Every finding on record at Heritage Green Rehab & Skilled Nursing

Based on interviews, observations, and record review conducted during a survey the facility did not ensure there was sufficient staff on a 24-hour basis to attain or maintain the highest practicable physical, mental and psychosocial well-being for residents in the facility. Residents #1, 2, 5, 7, 22, 37, 43, 60, 71, 76, 79 and 85 involved. The findings are: The Facility Assessment with a completed date of 02/16/2026, and a QAA (Quality Assessment and Assurance)/QAPI (Quality Assurance and Performance Improvement) review completed 8/26/2025 documented the facility has a secure dementia care unit (41 beds), long-term care unit compromised of 42 beds and another 51 bed that admits primarily short- term rehab. At least 65 percent of the facility's residents needed some assistance with dressing and bathing, 88 percent of residents needed some assistance with transfers, 93 percent needed some assistance with toileting, and 30 percent of residents needed some assistance with eating. The facility will ensure that there is sufficient and competent nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. The facility will make decisions on required staffing based on resident census, resident acuity/needs, facility odors, complaints, call-lights, and staff's ability to complete assignments. The assessment included a facility staffing plan that would be based on resident needs. The total number of licensed practical nurses providing direct care needed/average of eight (8)-11; nurse aides 15-24; other nursing personnel one (1) - two (2) unit managers, and one (1) Minimum Data Set Nurse per day. The facility is licensed for 134 beds and has a daily average census of 111 residents. The policy and procedure titled Emergency Staffing Strategies with a revised date of 01/06/2024, documented bonuses and incentives may be offered, as appropriate, to enlist available and/or able staff, and that staffing agencies would be contacted for possible staffing assistance. The undated policy and procedure titled Call Bell Policy documented all staff were responsible for answering call bells, and to answer the call bell promptly when sounded. Staff are not to turn off the call bell unless they are able to provide assistance. Review of the Payroll Based Journal staffing report for Quarter 4 July 2025 - September 2025 revealed the facility had a one-star rating for staffing and triggered for low staffing levels on weekends. The facility resident census at the time of survey entrance on 02/23/2026 was 115. The undated document titled Heritage [NAME] Minimal Staffing Numbers, provided by the Facility Scheduler documented at a minimum they required: Nurses: 1st shift = four (Lake (1) Park (1) [NAME] (2)) 2nd shift = four (Lake (1) Park (1) [NAME] (2)) 3rd shift = three (Lake (1) Park (1) [NAME] (1))Certified Nurse Aides: 1st shift = six (Lake (2) Park (2) [NAME] (2))2nd shift = six (Lake (2) Park (2) [NAME] (2))3rd shift = three (Lake (1) Park (1) [NAME] (1)) Review of the facility daily staffing sheets dated 01/22/2026- 02/11/2026 revealed the Director of Nursing was counted in the facility's numbers to meet their minimum staffing numbers for direct care to the residents.During a telephone interview on 02/23/2026 at 9:59 AM, the Ombudsman stated they had received resident complaints regarding staffing issues. There were reported concerns of long call bell wait times, staff turnover, and resident appointments having to be cancelled because there was not enough staff to go out on transport with the residents. During a dining observation on 02/23/2026 at 11:50 AM, a meal cart was delivered to the [NAME] Unit by a kitchen staff member. Staff did not start passing trays until 11:59 AM. During an interview on 02/24/2026 at 9:14 AM, Resident #37 stated the coffee was lukewarm because there were not enough staff to pass trays. During an interview on 02/23/2026 1:47 PM, Resident #7 stated the facility did not have enough staff because they had to wait almost three (3) hours for their call light to be answered. Resident #7 stated they usually made their own bed because staff did not get to it in a timely manner. During an interview on 02/23/2026 1:34 PM, Resident #5 stated they have waited over an hour to go to the bathroom and ended up having to go in their brief, which was not right. Staff had told them they did not have enough help to get to them in time. During an interview on 02/24/2026 at 9:24 AM, Resident #22 stated there were not enough staff to help the residents with their needs. Resident #22 stated their call bell wait times were long, but when they finally answered, the staff were good. During the Resident Council meeting on 02/24/2026 at 10:04 AM, Residents #1, 43, 60, 79 and 85 were present. The residents stated they had monthly meetings, and staffing was a topic that was always discussed. The group all agreed that there were not enough certified nurse aides in the building. Resident #1 stated that they knew when a resident had to be transferred with a machine that two staff members were supposed to do it. They stated that at times staff would perform that transfer with only one staff member. Resident #1 also stated at times there were not enough staff to assist residents with eating, and they would help the residents sitting next to them. During an interview on 02/24/2026 at 10:48 AM, Resident #2 stated the facility did not have enough aides to go around and it was frustrating. They stated the staff would deliver their meals late and at times their call light could ring for an hour before they showed up to answer it. During a an interview on 02/25/2026 at 1:21 PM, the Food Service Director stated they get some resident complaints of food being cold, so they recently started doing more test trays. They stated they felt the issue was that there were not enough staff on the units to pass the trays timely. They stated the carts were usually delivered on time, but the staff might be providing care and unable to start passing them immediately. During an interview on 2/25/2026 at 10:14 AM, Licensed Practical Nurse #5 stated they had to start with one aide that morning from 6:00 AM until 7:30 AM. If a resident required two staff assist, they had to stop what they were doing and help the certified nurse aide. They stated that it happened more often than it should. There were usually only two (2) certified nurse aides and there were a lot of staff call offs. Licensed Practical Nurse #5 stated they usually stayed late to get their work done. During an observation and interview on 02/26/2026 from 10:05 to 10:39 AM, Resident #71's call light was observed to be activated for 10 minutes at 10:05 AM. Resident #71 was on the toilet, waiting for staff to return to get them off the toilet with the mechanical lift. At 10:39, Licensed Practical Nurse #4 and Certified Nurse Aide #2 entered the room with the lift. They provided toileting hygiene and assisted Resident #71 into their wheelchair. Certified Nurse Aide #2 stated it was difficult to get to all the residents timely with only two (2) Aides on the unit. During an interview on 02/26/2026 at 11:00 AM, [NAME] #1 stated they have reported trays often sat for extended periods of time before being delivered to residents by the unit staff. They recalled one time the [NAME] Unit had not yet served a breakfast cart until 10:25 AM which had been delivered at 8:25 AM. During an interview on 02/26/2026 at 12:35 PM, the family of Resident #76 stated they had not been happy with their family member's care recently. They stated the call bell wait times were too long. The staff will answer the bell but do not always come back when they said they would. During an interview on 02/26/2026 at 12:41 PM, Certified Nurse Aide #3 stated it was difficult to get their work done when they only had two (2) aides on the unit, which was almost every time they worked. They stated that they usually got everything done, but they knew the waiting times were long, and sometimes they were unable to get everyone their scheduled showers. During an interview on 02/26/2026 at 12:45 PM, Certified Nurse Aide #2 stated they always stayed late to complete their work and documentation. During an interview on 02/26/2026 at 4:35 PM, the family of Resident #5 stated their biggest concern was not having enough help to get their family to the bathroom in time; so, they had to go in their incontinence brief. They also stated the food was always cold. They have been there at lunch many times and have watched the trays sit in the cart for a long time before getting passed to the residents. During an interview on 02/272026 at 9:10 AM, the facility Scheduler stated there were times when there were not enough staff to work, but they would keep trying to get other staff to come in. They did not feel the facility minimum numbers were enough for providing good care to the residents, but the staff did their best and worked very hard. They could not say that staff called off because they were tired of working short staffed, but there were more call offs when the schedule was short. The facility Scheduler stated they were not currently utilizing agency staff. During an interview on 02/27/2026 at 9:55 AM, Activities Aide #1 stated the facility had less staff on the weekends. Activities Aide #1 stated there have been many times that residents missed an activity because there was no one to get them ready. They would go to their rooms for 1:1 if that happened. During an interview on 02/27/2026 at 10:24 AM, Registered Nurse Unit Manager #2 stated their unit typically had an average daily census of 39 residents and typical staffing consisted of two nurses and two or three aides on the day shift; two nurses and two aides on the evening shift; and one nurse and one aide on the night shift. They stated with those staffing numbers, the residents on the unit had their basic needs met but nothing beyond that. Registered Nurse #2 stated there was not a lot of extra time for social interaction with the residents and they felt their unit could use additional staff. They stated the resident wait time for care was long and the unit had multiple two assist transfers that added to an additional longer wait time for the residents. During a telephone interview on 02/27/2026 at 11:06 AM, Certified Nurse Aide #5 stated they worked 10:00 PM to 10:00 AM and usually they were the only aide on their unit. They stated they had got their work done but they knew the call light wait times were long. Certified Nurse Aide #5 stated they often had to get the nurse or an aide from another unit to help them, and they always stayed late to get their documentation done. During an interview on 02/27/20 at 11:07 AM, Licensed Practical Nurse #1 stated they worked on the day shift but would also pick up a lot of extra time on the evening shift. They stated they could not get all of their duties completed in an 8-hour shift but always stayed over their scheduled shift to ensure their work was done. Licensed Practical Nurse #1 stated they usually worked with just one aide in their hallway. They stated one aide working in a hallway was not enough staff and they spent a lot of their own shift helping get residents dressed, assist with feeding, assisted with transfers and toileting. They stated those types of duties took time away from their nursing duties. Licensed Practical Nurse #1 stated at times the aides cannot complete charting, showers, afternoon toileting and putting the residents back to bed in the afternoons. During an interview on 02/27/2026 at 11:49 AM, the [NAME] President Skilled Nursing Facilities Operations stated they were aware some residents had concerns with call bell wait times. They stated they tried to address each resident's specific concern. They were aware that staff complained about working short staffed, and they did have issues with call offs. During an interview on 02/27/2026 at 12:48 PM, the Director of Nursing stated they were aware their minimum staffing was not ideal, and it was not their goal for scheduling. They stated the staff had to work very hard when there were only two (2) of them on a unit. The Director of Nursing stated they were aware of the concerns regarding long call bell wait times. They have educated all staff to respond to the call bell and try to find someone who was able to help. They have worked through resident and family grievances and try to address each resident/family concern individually. They make care plan updates to meet each residents' needs. Staffing is their number one concern. During interviews on 02/27/2026 at 10:45 AM and 2:24 PM, the Administrator stated they had received complaints about food temperatures and that temperature audits were conducted and discussed in morning meetings and at resident council. They knew there were times when staff did not pass food trays promptly; they observed delays of about 10 minutes and notified the nurse manager and assisted when needed. They expected trays to be passed immediately to avoid foodborne illness and to ensure residents receive hot meals. The Administrator stated they were aware of the staffing concerns and long waiting times. Staffing was the top priority, and they discussed it every morning. They stated the minimum staffing numbers were not their goal. 10 New York Codes Rules Regulations 415.13(a)(b) (1) (i)

Based on interview and record review conducted during a survey the facility did not ensure the Director of Nursing served as a charge nurse, only when the facility had an average daily occupancy of 60 or fewer residents. Specifically, the Director of Nursing worked as a charge nurse when the facility had a daily average census of greater than 60. The findings are:Review of the undated document titled Director of Nursing Job Description documented that within the framework of the objectives and policies established by the Corporation, and the New York State Department of Health regulations, the Director of Nursing is responsible for planning, directing, and coordinating nursing services. Under the supervision of the Administrator, the Director of Nursing exercises authority, responsibility and accountability for the functions, activities and training of the nursing service staff. Participates as a member of the facility management team in planning, policy formulation, and administrative decision making with particular reference to the role, function, and operation of the facility's nursing services. Is responsible for the overall management of resident care 24 hours a day, seven (7) days a week. Additionally, the Director of Nursing ensures a sufficient number of qualified supervisory and supportive nursing personnel are assigned for each tour of duty to meet the resident's needs and nursing standard of care. The State Operations Manual dated 07/23/2025, documented a Charge Nurse is a licensed nurse with specific responsibilities designated by the facility that may include staff supervision, emergency coordinator, physician liaison, as well as direct resident care.The documents titled Census Summary Reports by Location for January 23, 2026- February 23, 2026, documented the following:01/28/2026 the resident census was 11302/05/2026 the resident census was 11502/11/2026 the resident census was 116 The facility census at the time of survey entrance on 02/23/2026 was 115 out of 135 available beds.The undated document titled Heritage [NAME] Minimal Staffing Numbers, provided by the Facility Scheduler documented they required two (2) nurses on [NAME] Unit for the 6:00 AM - 2:00 PM, and 2:00 PM - 10:00 PM shifts.Review of the facility daily staffing sheets dated 01/22/2026- 02/11/2026 revealed the Director of Nursing was counted in the facility's numbers to meet their minimum staffing numbers for direct care to the residents.02/05/2026 2:00 PM- 10:00 PM shift:Wood Unit- Director of Nursing worked 6:00 PM- 10:00 PM, acting as the second nurse on the unit. 02/11/2026 2:00 PM- 10:00 PM shift:Wood Unit- Director of Nursing worked 6:00 PM- 10:00 PM, acting as the second nurse on the unit. From 9:21 PM until 10:00 PM the Director of Nursing was the only nurse on the unit. During an interview on 02/27/2026 at 9:10 AM, the Facility Scheduler stated they tried not to have the Director of Nursing act as a staff nurse for the facility very often. They only did it when they were instructed to do so by the Director of Nursing or the Administrator. The Facility Scheduler was not aware that the Director of Nursing was not supposed to act outside their role as the Director of Nursing. They stated there were days that there were not enough staff, they tried their best to find coverage, but occasionally the Director of Nursing would help out. The Facility Scheduler stated the minimum staffing numbers were not ideal numbers of staff. It was very difficult for the staff to get all their work done and provide good care to all the residents. During an interview on 02/27/2026 at 12:48 PM, the Director of Nursing stated they were not aware of the exact regulation regarding the Director of Nursing acting as a charge nurse, they just thought it was frowned upon. They knew that the staff needed help, and they felt obligated to help them. They stated they would act as a certified nurse aide, a housekeeper or a medication nurse, whatever they needed at the time. They stated they were always available as the Director of Nursing while they were acting in a different role. During an interview on 02/27/2026 at 2:24 PM, the Administrator stated the minimum staffing numbers were not what their goal was. They always tried to have adequate staff, but they were also willing to help if their staff and residents needed them. 10 New York Codes Rules Regulations 415.13(b)(1)

