Every finding on record at Greenfield Health & Rehab Center

Based on interview and record review conducted during a survey the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than two (2) hours after the allegation is made, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law for one (1)(Resident #1) of three (3) residents reviewed for abuse. Specifically, an allegation of witnessed staff to resident abuse was not reported to the administrator immediately and to the State agency within the required time frames. The findings are: A policy and procedure titled Resident Abuse Investigation and Reporting dated January 2023 documented that all employees are required to report an act of resident abuse by a staff member or another resident immediately to their supervisor upon knowledge of the alleged abuse. Resident #1 was admitted to the facility with diagnoses of dementia and difficulty in walking. The Minimum Data Set (a resident assessment tool) dated 02/20/2026 documented the resident was severely cognitively impaired. The comprehensive care plan dated 12/23/2024 (current) documented that the resident had verbal, physical behavior and had a difficult time communicating with others related to dementia. It documented that staff were to intervene to protect the resident and others, redirect any negative behaviors, remove from situation, and take to another location. Review of the progress notes dated 02/01/2026 to 02/25/2026 documented that Resident #1 had incidents being combative with hands on care, threw objects at staff, hit and slapped staff. Review of a complaint report #2749147 dated 02/18/2026 at 9:30 PM, documented that Certified Nurse Aide #2 witnessed Certified Nurse Aide #1 choking and calling Resident #1 names. Certified Nurse Aide #2 took Resident #1 out of Resident #1's room and away from Certified Nurse Aide #1. Certified Nurse Aide #1 stated that they did not call Resident #1 any names or choke the resident. It was also documented that Certified Nurse Aide #1 stated that they did not push the resident, but they kept Resident #1 at arm's length due to Resident #1 hitting them Interview on 2/25/2026 at 8:41 AM, Resident #1 stated that they were not afraid of any of the staff members. Interview on 02/25/2026 at 8:50 AM, Certified Nurse Aide #4 stated that Resident #1 was unpredictable with their behaviors. Certified Nurse Aide #4 stated that when Resident #1 had behaviors, they leave the resident alone and reapproach later. Certified Nurse Aide #4 stated that they would report any abuse right away to their supervisor or charge nurse. Certified Nurse Aide #4 stated they were trained about abuse and abuse reporting regularly and at orientation. Interview on 02/25/2026 at 9:08 AM, Certified Nurse Aide #2 stated that the observed Certified Nurse Aide #1 choke Resident #1, heard Certified Nurse #1 call Resident #1 explicative names, and pushed Resident #1 out of their room in an aggressive manner at about 9:30 PM on 02/18/2026. They stated that they had removed Resident #1 from the situation. They stated they reported the incident to Resident Care Coordinator #1 the next morning, because they did not realize what they saw until the next day. Interview on 02/25/2026 at 10:34 AM, Certified Nurse Aide #1 stated they did not push or choke Resident #1 and did not call Resident #1 any names. They stated they attempted to keep Resident #1 at arm's length because Resident #1 had punched them. Interview on 02/25/2026 at 10:14 AM, Registered Nurse Resident Care Coordinator #1 stated that on 02/19/2026 at approximately 10:40 AM Certified Nurse Aide #2 told them about what happened on 02/18/2026 during the afternoon shift with Certified Nurse Aide #1 and Resident #1. Registered Nurse Resident Care Coordinator #1 stated at that time they had asked Certified Nurse Aide #2 why they didn't report the allegation right away, and Certified Nurse Aide #2 had replied to them, I don't know. Registered Nurse Resident Care Coordinator #1 stated at 10:45 AM that same day they went with Certified Nurse Aide #2 and reported the allegations to the Administrator. Registered Nurse Resident Care Coordinator #1 stated they expected staff to report allegations of abuse to them or the supervisor right away. They stated that Certified Nurse Aide #2 should have reported the incident right away. Interview on 02/25/2026 at 11:27 AM, Registered Nurse Supervisor #1 stated that no one reported any abuse allegations to them during the evening shift on 02/18/2026. They stated that staff were expected to report any incidents of abuse or suspected abuse right away to them or to their Resident Care Coordinator. Interview on 02/25/2026 at 11:40 AM, the Administrator stated that if any employee suspected abuse, they need to report it right away to a supervisor or to their Resident Care Coordinator. They stated that when they spoke with Certified Nurse Aide #2 and asked them why they didn't report it right away. Certified Nurse Aide #2 stated to them that Certified Nurse Aide #2 was in shock and didn't realize what happened until the next morning when they reported to their Resident Care Coordinator. The Administrator also stated the allegation was not reported in a timely manner. 10 New York Code Rules Regulation 415.4(b)(4)

Based on observation, interview, and record review conducted during the Standard survey completed on 08/08/2025, the facility did not ensure residents were free from unnecessary drugs for one (1) (Resident #157) out of five (5) residents reviewed. Specifically, Resident #157's psychotropic medication (Xanax, an anti-anxiety medication) dose was increased erroneously and without evidence of adequate indications. The findings are: The policy titled Medication Regimen Review revised 9/2017 documented the consultant pharmacist will perform a drug regimen review on each resident residing at the facility for the objective to try to minimize or prevent adverse consequences or to prevent resident from receiving unnecessary drugs. The policy documented all medication orders will be review for unnecessary medications, adequate and appropriate indications for each ordered medication, and the appropriateness of the medication, dose, frequency and route of administration. The policy titled BMARC (Behavior Modifying Agent and Review Committee) revised 1/2022 documented the policy was to assure that all psychopharmacological agents were prescribed appropriately and monitored by the interdisciplinary team, all psychopharmacological medications were reviewed at the recommendations of the Behavior Modifying Agent and Review Committee. Resident #157 had diagnoses including dementia, anxiety and major depression. The Minimum Data Set (a resident assessment tool) dated 06/05/2025 documented Resident #157 had severe cognitive impairment, sometimes understood and sometimes understands. The Minimum Data Set documented Resident #157 had no delusions, no hallucinations, no rejection of care, no behaviors and received antianxiety medication. The comprehensive care plan revised 09/25/2024, documented Resident #157 used anti-anxiety medications (Xanax) related to anxiety disorder. Interventions included to administered anti-anxiety medications as ordered and monitor for side effects and effectiveness every shift. The Order Recap Report dated 08/08/2025 documented Resident #157 had an order for Xanax 0.25 milligrams every eight (8) from 01/09/2025 until 01/30/2025. On 1/30/2025 the report documented an active order for Xanax 0.5 milligrams every eight (8) hours. Review of the GP Progress Note signed by Physician Assistant #2, (Psychiatry Physician Assistant) documented :-01/29/2025 at 12:12 PM Resident #157 was recently readmitted from the facility and received Xanax as previous prescribed. Physician Assistant #2 documented Resident #157 had no significant anxiety since readmission and mood was stable. It was documented to continue Xanax 0.25 milligrams as previously taking in the community and no increase or additional psychotropic medications were recommended at that time. -04/30/2025 at 9:16 PM Resident #157 continued to do well on Xanax as previously prescribed. It was documented to continue Xanax 0.25 milligrams as previously taking in the community and no increase or additional psychotropic medications recommended. -07/23/2025 at 10:10 AM Resident #157 continues Xanax 0.5 milligrams every eight (8) hours and maintains good control of previous symptoms. The note also documented to continue Xanax 0.25 milligrams as previously taking in the community and there was no increase or additional psychotropic medications recommended. Review of Nurse Practitioner #1 progress notes dated 01/28/2025 - 07/09/2025 documented Resident #157 was to continue Xanax 0.25 milligrams every eight (8) hours for generalized anxiety disorder with goal to wean to the lowest dose. Review of the BMARC Committee Follow-up (Behavior Modifying Agent and Review Committee) notes for Resident #157 documented:-01/29/2025 Xanax 0.25 milligrams every eight (8) hours for anxiety continues. The committee recommended no changes at this time.-04/30/2025 and on 07/23/2025 Xanax 0.5 milligrams every eight (8) hours continues, and the resident was stable on the lowest effective dose of medications at that time.There was no documented indications for the increase in the Xanax dosage. Review of the Medication Administration Record from 01/01/2025 to 08/07/25 Resident #157 received the Xanax as per medical provider's order. Review of the Progress notes dated 01/28/2025-02/04/2025 revealed there was no documented evidence Resident #157 was experiencing increased anxiety and/or gastrointestinal complaints. There was no documented evidence that a new order was received to increase Resident #157's Xanax dose or any indications for the need. During intermittent observations from 08/04/2025-08/07/2025 between the hours of 9:49 AM and 4:10 PM, Resident #157 was out of their room self-propelling the unit and participating in self-directed and group activities; being assisted with activities of daily living (toileting, medication administration) and sleeping in bed. Resident #157 was well kempt, pleasant, cooperative with staff and no behaviors were displayed. During a telephone interview on 08/07/2025 at 9:59 AM, Physician Assistant #2, (Psychiatry Physician Assistant), stated Resident #157 utilized Xanax because the resident perseverated on their gastrointestinal complaints versus anxiety issues. After review of review of their progress notes, Physician Assistant #2 stated they made a mistake in their documentation on 07/23/2025 and assumed the Xanax 0.5 milligrams was Resident #157's previous dosage. Physician Assistant #2 stated Resident #157 was taking Xanax 0.25 milligrams every eight (8) hours and the dosage was increased to Xanax 0.5 milligrams every eight (8) in January 2025 after a hospital stay. Physician Assistant #2 stated they were unsure why Resident #157's Xanax dosage was increased shortly after return from the hospital. During a telephone interview on 08/08/2025 9:50 AM, Physician Assistant #2 stated they did not recommend an increase in Resident #157's Xanax dosage and would not have expected a change in the dosage without a medical provider's order and family notifications. Physician Assistant #2 stated they attended the Behavior Modifying Agent and Review Committee (BMARC) meetings. During an interview on 08/07/2025 at 10:35 AM, the Pharmacy Consultant stated the Xanax dose was increased to 0.5 milligrams every eight (8) hours on 01/30/2025 after Physician Assistant #2 psychiatry visit. The Pharmacy Consultant stated they participated in the Behavior Modifying Agent and Review Committee (BMARC) meetings and Resident #157 was reviewed by the committee. The Pharmacy Consultant stated the committee notes on 04/30/2025 and 07/23/2025 documented the Xanax dose as 0.5 milligrams every eight (8) hours but there was no documentation regarding the increase or the indication. They stated the Behavior Modifying Agent and Review Committee (BMARC) documentation could be stronger. During a telephone interview on 08/08/2025 at 11:08 AM, the Pharmacy Consultant stated they could not locate any documented evidence and indication for the increase in the resident's Xanax dose. They stated they expected there to be documentation in the medical record for the clinical indication for increasing a psychotropic medication along with expected outcomes and goals for the resident. During a telephone interview on 08/07/2025 at 3:11 PM, Nurse Practitioner #1 stated on 01/30/25 they signed Resident #157's order for Xanax 0.5 milligrams every eight (8) hours. They stated they signed resident's medication orders via an application on their cellular phone and would only question a medication order if it was an odd dosage. Nurse Practitioner #1 stated they did not give a verbal order to increase the Xanax dose. The nurse that imputed the medication order into the electronic medical record transcribed the order inaccurately. After review of their progress notes, Nurse Practitioner stated they documented Resident #157 was receiving Xanax 0.25 milligrams every eight (8) hours. They stated their progress notes were not inaccurate for Resident #157 Xanax dosage rather Resident #157's order for Xanax 0.5 milligrams every eight (8) hours was the error, and the resident continued to receive the 0.5 milligram dose. During an interview on 08/07/25 at 3:35 PM, Registered Nurse #9 Unit Manager stated on 1/30/2025 they input an order for Resident #157 to have Xanax 0.5 milligrams every eight (8) hours. They stated Resident #157's Xanax was due for a 30-day narcotic reorder and they transcribed the order inaccurately. The order should have been Xanax 0.25 milligrams not 0.5 milligrams every eight (8) hours. Registered Nurse #9 stated they did not receive a verbal order or recommendation from the medical provider to increase the Xanax dosage. During an interview on 08/08/2025 at 9:20 AM, Registered Nurse #9, stated they could not locate any documented evidence or indication for the need to increase the Xanax dose. They also stated they were unsure why the Behavior Modifying Agent and Review Committee (BMARC) did not note the medication was increased during their review. During an interview on 08/07/2025 at 3:41 PM after review of Physician Assistant #2's progress notes, the Director of Nursing stated there was some confusion in the providers documentation and they would expect that all documentation be accurate. During an interview on 08/07/2025 at 4:12 PM, Registered Nurse #10 stated they were familiar with Resident #157, and the resident does not display any behaviors. During an interview on 08/07/2025 at 4:16 PM, Certified Nurse Aide #8 stated they were familiar with Resident #157 and was often responsible for their care. They stated Resident #157 did not display any signs of increased anxiety except when they needed to use the bathroom. Certified Nurse Aide #8 stated the resident would settle after they were assisted to the bathroom and then ask to use the bathroom again about 25 minutes later. They stated Resident #157 did not have any aggression or behaviors that disturbed others. During an interview on 08/07/2025 at 4:22 PM, the Director of Nursing stated they could not locate any evidence regarding an indication for the increase in the resident's Xanax dose. They would expect to see evidence (behaviors) documented in progress notes to support the need. The Director of Nursing stated Resident #157 was taking the incorrect dosage. 10 NYCRR 415.4(a)(1)

Based on observation, interview, and record review conducted during the Standard survey completed on 08/08/2025, the facility did not ensure that residents who had a catheter (tube inserted into the bladder) received the appropriate care and services for one (1) (Resident #113) of three (3) residents reviewed. Specifically, infection control practices were not maintained, and they were not provided with a urinary leg bag as they preferred and per facility practices. The finding is: Review of the policy titled Bladder Indwelling Urethral Catheter Site and Equipment Care dated 2/2024 documented drainage bag holders were available for all residents with Foley catheters. They were to be used if the resident does not use a leg bag. The Foley bag and tubing were placed inside the bag. Never let the tubing hang below the bag. Resident #113 had diagnoses including urinary tract infection, benign prostatic hypertrophy (enlarged prostate gland), and neuromuscular dysfunction of the bladder (a condition where the bladder does not empty urine). The Minimum Data Set (a resident assessment tool) dated 06/19/2025 documented Resident #113 was understood, understands and was cognitively intact. There were no refusals of care documented. The comprehensive care plan dated 6/13/25 documented Resident #113 had an indwelling catheter. Interventions included position the catheter bag and tubing below the level of the bladder and away from the entrance room door, check tubing for kinks, monitor and document intake and output as per facility policy. They care plan did not address the use of a leg bag when out of bed. Review of the Kardex (a guide used by staff to provide care) dated 08/04/2025 documented Resident #113 had a catheter, position the catheter bag and tubing below the level of the bladder and away from the entrance room door. The Kardex documented Resident #113 walked with a left hemi-walker, with a moderate assist of one (1) staff member for 85 feet. They care plan did not address the use of a leg bag when out of bed. Review of the nursing progress notes dated 07/01/2025 through 08/07/2025 lacked documented evidence that Resident #113 had refused a leg bag. Review of Nurse Practitioner #1's progress note dated 06/18/2025 documented Resident #113's chief complaint was urinary retention, and an infectious work up was ordered. The urinalysis appeared positive, and Resident #113 was diagnosed with a urinary tract infection.During an observation on 08/05/2025 at 7:50 AM, Resident #113 was lying flat in bed sleeping. The gravity drainage bag was in a blue privacy bag hanging on the door side of the bedframe. There was four (4) inches of catheter drainage tubing touching the floor next to the bed. During an observation and interview on 8/05/25 at 9:04 AM, Resident #113 was sitting up in bed with a gravity drainage bag in a blue privacy bag hanging on the bedframe. Resident #113 stated they preferred to have a leg bag on and always wore one when they were at home, but they rarely wore one at the facility. They stated the only time the staff would change their gravity drainage bag to a leg bag was when they would go out to appointments. Resident #113 stated at one point they asked the staff for a leg bag and was told a reason why they could not have one. They stated they did not remember the reason but remembered that they did not understand it. They preferred to wear a leg bag during therapy because they were afraid the catheter drainage tubing would get caught while they were walking and would cause the catheter to get ripped out of them.During an observation and interview on 08/06/25 at 12:38 PM, Resident #113 was sitting up in their wheelchair. There was a gravity drainage bag inside of a blue privacy bag that was attached underneath the wheelchair. There was 16 (inches) of catheter drainage tubing underneath the wheelchair touching the floor and Resident #113 had both of their feet on the tubing. Resident #113 stated they were never offered a leg bag in the morning, and they were not sure why they were not offered one.During an interview on 8/6/25 at 12:41 PM, Certified Nurse Aide #2 stated the catheter drainage tubing was on the floor and it should not have been like that. It should have been stuffed in the privacy bag under the chair because that was an infection control risk. During an interview on 8/7/25 at 10:44 AM, Certified Nurse Aide #4 stated usually any resident who had a foley catheter and that walks should have had a leg bag. It was the responsibility of either the certified nurse aide or the nurse to change the gravity bag to a leg bag. They stated they have seen catheter drainage tubing on the floor, and it should never have touched the floor because that was infection control. The certified nurse aides were responsible for making sure the catheter drainage tubing was in the privacy bag and off the floor. During an interview on 08/07/2025 at 10:50 AM, Certified Nurse Aide #5 stated they think that the certified nurse aides sometimes put a leg bag on Resident #113 but sometimes they do not put it on them. They stated sometimes therapy will get Resident #113 up out of bed without putting the leg bag on them. If any resident with a catheter had the ability to walk, then the staff were supposed to put a leg bag on them. It was just something that they were trained to do and something that all new staff were trained to do. They stated they have seen the catheter drainage tubing on the floor before, but it should never touch the floor because it was an infection control problem. During an interview on 08/07/2025 at 11:05 AM, Licensed Practical Nurse #5 stated any resident with a foley catheter should have a leg bag when they were out of bed. It was just what certified nurse aides were trained to because then the residents have more freedom of movement. Licensed Practical Nurse #5 stated the catheter drainage tubing should not touch the floor and should have been in the privacy bag for sanitation purposes. During an interview on 08/07/2025 at 11:35 AM, Certified Nurse Aide #3 stated they were assigned Resident #113 on 08/06/2025 but someone in therapy got them up and took them to therapy in the morning. They stated that as the certified nurse aide responsible for Resident #113, they should have double checked that a leg bag was put on instead of the gravity bag. They stated that it was important to switch Resident #113 to the leg bag because then it would be safely secured when Resident #113 walks around. Certified Nurse Aide #3 stated when Resident #113 had a gravity bag, the catheter drainage tubing should not have been on the floor because of infection control. Everyone on the unit including nurses and certified nurse aides were responsible for making sure the drainage tubing was not touching the floor. During an interview on 08/07/2025 at 11:40 AM, Licensed Practical Nurse #6 Unit Manager stated any resident who had a foley catheter and ambulated (walked) should have a leg bag because it would be easier for them. They stated that the certified nurse aides should read the care plan and if the resident had a foley catheter and ambulated, then a leg bag should have been placed. They stated Resident #113 would refuse their leg bag. Licensed Practical Nurse #6 Unit Manager stated when using the gravity drainage bag, the tubing should have never touched the floor because that was infection control. They stated Resident #113 had a urinary analysis in June 2025 and it was positive for a urinary tract infection. They stated that it was a group effort on the unit including certified nurse aides and nurses to make sure the catheter drainage tubing was not touching the floor. During an interview on 08/07/2025 at 12:04 PM, Physician Assistant #1 Physiatrist stated their job was to evaluate any barriers a resident might have prevented them from full participation in therapy. They stated that residents with foley catheters should have a leg bag during therapy because the tubing and gravity bag could interfere with their ability to fully participate in therapy. During a telephone interview on 08/07/2025 at 2:49 PM, Nurse Practitioner #1 stated the catheter drainage tubing should never be on the floor because of migrating bacteria, increasing the risk for infection. They stated Resident #113 had a history of urinary tract infections with the most recent one being in June. During an interview on 08/07/2025 at 3:00 PM, Physical Therapist #1 stated it varied if Resident #113 had a leg bag on during therapy sessions. They stated Resident #113 was not wearing a leg bag the week prior because their genital region had irritation. During an interview on 08/08/2025 at 8:34 AM, the Director of Nursing/Infection Preventionist stated it was the expectation that residents with foley catheters who attended therapy or walked to be provided a leg bag. When they were doing any walking, it was for their dignity and so they did not accidentally trip over the tubing. They stated even though it was not necessarily care planned to provide a leg bag, it was something that all staff were taught to do when they were hired. The certified nurse aides were responsible for switching a resident to a leg bag. If a resident refused a leg bag, then it would be expected that it was documented in a nursing note. The stated that Resident #113 had some genital erosion at the foley catheter insertion site but the staff on the unit were never told to stop providing a leg bag. The Director of Nursing/Infection Preventionist stated the catheter drainage tubing should have never touched the floor because it was an infection control issue. The certified nurse aide should have put the drainage bag and tubing into the privacy bag. They stated that Resident #113 would move around in bed quite a bit, but the expectation was that the staff anticipate them moving around and check to make sure the drainage tubing and bag were still in the privacy bag. They stated both certified nurse aides and nurses were responsible for making sure the catheter drainage tubing and bag were off the floor. 10 NYCRR 415.12(d)(1)

