the resident had an indwelling catheter and was on contact precautions. The CCP's for the resident needed to be updated to ensure goals and interventions were added to the care plan. This hadn't happened. The CCP should be updated quarterly, and the RN's were responsible to do this but that doesn't always get done. The RNUM stated they would fix the CCP to reflect the goals and interventions needed for care of Resident #78's current conditions. 10 NYCRR 415.11(c)(2)(i-iii)

Based on record review and interviews during an abbreviated survey (Case #NY00308435), the facility did not ensure each resident was treated with respect and dignity for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one (Resident #1) of 3 residents reviewed. Specifically, the facility did not ensure Resident #1 was treated with respect and dignity by the facility staff on 4/4/2023 at 3:00 AM, when assisting the resident after they had fallen on the floor. This is evidenced by: Refer to F684 Resident #1: Resident #1 was admitted to the facility with diagnoses of unstable burst fracture of first lumbar vertebra, Crohn's disease (inflammatory bowel disease that causes inflammation of the gastrointestinal tract) and dementia. The Minimum Data Set (MDS) dated [DATE], documented the resident's cognitive skills for daily decision making were severely impaired. The Policy and Procedure (P&P) titled Resident Rights dated 1/23, documented Federal and State laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right to a dignified existence, and to be treated with respect, kindness, and dignity. Review of a video file named EEED5F22-D935-42C8-B733-9ED88FF717E0 dated 4/4/2023 at 3:02 AM showed the following: -Resident #1 was laying on their right side, on the floor between the bedroom and the bathroom. The resident was laying close to the left side of the bathroom doorway and the resident's legs were visible in the bedroom area. The resident had socks on both feet and the resident's undergarment was down and wrapped around their left foot. Certified Nurse Aides (CNAs) #1 and #2 were in the bedroom. -As RNS #1 entered the resident's room RNS #1 stated, I have to zip my mouth right now. I really have to zip it and be nice. RNS #1 saw that the resident was on the floor, walked over to Resident #1 and RNS #1 stated, Resident #1, what are you doing? You're stark naked. What are you doing? -RNS #1 then turned on the bathroom light and stepped inside the bathroom. RNS #1 stated, Oh, poo. Poo everywhere. -Licensed Practical Nurse (LPN) #1 entered the resident's room. The camera view was then partially obstructed by where LPN #1 was standing in the room. -RNS #1 then told Resident #1, Ok, here we go [NAME]. CNA #1 then removed the resident's undergarment from their left foot. RNS #1 then stated, Come on. This is ridiculous and appeared to be moving the resident onto their back since the resident's feet were now both flat on the floor. -CNA #1 then walked over to the resident's right side and RNS #1 then stated, You gotta stay your ass in bed. You know that. This is ridiculous. Stand up., as RNS #1 and CNA #1 assisted the resident to stand. -RNS #1 then stated, Ridiculous, as they and CNA #1 began to walk the resident towards their bed. LPN #1 then stepped to left and the camera view was no longer obstructed. -RNS #1 then looked at the back of the resident who was naked and stated, She's got poop all over her. -CNA #2 then pointed to their forehead and RNS #1 then pointed to Resident #1's forehead and stated, Oh, she's got stitches in her head from another fall. RNS #1 then stated, Honey, you are in such big trouble. Let's get you over here to sit down. You are in such big trouble. Big trouble. Big, big as RNS #1 and CNA #1 walked the resident over to their bed. The undated facility investigation report by the Administrator (ADMIN #1), documented they reviewed the videos dated 4/4/2023. The ADMIN #1 documented that during the process of assisting Resident #1, the RN Supervisor (#1) stated, You gotta stay your ass in bed, this is ridiculous. RNS #1 then went on to state, Honey you are in big trouble. The ADMIN #1 documented the facility was not aware of the behavior of RNS #1 until 4/11/2023 at approximately 12:45 PM. During an interview on 4/13/2023 at 8:35 AM, the Administrator (ADMIN) #1 stated they reviewed the video footage dated 4/4/2023 at 3:00 AM and stated RNS # 1 spoke to Resident #1 in a derogatory manner. The ADMIN stated they were mortified that the resident was naked and was not covered. The ADMIN stated RNS #1 had violated facility policy and was suspended on 4/11/2023. The ADMIN #1 stated the facility was going through the process of terminating RNS #1. During an interview on 4/14/2023 at 12:26 PM, RNS #1 stated they were aware of the camera that the family had in the Resident's room. RNS #1 stated that when they went to the resident's room, the resident was laying on the floor was without clothing. RNS #1 stated