Based on observation, interview, and record review conducted during the Standard survey completed on 02/27/2026, the facility did not ensure: they assessed all residents for risk of entrapment from bed rails prior to installation, or provide documentation that preventive maintenance was conducted for all bed rails for three (3) (Residents #5,14, and 118) of three (3) residents reviewed. Specifically, the quarter side rails were loose and not secure (Resident's #5 and #14); and there was no documented evidence of routine preventative maintenance (Resident #5, 14, & 118). In addition, the quarter side rails were installed in error and not reflected on the care plan (Resident #5 and #118). The findings are: The policy and procedure titled Side Rail Use revised 10/2021 documented the intent of this policy and procedure is to provide a safe bed environment through assessment and planning of each resident's needs. Side Rail Safety Assessments shall be completed upon admission. Residents who are care planned to use side rails shall be assessed quarterly and with each significant change as long as they use side rails. The Registered Nurse shall list options or alternative equipment interventions to be taken to the Interdisciplinary Team Care Plan meeting for discussion and implementation. A Registered Nurse shall complete a care plan for residents assessed and found to be safe for using side rails. In the event resident(s) opt to utilize bed rail (s), the bed rails will only be used if the bed & bed rail system passes an entrapment- assessment to be completed by the maintenance department. The Registered Nurse, in conjunction with the Interdisciplinary Care Plan Team, may discontinue side rail use when it is determined the risk outweighs the benefit. 1.Resident #5 had diagnoses including wedge fractures (a compression fracture of the spine, where the front part of the vertebra collapses, creating a wedge-shaped deformity), difficulty walking, and cognitive communication deficit (impairment involving underlying issues like memory, attention, organization, and executive function). The Minimum Data Set ( a resident assessment tool), dated 01/14/2026, documented Resident #5 was cognitively intact, always understood & always understands others. Resident #5 required supervision by staff for bed mobility, and bed rails were not used. The comprehensive care plan dated 01/14/2025, documented Resident #5 had impaired functional status related to wedge compression fractures. They required partial/moderate assistance from staff for transfers; they were independent for bed mobility and had no bed rails. Review of the Use and Care Manual for the Encore series (Bed Manual), Resident Care Bed, revealed the bed required preventive maintenance every six (6) months. The facility should check the action of the side rails; the rails should move freely through their range, latch fully when raised, and not be excessively wobbly when raised.The Side rail assessment dated [DATE], documented Resident #5 was a high risk for injury. No side rails noted to bed. Risks reviewed with verbal understanding by the resident. The Side rail assessment, dated 05/02/2025, documented no side rails. The Side rail assessment, dated 01/26/2026, documented no side rails, risks of use and nonuse explained with understanding. During an observation and interview on 02/23/2026 at 1:41 PM, Resident #5 was in their recliner next to their bed. Their bed had gray plastic side rails on both sides of the upper portion of the bed (approximately 12 inches wide by 18 inches tall). Both rails were loose and wobbly. The bed also had a red foam padded area beneath the mattress covering the metal frame. During additional observations on 02/25/2026 at 10:11 AM, and 02/26/2026 at 9:59 AM, Resident #5's bed had the two gray upper side rails, and they were loose and wobbly. Resident #5 stated they used the bed rails to get into bed at night. They stated they never hurt themselves on the side rails.During an interview on 02/26/2026 at 11:02 AM, Registered Nurse #2, Unit Manager stated the side rail assessments were completed by a Registered Nurse, sometimes with the help of therapy. They stated that if the side rail assessment said no rails, it could be because the resident did not want them or because they were unsafe. Occasionally the side rails are already on the bed and they have to do the assessment to make sure the resident is safe. Registered Nurse #2 stated they did not know what maintenance tested with the side rails, but they thought they measured for the risk of entrapment. They stated the side rail assessments should be completed quarterly. Registered Nurse #2 stated that Resident #5 did not have side rails, and if they did, they did not know who put them on. During an interview on 02/26/2026 at 4:35 PM, Resident #5's daughter stated that Resident #5's bed was the same one they had when they first came to the facility, and the side rails had been on the bed the whole time. During an interview on 02/26/2026 at 4:35 PM, Resident #5 stated they had not seen anyone check on the side rails. During an interview on 02/27/2026 at 12:33 PM, the Director of Nursing stated the side rail assessment was done to assess the risk of entrapment and to determine whether the resident was able to use them. They stated side rails were used to help residents with mobility, but with cognitively impaired residents they were risky because they had poor safety awareness. The Director of Nursing stated if the side rail assessment documented no side rails, the resident should not have side rails. They stated that Resident #5 should not have the side rails, and someone should have noticed they were there and not on their care plan. The Director of Nursing stated that Certified Nurse aides and Licensed Practical Nurses had to sign off on the care plan every day. They should have noticed the side rails were not supposed to be there. The Director of Nursing stated that unit managers were supposed to do quarterly side rail audits. 2.Resident #14 had diagnoses including Fournier Gangrene (flesh eating disease of the genital), diabetes mellitus and morbid obesity. The Minimum Data Set, dated [DATE], documented the resident was cognitively intact, understood and understands. Resident #14 was dependent on staff for rolling left to right for bed mobility and side rails were not used. Review of the Comfort Q Series Beds Parts and Maintenance Manual dated 09/00 documented that every facility should incorporate a good preventative maintenance program. Equipment should be checked periodically to catch problems. The comprehensive care plan dated 01/29/2026 documented Resident #14 was independent with bed mobility and had two upper side rails. The document titled Side rail assessment dated [DATE], Registered Nurse #1 Unit Manager documented at 2:01PM that Resident #14 utilized one (1) staff member for bed mobility and Resident #14 had two upper side rails. The risks of entrapment with use/non-use were discussed with resident/family with a verbal understanding expressed. During an observation and interview on 02/24/2026 at 9:43 AM and 02/25/2026 at 11:17 AM Resident #14 had two (2) gray quarter side rails up on both sides of their bed. Resident #14 stated they used the side rails for bed mobility. The side rails were loose and wobbly from them yanking them when turning over in bed. Resident #14 then stated they had been there for three (3) years, and no one had checked the side rails to ensure they were secured. Resident #14 never asked to have them tightened. During an observation and interview on 02/26/2026 at 11:33 AM Certified Nurse Aide #6 observed Resident $14's side rails, shook them, and stated they were loose. Certified Nurse Aide #6 stated Registered Nurse #1 Unit Manager checked the rails every three (3) months to make sure they were steady, and residents still required them. 3.Resident #118 had diagnoses including dementia, pneumonia, and anxiety. The Minimum Data Set, dated [DATE], documented Resident #118 had moderate cognitive impairment, sometimes understood and sometimes understands. Resident #118 was independent for rolling left to right for bed mobility and side rails were not used. The comprehensive care plan dated 03/12/2025 documented Resident #118 was independent with bed mobility with no side rails. Review of the Side rail assessment dated [DATE] at 2:33 PM, revealed Registered Nurse #1 Unit Manager documented that Resident #118 was independent for bed mobility and Resident #118 had no side rails. The risks of entrapment with use/non-use were discussed with resident/family with a verbal understanding expressed. During observations on 02/24/2026 at 9:17 AM, 9:45 AM and on 02/25/2026 at 11:30 AM Resident #118 was asleep in bed. There was one (1) quarter side rail up on the left side of the bed. The quarter rail on the right side of the bed was in the down position. The Maintenance Supervisor provided a binder and a folder that included what they identified as preventative maintenance logs and bed system measurement device test results worksheets on 02/25/2026. The binder contained logs that were dated for the years 2024 and 2025. The logs included the unit where the bed was located, room number of the bed, model number of the bed and manufacturer and serial number of the bed. There was no documented routine preventative maintenance for the side rails and there were no logs for the year 2026. The folder contained the most current documentation of bed system measurement device test results worksheets that were dated 2023. There were no additional worksheets. During an interview on 02/26/2026 at 9:26 AM the Maintenance Supervisor stated there were three (3) styles of beds and that maintenance was responsible for checking the beds for entrapment. Entrapment was measured based on the style and specific type of bed, not resident specific and they had no current records of entrapment checks. The side rails were visually checked every six (6) months, and they had no documentation of routine inspections of the side rails. They were notified if a rail was loose or not secure by the nursing staff by E maintenance (a program used for communication) and they had no notifications for loose side rails. During observation and interview on 02/26/2026 at 11:57 AM, Facility Technician #1 measured the quarter side rails at twenty-one and 3/4 inches by 10inches by 1/4 inches. They stated they checked the beds monthly for broken parts, wires or defects and physically pulled up on the side rails to make sure they were secure. The Facility Technician #1 shook Resident #14 side rails and stated they were loose, but the side rails were not going anywhere as it would be impossible for the rails to snap or break off and cause injury. Preventative maintenance was done every six (6) months, but they did not document specifically on the side rails. During an interview on 02/27/2026at 8:15 AM, Registered Nurse #1 Unit Manager stated maintenance was responsible to install or take side rails off and measure for entrapment. They expected the staff to notify them of Resident #14's loose side rails. They would have contacted maintenance to tighten them. When the side rails were loose and wobbly they could snap during bed mobility, fall off and cause a fall out of bed. Resident #118's care plan said no devices for bed mobility, and they discovered on 02/26/2026 the side rail should not have been up. They would have expected the aides to let them know that Resident #118's rail was up by checking the care plan. Resident #118 could have sustained a skin tear or had a fall related to the side rail being up. During an interview on 02/27/2026 at 9:20 AM, Physical Therapist #1 stated Registered Nurse #1 Unit Manager was responsible for completing side rail assessments and updating care plans. Loose side rails put Resident #14 at risk of getting caught or having a fall. Routine inspections would ensure the side rails were secure on a routine basis and could prevent injury. During an interview on 02/27/2026 at 1:55 PM, the Director of Nursing stated Registered Nurse #1 Unit Manager did the side rail assessments. Physical therapy determined if side rails were safe for Resident #14 and maintenance determined that the side rails were compliant and did not pose an entrapment risk. The Director of Nursing expected maintenance to keep track of preventative maintenance of the side rails that should be done per the equipment manual and could not explain the lack of documentation. Someone should have noticed Resident #118's rail was up and reported it to the Unit Manager. Registered Nurse #1 Unit Manager should have caught that the side rail was up when doing Resident #118's quarterly assessment. Having the side rail posed an injury risk for Resident #118 as they could have bumped their arm, caused bruising or a skin tear. If Resident #118 was not as mobile as they are the side rail in the up position could have caused falls and there would be the risk for entrapment. During an interview on 02/27/2026 at 2:11 PM, the Administrator stated the Unit Managers were responsible for the side rail assessments. Maintenance installed the side rails after an entrapment risk was done. Maintenance should have been documenting preventative maintenance routinely with consistency and should have incorporated specifics of the beds in addition to the side rails to all be part of one routine preventative maintenance program. 10 NYCRR 415.12(h)(1)

Based on observation, record review, and interviews during a survey, the facility did not ensure that services provided or arranged by the facility met the current professional standards of quality for one (Resident #82) of one resident reviewed. Specifically, Resident #82's medications were not administered as per the physician's order, medications were left on resident's overbed table, and nursing staff documented that the medications were administered in the Medication Administration Record. The findings are. Refer to F 761 scope and severity = D The policy and procedure titled Medication Administration dated 10/17/2019 documented only licensed nurses shall prepare and administer medications. The designated licensed nurse shall prepare medications immediately prior to administration; be certain that the resident takes the prescribed medication in their presence; and never leave any medication in the resident's possession or at the bedside unless the physician orders in writing, state to do so. Each medication given is to be recorded on the resident's medication record. The policy and procedure titled Self-Administration of Medications dated 11/03/2015 documented when a resident chooses to accept the responsibility for self-administration of drugs the interdisciplinary team will assess the resident's cognitive, physical, and visual ability to carry out this responsibility; determine whether or not this would be a danger to resident or others; and document date of re-evaluation and determination. Resident #82 had diagnoses that included congested heat failure (a condition where the heart is too weak to pump blood), hypertension (high blood pressure), and chronic obstructive pulmonary disease (chronic lung disease). The Minimum Data Set (a resident assessment) dated 02/06/2026 documented Resident #82 was cognitively intact. The comprehensive care plan dated 01/30/2026 documented Resident #82 was alert and oriented x3 (person, place, and time) and medications were to be administered as ordered.The Physician Orders dated 01/30/2026 - 02/27/2026 documented an order for Potassium Chloride (electrolyte supplement to prevent low blood potassium)10 milliequivalent extensive release tablet, give two (2) tablets to equal 20 milliequivalents once daily in the morning. The Medication Administration Record dated 02/2026 documented Resident #82's Potassium Chloride was signed out as administered on 02/24/2026 at 6:25 AM, 02/25/2026 at 7:06 AM, and 02/26/2026 at 6:35 AM.During an observation and interview on 02/24/2026 at 8:55 AM, Resident #82 was observed sitting in their room in a recliner chair with two (2) yellow pills observed on the bedside table in a small round clear plastic container with a lid. Resident #82 stated the two pills were potassium and they preferred to take it at night. They stated the nurses brought the medication into them in the morning and they would put it to the side to take later before bed. Intermittent observations made on 02/24/2026 at 4:22 PM, 02/25/2026 at 10:37 AM and 02/26/2026 at 9:00 AM, revealed Resident #82 continued to have two (2) yellow pills in a small clear plastic container on their bedside table. During an observation and interview on 02/26/2026 at 9:23 AM, Licensed Practical Nurse #2 stated they had administered medications to Resident #82 this morning (02/26/2026) and on 02/25/2026. They stated this morning Resident #82 had five (5) pills left to take when they had left their room and was unaware of what two (2) yellow pills were left on their bedside table. Licensed Practical Nurse #2 entered Resident #82's room and identified the pills on the bedside table as potassium chloride. They stated nurses were expected to stay in the room with residents until all medications were taken. Licensed Practical Nurse #2 stated they did not check back to see if Resident #82 took all their pills and should have. During an interview on 02/26/2026 at 9:41 AM, Licensed Practical Nurse #3 stated they administered Resident #82's morning medications on 02/24/2026. They stated Resident #82 preferred to take their potassium after breakfast and Resident #82 would place them in a container on their bedside table. Licensed Practical Nurse #3 stated they left the potassium pills in Resident #82's room and would follow up with them after breakfast to ensure the medication was taken. Licensed Practical Nurse #3 stated when they followed up with Resident #82 after breakfast, they had witnessed them taking their potassium. Licensed Practical Nurse #3 stated medications should not be left unattended, it was important to ensure all medications were taken because they were ordered for a reason. Licensed Practical Nurse #3 stated Resident #82 was alert and oriented x3, knew their medications well, and assumed they would take their pills. During an interview on 02/26/2026 at 9:52 AM, Registered Nurse Manager #1 stated nurses were expected to stay with the residents until all medications were taken. They stated pills were not to be left with the residents for any reason unless there was a physician order to do so, they stated Resident #82 does not have an order to self-administer potassium. Registered Nurse Manager #1 stated if Resident #82 wanted to take their medication at a different time the pills should have been removed from their room immediately and the medical provider should have been contacted. During an interview on 02/26/2026 at 1:42 PM, the Director of Nursing stated medication was never to be left unattended in the resident's possession. They stated nurses were expected to stay with the residents and assess that proper intake of medication administration was being completed. The Director of Nursing stated leaving medications at the bedside increased the risk of missed doses which could lead to medical complications. They stated if Resident #82 wanted their medication at a different time, they would have expected the nurses to contact the medical provider and have the medication time changed. The Director of Nursing stated leaving medications at the bedside was unacceptable and should never have happened. 10 New York Code Rules Regulations 415.11(c)(3)(i)

