Every finding on record at Golden Hill Nursing and Rehabilitation Center

Based on observation, record review, and interviews conducted during the Abbreviated Survey the facility did not ensure the services provided were consistent with professional standards of medication administration that include obtaining physician clarification when the ordered medication could not be dispensed as written prior to administration, for one (Resident #2) of three residents reviewed for medication administration. Specifically, Resident #2 was re-admitted to the facility on [DATE] with a physician's order for Clozapine 100 milligrams, give 1.75 tablet by mouth at bedtime for psychosis. A Pharmacy clarification email provided by the Director of Nursing documented that on 01/16/2026, the pharmacy notified the facility that the medication could not be dispensed as ordered and requested that the physician be contacted to change the order. There was no evidence that the physician was contacted or that a new or clarified order was obtained by facility staff until 01/20/2026. The January 2026 Medication Administration Record revealed Licensed Practical Nurse #2 administered Clozapine to Resident #2 from 01/16/2026 through 01/19/2026. The Physician order was discontinued on 01/20/2026 and a new clarified order was written by the physician. The medication was delivered late by the pharmacy and was not administered at the scheduled time as ordered.The findings include: Review of the facility policy titled Physician Orders, dated 02/24/2025, documented that all physician orders shall be acknowledged, documented, and carried out in a timely and appropriate manner in accordance with applicable standards of practice and facility procedures. The policy further documented that physician orders shall be reviewed promptly by appropriate licensed clinical staff upon receipt. The policy also documented that any order that is unclear, incomplete, or potentially inappropriate shall be clarified with the ordering provider prior to implementation. Resident #2 was admitted with diagnoses including but not limited to dementia, depression, and psychosis. The 01/23/2026 Quarterly Minimum Data Set documented that Resident #2 had severely impaired cognition and received antipsychotic medication. Review of the 01/16/2026 physician's order documented that Resident #2 had an order for Clozapine oral tablet 100 milligrams, give 1.75 tablet by mouth at bedtime for psychosis. Review of the pharmacy clarification email, provided by the Director of Nursing, documented that on 01/16/2026 at 08:01 PM, the pharmacy communicated with the facility writing Cannot cut Clozapine 100 milligram tablets entered to give 1.75 tablets. Cannot cut tablets into 3/4. Please change this order to clozapine 100 milligrams plus clozapine 25 milligrams (give 3 tablets) to be given together. There was no documented evidence that the Physician was contacted and notified of the need for clarification of the Clozapine order. Review of January 2026 Medication Administration Record revealed Licensed Practical Nurse #2 Resident #2 received administered Clozapine to Resident #1 on 01/16 Licensed Practical Nurse #2 administered Clozapine to Resident #1 using 25 milligram tablets intended for a different physician's order, without physician authorization for the change in formulation or administration. Review of the pharmacy delivery receipt documented that 42 Clozapine 25 milligram tablets were delivered to the facility on [DATE] at 12:07 AM, which was after the scheduled administration time of 09:00 PM on 01/16/2026, and therefore were not available in the facility at the time of the ordered administration. The 01/16/2026 Physician order for Clozapine 100mg give 1.75 tablet by mouth was discontinued on 01/20/2026. Review of the 01/20/2026 physician's order documented that Resident #2 had an order for Clozapine oral tablet 25 milligrams, give 3 tablets by mouth one time a day for psychosis and give 3 tablets by mouth at bedtime for psychosis, to be administered with 100 milligram tablets of Clozapine to total 175 milligrams. During an interview on 03/17/2026 at 02:41 PM, Registered Nurse Unit Manager #1 stated that the pharmacy clarification email was received on 01/16/2026 and was distributed to nursing and administration. Registered Nurse Unit Manager #1 stated that at the time the email was received, they had left and was off, and they did not return to work until 01/20/2026. Registered Nurse Unit Manager #1 stated that upon returning to work, the email was reviewed, and it was identified that the physician's order had not been changed, and the issue had not been addressed. Registered Nurse Unit Manager #1 stated that they addressed and updated the order on 01/20/2026.During an interview on 03/19/2026 at 11:40 AM, Nurse Practitioner #1 stated that they were not included on the pharmacy clarification email distribution and were not notified by facility staff that the medication was unavailable as ordered. During an interview on 03/19/2026 at 05:14 PM, the Director of Nursing stated that when a medication is ordered and is not available, nursing staff are expected to contact the physician and the pharmacy to clarify the order prior to administration. The Director of Nursing stated that staff should verify orders when there are questions or when medications are not available as ordered. The Director of Nursing further stated that pharmacy clarification emails are accessible to nursing and supervisory staff, including nurse managers and Registered Nurses on duty, and could have been addressed by available staff. During an interview on 03/26/2026 at 03:20 PM, the Pharmacy Director stated that on 01/16/2026, the pharmacy notified the facility that the Clozapine 100 milligram tablet could not be cut to administer 1.75 tablets and requested that the physician be contacted to change the order. The Pharmacy Director stated that the pharmacy sent 42 Clozapine 25 milligram tablets for another physician's order to administer three tablets by mouth one time a day for psychosis, with a start date of 01/17/2026 at 09:00 AM. The Pharmacy Director stated that medications dispensed for one physician order must not be used for other medication orders, even if the dose is the same. The Pharmacy Director stated that the medications are dispensed based on insurance coverage and that using seven tablets per administration of the 175milligram dose would deplete the supply for the other doses in approximately six days. During a follow-up interview on 03/27/2026 at 02:13 PM, Licensed Practical Nurse #2 stated that Clozapine for Resident #2 was scheduled to be administered at 09:00 PM. Licensed Practical Nurse #2 stated that they did not have access to pharmacy clarification emails and therefore were not aware that the pharmacy had notified the facility that the Clozapine order needed to be changed. Licensed Practical Nurse #2 stated that they did not contact the physician or the pharmacy when the ordered medication was not available as written and did not obtain clarification prior to administration. Licensed Practical Nurse #2 stated that the physician's order for Clozapine 1.75 tablet was read as 175 milligrams. Licensed Practical Nurse #2 stated that Clozapine was administered late after receipt from the pharmacy. Licensed Practical Nurse #2 stated that the start date of 01/17/2026 at 09:00 AM for the Clozapine 25 milligram tablets was not identified prior to administration. Licensed Practical Nurse #2 stated that with clarification, the pharmacy typically contacts the nursing supervisor or unit; however, Licensed Practical Nurse #2 stated that no such communication was received. 10 New York Code Regulatory Reference 415.15(b)(1)(i)-(ii)

Based on record review and interviews conducted during the Abbreviated Survey, the facility did not ensure that a resident who was experiencing pain was assessed and provided appropriate and timely pain management, including the timely administration of medications, for one (Resident #3) of four (4) residents reviewed for pain management. Specifically, the Facility Medication Administration Audit Report dated 08/02/2025 through 08/03/2025 documented that Resident #3 was scheduled to have a pain assessment completed at 7:00 PM on 08/02/2025. There was no documentation that the pain assessment was completed as ordered. 2.The 08/02/2025 Medication Administration Audit Report also documented that Resident #3 was scheduled to receive Melatonin 10 milligrams at 8:00 PM and Gabapentin 100 milligrams at 9:00 PM on 08/02/2025. There was no documentation that the medications were administered as ordered, and the Medication Administration Record indicated a signature at 2:10am on 08/03/2025 with reference to nursing progress notes.The findings include: The facility policy titled Pain Assessment and Management dated 11/18/2025 documented that monitor the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain. The policy further documented to monitor the residents by performing a basic assessment with enough detail and as needed, with standardized assessment tools (e.g., approved pain scales, etc.). The policy also documented to assess the resident whenever there is a suspicion of new pain or worsening of existing pain. Resident #3 was admitted with diagnoses including but not limited to low back pain, Fibromyalgia (pain in joint), diabetic neuropathy and insomnia The 08/01/2025 Quarterly Minimum Data Set documented that Resident #3 had intact cognition. Review of physician's orders dated 06/12/2025 documented that Resident #3 was to receive Melatonin 10 milligrams, give one tablet by mouth at bedtime (9:00 PM) for insomnia. Review of physician's orders dated 05/29/2025 documented that Resident #3 was to have pain monitoring completed every shift for history of diabetic neuropathy, fibromyalgia, osteoarthritis, and low back pain. Review of the August 2025 Medication Administration Record documented that Resident #3's Melatonin was scheduled for 8:00 PM and Gabapentin 100 milligrams was scheduled for 9:00 PM on 08/02/2025. were not documented as administered as ordered. The Medication Administration Record documented code 9 which means other/see progress notes. There was no nursing progress note on 08/02/2025 from Licensed Practical Nurse #1. The Facility 2025 Medication Administration record revealed a note from Licensed Practical Nurse #1 at approximately 2:10am on 08/03/2025. Review of the Medication Administration Record documented that the pain assessment for Resident #3 scheduled for 7:00 PM was not documented as completed. A Nursing Progress note dated 08/03/2025 at 7:14AM documented Resident #3 was verbally disruptive and refused to take PO (by mouth) medications. During an interview with Resident #3 on 03/18/2026 at 4:51 PM, Resident #3 stated that they recall an incident involving a staff member and they recall yelling and arguing over their medications not been administered on time. Resident #3 also reported experiencing pain and stated that it was difficult to sleep without his medications been given timely when they requested it. During an interview on 03/19/2026 at 3:51 PM, Licensed Practical Nurse #1 stated that on 08/02/2025, upon arrival at 7:00 PM, Resident #3 was already calling out for their medication. Licensed Practical Nurse #1 stated that Resident #3 continued calling out and yelling every five minutes requesting pain medication, but they were unable to respond to Resident #3 to administer their pain medication or perform a pain assessment due to insufficient staffing including periods where they were the only staff present and responsible for call bells, medication administration, and resident care. Licensed Practical Nurse #1 stated that a pain assessment was not completed at the beginning of the shift or at the time of the residents' request. Licensed Practical Nurse #1 stated that when they brought Resident #3 their medications later in the shift at approximately 12:00 AM on 08/03/2025, Resident #3 was upset and refused the medications. Licensed Practical Nurse #1 stated that Resident #3 was calling out and ringing the call bell every five minutes for an one hour prior. They were unable to administer medications on time. Licensed Practical Nurse #1 stated that medications are to be documented as administered at the time however they did not complete their documentation until 2:10AM on 08/03/2025. During an interview on 03/19/2026 at 5:25 PM, the Director of Nursing stated that if a resident is requesting pain medication or exhibiting signs of pain, the resident should be assessed for pain at that time to determine pain level. The Director of Nursing stated that residents on routine pain monitoring should receive pain assessments/pain meds as ordered. The Director of Nursing stated that medications, including pain medication and sleep medication such as Melatonin, should be administered as ordered and within one hour before or after the scheduled time. They should not be administered late. The Director of Nursing further stated that medications are to be documented as administered at the time of administration. 10 NYCRR 415.12(c)