they did not review the video footage dated 4/4/2023 at 3:00 AM. RNS #1 stated, I am animated, but it wasn't done in a negative manner. I'm sure it looks very unprofessional. RNS #1 stated that their behavior was inappropriate and stated, I was wrong. During an interview on 4/18/2023 at 2:19 PM, the Director of Nursing (DON) #1 stated they reviewed the video footage dated 4/4/2023 at 3:00 AM. The DON stated RNS #1 did not treat Resident #1 respectfully and stated staff could have put a gown over the resident. During an interview on 4/18/2023 at 3:25 PM, the Assistant Director of Nursing (ADON) stated they reviewed the video footage dated 4/4/2023 at 3:00 AM. The ADON stated the facility started educating staff right away about what they saw on the video and to tell a resident they were in trouble was not good. The ADON stated staff might not have wanted to get the resident fully dressed at that point in time, but they could have put something over the resident to cover them up. The ADON stated the facility did have gowns. During an interview on 4/20/2023 at 3:47 PM, CNA #1 stated they did not recall what RNS #1 said to Resident #1 on 4/4/2023 at 3:00 AM, when the resident had fallen. During an interview on 4/21/2023 at 12:53 PM, CNA #2 stated they recalled RNS #1 saying it's ridiculous and stated they thought RNS #1 said that because Resident #1 had fallen so many times. 10 NYCRR 415.5(a)

Based on record review and interviews during an abbreviated survey (Case # NY00308435), the facility did not ensure each resident received treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 3 residents reviewed. Specifically, the facility did not ensure that their policy for Falls Protocol and Incident and Accident Reporting was followed when Resident #1, who had a history of falls and chronic compression fractures (small breaks in the bones of the spine), was found on the floor in their room on 4/4/2023 at 3:00 AM and was not assessed for injury by the Registered Nurse before the resident was moved onto their back and then assisted to a standing position. This is evidenced by: Refer to F550 Resident #1: Resident #1 was admitted to the facility with diagnoses of unstable burst fracture of first lumbar vertebra, Crohn's disease (inflammatory bowel disease that causes inflammation of the gastrointestinal tract) and dementia. The Minimum Data Set (MDS) dated [DATE], documented the resident's cognitive skills for daily decision making were severely impaired. The Policy and Procedure (P&P) titled Falls Protocol dated 7/22/16, documented steps to be taken with all falls. The first step documented a Registered Nurse (RN) was to assess the resident before the resident was moved. The (P&P) titled Incident and Accident Reporting dated 6/2022, documented a nursing assessment would be completed for all incidents by the Registered Nurse Supervisor/RN Charge Nurse/RN On-Call. It documented a RN assessment was required for all observed and unobserved falls prior to the resident being moved. The Comprehensive Care Plan (CCP) for Risk for Falls related to Crohn's and dementia last revised 4/6/2023, documented the resident was at high risk for falls secondary to spontaneous personality and non-compliance. The resident was impulsive and had poor safety awareness. The CCP documented 9 incidents of falls from 1/17/2023 to 4/1/2023. The CCP for Musculoskeletal Disorder: History of Fracture last revised 4/4/2023, documented the resident had a history of fracture of L1 compression fracture. The resident was being followed by the bone and joint specialist and had osteoporotic compression fractures. The CCP for Pain Management last revised 4/6/2023, documented the resident had pain related to L1 compression fracture, history of osteoporosis, and osteoporotic compression fractures. Review of a video file named EEED5F22-D935-42C8-B733-9ED88FF717E0 dated 4/4/2023 at 3:02 AM showed the following: -Resident #1 was laying on their right side, on the floor between the bedroom and the bathroom. The resident was laying close to the left side of the bathroom doorway and the resident's legs were visible in the bedroom area. The resident had socks on both feet and the resident's undergarment was down and wrapped around their left foot. Certified Nurse Aides (CNAs) #1 and #2 were in the bedroom. -As RNS #1 entered the resident's room and saw that the resident was on the floor. RNS #1 walked over to Resident #1 and RNS #1 stated, Resident #1 what are you doing? You're stark naked. What are you doing? -RNS #1 then turned on the bathroom light and stepped inside the bathroom. -Licensed Practical Nurse (LPN) #1 entered the resident's room. The camera view was then partially obstructed by where LPN #1 was standing in the room. -RNS #1 then told Resident #1, Ok, here we go [NAME]. CNA #1 then removed the resident's undergarment from their left foot. RNS #1 then stated, Come on and appeared to be moving the resident onto their back