Based on observation, interview, and record review conducted during a the facility did not ensure that drugs and biologicals were securely store in accordance with State and Federal laws for one (1) (Resident #82) of one (1) reviewed. Specifically, Resident #82 had medications stored and unsecured on an over the bed table in their room.The findings are:Refer to F 658 scope and severity= DThe policy and procedure titled Medication Administration dated 10/17/2019 documented the designated licensed nurse shall never leave any medication in the resident's possession or at the bedside unless the physician orders in writing, state to do so.Resident #82 had diagnoses that included congested heat failure (a condition where the heart is too weak to pump blood), hypertension (high blood pressure), and chronic obstructive pulmonary disease (chronic lung disease). The Minimum Data Set (a resident assessment) dated 02/06/2026 documented Resident #82 was cognitively intact, was understood and understands others.The comprehensive care plan dated 01/30/2026 documented Resident #82 was alert and oriented x3 (person, place, and time) and medications were to be administered as ordered. The comprehensive care plan lacked documented evidence that Resident #82 preferred or was able to self-administer medications.Review of Physician Orders from 01/30/2026 - 02/27/2026 including all discontinued and completed orders revealed there was no physician's order to self-administer oral medications or to leave medications at the bedside. In addition, an order Potassium Chloride (electrolyte supplement to prevent low blood potassium) 20 milliequivalent extensive release was to be administered once daily in the morning.During an observation and interview on 02/24/2026 at 8:55 AM, Resident #82 was observed sitting in their room in a recliner chair with two (2) yellow pills observed on the bedside table in a small round clear plastic container with a lid. Resident #82 stated the two pills were potassium and they preferred to take it at night. They stated the nurses brought the medication into them in the morning and they would put it to the side to take later before bed.Intermittent observations made on 02/24/2026 at 4:22 PM, 02/25/2026 at 10:37 AM and 02/26/2026 at 9:00 AM, revealed Resident #82 continued to have two (2) yellow pills in a small clear plastic container on their bedside table.During an observation and interview on 02/26/2026 at 9:23 AM, Licensed Practical Nurse #2 stated they had administered medications to Resident #82 this morning (02/26/2026) and on 02/25/2026. Licensed Practical Nurse #2 entered Resident #82's room and identified the pills on the bedside table as potassium chloride.During an interview on 02/26/2026 at 9:41 AM, Licensed Practical Nurse #3 stated they administered Resident #82's morning medications on 02/24/2026. They stated Resident #82 preferred to take their potassium after breakfast and Resident #82 would place them in a container on their bedside table.During an interview on 02/26/2026 at 9:52 AM, Registered Nurse Manager #1 stated pills were not to be left with the residents for any reason unless there was a physician order to do so, and further stated Resident #82 does not have an order to self-administer medications.During an interview on 02/26/2026 at 1:42 PM, the Director of Nursing stated medication was never to be left unattended in the resident's possession. The Director of Nursing stated leaving medications at the bedside was unacceptable and should never have happened.10 New York Code Rules and Regulations 415.18 (e) (1)

Based on observation, interview, and record review conducted during the survey, the facility did not provide food and drink that was palatable and served at a safe and appetizing temperature for two (2) (Park Unit and Lake Unit) of three (3) unit test trays. Specifically, food and beverages during meals were served at suboptimal temperatures and were not palatable. Residents #8, 11, 32, 37, 41, and 71 were involved. The findings are:The policy titled Food Safety Requirements dated 06/13/2018, documented it is important to focus attention on the risks that are associated with foodborne illness by identifying critical control points in the food preparation processes that, if not controlled, might result in food safety hazards including, thawing, cooking, cooling, holding, reheating of foods, and employee hygienic practices.The policy titled Mealtime Procedure revised on 06/23/2015, documented to serve the tray so that trays may be served promptly - all nursing personnel are expected to assist.The policy titled Food Preparation dated 09/20/2002, documented foods will be heated to a minimum of 165 degrees Fahrenheit and foods will be held at 140 degrees Fahrenheit or higher until service. Refrigerators must be in good repair and hold cold foods at 41 degrees Fahrenheit or less.During an interview on 02/23/2026 at 11:14 AM with Resident #71 they stated the food was awful, it was good when they first came to the facility, but it had gone downhill. They stated it was always cold, and the coffee was always cold.During an interview on 02/23/2026 at 11:38 AM, Resident #11 stated the food used to be better, frequently have tuna and chicken casserole and only receive one (1) scoop. They stated when they asked for salad, they received only lettuce and tomato, and the food lacked seasoning and taste.During an interview on 02/23/2026 at 3:18 PM, Resident #41 stated the food was terrible, had no taste, sometimes was cold and did not get enough on their plate. They stated the food was just not decent.During an interview on 02/24/2026 at 9:14 AM with Resident #37 they stated the coffee was lukewarm and that there was not sufficient staff to pass trays.During an interview on 02/24/2026 at 11:38 AM with Resident #8 they stated that the food was always cold, especially breakfast.A continuous observation of the kitchen lunch tray line on 02/25/2026 from 11:37 AM to 1:21 PM revealed multiple delays that included food items that needed to be reheated (gravy), running out of food items (squash) and the need to substitute and heat up a new vegetable, and running out of clean plates mid-service resulting in carts that left the kitchen late.1.During a lunch meal test tray observation on 02/25/2026 tray cart that contained the test tray arrived on the Park Unit at 12:52 PM. All trays were passed by 12:54 PM. At 12:55 PM the following food temperatures were obtained by the Director of Food Service using the facility's thermometer:-Pork: 89.5 Fahrenheit tasted cold and dry.-Stuffing: 122.9 Fahrenheit, tasted lukewarm.During an interview on 02/25/2025 at 1:00 PM, the Director of Food Service stated the pork temperature was 172 degrees Fahrenheit on the steam table at the start of tray line. They stated the pork should have been at least 120 degrees Fahrenheit when the cart reached the unit. They stated they had different staff learning new positions and that didn't help with the delay. During an interview on 02/25/2026 at 1:05 PM with Resident #32 they stated that their pork chop was cold and dry and did not have any gravy on it.2. During a lunch meal test tray observation on 02/25/2026 the tray cart that contained the test tray arrived at 1:00 PM. All lunch trays from the Lake Unit were passed to the residents by 1:08 PM. The test tray temperatures were taken by the Director of Food Service at 1:09 PM using the facility's digital thermometer. The temperatures and taste were as follows:-Pork with gravy: 112.9 degrees Fahrenheit - tasted lukewarm was not hot, light flavor noted-Stuffing with gravy 110 degrees Fahrenheit - lukewarm to taste, lacked flavorDuring an interview on 02/25/26 at the time of the Lakeside Unit test tray, Director of Food Service stated they would have liked the temperature of the pork and the bread stuffing to have been a little higher. They stated the temperature of both the pork and bread stuffing should have been served at 120 degrees Fahrenheit or higher. The Director of Food Service stated it was difficult to maintain the temperature of pureed food because once it was plated the food would spread causing the temperature to drop fast. During an interview on 02/26/2026 at 11:00 AM with [NAME] #1 they stated during tray line, staff did not take mid tray line temperatures only before the food goes in the steam table and the steam table was set at 190 degrees Fahrenheit to hold the temp until served. They stated hot food needs to be at 165 degrees Fahrenheit to avoid foodborne illness and acknowledged that a temperature of 86 degrees Fahrenheit could cause a problem. They stated, when residents complained food was cold, staff replaced the meal. They stated it was important to maintain resident's food temperatures, so they won't get sick, and no one enjoyed cold food. They stated trays often sat for extended periods of time before trays were delivered to residents by the unit staff. Regarding tray line timing, lunch began at 11:15 AM and was usually completed by 12:35 PM.During an interview on 02/26/2026 at 01:08 PM with the Dietitian Assistant #1 they stated the temperature of hot foods should be heated to 165 degrees Fahrenheit and held at 135 degrees Fahrenheit, so no one gets ill. They stated the steps staff should complete to maintain the appropriate temperature of the food, would be to take the temperature of the food before tray line starts, and ensure the food was held at appropriate temperatures throughout tray line. They stated the food temperatures should be done when it came out of the oven but was not certain if food temperatures were checked throughout tray line. They stated the steams tables should maintain the temperature up until serving time, but after a certain amount of time they would expect staff to re-temp to ensure the food held its appropriate temperatures.During an interview on 02/26/2026 at 1:38 PM with the Director of Food Service they stated normally test trays were audited monthly but recently had been doing them weekly due to complaints of cold food. They stated the lunch carts were extremely late on 02/25/2026 and thought the biggest issue was staffing on the units. They stated the carts sat there and the staff did not start passing the trays right away because they were busy providing care. They stated they would expect food temperatures to be at least at 120 degrees Fahrenheit when served. They stated this was important because bacteria could be created if the temp was not maintained and also the residents want to eat hot food. They stated their process to ensure food temperatures were held at an acceptable range during tray line and up to service, was to take food temperatures before placing it in the steam tables, but they did not have a process in place to test the temperatures during tray line. They stated they should, especially when tray line took over an hour.During an interview on 02/27/2026 at 10:45 AM with the Administrator they stated meals should be delivered within one hour of leaving the kitchen to all residents. They confirmed receiving complaints about food temperatures and that temperature audits were conducted and discussed in morning meetings and at resident council. They stated their expectation was for food temperatures to be taken at the start of tray line, in between and when the last tray was put on the cart in the kitchen. They reported instances when staff did not pass food trays promptly; they observed delays of about 10 minutes and notified the nurse manager and assisted when needed. They expected trays to be passed immediately to avoid foodborne illness and to ensure residents receive hot meals. They expected the cook to take temperatures during tray line to ensure food is holding temperature and stated this issue had been brought to their attention previously.10 NYCRR 415.14(d)(2)

Based on observation, interviews and record review during the survey, the facility did not ensure the results of the most recent health surveys were posted in a place readily accessible to residents, family members, and legal representatives of residents. Specifically, the facility's past survey results were located in a binder stored behind the reception desk with other binders and were not readily accessible. Additionally, the facility's past survey results binder did not contain all complaint investigation results with plan of corrections for the past three (3) years. Residents #1, 43, 60, 79, and 85 were involved. The finding is:The facility's policy titled Required Postings and Bulletin Board, dated 9/23/2009 documented the required postings on unit bulletin boards were to contain the results of the most recent New York State Health Department Survey of the facility.The State Operations Manual dated 07/23/2025 documented the definition for a Place readily accessible is a place (such as a lobby or other area frequented by most residents, visitors or other individuals) where individuals wishing to examine survey results do not have to ask to see them. The State Operations Manual dated 07/23/2025 documented the definition for Results of the most recent survey means the Statement of Deficiencies (Form CMS-2567) and the Statement of Isolated Deficiencies generated by the most recent standard survey and any subsequent extended surveys, and any deficiencies resulting from any subsequent complaint investigation(s). A resident council meeting as part of the survey facility task process was conducted on 02/24/2026 at 10:04 AM. Residents #1, #43, #60, #79 and #85 were present. Resident #1 stated they were unsure if the facility posted past survey results or knew where to locate those results. Resident #43, #60, #79 and #85 also agreed with Resident #1 that they were all unsure where the results were located and all were interested in where the results could be reviewed.During an interview and observation on 02/25/2026 at 9:08 AM, Social Worker #1 stated they oversee the resident council, plan the resident council meeting agendas and run the meetings. Social Worker #1 stated they believed past survey results were in a binder located at the reception desk. Observation of the reception desk revealed there was no binder visible around the area nor around the bulletin board across from the reception desk. Social Worker #1 went behind the reception desk and was unable to locate the binder with survey results. Social Worker #1 asked Unit Assistant #1, who was sitting behind the reception desk, if they knew where the past survey results were stored. Unit Assistant #1 stated the binder should be on the countertop stacked next to the other binders behind them. Unit Assistant #1 was able to locate the binder on top of a countertop behind the L shaped reception desk. The binder spine was not labeled, and it was stacked with other binders. Social Worker #1 stated the survey results book was not in a place that was readily accessible to residents and visitors without having to ask for them. They stated the residents could come behind the reception desk if they chose to, but the binder should be stored in an area where residents could see it. Observation and review of the binder revealed FORM CMS 2567 (an official document of Statement of Deficiencies and Plan of Correction) dated 02/01/2024 was in the binder but there was no evidence of any deficiencies resulting from any subsequent complaint investigations within the binder. After reviewing the contents of the binder, Social Worker #1 stated the binder only contained the survey results with the plan of correction dated 02/01/2024 and they were not sure of the regulations of posting past survey results. Social Worker #1 stated it was important for residents and visitors to be able to view past survey results so they knew what concerns the facility had and the corrective action of those concerns.During an interview on 02/25/202 at 9:22 AM, the Administrator reviewed the facility's binder of past survey results. They stated the only results of past survey results with the facilities plan of correction that was in the binder was from the 02/01/2024 recertification survey. The Administrator stated the binder did not contain any results of complaint surveys and the facility did have a complaint survey requiring a plan of correction after the last recertification survey. The Administrator stated that the binder was not in an easily accessible location for residents and visitors if it was stored behind the reception desk with other binders. They stated the spine of the binder should also be labeled. The Administrator stated it was important for residents and visitors to have access to past survey results because it was part of their resident rights. 10 NYCRR 415.3(d)(1)(v)