Based on observation, interview, and record review conducted during the Standard survey completed on 8/8/25, the facility did not ensure parenteral fluids were administered with professional standards of practice and in accordance with the physicians' orders, and the comprehensive person-centered care plan for one (1) (Resident #174) of one (1) resident reviewed for intravenous (IV) therapy. Specifically, there was a delay in the administration of intravenous (IV) antibiotics per the final hospital discharge summary, and a lack of orders to address central venous catheter (a long thin tube inserted into a large vein to provide long term access for medication, fluids, or blood draws; right internal jugular vein) maintenance and care (normal saline flushes and dressing changes). The finding is:The policy titled Central Venous Catheter Flush/SAS (saline, antibiotic, saline), last revised 5/2019 documented the Registered Nurse may flush venous catheters as ordered by the physician to prevent the clotting of blood within the catheter. The Registered Nurse must verify patient, cleanse port with alcohol, administer 10 cubic centimeters (ccs) of saline, infuse medication, cleanse port with alcohol, flush port with 10 cubic centimeters normal saline, then document. The policy did not address central venous catheter dressing changes. The policy titled Intravenous Antibiotic Administration, last revised 1/2020 documented intravenous antibiotics were utilized to achieve a constant, rapid, high blood level of drug therapy in the treatment of serious infection or infection that does not respond to antibiotics given but the oral or intramuscular route. Residents who required intravenous antibiotics would be provided those services. The policy titled admission procedure, last revised 10/2024, documented a nursing evaluation was completed on all new residents and readmission, information about resident admission was communicated in a timely manner to the appropriate departments. A skin check was completed by the team leader and reviewed by the Nursing Supervisor. The initial admission form was completed by the nurse. The Unit Manager/Desk Nurse/nurse transcribed the orders according to the approved transcription standard of care from preliminary/final discharge documents from hospital/facility or from the physician if entering from home. To secure additional information, the nurse shared the resident care plan with the incoming nurse, and they discuss information that must be gathered during the evening and night shifts. To assure continuity, the nurse manager or designee reviewed the resident care plan and served as coordinator of the plan.Resident #174 had diagnoses including diabetes mellitus, endocarditis (inflammation of heart valve), and cellulitis (bacterial skin infection). The comprehensive care plan dated 8/1/25 documented Resident #174 was cognitively intact and able to make their needs known. A focus area initiated on 8/5/25 documented Resident #174 was on intravenous medications related to endocarditis/bacteremia (presence of bacteria in the bloodstream).The Visual/Bedside Kardex (guide used by staff to provide care) dated 8/7/25 documented Resident #174 required touch assist of one (1) staff member for dressing, transferring, and bed mobility.The hospital final discharge summary report dated 8/1/25 documented Resident #174 was to receive ceftriaxone (antibiotic) 2 (two) grams intravenously once a day per their infectious disease consult and cardiology recommended outpatient TAVR (transcatheter aortic valve replacement) and [NAME] (device used for patients who could not tolerate blood thinners) after completion of Resident #174's intravenous antibiotics (8/18/25). Review of the active physician orders dated 8/1/25 revealed there were no orders to address central venous catheter maintenance and care to include but not limited to normal saline flushes and dressing changes; and there were no physician orders for the administration of intravenous (IV) antibiotics.Review of medication administration record dated 8/1/25 to 8/8/25 revealed orders initiated on 8/3/25 during the overnight shift (11:00 PM to 7:00 AM) to flush Resident #174's central line every shift with 10 (ten) cubic centimeters of normal saline and measure length of external catheter line and record every shift. Additional orders dated 8/4/25 were initiated to flush Resident #174s central line with 5 (five) cubic centimeters of normal saline, administer ceftriaxone (antibiotic medication) 2 gram intravenously one time a day for endocarditis until 8/20/25, then flush with 5 cubic centimeters of normal saline and to change extension tubing, clave (needleless connector), endcap (antiseptic barrier), and dressing every week. Review of undated initial admission skin check revealed Resident #174's had a central Resident #174's located in their right upper chest.Review of a provider progress note dated 8/4/25 at 1:16 PM revealed Nurse Practitioner #1 documented that Infectious Disease was consulted while Resident #174 was in the hospital and the resident was ordered Rocephin (ceftriaxone-antibiotic) 2 gram intravenous daily. Review of the facility identified 24-Hour Report sheets dated 8/1/25 to 8/4/25 revealed there was no documented evidence that Resident #174 had a central venous catheter, received maintenance flushes to central venous catheter, and they received intravenous antibiotic medication.During an observation and interview on 8/5/25 at 9:00 AM, Resident #174 was sitting in their wheelchair shirtless. A central venous catheter was observed in their right upper chest with a dressing dated 8/4/25. Resident #174 stated their central venous catheter had not been flushed for two days after their arrival, and they did not receive their intravenous antibiotic until 8/4/25. Resident #174 stated they gave the facility staff a large packet of discharge paperwork when they arrived and was unsure why staff had not provided the intravenous (IV) antibiotic. Resident #174 stated they needed to finish the course of the intravenous antibiotic to clear up the infection before they could have a heart valve replacement. Resident #174 added their family had questioned why they had not received the intravenous antibiotic the first two days of admission and questioned a nursing supervisor. During an interview on 8/6/25 at 9:45 AM, Registered Nurse #2 Unit Manager stated when a new admission entered the facility, their medication list was reviewed by the Desk Nurse or Nursing Supervisor, the team leader/Licensed Practical Nurse completed the admission paperwork and skin check, the Nursing Supervisor reviewed the admission paperwork, and all documents were filed away for them (Unit Manager) to review the next day. Registered Nurse #2 Unit Manager reviewed Resident #174's active medications and stated Registered Nurse #3 activated the orders upon admission. At this time, Registered Nurse #5 Desk Nurse walked over and stated they put Resident #174's medications into the system based on the preliminary report sent to them which did not have ceftriaxone (antibiotic) listed as a discharge medication, but did not activate them because they left at 4:00 PM on 8/1/25 and Resident #174 had not admitted to the facility yet. Registered Nurse #2 Unit Manager stated Registered Nurse #3 Nursing Supervisor activated Resident #174's medications that were entered by Registered Nurse #5; Licensed Practical Nurse #2 completed the paperwork and skin check portion, but they were unsure who reviewed the official discharge summary from the hospital. They stated the discharge paperwork should have been reviewed by the overnight Nursing Supervisor. Additionally Registered Nurse #2 stated they reviewed the discharge paperwork on 8/5/25 when they returned to the facility and noted Resident #174 had a central venous catheter, so whoever reviewed the discharge paperwork should have questioned why they had a central venous catheter but did not have any orders to flush the line. Registered Nurse #2 stated the preliminary discharge summary did document that Resident #174 was to be on intravenous antibiotics until 8/18/25, so they also should have questioned why there was no order for intravenous antibiotics. During an interview on 8/6/25 at 11:30 AM, Registered Nurse #3 Nursing Supervisor stated on 8/1/25 they activated orders that were entered by Registered Nurse #5 prior to the resident arriving as they were just trying to help out before they left. Registered Nurse #3 Nursing Supervisor stated they did not personally look at the discharge summary, they assumed they were all good. They left at 6:30 PM and the overnight Supervisor was in charge of completing the admission. Registered Nurse #3 stated whoever reviewed the paperwork and discharge summary should have questioned why there were no orders for the central venous catheter care or intravenous antibiotics. During an interview on 8/6/25 at 11:52 AM, the Director of Nursing stated prior to a new admission coming to the facility they receive a preliminary report that the Desk Nurse reviewed. The Director of Nursing stated Resident #174's preliminary report did not have their central venous catheter and intravenous antibiotic medication listed. Registered Nurse #6 Nursing Supervisor worked on 8/3/25 and discovered the discrepancy that triggered them to do a deep dive into Resident #174's hospital stay, and that was when it was discovered Resident #174 should have been on intravenous antibiotics and had a central venous catheter. The Director of Nursing stated they would have expected one of the Nursing Supervisors working on 8/1/25 overnight to have reviewed the whole packet the hospital provided including the final hospital discharge summary and realized the discrepancies sooner. The Director of Nursing stated maintenance flushes were missed and the line could have occluded. The Director of Nursing stated there were three (3) overnight Nursing Supervisors that worked on 8/1/25, but they were unsure who took part in what during the shift.During a telephone interview on 8/6/25 at 3:04 PM, Licensed Practical Nurse #2 stated they worked from 6:00 PM on 8/1/25 to 7:00 AM on 8/2/25 but did not review Resident #174's discharge summary, they were not in charge of admissions that night.A call was placed and message left on 8/6/25 at 2:28 PM for Registered Nurse #7 Nursing Supervisor with no return call. (Nursing Supervisor on 8/1/25 from 6:30 PM to 7:00 AM). During an interview on 8/6/25 at 3:04 PM, Licensed Practical Nurse #4 stated they completed the admission paperwork and skin check for Resident #174 and documented the resident had a right upper chest central venous catheter on the skin assessment form. Licensed Practical Nurse #4 stated they left at 6:30 PM on 8/1/25 and reported to the oncoming nurse, Registered Nurse #4, that Resident #174 had a central venous catheter, and Resident #174 had mentioned being on intravenous antibiotics. During a telephone interview on 8/6/24 at 3:44 PM, Registered Nurse #8 Nursing Supervisor stated they worked on 8/1/25 from 4:00 PM to 8:00 PM but had not participated in any of the new admissions on that day. Registered Nurse #8 stated they arrived to work on 8/4/25 at 4:00 PM and Resident #174's family member was questioning why the intravenous antibiotics had not been administered. Resident #174's intravenous antibiotic medication had just been delivered so they informed Resident #174s family member and bought the medication to the unit. Registered Nurse #8 stated it was the responsibility of the overnight Nursing Supervisor to review all new admission paperwork and hospital discharge summaries if the desk nurse was no longer available and make sure any discrepancies were corrected. During a telephone interview on 8/7/25 at 8:15 AM, Registered Nurse #4 stated they worked on 8/1/25 at 6:30 PM and received report from Licensed Practical Nurse #4 that the admission assessment was completed for Resident #174, and they had a central venous catheter in their right upper chest. Registered Nurse #4 stated they did not question at the time why orders never popped up for them to flush the central venous catheter and they should have. Typically, the computer would flag the nurse to flush central lines as they are flushed with normal saline every shift for maintenance. During an interview on 8/7/25 at 9:13 AM, Pharmacy Consultant stated they completed the medication reconciliation for Resident #174 on 8/3/25 based on the preliminary discharge summary uploaded into Resident #174's electronic medical record. Pharmacy Consultant stated Resident #174 was on an oral antibiotic for cellulitis but missed two days of their intravenous antibiotics and saline flushes. Pharmacy Consultant stated Resident #174's central line could have become occluded. During a telephone interview on 8/7/25 at 2:44 PM, Nurse Practitioner #1 stated they reviewed Resident #174's uploaded discharge summary and reviewed medications listed. They saw further down in discharge summary that intravenous antibiotic medications were to be continued and questioned why there were no orders for the medication. Nurse Practitioner #1 stated they would have expected whoever completed Resident #174's admission to review the final discharge summary report, question the discrepancies, and correct the issue. Nurse Practitioner #1 stated they were unaware Resident #174 did not have orders to flush their central line and had missed flushes for two and a half days. They stated they would have expected the nurse to question why there was a central venous catheter present but no orders for maintenance; the line could have occluded and would have needed to be replaced. During an interview on 8/8/25 at 9:31 AM, the Administrator stated the facilities admission process had changed last year to involve all new admissions having two admission packets to ensure everyone received a copy of the discharge paperwork that needed one. The Administrator stated they would have to change the process slightly to include final reports and make sure staff were not utilizing the preliminary reports provided prior to admission.During an interview on 8/8/25 at 11:38 AM, Licensed Practical Nurse #4 stated they were the Nursing Supervisor on 8/4/25 and they had initiated maintenance orders for Resident #174's central venous catheter because it needed to be flushed with normal saline every shift to avoid occlusion. 10 NYCRR 415.12 (k)(2)

Based on interview and record review conducted during a Standard survey completed on 08/08/2025, the facility did not ensure the Binding Arbitration Agreement explicitly granted the resident and their representative the right to rescind the agreement within 30 calendar days of signing the agreement for three (3) (Resident #104, #118 and #152) of three (3) resident reviewed for the arbitration task. Specifically, the facility's Binding Arbitration Agreement stated the resident/representatives had seven (7) calendar days to rescind the agreement. The findings are:Review of the facility's undated Arbitration Agreement documented, the parties understand and agree that upon execution, this Arbitration Agreement becomes part of the admission Agreement. Section eleven of the agreement documented the parties understand and agree that the resident may cancel the Arbitration Agreement within seven (7) days of its execution by written notice to the facility. 1. Resident #104 had diagnoses that included fracture of the hip, hypertension and depression. The Minimum Data Set, dated [DATE] documented Resident #104 was cognitively intact.Review of the Arbitration Agreement dated 10/03/2024 documented Resident #104 signed the agreement on 10/03/2024. The agreement stated the resident may cancel the Arbitration Agreement within seven (7) days. 2. Resident #118 had diagnoses that included hypertension, atrial fibrillation and depression. The Minimum Data Set, dated [DATE] documented Resident #118 was cognitively intact.Review of the Arbitration Agreement dated 06/26/2025 documented Resident #118 signed the agreement on 06/26/2025. The agreement stated the resident may cancel the Arbitration Agreement within seven (7) days. 3. Resident #152 had diagnoses that included heart failure, hypertension and atrial fibrillation. The Minimum Data Set, dated [DATE] documented Resident #152 was cognitively intact.Review of the Arbitration Agreement dated 05/21/2025 documented Resident #152's Power of Attorney signed the agreement on 05/21/2025. The agreement stated the resident may cancel the Arbitration Agreement within seven (7) days.During an interview on 08/08/2025 at 10:43 AM, the Director of Admissions stated they were responsible to explain the admission package including the Arbitration Agreement to the residents and/or their designated representatives upon their admission to the facility. They stated the residents and/or their representatives signed the Arbitration Agreement separately from other parts of admission package. The Director of Admissions stated they would explain the agreement, read the resident/representative the agreement and offer for the resident/representative a video to watch about Arbitration Agreements. The Director of Admissions stated they would explain to the resident/representative they had seven days to rescind the agreement if they chose to. The Director of Admissions stated they had worked at facility for a year and a half, and the [NAME] President of Business Development had trained them on Arbitration Agreements. The Director of Admissions stated they were unaware of the regulation that a resident should be granted 30-days to rescind their signed Arbitration Agreement. During an interview on 08/08/2025 at 10:39 AM, the Administrator stated Arbitration Agreements were handled by the Director of Admissions and the [NAME] President of Business Development. After review of the facilities Arbitration Agreement, the Administrator stated per the agreement a resident/representative had seven (7) days to rescind the agreement. They stated they were unaware of regulations regarding the length of time a resident had to rescind the agreement. The Administrator stated the facility's legal team along with the [NAME] President of Business Development were responsible for drafting the agreement. The Administrator further stated the facility did not have a policy for Arbitration Agreements and the Arbitration Agreement itself would be the policy. During a telephone interview on 08/08/2025 at 11:23 AM, the [NAME] President of Business Development stated they would support the admission Department as needed with Arbitration Agreements. They stated the facility's legal team developed the Arbitration Agreement as well as the facility's admission paperwork. They stated the facility was also provided education about Arbitration Agreements by the Coordinator of Education from the facility's legal team in August of 2024. The [NAME] President of Business Development stated, at the advice of the facility's legal team, the facility would use two different Arbitration Agreements. They stated that if a resident was a short-term rehabilitation resident they were provided the Arbitration Agreement where they would only be given seven days to rescind the letter and if the resident was admitted for long term care, they would be provided an agreement where they would have 30 days to rescind the agreement. The [NAME] President of Business Development stated they were not aware the federal regulation was all residents were required to be given 30 days to rescind the agreement and would have to look into the regulation.10 NYCRR 415.30