Based on observations, interviews, and record reviews, the facility did not ensure that one (1) of three (3) residents reviewed for blood sugar monitoring and insulin administration received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, Resident #1 had an order placed on admission, 09/24/2025, for 70/30 insulin with no clear order for blood sugar monitoring. Nursing staff inconsistently monitored Resident #1's blood sugar without an order for blood sugar monitoring until one was placed on 10/08/2025. Additionally, the physician notes indicated that Resident #1's blood sugars were being monitored before meals and at hour of sleep from 09/29/2025, but no order was entered until 10/08/2025.Resident #1 had diagnoses that included diabetes, heart failure, and left ankle fracture and repair.The admission Minimum Data Set, dated [DATE] documented Resident #1 had intact cognition, diagnoses included diabetes mellitus, and medications included insulin. The facility policy titled 70/30 insulin administration and monitoring last reviewed 08/2025 documented that the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. 70/30 Insulin will be administered only per physician order, using proper timing in relation to meals to prevent hypoglycemia. Blood glucose levels will be monitored and documented according to the care plan and prescriber orders.The physician order dated 09/24/2025 documented Insulin 70/30 pen-injector 100 unit/milliliter administer 24 units subcutaneously two times a day for diabetes.The Care Plan titled Resident has Diabetes Mellitus dated 09/24/2025, documented a goal that Resident #1 will remain free of signs and symptoms of hyperglycemia or hypoglycemia and have no complications related to diabetes. Interventions included diabetes medication as ordered, monitor for side effects and effectiveness. The physician progress notes dated 09/29/2025, 10/03/2025, and 10/06/2025 documented to monitor blood glucose before meals and at hour of sleep and document trends.There was no evidence of a blood sugar monitoring order from 09/24/2025-10/07/2025.The physician order dated 10/08/2025 documented to monitor Resident #1's blood sugar before meals and at bedtime. If blood sugar is greater than 200 or less than 70 notify the physician. The blood sugar monitoring log for Resident #1, dated 10/21/2025, documented multiple inconsistencies with the frequency of blood sugar readings obtained. The readings were as follows; blood sugar readings once daily on 09/24/2025, 09/29/2025, and 10/2-10/05/2025, twice daily on 09/25-09/28/2025, 09/30/2025, and 10/06-10/07/2025, and none on 10/01/2025. Blood sugar readings before meals and at hour of sleep (four times per day) were completed from 10/08/2025-10/12/2025, except for 10/10/2025 when the reading before breakfast was not obtained. Resident #1 was discharged on 10/13/2025, before which the one ordered blood sugar reading was obtained. During an interview on 10/21/25 at 3:09 PM, Registered Nurse Unit Manager #8 stated that Resident #1 did not have a separate order for blood sugars to be obtained before meals and at hour of sleep until 10/08/2025. Registered Nurse Unit Manager #8 stated that when a nurse signs to administer the 70/30 insulin the system prompts them to enter a blood sugar reading. It seems some nurses were uncertain and only some blood sugars were obtained from 09/24/2025 until 10/07/2025. Registered Nurse Unit Manager #8 stated that on 10/08/2025 there was a separate order entered for blood sugars to be obtained before meals and at hour of sleep. This order was entered after the family expressed concern about the monitoring of Resident #1's blood sugar. During an interview on 10/22/2025 at 12:18 PM, it was determined that Physician #9 was documenting in their notes starting 09/29/2025, prior to their order on 10/08/2025, that Resident #1's blood sugar was being monitored before meals and at bedtime. Physician #9 stated that the frequency of monitoring was not essential because of the type of insulin they were receiving, however it would assist in evaluating the trends for the management of their diabetes. Physician #9 was unable to state why there was no order to correspond with the notes they had been writing prior to 10/08/2025. During an interview on 10/22/2025 at 1:15PM Charge Licensed Practical Nurse #10 stated that orders could be entered by a nurse after a verbal request from the physician, or the physician will enter the order themselves. Charge Licensed Practical Nurse #10 referred to a conversation that occurred on 10/06/2025, when Resident #1's family expressed a concern about the frequency and timing of Resident #1's blood sugar monitoring. Charge Licensed Practical Nurse #10 stated they had not received any concerns from the family or resident regarding blood sugar monitoring, or any requests from the physician to enter an order for blood sugars to be monitored before meals and at the hour of sleep, before the conversation with the family on 10/06/2025. Charge Licensed Practical Nurse #10 stated they were uncertain why the blood sugar monitoring was done inconsistently prior to the 10/08/2025 order. During an interview on 10/22/025 at 03:50PM the Director of Nursing stated they reviewed the record for Resident #1 and did not see a separate order for the blood sugar monitoring prior to 10/08/2025. They could not say why there were inconsistencies with the blood sugar monitoring prior to the order being entered. And they were uncertain why the physician had documented blood sugar monitoring before meals and at the hour of sleep prior to there being an order for that on 10/08/2025. 10NYCRR 415.12

2) During an observation on 5/14/25 at 12:48 PM Resident #105, #93, #121 were served lunch and began eating. Fourth table mate, Resident #16 was not served lunch until 1:00 PM. Resident #93 verbalized that Resident #16 had not received lunch and repeatedly asked for them to be served. During an interview on 5/15/25 at 12:30 PM Certified Nurse Aide #17 stated they were not aware that all residents at the same table should have been served at the time before moving onto the next table. Unit Manager Registered Nurse #21 stated they were not aware of any residents' concern for everyone to be served at the same time. 10 NYCRR 415.3(d)(1)(i) Based on record review and interviews conducted during the recertification and abbreviated surveys (NY00376199), the facility did not ensure residents were treated in a dignified manor for 3 residents (Residents #1, #3, and #227), reviewed during a staff performance evaluation review, and for 1 resident (Resident #16) reviewed during dining. Specifically, 1) Review of Certified Nurse Aide #4's employment file revealed Residents #1, 3 and 227 were not treated in a dignified manner when requesting assistance from Certified Nurse Aide #4. 2) Resident #16 was served lunch 12 minutes later than the other residents at the table. Findings include: 1) A review of Certified Nurse Aide #4's employee file, during a Nurse Aide Performance Evaluation review on 5/14/25, revealed disciplinary notices for Certified Nurse Aide #4 related to customer service for Residents #1, #3, and #227. The 2/13/24 Occurrence Summary documented Resident #3 complained that they asked Certified Nurse Aide # 4 when they would be getting their hair washed. Certified Nurse Aide # 4's response made the resident feel like they were a bother and Certified Nurse Aide #4 did not want to help them. Certified Nurse Aide#4 was given a Corrective Discipline Notice and counseled on the importance of customer service being kind and respectful with all interactions with everyone, staff, resident, and family members. The 2/13/24 Occurrence Summary documented Resident #227 complained Certified Nurse Aide #4 was in their room at bedtime, they were feeling weak but was assessed to be independent level of care. Instead of helping them, Certified Nurse Aide #4 stood in the room with an aggravated look telling the resident how to get themselves ready for bed. Resident #227 also reported that Certified Nurse Aide #4 seemed to not like their job and did not want to help when they come to answer the call bell. The conclusion documented Certified Nurse Aide #4 was given a Corrective Discipline Notice and was counseled on the importance of customer service being kind and respectful with all interactions with everyone, staff, residents, and family members. The 2/29/24 Occurrence Summary documented Resident #1's spouse complained that Resident #1 was completely soaked at lunch time, Certified Nurse Aide #4 came in their room and told the resident to stop ringing the bell so much. Certified Nurse Aide #4 got the resident out of bed and brought them in the bathroom. The resident sneezed on the certified nurse aide, so they left the room for some time and they had a bad attitude. The conclusion documented Certified Nurse Aide #4 was given a Corrective Discipline Notice. Certified Nurse Aide #4 was given the mission statement and spoken to at length regarding resident complaints about her body language and mannerisms and how they could affect residents and family members who were already upset about their loved one's health and wellbeing. During an interview on 5/19/25 at 11:07 AM, the Assistant Director of Nursing stated the complaints from families were related to the way Certified Nurse Aide #4 responded to a directive, which was either very curt or brass. The Assistant Director of Nursing stated they observed Certified Nurse Aide #4 while they provided care and stated they were good with the residents. When requested, the Assistant Director of Nursing was unable to provide documented evidence of the care observations with Certified Nurse Aide #4. They stated Resident #227 was removed from Certified Nurse Aide #4's assignment at the request of the resident.