Based on observation, interview, and record review conducted during a Complaint investigation (NY00384369-530162, NY00384458-530191, NY00385240-530194) completed on 08/15/2025, the facility did not ensure sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, the facility did not ensure there was sufficient nurse staffing to meet the needs of the resident in accordance with their preferences and plans of care.The finding is:Review of the Dear Administrator letter 23-11 dated 06/30/23 sent to the nursing home administrators informing them that starting 04/01/2022 nursing homes were required to have an average daily staffing of 3.5 hours of care per resident per day with 2.2 hours for Certified Nurse Aides and 1.1 hours for Licensed Practical Nurses or Registered Nurses.The Facility Assessment, review dated 04/28/2025, documented the assessment is required by the nursing home Requirements of Participation to identify and analyze the facility's resident population and identify the personnel, physical plant, environmental and emergency response resources needed to competently care for the residents during the day-to-day operations and emergencies, including nights and weekends. The facility is licensed for 134 beds with an average daily census of 111. The facility will ensure that there is sufficient and competent staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care.Additionally, the Facility Assessment documented the following total number needed or average or range of nursing staff including days, evenings, nights, and weekends:- Licensed nurses providing direct care 8-11- Nurse Aides 18-24The undated handwritten Emergency Staffing Policy Plan Initiated documented the facility required one Registered Nurse on any shift per day; three Licensed Practical Nurses on first and second shift, and two Licensed Practical Nurses on third shift; five Certified Nurse Aides on first and second shift, and two Certified Nurse Aides on third shift.Review of the All Punches Detailed report of nursing staff directly responsible for nursing care documented the following:- 06/09/2025 - resident census117; Licensed Practical Nurse and Registered Nurse hours 100.25 or .75 hours per resident per day; Certified Nurse Aide hours 115.5 or 1.0 hours per resident per day. Based on the census there was not the required number of Licensed Nurse or Certified Nurse Aide hours per day.- 08/09/2025 - resident census 109; Licensed Practical Nurse and Registered Nurse hours 56.75 hours or .5 hours per resident per day; Certified Nurse Aide hours 116.5 hours or 1.0 hours per resident per day. Based on the census there was not the required number of Licensed Nurse or Certified Nurse Aide hours per day.- 08/10/2025 - resident census 109; Licensed Practical Nurse and Registered Nurse hours 78.5 or .75 hours per resident per day; Certified Nurse Aide hours 110.5 hours or 1.0 per resident per day. Based on the census there was not the required number of Licensed Nurse or Certified Nurse Aide hours per day.The Aspen Complaints/Incidents Tracking System (ACTS) complaint #NY00384458, Internet Quality Improvement & Evaluation System (iQIES) complaint #530191, documented the complainant reported 06/09/2025 Resident #1 had not gotten out of bed for three (3) days, had been wearing the same clothes for three (3) days, and incontinent brief appeared to be from days earlier.During a telephone interview on 08/14/2025 at 10:00 AM, Licensed Practical Nurse #1 stated they recalled the complainant reporting the condition of Resident #1 on 06/09/2025. Licensed Practical Nurse #1 stated it had appeared that Resident #1 had minimal Care care over the past few days, the resident and their bed were soiled, the bottom sheet was wet and had dried stains. Licensed Practical Nurse #1 stated there wasn't enough staff to properly care for the residents.During an interview on 08/13/2025 at 1:28 PM, Resident #2 stated they filed a grievance with the facility and things have gotten a little better. Usually, they get into bed about 11:30 PM which they are fine with, sometimes 12:00 AM but it was better than 2:30 AM. Resident #2 stated all they ask of the staff was to give them a time frame as when they will be in to put them to bed. Sometimes they have to wait long to be changed or use the bed pan, about 45 minutes. Resident #2 stated they know the staff are busy due to the facility being short staffed. During an interview/observation on 08/15/2025 at 9:04 AM, Resident #3 stated they had waited over an hour that morning for assistance to the restroom because they were a two (2) assist with a mechanical lift and there were only two (2) Certified Nurse Aides on the unit, one (1) for each hall. Resident #3 stated they were unable to wait for staff assistance and soiled their brief making a mess in the bathroom when they were finally assisted. The toilet in the bathroom was observed to have feces on the seat.During an interview/observation on 08/15/2025 at 9:11 AM, the call light system at the nurse's desk indicated Resident #5's call light had been ringing for eight (8) minutes. Resident #5 was observed in bed and appeared uncomfortable; a mechanical lift was observed in the room. Resident #5 stated they needed to have a bowel movement and did not want to have an accident, they stated one (1) staff member had brought the mechanical lift in the room but needed to find another staff member to assist. Staff were observed to enter the room at 9:29 AM to assist Resident #5.During an interview on 08/14/2025 at 9:53 AM, Licensed Practical Nurse #4 stated the unit they were assigned to normally had three (3) Certified Nurse Aides on the day shift and staff were unable to complete their assigned duties. Licensed Practical Nurse #4 stated residents may only be checked on once a shift if they don't put their call light on and showers were not given.During an interview on 08/14/2025, Certified Nurse Aide #1 stated they do their best with the staffing that was provided and residents that require assistance of two (2) staff members often have to wait longer than they should for assistance.During an interview on 08/14/2025 at 10:59 AM, Certified Nurse Aide #2 stated they were supposed to be on orientation but were given a full assignment and had not yet gotten to assist all the resident on their assignment.During an interview on 08/14/2025 at 11:03 AM, Certified Nurse Aide #3 stated the facility was often short staffed. Sometimes there were only two (2) Certified Nurse Aides on the day shift, at those times they go through the list of residents and ensure each resident gets changed at least once during the shift. Additionally, they stated they were unable to complete scheduled showers when working short staffed.During an interview on 08/15/2025 at 9:31 AM, Registered Nurse #2 Unit Manager stated there were times there were only two (2) Certified Nurse Aides on the day shift and the necessities can get done at least once, but not everything can get done.During an interview on 08/15/2025 at 10:23 AM, the Acting Administrator stated staffing had been difficult and challenging for the facility due to call offs. The facility had been working with minimum staffing since June and three (3) to four (4) days per week they have to strongly encourage staff to work over their scheduled shifts to ensure the residents were taken care of.10 NYCRR 415.13 (b)(1) (i-ii) (2)(ii)

Based on interview and record review conducted during a Complaint investigation (#NY00364661-530180), the facility did not ensure that a resident has the right to refuse treatment for one (1) (Resident #1) of six (6) residents reviewed for immunizations. Specifically, Resident #1 was administered the COVID-19 vaccine without consent.The finding is:The policy and procedure titled Standing Order for Provision of Influenza, Pneumococcal, and COVID-19 Vaccine, revised 01/06/2024 documented all residents will be screened upon admission to the facility to evaluate COVID-19 immunization status. Consent or declination of the COVID-19 vaccination will be obtained within seven (7) days of admission and documented in the medical record. Residents or responsible parties have the right to refuse any vaccination at any time, education and refusals will be documented in the medical record.The policy and procedure titled Medication Administration revision/reviewed dated 12/09/2024 documented to check the resident wristband or bracelet or badge before administering the medication to make accurate resident identification.Resident #1 had diagnoses that included dementia, depression, and hypertension. The Minimum Data Set (a resident assessment tool) dated 09/24/2024 documented the resident was cognitively intact.The undated COVID-19 Booster Immunization Screening and Consent Form, signed by Resident #1, documented the resident declined to receive the vaccine.The Interdisciplinary Note dated 09/27/2024 at 2:42 PM authored by Licensed Practical Nurse #2 documented vaccination was given to right arm, small red dot, slightly swollen and tender.The Medication Error Report dated 09/26/2024 documented Licensed Practical Nurse #1 failed to follow resident's rights of medication administration when they failed to identify the correct resident.During a telephone interview on 08/13/2025 at 10:08 AM, Licensed Practical Nurse #1 stated they did not check Resident #1's wristband, to ensure correct, prior to administering the COVID-19 vaccination.During a telephone interview on 08/13/2025 at 12:02 PM, Registered Nurse #1 Infection Preventionist stated they provide the education and obtain consents/declinations for the COVID-19 vaccination. Identifying the correct resident was one of the basic medication administration rights. Registered Nurse #1 Infection Preventionist stated Resident #1 received the COVID-19 vaccination, after signing a declination, which was a violation of Resident #1's rights.During an interview on 08/13/2025 at 12:18 PM, the Director of Nursing stated Resident #1 received the COVID-19 vaccination in error. Licensed Practical Nurse #1 did not verify the correct resident prior to the administration of the vaccination. The administration of the COVID-19 vaccination to Resident #1 violated their rights because the resident had signed a declination not to receive the vaccine.10 NYCRR 415.3(f)(1)(ii)

Based on observation, interview, and record review conducted during the Standard survey completed on [DATE], the facility did not ensure the system developed for advanced directives was implemented in a manner that was consistent with resident's wishes for one (Resident #62) of one resident reviewed for advanced directives. Specifically, the facility did not ensure that all resident advanced directives identifiers were consistent with the resident wishes. Additionally, there was no development of a care plan for advanced directives. The findings are: The undated policy and procedure titled Medical Orders for Life Sustaining Treatment (MOLST) documented honoring patient preferences was a critical element in providing quality end of life care. Residents who wish to be a FULL CODE (cardiopulmonary resuscitation) per their Medical Orders for Life Sustaining Treatment (MOLST) form will have a blue sticker on their nameplate, physical chart, blue wristband and resuscitate listed in the electronic medical record. A resident who wishes to be a Do Not Resuscitate (DNR, allow natural death) per their Medical Orders for Life Sustaining Treatment (MOLST) form will have a white wristband, and Do Not Resuscitate in the electronic medical record. The Medical Orders for Life Sustaining Treatment (MOLST) should be scanned in and placed in the appropriate section of the electronic health records. The policy and procedure titled Basic Life Support (CPR- cardiopulmonary resuscitation, provision of emergency measures including artificial ventilation and chest compressions in the absence of breathing and/or heart rate) revised [DATE] documented a resident who desires cardiopulmonary resuscitation will be identified by a blue wristband, a small blue sticker on the chart and blue sticker on the name tag at the door of their room. The policy and procedure titled Do Not Resuscitate dated [DATE] documented a Do Not Resuscitate Order in the resident's medical record instructs the medical staff not to try to revive the resident if breathing or heartbeat has stopped. The policy and procedure titled Means of Identification of Residents revised [DATE], documented all residents will wear ID arm band unless contraindicated. Non-DNR (do not resuscitate) residents will wear a blue band or have a blue dot on their band. Resident #62 had diagnoses which included chronic heart failure, type 2 diabetes, chronic obstructive pulmonary disease (COPD). The Minimum Data Set (a resident assessment tool) dated [DATE] documented Resident #62 was cognitively intact, was understood and was able to understand others. Review of the comprehensive care plan revealed the baseline care plan started on [DATE] did not document Resident #62's code status (advanced directives) and the goal documented their needs would be met in the first 48 hours from admission until the completion of their comprehensive care plan. The Care Plan printed [DATE] did not include the development of a care plan for advanced directives. Review of the Medical Orders for Life Sustaining Treatment (MOLST) dated [DATE] in the electronic medical record revealed a CPR Order: Attempt Cardio-Pulmonary Resuscitation. The order was last signed by the medical provider as reviewed on [DATE] with no change. Review of the Medical Orders for Life Sustaining Treatment (MOLST) dated [DATE] in the medical record (paper chart), revealed a DNR Order: Do Not Attempt Resuscitation. The Medical Orders for Life Sustaining Treatment was signed by Resident #62 and witnesses, Licensed Practical Nurse #9, and Nurse Practitioner #2. Review of the physician's orders dated [DATE] through [DATE] revealed there were documented orders for advance directives. Review of an interdisciplinary note dated [DATE] revealed there were new orders from Nurse Practitioner #2 for blood work and medication, however there was no documentation regarding the changes made with Resident #62's Medical Orders for Life Sustaining Treatment (MOLST). The medical provider service notes dated [DATE] and [DATE] did not document there was review of Resident #62's advanced directives and code status. During intermittent observations on [DATE] and [DATE] between 10:02 AM and 3:45 PM, Resident #62's nameplate outside their room had a small round blue sticker and Resident #62 was not wearing a wristband. During an interview on [DATE] at 3:24 PM, Secretary #3 stated residents that wear a blue wristband had full code status, and their nameplate outside their room would be blue. During an interview on [DATE] at 3:21 PM, Licensed Practical Nurse #6 stated they could access a resident's advanced directives from a resident's paper chart on the unit or in the electronic medical record. During an interview on [DATE] at 10:02 AM, Resident #62 stated their wristband broke over a week ago and hadn't been replaced even though they told someone, They must have forgot. During an interview on [DATE] at 2:43 PM, Certified Nursing Assistant #4 stated it was important to know whether a resident was a full code or had a do not resuscitate order, so the nursing staff could assist quickly, and a Code Blue (medical emergency) could be called. During an interview on [DATE] at 2:52 PM, Registered Nurse Unit Manager #2 stated advanced directives should be documented on the resident's care plan. A blue dot sticker indicated a full code status and per the resident's preference they should have a wristband on them or on their wheelchair. Registered Nurse #2 stated it was important to know if a resident was a full code so action could be taken immediately. Additionally, Registered Nurse #2 stated when there was a change with residents advanced directives, whomever gets that information should notify the charge nurse, secretary, and supervisor so the information could be acted on as promptly, so the resident's wishes would be honored. You don't want to code somebody that doesn't want to be. During an interview on [DATE] at 3:02 PM, Social Worker #1 stated unit secretaries were responsible for residents' wristbands and coding the residents' nameplates outside of their rooms. Social Worker #1 stated it was important for wristbands and nameplates to be coded correctly so staff knew what advanced directives each resident wanted. During an interview on [DATE] at 3:26 PM, the Director of Nursing stated once a MOLST (Medical Orders for Life -Sustaining Treatment) for cardiopulmonary resuscitation (CPR) or do not resuscitate (DNR), were completed they should be entered, scanned, into the electronic medical record and current MOLST was then kept in the resident's paper chart. The Director of Nursing stated the MOLST (Medical Orders for Life -Sustaining Treatment) acts as the order for the residents advanced directives. The Director of Nursing stated residents wear a bracelet with their name, room number, date of birth and was colored coded. A blue band indicated full code status/cardiopulmonary resuscitation (CPR). A blue dot sticker on the nameplate outside a resident's room would indicate the resident wanted cardiopulmonary resuscitation (CPR). The Director of Nursing reviewed Resident #62's MOLST (Medical Orders for Life -Sustaining Treatment) in the electronic medical record and stated their order was for cardiopulmonary resuscitation (CPR). The Director of Nursing stated staff would go by the hard copy of the MOLST in a resident's paper chart, but that it would be adequate to pull up the MOLST in the electronic medical record, as it should be the most current. The Director of Nursing stated it was important for a resident's record, both the paper chart and electronic medical record to be accurate so a resident's wishes were honored. During an interview and observation on [DATE] at 3:43 PM, the Director of Nursing reviewed Resident #62's paper chart on the unit and stated the MOLST completed on [DATE] documented the resident had a do not resuscitate status (DNR). The current MOLST (Medical Orders for Life Sustaining Treatment) was not scanned into Resident #62's electronic medical record and should have been. The Director of Nursing removed the blue sticker from Resident #62's nameplate outside their room and stated cardiopulmonary resuscitation (CPR) could have been performed against Resident #62's wishes. During an interview on [DATE] at 3:50 PM, Licensed Practical Nurse #9 stated they remembered Resident #62 changed their Medical Orders for Life Sustaining Treatment (MOLST). Licensed Practical Nurse #9 stated usually the secretary made the changes to the resident's wristband and sticker on nameplate. Licensed Practical Nurse #9 stated they did not recall if Resident #62's advance directive changes were communicated to the secretary and that the blue sticker on their nameplate should have been removed. During an interview on [DATE] at 1:12 PM, Social Worker #1 stated advanced directives should be a part of a residents' care plan to ensure that it was reviewed during interdisciplinary care plan meeting and reflected the resident wishes. 10 NYCRR 400.21

