Every finding on record at Isabella Geriatric Center Inc

Based on observation, record review, and interviews, the facility failed to ensure sufficient nursing staff were available to provide nursing and related services to assure resident safety to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, interviews with residents, resident representatives, the Resident Council, and staff members indicated that there were staffing concerns in the facility. Additionally, a review of staffing from 12/15/2025-03/25/2026 indicated multiple dates where the facility did not ensure sufficient nursing staffing based on their facility assessment's staffing levels.The findings include: The Facility Assessment last updated March 2026 included a Nursing Staffing Plan that documented that by employing acuity-based approach to staffing, the facility ensures that its residents receive the right level of care at the right time, promoting their well-being and overall quality of life. The facility develops par levels of Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistant staff based on the census size and acuity level on each unit. The facility assessment documented the following par levels for the facility:Day Shift (7:00 AM - 3:00 PM):House Building 3rd Floor (bed capacity of 41): One (1) Nurse, Four (4) Certified Nursing AssistantsHouse Building 4th Floor (bed capacity of 36): One (1) Nurse, Four (4) Certified Nursing AssistantsHouse Building 5th Floor (bed capacity of 41): One (1) Nurse, Four (4) Certified Nursing AssistantsHouse Building 6th Floor (bed capacity of 40): One (1) Nurse, Four (4) Certified Nursing AssistantsHouse Building 7th Floor (bed capacity of 40): One (1) Nurse, Four (4) Certified Nursing AssistantsHouse Building 8th Floor (bed capacity of 40): One (1) Nurse, Four (4) Certified Nursing AssistantsHouse Building 9th Floor (bed capacity of 36): Three (3) Nurses, Five (5) Certified Nursing AssistantsHouse Building 11th Floor (bed capacity of 40): One (1) Nurse, Four (4) Certified Nursing AssistantsSkilled Nursing Facility 3rd Floor (bed capacity of 45): Two (2) Nurses, Four (4) Certified Nursing AssistantsSkilled Nursing Facility 4th Floor (bed capacity of 45): Two (2) Nurses, 4 Certified Nursing AssistantsSkilled Nursing Facility 5th Floor (bed capacity of 45): Two (2) Nurses, 4 Certified Nursing AssistantsSkilled Nursing Facility 6th Floor (bed capacity of 45): Two (2) Nurses, 4 Certified Nursing AssistantsSkilled Nursing Facility 7th Floor (bed capacity of 45): Two (2) Nurses, 4 Certified Nursing AssistantsSkilled Nursing Facility 8th Floor (bed capacity of 45): Two (2) Nurses, Four (4) Certified Nursing AssistantsSkilled Nursing Facility 9th Floor (bed capacity of 45): Two (2) Nurses, Four (4) Certified Nursing AssistantsSkilled Nursing Facility 10th Floor (bed capacity of 30): Two (2) Nurses, Three (3) Certified Nursing AssistantsSkilled Nursing Facility 11th Floor (bed capacity of 31): Two (2) Nurses, Three (3) Certified Nursing AssistantsSkilled Nursing Facility 13th Floor (bed capacity of 31): Two (2) Nurses, Three (3) Certified Nursing Assistants Evening Shift (3:00 PM - 11:00 PM)House Building 3rd Floor (bed capacity of 41): One (1) Nurse, Three (3) Certified Nursing AssistantsHouse Building 4th Floor (bed capacity of 36): One (1) Nurse, Three (3) Certified Nursing AssistantsHouse Building 5th Floor (bed capacity of 41): One (1) Nurse, Three (3) Certified Nursing AssistantsHouse Building 6th Floor (bed capacity of 40): One (1) Nurse, Three (3) Certified Nursing AssistantsHouse Building 7th Floor (bed capacity of 40): One (1) Nurse, Three (3) Certified Nursing AssistantsHouse Building 8th Floor (bed capacity of 40): One (1) Nurse, Three (3) Certified Nursing AssistantsHouse Building 9th Floor (bed capacity of 36): Three (3) Nurses, Four (4) Certified Nursing AssistantsHouse Building 11th Floor (bed capacity of 40): One (1) Nurse, Three (3) Certified Nursing AssistantsSkilled Nursing Facility 3rd Floor (bed capacity of 45): One (1) Nurse, Three (3) Certified Nursing AssistantsSkilled Nursing Facility 4th Floor (bed capacity of 45): One (1) Nurse, Three (3) Certified Nursing AssistantsSkilled Nursing Facility 5th Floor (bed capacity of 45): One (1) Nurse, Three (3) Certified Nursing AssistantsSkilled Nursing Facility 6th Floor (bed capacity of 45): One (1) Nurse, Three (3) Certified Nursing AssistantsSkilled Nursing Facility 7th Floor (bed capacity of 