2) Resident #538 had diagnoses that included metabolic encephalopathy, hypertension, and muscle wasting. The 9/25/2024 admission Minimum Data Set (assessment tool) documented moderately impaired cognition, foley catheter, occasional incontinence of bowel, maximum assistance for toileting hygiene and transfers. The 12/18/2024 Discharge Minimum Data Set documented moderately impaired cognition, foley catheter, incontinent of bowel, dependent on assistance for toileting hygiene and transfers. The Certified Nurse Aide Kardex dated 12/7/24 documented Resident #528 required maximum assistance and was dependent on staff for all ADLs and transfers, except oral and personal hygiene. The September 2024 Documentation Survey Report contained no documented evidence that personal hygiene, toileting hygiene and toilet transfers were completed on 9/24/24 day shift, 9/26/24 evening shift, and 9/21 and 9/25/24 night shift. The October 2024 Documentation Survey Report contained no documented evidence that personal hygiene, toileting hygiene and toilet transfers were completed on 10/4/24 day shift and 10/31/24 evening and night shifts. The 10/22/24 and 10/29/24 nursing skin assessments documented dry fragile skin. The November 2024 Documentation Survey Report contained no documented evidence that personal hygiene, toileting hygiene, and toilet transfers were completed on 11/6, 11/24, and 11/28/24 day shift and 11/30/24 night shift. The 11/5/24 nursing skin assessment documented dry fragile skin. The 11/12/24 and 11/20/24 nursing skin assessments documented bilateral groin reddened areas-anti fungal powder. The 11/21/24 wound consultation documented sacrum and left buttocks moisture associated skin damage. The 11/27/24 nursing skin assessments documented wound to buttocks-triad and dry protective dressing. The December 2024 Documentation Survey Report contained no documented evidence that personal hygiene, toileting hygiene, and toilet transfers were completed on 12/10/24 day shift, 12/14/24 evening shift, and 12/1 and 12/5/24 night shift. The 12/4/24 and 12/11/24 nursing skin assessments documented wound to buttocks-triad and dry protective dressing. The 12/5/24 wound consultation documented sacrum and left buttocks moisture associated skin damage. During an interview on 05/20/25 at 10:07 AM, Registered Nurse Unit Manager #8 stated that Resident #538 required moderate-maximum assistance with washing and bathing, toileting hygiene personal hygiene and transfers. They expected Certified Nurse Aides to check and change Resident #538 every two-three hours. Peri care should be completed every shift regardless of whether a resident has foley catheter. There should not be omissions on the Documentation Survey Reports/Certified Nurse Aide's Accountability records. They stated if there was no documentation it was not done. 3) Resident #49 was admitted to the facility with diagnoses including non-Alzheimer's dementia, schizophrenia and muscle weakness. The Minimum Data Set (assessment tool) dated 2/15/25 documented the Resident #49 had severely impaired cognition and was dependent on staff assistance with toileting hygiene, required partial assistance with personal hygiene, and required supervision with chair to bed transfers. The Comprehensive Care Plan, Activities of Daily Living Needs, last updated on 8/14/23, documented Resident #49 required extensive assistance of one person with grooming/personal hygiene. During observations on 5/13/25 at 12:47 PM, on 5/14/25 at 11:01 AM, and on 5/15/25 at 1:32 PM Resident #49 was observed with long fingernails on both hands. During an interview on 5/15/25 at 1:39 PM, Certified Nurse Aide #17 stated they provided care today for Resident #49. They stated the resident was dependent on staff with assistance for personal hygiene, which included grooming task, such as shaving facial hair and trimming fingernails. The Certified Nurse Aide stated that they could see the resident's long fingernails on both hands, but did not have time to check the resident's fingernails today, and did not know when the resident's fingernails were last trimmed. During an interview on 5/15/25 at 2:01 PM, Licensed Practical Nurse #18 stated that they provide care for the resident at least three days a week. The nurse stated that when they started their shift and during the shift they observed Resident #49. Licensed Practical Nurse #18 observed Resident #49 and stated that the resident had long fingernails on both hands, which needed to be trimmed. The nurse stated that nobody reported to them about long fingernails and did not know when the resident's fingernails were last trimmed. They stated that since Resident #49 was not a diabetic, the Certified Nurse Aide was responsible for trimming the resident's fingernails. 10 NYCRR 415.12(a)(2) Based on observation, record review, and interviews conducted during the recertification and abbreviated surveys (NY00363395, NY00352562, NY00363234, NY00342723) from 5/13/25-5/20/25, the facility did not ensure each resident who was unable to carry out activities of daily living received the necessary care and services for 5 of 10 residents (Residents #49, #338, #538, #488, and #489) reviewed for Activities of Daily Living. Specifically, 1) for Residents #338, #538, #488, and #489, there was no documented evidence in the Certified Nurse Aide records Documentation Survey Report that assistance with activities of daily living was consistently provided, and 2) Resident #49 who required dependent assistance with activities of daily living was observed during multiple observations with fingernails that were long and ungroomed. The findings include: The March 2024 facility policy, Activity of Daily Living, documented the facility will provide ADL care to all residents based on assessment of needs, which includes bathing, dressing, eating, transfers, toileting, bed mobility, ambulation. It documented it is the licensed nurse's responsibility to assess the resident to determine their ADL needs and the certified nurse aide's responsibility to provide care and assistance with care in accordance with the instructions (plan of care). 1. Resident #338 was admitted with diagnoses including Parkinson's disease, history of falls, and dementia. The 4/24/24 admission / Medicare-5 Day Minimum Data Set (resident assessment) documented Resident #338 had moderately impaired cognition, was frequently incontinent of bladder, and required moderate assistance with toileting hygiene, personal hygiene, and toilet transfers. The Certified Nurse Aide Kardex dated 5/15/2024 documented to provide moderate assistance with toilet transfers, toileting hygiene and personal hygiene. The April 2024 Documentation Survey Report contained no documented evidence that personal hygiene, toileting hygiene and toilet transfers were completed on 4/20, 4/21 and 4/28/24 for day shift, 4/22, 4/24, 4/26, 4/27, and 4/28/24 for evening shift, and 4/19 and 4/30/24 for night shift. The May 2024 Documentation Survey Report contained no documented evidence that personal hygiene, toileting hygiene and toilet transfers were completed on 5/1, 5/4, and 5/5/24 for day shift 5/13/24 for evening shift, and 5/14 and 5/15/24 for night shift. During an interview on 5/16/25 at 9:38 AM, Licensed Practical Nurse #7 stated they did not know why there were blanks on some dates. They stated it could have been due to the cares not being completed or due to another reason. They stated the nurses were responsible to assure the certified nurse aides complete the resident's care and the unit manager was responsible to assure the Certified Nurse Aides complete documentation on the Documentation Survey Report. During an interview on 5/16/25 at 9:52 AM, Registered Nurse Unit Manager #8 stated the unsigned Documentation Survey Reports was due to Certified Nurse Aides not documenting the care they provided but they could not provide a reason for not documenting. During an interview on 5/16/25 at 11:09 AM, Certified Nurse Aide #9 stated the undocumented cares might have been incomplete because either the staff did not have time to document the cares, or the cares were not provided.

Based on interview and record review during the recertification and abbreviated (NY00376199) survey from 05/13/25 through 05/20/25, the facility did not ensure Certified Nurse Aide performance reviews were completed at least once every 12 months. Specifically, five of five Certified Nurse Aides (#1, #2, #3, #4, #5) did not have a performance review documented at least once every 12 months. The findings include: Policy and Procedure Titled Staff Evaluations dated 1/25 documented the purpose is to establish a consistent and fair process for evaluating the performance of Nursing Home staff to ensure high-quality resident care, compliance with regulations and professional development. A review of 5 Certified Nurse Aide performance reviews noted 5 out of 5 Certified Nurse Aides had no annual performance appraisals in the last 12 months. Certified Nurse Aide #4, with a hire date of 10/24/23, had 14 corrective discipline notices dated 1/11/24 to 5/2/25 in their employment file. The notices included poor customer service, insubordination, failure to follow policy, absenteeism, tardiness, and violation of company policy. Certified Nurse Aide #4 was terminated on 5/2/25. The file did not contain an annual performance appraisal. Certified Nurse Aide #1 with a hire date of 9/5/23 had an undated and unsigned employee performance review in the Human Resource File. Certified Nurse Aide #2 with a hire date of 5/22/23, Certified Nurse Aide #3 with a hire date of 9/8/23, and Certified Nurse Aide #5 with a hire date of 11/28/21 had no performance appraisal in the last 12 month. During an interview on 05/20/25 at 11:56 AM, the Director of Human Resources stated the Unit Managers were responsible to complete Annual Performance Reviews. The Unit Managers should have reviewed the hire date and ensured the performance reviews were completed at least once every 12 months. The Unit Managers should have presented the evaluation to the employee and had them sign it. Once completed it should have been brought to Human Resources for filing. During an interview with the Unit Managers of C1 on 5/20/25 at 12:05 PM, they stated they were responsible to complete performance reviews. They had a list of staff members and the hire dates. Performance reviews should have been completed annually. During an interview on 05/20/25 at 12:36 PM, the Director of Nursing stated the with the Director of Nursing were responsible for completing annual performance reviews. They were unaware they were not being completed. 10NYCRR 415.26 (c) (2) (iii)

Based on observation and interview conducted during the recertification and abbreviated (NY00365130) surveys from 5/13/25 to 5/20/25, the facility did not ensure residents were provided food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, a test tray was sampled and found food was not served at a palatable, appetizing temperature; and many residents complained about the food. Findings include: The facility policy titled Meal Delivery documented, meals should be delivered promptly to ensure appropriate temperatures, and all staff is responsible to report any concerns regarding meal temperatures and resident satisfaction. During an interview on 05/13/25 at 10:52 AM, Resident #174 stated the food at the facility is terrible. The vegetables were often undercooked and hard, and the meats were often overdone. The meals came luke warm and alternates were offered but they were not very good either. During interviews on 05/13/25 at 3:27 PM and 05/16/25 at 10:52 AM, Resident #106 stated that they did not like the food at the facility. They stated the food quality was poor regardless of the mealtime and they refuse it. Stated they did not like most of the alternates offered either, so they just order out all the time. During an interview on 5/14/25 at 10:02 AM, Resident #202 stated they did not eat the food served, but ordered take out. During an interview on 5/15/25 at 11:31 AM, the Assistant Food Service Director stated there had been complaints about cold food. The facility had some enclosed insulated food carts that were used on the units further away from the kitchen. The units that were closer to the kitchen used the open racks for meal trays. The facility had a pellet system, and they had called the company to service the pellet system to make sure it was heating properly. During an interview on 5/15/25 at 1:23 PM, the Administrator stated there had been no recent complaints regarding cold food. Currently open racks are used to deliver food to closer units and closed carts were used for the further distance units. There was no timeline plan for moving over to the enclosed thermal carts for the entire building. On 5/16/25 at 11:17 AM, tray line food temperatures were taken with the Assistant Food Service Director. The fish was 140 degrees Fahrenheit, steak fries were 120 degrees Fahrenheit, the asparagus was 140 degrees Fahrenheit. The Assistant Food Service Director asked the cook to reheat the steak fries. On 5/16/25 at 11:49 AM lunch meal trays were delivered to unit C1 on an open rack. The lunch meal for Resident #174 was intercepted just prior to delivery to the room at 12:09 PM and was used as a test tray for palatability and temperature. The cod fish and asparagus taste were acceptable but temperature was lukewarm. The steak fries were cold with a tough texture. The soup taste was acceptable and had a temperature of 100 degrees Fahrenheit and the coffee was unappetizing and lukewarm at 78 degrees Fahrenheit. During an interview on 5/19/25 at 1:33 PM with the Diet Clerk, they stated they visited Resident #202 almost every day for food preferences and offered items from all menus to try to achieve satisfaction. They stated Resident #202 complained about the food being served cold. During an interview on 5/19/25 at 2:28 PM Licensed Practical Nurse Charge Nurse #7, stated Resident #202 would go to the cafe if they did not like what was served at meals. During an interview on 5/19/25 at 3:55 PM, Resident #204's friend stated Resident #204 had reported to them that the meals were delivered cold day after day, and Resident #204 had expressed this to the staff with no resolution. 10NYCRR 415.14 (d)(1)(2)