Based on observation, interview, and record review conducted during a Standard survey completed on 12/18/23, the facility did not ensure the resident's right to personal privacy during medical treatments for one (Resident #62) of one resident reviewed. Specifically, the Podiatrist completed Resident #62's exam and treatment in a common area in the presence of other residents. The finding is: The policy and procedure titled Residents' Rights revised 11/2014 documented the facility respects residents' rights in providing care. All residents are afforded their right to a dignified existence, self-determination, respect, full recognition of their individuality, consideration and privacy in treatment and personal care for personal needs and communications with and access to persons and services inside and outside of the facility. The facility shall protect and promote the rights of each resident and shall encourage and assist each resident in the fullest exercise of these rights. The policy and procedure titled Podiatry dated 2/2019 documented all podiatry treatments are rendered in the resident's room (unless otherwise arranged for specific reason). Resident #62 had diagnoses including dementia, hypertension, and depression. The Minimum Data Set - (a resident assessment tool) dated 9/29/23 documented Resident #62 had moderate cognitive impairments, was understood, and understands. The Minimum Data Set documented no behaviors. The Certified Nursing Assistant Care Guide (guide used by staff to provide care) dated 12/18/23 documented Resident #62 was a one assist with a rolling walker for ambulation and transfers. The Comprehensive Care Plan revised 8/1/23 documented Resident #62 required podiatry visits as needed for long thick nails. The podiatry schedule documented Resident #62 had nailcare services on 12/15/23. During an observation on 12/15/23 at 9:48 AM in the D Wing Team 2 common area with other residents present, the Podiatrist knelt on one knee next to Resident #62's recliner, placed a barrier pad on the floor, removed Resident #62's socks and filed the bottom of Resident #62's feet over the barrier pad. The Podiatrist then clipped Resident #62's toenails on both feet and then replaced the socks on Resident #62's feet. The Podiatry Progress Note dated 12/15/23 documented Resident #62 was seen and examined for podiatry services. Aseptic debridement was performed for hypertrophic (thick), dystrophic (discolored, thickened, deformed), and trimmed all toenails without complications. During a telephone interview on 12/15/23 at 3:49 PM, the Podiatrist stated they filed Resident #62's feet and clipped their toenails while seated in a recliner in the D wing common area. The Podiatrist stated they did not take Resident #62 back to their room or request assistance from the nursing staff as it would have been a hassle due to their behavior. The Podiatrist stated they treated Resident #62 without providing privacy and stated, It was easier to cut the nails while Resident #62 was in the recliner, than to not have cut them at all. During an interview on 12/18/23 at 9:58 AM, Licensed Practical Nurse #11, Unit Coordinator stated they saw the Podiatrist just as they were finishing Resident #62 treatment on 12/15/23. Licensed Practical Nurse #11, Unit Coordinator stated cutting nails was personal care that should be done behind closed doors for privacy and dignity. Not everyone wants to see feet being worked on, in their living room. Cutting nails should be done in private, and was disrespectful to the resident. During an interview on 12/18/23 at 12:14 PM, the Director of Nursing stated, completing nail care in the common areas on the units was unacceptable. The Podiatrist should have brought the resident back to their room, or had staff do it, to provide privacy to the resident. 10NYCRR 415.3 (d) (1)(ii)

Based on observation, interview, and record review conducted during a Complaint investigation (Complaint #NY00324906) completed during the Standard survey on 12/18/23, the facility did not ensure the resident's right to be free from verbal abuse and neglect for one (Resident #134) of four residents reviewed. Specifically, on 9/26/23 Resident #134 reported Certified Nursing Assistant #11 yelled, swore at them, took their call light away and threw it at the wall. The finding is: The policy and procedure titled Resident Abuse: Investigation and Reporting dated 1/23, documented it is the facility's policy to prohibit and assure the residents' rights to be free from verbal abuse, physical abuse, sexual abuse, neglect, exploitation, mistreatment, and misappropriation of resident property. The policy and procedure documented that verbal abuse is defined as the use of language that willfully includes disparaging and derogatory terms to the resident. The policy and procedure documented that neglect is defined as is failure of employees to provide goods and services to a resident necessary to avoid harm, pain, mental anguish, or emotional distress. Resident #134 had diagnoses including cerebral infarction with hemiplegia (weakness) and language deficits, gastrointestinal hemorrhage, and difficulty walking. The Minimum Data Set (a resident assessment tool) dated 9/4/23 documented Resident #134 had intact cognition, was understood, and understands. The comprehensive care plan dated 9/18/23 documented Resident #134 required assistance with activities of daily living related to cerebral vascular accident (CVA, stroke). Interventions included that Resident #134 was non ambulatory, an extensive assist of one staff member for bed mobility and an extensive assist of two staff members with a platform walker for transfers. Review of the untitled facility investigation provided by and signed by the Administrator documented that on 9/26/23 while Physical Therapist #3 was working with Resident #134 a report was made of potential verbal abuse. It was reported that a Certified Nursing Assistant was rough, used vulgar language and threw items at the wall in Resident #134 room over the weekend. The investigation documented that interview with Resident #134 revealed the item that was thrown was a call bell and the call bell logs were reviewed. The investigation documented that review of the call light logs on 9/23/23 revealed no call bell was used for the 11:00 PM to 7:00 AM shift and on 9/24/23 limited call bell use for the 11:00 PM - 7:00 AM. The investigation documented the conclusion was the complaint was substantiated based on identifiers provided by Resident #134 and limited call bell use on the dates of 9/23/23 and 9/24/23. Review of an employee statement dated 9/26/23 signed by Physical Therapist #3 revealed that while asking Resident #134 during a therapy treatment how they were doing using the platform walker the resident stated the staff do not have patience for them. The employee statement documented that Resident #134 stated a Certified Nursing Assistant yelled, God damn it and hurry the hell up during care. The statement documented that Resident #134 stated that a staff member was rough and threw things at their wall. Review of an employee statement dated 9/26/23 signed by the Director of Social Work and Registered Nurse #5 documented that Resident #134 stated that a Certified Nursing Assistant that was caring for them treated them like dirt, swore at them, grabbed the call bell from them and threw it against the wall. The statement documented that the resident did not want to say anything, was afraid and that the Certified Nursing Assistant would be able to find out where Resident #134 lived. The statement documented that Resident #134 stated the situation occurred probably on Sunday night. Review of an email dated 9/29/23 at 1:14 PM sent to the Director of Nursing received from Certified Nursing Assistant #11 documented that Certified Nursing Assistant #11 statement was that they were unaware of anything out of the ordinary as far as my care for residents on the nights on 9/23/23 and 9/24/23 for rooms 123-130. Review of the call light log for Resident #134 revealed on: -9/23/23 from 8:47 PM until 9/24/23 at 7:45 AM the call bell was not activated. -9/25/23 from 1:28 AM until 6:51 AM the call bell was not activated. Review of the untitled Unit A Certified Nursing Assistant room assignment sheets Certified Nursing Assistant #11 was assigned to Resident #134 on 9/23/23 and 9/24/23 for the 11:00 PM-7:00 AM shift. During an interview on 12/13/23 at 9:33 AM, Resident #134 stated that they felt they were in an abusive situation with a Certified Nursing Assistant. Resident #134 stated that while they were getting into bed at night a Certified Nursing Assistant was rough with them, took their call bell away and threw it at the wall. Resident #134 stated they were concerned the staff member was abusive to other residents. During an interview on 12/15/23 at 11:52 AM, Resident #134's Health Care Proxy stated Resident #134 informed them of a Certified Nursing Assistant lost their patience with Resident #134 while caring for them. Resident #134 Health Care Proxy stated that Resident #134 was upset and irritated because a Certified Nursing Assistant took their call bell away, threw it at the wall and did not want to care for them. Resident #134's Health Care Proxy stated they felt the situation was abusive because of the vulnerability of Resident #134. During a telephone interview on 12/15/23 at 1:47 PM, Certified Nursing Assistant #11 stated that they worked A unit team #3 on 9/23/23 into 9/24/23 and 9/24/23 into 9/25/23. Certified Nursing Assistant #11 stated that they were angry that they had team #3 two days in a row because team #3 care that was required was heavy. During an interview on 12/15/23 at 1:18 PM, the Director of Social Work stated that Resident #134 was afraid, and that Resident #134 thought the staff member would find out where they lived and harm them. The Director of Social Work stated that per Resident #134 interview, neglect and verbal abuse occurred and that all residents have the right to remain free from abuse. During an interview on 12/18/23 at 8:45 AM, Physical Therapist #3 stated that during a therapy treatment on 9/26/23 they asked Resident #134 how they were doing transitioning to the platform walker. Physical Therapist #3 stated that Resident #134 reported that the night before a Certified Nursing Assistant did not have patience with them, yelled at them to hurry the hell up and threw items at the wall. Physical Therapist #3 stated that Resident #134 reported that they were afraid to tell anyone, and they appeared to be uncomfortable with the situation. Physical Therapist #3 stated they told Register Nurse #5 immediately because they consider the situation an allegation of abuse and that all residents should be safe from abuse. During an interview on 12/18/23 at 8:58 AM, Register Nurse #5 (Unit manager of A wing) stated they reported the situation to the Director of Nursing and the Administrator. Register Nurse #5 stated that removing the call light from Resident #134 was neglect because they could not call for help when needed and swearing at Resident #134 was a form of verbal abuse. During an interview on 12/18/23 at 10:34 AM, the Director of Nursing stated that their conclusion to their investigation was that abuse occurred and that every resident has a right to remain free from abuse, neglect, and mistreatment. During an interview on 12/18/23 at 12:54 PM, the Administrator stated their conclusion was neglect and verbal abuse occurred based on review of the call bell log report, Resident #134's statement and a second statement given from a different resident. 10 NYCRR 415.4 (b)(1)(ii)

Based on observation, interview, and record review conducted during a Complaint investigation (Complaint #NY00325623) during the Standard survey completed on 12/18/23, the facility did not ensure that all residents were free from physical restraints for the purpose of discipline or convenience, and that are not required to treat the resident's medical symptoms for one (Resident #113) of one resident reviewed for physical restraints. Specifically, on 10/8/23 a wet floor sign was placed behind the rear wheels of Resident #113's wheelchair to prevent them from moving freely. The finding is: The policy and procedure titled Restraints dated 10/2022 documented the facility creates and maintains an environment that fosters minimal use of restraints. A physical restraint is any manual method of physical/mechanical devices, material or equipment attached or adjacent to the resident's body that the resident cannot remove easily, which restricts freedom of movement or normal access to one's body. Physical restraints will not be ordered or used: for staff convenience; for purpose of discipline or as a substitute for direct care, activities, and other services. Resident #113 had diagnoses which included cognitive communication deficit, unspecified dementia, and neuromuscular dysfunction of bladder (nerves and muscles of bladder don't work well together). The Minimum Data Set (a resident assessment tool) dated 9/28/23 documented Resident #113 understood, understands, had moderate cognitive impairment and displayed physical and verbal behaviors 4 to 6 days. The Minimum Data Set documented physical restraints weren't used. The comprehensive care plan revised on 9/25/23, documented Resident #113 had the potential for a communication problem related to diagnosis of cognitive communication deficit. Interventions included to anticipate and meet their needs, allow adequate time to respond, do not rush, request clarification from the resident to ensure understanding, use simple, brief, consistent words/cues. Additionally, Resident #113 had was at risk for falls related to confusion and generalized muscle weakness. Interventions included to offer the recliner when in the common area, physical therapy to evaluate and treat as ordered or as needed. The comprehensive care plan did not document the use of restraints. Review of an email dated 10/9/23 at 12:09 PM sent by the Administrator documented Nursing Home Facility Incident Report Successfully Submitted. Per Dietary Aides #1 and #2, Resident #113 was present in the dining room for breakfast on 10/8. Resident #113 attempted to leave the dining room several times, staff members were able to bring Resident #113 back to the room. Unknown staff members placed a collapsible wet floor sign behind Resident #113's wheelchair to block their exit from the dining room table. Resident #113 was then unable to leave the dining room table with the signs behind their wheelchair. Recreation of the described event indicates that a wheelchair would not be able to move backward if wet floor signs were placed behind the wheels unless significant force was used to wheel over. Interviews with Dietary Aides #1 and #2 completed to identify staff members involved in activity. Staff to be educated on restraints and residents right to refuse. Review of typed phone conversation with Licensed Practical Nurse #7 dated 10/9/23 signed by the Director of Nursing, documented an incident occurred with Resident #113 in the dining room on Sunday, 10/8/23. Licensed Practical Nurse #7 stated that on 10/8/23, they were encouraging Resident #113 to eat in the dining room during breakfast. Resident #113 was given their tray and then began moving their wheelchair backwards, which ran into Licensed Practical Nurse #7's foot. Licensed Practical Nurse #7 stated they put wet floor signs under Resident #113's large wheelchair wheels to attempt to keep them at the table so they could be motivated to eat. Licensed Practical Nurse #7 stated that Resident #113 was able to roll over the signs without difficulty. Additionally, the Director of Nursing documented Licensed Practical Nurse #7 was counseled regarding resident's rights, and that placing items behind a wheelchair were considered restraints and were against policy. During several observations on 12/14/23 and 12/15/23 between 8:46 AM and 1:20 PM, Resident #113 was in their wheelchair in the dining room or in the common area. Resident #113 was not observed to self-propel their wheelchair and did not display any verbal or physical behaviors. During a telephone interview on 12/14/23 at 3:45 PM, Dietary Aide #1 stated on 10/8/23 they were getting breakfast ready at the servery in the dining room and observed Resident #113 leaving their table. Unknown nursing staff kept telling Resident #113 to stay there (at the table in the dining room). Dietary Aide #1 stated their co-worker, Dietary Aide #2, stated to them they placed a sign under Resident #113's wheels. Dietary Aide #1 stated when they turned around, they observed the sign under Resident #113's wheelchair wheels and did not see who placed it there or how long the sign was in place. Dietary Aide #1 stated they reported the incident on 10/9/23 after saying something to someone else who told them they should report the incident because it was technically abuse. Dietary Aide #1 stated they felt the situation was ridiculous and that staff should have allowed Resident #113 to leave the dining room if they didn't want to eat. Dietary Aide #1 stated at the time this occurred they didn't think it was a form of abuse, but now they know it was. During a telephone interview on 12/14/23 at 3:56 PM, Dietary Aide #2 stated they were serving residents breakfast in the dining room and heard Resident #113 state to staff that they weren't hungry as they were trying to leave the dining room. Dietary Aide #2 stated a staff member then took and placed a wet mop sign under Resident #113's rear wheelchair wheel. Dietary Aide #2 stated Resident #113 was trying to wheel over it but would get stuck on it and wasn't able to move any further. Dietary Aide #2 stated Resident #113 seemed aggravated, very upset, raising their voice trying to get staff to listen to what they were saying. Dietary Aide #2 felt this was abuse, because other residents were able to come and go but staff were preventing Resident #113 from leaving. Dietary Aide #2 stated they didn't think about reporting the incident to their supervisor and didn't know what nurse to report it to. Dietary Aide #2 stated they should have reported it right away so something could have been done sooner if possible. During a telephone interview on 12/14/23 at 4:18 PM, Licensed Practical Nurse #7 stated Resident #113 was uncooperative and wanted to leave the facility the morning of 10/8/23. Licensed Practical Nurse #7 stated that Licensed Practical Nurse #8 asked them to keep Resident #113 in the dining room. Licensed Practical Nurse #7 stated Resident #113 wasn't having it, they wanted to go, Resident #113 was upset, verbally abusive and didn't want to cooperate with staying in the dining room. Licensed Practical Nurse #7 stated approximately 15 minutes before the meal was served, Resident #113 was in and out of dining room. Licensed Practical Nurse #7 stated before Resident #113's breakfast tray came, they placed the sign behind the back wheels of Resident #113's wheelchair, as they wanted to try and keep Resident #113 in the dining room so they could keep an eye on them but wasn't successful. Licensed Practical Nurse #7 stated Resident #113 rolled over the sign, Licensed Practical Nurse #7's foot, and left the dining room. Licensed Practical Nurse #7 stated they were trying to keep Resident #113 safe and attempted to prevent Resident #113 from leaving the dining room. Licensed Practical Nurse #7 stated they wouldn't want this done to their family member because it was their right to move around freely as desired and it's their home. Licensed Practical Nurse #7 stated they received education over the phone from Director of Nursing and Administrator and understands this could be considered a restraint and that it was wrong. During a telephone interview on 12/14/23 at 4:40 PM, Licensed Practical Nurse #8 stated they weren't fully aware of what occurred with Resident #113 on 10/8/23. Licensed Practical Nurse #8 stated Resident #113 was a handful and was exit seeking that morning and asked co-worked, Licensed Practical Nurse #7, to keep an eye on Resident #113. Licensed Practical nurse #8 stated they did not witness Resident #113 being restrained by a wet floor sign. Licensed Practical Nurse #8 stated that placing a wet floor sign behind a resident's wheelchair would be considered a restraint because the resident wouldn't be able to move freely, and Resident #113 would not be able to move the wet floor sign. During an interview on 12/18/23 at 12:58 PM, the Director of Nursing stated they spoke with Licensed Practical Nurse #7 over the phone and counseled them. The Director of Nursing stated they couldn't remember the conclusion to the Facility Reported Investigation regarding Resident #113, that the Administrator completed it. The Director of Nursing stated the Licensed Practical Nurse #7 should not have placed the wet floor sign behind Resident #113's wheelchair because it was a form of a restraint. During an interview on 12/18/23 at 3:07 PM, the Administrator stated they concluded the incident with Resident #113 was unsubstantiated. The Administrator stated they recreated the scenario, and they (the Administrator) were able to roll back over a wet floor sign in a wheelchair. The Administrator stated the floor sign could have been a restraint if Resident #113 wasn't able to roll over it and if they knew Resident #113 wasn't able to move their wheelchair over the floor sign, the incident would have been substantiated as a form of abuse rising to a level of deficient practice with disciplinary action. The plan of correction was for everybody involved to be in-serviced on resident rights and restraints. The Administrator stated this was completed, however the signature sheet couldn't be found. 10 NYCRR 415.4(2)(iv)