since the resident's feet were now both flat on the floor. -CNA #1 then walked over to the resident's right side and RNS #1 then stated, This is ridiculous. Stand up, as RNS #1 and CNA #1 assisted the resident to stand. -RNS #1 and CNA #1 began to walk the resident towards their bed. LPN #1 then stepped to left and the camera view was no longer obstructed. RNS #1 did not assess the resident for injury prior to turning Resident #1 onto their back or prior to assisting the resident to stand. The Nursing Progress Note dated 4/4/2023 at 4:18 AM by RNS #1, documented that at 3:00 AM, they found the resident on the floor between the bathroom and bedroom. The resident had removed their clothes and was laying on their right side and the walker was on the floor in the bathroom. The resident was rolled over to back position and stood with two-assist. Resident was walked back to bed and then requested to go back to the toilet. The undated facility investigation report by the Administrator (ADMIN #1), documented that after reviewing the videos dated 4/4/2023, it appeared that Resident #1 fell on the floor in their bathroom on 4/4/2023 at approximately 3:00 AM. There were two nurse aides that entered the room and waited for the RNS (#1) to come into the room before moving the resident. The RNS (#1) entered the room and assisted the resident with one of the nurse aides. RNS #1 was asked if they conducted an assessment of the resident prior to moving the resident. RNS #1 stated they conducted a visual assessment and it appeared that the resident's hips and legs were in alignment. RNS #1 stated the resident was placed in bed and that they completed a more thorough assessment. It was documented that after discussing the entirety of the incident, it did not appear that RNS #1 did a complete assessment before moving the resident from the floor to the bed. During an on 4/14/2023 at 12:26 PM, RNS #1 stated Resident #1 fell at 3:00 AM. RNS #1 stated they did not assess the resident prior to moving the resident. RNS #1 stated they were not disputing that the resident should have gotten a thorough assessment when they were on the floor but did not remember saying that they finished assessing the resident when they were put back to bed. RNS #1 stated they did not assess the resident when the resident was on the floor or when they were put back to bed. During an interview on 4/18/2023 at 2:19 PM, the Director of Nursing (DON) #1 stated they reviewed the videos dated 4/4/2023. The DON #1 stated it did not appear that an assessment of the resident was done. The DON #1 stated a full body assessment with neurological checks should have been done while the resident was still on the floor, to assess for injury. The DON #1 stated the whole purpose of the RN supervisor was for them to do an assessment of the resident. During an interview on 4/18/2023 at 3:25 PM, the Assistant Director of Nursing (ADON) #1 stated when a resident falls, the facility policy was for the RN to do a basic assessment; check range of motion and assess for pain and do a neurological check before the resident is moved. The ADON #1 stated RNS #1 said they assessed the resident after the resident used the bathroom and was put back to bed. The ADON #1 stated they watched the videos dated 4/4/2023 and did not see RNS #1 assess the resident for injury. During an interview on 4/20/2023 at 3:47 PM, CNA #1 stated they could not recall if RNS #1 assessed Resident #1 for injury after they had fallen on 4/4/2023 at 3:00 AM. During an interview on 4/21/2023 at 12:53 PM, CNA #2 stated RNS #1 did not do an assessment of Resident #1 when they had fallen on the floor on 4/4/2023. CNA #2 stated RNS #1 was supposed to assess the resident and then tell the CNAs when they could move the resident. CNA #2 stated that instead, RNS #1 and CNA #1 stood the resident up. CNA #2 stated the reason they call the supervisor and do not move a resident when they fall is so that the resident can be assessed for injury prior to moving the resident. During an interview on 4/21/2023 at 3:31 PM, LPN #1 stated whenever a resident falls, the RN does an assessment of the resident for injury. LPN #1 stated the moving of the resident was based on what the RN does and finds during the assessment. LPN #1 stated staff were aware they were not to move a resident before an assessment was done by the RN. 10 NYCRR 415.12