Based on observation and interviews conducted during the recertification survey from 5/13/25 to 5/20/25, the facility did not ensure food was distributed and served in accordance with professional standards for food service safety. Specifically, 1.) On initial kitchen tour, food items were found undated, unsealed, and expired. The handwash sink in food prep area did not work. 2) On follow-up kitchen tour, food temperatures were not at control level on the steam table and dietary staff did not wear proper hair/beard restraint or utilize hygienic practices. 3) The pantry refrigerator on Unit C1 contained undated foods, expired foods and an incomplete temperature log. Findings include: The facility policy Food Receiving and Storage, dated 1/30/24 included documentation that food shall be stored off the floor; all food items will be covered, labeled and dated; refrigerator and freezer temperatures must be monitored and logged; food must be dated and sealed/covered and held no longer than 72 hours. The facility policy Personal Hygiene dated 1/30/24 included documentation that employees must use hair restraint and beard restraint when applicable, refrain from touching face when preparing food, and properly wash hands. The Label and Dating Policy updated 2/4/16, and posted on the C1 Unit refrigerator, documented that all items in the refrigerator should be labeled properly with resident name, item description, and date opened. Every food item opened or freshly made has a 72-hour shelf life. All items will be discarded after that time. Anything without proper labeling will be discarded during floor stocking. 1) During the initial tour of the kitchen on 5/13/25 at 9:57 AM, the following items were observed: -In the freezer there were unsealed frozen hamburgers, unsealed chicken nuggets, and unsealed frozen rolls. There were waffles with an expiration date of 5/5/25. In the dry storage there were unsealed bag of granola and unsealed cranberry juice. The angel food cake mix had an expiration date of 2/2/24 and the biscuit mix expired 4/3/25. Boxes of grape jelly were observed stored on the floor. -In the refrigerator there was undated pepperoni, tortillas, humus, tossed salads, sandwiches, fruit cups and pudding. -The handwash sink was not working, and kitchen staff mentioned the sensor had not been working for about a week. During an interview with the Assistant Food Service Director at the time of the tour, they stated all food should be sealed once opened, all foods should be dated, and all staff was responsible for disposing of expired foods. They were unaware of sink sensor not working and would be notifying maintenance. 2) During a follow up visit to the kitchen on 5/16/25 at 11:17 AM, lunch food temperatures were taken with the Assistant Food Service Director for steam table service. The steak fries were 120 degrees Fahrenheit, and the puree meat was 130 degrees Fahrenheit. The Assistant Food Service Director advised staff to remove the items and replace with new product from the oven. During this observation of the tray line Diet Aide #19 was not wearing a beard restraint as they served soup. Diet Aide #20 used gloved hand to pick up steak fries to place onto the plate and pushed vegetables onto the plate, then wiped brow with gloved hand. During an interview with the Assistant Food Service Director at the time of the observation, they stated the staff needed a lot of retraining and supervision. They asked Diet Aide #19 to step away from the tray line to don a beard restraint and wash hands and Diet Aide #20 to use tongs to pick up food and don new gloves. 3) During an observation of the C1 Dining Room Pantry Refrigerator on 5/13/25 at 12:26 PM the refrigerator temperature log was blank from 4/29/25-5/12/25 and documented on 5/13/25 at 10:12 AM the refrigerator was 36 degrees, and the freezer was -2 degrees. The refrigerator contained multiple open items with no dates including juice bottles, applesauce, a pizza box, and guacamole. There were two sandwiches dated 5/5/25, for Residents #54 and #211. There was personal food for Resident #10 dated 5/1/25, and multiple Yoplait yogurts with an expiration date of 3/18/2025. During an interview on 05/13/25 at 1:05 PM, Licensed Practical Nurse Unit Manager #6 stated that it was the responsibility of food services to monitor and check the temperatures of the freezer and refrigerator. Nursing and food services were both responsible for checking the contents of the refrigerator. They stated that the refrigerator contained many items that needed to be discarded, and the temperature log was incomplete. 10 NYCRR 415.14(h)

Based on observations, interviews, and record reviews during the Recertification and Abbreviated (NY00363234) surveys from 5/13/2025-5/20/2025, the facility did not ensure a comfortable and homelike environment by maintaining comfortable sound levels. Specifically, during construction on the South 1 Unit, sounds were not maintained at comfortable levels. Findings included: The Approval for Construction from the Department of Health dated 7/20/2024 documented construction to start on or before 12/2024 and must be completed by 5/1/2025, and project completion by 8/1/2025. An extension was attached and documented a new completion of construction date as November 1, 2025, and project completion date as 2/1/2026. The attached Resident Safety Plan documented that the renovations would occur Monday to Friday 8:00 AM-5:00 PM and Sunday 8:00 AM-5:00 PM. At all times the health, dignity, privacy, and safety of the residents will take precedence over the renovation process. The undated facility Renovation/Construction Policy documented that the facility that must ensure that all renovation activities in the nursing home are conducted safely, efficiently, and with minimal disruption to residents, staff, and visitors. Residents will be temporarily relocated if work affects their rooms or living areas. Noise and dust control measures must be in place. The undated Notification of Construction documented that residents were notified verbally by the facility marketers of construction on the rehabilitation units where they would be admitted . There was no documented evidence of resident notification. A Stop Work order dated 1/8/2025 documented an order to cease all construction due to failed and missing inspections. During an observation on 5/15/25 at 9:44 AM, evidence of ongoing construction was observed. On the South 1 unit there was a tarp hanging, signage indicating areas of construction, and unfinished sheet rock to the left of the nurses' station. Residents were present sitting by the nurses' station and residing on the unit. During an interview on 5/15/25 at 10:00 AM, Licensed Practical Nurse #12 stated that the unit was recently renovated, uncertain of when it commenced and how long it would last. They stated when the construction was being completed, they tried to keep the residents that resided on the unit away from the area being worked on. During an interview on 5/15/25 at 10:06 AM, Certified Nursing Assistant #11 stated they had worked at the facility since the end of October 2024. They stated there was construction going on when they started at the facility on the South 1 unit, but they could not remember specific details about the construction or instructions for the residents residing on the South 1 unit. During an interview on 5/15/25 at 03:37 PM, the Director of Maintenance stated that there had been ongoing renovations on the South 1 unit. They stated that they isolated and contained the areas that were being worked on to prevent residents from being exposed to dust, smells, and noise. They coordinated their work with nursing, and the hours for construction were daytime hours, unless there was a need for less staff on the unit like flooring replacement. During an interview on 5/16/25 at 11:10 AM with Visitor #1, they stated that construction on the South 1 Unit during the months of November and December 2024 was going on right near the residents and in the rooms next door to the resident rooms. They stated they complained to the facility about the noise and the fact that the work was going on with the residents close by. They stated it was also dusty, but the noise was their main concern. The banging was terrible. They thought the facility may have responded to their complaint because work stopped after they complained. They stated they made many phone calls to different agencies to report the noise. During an interview on 05/20/25 at 10:07 AM, Registered Nurse Unit Manager #8, stated that renovations had been going on for approximately one year in January 2025. They stated everything had been done in phases and they usually tried to do the rooms in blocks. Two rooms were worked on at a time, and the two rooms surrounding them were kept empty. When they had a lower census, they would try to adjust the layout and move residents away from the areas being worked on. Construction was performed during day hours and they only did quiet tasks during later hours. They stated when the nurses' station was being renovated they had no workstation and there was a lot of loud noise including jackhammering. During an interview on 05/20/25 at 3:08 PM, the Administrator stated that the County did come in to inspect the facility because of a complaint received regarding the noise from the construction. The County did issue a stop work order, but stated that was the result of missing forms, not the noise. They stated that residents were informed of the construction by the facility marketers prior to admission. 10NYCRR 415.5(h)(5)

Based on observations, interviews and record reviews conducted during the recertification and abbreviated (NY00346686, NY00352562) surveys from 5/13/25 to 5/20/25 it was determined that for 1 of 6 residents (Resident #32) reviewed for Accidents, and for 1 of 4 residents (Resident #489) reviewed for Abuse, the facility did not ensure that injuries of unknown origin were reported to the state agency. Specifically, 1) Resident #32 the Department of Health was not notified after the 12/07/24 Accident/Incident Report documented Resident #32 was observed with bruising to their hand and arm, and 2) Resident #489 was documented on 6/24/24 to have bruising to bilateral arms and small area on left hip, and it was not investigated or reported to the Department of Health. The findings include: Policy and Procedure titled Abuse Prevention dated 6/24 documents Reporting/Response - report alleged violations and substantiated incidents to appropriate authorities. 1. Resident #32 with diagnoses of osteoarthritis, bipolar disorder, and dementia. A review of the Quarterly Minimum Date Set (assessment tool) dated 5/1/25 documented the resident's cognition was intact. The resident required supervision for eating and substantial to maximal assist for all other activities of daily living. A review of the progress note dated 12/7/24 documented the resident's daughter advised the desk nurse about bruising. Bruising was noted to left hand and upper left arm. A review of an Accident & Incident report dated 12/7/24 at 3:30 PM documented the resident was observed with a 5-centimeter x 5 centimeter circular area of discoloration on the back of their right hand that was purple/red/black, and a 0.4 x 0.4 centimeter area under the right upper arm of the same color. The resident reported it happened during cares early Thursday morning (12/5/24) at around 5 AM. The incident report documented the Interdisciplinary Team met and determined no abuse/neglect/mistreatment on 12/9/24 and was signed off by the Director of Nursing on 12/30/24 and the Administrator on 1/9/25. The Occurrence Report Investigation Summary documented on 12/7/24, Resident #32's family member came to the nurses' desk asking about bruising. Investigation that was not signed, dated or timed and did not rule out abuse . The Investigation included untimed statements from staff that did not include any information regarding the bruises, none of the statements included whether the bruises were present or not present when the staff provided care. Four certified nurse aide statements were verbal and only documented they did not see anything out of the ordinary. During an Interview with Director of Nursing on 5/16/25 at 2:53 PM, they stated the investigation was completed by the Assistant Director of Nursing. They felt they did do a complete investigation and ruled out abuse. The did not know why the investigation did not document abuse was ruled out. The investigation was about the accusation the resident made about being man handled by a Certified Nurse Aide. When we started the investigation, and we felt there was no reasonable cause to believe abuse occurred. It was noted on the root cause analysis the resident has fragile skin. Staff often offer the resident support to stand by holding onto the resident's upper arm which most likely caused the bruise. They did not know if the staff was not interviewed regarding the bruises. During an interview with Assistant Director of Nursing on 05/19/25 at 2:45 PM stated they completed the investigation regarding the abuse allegation from 12/7/24 when it was reported. The bruises were most likely caused by her behavior of sitting in the doorway. The resident was not evaluated by the physician. We did obtain statements they think within the 2-hour time frame. They do not know what time the staff statements were obtained; they did not know why the staff were not questioned about the presence or absence of the bruises. They did not report to the Department of Health because we felt we had ruled out abuse. 2. Resident #489 was admitted to the facility with diagnoses including cerebrovascular accident, non-Alzheimer's dementia, and muscle weakness. The 4/26/24 Minimum Data Set (assessment tool) documented the resident had severely impaired cognition and was dependent on staff with toileting hygiene, needed substantial assistance with shower/bathe self, partial assistance with personal hygiene and chair to bed transfer. The Comprehensive Care Plan, Risk for Skin Impairment, last revised on 5/22/24, documented to observe skin redness, swelling or bruising with cares, provide comfort and well-fitting clothing, weekly skin observations, consult Physical and Occupational Therapy for proper positioning. The 1/19/2024 Physician's order documented Clopidogrel Bisulfate Tablet 75 MG (blood thinner), Give 1 tablet by mouth one time a day for blood clot. The 3/11/24 Physician's order documented Skin Check every day shift every Monday ensure skin check and shower is completed- fill out skin evaluation. Review of the Skin Observation Tool dated 6/24/24 documented bruising on bilateral arms and small area remains on left hip. There was no documented evidence that an investigation was completed in relation to the resident's bruising on bilateral arms and the area on left hip. During an interview on 5/19/25 at 12:06 PM, the Acting Director of Nursing stated that there was no Accident/Incident Report for June 2024 for Resident #489. During an interview on 5/20/25 at 10:51 AM, the Director of Nursing stated that once the nurse identified bruises of unknown origin, the nurse should have initiated an investigation, interviewed the staff and the resident, conducted a skin assessment, contacted the doctor and resident's family, and reported the incident to the New York State Department of Health. In this case, the incident was not reported because the nurse did not report bruises, and the investigation was not initiated. NYCRR 415.4(b)(2)