Based on observation, interview, and record review conducted during a Standard survey completed on 12/18/23, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #15) of three residents reviewed. Specifically, Certified Nursing Assistant #8 did not provide/utilize a rolling walker during a transfer per the plan of care and the resident fell . The finding is: The policy and procedure titled Resident Accident and Incident Report and Follow up Investigation revised 6/2022 defined Accident as an unintentional or unexpected occurrence that is undesirable or unfortunate and did result in, or might have resulted in, injury, damage, harm, or loss. The facility could not provide a policy and procedure for care plan implementation. Resident #15 had diagnoses which included urinary tract infection (UTI), weakness, and hypertension (HTN, high blood pressure). The Minimum Data Set (a resident assessment tool) dated 10/16/23 documented Resident #15 had severe cognitive impairment, was understood, and understands. The Minimum Data Set documented the resident transferred with a walker and was dependent on staff for bed/chair to chair transfers. The undated closet care plan (guide used by staff to provide care) documented Resident #15 required moderate assistance from one staff member with a rolling walker for bed/chair to chair transfers. The comprehensive care plan dated 11/27/23 documented Resident #15 had a fall on 11/27/23 which resulted in an injury that included a hematoma (collection of blood under the skin) to the top of Resident #15's head. The new planned intervention included cleaning the floor of ants. During an observation and interview on 12/12/23 at 10:20 AM, Resident #15 had bilateral (both) periorbital (around the eyes) and forehead ecchymosis (bruising) and was sitting in their room in a recliner. Resident #15 stated they fell the other day, landed face first on the floor and hit the left side of their face on the walker that was in front of the dresser. The untitled facility incident report dated 11/27/23 documented a witnessed fall at 1:57 PM. Certified Nursing Assistant #8 transferred Resident #15 and during the transfer Resident #15 was staring at the ground due to ants being all over the floor. Resident #15 leaned forward, began to fall. Certified Nursing Assistant #8 attempted to stop Resident #15 from falling and ended up falling over with Resident #15. Resident #15 sustained a hematoma to the top of the scalp. Under the Predisposing Situation Factors section of the facility incident report the box indicating none was checked. The box for using wheeled walker was left blank. The unsigned and dated 11/27/23 employee statement from Certified Nursing Assistant #8 documented as they were transferring Resident #15 to their chair for lunch Resident #15 was focused on the ants on the floor, leaned forward towards the ants and fell to the floor. Certified Nursing Assistant #8 tried preventing Resident #15 from falling and fell with Resident #15. During an interview on 12/14/23 at 1:15 PM, Certified Nursing Assistant #8 stated on 11/27/23 at 11:50 AM they transferred Resident #15 from their recliner to their wheelchair for lunch. Resident #15 kept their head down and was focused on ants on the floor and fell . Certified Nursing Assistant #8 stated they tried to stop the fall instead they fell with Resident #15 and yelled for help. During an interview on 12/14/23 at 1:30 PM, Certified Nursing Assistant #8 stated a rolling walker was documented on Resident #15's closet care plan. The rolling walker was in front of the dresser and was not used when Resident #15 fell on [DATE]. Certified Nursing Assistant #8 stated, Just because a rolling walker was on the closet care plan, didn't mean we had to use them all the time, only when the resident requested to use it. On 11/27/23 at 11:50 AM Resident #15 fell forward, hit their head on the rolling walker, landed face down and smacked their head on the rolling walker. Certified Nursing Assistant #8 stated they should have reviewed Resident #15's closet care plan. Rolling walkers were used for support and could have prevented the fall on 11/27/23. During an interview on 12/15/23 at 10:42 AM, Physical Therapist #2 would have expected staff to review the closet care prior to entering a resident's room. Rolling walkers were expected to be used when documented on the closet care plan for safety and stability. Gait belts were assistive devices worn around the waist. They were used for safe transfers, assisting with sitting and standing and used while walking. Gait belts were to be held onto by the staff during transfers and not assisting residents from under their arms. Lifting someone from under their arms could cause subluxation (dislocation). During an interview on 12/18/23 at 9:04 AM, Physical Therapist #1 stated Certified Nursing Assistants were expected to read the closet care plans before giving care. Resident #15 was kyphotic (hunchback), making it difficult to raise their head. The rolling walker was the safest means of transfer for Resident #15 and should have been used. The rolling walker could have prevented Resident #15's fall on 11/27/23, but I cannot say for certain. During an interview on 12/18/23 at 9:10 AM, the Director of Physical Therapy stated closet care plans were reviewed prior to providing care. Resident #15 should have had the rolling walker positioned in front of them. Certified Nursing Assistant #8 should have had Resident #15 hold onto the walker, Certified Nursing Assistant #8 should have had ahold of the gait belt and the rolling walker, guided the buttocks, and backed up Resident #15 to a seated position. Lifting on Resident #15's arm could cause damage. The rolling walker should have been used as specified on the closet care plan and potentially prevented the fall on the floor on 11/27/23. During an interview on 12/18/23 at 10:02AM, Licensed Practical Nurse #11 Unit Coordinator stated the rolling walker helped with Resident #15's balance. Certified Nursing Assistant #8 should have provided Resident #15 their rolling walker after reviewing the closet care plan and could have prevented the fall on 11/27/23. During an interview on 12/18/23 at 12:02 PM, the Director of Nursing, stated that they would expect the staff to review the closet care plan prior to care. It was unacceptable not to use a rolling walker. Certified Nursing Assistant #8 could have prevented Resident #15 from falling perhaps if the rolling walker was used. During an interview on 12/18/23 at 1:21 PM, the Administrator stated the rolling walker would have given Resident #15 and Certified Nursing Assistant #8 more control therefore could have prevented Resident #15 from falling forward and sustaining a hematoma. 10 NYCRR 415.2 (h) (1)

Based on observation, interview and record review conducted during a Standard survey completed 12/18/23, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, to help prevent the development and transmission of communicable diseases and infections for three (Residents #31, #95, and #116) of three residents reviewed for airborne and droplet precautions. Specifically, staff did not wear appropriate personal protective equipment, including gowns, gloves, eye protection and N95 (respirator, not resistant to oil- based aerosols, 95 efficiency) masks prior to entering COVID-19 (Coronavirus Disease 2019) positive resident's rooms. Additionally, Resident #116's door lacked airborne/droplet precaution instructions to put on a N95 mask before entering the room. The findings are: The policy and procedure titled Airborne Precautions last revised 12/2021, documented the purpose of airborne precautions was to reduce the risk of airborne transmission of infectious agents. The precautions applied to patients/residents known or suspected to have infections transmitted by the airborne route, including but not limited to pulmonary tuberculosis, varicella, COVID-19 (Coronavirus Disease 2019), and measles. All staff, directly or indirectly involved in resident/patient care are responsible for following airborne precautions in conjunction with standard precautions. Major emphasis included the following: N95 or equivalent for persons who must share air space with an infected resident/patient. The policy and procedure titled Droplet Precautions, last revised 12/21, documented it was the responsibility of the Infection Control Nurse or designees to initiate and ensure that droplet precautions were properly implemented. All staff, directly or indirectly involved in resident/patient care were responsible for following droplet precautions in conjunction with standard precautions. Droplet precautions apply to any patient/resident known or suspected to have infections transmitted by infectious droplets, including but not limited to Coronavirus Disease 2019 (COVID-19). Review of an untitled facility document dated of 12/14/23, identified by the Registered Nurse/Assistant Director of Nursing/Infection Preventionist as the resident COVID-19 (Coronavirus Disease 2019) positive list, documented Resident #116 had a positive rapid test on 12/9/23, Resident #95 had positive rapid test on 12/12/23, and Resident #31 had positive rapid test on 12/14/23. 1. Resident #116 had diagnoses including heart failure, dementia, and benign prostatic hyperplasia (BPH, enlarged prostate gland). The Minimum Data Set (a resident assessment tool) dated 11/17/23 documented Resident #116 was understood, sometimes understands, and had severe cognitive impairment. During an observation on 12/12/23 at 11:28 AM, Resident #116's room door was closed, a three-drawer bin was outside the room that contained personal protective equipment including gloves, gowns, surgical masks, eye shields, and N95 masks. A laminated droplet precaution sign was posted on the door. The sign documented families and other visitors were to follow precautions for common conditions including seasonal Influenza, Pertussis (Whooping Cough), Bacterial Meningitis, and Mumps. COVID-19 (Coronavirus Disease 2019) was not listed on the sign. Personal protective equipment was to be put on in this order: wash or sanitize hands, gown, mask (the sign did not list the specific type of mask to be worn), eye cover and gloves. Additionally, during this observation, Licensed Practical Nurse #4 was wearing a surgical mask, donned (put on) a gown, gloves, and entered Resident #116's room without donning a N95 mask and eye protection. 2. Resident #95 had diagnoses including COVID-19 (Coronavirus Disease 2019), congestive heart failure (heart condition), and chronic obstructive pulmonary disease (COPD, group of lung diseases that block airflow). The Minimum Data Set, dated dated dated [DATE] documented Resident #95 usually understands, was usually understood, and had moderate cognitive impairment. During an observation on 12/13/23 at 10:23 AM, Resident #95's room door was closed and had a white Airborne/Droplet Precautions sign posted stating, only essential personnel were to enter the room and a fit tested N95 mask was required before entering the room. Staff must wash their hands, put on a gown, N95 mask, goggles or face shield, and gloves. Remove all personal protective equipment before exiting the room, wash hands and place your surgical mask on outside the room. During an observation on 12/13/23 from 12:02 PM to 12:20 PM, Resident #95 was in their room, in bed, and had an occasional loose, wet cough. Resident #95 stated they were very thirsty, and the call bell was turned on. At 12:12 PM, Resident Aide #1 entered Resident #95's room not wearing a gown, gloves, or eye protection, and had a N95 mask incorrectly applied/positioned over a surgical mask on their face. Resident Aide #1 touched the blanket on the bed, was in direct contact while they covered Resident #95 with the blanket and turned off the call bell without wearing gloves. Resident Aide #1 exited the room without sanitizing/washing their hands carrying Resident #95's water pitcher. At 12:20 PM Resident Aide #1 was outside Resident #95's room and stated to Occupational Therapist #1, no one ever told me I needed to wear this. The Occupational Therapist #1 stated to Resident Aide #1, it's on door prior to entering. During an observation and interview on 12/13/23 at 12:21 PM, Occupational Therapist #1 stated the sign posted on the door told staff what personal protective equipment was required prior to entering a COVID-19 (Coronavirus Disease 2019) positive room. Occupational Therapist #1 stated it was important to have personal protective equipment on prior to entering the room because once they were in the room they were exposed to airborne pathogens. Occupational Therapist #1 stated they could become sick if they didn't wear the appropriate personal protective equipment and they wouldn't be protecting the resident either. During an observation on 12/14/23 at 10:59 AM, Licensed Practical Nurse #6 entered Resident #95's room carrying a medication cup and a spoon in their hand wearing only a surgical mask and no other personal protective equipment. The door was left opened and Licensed Practical Nurse #6 leaned forward toward Resident #95, within 3 feet, to speak to Resident #95. During an interview on 12/14/23 at 11:02 AM, after they exited Resident #95's room, Licensed Practical Nurse #6 stated Resident #95 was on COVID-19 (Coronavirus Disease 2019) precautions and they only needed to gown up and apply a COVID mask (N95) if they were going to be in contact with a resident. Licensed Practical Nurse #6 stated they did not read the sign posted on the door, and they should have because Resident #95 had COVID-19 (Coronavirus Disease 2019). Licensed Practical Nurse #6 stated they didn't know why the precaution signs on Resident #116 and Resident #95's doors were different. Licensed Practical Nurse #6 stated both Resident #116 and #95 had COVID-19 (Coronavirus Disease 2019) and the precaution signs should be the same. During an interview at 11:56 AM, Licensed Practical Nurse #6 stated they probably should have worn personal protective equipment, including a N95 mask because they were in a resident's room that was on airborne precautions. During an interview on 12/15/23 at 11:07 AM, Resident Aide #1 stated if they saw a precaution sign on a resident door, they would read it and follow it. Resident Aide #1 stated they would wear personal protective equipment according to sign before entering the room. Resident Aide #1 stated to be honest they were a little confused, not clear on what I was reading prior to entering Resident #95's room on 12/13/23 at 12:12 PM. Resident Aide #1 stated they should have read the sign, asked a nurse if they didn't understand it because personal protective equipment protects them, and they should make sure they were following the policy. 3. Resident #31 had diagnoses including Alzheimer's disease, COVID-19 (Coronavirus Disease 2019), and anxiety disorder. The Minimum Data Set, dated dated dated [DATE] documented Resident #31 usually understands, was usually understood, and had severe cognitive impairment. During an observation on 12/15/23 at 9:43 AM, Licensed Practical Nurse #4 entered Resident #31's room without a N95 mask on. The sign posted on the resident's door documented a N95 mask was required. During an interview on 12/15/23 at 11:44 AM, Licensed Practical Nurse #4 stated they were aware of which residents were on precautions through report, rooms had bins inside/outside the door, and usually had a sign stating what personal protective equipment to wear in the room. Licensed Practical Nurse #4 stated they knew Resident #31 was on COVID-19 (Coronavirus Disease 2019) precautions and knew what personal protective equipment was required, I'm a professional Licensed Practical Nurse, been dealing with COVID (Coronavirus Disease) since it came out and it's on the door. Licensed Practical Nurse #4 stated that they did not need a N95 mask if they had a face shield on. Licensed Practical Nurse #4 stated the sign stated they needed N95, they probably got flustered and didn't wear the N95 but they should have. Licensed Practical Nurse #4 stated it was important to follow precaution signs to protect themselves, other residents, and families. During an interview on 12/14/23 at 11:09 AM, Licensed Practical Nurse #3, Unit Coordinator, stated they had three COVID-19 (Coronavirus Disease 2019) positive residents on their unit. Licensed Practical Nurse #3 stated upon entering and providing care, full personal protective equipment (gown, gloves, N95 mask covered with surgical mask and face shield) were to be worn. Licensed Practical Nurse #3, stated a N95 mask was required upon entering a COVID-19 (Coronavirus Disease 2019) positive room no matter what. Licensed Practical Nurse #3 stated personal protective equipment was important to prevent the spread of COVID-19 (Coronavirus Disease 2019) to other residents and staff. Licensed Practical nurse #3 stated the precaution signs on Resident #95 and Resident #116's doors were different because one sign was older and the other was newly made. Licensed Practical Nurse #3 stated both signs should indicate the use of a N95 mask as they were COVID-19 (Coronavirus Disease 2019) rooms. During an interview on 12/14/23 at 12:12 PM, Registered Nurse/Assistant Director of Nursing/Infection Preventionist stated an airborne/droplet precaution sign should be posted on COVID-19 (Coronavirus Disease 2019) positive room doors. The Registered Nurse/Assistant Director of Nursing/Infection Preventionist stated proper precaution signage was needed to let the staff know exactly what personal protective equipment to wear to prevent the spread of infectious disease. Registered Nurse/Assistant Director of Nursing/Infection Preventionist stated staff were required to wear a N95 mask upon entering a COVID-19 (Coronavirus Disease 2019) room. During an interview on 12/18/23 at 12:58 PM, the Director of Nursing stated COVID-19 (Coronavirus Disease 2019) positive residents have airborne/droplet precautions signs on their doors. The Director of Nursing stated they expected the staff to be wearing full personal protective equipment, including a N95 mask prior to entering the room. The Director of Nursing stated it was important for the proper precaution sign to be posted so staff knew what they were supposed to do, and so families knew what to wear when entering a precaution room. 10 NYCRR 415.19 (a) (1-2)