Based on observation, record review and staff interview during complaint investigations (#NY 423 and NY 884), the facility did not ensure for 2 (#s- 1 and 4) of 3 resident's reviewed that the resident received adequate supervision and that assistance devices were in place to prevent accidents. Specifically, Resident #1 was identified as a fall risk and was care planned to be supervised on a one-to-one (1:1) basis at all times with fall mats while in bed. Resident #1 fell from bed on 11/1/12 while being supervised 1:1 and sustained a 1 centimeter (cm) laceration above her right eye and fell again from bed on 11/8/12 while being supervised 1:1 and sustained a 4.5 cm laceration to the left side of her forehead necessitating transfer to the hospital for sutures an fall mats were not in place. Resident #4 was care planned for total assistance with all meals was observed after lunch in the hallway with wet pants stating "I burned my leg." The resident sustained [REDACTED].#1 and Resident #4 that is not immediate jeopardy. This is evidenced by the following: Resident #1 The resident was admitted to the facility on [DATE] diagnosed with [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident had moderate cognitive impairment. Physical Therapy Recommendations to Nursing Services dated 7/27/12 documented that Resident #1 should be transferred via a Stand Pivot Transfer (SPT) with the assistance of 2 staff. The Comprehensive Care Plan (CCP) for Falls initiated on 12/6/11 documented an intervention of mats on floor while in bed. On 5/3/12 an intervention was added that the resident was a SPT with the assistance of two staff and on 7/30/12 the resident was placed on 1:1 supervision per nursing judgment or 1:2 if needed per nursing judgment. Nurse's note dated 11/1/12 at 6:10 am signed by Registered Nurse Supervisor (RNS) documented that at 5:10 am, the resident was being supervised by a Certified Nurses Assistant (CNA) who stepped away from the resident's bed to wash her hands at the sink and the resident rolled out of bed and sustained a 1 cm laceration above her right eye. The area was treated with first aide. Nurse's note dated 11/8/12 at 5:11 am signed by Registered Nurse Supervisor (RNS) documented that at 3:35 am, the resident was being put back to bed and "flipped" herself onto the floor and sustained a 4.5 cm laceration to the left side of her forehead. Physician orders [REDACTED]. The noted further documented that 2 CNAs were with the resident at the time of the fall because they were putting her back to bed via lift. Nurse's note dated 11/8/12 at 5:48 am signed by Licensed Practical Nurse (LPN) #1 documented that two CNAs took the resident to her room to give care at 3:30 am, after placing the resident in bed, one of the CNAs went to the sink and the other CNA turned to get the resident's floor mat at the side of the bed and she turned to see the resident roll out of bed on her left side. The resident sustained [REDACTED]. emergency room Discharge Instructions dated 11/8/12 at 6:45 am documented that the resident sustained [REDACTED]. During an interview on 11/8/12 at approximately 9:30 am, the Director of Nursing stated that in addition to Resident #1's fall with injury on 11/1/12, the resident was currently being returned from the hospital with sutures after another fall at 3:30 am this date. The DON stated the initial report today indicated that again, the fall mat was not placed at the resident's bedside. The DON stated in response to the first fall on 11/1/12, the facility conducted reeducation with the CNA involved in the first incident only and that no other floor staff were educated or spoken to about the need for safety devices at Resident #1's bedside. During an interview on 11/8/12 at 1:45 pm, CNA #2 stated that she was assigned to the resident as a 1:1 on the 11:00pm - 7:00am shift on this date (11/8/12) and that she and CNA #3 transferred the resident to bed. CNA #3 was about to leave the room as she took one to two steps away from the resident lying in bed to retrieve the floor mat and when she turned the resident had fallen out of bed. CNA #2 stated that she should have had the floor mat in place and should not have stepped away from the resident. During an interview on 11/8/12 at 2:30 pm, CNA #3 stated that she and CNA #2 brought the resident into her room and transferred the resident to bed with each of the CNAs on each side of the resident's body and placed their arms underneath the resident's arms and legs and lifted her into bed. CNA #3 stated that she was placed in bed and CNA #2 was going to provide care, so she began to leave when she heard a thump and the resident was on the floor, bleeding from her head. Observation on 11/9/12 at approximately 3:45 pm with the Administrator and Director of Nursing (DON) in attendance, CNA #4 and CNA #5, each on one side of the resident, lifted Resident #1 from her geri chair by placing the arms under the arms and legs of the resident and physically lifting the resident to transfer to the bed. Observation included the resident's feet never touching the floor or extending her legs to a standing position. During an interview on 11/9/12 at approximately 3:45 pm, the Administrator and DON observed the transfer of the resident by CNA #4 and CNA #5 and stated, "that was not a SPT...that was very dangerous...anything could happen during that type of transfer, we did not know that staff were transferring the resident in that manner, it is not an acceptable transfer technique". During an interview on 