Based on observation, record review and interviews during the recertification survey and abbreviated (NY00352562) surveys, the facility did not ensure that an investigation was completed for a resident with an injury of unknown origin for 1 (Resident #489) of 4 residents reviewed for abuse. Specifically, there was no documented evidence an investigation was conducted for Resident #489 with documented bruising on bilateral arms and left hip. The findings are: Resident #489 was admitted to the facility with diagnoses including cerebrovascular accident, non-Alzheimer's dementia, and muscle weakness. The 4/26/24 Minimum Data Set (assessment tool) documented the resident had severely impaired cognition and was dependent on staff with toileting hygiene, needed substantial assistance with shower/bathe self, partial assistance with personal hygiene and chair to bed transfer. The Comprehensive Care Plan, Resident is at Risk for Skin Impairment, last revised on 5/22/24, documented to observe skin redness, swelling or bruising with cares, provide comfort and well-fitting clothing, weekly skin observations, consult Physical and Occupational Therapy for proper positioning. The 1/19/2024 Physician's order documented Clopidogrel Bisulfate Tablet 75 MG (blood thinner), Give 1 tablet by mouth one time a day for blood clot. The 3/11/24 Physician's order documented Skin Check every day shift every Monday ensure skin check and shower is completed- fill out skin evaluation. The 6/24/24 Skin Observation Tool documented bruising on bilateral arms and small area remains on left hip. There was no documented evidence that an investigation was completed in relation to the resident's bruising on bilateral arms and the area on left hip. During an interview on 5/19/25 at 12:06 PM, the Acting Director of Nursing stated that there was no Accident/Incident Report for June 2024 for Resident #489. During an interview on 5/19/25 at 3:38 PM, Licensed Practical Nurse #16 stated that Resident #489 had very small skin discoloration spots on both arms and small area on their left hip, which did not look like bruises. They stated that they should not have documented those skin discoloration as bruises. Licensed Practical Nurse #16 stated when they found these skin discolorations, they did not have any concerns for abuse and decided not to document or report this to the manager. They stated that Resident #489 at times exhibited restlessness while sitting at the table and could banging their arms and legs against the table, and was on Clopidogrel (blood thinner). Licensed Practical Nurse #16 stated that they received annual in-services related to Accidents/Incidents and Abuse. During an interview on 5/19/25 at 4:33 PM, Registered Nurse Supervisor #15 stated that when the Licensed Practical Nurse observed bruises of unknown origin, they should have reported that to the Registered Nurse Supervisor to initiate an investigation, which required to determine whether there was any abuse especially in cognitively impaired residents. The doctor and the resident's family needed to be informed. Registered Nurse Supervisor #15 stated that they had not heard anything from Licensed Practical Nurse #16 about Resident #489's bruises. During an interview on 5/20/25 at 10:51 AM, the Director of Nursing stated that once the nurse identified bruises of unknown origin, the nurse should have initiated an investigation, interviewed the staff and the resident, conducted a skin assessment, contacted the doctor and resident's family. In this case Licensed Practical Nurse #16 should have reported this to their supervisor to initiate an investigation, which was not done. 10 NYCRR 415.4(b)(1)(ii)

Based on observation, interview, and record review completed during a Recertification survey from 5/13/25-5/20/25 the facility did not ensure provision of a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #167) of five (5) residents reviewed for Pressure Ulcers. Specifically, Resident #167 who had a Pressure Ulcer and a Chronic Vascular ulcer with Physician ordered dressing changes was not placed on enhanced barrier precautions (interventions designed to reduce transmission of multi-drug-resistant organisms including gown and glove use during high contact resident care activities) and staff did not wear proper personal protective equipment (gowns) during care while completing wound dressing changes. The finding is: A Policy and Procedure titled Enhanced Barrier Precautions dated 4/24 stated, the use of gowns and gloves for high-contact resident care activities is indicated for nursing home residents with wounds and or indwelling medical devices. Resident #167 had diagnoses including Diabetes, Dementia, and a pressure ulcer to left buttock. The 4/6/25 quarterly Minimum Data Set (assessment tool) documented the resident's cognition as moderately impaired. The resident required partial to moderate assist with eating, substantial to moderate assist with toilet hygiene, and partial to moderate assist with all other activities of daily living. The resident was documented as having one Stage 3 pressure ulcer. During observations on 05/14/25 at 10:45 AM and 05/15/25 at 9:01 AM, the resident was noted in bed asleep. There was no Enhanced Barrier Precautions sign on the door. During an observation and interview on 05/15/25 at 1:55 PM of wound care for both buttock, and left heel dressings changes, the Infection Preventionist stated the resident was not on Enhanced Barrier Precaution because the wounds were not draining. The Infection Preventionist and Licensed Practical Nurse Unit Manager #10 did not don a gown prior to changing the resident's dressing. The electronic medical record did not document a Physician's order or a care plan for Enhanced Barrier Precautions. During an interview with the Infection Preventionist on 05/15/25 at 1:26 PM, they stated they made a mistake, and the resident should have been on Enhanced Barrier Precautions. They stated they should have worn a gown when changing the resident's dressing. 10 NYCRR 415.19(a)(2)

Based on record review and interviews conducted during the abbreviated survey (NY00377486) the facility did not ensure that the resident, resident's representative(s), or ombudsman was notified of the transfer or discharge, and the reasons for the move, in writing and in a language and manner they understand for 1 (Resident #3) of 3 residents reviewed for discharge. Specifically, Resident #3 was discharged home on 3/13/2025 and there was no documented evidence that the facility provided a notice of discharge at least 30 days before the resident was discharged . a bed hold notice was not provided, the facility did not document discussions with the resident and/or the representative that included information on discharge planning and arrangements for post-discharge care. Additionally, there was no progress notes that documented the reason for discharge, the effective date of discharge, or the location of where the resident will be discharged to. There was no documented evidence that the Managed Long-Term Care were notified to assess the resident for additional hours at home as per Resident's request. Furthermore, the discharge documentation indicating that Resident #3 will be discharged on [DATE] was incomplete with no date indicating when the home care nursing services, physical and occupational therapies, or med assist was notified. The form titled Team discharge and Care Plan Summary Guide was not initiated until 3/7/2025. The findings are: The facility policy titled Transfer/Discharge Notice revised on 12/2024 documented that the facility shall provide a resident and/or the resident's representative (sponsor) with a thirty (30) day written notice of an impending transfer or discharge. The resident and/or representative (sponsor) will be notified in writing of the following information: a. The reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location to which the resident is being transferred or discharged . The reasons for the transfer or discharge will be documented in the resident's medical record. The Facility Policy titled Notice of Transfer or Discharge, last revised October 2024, documented the facility must notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The Social Worker and Nurse Supervisors/Unit managers are responsible to ensure residents, and their representatives are notified of any transfers and discharges in a timely manner indicating reason of transfer and discharge. Notice to the Office of the State Long Term Care Ombudsman must occur at the same time the notice of discharge is provided to the resident and resident representative. Resident #1 was admitted with diagnoses including but not limited to anxiety disorder, chronic obstructive pulmonary disorder, depression, and Polye osteoarthritis. The 2/1/2025 Admission 5-day Minimum Data Set (an assessment tool) documented that Resident #1 had intact cognition, and there were no reports of entry/discharge. The 5-day Minimum Data Set assessment dated [DATE] documented Resident #8 had intact cognition, required maximum assistance or was dependent on staff for most activities of daily living except eating and oral hygiene. The 2/6/2025 Social worker Progress Note documented that a Care plan meeting was held with Resident #3, family and the facility Interdisciplinary team. Resident's discharge plan is to return home. Resident #3 is requesting an assessment with their Managed Long-Term Care (MLTC -Fidelis) for increase in hours at home. Discharge Planning was to reach out to Fidelis to schedule and assessment. There was no documented evidence that Resident #3's Managed Long-Term Care (MLTC) was notified to assess Resident #3 for additional hours prior to the discharge home. The 3/11/2025 Nursing Progress note documented that Physician saw resident for a discharge visit, and Resident #3 was cleared for discharge on 3/13/2025. The 3/13/2025 Nursing Progress Note documented that Resident #3 was discharged from facility with all personal belongings, and that all medications and follow up appointments was reviewed with resident. There was no documented evidence that the facility discussed discharge with Resident #3 or their representative that included information on discharge planning and arrangements for post-discharge care. There was no documented evidence that Resident #3 was provided with a bed hold notification for discharge on 3/13/2025. The 3/13/2025 Social Worker Progress Note documented that they discharged resident home with all their personal belongings. A friend was there to transport, the daughter was made aware of discharge, and referrals were made for the visiting nurse, an aide, and Occupational Therapy/Physical Therapy. Also provided was the med assist and lifeline of the [NAME] valley contact numbers. There was no documented evidence that Resident #3 or resident representative was provided a 30-day notice prior to discharge on 3/13/2025. Upon request of records from facility on 5/9/2025, the facility was unable to provide documented evidence that the Ombudsman was notified of Resident #3's discharge on 3/13/2025. During an interview on 5/9/2025at 3:09 PM, the Social Worker stated that Resident #3 had an initial Care Plan meeting on 2/6/2025, where therapy addressed their goals, gathered information about who they live with, long term care options if they want to. The Social Worker stated that Resident #3 had Management Long term care (MLTC) at home and was looking for more long-term hours, and that they requested that the Managed Long-Term Care come into facility to assess to see if they could get more hours. The Social Worker stated that they were not aware of the Managed Long-Term Care coming in to assess Resident #3. The Social Worker stated that when a family comes to the Care Plan meetings, they let them know the plans for discharge if any and was able to provide documentation that they discussed discharge planning and interventions to be put in place before going home. The Social Worker stated that the Resident's family should always be involved with discharge, and that if a resident is discharged from the facility, it should always be a safe discharge, and that everything should be in place prior to discharge including the referrals for therapy, a home health care (aide in home) as well as adaptive equipment. The Social Worker stated that they do not facilitate discharges because they have a discharge liaison in the facility that handle discharges. During an interview on 5/9/2025 at 3:44 PM, Discharge Liaison #1 stated they have weekly Utilization Review meetings once a week which consists of facility staff to discuss all residents, and if a Resident is nearing discharge, they discuss what adaptive equipment they may need when they go home and to make sure it is place before discharge, they set up medical services for post discharge for a safe discharge, and will make sure home cares services are in place before discharge. During an interview on 5/9/2025 at 3:51 PM, Discharge Liaison #2 stated that they notified Resident #3's Management Long term care but they never came to the facility to assess the resident before discharge as per the family members recommendation and the resident's request. Discharge Liaison #2 stated they did not write a progress note. Discharge Liaison #2 stated they notified Resident #3's family about the discharge but they did not write a progress note. They were supposed to complete their documentation before they leave the facility to be sure everything is in place. When requested, Discharge Liaison #2 was unable to provide documentation that Resident #3 or their representative was notified of discharge 30 days prior to their discharge on 3/13/2025, or that a bed hold notification was provided, and that the Ombudsman was notified. 10NYCRR 415.3(i)(1)(iii)(a-c)