45): One (1) Nurse, Three (3) Certified Nursing AssistantsSkilled Nursing Facility 8th Floor (bed capacity of 45): One (1) Nurse, Three (3) Certified Nursing AssistantsSkilled Nursing Facility 9th Floor (bed capacity of 45): One (1) Nurse, Three (3) Certified Nursing AssistantsSkilled Nursing Facility 10th Floor (bed capacity of 30): One (1) Nurse, Three (3) Certified Nursing AssistantsSkilled Nursing Facility 11th Floor (bed capacity of 31): One (1) Nurse, Three (3) Certified Nursing AssistantsSkilled Nursing Facility 13th Floor (bed capacity of 31): One (1) Nurse, Three (3) Certified Nursing Assistants Night Shift (11:00 PM-7:00 AM)House Building 3rd Floor (bed capacity of 41): One (1) Nurse, Two (2) Certified Nursing AssistantsHouse Building 4th Floor (bed capacity of 36): One (1) Nurse, Two (2) Certified Nursing AssistantsHouse Building 5th Floor (bed capacity of 41): One (1) Nurse, Two (2) Certified Nursing AssistantsHouse Building 6th Floor (bed capacity of 40): One (1) Nurse, Two (2) Certified Nursing AssistantsHouse Building 7th Floor (bed capacity of 40): One (1) Nurse, Two (2) Certified Nursing AssistantsHouse Building 8th Floor (bed capacity of 40): One (1) Nurse, Two (2) Certified Nursing AssistantsHouse Building 9th Floor (bed capacity of 36): Three (3) Nurses, Three (3) Certified Nursing AssistantsHouse Building 11th Floor (bed capacity of 40): One (1) Nurse, Two (2) Certified Nursing AssistantsSkilled Nursing Facility 3rd Floor (bed capacity of 45): One (1) Nurse, Two (2) Certified Nursing AssistantsSkilled Nursing Facility 4th Floor (bed capacity of 45): One (1) Nurse, Two (2) Certified Nursing AssistantsSkilled Nursing Facility 5th Floor (bed capacity of 45): One (1) Nurse, Two (2) Certified Nursing AssistantsSkilled Nursing Facility 6th Floor (bed capacity of 45): One (1) Nurse, Two (2) Certified Nursing AssistantsSkilled Nursing Facility 7th Floor (bed capacity of 45): One (1) Nurse, Two (2) Certified Nursing AssistantsSkilled Nursing Facility 8th Floor (bed capacity of 45): One (1) Nurse, Two (2) Certified Nursing AssistantsSkilled Nursing Facility 9th Floor (bed capacity of 45): One (1) Nurse, Two (2) Certified Nursing AssistantsSkilled Nursing Facility 10th Floor (bed capacity of 30): One (1) Nurse, Two (2) Certified Nursing AssistantsSkilled Nursing Facility 11th Floor (bed capacity of 31): One (1) Nurse, Two (2) Certified Nursing AssistantsSkilled Nursing Facility 13th Floor (bed capacity of 31): One (1) Nurse, Two (2) Certified Nursing Assistants On 03/24/2026 at 02:13 PM, the Director of Nursing was interviewed and stated that the par levels for Skilled Nursing Facility 12th floor (bed capacity 31) were two (2) Nurses and three (3) Certified Nursing Assistants on the day shift, one (1) Nurse and three (3) Certified Nursing Assistants for the evening shift, and one (1) Nurse and two (2) Certified Nursing Assistants for the night shift. The Director of Nursing further stated that the par levels for House Building 10th floor (bed capacity 40) were one (1) Nurse and 4 Certified Nursing Assistants for the day shift, one (1) Nurse and 3 Certified Nursing Assistants for the evening shift, and one (1) Nurse and 2 Certified Nursing Assistants for the night shift. The Director of Nursing stated that this is not included in the par level sheet included with the Facility Assessment because residents were recently removed from those units and the par level sheet reflects the updated resident units. The Director of Nursing stated that the other par levels reflected on the facility assessment, which are listed above, were consistent with the par levels required during the lookback period of 12/15/2026 through 03/25/2026. Review of the actual staffing schedules from 12/15/2026 through 03/24/2026 documented the following:On 12/15/2025 on the day shift: Skilled Nursing Facility 3rd Floor was short of one (1) Certified Nursing Assistant, Skilled Nursing Facility 5th Floor was short of one (1) Certified Nursing Assistant, Skilled Nursing Facility 7th Floor was short of one (1) Nurse, Skilled Nursing Facility 9th Floor was short of one (1) Nurse.On 12/16/2025 on the day shift: Skilled Nursing Facility 5th Floor was short of one (1) Nurse, Skilled Nursing Facility 6th Floor was short of one (1) Nurse and one (1) Certified Nursing Assistant.On 12/19/2025 on the day shift: Skilled Nursing Facility 6th Floor was short of one (1) Certified Nursing Assistant, Skilled