Based on observation, interview and record review conducted during a standard survey completed on 2/1/24, the facility did not ensure that the provider was notified of a need to alter treatment, or to commence a new form of treatment, for one (Resident #61) of one resident reviewed. Specifically, staff did not notify the provider when Resident #61's ACE wraps were not applied to both lower extremities on multiple occasions as ordered. The finding is: Per the Director of Nursing, the facility did not have a policy and procedure for the application of ACE wraps for edema (swelling caused be excess fluid accumulation). The policy and procedure titled Anti-Embolism Stockings, dated 1/14/2015, documented that the garment should be applied in the morning, before swelling occurs. Resident #61 had diagnoses including unspecified dementia without behaviors, localized edema, and type II diabetes mellitus. The minimum data set (a resident assessment tool) dated 1/3/24, documented Resident #61 was cognitively intact, usually understood and usually understands. Resident #61's Physician Orders dated 9/22/23 documented ACE wraps on in the morning, off at bedtime. The updated order dated 1/31/24 documented ACE wraps to BLE (both lower extremities), on in the AM and off in the PM for edema. Review of Resident #61's Treatment Record for December 2023 documented four refusals of the ACE wraps. The Treatment Record for January 2024 documented seven refusals of the ACE wraps on 1/17/24, 1/18/24, 1/23/24, 1/25/24-1/28/24 and eight occasions of treatment not administered of the ACE wraps on 1/8/24-1/11/24, 1/13/24, 1/15/24, 1/16/24 and 1/30/24. Review of the Interdisciplinary Notes dated 1/1/24 to 1/31/24, revealed the provider had not been notified that Resident #61's ACE wraps had not been applied on multiple occasions. During an observation and interview on 1/28/24 at 10:58 AM, Resident #61 was in the hall, seated in their wheelchair, with their bare feet on the floor. Resident #61's lower extremities appeared swollen and red. Resident #61 stated they were supposed to have their legs wrapped whenever they were up in their chair. There was a single ACE wrap located on the arm chair in Resident #61's room. During an observation and interview on 1/29/24 at 8:56 AM, Resident #61 was in their room, seated in their wheelchair with their bare feet on the floor. Both lower extremities appeared swollen and red. The single ACE wrap was sitting on the same chair in the room in the same position as the day before. Resident #61 stated the nurse did not apply the ACE wraps yesterday. During an observation and interview on 1/30/24 at 8:31 AM, Resident #61 was in their room in their wheelchair, with bare feet on the floor. Both lower extremities appeared swollen and red. Resident #61 stated they never refused to let the nurse apply the ACE wraps. The single ACE wrap was in the chair in their room. During an interview on 1/30/24 at 1:37 PM, Nurse Practitioner #1 stated that Resident #61 approached them at the nurse's station and asked them to apply their ACE wraps today. They went into Resident #61's room to apply the ACE wraps and found the single wrap. They then asked the nurse to get them a second wrap and applied them both to the resident's legs. Nurse Practitioner #1 stated they were not aware that Resident #61's ACE wraps had not been applied on multiple occasions. Nurse Practitioner #1 stated Resident #61 never refused the ACE wraps for them. During an observation and interview on 1/31/24 at 9:15 AM, Resident #61 was in their room in their wheelchair with their bare feet on the floor. The edema on both lower extremities appeared to be improved from previous observations. Resident #61 stated that they wore the ACE wraps all day on 1/30/24 and that the nurse was coming to put them on today after they finished breakfast. During an interview on 1/31/24 at 10:10 AM, Licensed Practical Nurse #2 stated that Resident #61's ACE wraps were important to keep excess fluid off their lower legs. They stated that Resident #61 refused their ACE wraps to be applied on multiple occasions. Licensed Practical Nurse #2 stated that they should notify the provider if a resident refused their treatment for more than seven days because they might want to change the order or have them discontinued. During an interview on 1/31/24 at 10:18 AM, Registered Nurse #2, Unit Manager, stated that the nurse should have notified them if the resident refused their ACE wraps on multiple occasions so they could speak to the resident and notify the provider. They stated that ACE wraps were important to reduce edema and to protect the resident's skin. During an interview on 1/31/24 at 12:41 AM, the Director of Nursing stated that ACE wraps were important to prevent fluid from pooling in the resident's lower extremities. They stated that the ACE wraps should be applied before the resident gets out of bed. The Director of Nursing stated that if a resident refused their ACE wraps on more than three occasions the nurse should report it to their manager or supervisor so the provider could be notified. During an interview on 2/1/24 at 9:53 AM, Nurse Practitioner #1 stated that they would expect to be notified after the second refusal of a resident's treatment. During further interview on 2/1/24 at 9:55 AM, Licensed Practical Nurse #2 stated they were not aware of the provider notification process for the facility. 10NYCRR 415.3(f)(2)(ii)(c)

Based on observation, interview, and record review conducted during a Standard survey completed on 2/1/24, it was determined that the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for one (Resident #90) of five residents reviewed. Specifically, the resident was observed with 1/2 inch to one-inch-long whiskers on their chin and neck. The policy and procedure titled Activities of Daily Living dated 1/14/15 documented the nursing staff will assist the resident with any activities he/she was unable to perform by him/herself. Resident #90 had diagnoses of dementia and seizure disorder. The Minimum Data Set (a resident assessment tool) dated 12/13/23 documented Resident #90 was severely cognitively impaired and required substantial/maximal assistance of a helper with more than half the effort to perform personal hygiene. During an observation on 1/28/24 at 11:58 AM, Resident #90 had multiple 1/2 inch long, white hairs on their chin and one-inch-long white hairs on their neck. During an observation on 1/29/24 at 7:58 AM, Resident #90 had multiple 1/2 inch long, white hairs on their chin and one-inch-long white hairs on their neck. During an observation on 1/30/24 at 8:34 AM, Resident #90 had multiple 1/2 inch long, white hairs on their chin and one-inch-long white hairs on their neck. During an interview on 1/30/24 at 10:09 AM, Certified Nursing Assistant #1 stated Resident #90 had visible whiskers and needed to be shaved. During an interview and observation on 1/30/24 at 10:19 AM, Licensed Practical Nurse #1, stated none of the Certified Nursing Assistants had told them Resident #90 had refused to be shaved. They stated the resident had whiskers and should have been shaved as that was part of their regular grooming. During an interview on 1/30/24 at 11:58 AM, Registered Nurse Unit Manager #1 stated they expected their staff to shave a resident on their shower days and when it was needed. They stated staff was expected to report any refusals and document the refusals. During an interview on 1/31/24 at 9:40 AM, the Director of Nursing stated they expected staff to shave residents on shower days and when there were visible chin hairs. They stated it was a dignity issue for a resident not to be clean shaven. 10NYCRR 415.12(a)(3)