11/9/12 at approximately 3:45 pm, CNA #4 stated that the observation of the transfer was the way the resident has been transferred for months as she is unable to bear weight. CNA #4 confirmed that the resident transfer status on her care plan was 2 person SPT and this is not the technique they use to transfer the resident. During an interview on 11/9/12 at approximately 3:45 pm, CNA #5 stated that the observation of the transfer was the way the resident has been transferred for months as she is unable to bear weight. CNA #5 stated they did not transfer the resident according to the care plan. During an interview on 11/30/12 at 5:45 am, CNA #1 stated that she was assigned to the resident on 11/1/12 as her 1:1 aide. CNA #1 stated that she stepped away from the resident's bed to wash her hands at the sink and when she turned around, the resident had fallen on the floor. CNA #1 stated that she was aware that the resident was care planned to have a mat on the floor, but that there was no mat placed when she took over supervision of the resident on 11/1/12. CNA #1 stated that she later found the mat pushed underneath the resident's bed. CNA #1 stated that she didn't like to sit her chair on the mat during her 1:1 sessions with the resident and many of the staff in the facility did not have the mats down while the resident was in bed because they sat their chair right next to the bed. During an interview on 11/30/12 at 11:30 am, the Administrator stated that the facility was still investigating the incidents as some of the information obtained is just not adding up, but that the resident should not have been transferred in the manner that we observed on 11/9/12 and the resident should have had 1:1 supervision and mats at bedside to prevent falls. Resident #4 The resident was admitted to the facility on [DATE] diagnosed with [REDACTED]. The MDS dated [DATE] assessed the resident had severe cognitive impairment. Observation on 1/16/13 at 2:00 pm of snack carts being transported to each unit containing hot coffee and hot water for tea. The temperature of four pots of coffee were obtained and revealed the temperatures of 168.5, 181, 189 and 155 degrees. The temperatures of four pots of hot water were obtained and revealed the temperatures of 185, 181.5, 184.5 and 190 degrees. The CCP entitled Altered Activities of Daily Living initiated on 12/5/12 documented that the resident required total assistance for feeding. The Care Card last updated on 12/11/12 documented that the resident was in need of total assistance for meals. The Temperature Log for Resident #4's Unit dated 1/3/13 was documented meal temperatures of 176 - 180 degrees and does not document hot beverage temperatures. The Accident and Incident Report dated 1/4/13 (untimed) documented on 1/3/13 at 1:00 pm, Resident #4 called to Licensed Practical Nurse (LPN) stating that she had burned her leg, pointing to her right knee and thigh above the knee. The report documented that the resident was noted with wet clothing, was changed and the LPN observed her right knee and thigh and noted no blisters or redness and that Register Nurse (RN) was present, observed the area as well and looked at the resident's leg. Nurse's note dated 1/4/13 at 6:13 am documented that during first checks, CNA noticed and reported a blister to the right hip area and at 6:00 am noted to have two adjacent blisters to the right hip area that are now ruptured area 7 centimeter (cm) in size, and a covering was placed over the area for protection. A physician note dated 1/4/13 at 9:17 am, documented that apparently the resident spilled liquid coffee over her right thigh during lunch yesterday with blisters on the right lateral thigh with skin peeled off and [DIAGNOSES REDACTED], will apply ointment. Nurse's note dated 1/4/13 at 9:53 am documented a late note for 1/3/13 at 1:30 pm, that the RN was on the unit when LPN was bringing the resident to her room as she had food on her clothing and was pointing to her inner thigh saying "it burns". RN documented that she looked at the residents inner thigh and saw no evidence of injury. Nurse's note dated 1/4/13 at 10:15 am documented a late note for 1/3/13 at 1:30 pm documented that the LPN witnessed the resident stating "I burned my leg" and the resident had food all over her clothes and and they were wet and the resident was pointing and rubbing her right thigh. The LPN documented that she looked at the right thigh and there was no redness or blisters noted. During an interview on 1/16/13 at 10:15 am, the Administrator stated that Resident #4 sustained a burn on her leg. The Administrator stated that the resident requires total assistance for meals and after reviewing the facility investigation, she believed the resident was able to spill hot coffee on herself in the dining room on 1/3/13. The Administrator stated that based on the investigation, it did not appear staff were supervising the resident in the dining room because