Nursing Facility 7th Floor was short of one (1) Certified Nursing Assistant, Skilled Nursing Facility 9th floor was short of one (1) Nurse.On 12/20/2025 on the day shift: Skilled Nursing Facility 3rd Floor was short of one (1) Nurse, Skilled Nursing Facility 5th Floor was short of one (1) nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 7th Floor was short of one (1) Nurse, Skilled Nursing Facility 8th Floor was short of one (1) Nurse, Skilled Nursing Facility 9th Floor was short of one (1) Nurse, Skilled Nursing Facility 10th Floor was short of one (1) Nurse, Skilled Nursing Facility 11th Floor was short of one (1) Nurse, Skilled Nursing Facility 13th Floor was short of one (1) Nurse.On 12/21/2025 on the day shift: Skilled Nursing Facility 3rd Floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 4th Floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 5th Floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 6th Floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 7th Floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 8th Floor was short of one (1) Nurse, Skilled Nursing 11th Floor was short of one (1) Nurse, Skilled Nursing 13th Floor was short of one (1) Nurse, House Building 4th Floor was short of one (1) Certified Nursing Assistant, House Building 5th Floor was short of one (1) Certified Nursing Assistant, House Building 7th Floor was short of one (1) Certified Nursing Assistant.On 12/22/2025 on the day shift: Skilled Nursing Facility 5th Floor was short of one (1) Nurse, Skilled Nursing Facility 6th Floor was short of one (1) Nurse, Skilled Nursing Facility 9th Floor was short of one (1) Nurse, House Building 4th Floor was short of one (1) Certified Nursing Assistant.On 12/23/2025 on the day shift: Skilled Nursing Facility 4th Floor was short of one (1) Nurse, Skilled Nursing Facility 5th Floor was short of one (1) Nurse, Skilled Nursing Facility 6th Floor was short of one (1) Nurse, Skilled Nursing Facility 8th Floor was short of one (1) Nurse, Skilled Nursing Facility 9th Floor was short of one (1) Nurse, House Building 4th Floor was short of one (1) Certified Nursing Assistant.On 12/24/2025 on the day shift: Skilled Nursing Facility 3rd Floor was short of one (1) Nurse, Skilled Nursing Facility 6th Floor was short of one (1) Certified Nursing Assistant, Skilled Nursing Facility 7th Floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 8th Floor was short of one (1) Nurse, Skilled Nursing Facility 9th Floor was short of one (1) Nurse.On 12/25/2025 on the day shift: Skilled Nursing Facility 3rd Floor was short of one (1) Nurse, Skilled Nursing Facility 4th Floor was short of one (1) Nurse, Skilled Nursing Facility 5th Floor was short of one (1) Nurse, Skilled Nursing Facility 8th Floor was short of one (1) Nurse, Skilled Nursing Facility 11th Floor was short of one (1) Nurse.On 12/26/2025 on the day shift: Skilled Nursing Facility 3rd Floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 4th Floor was short of one (1) Nurse, Skilled Nursing Facility 5th Floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 6th Floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 7th Floor was short of one (1) Certified Nursing Assistant, Skilled Nursing Facility 8th Floor was short of one (1) Nurse, Skilled Nursing Facility 9th Floor was short of one (1) Nurse, Skilled Nursing Facility 13th Floor was short of one (1) Nurse, House Building 4th Floor was short of one (1) Certified Nursing Assistant.On 12/27/2025 on the day shift: Skilled Nursing Facility 3rd floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 4th Floor was short of one (1) Nurse, Skilled Nursing Facility 5th Floor was short of one (1) Nurse, Skilled Nursing Facility 6th Floor was short of one (1) Nurse, Skilled Nursing Facility 7th Floor was short of one (1) Nurse, Skilled Nursing Facility 8th Floor was short of one (1) Nurse, Skilled Nursing Facility 9th Floor was short of one (1) Nurse, Skilled Nursing Facility 11th Floor was short of one (1) Nurse, Skilled Nursing Facility 13th Floor was short of one (1) Nurse, House Building 4th Floor was short of one (1) Certified Nursing Assistant.On 12/28/2025 on the day shift: Skilled Nursing Facility 3rd floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 4th floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 5th floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 6th floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 