Based on observation, interview, and record review conducted during a Complaint investigation (Complaint #NY00330011) during the Standard survey completed 2/1/24, the facility did not ensure that each resident receives adequate supervision to prevent accidents for one (Resident #39) of three residents reviewed for elopement. Specifically, Resident #39, eloped from the facility on 12/16/23, did not have an elopement risk assessment completed since 2021, and had no care plan interventions to address their wandering behaviors prior to the elopement incident. The finding is: The policy and procedure, Unsafe Wandering Elopement Risk revised 11/3/2016, documented the facility was to provide a safe and secure environment for all residents. Unsafe wandering/elopement risk assessment will be done on all new admissions in conjunction with the initial Minimum Data Set (a resident assessment tool). Subsequent use would be in conjunction with any onset of wandering behaviors. Individualized care plans will be developed for each resident found at risk for unsafe wandering or elopement. The policy and procedure, Unsafe Wandering/Elopement Risk Assessment revised 1/14/15, documented any resident that triggers a yes response to any questions 5-9 will automatically have a wander guard/roam alert bracelet applied for a minimum of 30 days until nursing can adequately assess for unsafe wandering or exit seeking behaviors and the care plan would be individualized based on the findings of the assessment. The policy and procedure, Door Breach revised 7/23/15, documented staff were to account for the occurrence of all door alarms and to prevent any resident elopement. Resident #39 had diagnoses including unspecified dementia, cerebral infarction (a stroke), and type 2 diabetes mellitus. The Minimum Data Set, dated dated dated [DATE] documented Resident #39 was severely cognitively impaired, usually understood, usually understands, and exhibited no wandering behaviors. The Minimum Data Set, dated dated dated [DATE] documented Resident #39 exhibited wandering behavior 1 to 3 days, and they were independent with wheelchair mobility. The comprehensive care plan dated 12/18/23 documented Resident #39 tended to wander related to a history of checking doors. Interventions included to have all staff notify their unit if they are found in another area in the facility and ask staff to assist them back to their unit. The goal was for Resident #39 to be able to wander safely in their environment and to experience as much independence as possible while decreasing their risk for elopement and that they would not have any episodes of elopement through the next review. Review of the Health Electronic Response Data System, Facility Incident Report submitted on 12/17/23 at 2:35 AM, documented Resident #39 was last seen on 12/16/23 at 7:30 PM and was noted missing at 9:30 PM. Resident #39 was found outside Door #9 (located next to the reception desk) near the dumpster by Unit Assistant #1 on 12/26/23 at 9:45 PM. The system to prevent elopement was not functioning properly at Door #9. Review of Certified Nursing Assistant Worksheet Careplan (guide used by staff to provide care) dated 1/29/24 documented Resident #39 was independent with wheelchair locomotion on/off the unit. Review of Resident #39's Unsafe Wandering/Elopement Risk Assessments, revealed the last assessment completed was on 2/10/21 at 5:36 PM. There were no additional Unsafe Wandering/Elopement Risk Assessments completed until 1/31/24. During an observation and interview on 1/30/24 at 10:30 AM, Resident #39 self-propelled their wheelchair on the unit to exit door #3, a double door located at the end of the hallway that exited to the outside of the building and pressed on the push bars. Resident #39 stated they were making sure the doors were closed and if they're opened, I close them. During intermittent observations on 1/30/24 at 10:44 AM, Resident #39 self-propelled their wheelchair off the unit and stopped at the double doors labeled not an exit, which lead outside to a courtyard, and pushed on the door. The door was locked and did not open. At 11:32 AM, Resident #39 was sitting in their wheelchair at exit door #3 and pressed on the exit door push bars, the door didn't open. Staff were present in the hallway and did not redirect the resident away from the doors. During observations on 1/31/24 at 11:39 AM, Resident # 39 self-propelled in their wheelchair on the unit to exit door #3 and pressed on the left push bar. During a telephone interview on 1/30/24 at 3:41 PM, Unit Attendant #1 stated they did not know how long the exit door #9 alarm had been sounding prior to verifying which exit alarm was going off at the nurse's station on 12/16/23. Unit Attendant #1 stated upon arriving to exit door #9 they observed exit door #9 opened and they almost closed the doors, but then they saw Resident #39 walking behind their wheelchair outside toward the parking lot by the dumpsters. Unit Attendant #1 stated that Resident #39 stated they were going home. Unit Attendant #1 stated it was cold outside and Resident #39 was wearing a robe over their pajamas and was just wearing socks on their feet when they were located outside. Unit Attendant #1 stated after they assisted Resident #39 back into the facility, they reported the incident to Licensed Practical Nurse #3. During a telephone interview on 1/31/24 at 12:27 PM, Licensed Practical Nurse #3 stated on the night of 12/16/23, Unit Attendant #1 reported to them that they found Resident #39 outside and that exit door #9 wasn't locking or shutting tightly. Licensed Practical Nurse #3 stated they reported the incident to Licensed Practical Nurse #4 Supervisor, and Licensed Practical Nurse #4 Supervisor went and checked the exit door. Licensed Practical Nurse #3 stated that Resident #39 wandered, went anywhere they wanted to go in their wheelchair, and that they had observed Resident #39 go to exit doors a lot and they had pushed on the exit doors on the unit to get out before. Licensed Practical Nurse #3 stated they made it very well known, had expressed their concern regarding Resident #39 exit seeking to a prior Unit Manager and other nurses. Licensed Practical Nurse #3 stated they didn't understand why Resident #39 wasn't placed on the locked unit. During an interview on 1/30/24 at 5:08 PM, Licensed Practical Nurse #4 Supervisor stated they were notified on 12/16/23 that Resident #39 was found outside and brought back into the facility by Unit Attendant #1. Licensed Practical Nurse #4 stated they saw Resident #39 after they were brought back inside and Resident #39 stated to them that the door (exit door #9) wasn't locked and they went outside to try and fix it. Licensed Practical Nurse #4 stated they called the Director of Nursing and notified them of the incident and that exit door #9 wasn't latching/locking right. Licensed Practical Nurse #4 stated the facility had video surveillance, but didn't know if it was working and had no idea what a Wandering/Elopement Risk Assessment was. During an interview on 1/30/24 at 5:28 PM, the Director of Nursing stated Licensed Practical Nurse #4 Supervisor notified them by phone between 9:00-10:00 PM on 12/16/23 that Resident #39 had been found outside near the dumpster by Unit Attendant #1. The Director of Nursing stated the exit door alarm was sounding and that was what led Unit Attendant #1 to check the doors. The Director of Nursing stated they had the Licensed Practical Nurse #4 Supervisor check Resident #39's temperature, physical appearance for injuries and complete a roster check to verify and ensure the safety of all residents in the facility. The Director of Nursing stated they made the Acting Administrator aware as well at that time. The Director of Nursing stated they did not know the exact cause as to how Resident #39 was able to get out the exit door and they considered this incident an elopement. During an interview on 1/31/24 at 1:25 PM, the Registered Nurse #1 Unit Manager stated they thought the Unsafe Wandering/Elopement Risk Assessments were supposed to be completed annually. Registered Nurse #1 Unit Manager stated administration informed them yesterday that the Unsafe Wandering/Elopement Risk Assessments were supposed to be completed quarterly, with each Minimum Data Set and if needed due an incident of wandering/elopement. The Registered Nurse #1 Unit Manager stated unsafe wandering/elopement should be addressed in a resident's care plan to let staff know how to provide care, keep residents safe and recognize any changes in the resident's assessment. During a follow up interview on 1/31/24 at 1:51 PM, the Director of Nursing stated Unsafe Wandering/Elopement Risk Assessments should be completed by the nurse managers or designee quarterly and if prompted due to exit seeking behavior. The Director of Nursing stated Unsafe Wandering/Elopement Risk Assessments were completed for the safety of the residents, to ensure there aren't any changes/additional risks for elopement, and so care plans can be updated with needed interventions to prevent elopement. The Director of Nursing reviewed Resident #39's electronic medical record and stated 2/10/21 was Resident #39's last completed Unsafe Wandering/Elopement Risk Assessment. The Director of Nursing stated Resident #39 should have had other Unsafe Wandering/Elopement Risk Assessments completed, one should have been completed at the time of the incident on 12/16/23 and they didn't have an answer as to why additional Unsafe Wandering/Elopement Risk Assessments weren't completed. During an interview on 1/31/24 at 3:50 PM, the Director of Environmental Services stated they weren't aware of any issues to exit door #9 prior to 12/16/23. The Director of Environmental Services stated maintenance completed exterior door checks every week. The Director of Environmental Services stated there was functioning camera surveillance at the facility, but camera footage only went back 30 days. The Director of Environmental Services stated the distance from exit door #9 to the dumpsters was maybe 50-60 feet from the facility. During an interview on 1/31/24 at 4:09 PM, the Acting Administrator reviewed the elopement conclusion and stated they thought that this incident was an elopement and reported it. After reporting, they were instructed by regional staff that the incident should not have been reported to the Department of Health as it was not an undetected event because the door alarm to exit door #9 went off. The Administrator stated they did not speak to Unit Attendant #1; they received their statement and did not follow up with them. Additionally, at 5:17 PM, the Acting Administrator stated they did not review the camera surveillance from 12/16/23 as they weren't sure that much was available. 10NYCRR 415.12(h)(2)

Based on interviews and record review conducted during a Standard survey completed on 2/1/24, the facility did not ensure that each resident received the necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being for one (Resident #60) of one resident reviewed. Specifically, a Psychiatry consult was not followed up on and/or implemented. Additionally, there was a lack of care plan development for a history of sexual trauma. The finding is: The policy and procedure titled Antipsychotic Drugs revised 12/23/13 documented to obtain psychiatric or psychological consultation whenever necessary to establish a diagnosis or alternative treatment program. The policy and procedure titled Computerized Care Plan revised 1/14/15 documented that care plans should reflect the facility's approach to a problem and will be updated as needed. During an interview on 2/1/24 at 1:05 PM, Director of Nursing stated they had no policy and procedures related to consultations or psychiatry consult recommendations. Resident #60 had diagnoses that included severe dementia with anxiety, and mood disorder. The Minimum Data Set (a resident assessment tool) dated 1/3/24 documented Resident #60 was usually understood, usually understands, and had severe cognitive impairment. The Minimum Data Set documented Resident #60 was not taking an antipsychotic medication. The Comprehensive Care Plan with start date 10/26/23 identified as current, documented Resident #60 had diagnoses of dementia, anxiety, and depression. Interventions included to encourage Resident #60 to talk about their feelings, provide medications as ordered, schedule a psychiatric evaluation, and follow any treatment recommendations. The comprehensive care plan did not document that Resident #60 had a history of significant sexual trauma. A facility investigation dated 11/21/23 and signed by the Director of Nursing documented, Resident #60 informed two Certified Nursing Assistants, as they were about to provide care, they had been brutally raped and there was too much blood that needed to be cleaned up. The investigation concluded that the allegation of sexual abuse was unfounded. Through investigation/interviews with Resident #60's health care proxy the Director of Nursing documented they were notified that Resident #60 had a history of physical and sexual abuse prior to admission to the facility. The investigation documented that Resident #60 was to have a follow up visit with Psychiatrist #1 and their care plan was updated to no male care givers. The SOAP (Subjective, Objective, Assessment and Plan) note (psychiatrist note) dated 12/13/23 and entered by Psychiatrist #1 documented that Resident #60 was seen for a psychiatric follow up, since last visit the resident had no improvement, and the resident had flashbacks of significant trauma that they had experienced. Psychiatrist #1 documented that they recommended Seroquel (an antipsychotic medication) 25 milligrams to start at bedtime. Review of physician's orders dated 12/1/23 through 1/31/23 did not include an order for Seroquel 25 milligrams at bedtime. Review of facility providers notes dated 12/13/23 through 1/31/24 revealed there was no documented evidence regarding a follow-up visit from Psychiatrist #1 and did not document a rationale as to why Seroquel 25 milligrams was not ordered as recommended by Psychiatrist #1. Review of the Interdisciplinary Notes dated 12/13/23 through 1/31/24 revealed there was no documented evidence regarding a follow-up visit from Psychiatrist #1 and no documented evidence as to why Seroquel 25 milligrams was not ordered at bedtime as recommended by Psychiatrist #1. Review of the Medication (Assistance or Administration) Records dated 12/1/23 through 1/31/24 revealed there was no documented evidence that Seroquel 25 milligrams was administered at bedtime. During an interview on 1/31/24 at 4:42 PM, Social Worker #1 stated they were responsible for scheduling and delivering psychiatrist's notes, including any recommendations, to the nursing unit managers. After review of psychiatrist's note dated 12/13/23 for Resident #60, Social Worker #1 stated the provider recommended Seroquel 25 milligrams to be started at bedtime. Social Worker #1 stated the medication had not been started. During an interview on 2/1/24 at 9:22 AM, Social Worker #1 stated the previous Social Worker was responsible in December 2023 for notifying the nursing staff of the psychiatrist's recommendations. Social Worker #1 stated Resident #60's 12/13/23 psychiatrist recommendation was not given to the nursing staff and resulted in a delay in treatment. After review of Resident #60's Comprehensive Care Plan they stated Resident #60 was not care planned for a history of sexual trauma and that they should have been. During an interview on 2/1/24 at 10:09 AM, Nurse Practitioner #2 stated the nursing staff did not provide them Psychiatrist #1's 12/13/23 note for Resident #60 and was not made aware of their recommendation for Seroquel 25 milligrams at bedtime until Director of Nursing #1 notified them on 1/31/24. Nurse Practitioner #2 stated their expectation was for the nursing staff to relay to them any consult recommendations and if they were to disagree with a recommendation, they would contact Psychiatrist #1 themselves to discuss the case. During a telephone interview on 2/1/24 at 10:35 AM, Psychiatrist #1 stated they expected the nursing staff to notify the medical provider of their recommendations. They stated they were providing psychiatry services and expected the consult recommendations to be followed unless the medical provider disagreed. Psychiatrist #1 stated there was a delay in treatment to Resident #60 when there was a lack of follow through to their 12/13/23 recommendations. During an interview on 2/1/24 at 10:54 AM, the Director of Nursing stated through investigation of Resident #60's allegation of rape on 11/21/23, the family notified them Resident #60 had a traumatic sexual experience in the past. The Director of Nursing stated they updated Resident #60's care plan for no male caregivers but should have implemented a history of sexual trauma care plan. The Director of Nursing stated the Psychiatrist's recommendations for Resident #60 on 12/13/23 was not followed because it was not sent to the appropriate staff member during transition of social workers. Director of Nursing #1 stated Resident #60 had a delay in treatment because a recommendation by the psychiatrist was not given to the medical provider for review. During an interview on 2/1/24 at 12:22 PM, the Acting Administrator stated they expected that any psychiatrist recommendations would be brought to the attention of the medical provider within 24 hours. 10 NYCRR 415.12(f)(1)