no one directly observed the origin of the wet pants or injury to the resident until the next day. During an interview on 1/16/13 at 2:00 pm, the Food Service Manager (FSM) stated that he was delivering the afternoon snack to the units which included hot coffee and tea. The FSM when asked what the temperatures of the coffee and hot water was, stated, I don't know, the machine is set at 180 degrees. The FSM stated that he should have checked the temperature of the coffee and tea before he left the kitchen but had not. After retrieving a thermometer from the kitchen, the FSM stated that the temperatures were 168.5, 185, 181,181.5, 189, 184.5, 155 and 190 degrees. The FSM stated the hot beverages should be served at 160 degrees or less. The FSM stated that "coffee loses temperature quickly so by the time it gets down there and it is served it should be okay." During an interview on 1/16/13 at 2:20 pm with a CNA who was in the dining room serving the hot beverages, the CNA stated she did not know the temperature of the coffee. The CNA stated that she has ice on her cart and pointed to 3 resident's that had received beverages and stated "I added ice, so they don't get burned." After retrieving a thermometer, the CNA measured the temperature of the coffee she was serving and stated that it measured at 180.3 degrees. The CNA stated that this was the first day of a new procedure and she thought that the dietary staff would be checking the temperatures of the beverages. The CNA stated that she thought beverages should be served no higher than 170 degrees. During an interview on 1/16/13 at 2:40 pm, the Director of Food Service stated that all hot items, including beverages, should be served between 140 and 160 degrees and had inserviced all of her kitchen staff on Friday (5 days prior). The FSD stated that the kitchen staff record serving temperatures for every meal on a log however, beverages are not tracked. The FSD stated that based on the temperatures observed by the surveyor today, all hot beverages in the facility were held by staff until they reached a maximum of 160 degrees before they were served. During an interview on 1/16/13 at 4:00 pm, the FSM stated that he misspoke earlier and has learned that the coffee and hot water machines are set to deliver the beverages at 190 degrees and has contacted the vendor to lower the temperatures. During an interview on 1/17/13 at 11:50 am, the Administrator stated that a couple of months ago, the facility was receiving complaints that the hot beverages were being served not hot enough and the facility switched to a better and more insulated pot. The Administrator stated that she believed that all meal temperatures were being kept and was unaware that they were incomplete or had a recorded temperature above 160 degrees. The Administrator stated that the FSD was auditing the food temperatures and she had not heard about any problems. The Administrator stated that it was brought to her attention today that beverage temperatures were not being kept at all and audits were not available today when she requested them. When asked, if after Resident #4's incident on 1/3/13 had she seen or requested to see the audits of the temperatures, the Administrator stated, "no, I should have, I thought they were being done." 10 NYCRR 415.12(h)(2)

Based on medical record review and staff interview during a complaint investigation (Case #NY 272), the facility did not ensure that one (#1) of two residents reviewed, received services that provided the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance to the plan of care. Specifically, the facility did not ensure that the resident was assessed in a timely manner by a Registered Nurse (RN) after blood was found in the resident's stool. Additionally, the resident's physician was not notified, timely of the presence of blood in the stool. The resident was at risk for bleeding due to receiving [MEDICATION NAME] (an anticoagulation medication) and Aspirin. Subsequently, the resident was transferred to the hospital 7 hours, after the first episode of [MEDICAL CONDITION] and required [MEDICAL CONDITION] of blood. This resulted in actual harm that was not immediate jeopardy. This was evidenced by the following: Resident #1 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having short term memory problems and moderately impaired decision making skills. The Resident Care Plan Report titled, Potential for Acute Cardiopulmonary Distress related to Chronic Anticoagulation dated 1/23/07 and updated on 7/2010, there were no documented interventions to monitor for bleeding. The physician's orders [REDACTED]. laboratory results dated [DATE] documented Pro Time (PT) results of 30.6 (normal 9.6 - 10.0) and International Ration (INR) of 3.1 (normal 0.9-1.2). The physician's orders [REDACTED]. The nursing progress note dated 9/7/10 at 1:00 am, written by the Licensed Practical Nurse (LPN) documented, that the Certified Nurse Aide (CNA) reported a large amount of foul, dark loose stool expelled with reddish coloring around the outer pad. The 24 hour report form documented at 1:00 am on 9/7/10, that the stool was positive for occult (hidden) blood. The nursing progress note dated 9/7/10 at 2:00 am, written by the LPN documented that the resident's blood pressure (BP) was 86/44, (BP of 100/52 and 110/50 were documented in nurse's progress notes on 9/3/10 and on 9/4/10). The resident was pale and alert and conversing and for a second time, expelled loose stool with odor and black in color, with a red outer perimeter. There was no documentation of a pulse rate. The 24 hour report form dated 9/7/10 documented at 2:00 am, that the resident had 2 additional loose, dark stools. The nursing progress record (a form located in the physician's progress note section of the chart used to alert the physician to problems) dated 9/7/10 and untimed, documented that the night RN supervisor (N/RNS) received a call from the LPN at approximately 2:15 am, to report loose stools that tested positive for blood. There was no documented evidence that the RN assessed the resident. The nursing progress record dated 9/7/10 at 5:30 am, written by the N/RNS documented that according to verbal report and a review of the 24 hour report, it was identified that the resident had multiple episodes of loose stools, with foul odor during the night. The note stated that blood work was drawn this morning per Medical Doctor (MD) order and the results were pending. The resident was scheduled to have laboratory work ordered performed on 9/7/10. An International Normalized Ratio (INR), [MEDICATION NAME] and a complete blood count (CBC) were drawn. There was no documented order for a CBC in the medical record. The results of the blood work dated 9/7/10 were INR 1.4 (normal range 0.9-1.2), [MEDICATION NAME] was 13.6 (normal range 9.6-10.7). The hemoglobin was 7.8 (normal range 12.0-16.0) and hematocrit was 22.3 (normal range 36.0-48.0). The nursing progress record dated 9/7/10 at 7:00 am documented, that the daughter was notified and stated that she wished the resident to be sent to hospital. The MD was called and an order was received to transport resident to the hospital. The 24 hour report dated 9/7/10 documented that the resident was transferred to the hospital emergency room at 8:00 am and was admitted with [MEDICAL CONDITION]. The hospital consultation report dated 9/7/10 documented the resident had a significant drop in her hemoglobin and hematocrit (H&H). The resident's hemoglobin was 7.8 this morning. Her last H&H were 12.8 and 36.7, when last checked on 9/1/10. The resident had already received a unit and a half of blood. During an interview on 9/17/10 at 10:00 am the Certified Nurse Aide (CNA) who was caring for the resident the night of 9/7/10, stated that the resident had foul smelling bowel movements each time they changed her, about 5 stools in the night shift that she could remember. She stated that she told the LPN and the N/RNS who was on the unit during the night, that the resident was having dark foul smelling stools. During an interview on 9/17/10 at 11:35 am, with the N/RNS who worked on 9/7/10 stated she stated did not assess the resident. The N/RNS stated she was told by a CNA on first rounds around 1:00 am, that the resident had foul smelling, dark stools and that the stools had evidence of blood. The N/RNS stated that the LPN was not on the floor at this time. The N/RNS further stated that on her two other rounds, she was aware of the blood in the stool and that the resident's blood pressure was low. She further stated that around 5:00 am, the laboratory technician told her that the resident was foul smelling and the technician informed the N/RNS that he was going to draw a CBC. The N/RNS stated that she did not think to call the doctor at this point and that she was not sure what to do. The N/RNS stated she was aware there was not an order for [REDACTED]. The surveyor was unable to contact the LPN that worked 11:00 pm - 7:00 am on 9/7/10. During an interview on 9/17/10 at 10:15 am the D/RNS stated she worked on the day the resident was sent to the hospital, and stated that there was no assessment completed by the nurse on the night shift for the resident. When she began her shift on the day of 9/7/10, the D/RNS had to tell the N/RNS to call the family and the doctor. The D/RNS did not complete a RN assessment at that time. During an interview on 9/17/10 at 10:25 am with the resident's doctor, and the doctor who was on call the night of 9/7/10, stated his expectation would have been to get a call from the nurse informing him of the resident's status, at the beginning of the shift when the positive blood was noted in the resident's stool. During an interview on 9/17/10 at approximately 8:00 am, with the Director of Nursing who stated that the resident did not have a RN assessment and should have had an assessment. 10NYCRR 415.12