Based on observations, record review, and interviews conducted during an Abbreviated Survey (NY00340219), the facility did not ensure residents were free of significant medication errors for 1 (Resident #1) of 4 residents reviewed for Medication Administration. Specifically, on 4/23/24 at 8pm, Licensed Practical Nurse #1 administered Coumadin 2mg to Resident #1 which was put on hold as per Physicians orders on 4/23/24 at 1:24 pm, due to their International Normalized Ratio (INR) being high at 3.3 (normal range 2.0-3.0). Subsequently, Resident #1's International Normalized Ratio (INR) rate increased to 7.9. Resident #1 received 2.5mg of Vitamin K (for prevention of bleeding) immediately. Resident #1's coumadin 2.5mg was discontinued until the International Normalized Ratio (INR) became therapeutic. The Findings are: The undated facility policy titled Medication Errors documented that a medication error is any event that may cause or lead to inappropriate medication use or resident harm. Types of errors include but are not limited to medication that is administered even though it has been held. Resident #1 was admitted with diagnosis including but not limited to atrial fibrillation, cervical disc degeneration, congestive heart failure, and pulmonary edema. The 4/19/24 Admission Minimum Data Set documented that Resident #1 had intact cognition and received an anticoagulant. The 4/23/24 at 1:24pm Physicians orders, documented that Resident #1's Coumadin 2mg was put on hold due to their International Normalized Ratio (INR) being 3.3. The Medication Error Report documented that on 4/23/24 at 8pm Licensed Practical Nurse #1 administered Coumadin 2mg that was put on hold as per Physicians orders from 4/23/34 at 1:24pm. The 4/24/24 at 7am Physicians orders documented that Resident #1's is to be given Phytonadione (Vitamin K) 2.5mg one time only for International Normalized Ration (INR) being 7.9 The 4/24/24 Physicians orders documented that Resident #1's Coumadin 2mg is to be discontinued International Normalized Ratio (INR) becomes therapeutic. The 4/16/24 Anticoagulant Care Plan documented that Resident #1 is on anticoagulant therapy (coumadin) related to atrial fibrillation. Interventions included administering labs as ordered, report abnormal lab results to the Medical Doctor. Anticoagulant medications as ordered by physician The 4/12/24 Medication Care Plan documented that Resident #1 utilizes medication with anticoagulation properties related to mechanical mitral valve replacement and is at increased risk for purpura, bruising, and bleeding. Interventions included doing International Normalized Ratio (INR) labs as per order, monitoring appropriate labs to assess possible bleeding as ordered, and monitoring for signs and symptoms of bleeding. The 4/23/24 at 1:55 pm Nursing Progress Note documented that the Physician saw Resident #1 for follow up visit and International Normalized Ratio was 3.3 and gave order to hold coumadin on 4/23/24 and resume 2.5mg on 4/24/24. The 4/25/24 at 1:16 pm, a Late entry (4/24/24 at 1:08 pm) Medical Progress Note documented that Resident #1 was seen for acute care visit due to receiving a dose of Coumadin in error, and their International Normalized Ratio is 7.9 in which they received vitamin K 2.5 mg. The plan is to hold Coumadin, and to follow up with International Normalized Ratio early in the evening. During an interview on 3/20/25 at 10:17 am, the Complainant stated that Resident #1 called them early in the morning on 4/25/24 upset stating that the nurse told them that they gave them their Coumadin that was put on hold by the Physician due to an elevated International Normalized Ratio and that the nurse told them that they did not check the notes. During an interview on 3/20/25 at 12:23 pm, Licensed Practical Nurse #2 stated that they get report from the prior shift of medications on hold or discontinued but it is up to the nurses to check the electronic health records and Physicians orders prior to medication administration so that a medication error does not occur. During an interview on 3/20/25 at 2:40 pm, Physician #1 stated that they were not sure when they were notified about Licensed Practical Nurse #1 administering Resident #1's Coumadin 2mg that was held due to an elevated International Normalized Ratio and that administering the Coumadin could have harmed Resident #1 if they developed a bleed. Physician #1 stated that administering Coumadin with an elevated International Normalized Ratio can cause the resident to have a greater risk of bleeding causing them to spontaneously bleed, and drawing blood would become dangerous. Physicians #1 stated that that they were not sure if the International Normalized Ratio went up to 7.9 due to giving Coumadin with an already increased International Normalized Ratio, but Resident #1's International Normalized Ratio target range is 2-3 and Vitamin K was given immediately to quicky reduce the International Normalized Ratio. During an interview on 3/21/25 at 1:34 pm, Licensed Practical Nurse #1 stated that they mistakenly administered Resident #1 Coumadin that was on hold, and that they realized after administration. Licensed Practical Nurse #1 stated that they did see the physicians order that it was on hold but gave it by accident because they were overwhelmed because they were working alone. During an interview on 3/24/25 at 5:27 pm, the Director of Nursing stated that nurses should follow Physicians orders and do the 5 rights of medication administration prior to administering medications. The Director of Nursing stated that if Coumadin is given with an elevated International Normalized Ratio, the resident has a risk of bleeding out. 10 NYCRR 415.12(m)(2)

Based on observation and interview conducted during a recertification survey from [DATE] to [DATE], the facility did not ensure that food was stored in accordance with professional standards for food safety practice, contact and non-food contact equipment and kitchenware were maintained in sanitary condition in accordance with the standards for food service safety. Specifically, leftover foods were unlabeled and labeled foods were expired in the kitchen refrigerator, expired food items were stored on the shelve and dented cans were not separated from good cans, and the milk cooler was full of food particles and debris. The findings include: Observations and interviews from the kitchen tour conducted on [DATE] at 10:45 AM, [DATE] at 9:45 AM and [DATE] between 1:15 PM and 1:25 PM revealed - Expired leftover prunes were found in the refrigerator, with a start date of [DATE] and an intended use-by date of [DATE]. Additionally, slices of cake and leftover cucumber salad lacked proper labeling. - Two bottles of kitchen bouquet were discovered to be expired, with one nearly fully utilized, and both bottles bearing an expiration date of [DATE]. - Dented cans of applesauce were mixed with undamaged cans, occurring twice during the observation. - Red liquid was observed on the floors of both dry storage and the kitchen, indicating a spill or leakage. - On [DATE] at 9:45 AM, the milk cooler was observed to be heavily soiled with food particles and debris. - Pudding and pie filling mix containers lacked expiration dates. On [DATE] at 10:45 AM during an interview, the Food Service Director stated it was mentioned that the prunes were initially labeled incorrectly, prompting immediate relabeling of the cake and cucumber salad. The Food Service Director also acknowledged the expired kitchen bouquet bottles and promptly removed them from shelves, along with addressing the issue of mixed dented and undamaged cans upon inquiry. However, regarding the filthy milk cooler, the Food Service Director stated there was a cleaning schedule but could not provide a documented log. Similarly, the absence of expiration dates on the pudding and pie filling mix was discussed, with an explanation provided based on the manufacturer's shelf life of 730 days. On [DATE] at 1:15 PM during an interview the Dietary Aide Supervisor stated that any staff member could be assigned to check for dented cans, and they had received training on this procedure. On [DATE] at 1:25 PM during an interview, the [NAME] stated that whoever packed new food items was responsible for checking the expiration dates of older items before restocking shelves and ensuring all items in their pantry were properly labeled. 10NYCRR 415.14 (h)