7th floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 5th floor was short of one (1) Nurse, Skilled Nursing Facility 9th floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 10th floor was short of one (1) Nurse, Skilled Nursing Facility 11th floor was short of one (1) Nurse, Skilled Nursing Facility 13th floor was short of one (1) Nurse, House Building 4th Floor was short of two (2) Certified Nursing Assistants, House Building 7th Floor was short of one (1) Certified Nursing Assistant.On 12/29/2025 on the day shift: Skilled Nursing Facility 3rd floor was short of one (1) Nurse, Skilled Nursing Facility 4th floor was short of one (1) Nurse, Skilled Nursing Facility 5th floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 6th floor was short of one (1) Nurse, Skilled Nursing Facility 7th floor was short of one (1) Nurse, Skilled Nursing Facility 8th floor was short of one (1) Nurse, Skilled Nursing Facility 9th floor was short of one (1) Nurse, Skilled Nursing Facility 10th floor was short of one (1) Nurse.On 12/30/2025 on the day shift: Skilled Nursing Facility 4th floor was short of one (1) Nurse, Skilled Nursing Facility 5th floor was short of one (1) Nurse, Skilled Nursing Facility 8th floor was short of one (1) Nurse, Skilled Nursing Facility 9th floor was short of one (1) Nurse, Skilled Nursing Facility 10th floor was short of one (1) Nurse, Skilled Nursing Facility 11th floor was short of one (1) Nurse, House Building 4th floor was short of one (1) Certified Nursing Assistant.On 12/31/2025 on the day shift: Skilled Nursing Facility 3rd floor was short of one (1) Nurse, Skilled Nursing Facility 5th floor was short of one (1) Nurse, Skilled Nursing Facility 7th floor was short of one (1) Certified Nursing Assistant, Skilled Nursing Facility 8th floor was short of one (1) Nurse, Skilled Nursing Facility 11th floor was short of one (1) Nurse.On 01/01/2026 on the day shift: Skilled Nursing Facility 6th floor was short of one (1) Nurse, Skilled Nursing Facility 7th floor was short of one (1) Nurse, Skilled Nursing Facility 8th floor was short of one (1) Nurse, Skilled Nursing Facility 9th floor was short of one (1) Nurse, Skilled Nursing Facility 10th floor was short of one (1) Nurse, House Building 4th floor was short of one (1) Certified Nursing Assistant.On 01/02/2026 on the day shift: Skilled Nursing Facility 3rd floor was short of one (1) Nurse, Skilled Nursing Facility 4th floor was short of one (1) Nurse, Skilled Nursing Facility 6th floor was short of one (1) Nurse, Skilled Nursing Facility 7th floor was short of one (1) Certified Nursing Assistant, Skilled Nursing Facility 8th floor was short of one (1) Nurse, Skilled Nursing Facility 9th floor was short of one (1) Nurse, Skilled Nursing Facility 11th floor was short of one (1) Nurse, Skilled Nursing Facility 13th floor was short of one (1) Nurse, House Building 4th Floor was short of one (1) Certified Nursing Assistant.On 01/03/2026 on the day shift: Skilled Nursing Facility 3rd floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 5th floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 6th floor was short of one (1) Nurse, Skilled Nursing Facility 7th floor was short of one (1) Certified Nursing Assistant, Skilled Nursing Facility 8th floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 9th floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, House Building 4th floor was short of one (1) Certified Nursing Assistant.On 01/04/2026 on the day shift: Skilled Nursing Facility 3rd floor was short of one (1) Nurse, Skilled Nursing Facility 4th floor was short of one (1) Nurse, Skilled Nursing Facility 5th floor was short of one (1) Nurse, Skilled Nursing Facility 6th floor was short of one (1) Nurse, Skilled Nursing Facility 7th floor was short of one (1) Nurse, Skilled Nursing Facility 8th floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 9th floor was short of one (1) Nurse, House Building 4th floor was short of one (1) Certified Nursing Assistant.On 01/05/2026 on the day shift: Skilled Nursing Facility 3rd floor was short of one (1) Nurse, Skilled Nursing Facility 4th floor was short of one (1) Nurse, Skilled Nursing Facility 5th floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 6th floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 7th floor was short of one (1) Certified Nursing Assistant, Skilled Nursing Facility 8th floor was short