Based on observation, interview, and record review conducted during a Recertification Survey completed on 12/7/21, the facility failed to ensure sufficient nursing staff with appropriate competencies and skill sets to provide nursing and related services and safety to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care for residents on 1 of 3 units reviewed. Specifically, on 12/1/21 the Registered Nurse Supervisor (RNS) #3 Nurse Supervisor, was scheduled as the facility supervisor and the sole nurse on the Lake Unit. RNS #3 was not able to complete the medication pass timely, as the RN was assigned additional duties due to staff shortage on one (Lake Unit) of three units, that delayed medication pass. Resident (#1) with history of seizures did not receive medications timely. Resident (#2) with history of diabetes did not receive medications timely. Resident (#3) with history of hypertension did not receive medications timely. Resident (#4) with history of GI issues did not receive medications timely, resulting in GI issues including diarrhea and the potential to develop skin issues, electrolyte imbalance and dehydration. RN did not complete scheduled treatments for 13 of 28 residents with standing orders. Staff stated they are unable to administer and provide treatments within the allotted time frame due to being pulled away from their nursing duties on one (Lake) of three resident units. This resulted in no actual harm with the likelihood for more than minimal harm that is Immediate Jeopardy to resident health and safety. This had the potential to affect all 28 residents on Lake Unit in the facility. The findings are but not limited to: The facility policy and procedure (P&P) titled Emergency Staffing dated February 2020 documented the purpose was to secure needed staff in event of emergency situations and that when the facility staffing level was critical impeding on resident care, the facility will take certain actions. These actions include staff remaining on duty, the Director of Nursing (DON) will notify administrative nursing staff to enlist their services, staff members who are a Certified Nurse Aide (CNA) will work with residents directly and arrange for a loan of nursing personnel from sister facilities. Review of the Facility Assessment for staffing plan (tool used to determine resources necessary to care for facility residents competently during both day-to-day operations and emergencies) modified date April 2021 and signed and dated by the current Administrator on 11/30/21 documented the facility was currently licensed for 134 beds with an average daily census of 126. There were no specific staffing requirements documented under staffing plan in the facility assessment. During an interview on 12/1/21 at 1:45 PM, the Administrative Assistant to the Administrator stated the facility assessment that we gave to you was sent to us from the former Administrator and they had updated it earlier this year. The staffing levels should be on it, but I do not know why they are not. The facility Resident Roster dated 12/1/21 documented a facility census of 98 and Lake Unit had a census of 28. The facility Matrix dated 11/29/21 for the Lake Unit documented 14 residents had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility nursing schedule dated 12/1/21 for the 6:00 AM to 2:00 PM shift documented RN Supervisor #3 was scheduled as the facility supervisor and the sole nurse on the Lake unit. The policy and procedure (P&P) titled Medication Administration Schedule dated 2/25/2015 documented the Licensed Nurse (RN, LPN (licensed practical nurse)) was responsible for adhering to the Standard Medication Administration time codes which are used in each long-term care facility to indicate when medications are to be given to their residents. Unless a specific hour is ordered, all medication will be given within established standard time codes. Standard medication administration time codes were documented as follows: Time/class: 7:00 - 10:00 AM carry as AM. Insulin (routine and sliding scale coverage doses) carry as upon arising in the AM, 30 minutes - 1 hour prior to a meal or at HS (hour of sleep) depending on the type of insulin and the resident's preference and sleep schedule. Medications ordered to be given at a specific time will be administered within one hour of that time. During an interview on 12/1/21 at 11:45 AM, RNS #3 stated that AM medications still needed to be administered to 10 more residents. These Residents were #'s 1, 2, 3, 14, 26, 34, 43, 54, 67 and 85. a.) Resident #4: During an observation on 12/1/21 from 11:23 AM to 11:45 AM, RNS #3 prepared medications for administration for Resident #4. RNS #3 dispensed the 8:00 AM and the AM medications totaling 11 medications at this time. Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 9/1/21 documented Resident #4 was usually understood, usually understands, and was cognitively intact. Review of food and environmental allergies for Resident #4 revealed the resident had a lactose intolerance (inability to break down or digest lactose). physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, Resident #4 had active treatment orders for [MEDICATION(S)] (antifungal medicine) 2% shampoo topical 3 times a week apply to scalp and leave in for 5 minutes before rinsing out. The Medication Record dated 12/2021 documented [MEDICATION(S)] 9,000-unit chew tab was to be administrated at 8:00 AM, 1:00 PM, and 5:00 PM. [MEDICATION(S)] 80mg tab was to be administered at 8:00 AM, 12:00 PM, 5:30 PM, and 8:00 PM. Review of the Medications/Treatments Administered document dated 12/1/21 revealed [MEDICATION(S)] and [MEDICATION(S)] were administered after the breakfast meal at 11:26 AM. Review of the Treatment Record dated 12/2021 for Resident #4 revealed AM treatment orders for [MEDICATION(S)] (antifungal medicine) 2% shampoo were not signed as having been completed as scheduled. During a telephone interview on 12/1/21 at 3:44 PM, the Nurse Practitioner (NP) stated medications were to be administered within the parameter of one hour before or after the scheduled time. Resident #4 had complaints of diarrhea and abdominal issues. Residents missing scheduled medications that can prevent diarrhea and GI (gastrointestinal) issues was upsetting. This can be embarrassing to the resident, they can develop skin issues, electrolyte imbalances and dehydration, if they are having frequent diarrhea. During an interview on 12/1/21 at 5:16 PM, Resident #4 stated they have bouts of diarrhea after their meals, and they can't control it. b.) Resident #1: Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #1 was usually understood, usually understands, and was moderately cognitively impaired. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, Resident #1 had active treatment orders: AFO (ankle foot orthosis) off-once daily (AM) nurse to remove AFO once resident was ready to get out of bed for the day or if requests for it to be removed. Inspect skin after removing; skin prep to top of left foot- 1 application twice daily (AM/ hour of sleep (HS)) for red area; Icy Hot Balm 10/30% -topical twice daily (8:00 AM and 8:00 PM) to B/L (bilateral) hands and knees; Hydrocortisone 1% cream topical twice daily until clear to B/L ears. Review of the Medication Record dated 12/1/21 revealed [MEDICATION(S)] 0.25mg was to be administered at 7:30 AM and 1:30 PM and [MEDICATION(S)] 100mg was scheduled to be given in the AM (7:00 AM-10:00 AM) and HS (7:00PM- 10:00 PM). Review of the Medications/Treatments Administered document dated 12/1/21 revealed the 7:30 AM [MEDICATION(S)] 0.25mg dose was administered at 12:26 PM and the 1:30 PM [MEDICATION(S)] dose was administered at 1:09 PM. [MEDICATION(S)] 100mg was administered at 12:26 PM- two hours after the medication administration window of the physician ordered AM dose. Resident #1 received two doses of [MEDICATION(S)] 0.25mg within 34 minutes of each other. Review of the Treatment Record dated 12/2021 for Resident #1 documented on 12/1/21 AM treatment orders for the removal of the AFO, skin inspection the application of Hot Balm, Hydrocortisone cream were not signed revealing the resident's treatments were not completed within the administration window. c.) Resident #2: Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #2 was usually understood, usually understands, and was moderately cognitively impaired. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, Resident #2 had active treatment orders for Magic Mixture Compound (combination of medications)100,000-0.1 topical TID AM/AF(afternoon)/HS) to bilateral posterior (back) thighs, wounds; off load pressure to heels when in bed every shift (QS) when in bed; off load pressure to Right ischium (lower part of hip bone) with repositioning in accordance with assessed needs QS; Skin prep (protective barrier) to bilateral heels QD (AM). Review of the Medication Record dated 12/2021 documented [MEDICATION(S)] ER 500mg po BID with administration time of 8:00 AM and 8:00 PM: [MEDICATION(S)] 30units SQ QD for DM at 8:00 AM. Review of the Medications/Treatments Administered document dated 12/1/21 revealed [MEDICATION(S)] ER and [MEDICATION(S)] were administered at 1:02 PM. Resident #2 was administered their 8:00 AM medications 3 hours and 2 minutes after the medication administration window of the physician ordered AM dose. Review of the Treatment Record dated 12/2021 for Resident #2 documented on 12/1/21 treatment orders for the Magic mixture compound, off- loading of pressure to heals and ischium, and skin prep were not signed revealing the resident's treatment was not completed as scheduled for the AM, Afternoon and 6:00 AM-2:00 PM shift. d.) Resident #3: Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #3 was usually understood, usually understands, and was severely cognitively impaired. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Record dated 12/2021 documented [MEDICATION(S)] ER 100mg po QD with administration time of AM (7:00-10:00 AM); [MEDICATION(S)] 20mg po QD with administration time of AM; [MEDICATION(S)] XL 180mg po QD with administration time of AM; [MEDICATION(S)] 1000mg po BID with administration time of 8:00 AM and 8:00 PM; [MEDICATION(S)] 20 units SQ QD for DM at 8:00 AM and 8:00 PM. Review of the Medications/Treatments Administered document dated 12/1/21 revealed [MEDICATION(S)] ER, [MEDICATION(S)] 20mg, [MEDICATION(S)] XL 180mg were administered at 11:58 AM, this was 1 hour and 58 minutes after the window of administration. [MEDICATION(S)] 1000mg, and [MEDICATION(S)] were administered at 11:58 AM, this was 3 hours and 58 minutes after the scheduled administration time. Additional review of the Medication Records dated 12/1/21 for Resident's #1, 2, 3, 14, 26, 34, 43, 54, 67 and 85 revealed the scheduled and AM medications had not been administered within the time frames of the administration window. Additional review of the Treatment Records dated 12/1/21 for Resident's #26, 41, 43, 49, 64, 67, 73, 84, 306 and 307 revealed treatments had not been completed within the time frames of the administration window. During an interview on 12/1/21 at 2:21 PM, RNS #3 stated the reality was that there was a staffing crisis and residents were not getting their medications on time. RNS #3 stated that medications and treatments were not administered within medication administration window because the RNS was pulled off unit several times to complete supervisory duties which included: tracking down and completing five employee COVID-19 swabs for testing (waiting 15 minutes with each), attending three resident care plan meetings, staying with maintenance while they repaired the narcotic cabinet in the medication room, collection of emergency drug boxes for pharmacy to pick up and being interrupted to answer phone calls and assist staff. During a telephone interview on 12/1/21 at 3:44 PM, the Nurse Practitioner (NP) stated they were not aware that medications were being administered outside of the administration window. During a telephone interview on 12/2/21 at 8:37 AM, LPN #4 (who works the Lake unit) stated that medications take priority over treatments. Medication administration may be late, and at times they do not get all the residents treatments completed. There is just not enough time due to staffing. During an interview on 12/2/21 at 9:24 AM, RNS #4 stated that when they take a medication cart and supervise the building, they were unable to administer scheduled medications to residents on time. During an interview on 12/2/21 at 10:00 AM, the Administrator stated they were partially aware of the problem as they round within the facility every 2 hours and assumed the medications were going to be late. The Administrator stated they spoke with RNS #3 first thing in the morning to call if they were falling behind and stated, I expect them to call and get assistance via going up the ladder. Based on the survey team's observations of staffing levels, timely medication pass and staff interviews verifying in-service education was completed, the survey team declared the facility removed the immediacy as of 12/03/21 at 10:00 AM. Corrective actions the facility took to remove the immediacy included: - Evaluated and adjusted current staffing needs of the facility to include an additional day time supervisor and a nurse for the Lake Unit. - Immediate education provided to nursing supervisors to check in with each unit nurse to evaluate completion of ordered meds and treatments. Nursing Supervisors instructed to call Administrator or DON in the event of anticipated delays. Instruction to nursing staff to communicate ability to complete med pass and treatments as ordered for residents, to evaluate workloads and anticipate needs so that support can be arranged, and a plan can be made to assist and notification to administration. 415.12(l)(2)(ii)

Based on observation, interview and record review conducted during the Standard survey completed on 12/7/21, the facility did not ensure residents are free of any significant medication error for one (Resident #4) of 4 medication pass observations. Specifically, Resident #4 with history of gastrointestinal distress did not receive medications as ordered and in accordance with facility practices. The finding is: The policy and procedure (P&P) titled Medication Administration Schedule dated 2/25/2015 documented the Licensed Nurse (RN, LPN (licensed practical nurse)) was responsible for adhering to the Standard Medication Administration time codes which are used in each long-term care facility to indicate when medications are to be given to their residents. Unless a specific hour is ordered, all medication will be given within established standard time codes. Medications ordered to be given at a specific time will be administered within one hour of that time. 1. Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 9/1/21 documented Resident #4 was usually understood, usually understands, and was cognitively intact. Review of food and environmental allergies for Resident #4 revealed the resident had a lactose intolerance (inability to break down or digest lactose). During a continuous observation on 12/1/21 from 11:23 AM to 11:45 AM, RN #3 prepared medications for administration for Resident #4. RN #3 was required to answer pop up questions on electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . At this time RN #3 dispensed all the 8:00 AM and the AM medications. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Record dated 12/2021 documented [MEDICATION(S)] 9,000-unit chew tab was to be administrated at 8:00 AM, 1:00 PM, and 5:00 PM. [MEDICATION(S)] 80mg tab was to be administered at 8:00 AM, 12:00 PM, 5:30 PM, and 8:00 PM. Review of the Medications/Treatments Administered document dated 12/1/21 revealed [MEDICATION(S)] and [MEDICATION(S)] were administered after the breakfast meal at 11:26 AM. Review of the Medications/Treatments Administered document for November 2021 revealed [MEDICATION(S)] and [MEDICATION(S)], were administered outside the indicated timeframe on 14 of 30 days. During an interview on 12/1/21 at 2:21 PM, RN #3 stated that medications were not administered within the window. During a telephone interview on 12/1/21 at 3:44 PM, the Nurse Practitioner (NP) stated medications were to be administered within the parameter of one hour before or after the scheduled time. Resident #4 had complaints of diarrhea and abdominal issues. Residents missing scheduled medications that can prevent diarrhea and GI (gastrointestinal) issues was upsetting. This can be embarrassing to the resident, they can develop skin issues, electrolyte imbalances and dehydration, if they are having frequent diarrhea. During an interview on 12/1/21 at 5:16 PM, Resident #4 stated they have bouts of diarrhea after their meals, and they can't control it. During an interview on 12/7/21 at 10:04 AM, RN #7 Unit Manager (UM) for Lake unit stated that medications are scheduled for a reason, some medications need to be spaced out to work adequately, some require to be administered with food or prior to food for the stomach. During an interview on 12/7/21 at 11:00 AM, the facility Director of Nurses (DON) stated scheduled medications should be administered within one hour before or one hour after scheduled time scheduled medications because they may be required to be given more frequently and/or could alter the therapeutic effect of the medication if not given as scheduled. 415.12(m)(2)