Based on observation, record review, and interview during the recertification survey conducted from 4/8/24 to 4/16/24, the facility did not establish and maintain an infection prevention and 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 5 of 5 residents reviewed for indwelling medical devices. Specifically, Residents #230, #38, #198, and #122 had urinary catheters, Resident # 224 had nephrostomy tubes, and enhanced barrier precautions were not implemented. The findings are: The Centers for Medicaid and Medicare Services Quality Safety and Oversight Group documented that Enhanced Barrier Precautions must be implemented on April 1st 2024 for high contact resident care activities for nursing home residents with wounds and indwelling medical devices and for residents with multi-drug resistant organism infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions include (but are not limited to) dressing, bathing, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator), and wound care. The procedure included placing an enhanced barrier precaution sign on the door. Wear a gown and gloves whenever high-contact resident activities are performed. 1.Resident #230 was admitted to the facility with diagnoses which included inhibited neuropathic bladder, other complications of colostomy, and dementia. The admission Minimum Data Set (resident assessment tool) dated 1/12/2024 documented the resident had an indwelling urinary catheter and colostomy. The resident required maximal assistance with toileting hygiene and bathing, and was dependent with transfers. During an observation on 4/9/2024 at 10:00 AM, Resident #230 was lying in bed with an indwelling catheter. Outside the resident room, there was no observed personal protective equipment caddy or enhanced barrier precautions signs. On 4/15/2024 at 9:15 AM during an interview, Staff #12 (Certified Nurse Aide) stated that the enhanced precaution signs and the caddies were put in place on 4/11/2024. Prior to the signs being posted, they provided care for the resident without gloves or gowns. On 4/15/2024 at 9:30 AM during an interview, Staff #11 (Registered Nurse Unit Manager) stated the enhanced barrier precaution signs were up on Thursday, 4/11/2024, but the physician orders, the care plan, and the certified nurse aide care instructions were not updated with enhanced barrier precautions until 4/12/2024. On 4/15/2024 at 10:05 AM during an interview, the Infection Control Nurse stated that education for enhanced barrier precautions was ongoing, but it was not fully implemented. They stated they were responsible for the education and posting of the signs and the caddies. 2. Resident #224 was admitted with diagnoses including cancer, multidrug-resistant organism urinary tract infection in the previous 30 days, and artificial openings of urinary tract status. The resident required maximal assistance with bathing and toileting hygiene, and was dependent with transfers. The admission Minimum Data Set (resident assessment tool) dated 2/19/2024 documented the resident had been receiving intravenous antibiotics, hemodialysis, and they had a central line for intravenous access. Physician's orders documented: - on 2/12/2024 change nephrostomy drainage bag as needed. - on 4/10/2024 Registered Nurse to flush bilateral nephrostomy tubes with 10 milliliters of normal saline weekly on Wednesdays. A care plan dated 2/9/2024 (updated 3/20/2024 and 4/9/2024) documented the resident needed hemodialysis related to renal failure, and nephrostomy tubes. Interventions included to maintain nephrostomy tubes as per medical order, change dressing as per medical MD order, and empty nephrostomy tubes as per order. On 04/12/24 at 12:06 PM during an interview, Staff #17 (Licensed Practical Nurse Unit Manager) stated the enhanced barrier precautions had just been rolled out, and they received education from the corporate Registered Nurse and the infection control nurse. When asked how staff were informed of the residents requiring enhanced barrier precautions, Staff #17 stated they were going according to the policy that was provided to them. At that time, surveyor reviewed the enhanced barrier precautions policy with Staff #17, and Staff #17 stated that the implementation of the enhanced barrier precautions and care plan update had not been completed yet and they thought that the infection control nurse was working to implement it as soon as possible. On 4/12/24 at 12:33 PM during an interview, the Infection Control Nurse stated that they had educated the staff on enhanced barrier precautions. The Infection Control Nurse stated that they had not obtained medical orders for enhanced barrier precautions, and they had not implemented the enhanced barrier precautions on the care plans or certified nurse aide tasks for the affected residents. 3. Resident #38 was admitted with diagnoses including hematuria (blood in the urine), malignant neoplasm (cancer) of prostate, unspecified urethral stricture (narrowing of the urine duct). The 3/10/24 quarterly Minimum Data Set (resident assessment tool) documented the resident had an indwelling urinary catheter. The resident was dependent with toileting hygiene and toilet transfers, required maximal assistance with bathing, and required moderate assistance with transfers. On 04/08/24 at 11:47 AM and 4/12/24 at 3:00 PM , no enhanced barrier precaution signage was observed posted on the resident's door and no personal protective equipment cart was observed at or near the resident's room door. The 12/6/23 Care Plan titled, the resident is at risk for urinary tract infection related to utilizing a urinary catheter for urinary structure. Interventions included to change the urine drainage bag every 2 weeks, document urine output amount every shift, observe output for sediment, mucous shreds, blood, color changes, odor changes, perform catheter care at insertion site daily. There was no documented evidence in the April 2024 certified nurse aide and/or physician orders directing enhanced precautions for urinary catheter care. On 4/12/24 at 12:44 PM during an interview, Staff #4 (Registered Nurse Unit Manager) stated that enhanced precautions had not been implemented yet and the Infection Preventionist was responsible for the implementation and education of the enhanced precautions. 10 NYCRR 415.19 (b)(2) 37658 43478 45478

Based on observation, record review and interview conducted during the recertification survey from 4/8/24- 4/16/24, the facility did not ensure that the call bell system was accessible for 1 of 35 residents reviewed for environment. Specifically, Resident #133 was observed on two occasions with the call bell system not within the resident's reach. The findings: Resident # 133 was admitted to the facility with diagnoses including mild cognitive impairment, generalized muscle weakness, and hypertension. The 3/4/24 Quarterly Minimum Data Set Assessment documented the resident had intact cognition, required set up assistance with bed mobility and transfers, and required minimal assistance with activities of daily living. On 04/08/24 at 10:44 AM the resident was observed in bed. The call bell cord was observed wrapped on a hook on a wall near the resident's dresser and was not within arm's length of the resident. On 04/09/24 at 09:49 AM the resident was observed in bed. The call bell cord was observed leading from the wall to the floor behind the resident's dresser and was not within arm's length of the resident. On 04/15/24 at 10:11 AM during an interview, Staff # 13 (Licensed Practical Nurse) stated that resident should have their call bell within reach when in bed or sitting in a chair. On 04/16/24 at 10:39 AM during an interview, Staff # 14 (Licensed Practical Nurse) stated Resident #133 knew how to use their call bell. They stated that the call bell should be within reach whether the resident was in the bed or chair. 10NYCRR 415.3

Based on observation, interview, and record review conducted during the recertification survey from 4/8/24 to 4/16/24, the facility did not maintain a safe, clean, and comfortable environment in 2 resident rooms (Room C2-14, and C2-16). Specifically, Room C2-14 had a hole in the ceiling near the resident's bed and damaged ceiling tiles towards the front of the room, and Room C2-16 had large areas of uncovered ceiling where tiles were missing. Findings include: During an observation on 04/08/24 at 12:09 PM, room C2-14 had a large hole in the ceiling above the light fixture near the resident's bed. Water damage was noted around the hole and throughout the ceiling. More water damage was noted to the ceiling near the front of the room. During an observation on 04/09/24 at 09:52 AM, room C2-14 continued to have the large hole in ceiling near the resident's bed and it remained uncovered. The damaged ceiling tiles near the front of the room remained uncovered. During an observation on 04/09/24 at 12:12 PM, room C2-16 had water damage throughout the room. There was a large, uncovered area in the ceiling by the window on the A side of the room, where ceiling tiles were missing. There was another large uncovered open area in the ceiling over the dresser on the B side of the room. During an observation on 04/11/24 at 09:50 AM it was noted both C2-14 and C2-16 remained with uncovered open areas in the ceiling. No water was noted coming through these openings. On 4/9/24 at 12:12 PM during an interview, Resident #36 stated that there was a big flood, and the ceiling had been like that since last year. On 4/9/24 at 12:25 PM during an interview, the Director of Maintenance stated that replacing the ceiling tiles in the resident rooms was a work in progress and that other resident rooms had ceiling tiles that must be replaced. The Director of Maintenance further stated that there was sometimes an overflow of condensation from the individual heat and air units in the rooms that caused damage to the ceiling tiles, and the pumps had to be adjusted or there was an overflow from the toilets. On 04/11/24 at 11:13 AM during an interview, the Director of Nursing and the Administrator stated that the holes in room C2-14 and C2-16, should have been reported by staff, staff were supposed to put in a work order, and notify a supervisor, or maintenance worker that there was an issue. They stated that ceiling tiles were something that the facility had been working on and had been repairing them, but the tiles were no longer made. On 04/15/24 at 10:11 AM during an interview, Staff #13 (Licensed Practical Nurse) stated that the issue in room C2-14 and C2-16 had been like that for a while and it was an ongoing problem. Staff #13 stated the water was coming into those rooms (C2-14 and C2-16) from someone clogging the toilet above and water flowing down. The resident upstairs was flushing socks and shirts down the toilet. The maintenance crew was fixing the tiles constantly and then they stopped. Staff #13 stated that unit staff were constantly putting in work orders when the floods were happening. There was no discussion of a temporary fix to the holes in the ceiling. Maintenance was keeping up with it before but lost some staff in the department. 10 NYCRR 415.3

Based on record review and interviews during the re-certification survey from 4/8/24 to 4/16/24, the facility did not ensure Minimum Data Set 3.0 comprehensive assessments were completed in a timely manner. Specifically, the annual assessment was not completed within 14 calendar days from admission and/or by the required Assessment Reference Date. This was evident for 1 of 1 resident reviewed for Resident Assessment (Resident #120). The findings are: The facility policy and procedure titled Minimum Data Set 3.0 Policy and Procedure (last revised 5/2023) documented the following: According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the Resident Assessment Instrument specified by the State. An Annual Assessment - completed using an Assessment Reference Date not >366 days from the most recent prior comprehensive assessment and not >92 days from the most recent Quarterly Assessment (counting Assessment Reference Date to Assessment Reference Date). Resident #120 was admitted to facility on 1/16/2023. There was no documented evidence to indicate the completion of the Annual Minimum Data Set (an assessment tool) that was due January 2024. The Annual Minimum Data Set Assessment for resident #120 was documented as completed on 3/14/24 and signed by Minimum Data Set Coordinator on 3/27/24. On 4/15/24 at 1:17 PM, the Minimum Data Set Coordinator stated they were responsible for the submissions of the Minimum Data Set. The Coordinator stated the annual Minimum Data Set was to be completed in January of 2024 and that it was an oversight. The Minimum data Set Coordinator stated they completed a care plan meeting on 1/31/24 and there was a documented care plan note but did not have an explanation as to why the Annual Minimum Data Set was not completed when the care plan was completed. 10 NYCRR 415.11(a)(3)(i)