Based on interview and record review conducted during a Standard survey completed 12/18/23, the facility did not implement an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for one (Resident #131) of two residents reviewed. Specifically, Resident #131 received Macrodantin (an antibiotic) since 5/23/23 for urinary tract infection prophylaxis (prevention) without documented evidence to support its continued use, appropriate indications for continued use, and lack of monitoring and tracking of its use. Additionally, no rationale regarding prophylactic antibiotic use was given by the physician/prescriber on the medication regimen review dated 7/29/23. The finding is: Review of the policy and procedure titled Antibiotic Stewardship Policy revised 12/2022, documented the facility will develop an Antibiotic Stewardship program that promotes appropriate use of antibiotics for quality of care, successful resident outcomes and reduction of potential adverse consequences related to antibiotic use. Antibiotic Stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. This can be accomplished through improving antibiotic prescribing, administration and management practices thus reducing inappropriate use to ensure that residents receive the right antibiotic for the right indication, dose, and duration. The Infection Preventionist will track antibiotic use and monitor adherence to evidence-based criteria, including documentation related to antibiotic selection and use, tracking antibiotics used to review patterns of use and determination of the impact of the antibiotic stewardship interventions, monitoring for clinical outcomes and provide reports related to monitoring antibiotic usage and resistance data to the QA Committee. Review of the policy and procedure titled Resident/Employee Infection Surveillance Program revised 8/2021 documented the program provides a means to identify the incidence and prevalence of infections within the facility and maintain relevant statistical data. It was the responsibility of the Infection Control Nurse to maintain the Resident/Employee Infection Control Program. Review of the policy and procedure titled Infection Tracking revised 6/2021 documented effective measures were developed to prevent, identify, and control infections acquired or brought into the long-term care facility from the community for the purpose of producing early, uniform identification and reporting. Facility will follow McGeer's criteria (infection surveillance checklist) for tracking urinary tract infections. Prophylactic antibiotics will be reviewed by Medical Doctor/pharmacy consultant. 1. Resident #131 diagnoses included neuromuscular dysfunction of bladder (nerves and muscles of bladder don't work well together), urinary tract infection, and benign prostatic hyperplasia (BPH, noncancerous enlargement of the prostate gland) without lower urinary tract symptoms. The Minimum Data Set (resident assessment tool) dated 10/12/23 documented Resident #131 had severe cognitive impairment, had an indwelling catheter (tube inserted into the bladder to drain urine), and used antibiotic medication. The comprehensive care plan revised 5/25/23, documented Resident #131 was on antibiotic therapy Levaquin (antibiotic) related to a current infection (urinary tract infection), and Macrodantin for urinary tract infection prophylaxis. Interventions included to administer antibiotic medications as ordered by the physician, monitor/document side effects and effectiveness every shift. Review of Resident #131's Order Summary Report from 4/10/23 to 12/16/23 documented an active physician order for Macrodantin oral capsule 50 milligrams, give 1 capsule by mouth in the morning for urinary prophylaxis with a start date of 5/27/23 and there was no stop date. Additionally, Resident #131 received Levofloxacin (antibiotic) 500 milligrams by mouth in the evening for a urinary tract infection for 7 days from 5/19/23-5/26/23; Amoxicillin (antibiotic) 500 milligrams by mouth every 8 hours for occlusal trauma (dental damage) for 7 days from 7/8/23-7/15/23; Ciprofloxacin (antibiotic) 500 milligrams by mouth every morning and at bedtime for a urinary tract infection for five days from 7/21/23-7/26/23; Amoxicillin 500 milligrams by mouth every 8 hours for tooth infection for 7 days from 10/6/23-10/13/23; Macrobid (antibiotic) 100 milligrams by mouth two times a day for urinary tract infection for 5 days from 11/17/23-11/22/23; Obtain urinalysis/culture and sensitivity one time only completed 11/19/23; Ertapenem Sodium (antibiotic) 1 gram inject intramuscularly one time only for urinary tract infection until 12/4/23; Ciprofloxacin 500 milligrams by mouth every morning and at bedtime for urinary tract infection for 5 days from 12/4/23-12/9/23; Ceftriaxone Sodium (antibiotic) inject 1 gram intramuscular in the evening for infection for 5 days from 12/5/23-12/10/23. Review of the Monthly Infection Tracking Form from May 2023 through November 2023 did not list or monitor and track Macrodantin 50 milligrams daily for urinary tract infection prophylaxis for Resident #131. Additionally, the Amoxicillin Resident #131 received from 7/8/23-7/15/23, 10/6/23-10/13/23 and the Macrobid received from 11/17/23-11/22/23 were not documented or tracked on the Monthly Infection Tracking Form. Review of Lab Results Report documented Urine Culture results as followed: -Collection Date: 5/17/23, Reported Date: 5/19/23, documented abnormal results and resistance to Nitrofurantoin (Macrodantin) -Collection Date: 7/19/23, Reported Date: 7/21/23, documented abnormal results and resistance to Ciprofloxacin (Cipro) -Collection Date: 11/20/23, Reported Date: 11/23/23, documented abnormal results with two microorganisms present, only one of the microorganisms was sensitive to Nitrofurantoin -Collection Date: 12/1/23, Reported Date: 12/4/23, documented abnormal results and resistance to Nitrofurantoin Outside consults for Resident #131 did not contain a consultation from a Urologist. Review of Medication Administration Record from May 2023 through December 2023 documented Resident #131 received Macrodantin 50 milligrams daily for urinary tract prophylaxis starting 5/27/23 through 12/16/23, except from 11/18/23-11/22/23, while the resident received Macrobid 100 milligrams twice a day for a urinary tract infection for five days. Review of the Consultant Pharmacist Review: Behavioral (medication regimen review) dated 7/29/23, revealed a recommendation to document periodic support and monitoring for prophylactic antibiotic use for compliance purposes. The Medical Doctor #2 signed this form on an unknown date, that they disagreed with this recommendation and no rationale was documented as to why they disagreed. Review of GP (General Practitioner) Progress Note dated 5/17/23 at 12:47 PM, Nurse Practitioner #1 documented Resident #131 had a past medical of history of urinary tract infection, an indwelling catheter secondary to retention, and they were going to start prophylactic Macrodantin and cranberry due to the indwelling catheter. The plan was to start Macrobid 100 milligrams twice a day for 5 days for urinary tract infection, cranberry caps 425 milligrams twice a day for prophy, and to start Macrodantin 50 milligrams daily once the Macrobid was completed. No further Nurse Practitioner notes addressed the use of the prophylactic antibiotic. Review of Medical Doctor/Nurse Practitioner/Physician Assistant Progress Notes dated 7/18/23 through 11/30/23 revealed no documentation that the resident received a prophylactic antibiotic and no documented rationale for the continued use of the antibiotic. Review of Resident #131's nursing Progress Notes 5/15/23 through 12/16/23 did not document/monitor the use of the prophylactic antibiotic. During an interview on 12/15/23 at 4:37 PM, Registered Nurse/Assistant Director of Nursing/Infection Preventionist stated they tracked antibiotic use for the facility but didn't track prophy antibiotic use because it didn't need to be tracked. Registered Nurse/Assistant Director of Nursing/Infection Preventionist stated per the McGeer's criteria they did not need to track prophylactic antibiotics on their antibiotic tracking report. They stated they did not know how many residents in the facility were on a prophylactic antibiotic and it was up to the doctor to decide if a prophylactic antibiotic should be stopped/discontinued. Additionally, they stated antibiotics should have reason for being recommended. They stated every morning they pull up the dashboard in the electronic medical record system and look to see who was started on an antibiotic, why and if it meets McGeer criteria. They compare their monthly report with the pharmacy report. During an interview on 12/18/23 at 10:16 AM, Registered Nurse/Assistant Director of Nursing/Infection Preventionist stated it doesn't state in the McGeer criteria that they have to track prophylactic antibiotics. They stated prophylactic antibiotics were reviewed by the medical doctor and pharmacy consultant. During an interview on 12/18/23 at 12:16 PM, Registered Nurse #5, Unit Coordinator, stated not all residents with indwelling catheters received prophylactic antibiotics. They stated improper use of antibiotics could cause gastrointestinal issues and antibiotic resistance. During an interview on 12/18/23 at 11:30 AM, Pharmacist #2 stated with excessive use of antibiotics, antibiotic resistance can occur, and an infection can get more out of control. During an interview on 12/18/23 at 11:55 AM, Consultant Pharmacist #1 stated that prophylactic antibiotic use was a provider's clinical decision. The Consultant Pharmacist stated they tried to get rid of prophylactic antibiotics, but they got a lot of pushback from doctors. All antibiotics were required to be tracked with a rationale and a duration needed to be included. The Consultant Pharmacist stated continued use of antibiotics could lead to overgrowth of non-susceptible organisms, lack of efficacy over time, blood dyscrasias (disease or disorder of the blood) and antibiotic resistance. During an interview on 12/18/23 at 1:00 PM, the Director of Nursing stated they expected antibiotics to be tracked for any acute infections and for the McGeer's criteria to be followed. The Director of Nursing stated they would hope the medical providers would document an explanation for use of all antibiotics. The Director of Nursing stated that if residents received prolonged antibiotics, the medication could end up not doing the resident any good, and the resident could build resistance to antibiotics. The Director of Nursing stated there should be a rationale, as well as a note documented if the provider disagrees with a Medication Regime Review. During an interview on 12/18/23 at 1:53 PM, Nurse Practitioner #1 stated recurrent urinary tract infections would be the only reason they would prescribe someone on a prophylactic antibiotic. Nurse Practitioner #1 stated a resident having an indwelling catheter was not an appropriate indication for the use of a prophylactic antibiotic. Additionally, Nurse Practitioner #1 stated dual/duplicate antibiotic therapy should be avoided and they would expect a prophylactic antibiotic to be held until new antibiotic was completed. During telephone interview on 12/18/23 at 2:07 PM, Medical Doctor #2 stated they usually wrote a note in the electronic medical record upon reviewing medication regime reviews. Medical Doctor #2 stated it is subjective on whether to use prophylactic antibiotics. They stated use of prophylactic antibiotic was to prevent Resident #131 from getting more urinary tract infections. Medical Doctor #2 stated they were sure the facility tracked antibiotic use and would know if there were any side effects. 10 NYCRR 415.12(l)(1)

Based on interviews and record review conducted during an Abbreviated survey (Complaint #NY00292911) completed 1/18/23, the facility did not have evidence that all alleged violations of abuse or mistreatment were thoroughly investigated for one (Resident #1) of three residents reviewed. Specifically, there was a lack of documented statements/interviews with other residents that had the potential for victimization. The finding is: The facility policy and procedure (P&P) titled Resident Abuse: Investigation and Reporting revised on 6/22 documented when an incident of suspected resident abuse was reported to Administration, an investigation would be started, and any supervisory person must put the investigation in writing. The investigation shall consist of interviews with witnesses, interviews with the resident, and interviews with the resident's roommate, if applicable. The P&P did not include interviews or assessments of other residents an accused employee had contact with. 1. Resident #1 had diagnoses including cerebral infarction (stroke), hemiplegia (paralysis on one side of body), and diabetes. The Minimum Data Set (MDS-a resident assessment tool) dated 3/9/22 documented Resident #1 was cognitively intact, had some physical behaviors directed toward others and rejection of care. The comprehensive care plan dated 12/13/21 documented Resident #1 required total assistance of two staff members for bed mobility and toileting hygiene/incontinence care. Resident #1 was alert and oriented with some memory impairment and had the potential for increased mood/behaviors related to traumatic life experiences. Interventions included to ensure the resident's safety, both physically and emotionally. The Accident/Incident Report dated 3/19/22 at 12:00 AM, documented Resident #1 had 6 cm (centimeter) by 3 cm reddened tissue on the left side of their face from the tear duct to the mid cheek. The resident stated the CNA (Certified Nurse Aide) punched me in my face. The investigation did not include statements or observations from other residents who the CNA #1 cared for. Review of Resident #1's Progress Notes dated 3/18/22-3/25/22 revealed there was no specific documentation of the resident's allegation of being punched in the face by a CNA. However, a nurse Progress Note dated 3/20/22 at 6:43 PM, documented the resident had no complaints of pain or discomfort due to incident to resident's face. During an interview on 1/18/23 at 10:12 AM, the Director of Social Services stated they talked to the resident the day after the incident but couldn't recall if they talked to any other residents the accused CNA #1 cared for. The Director of Social Services stated it was likely that they talked to other residents on the CNA's assignment but was not able to recall any specific residents and would have only documented their conversation if a resident had a concern. During an interview on 1/18/23 at 10:39 AM, the Licensed Practical Nurse (LPN) Unit Coordinator (UC) #1 stated the day after the incident, the supervisors asked Resident #1 about what happened, and the resident had no recollection of what happened. The LPN UC #1 stated they didn't remember which residents were included in the accused CNA's group that night, but that they did ask the residents who resided in the room next to Resident #1 about the night before and if they had any issues. The LPN UC #1 stated this was not something they would have documented because no residents reported anything was wrong. During an interview on 1/18/23 at 10:50 AM, the Director of Nursing (DON) stated their incident investigations included statements from any staff who were working on the unit, resident assessment, family, and physician notification. The DON stated they couldn't say they automatically go and ask other residents any questions about an incident, especially on a dementia unit. The DON stated it wasn't part of their policy to follow up with other residents the accused employee took care of. During an interview on 1/18/23 at 11:45 AM, the Administrator stated their policy was that if an incident happened in a resident room and there was a roommate, they would interview the roommate. Interviewing other residents on an accused employee's assignment is not how they've done it, and just focused on a roommate but not the entire unit. The Administrator stated they followed their policy as this incident happened in a private room, so there was no roommate to interview. During a telephone interview on 1/18/23 at 12:40 PM, the Assistant Director of Nursing (ADON) stated they were Director of Inservice Education when this incident occurred. The ADON stated that anytime they get an abuse allegation they tried to go back to look at the accused employee's assignment and possibly talk to other residents who were alert and able to be interviewed to see if it was a widespread issue or if there was just one resident involved. The ADON stated they didn't know if this was done for this specific incident and wasn't sure if it would be documented. The ADON stated a lot of the residents on that unit probably weren't alert enough to give statements but would think staff would be watching residents for any behavioral changes or signs of fearing staff members. During an interview on 1/18/23 at 1:15 PM, the Administrator stated they had no further documentation to provide. NYCRR 415.4(b)(3)

Based on record review and interviews conducted during a Partial Extended Abbreviated survey(Complaint #NY00307854), the facility failed to initiate Cardiopulmonary Resuscitation (CPR) to a resident who had Full code status with advance directives in place for one (Resident #1) of four residents reviewed. Specifically, on [DATE] Resident #1, whose advance directives status was a Full code, had a change of condition at 2:45 AM. The Licensed Practical Nurse (LPN) Team Leader #2 correctly identified Resident #1 as a full code and notified the LPN Supervisor #1. LPN Supervisor #1 relayed the change of condition to the Registered Nurse Supervisor (RNS #1). RNS #1 incorrectly identified Resident #1's chart and informed LPN Team Leader #2 and LPN Supervisor #1 that Resident #1 had Do Not Resuscitate (DNR)/ Do Not Intubate (DNI)/ Comfort measure orders. The MD (medical doctor) was notified of the incorrect code status of Resident #1. Facility staff failed to check other identifiers for Advanced Directives such as Resident's identification band and door name tag. Resident #1 expired at 5:10 AM [DATE]. This resulted in actual harm and had the likelihood for serious harm to the health and safety of all residents in the facility that was Immediate Jeopardy and Substandard Quality of Care. The finding is: The facility policy and procedure (P&P) titled Medical Orders for Life Sustaining Treatment (MOLST) Form with a revised date of ,d+[DATE] documented the MOLST form is a medical order form that converts an individual's wishes regarding life-sustaining treatment in medical orders. Once a MOLST form is completed and the resident's code status is determined, the nurse will provide the resident with and identification band. A blue band indicates a Full Code and white band indicates DNR. Facility P&P titled CODE BLUE with a revised date of ,d+[DATE], documented the purpose was to assure that a system was in place to identify a resident's resuscitative status: -Nurse will apply an identification band and door name tag once their MOLST form is completed. -A blue band/door tag indicates Full Code and white band/door tag indicates DNR. -The decision to initiate or not initiate CPR on a resident will be made by the Basic Life Support (BLS) certified staff member after careful observation of the resident's condition. -The licensed personnel will be responsible for identifying the need for cardiopulmonary resuscitation or the impending need. Verification of resuscitation status is obtained. -The highest ranking RN staff member will direct the code. -A nursing note will be written, noting the event and outcome. Review of the facility Daily Census document dated [DATE], provided by the facility, documented a resident census of 141. The facility identified there were 37 full code residents in the facility. 1. Resident #1 had diagnoses that included congestive heart failure (CHF), diabetes, and chronic obstructive pulmonary disease (COPD- constriction of the airways causing difficulty breathing). The Minimum Data Set (MDS- a resident assessment tool) dated [DATE] documented Resident #1 had severe cognitive impairment, was rarely to never understood and did not have a DNR order. The MOLST dated [DATE], signed by the resident and physician, documented Resident #1 wanted to be sent to the hospital, and wanted CPR attempted if they had no pulse and were not breathing. The comprehensive care plan dated [DATE] documented Resident #1 had advance directives in place, staff would honor the resident's wishes, and the advance directives would remain on file in the resident's medical record. Review of the electronic medical record Orders documented an order for CPR dated [DATE]. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated [DATE] - [DATE] documented Resident #1 wanted CPR. The Progress Notes dated [DATE] at 2:45 AM, written by LPN #1 Supervisor, documented Resident #1 was having some respiratory distress during supervisor rounds. Respirations were 36 per minute and resident was using auxiliary muscles for breathing. The resident had a blue tinge to their fingernail beds and slight mottling in bilateral lower extremities (BLE). Call placed to MD. New order for Roxanol (opioid medication used to manage pain or trouble breathing with illness or at the end of life) sublingual (SL) every (Q) two hours (hrs.) as needed (PRN) for increased respirations and pain. Also, ordered Ativan 0.25 milligram (mg) SL Q8hr PRN for agitation/anxiety. Oxygen (O2) at 2 liters (L) also applied for comfort. Additionally, the note documented that a PRN dose of Roxanol was administered for increased respirations of 36. The progress note did not document that the MD was informed of the resident's advanced directives/ code status, and did not document additional vital signs (heart rate (HR), blood pressure (BP), pulse oximetry PO2 (oxygen saturation level, amount of oxygen in the blood). The Progress Notes dated [DATE] at 5:42 AM, written by the LPN Supervisor #1, documented RNS #1 found Resident #1 to be without HR, respirations and BP. Resident pronounced deceased at 5:10 AM on [DATE]. The facility staff did not initiate Code Blue, CPR, or call emergency services (911). The facility's investigation included a copy of email dated [DATE] at 3:58 PM from Director of Nursing (DON) to facility Administrator with the heading Reportable [DATE], documented that upon an audit of Resident #1's death it was noted the resident's MOLST form stated CPR was to be given and CPR was not given. Review of interviews from LPN Supervisor #1 and RNS #1 included in the investigation documented CPR was not performed on Resident #1 as they believed the resident had order for a DNR/DNI and on comfort measures. During a telephone interview on [DATE] at 10:33 AM, LPN Supervisor #1 stated on [DATE] Resident #1 was noted to be awake, restless, and not breathing right, huffing a little bit. LPN Supervisor #1 stated they applied oxygen to Resident #1 to help with the increased respirations and informed RNS #1. LPN Supervisor #1 stated that RNS #1 told them that they had checked the chart and that Resident #1 had DNR/DNR/ comfort measures orders, and do not send to hospital. LPN Supervisor #1 stated they called the MD and informed them Resident #1 had DNR/DNI, comfort measures orders and MD gave a new order for Roxanol. LPN Supervisor #1 stated they did not double check Resident #1's MOLST, name band or door tag to verify that code status was correct. I blindly followed what the RN Supervisor told me and did not check the other measures (code status identifiers) that we have in place to double and triple check. During a telephone interview on [DATE] at 10:48 AM, LPN Team Leader (#2) stated they were employed by an agency and had worked at the facility for approximately 2 weeks. They stated they had orientation to the facility on two shadow shifts going over everything, prior to a solo shift. LPN Team Leader #2 stated they were notified by Certified Nurse Aide (CNA) #1 that Resident #1's breathing was little different than usual. LPN Team Leader #2 stated they took Resident #1's vital signs and they were OK and gave them to the LPN Supervisor #1 when they were doing rounds a few minutes later. There were two Supervisors on duty, and they took over. One called the MD, the other went to grab the medication from the pyxis (automated medication dispensing system). I informed LPN Supervisor #1 the eMAR (electronic medication administration record) said Full Code. LPN Supervisor #1 told me the resident was a DNR/DNI on comfort measures and wouldn't be sent out. LPN Team Leader #2 stated they did not check the resident's MOLST, identification band or door tag. During a telephone interview on [DATE] at 11:37 AM, RNS #1 stated, I don't remember if they called me or I walked to the unit, but I went to grab Resident #1's chart, or so I thought, it was sitting next to four other charts in a metal chart rack/cart. I opened the chart and saw DNR/DNI. LPN #1 was on the phone with the MD, I went to grab the medication from the pyxis, after the MD gave the order. I gave the medication to the resident and waited until the resident was able to relax. At 5:10 AM, I got the call that staff thought the resident had passed. I believed the resident was comfort care. RNS #1 stated they did not double check the other identifiers in place (door tag and identification band), the EMR (electronic medical record) or double check that it was the right name on the spine of the chart and the MOLST. It was our responsibility as Supervisors, the LPN Team Leader (#2) relayed the information (change in condition) to us and we took over. During an interview on [DATE] at 2:26 PM, the MD stated they were called in the middle of the night and notified that Resident #1 had a DNR/DNI and was on comfort measures, was struggling to breathe and needed something for comfort. The MD stated they would have expected the MOLST be checked, and the resident's code status to be confirmed before they called. It was not my intent to override the resident wishes. I would never do that. During a telephone interview on [DATE] at 2:33 PM, CNA #1 stated in the middle of the night on [DATE], while doing their rounds Resident #1 was slouched over and breathing really heavy, they tried to make the resident more comfortable and went and told LPN Team Leader #2. CNA #1 stated they (themselves) checked on the resident every ,d+[DATE] minutes throughout their shift and believed it was about 4:30 AM - 5:00 AM when Resident #1 was not breathing and was getting cool. LPN Team Leader #2 checked and called the Supervisors. CNA #1 stated they did not check the resident's MOLST and could not recall the color of the resident's identification band or door tag. During an interview on [DATE] at 5:55 PM, the Administrator stated the expectation was for staff to follow facility protocol for Advance Directives, Code Blue and when a resident has a change in condition. Protocols were not followed for Resident #1 on [DATE] and the resident's wishes were not honored. 415.3 (e)(2)(iii) 10 NYCRR 400.21