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY 363) completed on [DATE], the facility did not ensure the right to request, refuse, and/ or discontinue treatment, and to formulate an advance directive for one (Resident #1) of six residents reviewed for advance directives. Specifically, Resident #1 had a Do Not Resuscitate (DNR - allow natural death) order and received cardio-pulmonary resuscitation (CPR - chest compressions and artificial breathing) when the resident was absent of a pulse and respirations. The finding is: The undated facility policy and procedure (P&P) titled Medical Orders for Life Sustaining Treatment (MOLST) documented honoring patient preferences is a critical element in providing quality end of life care, to help physicians and other health care providers discuss and convey a patients' wishes regarding CPR and other life sustaining treatment. A completed, fully executed MOLST is a valid medical order and is immediately actionable. On the day of admission, if the resident does not have a MOLST form, the resident's preferences for resuscitation must be ascertained. Medical records will be notified of code status and electronic medical record will be updated. The MOLST form will be placed in the appropriate section of the medical record (front of the chart). The facility P&P titled Do Not Resuscitate (DNR), dated [DATE], included a DNR in the resident's medical record instructs the staff not to try to revive the resident if breathing or heartbeat has stopped. This means physicians, nurses and others will not initiate such emergency procedures as mouth to mouth resuscitation or external chest compression. 1. Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - a resident assessment tool) dated [DATE] documented Resident #1 had no speech (absence of spoken words), was usually understood, and had severe cognitive impairment. Review of Resident #1's MOLST signed and dated [DATE] by Nurse Practitioner (NP) #1 documented Resident #1's responsible party requested a DNR order. A Resident Incident Report dated [DATE] 9:35 AM to 10:05 AM by Registered Nurse (RN) #1 Nurse Manager documented, Resident #1 was unresponsive in the shower room at 9:35 AM. A sternal rub (the application of painful stimulus with the knuckles of closed fist to the center chest of a patient who is not alert and does not respond to verbal stimuli) was performed by RN #1 without response. Resident #1 was assisted to their room and placed in bed. Resident #1 remained unresponsive with no pulse, no respirations, and no blood pressure. Oxygen was applied at ,d+[DATE] liters (L) via non-rebreather mask (medical device that delivers high concentration of oxygen in emergency situations), and NP #1 gave order to begin chest compressions at 9:43 AM. Chest compressions were halted at 9:48 AM, Resident #1 remained unresponsive with their pulse rate (normal resting pulse rate ,d+[DATE]) in the 90's and oxygen saturation level (normal oxygen saturation level ,d+[DATE]% (percent)) at 97%. During an interview on [DATE] at 11:11 AM, RN #1 Nurse Manager stated Resident #1 was admitted to the facility as a Full Code (attempt CPR) status. Resident #1's responsible party was contacted on day of admission and the responsible party requested Resident #1's advanced directive status be changed to a DNR. During an interview on [DATE] at 11:52 AM, NP #1 stated she responded to a Code (term used to refer to a patient in cardiopulmonary arrest) for Resident #1. NP #1 stated she reviewed Resident #1's code status in the Electronic Medical Record (EMR) and the EMR documented a Full Code status. NP #1 gave the order for staff to begin CPR based upon the EMR. CPR was halted when Resident #1 regained vital signs, but the resident remained unresponsive. The EMR face-sheet resuscitate code status on [DATE] documented No. During an interview on [DATE] at 11:29 AM, Medical Records (MR) #1 stated they are the only person in the facility that have the capability to change code status in the EMR. Resident #1 was originally admitted to the facility as a Full Code. When the MOLST was initiated on [DATE], MR #1 was not notified of the change in code status and therefore the EMR was not updated. Additionally, MR #1 stated they had changed the code status from FULL to NO in the EMR on [DATE] after they became aware of the MOLST. During an interview on [DATE] at 1:31 PM, the facility Administrator stated the change of code status for Resident #1 was not communicated to the right person to update the EMR, and that resulted in not honoring Resident #1's advance directive for DNR. 415.3(e)(1)(ii)

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY 819) completed on 11/21/19, the facility did not report all alleged violations of abuse for two (Residents #1, 2) of four residents reviewed for abuse. Specifically, four incidents that involved resident to resident inappropriate behaviors were not reported to the New York State (NYS) Department of Health (DOH) as required. The findings are: Review of a facility policy and procedure titled Resident Abuse Prohibition Protocol revised 8/7/18 revealed it is the responsibility of our employees, facility consultants, attending physicians, family members and visitors to promptly report to facility management any incident or suspected incident of resident neglect, mistreatment or abuse including injuries of unknown source. Resident to resident abuse must be reported to the DOH if there is inappropriate physical contact resulting in injury or likely to harm a resident. The policy did not reflect CMS (Centers for Medicare & Medicaid) revised regulation effective 11/28/17 for reporting. 1. Resident #1 had [DIAGNOSES REDACTED]. The resident had moderate cognitive impairment, required extensive assist with activities of daily living and is non-ambulatory. Resident #2 had [DIAGNOSES REDACTED]. The resident was cognitively intact and is limited assist of one with the wheelchair. Review of Nurse's Notes revealed the following: -10/28/19 at 17:11, Licensed Practical Nurse (LPN) documented Resident #1 was noted being inappropriate with a male resident in the dining room. Asked several times by the Certified Nursing Assistant (CNA) and LPN to respect the other residents in the dining room. Supervisor aware and able to redirect. Unit Manager aware to monitor. -10/29/19 at 13:44, LPN documented during lunch Resident #2 wheeled himself next to Resident #1. Resident #1 started running her fingers through his beard telling him how much she liked it. Resident #2 started to stand up and the LPN told him to sit down because he was going to fall. Resident #2 pulled Resident #1's chair toward him and they kissed each other on the lips. The residents were told this was inappropriate. Resident #2 wheeled back to his table and finished eating. -10/31/19 at 22:06, General Practical Nurse (GPN) documented Activities came to the Nurse's Station to say that another resident was fondling and kissing Resident #1 inappropriately. Resident #1 was removed to another location. -11/3/19 at 16:55, LPN documented prior to lunch Resident #1 was resting in her Broda chair in the dining room when another resident began holding her right hand without issue. Resident #2 approached Resident #1 from the left side and began holding her left hand and feeling up her shirt. Staff approached and asked the residents to stop the inappropriate behavior, no effect noted. During an interview on 11/18/19 at 1:00 PM, LPN #1 stated she observed the incident on 10/29/19 and was aware that Residents #1 and #2 needed to be monitored. Resident #2 used to eat meals in his room but was now coming to the dining room. LPN #1 informed RN #1 and the staff on the second shift coming on duty of the incident. During an interview on 11/18/19 at 1:50 PM, the Director of Nursing (DON) stated she was not aware of the incidents documented between 10/28/19 and 11/3/19 that involved Residents #1 and #2. If she had been aware, she would have reported the incidents to the DOH within 2-hours. During an interview on 11/21/19 at 10:45 AM, the Administrator stated the incidents that ocurred between 10/28/19 and 11/3/19 were not brought to administration's attention. If administration had known about the incidents, they would have been reported within 2-hours required by regulation. 415.4(b)(4)

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY 819) completed on 11/21/19, the facility did not have evidence that all alleged violations are thoroughly investigated for two (Residents #1, 2) of four residents reviewed for abuse. Specifically, there was a lack of investigations of four incidents of inappropriate behavior between two residents. The findings are: Review of a facility policy and procedure titled Resident Abuse Prohibition Protocol revised 8/7/18 included the purpose of this policy is to establish a mechanism for educating all responsible parties, and to create a procedure for reporting and investigating all allegations of resident neglect, mistreatment and abuse. 1. Resident #1 had [DIAGNOSES REDACTED]. The resident had moderate cognitive impairment, required extensive assist with activities of daily living and is non-ambulatory. Resident #2 had [DIAGNOSES REDACTED]. The resident was cognitively intact and is limited assist of one with the wheelchair. Review of Nurse's Notes revealed the following: -10/28/19 at 17:11, Licensed Practical Nurse (LPN) documented Resident #1 was noted being inappropriate with a male resident in the dining room. Asked several times by the Certified Nursing Assistant (CNA) and LPN to respect the other residents in the dining room. Supervisor aware and able to redirect. Unit Manager aware to monitor. -10/29/19 at 13:44, LPN documented during lunch Resident #2 wheeled himself next to Resident #1. Resident #1 started running her fingers through his beard telling him how much she liked it. Resident #2 started to stand up and the LPN told him to sit down because he was going to fall. Resident #2 pulled Resident #1's chair toward him and they kissed each other on the lips. The residents were told this was inappropriate. Resident #2 wheeled back to his table and finished eating. -10/31/19 at 22:06, General Practical Nurse (GPN) documented Activities came to Nurse's Station to say that another resident was fondling and kissing Resident #1 inappropriately. Resident #1 was removed to another location. -11/3/19 at 16:55, LPN documented prior to lunch Resident #1 was resting in her Broda chair in the dining room when another resident began holding her right hand without issue. Resident #2 approached Resident #1 from the left side and began holding her left hand and feeling up her shirt. Staff approached and asked the residents to stop the inappropriate behavior, no effect noted. Review of Resident Incident Reports for (MONTH) and (MONTH) 2019 revealed no Incident Reports for the incidents on10/28/19, 10/29/19, 10/31/19 and 11/3/19. Review of the Comprehensive Care Plans for Resident #1 and #2 revealed no changes in care plan after each incident. During an interview on 11/18/19 at 1:00 PM, LPN #1 stated she observed the incident on 10/29/19 and was aware that Residents #1 and #2 needed to be monitored. Resident #2 used to eat meals in his room but was now coming to the dining room. LPN #1 informed RN #1 and the staff on the second shift coming on duty of the incident. During an interview on 11/18/19 at 11:00 AM, RN #1 stated Resident #1 had a history of [REDACTED]. Staff were aware to watch and document on the behavior between Residents #1 and #2. RN #1 stated that no Incident Reports were filed for the incidents on10/28/19, 10/29/19, 10/31/19 and 11/3/19 due to staff documented in the Interdisciplinary Notes. During an interview on 11/18/19 at 1:50 PM, the Director of Nursing (DON) stated she was not aware of the incidents documented between 10/28/19 and 11/3/19 between Residents #1 and #2. If she had been aware, she would have filed Incident Reports and made appropriate care plan changes at that time. 415.4(b)(3)

Based on interview and record review conducted during a Standard survey completed on 3/29/19, it was determined that the facility did not ensure that they immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident's representative (s) when a significant change in the resident's physical, mental, or psychosocial status and there is a need to alter treatment significantly. Specifically, one (Resident #92) of one resident reviewed for notification of change revealed that the resident's family and physician were not notified the resident refused medications for 12 days in (MONTH) 2019. The finding is: The policy and procedure (P&P) entitled Procedure for Medication Administration dated (MONTH) (YEAR) documented if a resident refuses medication for three times to notify the provider so that a determination can be made on how to proceed. Further review of the P&P revealed that nursing staff is to document the resident's refusal and any effects of the refusal. 1. Resident #92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS - a resident assessment tool) dated 2/29/19 revealed that the resident was severely cognitively impaired, usually understood and usually understands. A review of the resident's signed Physician order [REDACTED]. - [MEDICATION NAME] 40 milligrams (mg) by mouth once a day for chronic heart failure ([MEDICAL CONDITION]). - [MEDICATION NAME] 0.4 mg by mouth once a day for bladder neck obstruction. - [MEDICATION NAME] 4 mg by mouth every other day for hypoxemia (abnormally low oxygen levels). - [MEDICATION NAME] 20 mg by mouth once a day for acid reflux. - Senna-[MEDICATION NAME] 8.6 mg/50 mg by mouth at bedtime for constipation. - [MEDICATION NAME] ER 1000 mg by mouth once a day for diabetes mellitus. - [MEDICATION NAME] 30 mg by mouth at bedtime for high cholesterol. - Potassium CL ER 20 meq (milliequivalent) by mouth once a day. - [MEDICATION NAME] 5 mg by mouth at bedtime for high blood pressure. - [MEDICATION NAME] 80 mg by mouth once a day for [MEDICAL CONDITION] (rapid heart rate). - [MEDICATION NAME] 300 mg give two tablets (660 mg) by mouth once a day for [MEDICAL CONDITION]. - [MEDICATION NAME] 3 mg by mouth at bedtime for sleep. A review of the resident's (MONTH) 2019 Medication Administration Record [REDACTED]. A review of the corresponding Interdisciplinary (ID) Notes revealed that staff nurses put an ID note that the resident refused medications on 3/10/19, 3/14/19, and 3/21/19. A review of an email sent to the nursing staff from the Director of Nursing (DON) dated 2/28/19 revealed that nursing staff is to document in the ID notes what medication the resident refused, why the resident refused the medication, the education provided to the resident, and how many attempts made to see if the resident would take the medications. Further review of the email revealed that if a resident refused medications for more than a dose or two, nursing staff is to contact the NP (Nurse Practitioner) or the Physician and document this. An interview with Licensed Practical Nurse (LPN) #2 on 3/27/19 at 10:17 AM revealed that if a resident refused medications, she would re-approach the resident a couple of times and see if they will take it. If the resident refused medications repeatedly, she would let the NP know. An interview with the NP on 3/28/19 at 11:05 AM revealed she had found out about the refused medications on 3/27/19. The LPN's did not inform her of the refused medications and she talks to them every day about the residents. She stated that because the resident was on [MEDICAL CONDITION] medications the resident should have been titrated down, then titrated back up, and not started on same dose as before. The NP had spoken with the resident's daughter who told her that she and the resident had an argument on 3/9/19 and that's when the resident started to refuse the medications. The NP stated the resident had a history of [REDACTED]. The NP expected the nursing staff to call her immediately if a resident refuses three doses or three days of medications in a row. An interview with LPN #1 Unit Manager on 3/28/19 at 11:18 AM revealed that the NP had spoken to her about the resident's medication refusals and that she was not aware of the refusals. The nursing staff can look up in the computer system whether a resident has not gotten medications through the monthly view. The LPN stated that she expected her staff to notify the Physician or the NP if the resident was refusing medications. Additionally, if staff did not notify the Physician or the NP, that staff could notify her, and she would let the NP know about the refusal of medications. An interview with the Director of Nursing (DON) on 3/28/19 at 12:00 PM revealed that she expected her staff to put in an ID note about why the resident refused the medications. If the resident continually refused the medications, they should have called the NP or the Physician. Notifying the Physician of medication refusals was part of the medication pass training when a nurse is hired. A telephone interview with LPN #3 on 3/29/19 at 3:51 AM revealed he would only look at the day's medications but would normally look at the whole month. The LPN did not know the resident had refused medications for a few days. He stated that if he was aware that the resident was not taking her medications, he would email his Unit Manager or let his Supervisor know. A telephone interview with LPN #4 on 3/29/19 at 4:01 AM revealed that she attempted to give the resident her medications while the resident's daughter was there, and the resident refused. The LPN could not remember the day when she told the daughter, but the daughter got the resident to take her medications and asked the LPN how many days did the resident miss medications. The LPN stated when she looked up the resident's MAR indicated [REDACTED]. The LPN further stated she did not put in an ID nor did she notify the Physician or the NP, and she should have notified her Unit Manager and put an ID note into the computer. A review of a facility investigation for the medication refusals given to the Surveyor on 3/29/19 revealed the resident refused medications from 3/9/19 to 3/22/19. The investigation documented the nursing staff did not document in ID notes the reason for the refusal, any evaluation of the resident, communication to the next shift, or to the Unit Manager or NP. 415.3(e)(2)(b)(c)