Based on observation, record review, and staff interview during the recertification survey from 4/8/24 to 4/16/24, the facility did not ensure that appropriate treatment and services were provided to prevent a further decrease in range of motion for 1 of 2 residents (Resident #102) reviewed for position and mobility. Specifically, Resident #102 was observed on two occasions without the blue carrot (or hand roll) in their left hand as ordered. Findings include: Resident #102 had diagnoses including cerebral vascular accident, quadriplegia, and left arm contracture. The quarterly Minimum Data Set (resident assessment tool) dated 12/14/2023 documented the resident had upper and lower extremity impairments on both sides, their cognition was severely impaired, and they were dependent on staff for all activities of daily living. The 6/19/23 Care Plan titled Alteration in Musculoskeletal Status-Severe Osteopenia, at risk for spontaneous fractures without an identifiable or precipitating event, contractures of all extremities. Interventions included to apply blue carrot (or hand roll) in left hand in AM, (check skin integrity), and remove at bedtime (check skin integrity). The 6/6/23 physician's order documented apply blue carrot (or hand roll) in left hand in AM, (check skin integrity) and remove at bedtime (check skin integrity). On 04/08/24 at 12:21 PM, observed Resident #102 lying in bed, observed their left hand was contracted, and no blue carrot (or hand roll) was observed in their left hand. On 04/09/24 at 11:45 AM, observed Resident #102 sitting in their gerichair at the nurse's station, observed their left hand was contracted, and no blue carrot (or hand roll) was observed in their left hand. On 04/09/24 at 11:56 AM during an interview, Staff #2 (Certified Nurse Aide) stated they were not sure who should put the blue carrot in Resident #102's left hand. Staff #2 checked the certified nurse aide instructions and stated the blue carrot (or hand roll) was not documented in the certified nurse aide instructions. Staff #2 stated the nurse did not communicate with them any instructions regarding the blue carrot or hand roll. On 04/09/24 at 12:12 PM during an interview, Staff #3 (Licensed Practical Nurse) stated the blue carrot (or hand roll) should be placed in Resident #102's left hand in the morning by the nurse. Staff #3 stated when they administered medications to the resident at 8:00AM, they should have applied the blue carrot (or hand roll). On 4/12/24 at 3:53 PM during an interview, the Director of Rehabilitation stated that the order for the blue carrot (or hand roll) to Resident #102's left hand during the day was for the purpose of keeping the resident's fingernails from digging into their left palm, and to prevent further contracture of their left hand. The Director of Rehabilitation stated the nurses should be applying the blue carrot (or hand roll) to Resident #102's left hand as ordered. 10 NYCRR 415.12

Based on observations, interviews and record reviews conducted during an Abbreviated Survey (Complaint #NY 3965), the facility did not ensure safe and effective proper use of an assistive device to prevent serious injury to 1 of 3 residents reviewed for accidents (Resident #1). Specifically, a Certified Occupational Therapist Assistant (COTA #1) used a heat pack on Resident #1's hand without a care plan or order, resulting in heat blisters on five fingers. The Findings are: Resident #1 is a [AGE] year-old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS; a resident assessment tool) dated 7/8/2020 indicated that the resident was moderately cognitively impaired. Review of an Accident/Incident Report dated 9/3/2020 showed that on 9/3/2020, Resident #1 had a heat pack applied to his hand leading to [MEDICAL CONDITION] his hand. The investigation also showed that the heat pack was applied without a Physician's Order or Care Plan (CP) and concluded that there was no evidence of abuse, neglect or mistreatment. Review of Progress Notes dated 9/3/2020 at 12:40pm, documented that COTA #1 placed a hot pack on Resident #1, telling him to leave it for 15 minutes. COTA #1 returned in 15 minutes and removed it. Review of the Employee Corrective Discipline Notice dated 9/4/2020 showed that COTA #1 utilized a hot pack on Resident #1's hand, leading [MEDICAL CONDITION] 5 blisters. The Notice also documented that the hot pack was utilized without a Physician's Order or CP. Interview with the Director of Nursing on 11/24/2020 at 9:15am indicated that COTA #1 did not use enough towels between the heat pack and Resident #1's hand. COTA #1 also used the heat pack without a Physician's Order or a CP in place. Interview with the COTA #1 on 11/24/2020 at 10:15am showed that he put the hot pack on Resident #1 with 3 or 4 layers between the hot pack and Resident #1's skin. COTA #1 stated that he should have used 7 to 8 layers. He also indicated that he should have contacted the therapist to evaluate Resident #1 being that there was no Physician's Order or CP in place. During interview with the Physical Therapist (PT #1) on 11/24/2020 at 10:25am, he stated that COTA #1 used a hot pack without a Physician's Order or CP which resulted in Resident #1 [MEDICAL CONDITION] all 5 fingers. He indicated that COTA #1 should have contacted the therapist to evaluate Resident #1 before placing the hot pack on his hand. Despite several requests, the facility could not provide policy and procedure for applying heating pads. During interview with the Corporate Regional Administrator on 11/24/2020 at 11:30am, she indicated that the facility changed ownership on August 28, 2020. She went on to explain that all Policies and Procedures for the facility were not shared and were kept by the previous ownership. 483.25(d)(1)(2)

Based on staff interviews and record review, the facility did not ensure that services were provided in order to meet a resident ' s highest practicable level of functioning and well-being. Specifically, a resident with Advance Directives for cardiopulmonary resuscitation (CPR) was not provided with CPR. This resulted in actual harm that is not immediate jeopardy. (Resident #1) Complaint #NY 009 Findings include: Resident #1 was an [AGE] year old female who was re-admitted to the facility on [DATE] after a hospitalization for pneumonia. The resident ' s [DIAGNOSES REDACTED]. A Determination for Lack of Capacity form was signed and concurred by two physicians on [DATE], assigning a resident ' s proxy. The resident ' s readmission Physician order for [REDACTED]. A review of the 9:00 PM nurse ' s note of [DATE] completed by Licensed Practical Nurse (LPN) #1 documented that the resident ' s oxygen saturation SPO2 (a noninvasive method of monitoring the oxygen level in the blood) was 71% after receiving nebulizer treatment (normal oxygen saturation level ranges from 92% - 100%). The nurse ' s notes documented that the nursing supervisor was notified of the resident ' s condition. The oxygen saturation went down to 60% and the resident remained on oxygen at 2 liters per minute. This nurse ' s notes further documented " while attempting to reach physician for order to send to the hospital the Certified Nursing Attendant (C.N.A.) called her into the room. Resident expired at 7:35 PM, family notified. " A review of Registered Nurse Supervisor#1(RNS#1) written statement dated [DATE], documented that as she hung up the phone after speaking with the resident ' s daughter about why the resident was being sent to the hospital, a staff member informed her that the resident had passed away seven or eight minutes ago while she was on the phone with the daughter. RNS #1 then went back to the resident ' s room and found the resident without any respiration, pulse was absent and blood pressure was unobtainable. This was documented on a late nursing entry note of [DATE] at 4:30 PM. There was no documented evidence that cardiopulmonary resuscitation was initiated while she was on the phone with the daughter. The [DATE] nursing supervisor ' s note completed by RNS#1 documented that an order was obtained from the attending physician at 8:15 PM to release body to the funeral home. A review of the Accident/Incident Report dated [DATE] by RNS#1 documented a corrective action and measures instituted to prevent reoccurrence which include " staff will review CPR policy and procedures -staff to follow facility CPR policy and procedures in future. " A review of the facility policy on " Do No Resuscitate Orders " dated [DATE] required that the facility will follow standards of practice as defined by the American Heart Association and the Emergency Medical Service (EMS) Advance Life Support (ALS)/ Basic Life Support (BLS) protocol for withholding life support - indicating that CPR is not initiated when there are signs of irreversible death such as dependent lividity or rigor mortis. Following as assessment by an RN, documentation will include the clinical findings that substantiate the assessment of dependent lividity/rigor mortis. During an interview with LPN #1 on [DATE] at 3:30 PM, she stated that at about 6:30 and 7:00 PM, the Certified Nursing Assistant assigned to resident called her into the room because he did not think the resident looked right and was not breathing well. She stated that when she went into the room, she found the resident congested with increased respirations and a decreased oxygen saturation of 71%. She stated she then called the RN supervisor. The RNS#1 (Registered Nurse Supervisor) arrived on the unit with an AED (automated external defibrillator). LPN #1 then took another oxygen saturation reading which was now 60% and was then advised by RNS#1 to call the family and the attending physician to send the patient to the hospital. LPN #1 further stated that the resident was wearing a red wrist band indicating that she was a full code and was aware of this at the time when the resident was having trouble breathing. She stated that the resident was still breathing and alive when the RNS#1 came into the room. An interview with RNS #1 was conducted on [DATE] at 4:00 PM. She stated that another RNS in the supervisor ' s office received a call from LPN #1 stating that the resident ' s oxygen saturation level was 60%. RNS#1 stated she grabbed the AED cart and went to the unit. While doing this, she saw LPN #1 and advised her to call the resident ' s family and attending physician to send the resident out to the hospital. She stated that she found the resident with head elevated, mouth open, respirations at 26 per minute (16- 20 per minute is normal), oxygen was on and the resident had diminished lung sounds. She stated that she did not feel the resident was going into any cardiac event but felt that she needed to get the resident out to the hospital. She stated she then left the room to get a small blood pressure cuff. At that time, she instructed LPN#1 to call the physician ' s answering service as the LPN#1 had not reached the attending physician. RNS #1 then went back into the resident room to get the resident ' s blood pressure and again felt that there was no immediate event. RNS #1 stated that she then went to nurse ' s desk to make copies for a transfer packet. In the meantime, the resident ' s daughter called back while LPN#1 was on phone with attending physician ' s answering service. She stated she then saw LPN#1 come out of the resident ' s room at approximately 7:43 PM and LPN#1 stated to her that the resident passed away. RNS#1 states she then went back to check the resident and did not initiate CPR because of the time and felt that it would have been uneventful and that too much time had passed, " at least 8 minutes " . RNS#1 stated that the resident had no pulse, respirations, or blood pressure but did not observe signs of dependent lividity or rigor mortis except that her jaw may have been stiff. RNS#1 states that she did not activate EMS or call 911, Stated, " I never call 911 ", "I always call the attending physician first for orders to send the residents out". She states that after she receives orders from physician she calls an ambulance for transport to the hospital. During an interview with the Director of Nursing on [DATE] at 1:30 PM, she stated that she received a call from the nursing staff on [DATE], the evening of the incident. She stated that after conducting an investigation, she found that RNS#1 did not initiate CPR per the resident ' s Advance Directive or call 911 for the resident. 415.12