Based on interview and record review conducted during a Partial Extended Abbreviated Survey (Complaint #NY00307854) completed on [DATE], the facility did not immediately inform the resident's representative(s) when a significant change in the resident's physical status and the need to alter treatment significantly for one (Resident #1) of five residents reviewed for notification. Specifically, the family was not notified when Resident #1 had a significant change in their health status (respiratory distress) resulting in new orders for the initiation of Roxanol (opioid medication used to manage pain or trouble breathing with illness or at the end of life and pain, and Ativan (Lorazepam- anti anxiety medication). The finding is: Facility policy and procedure (P&P) titled Change in Resident's Condition or Status dated ,d+[DATE] documented the facility shall immediately inform notify the Resident's designated representative of changes in the Resident's condition and/or status to ensure prompt medical attention. The Nursing Supervisor/Coordinator will inform if known notify the Resident's designated representative when there is: - significant decline in the Resident's physical, mental or psycho-social status in accordance with generally accepted standards of care (i.e., deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). -A need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences or commence a new form of treatment to deal with a problem (i.e., the use of any medical procedure, or therapy that has not been used on that Resident before). 1. Resident #1 had diagnoses that included congestive heart failure (CHF), diabetes, and chronic obstructive pulmonary disease (COPD- constriction of the airways causing difficulty breathing). The Minimum Data Set (MDS- a resident assessment tool) dated [DATE] documented the resident had severe cognitive impairment, was rarely to never understood. Review of the Progress Notes dated [DATE]-[DATE] documented the following: -[DATE] at 2:45 AM, written by the LPN Supervisor #1, Resident #1 noted to be having some respiratory distress during supervisor rounds. Respirations were 36 per minute and resident was using auxiliary muscle for breathing. Resident also noted to have blue tinge to fingernail beds and slight mottling in bilateral lower extremities (BLE). Call placed to MD. New order for Roxanol (morphine sulfate-opioid medication used to manage pain or trouble breathing with illness or at the end of life) sublingual (SL, under tongue) every (Q) two hours (hrs.) as needed (PRN) for increased respirations and pain. Also, ordered Ativan 0.25 milligram (mg) SL Q8hr PRN for agitation/anxiety. Oxygen (O2) at 2 liters (L) also applied for comfort. Additionally, the note documented PRN dose of Roxanol was administered for increased respirations of 36. There were no additional vital signs documented. -[DATE] at 5:42 AM, written by the LPN Supervisor, RN Supervisor found Resident #1 to be without heart rate, respirations, and blood pressure. The resident was pronounced deceased at 5:10 AM, and the resident's son was called at 5:25 AM and informed. Review of electronic medical record Orders tab documented the following orders: -Morphine Sulfate (Roxanol) 20mg/5ml give 0.25 ml SL Q2 hrs. PRN for increased respirations and pain with a start date of [DATE]. -Lorazepam (Ativan) concentrate 2mg/ml give 0.25 mg SL Q8hr PRN for agitation/anxiety with a start date of [DATE]. The Progress Notes lacked documented evidence the family was notified of Resident #1 change in condition (declining respiratory status) or the initiation of Roxanol and Ativan as ordered by the MD. During a telephone interview on [DATE] at 10:33 AM, Licensed Practical Nurse (LPN) Supervisor #1 stated they were doing their rounds on [DATE] when Resident #1 was noted to be awake, restless, and not breathing right, huffing a little bit. LPN Supervisor stated they applied oxygen on the resident to help with the increased respirations. At that time Resident #'s fingertips were a little blue and legs were reddish- bluish. LPN Supervisor stated they called the MD and new orders were given for Roxanol. The LPN #1 Supervisor stated they and/or RN Supervisor #1 would have been responsible to call and update the family, but they did not and should have. During a telephone interview on [DATE] at 10:48 AM, LPN Team Leader #1 stated they were employed by an agency and had worked at the facility approximately 2 weeks. LPN #1 Team Leader stated they were informed by CNA #1 Resident #1's breathing was little different than usual. I took the Resident's vital signs, which were OK and gave them to the LPN Supervisor #1 when she was doing rounds a few minutes later. There were two Supervisors on duty, they took over. One called the MD, the other went to grab the medication from the pyxis (automated medication dispensing system). I did not call the family. Actual facility staff, usually, do that because they have a rapport with families. During a telephone interview on [DATE] at 11:37 AM RN #1 Supervisor stated, it was our responsibility as Supervisors, the LPN Team Leader #1 relayed the information (change in condition) to us and we took over. We should have called the family, LPN Supervisor #1 or I would have been responsible to call the family to update regarding the change in condition, I don't know why we didn't. During an interview on [DATE] at 10:15 AM, the Director of Nurses (DON) stated LPN #1 and RN #1 Supervisors did not follow facility policy regarding Resident #1's change in condition. The family should have been notified even if the resident was comfort care. During interview on [DATE] at 5:55 PM, the Administrator stated the expectation was for staff to follow facility protocol when a resident had a change in condition. On [DATE], LPN #1 and RN #1 Supervisors did not follow the facility's protocol and did not call the family to update then when it was first discovered that Resident #1 had a change in condition. 415.3(e)(2)(ii)(b)(c)

Based on interview and record review during a complaint investigation (Complaint #NY 853) completed on a Standard survey conducted from 5/23/22 through 5/31/22, the facility did not ensure that all alleged violations including abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin, are reported immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse, to the appropriate official (including the State Survey Agency). Four (Residents #16, 22, 60, and 109) of four residents reviewed for reporting of alleged violations of abuse were involved in incidents not reported timely to the New York State (NYS) Department of Health (DOH) as required. Specifically, resident to resident altercations (#16, 22, 60, and 109) and injury of unknown origin (#60). The findings are: A facility policy titled Resident Abuse: Investigation and Reporting revised 9/2020 documented Federal and State regulations require the facility to report alleged violations of mistreatment, neglect, and abuse, including injuries of unknown origin. It shall be the policy of this facility to prohibit and assure the resident's right to be free from verbal, physical, or sexual abuse, exploitation, mistreatment, neglect, and misappropriation of resident property. Report to the NYS DOH all instances where there is sufficient evidence for a prudent person to believe that above abuses identified has occurred. The policy documented the individual must have acted deliberately, not that he/she must have intended to inflict injury or harm. 1. Resident #22 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS - a resident assessment tool) dated 4/22/21 revealed the resident had severe cognitive impairment, sometimes understood, and sometimes understands. Review of the Comprehensive Care Plan (CCP) dated 11/16/21 documented physical behaviors towards other residents. The plan included to administer medications as ordered; analyze times of day, triggers and document interventions used to de-escalate behaviors. The CCP further documented fragile skin with anticoagulant use and to monitor for increased bruising. Review of the Kardex (guide used by staff to provide care) dated 4/16/21 revealed resident #22 ambulated independently without any assistive device. 2. Resident #60 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS dated [DATE] revealed the resident had moderate cognitive impairment, usually understood, and usually understands. Review of the CCP dated 12/3/21 documented resident #60 ambulated independently with a rolling walker. Review of the Kardex dated 4/16/21 revealed resident #60 transferred independently with a rolling walker. a.) Review of the facility Accident/Incident Report dated 4/16/21 revealed at 6:00 PM, resident #22 hit resident #60 on the left arm with a hairbrush. The residents were separated. Review of the Health Electronic Response Data System (HERDS) Nursing Home Incident Form revealed the Administrator reported the alleged abuse to the DOH on 4/19/21 at 4:16 PM. During an interview on 5/25/22 at 2:01 PM the Registered Nurse (RN) #1, Supervisor stated they reported the resident-to-resident altercation to the Director of Nursing (DON), immediately after the incident occurred on 4/16/21 and was aware the of the State Agency required 2-hour reporting timeframe. The DON notified the Administrator. The Administrator would report alleged abuse to the DOH. b.) Review of the facility Accident/Incident Report dated 3/28/22 documented at 7:30 AM resident #22 had a small abrasion with a bruise of unknown origin on their left upper extremity. Review of the HERDS Nursing Home Incident Reporting System revealed the facility did not report the bruise of unknown origin noted to resident #22's left arm on 3/28/22 to the DOH as required. During an interview on 5/26/22 at 9:40AM the RN #2, Unit Coordinator stated an investigation included employee statements to determine the root cause of the bruise to resident #22's left arm. RN#2 stated they were unable to recall reporting the bruise to the DON or reviewing the incident report in morning report with the Interdisciplinary Team (IDT). The DON or Administrator would be responsible for reporting a bruise of unknown origin to the State Agency within 2 hours after being notified. During an interview on 5/26/22 at 4:10 PM the DON stated an investigation was initiated of the resident-to-resident altercation on 4/16/21. The DON concluded that resident #22 had no intent to hit resident #60 with the hairbrush due to dementia. Therefore, the Administrator didn't report the resident-to-resident altercation to the State Agency until three days later. The DON further stated the facility followed the 2016 Incident Reporting Manual for guidance and was not familiar with the most current guidance. The resident-to-resident altercation on 4/16/21 and bruise of unknown origin on 3/28/22 should have been reported by the Administrator within 2 hours to the State Agency according to the State Operations Manual and were not. During an interview on 5/26/22 at 4:30 PM the Administrator stated the facility followed the 2016 Incident Reporting Manual as a guidance tool and was unaware of the most current guidance in the State Operations Manual (SOM). The Administrator further stated the resident-to-resident altercation between resident #22 and resident #60 and the bruise of unknown origin for resident #60 on 3/28/22 should have been reported within 2 hours to the State Agency and were not. Ultimately, I'm the one who is responsible. 3. Resident #109 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . and no physical or verbal behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, threatening, screaming, or cursing at others). Review of the CCP dated 2/18/22 documented the resident is noted to easily agitate others at times. Three noted resident to resident encounters. Interventions included educate resident on proper behavior towards others. If reasonable, discuss behavior and explain why inappropriate and/or unacceptable. Resident given the option to change rooms and wanted to. Keep resident away from another resident who they had the negative encounter with. Redirect at times of agitation. Review of the Kardex dated 1/7/22 documented staff to encourage and maintain that resident is kept away from another resident (#16). 4. Resident #16 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented the resident was severely cognitively impaired. Additionally, the MDS documented physical and verbal behavioral symptoms directed towards others on one to three days in the seven day look back. The MDS further documented the identified symptoms put the resident and others at significant risk for physical injury, and significantly intruded on the privacy or activity of others. Review of the CCP dated 2/18/22 documented history of aggression/threatening behavior towards staff and peers. Two resident to resident altercations, with history of wandering into other rooms. Interventions included monitor resident's behavior and keep distance between themselves and other stated resident (#109) on 2/15 into morning of 2/16/22. Caregivers to provide opportunity for positive interaction, attention. Stop and talk with resident when passing by. Continue psych med review for aggressive behaviors toward staff and peers. Medication review and room change due to peer-to-peer altercation. Provide distraction. Additionally, the CCP documented potential to be verbally/physically aggressive towards staff and peers at times with refusal of care related to dementia. Interventions included analyze of key times, places, circumstances, triggers, and what de-escalates. Review of the Kardex dated 1/7/22 documented staff to encourage and attempt to maintain resident is kept away from another resident (#109). Review of the facility Accident/Incident Report dated 1/6/22 documented at 11:45 PM Resident #16 struck another resident (#109). Resident #109 was sitting in their wheelchair (w/c) in common area waiting for a snack from nurse. Resident #16 approached resident #109 and grabbed the w/c. Argument started, resident #16 struck resident #109 on back two times, one witnessed by nurse. Staff separated. Resident #109 version of incident documented I want to deck resident #16, just let me at them. Resident #16 version of incident documented You're a bunch of liars and resident #16 became verbally abusive and threatened physical abuse. During an interview on 5/23/22 at 11:44 AM resident #109 stated resident #16 on D Unit, about six months ago, hit me with a yellow floor sign and I punched them in the face. I moved to this unit. I was sick of them (Resident #16) always beating up on me. On 5/27/22 at 11:06 AM, resident #109 stated resident #16 came in my room, all the time, and would walk by and give me the shaking fist and I would say go on, get out of here. Why should I have to move to please Resident #16? Why should I have to change my room? I liked my room on D Unit, but I decided to give it a try and I like it down here on B Unit. I wasn't afraid of Resident #109. Review of the Complaint/Incident Tracking System Report (software that logs and tracks nursing home complaints) revealed the incident was not reported to the NYS DOH as required. During an interview on 5/27/22 at 6:55 AM, Licensed Practical Nurse (LPN) #3 stated they witnessed resident #16 hit resident #109, with an open hand, to the back. It was a resident-to-resident altercation. Resident #109 was in the common area waiting for a snack and resident #16 grabbed resident #109's w/c. Resident #109 got angry. Resident #16 slapped with an open hand. LPN #3 stated they didn't think resident #16 meant to hurt resident #109, I think resident #16 just wanted to hit resident #109 because they were next to them. I guess it would be resident to resident abuse because they came in contact with each other. This should have been reported to the NYS DOH. LPN #3 stated they notified the Nursing Supervisor, on duty, and they would have been responsible to notify the DON. During interview on 5/27/22 at 7:29 AM, LPN #4 stated they were the Supervisor on 1/7/22. LPN #4 stated Registered Nurse (RN) #4 assessed both residents. LPN #4 stated they notified the DON immediately. Any resident-to-resident situations are taken care of immediately. There is a two-hour window, but I notify the DON or whoever is on call right away. I am expected to notify my superior and they report to the DOH, that is what I know. During interview on 5/31/22 at 10:54 AM, LPN #5 Unit Coordinator (UC) stated they were aware of the resident-to-resident altercation because it was discussed at morning meeting the following day. LPN #4 stated the expectation is that supervision is notified of any incident, and they would be responsible to notify, administration, so they are aware of the resident-to-resident altercation. It's immediate. During interview on 5/31/22 at 11:08 AM the DON stated the incident was investigated and discussed to rule in or out abuse. Resident #109 usually stayed in their room but came out for snacks. Resident #16 usually sits in the common area near their room and is very territorial of that area. We thought there was no intent, resident #16 was startled, it was isolated. If staff calls me for something like this we start the investigation and I call the Administrator. The Administrator does all the reporting to the DOH, at this time. There have been discussions about opening up reporting access to other staff. During interview on 5/31/22 at 11:44 AM the Administrator stated the incident should have been reported to NYS DOH. We considered this incident isolated and were following the 2016 Incident Reporting Manual, which I have learned is outdated. Now that I know that all allegations are to be reported, this should have been reported. 415.4(b)(4)

Based on interview and record review during the COVID-19 Focused Infection Control Survey conducted on [DATE], the facility did not ensure that residents' family and/or next of kin were notified of either a single confirmed infection of COVID-19 by 5:00 PM the next calendar day or a COVID-19 death within 24 hours from the date of occurrence for two (Residents #1 and #2) of two residents reviewed. Specifically, the facility did not provide verbal or written notification to a resident's family and/or next of kin when a resident at the facility tested positive for COVID-19 or suffered a COVID-19 related death. The findings are: The Centers for Medicare and Medicaid Services (CMS) guidance titled, Interim Final Rule Updating Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes (Ref: QSO-,[DATE]-NH), dated [DATE], documented that as part of a skilled nursing facility's COVID-19 reporting requirements, facilities must Inform residents, their representatives, and families of those residing in facilities by 5:00 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. Such requirements were made effective [DATE] in regulatory amendments to 42 CFR 483.80 pursuant to 85 Fed. Reg. , . New York State Executive Order 202.18 dated [DATE] documented Any skilled nursing facility, nursing home, or adult care facility licensed and regulated by the Commissioner of Health shall notify family members or next of kin if any resident tests positive for COVID-19, or if any resident suffers a COVID-19 related death, within 24 hours of such positive test result or death. Review of an undated facility document titled Facility Notification Protocol COVID-19 documented in accordance with state and federal recommendations the facility will provide notifications regarding COVID-19 related new lab confirmed positive cases and deaths, and new onset of respiratory clusters of three (3) or more residents/staff to all residents and representatives, their families and next of kin by 5 PM the next calendar day. Include any cumulative updates for residents, their representatives, and families at least weekly or by 5 PM the next calendar day following the subsequent occurrence of either: each time a confirmed infection of COVID-19 is identified, or whenever three or more residents or staff with new onset of respiratory symptoms occur within 72 hours of each other. For representatives and family/next of kin an automated phone call will go out to health care proxy (HCP). Review of an untitled facility document identified by the Administrator as the facility COVID-19 positive employees line list revealed 13 staff members tested positive for COVID-19 [DATE] through [DATE]. Review of an untitled facility documented identified by the Administrator as the facility COVID-19 positive residents line list revealed 10 residents tested positive for COVID-19 [DATE] through [DATE] with the most recent COVID-19 positive resident case identified on [DATE]. Review of resident Death Certificates from [DATE] through [DATE] revealed 13 residents expired related to COVID-19 with the most recent COVID-19 related resident death on [DATE]. 1. Resident #1's Minimum Data Set (MDS - a resident assessment tool) dated [DATE] documented the resident was moderately cognitively impaired. Review of progress notes dated [DATE] through [DATE] revealed no documented evidence Resident #1's family and/or next of kin were notified of new COVID-19 positive cases or COVID-19 related deaths in the facility. A telephone interview on [DATE] at 11:42 AM, Resident #1's daughter, who was the designated family contact, stated the facility had been contacting her regarding COVID-19 positive staff or residents but that she had not received any calls in the past two weeks. She stated she used to receive an automated ROBO call with updates regarding COVID-19 positive cases. An interview on [DATE] at 1:05 PM, Licensed Practical Nurse, Unit Coordinator (LPN UC) #1 stated, she, the Nursing Supervisor or the Social Worker (SW) call the resident's family/next of kin when there is a new positive COVID-19 resident or staff member and thought this had to be done within 24 hours. LPN UC#1 stated the last positive resident in the building was the weekend of [DATE] and recalled speaking to Resident #1's daughter on Monday [DATE]. She said, she didn't recall updating the daughter of the positive COVID-19 resident. LPN UC#1 stated she was assigned to a specific list of residents' family/next of kin to provide weekly updates of general information, not specifically COVID-19 information. 2. Resident #2's Minimum Data Set (MDS - a resident assessment tool) dated [DATE] documented the resident was severely cognitively impaired. Review of progress notes dated [DATE] through [DATE] revealed no documented evidence Resident #2's family and/ or next of kin were notified of any new COVID-19 positive cases or COVID-19 related deaths in the facility. A telephone interview on [DATE] at 1:34 PM, Resident #2's son, who was the designated family contact, stated the facility had been notifying him about COVID-19 positive staff and residents but when he talked to the Social Worker (SW) yesterday, she didn't say anything about any new COVID-19 cases. The SW was just calling about general updates about Resident #2. The son stated the last time he was notified of a positive COVID-19 resident or staff member was approximately three weeks ago. An interview on [DATE] at 2:16 PM, LPN UC #2 stated she is notified of positive staff or residents by the Administrator or Director of Nursing (DON) and she or the SW would call the resident's family/next of kin to update about the new positive COVID-19 cases. She stated the last COVID-19 positive resident was identified on the weekend of [DATE], and the Nursing Supervisor should have called Resident #2's family and documented the conversation. LPN UC #2 stated the facility used to have a ROBO call for notification but now staff are assigned a specific group of residents to call their family/next of kin weekly and provide a general update of the resident's status. LPN UC #2 stated she did not call Resident #2's family about the newly identified COVID-19 positive resident from [DATE]. An interview on [DATE] at 2:34 PM, the Director of Social Work (DSW) stated she gets notified of newly identified positive COVID-19 residents or staff from morning reports. DSW recalled she was notified on Monday, [DATE]th, 2021, of the last newly identified COVID-19 positive resident. The DSW stated weekly calls are made to resident's family/next of kin to provide an update of positive COVID-19 cases and can be done anytime during the week. She stated, SW #2 should have notified Resident #1 and Resident #2's family/next of kin. An interview on [DATE] at 3:23 PM, SW #2 stated she had not called Resident #2's family because Resident #2 is not on her assigned room list. SW #2 stated she makes weekly calls to Resident #1's family of general updates but does not notify the family of COVID-19 positive cases and stated she was not aware she was responsible to notify resident's family/ next of kin about positive COVID-19 cases. An interview on [DATE] at 2:41 PM, the Assistant Director of Nursing Infection Preventionist (ADON/IP) stated the process for positive COIVD-19 notification to family/ next of kin is: the SW, LNP UC, DON or she will call the family/next of kin, but the SW regularly calls the family and the LNP UC calls with updates, therefore they most likely notify the family/ next of kin. The timeline for notification is to be made any time during that week. The ADON/IP stated the facility used to use ROBO call for updates, but now staff make weekly calls to resident's family/ next of kin. An interview on [DATE] at 2:55 PM, the DON stated ROBO calls were used to notify the resident's family/next of kin immediately of newly identified COVID-19 positive staff or residents but were stopped mid [DATE]. At that time the process was changed to personal phone calls. The DON stated the resident's family/next of kin of the resident that is identified as COVID-19 positive is notified immediately and all the other resident's family/ next of kin are called within the week. An interview on [DATE] at 3:06 PM, the Administrator stated the resident's family/next of kin used to be notified by ROBO calls of newly identified resident or staff COVID-19 positive cases; but that process was changed and staff were to make personal phone calls to the Resident's family/next of kin. The Administrator stated the notification should be within 48 hours and SW #2 should have notified Resident #1's and Resident #2's family/next of kin of the newly identified COVID-19 positive resident. The Administrator stated she was unaware there was a timeline requirement for notification of newly identified resident and staff COVID-19 positive cases and did not know the facility was required to notify resident's v of a COVID-19 related resident death. The Administrator stated there had been 14 COVID-19 related resident deaths since [DATE], 1 in the hospital and 13 in the facility. The administrator further stated the facility may go back to using the ROBO call system, so the notification is completed timely. 10 NYCRR 400.2

Based on interview and record review conducted during the COVID-19 Infection Control Focused Survey (Complaint # NY 799) completed on 9/30/20, the facility did not ensure residents and facility staff, including individuals providing services under arrangement and volunteers, were tested and documented that testing was complete with the results of each test for COVID-19 that is consistent with current infection control measures during staff testing for COVID-19. Specifically, for three (Employees #1, 2, and 3) of three contract employees reviewed for COVID-19 testing the facility had no documented evidence of COVID-19 test results prior to employment and weekly COVID-19 tests were not conducted during a facility COVID-19 outbreak. The finding is: New York State Executive Order (EO) 202.30 (dated May 10, 2020), as modified by EO 202.40 (dated June 9, 2020), provides: the operator and administrator of all nursing homes and all adult care facilities, which are located in regions that have reached Phase Two of reopening, must test or make arrangements for the testing of all personnel, including all employees, contract staff, medical staff, operators and administrators, for COVID-19, once per week. The Center for Medicare & Medicaid QSO-20-38-NH dated 8/26/20: Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements and Revised COVID19 Focused Survey Tool, documented: the facility is required to obtain documentation that the required testing was completed during the timeframe that corresponds to the facility's testing frequency. Review of the facility policy and procedure (P&P) titled COVID-19 Testing revised 9/20 documented all employees, contract staff, per diem staff, medical staff, operators, administrators, and volunteers must be tested . Staff who work at a facility must be tested on ce a week. Diagnostic tests of nursing home staff that are performed outside of the facility meet testing requirement, so long as the employee has the appropriate documentation to provide to the nursing home administrator, such that the administrator can certify compliance. Review of the untitled resident line list provided by the facility for COVID-19 positive residents revealed twenty-two residents had tested positive for COVID-19 on Unit D between 9/4/20 and 9/17/20. Review of untitled employee line list provided by the facility for COVID-19 positive employees revealed five staff members tested positive for COVID-19 between 9/4/20 and 9/24/20. Review of the schedule for the contract agency titled Regular Monthly Schedule from 9/4/20 through 9/29/20 revealed: - Employee #1 worked on 9/14/20 on Unit D and 9/19/20 on Unit B. - Employee #2 worked on 9/8/20, 9/15/20, 9/22/20, 9/23/20 on Unit B and on 9/9/20 and 9/16/20 on Unit A. - Employee #3 worked on 9/15/20 on Unit C, on 9/17/20, 9/19/20, & 9/25/20 on Unit A and on 9/27/20 on Unit B. Review of the facility required employee testing from 9/4/20 to 9/29/20 revealed no evidence of a COVID-19 test result prior to employment in the facility or that weekly COVID-19 tests were conducted for Employees #1, 2, & 3. During an interview on 9/29/20 at 2:34 PM the Staffing Scheduling Coordinator stated the Agency is responsible to test contract staff for COVID-19. She would contact the Agency to let them know shift availability. The contract staff are expected to provide the test results to their corresponding agency. The agency should send a receipt documenting the test had been completed. Once results are received the agency should send the results by email. I guess it doesn't always happen. It was my responsibility to make sure the contract staff had negative results prior to working and I did not. During an interview on 9/29/20 at 4:55 PM the Supervising Administrator (SA) stated it was the facility's responsibility to ensure contract staff had negative COVID-19 test results prior to their first scheduled shift in the building or they would not be allowed to work. The SA stated there was no documented evidence that Employees #1, 2, & 3 had negative COVID-19 test results prior to working their first shift at the facility or that they had been tested weekly for COVID-19. The SA stated that the staff should have been tested and the facility had never provided weekly testing for Contract staff. During an interview on 9/29/20 at 5:05 PM the Director of Nurses (DON)/ Infection Preventionist (IP) revealed COVID-19 testing was offered to facility staff. Contract staff were tested elsewhere and were responsible to provide documentation to the Staffing Scheduling Coordinator. The DON stated that if it is not the case then they should not have been allowed to work in the building. The DON stated she was unsure the lack of testing was related to the recent COVID-19 outbreak, but certainly can be. During a telephone interview on 9/30/20 at 12:17 PM the agency Branch Director #1 stated the agency had no responsibility in COVID-19 testing for their employees. Most facilities perform testing on their own. Contract staff who work in other facilities may be tested at other facilities and are responsible to provide the current facility with their weekly COVID-19 test results. The facility should maintain documented test results of their contract staff in their employee's file. Branch Director #1 stated there was no evidence that Employee #2 had been tested prior to working at the facility or that weekly testing had been conducted. During a telephone interview on 9/30/20 at 2:02 PM the agency Regional Director #1 stated facilities are required to provide weekly testing and to report when an employee tests positive not the agency. Typically, it would be specified in the contract when the agency is responsible to provide testing and it does not. We are partially at fault because we did not ensure Employee #1 was tested prior to working in their building. We both dropped the ball. 415.19(a)(1) 400.2

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY 817) completed on 9/29/20, it was determined the facility did not ensure that all alleged violations of abuse, neglect or mistreatment including injuries of unknown origin are thoroughly investigated for one (Resident #1) of one resident reviewed. Specifically, the facility did not complete a thorough investigations of an injury of unknown origin (reddened area on resident's forehead) and an incident where a resident was lowered to the floor from the toilet following an unresponsive episode. The finding is: A facility policy and procedure (P&P) titled Resident Accident and Incident Report and Follow-Up Investigation last revised 7/20/20 documented it is the policy of the facility to complete Accident and Incident reports in accordance with definitions of accidents and investigations (A/I) as outlined in the policy and ensure ongoing monitoring of incidents, and implement interventions to reduce the likelihood of reoccurrence. The definition of an accident includes an unintentional or unexpected occurrence that is undesirable or unfortunate and did result in, or might have resulted in, injury, damage, harm or loss. The definition of Incident is an unusual or abnormal event or occurrence in, at, or affecting the facility and or the residents of the facility. Forms include A/I reports, Neurological assessment record (if applicable) and referral forms (if applicable). Incident reports should be written by the licensed professional receiving the report after the incident is discovered. The incident must also be noted on the 24-hour nursing report and the resident status noted in the Nurses Notes every shift for a period of at least 72 hours and must include condition of resident and status of injury. Resident statements should be carefully recorded. Vital signs must be taken for three shifts (24 hours starting with the shift of occurrence, or more often depending upon the severity and nature of the injury). Neurological assessments (neuro checks) are to be done for all potential head injuries and unwitnessed falls. 1. Resident #1 had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS, a resident assessment tool) dated 12/9/18 documented the resident had moderate cognitive impairments. Review of an undated comprehensive care plan revealed Resident #1 was alert and orientated times two with some memory impairments. Review of a Progress Note dated 2/1/19 at 12:15 PM revealed neuro checks were initiated due to a reddened area noted on resident #1 forehead and the origin was unknown. There was no hematoma (a solid swelling of clotted blood within the tissues) present. Night shift nurse notified supervisor. Resident #1 had no complaints of a headache, discomfort or pain. Neurological function and vital signs were within normal limits (WNL). Further review of the Progress Notes dated 2/1/20 through 2/14/20 revealed there was no further documentation or assessments of the reddened area on Resident #1's forehead. Interview with the Director of Nursing (DON) on 9/29/20 at 1:12 PM revealed she was able to locate a neuro check sheet (neurological assessment) for the incident dated 2/1/19. At 2:20 PM, the DON stated there was no investigation completed for the injury of unknown origin (reddened area). The DON stated there should have been an investigation completed regarding the reddened area on the Resident #1's forehead that was noted on the 2/1/19. Review of a Progress Note dated 2/16/19 revealed Resident #1 had an unresponsive episode while on the toilet at 10:40 AM [MEDICATION NAME] only a few minutes, then became alert with vital signs in normal range. Oxygen was applied. While being lowered to the floor from the toilet a skin tear was noted on the resident's left elbow. The daughter was notified of the incident and requested Resident #1 be sent to hospital. Interview with the Supervising Administrator on 9/29/20 at 11:30 AM revealed she would have expected an investigation be completed on the 2/16/20 incident. Interview with the DON on 9/29/20 at 2:20 PM revealed they could not locate an investigation of the incident that occurred on 2/16/20 and the DON stated there should have been an investigation completed for the incident. 415.4(b)(3)

Based on interview, and record review conducted during the Standard survey completed on 8/13/19, the facility did not treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one (Resident #193) of one resident reviewed for dignity. Specifically, Resident #193 reported a medical provider asked personal health related questions in the dining room, during mealtime, with other residents and visitors present, that were embarrassing. The finding is: 1. Resident #193 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan initiated on 8/5/19 documented the resident was alert and oriented x 3 (person, place, time) with memory intact. He was able to make his needs known and is independent with decision making. Review of History and Physical, signed and dated 8/6/19 by MD (Doctor of Medicine) #2 included Resident #193 was seen and examined by MD #2 on 8/6/19. In addition, upon physical exam, MD #2 documented the resident was AAOx3 (awake, alert, and oriented to person, place, or time). Additionally, the MD documented upon interview he reported initially he did have some hematuria (blood in urine) but it was improving, had some intermittent dizziness and reported having loose bowel movements. During a medication administration observation on 8/8/19 at 8:22 AM, with Licensed Practical Nurse (LPN) #2 present, Resident #193 stated, I was having dinner with my wife and another couple when one of the doctors came into the dining room and started to discuss my medical issues, my intestinal and stomach issues. The other couple got up and left the table. It made me feel awkward. It was a violation of privacy and dignity. She didn't even introduce herself. I told the social worker; she said she was going to report this up so administration can look into it, but no one ever got back to me. During an interview on 8/13/19 at 9:48 AM, the Director of Social Work stated, Resident #193 had concerns about a provider discussing issues with him in the dining room. He did not go into detail. I told him I would talk to supervising staff and I informed the DON. During an interview on 8/13/19 at 11:39 AM, the Assistant Food Service Director stated, sometimes the providers will come into the main dining room. They don't usually like to disturb meal service but if they have questions, they will come an speak to residents. During an interview on 8/13/19 at 11:43 AM Certified Nurse Aide (CNA) stated, I have seen the MD's and NP's (Nurse Practitioner) come and talk to people in the dining room. During an interview on 8/13/19 at 11:48 AM, Rehab Aide #1 stated, I have seen providers in the main dining room at meal times, not during the meal, but before and after meals speaking with the residents. During an interview on 8/13/19 at 1:36 PM, MD #2 stated, I did have conversations in main dining room (with Resident #193), but I can't remember the details. I don't remember, I might have, I might not have, spoken about intestinal issues and diarrhea. I don't want to say if I can't really remember. During an interview on 8/13/19 at 12:27 PM the Administrator stated, Providers would not conduct a visit in the main dining room. I would expect they meet with the patient in their room and if a semi-private room to pull the curtain. We also have an office (on the unit) that can be used for private conversations. 415.5(a)

Based on observation, interview, and record review conducted during the Standard survey completed on 8/13/19 the facility did not ensure that residents who use psychotic drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for one (Resident #103) of four residents reviewed for antipsychotic medications. Resident #103 received [MEDICATION NAME] ([MEDICATION NAME], an antipsychotic medication) 0.25 mg (milligrams) QOD (every other day) from 3/21/19 to 6/3/19 for dementing illness associated behavioral symptoms. On 6/3/19 [MEDICATION NAME] was increased to 0.25 mg QD (daily) lacking supporting behavioral documentation and [DIAGNOSES REDACTED]. The findings are: Review of the policy titled Psychoactive Medication Use and Behavior Assessment/ Reassessment dated [DATE] revealed each resident will receive and will be provided the necessary behavioral health care and services to obtain or maintain in the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Any resident who exhibits behaviors or who is on psychoactive medication will be assessed utilizing the BMARC (Behavioral Modification Administration Review Committee) forms. Behavior problems such as: Behavior which endangers the Resident or other Residents; Resistance to care/ refusal; Difficulties dealing with people and coping in the facility such as verbal outbursts; and behavior relating to specific [DIAGNOSES REDACTED]. 1. Resident #103 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 7/12/19 revealed the resident was severely cognitively impaired and is usually understood and usually understands. Section N: documented the resident received antipsychotic medications during the last seven days and on a routine basis only. GDR was attempted 3/21/19 and GDR has not been documented by a physician as clinically contraindicated. The comprehensive care plan initiated 3/28/19 documented the resident was currently prescribed medications for DX (diagnosis) dementia and [MEDICAL CONDITION]. Interventions included to administer [MEDICAL CONDITION] medications as ordered by physician; monitor for side effects and effectiveness every shift; allow calming choices/ non-pharm logical interventions including- coloring books, expressing her thoughts and feelings to staff and family, some music, organizing her room, visit table mates; consult with pharmacy, physician to consider dosage reduction when clinically appropriate at least quarterly; discuss with physician/ family regarding ongoing need for use of medication. Review behaviors/ interventions and alternate therapies attempted and their effectiveness as per facility policy; educate resident/ family/ caregivers about risks, benefits and the side effects and/or toxic symptoms of medications. During an observation and interview on 8/6/19 at 9:55 AM, Resident #103 was in her room in her wheel chair straightening her room. The resident was very appropriate with her answers. Additionally, she was calm and showed no signs of any type of behavior. During an observation on 8/8/19 at 10:10 AM Resident #103 was in her room wiping down her wheelchair and straightening up her room. Surveyor spoke with the resident at that time. Resident showed no signs of behaviors. During of intermittent observations between on 8/12/19 and 8/13/19 between 8:00 AM and 2:00 PM resident stayed mainly in her room. The resident did not display any behaviors. Review of the Medication Review Report signed by the physician on 7/2/19 revealed the following order [MEDICATION NAME] Tablet 0/.25 mg - give one tablet by mouth at bedtime for [MEDICAL CONDITION]. Review of the Medication Review Report signed by the physician 5/7/19 revealed discontinue [MEDICATION NAME] and monitor behavior. Review of the Order Recap Report dated 8/12/19 revealed Resident #103 revealed the following orders: - [MEDICATION NAME] 0.25 mg- give 1 tablet by mouth at bedtime for dementia start date 8/14/18 end date 1/7/19. - [MEDICATION NAME] 0.25 mg- give 1 tablet by mouth at bedtime for anxiety start date 1/7/19 end date 1/9/19. - [MEDICATION NAME] 0.25 mg- give 1 tablet by mouth at bedtime for dementing illness associated behavioral symptoms start date 1/9/19 end date 3/21/19. - [MEDICATION NAME] 0.25 mg- give 1 tablet by mouth at bedtime every other day for dementing illness associated behavioral symptoms start date 3/21/19 end date 6/3/19. - [MEDICATION NAME] 0.25 mg- give 1 tablet by mouth at bedtime for depression start date 6/3/19 end date 6/25/19. - [MEDICATION NAME] 0.25 mg- give 1 tablet by mouth at bedtime for [MEDICAL CONDITION] start date 6/25/19. Review of the Medication Administration Record [REDACTED] - [MEDICATION NAME] 0.25 mg- give 1 tablet by mouth at bedtime from 8/1/18 to 3/21/19. - [MEDICATION NAME] 0.25 mg- give 1 tablet by mouth at bedtime every other day from 3/21/19 to 6/3/19. - [MEDICATION NAME] 0.25 mg- give 1 tablet by mouth at bedtime from 6/3/19 to 8/11/19. Review of the Nursing Progress Notes between 3/3/19 through 8/12/19 revealed there was no documentation regarding any behaviors for Resident #103. Review of Follow Up Question Report for Behavior Symptoms dated 3/1/19 through 7/31/19 revealed there were no behavior symptoms observed. Review of BMARC Committee Follow-up revealed the following: - 4/10/19 [MEDICATION NAME] 0.25 mg recommended to be d/c (discontinued). MD (physician) comments: OK to d/c [MEDICATION NAME] and monitor behavior, signed 4/16/19. - 5/1/19 [MEDICATION NAME] 0.25 mg Recommendations: discontinue of [MEDICATION NAME]. Call Psych to notify. Monitor behavior 30 days. MD comments: d/c [MEDICATION NAME] and monitor behavior. - 6/12/19 Recommendations: Psych MD changed [MEDICATION NAME] on 6/3/19. Please evaluate need for medication to be daily. Patient is asymptomatic at this time. Monitor mood and behavior every shift time 1 month. MD Comments: Monitor behavior and record. - 6/19/19 Recommendations: Clarify indication for [MEDICATION NAME]. MD Comments: change to [MEDICAL CONDITION]. - 7/17/19 Recommendations: [MEDICATION NAME] 0.25 mg every other day for 14 days. Behavior charting. MD comments: discontinue. *Family NOT in agreement * dated 7/17/19. Review of undated Gradual Dose Reduction sheet revealed [MEDICATION NAME] 0.25 mg daily by mouth- resident's family refusing GDR at this time. Resident followed by Psych and prescribed this medication by Psychiatrist. Signed by MD on 5/29/19. Review of undated Gradual Dose Reduction sheet revealed [MEDICATION NAME] 0.25 mg daily by mouth GDR ordered and signed by MD on 7/23/19. Review of the Consultant Pharmacy MRR (Medication Regime Review) revealed there were no recommendations dated 8/31/18; 9/29/18; 10/27/18; 11/29/18; 1/28/19; 2/25/19; 3/30/19; 4/30/19; 5/31/19; 6/30/19. Review of the Consultant Pharmacist Reviews revealed the following: - 12/30/19 This resident is receiving the antipsychotic [MEDICATION NAME] but lacks an allowable [DIAGNOSES REDACTED]. Physician/ Prescriber Response: Agree- per Psychiatrist indication is dementing illness with associated behavioral symptoms. Please see my note for DX signed 1/8/19. - 2/6/19 GDR of antipsychotic recommended. - 5/7/19 Staff does not report and has not documented any ongoing behaviors, a GDR trial for [MEDICATION NAME] should be attempted periodically as dementia is progressive and resident may not exhibit signs and symptoms of behaviors required to support the use of an antipsychotic. Physician/ Prescriber Response: other- will evaluate at next office appointment scheduled 6-3-19, signed by the Psychiatrist and dated 5/7/19. - 7/28/19 Pharmacy consultant had a phone conversation with resident's son. He related a lifelong HX (history) of behavioral issues including several treatments with ECT (electroconvulsive therapy- procedure in which small electric currents are passed through the brain). He lacked written documentation but voiced concern for any changes in medications that could exacerbate her condition. I reviewed the current medication regimen with him including the benefit/ risk and that there may be options if this therapy is considered inappropriate and resident is stable. Medical will have to continue to monitor and determine if therapy continues to be appropriate. Physician/ Prescriber Response: Agree signed and date 7/30/19 Review of an e-mail sent from the Consultant Pharmacist to the DON (Director of Nursing) dated 7/22/19 revealed: I spoke at length with the son. I feel that it would be very difficult for us to compel any changes at this time and might actually be worse for us in light of pending survey. I think I'd like to take a look at some of the documentation again, take a look at some of her options, get some more documentation of a review of our sense of what detriments there might be to making changes at this time. So, we can hopefully support that and take it from there in other words for now. I think getting rid of it or cutting it down further might actually be a problem and we should think of what documentation supports our position. Review of physician progress notes [REDACTED]. - Seen on 3/19/19 under assessments- Dementia with behavior, normal pressure [DIAGNOSES REDACTED]. Her behavior/ [MEDICAL CONDITION] is managed with current meds. Will continue [MEDICATION NAME] and [MEDICATION NAME]. - Seen on 5/7/19 under assessment- Dementia with behavior, normal pressure [DIAGNOSES REDACTED]. Her behavior/ [MEDICAL CONDITION] is stable. Will GDR [MEDICATION NAME] and monitor behavior. Under plan- discontinue [MEDICATION NAME] if OK with Psych consult. - Seen on 7/2/19 under assessment- Dementia with behavior, normal pressure [DIAGNOSES REDACTED]. Her behavior/ [MEDICAL CONDITION] is stable with current [MEDICATION NAME]. Review of the Psychiatrist consultations revealed the following: - Signed and dated 4/1/19 Clinically improving. Patient has difficulty communicating with only one working hearing aid. [MEDICATION NAME] 0.25 mg Q (daily) PO (by mouth) at HS (hour of sleep) and [MEDICATION NAME] ([MEDICATION NAME] - antidepressant) 50 mg by mouth at AM and 25 mg at HS. Follow-up 6/3/19. Reviewed/ Signed and dated by facility Physician on 4/16/19. - Signed and dated 6/3/19 [MEDICATION NAME] 50 mg Q AM and 25 mg Q HS. [MEDICATION NAME] 0.25 mg PO HS. Her son reports patient noted to have increased confused and moody for a couple of months. Her medication log reflects that patient is getting [MEDICATION NAME] every other night. Administer [MEDICATION NAME] 0.25 mg po HS. Next appointment: 8-12-19 at 2:00 PM. Reviewed/ - Signed and dated by facility Physician on 6/14/19. Note the following Psych Consult was done after the facility was made aware of an issue with proper documentation for the use of an antipsychotic medication. - 8/12/19 Continue [MEDICATION NAME] 50 mg Q AM and 25 mg Q HS. [MEDICATION NAME] 0.25 mg PO HS. Patient has H/O (history of) depression with H/O ECT in 2004, with periods of increased confusion and [MEDICAL CONDITION], especially when she was not on [MEDICATION NAME]. Small doses of [MEDICATION NAME] needed to keep her stable. Recently dose was reduced to QOD (every other day) and her symptoms got worse with increased agitation, confusion and paranoid thoughts. During an interview on 8/8/19 at 10:09 AM, Resident #103 stated she was doing well. The Surveyor and the resident had a nice conversation. During the interview the resident was calm and displayed no behaviors. During an interview on 8/8/19 at 11:41 AM LPN (Licensed Practical Nurse) #1, Unit Manager stated, The nurses place their behavior charting in the progress note section in the electronic medical records. CNAs (certified nurse aide) record the behaviors in the task part of the electronical medical record. Resident #103 will get antsy and agitated at time, really fast. We will do 1:1 which helps at the time, but for the remainder of that day she still is antsy and agitated. I have not seen any other behaviors. The BMARC has recommended discontinuing the [MEDICATION NAME] several times, but the son is so against discontinuing the [MEDICATION NAME]. The resident herself has said to leave her on the medication, but no I do not think she would be able to make that decision. During an interview on 8/8/19 at 12:04 PM, the Rehab Aide/ CNA #1 stated, I will do ROM (range of motion) with her and assist her when needed. Most of the time she is pretty good and will do what you ask her to do. She is never aggressive or has behaviors. She is more confused than anything, sometimes not always. I still try to assist her when she is confused, and she is fine. She is a very sweet lady, she likes her room neat and in a certain way. During an interview on 8/8/19 at 12:24 PM, SW (Social Worker) #1 stated, Resident #103 has periods of weepiness and periods of getting worked up, anxious. I usually talk with her. Sometimes it calms her down. She is a busy body and she likes everything a certain way. She sees the outside Psych and they did not want to change recommendations made by the BMARC. Medication wise I cannot comfortable speak on them. I do attend the BMARC meetings. During an interview on 8/8/19 at 3:11 PM, LPN #1, Unit Manager stated, This order that was written on 5/7/19 to d/c [MEDICATION NAME] and monitor behavior was never ordered and placed in the computer. I do not know why this was never done. If the physician decided he did not want this, we would have written on it and had the physician sign it. I am not sure what to tell you about this order as I was not down here at the time it was written. The unit manager who was here at the time is no longer here. During an interview on 8/8/19 at 2:00 PM, the Pharmacy Consultant stated, We did a GDR from (MONTH) to June. It was increased back up to everyday because of the psych recommendation. I did make a recommendation in 12/2018 to the physician to consider an appropriate diagnoses/ conditions for the use of the [MEDICATION NAME] which on 6/25/19 it was order for [MEDICAL CONDITION]. I do not know if there was any documentation from nursing reporting this type of behavior. On 5/7/19 I did write a recommendation that staff does not report and has not documented any ongoing behaviors and recommended a GDR trial for [MEDICATION NAME]. I do attend the BMARC meetings. At that time the psychologist wanted to wait for the residents next office visit which is when the medication was increased back to daily. I did speak to the son recently regarding the use of these medications in the elderly and explained the goal is to reach the lowest affective dose usage possible. The son explained to me that his mother all her life has been on these types of medications and has gone through ECT (electroconvulsive therapy) three times and does not feel comfortable taking his mother off this medication. Son did state he does not have supporting documentation for this, but I feel that at this time we should leave this residents medication alone. The dose was lowered from (MONTH) 2019 to (MONTH) 2019 and the resident did not have any behavior changes, but psych felt we made a mistake by doing this and that is why they increased it back to daily. During a telephone interview on 8/9/19 at 8:57 AM, the Physician stated, I increased the [MEDICATION NAME] back up on 6/3/19 probably because the staff were complaining to me that the resident was having increased behaviors. I did not check the chart for any behavior documentation. It may also have been because of the son. I cannot remember, but families will get mad sometimes and I try to take everything into consideration. I have to listen to both the staff and the families. I rely on the staff a lot because I am only there one day a week. I do follow the BMARC and Pharmacy recommendations. 415.12(1)(2)(i)

Based on observation, interview and record review conducted during an Abbreviated survey (complaint # NY 458) completed 3/28/13, the facility did not ensure that residents are free of significant medication errors. Specifically, for one (Resident #1) of three residents reviewed for medications, the facility did not ensure that the resident received [MEDICATION NAME] (a blood thinning medication used to prevent blood clots and stroke in people with [MEDICAL CONDITION] (irregular heart rate), as ordered by the physician. The resident subsequently was admitted to the hospital with [REDACTED]. The finding is: 1. Resident #1 was admitted to the nursing home on 3/22/13 for short term rehab (rehabilitation) with [DIAGNOSES REDACTED]. Review of hospital Progress Notes dated 3/16/13 through 3/18/13 revealed that the resident had a history of [REDACTED]. An Orthopedic Progress Note dated 3/16/13 documented "acknowledging risk of stroke, recommend hold [MEDICATION NAME] till Tuesday" for the planned surgical repair of the resident's left [MEDICAL CONDITION]. Review of a hospital Progress Note dated 3/21/13 revealed the [MEDICATION NAME] was resumed and the hospital Discharge Summary dated 3/22/13 documented that Discharge Medications included [MEDICATION NAME] 150 milligrams (mg) twice a day. Review of a "Physician's Statement" completed by the Attending Physician at the time of the initial H&P (History and Physical) dated 3/22/13, revealed that the resident had good rehab potential and the capacity to handle her own affairs. Review of physician's orders [REDACTED]. Review of a Pharmacy Delivery Sheet dated 3/22/13 and signed by facility staff revealed that the medication [MEDICATION NAME] was delivered to the facility for Resident #1. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Nurses' Medication Notes, on the back of the MAR, dated 3/23/13, 3/24/13 and 3/26/13 documented "[MEDICATION NAME] not given, not in from pharmacy". Review of Interdisciplinary Progress Notes and 24-Hour Report Sheets, dated 3/22/13 through 3/26/13, revealed no documented evidence that the physician was notified that the [MEDICATION NAME] was not available/ administered. Review of a Nursing Progress Note dated 3/26/13 at 11:57 AM revealed the resident was laying in bed in a supine (lying down with the face up) position with her head slightly elevated, and was "noted to have right sided facial droop, right sided weakness and irregular breathing. Patient unable to answer questions and only arousable by sternal rub (aggressive rubbing of the breastbone with the knuckles to assess the level of responsiveness)". "Order obtained from MD (medical doctor) to transfer patient to hospital for evaluation". Review of an ED (emergency department) MD Note dated 3/26/13 revealed that the resident presented to the emergency room with right sided weakness, facial droop, confusion and the inability to speak. The ED MD Note documented that a CTA (computerized tomography angiogram - a diagnostic test that provides detailed images of the blood vessels in the brain) of the head showed that the resident had an acute stroke. The ED MD assessment documented that the resident had an acute [MEDICAL CONDITION] ([MEDICAL CONDITION] -stroke) and was admitted to the hospital. Review of a facility policy entitled Medication Administration Standards, last revised 11/10, revealed that if a medication is not available before the end of the shift, the nurse/ Supervisor must notify the MD (medical doctor) to obtain an order either to "hold" (not administer temporarily) until the medication is delivered or obtain an order for [REDACTED]. The Administrator and the ADON (Assistant Director of Nursing) confirmed during an interview on 3/28/13 at approximately 8:50 AM that the resident did not receive any doses of [MEDICATION NAME] during her stay at the facility from 3/22/13 through 3/26/13 because the nursing staff assumed that the medication was pending delivery from the pharmacy and did not notify the attending physician that the medication was not available. The ADON stated that she noted an "issue" with the resident's [MEDICATION NAME] when she worked the 11:00 PM to 7:00 AM shift on March 24th into the morning of the 25th and instructed the RN (Registered Nurse) Rehab Unit Coordinator to follow up. The ADON stated that the [MEDICATION NAME] was eventually located in another medication cart on the unit by the RN Rehab Unit Coordinator on 3/26/13. The Administrator and ADON stated that it is their expectation that when a medication is not available, nursing should contact the pharmacy and notify the doctor for an alternative medication by the end of the shift. Nursing staff is educated to the process in orientation. The full-time RN Rehab Unit Coordinator stated during an interview on 3/28/13 at approximately 1:10 PM that she was first made aware of an "issue" with the resident's [MEDICATION NAME] on Monday, 3/25/13 at approximately 7:00 AM, when the ADON, brought it to her attention. The RN Unit Coordinator stated that she did not ask what the "issue" was and put it on her list of issues to address. The RN stated that she did not address the issue on 3/25/13. The RN Unit Coordinator explained that on 3/26/13 at approximately 8:00 AM, the LPN (Licensed Practical Nurse) Team Leader informed her that the resident still did not have her [MEDICATION NAME]. The RN checked the pharmacy delivery sheet that showed the [MEDICATION NAME] was delivered on 3/22/13, she called the pharmacy and a Pharmacist informed her that the medication was delivered on 3/22/13. The RN Unit Coordinator stated she proceeded to check all the medication carts on the unit and located the [MEDICATION NAME] on the Team 3 medication cart. The RN stated that "ideally, no medications should be missed and that the doctor should have been notified". The part-time RN Rehab Unit Desk Nurse stated during an interview on 3/28/13 at approximately 1:30 PM that her normal hours of work are 9:30 AM to 10:00 PM. The Desk RN stated that on the evening of 3/25/13, she was "pulled off the desk" to pass medications, she noticed that the resident had not received [MEDICATION NAME] since admission and it was unclear to her as to why. The Desk RN stated that she informed the oncoming Desk Nurse that she did not follow up. The Desk RN concluded by stating "I know the importance of the medication ([MEDICATION NAME]) and I should have taken matters into my own hands". The full-time LPN Team Leader (staff nurse) stated during an interview on 3/28/13 at approximately 2:00 PM that he worked the day shift (7:00 AM to 3:00 PM) on 3/23/13, 3/24/13, and on 3/26/13. The LPN stated he believed that the resident's [MEDICATION NAME] was not delivered from the pharmacy because it was not on his medication cart. The LPN stated that he contacted the pharmacy on 3/23/13 and 3/24/13 and that he believed that the medication was going to be delivered based on his conversation with the pharmacy. The LPN stated that he notified the Desk Nurse that Resident #1 had not received the [MEDICATION NAME] and passed the information along to the oncoming nurse to expect the medication with the next pharmacy delivery. The LPN concluded by stating that he did not notify the doctor because that was not within his scope of duties as an LPN Team Leader. The Attending Physician / Medical Director stated during an interview on 3/28/13 at approximately 2:30 PM that his expectation was to be notified that the [MEDICATION NAME] was not available so he could have ordered an alternative medication that was readily available in the facility to prevent blood clots or stroke. The Physician stated he was present in the facility every day except Saturday (3/23/13). 415.12(m)(2)