of one (1) Nurse, Skilled Nursing Facility 9th floor was short of one (1) Nurse, House Building 4th floor was short of one (1) Certified Nursing Assistant.On 01/06/2026 on the day shift: Skilled Nursing Facility 3rd floor was short of one (1) Certified Nursing Assistant, Skilled Nursing Facility 5th floor was short of one (1) Certified Nursing Assistant, Skilled Nursing Facility 6th floor was short of one (1) Certified Nursing Assistant, Skilled Nursing Facility 8th floor was short of one (1) Nurse, Skilled Nursing Facility 9th floor was short of one (1) Nurse, Skilled Nursing Facility 10th floor was short of one (1) Certified Nursing Assistant, House Building 4th Floor was short of one (1) Certified Nursing Assistant.On 01/09/2026 on the day shift: Skilled Nursing Facility 3rd floor was short of one (1) Nurse, Skilled Nursing Facility 4th floor was short of one (1) Nurse, Skilled Nursing Facility 5th floor was short of one (1) Nurse, Skilled Nursing Facility 6th floor was short of one (1) Nurse, Skilled Nursing Facility 7th floor was short of one (1) Nurse, Skilled Nursing Facility 8th floor was short of one (1) Nurse, Skilled Nursing Facility 9th floor was short of one (1) Nurse, Skilled Nursing Facility 10th floor was short of one (1) Nurse, Skilled Nursing Facility 11th floor was short of one (1) Nurse, Skilled Nursing Facility 13th floor was short of one (1) Nurse, House Building 4th floor was short of one (1) Nurse.On 01/10/2026 on the day shift: Skilled Nursing Facility 3rd floor was short of one (1) Nurse, Skilled Nursing Facility 4th floor was short of one (1) Certified Nursing Assistant, Skilled Nursing Facility 5th floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 6th floor was short of one (1) Nurse, Skilled Nursing Facility 7th floor was short of one (1) Nurse, Skilled Nursing Facility 8th floor was short of one (1) Nurse, Skilled Nursing Facility 9th floor was short of one (1) Nurse, Skilled Nursing Facility 11th floor was short of one (1) Nurse, House Building 4th floor is short one (1) Certified Nursing Assistant.On 01/11/2026 on the day shift: Skilled Nursing Facility 3rd floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 5th floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 6th floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 7th floor was short of one (1) Nurse, Skilled Nursing Facility 8th floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 9th floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, House Building 4th floor was short of one (1) Certified Nursing Assistant.On 01/12/2026 on the day shift: Skilled Nursing Facility 5th floor was short of one (1) Nurse, Skilled Nursing Facility 8th floor was short of one (1) Nurse, Skilled Nursing Facility 9th floor was short of one (1) Nurse.On 01/16/2026 on the day shift: Skilled Nursing Facility 3rd floor was short of one (1) Nurse, Skilled Nursing Facility 6th floor was short of one (1) Nurse, Skilled Nursing Facility 7th floor was short of one (1) Nurse, Skilled Nursing Facility 9th floor was short of one (1) Nurse.On 01/17/2026 on the day shift: Skilled Nursing Facility 3rd floor was short of one (1) Nurse, Skilled Nursing Facility 7th floor was short of one (1) Nurse, Skilled Nursing Facility 8th floor was short of one (1) Nurse, Skilled Nursing Facility 9th floor was short of one (1) Nurse, House Building 4th floor was short of one (1) Certified Nursing Assistant.On 01/18/2026 on the day shift: Skilled Nursing Facility 3rd floor was short of one (1) Nurse, Skilled Nursing Facility 5th floor was short of one (1) Certified Nursing Assistant, Skilled Nursing Facility 7th floor was short of one (1) Nurse, Skilled Nursing Facility 8th floor was short of one (1) Nurse, Skilled Nursing Facility 9th floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, House Building 3rd floor was short of one (1) Certified Nursing Assistant, House Building 4th floor was short of one (1) Certified Nursing Assistant, House Building 8th floor was short of one (1) Certified Nursing Assistant.On 01/23/2026 on the day shift: Skilled Nursing Facility 3rd floor was short of one (1) Nurse, Skilled Nursing Facility 4th floor was short of one (1) Nurse, Skilled Nursing Facility 8th floor was short of one (1) Nurse, Skilled Nursing Facility 9th floor was short of one (1) Nurse.On 01/24/2026 on the day shift: Skilled Nursing Facility 3rd floor was short of one (1) Nurse.On 01/25/2026 on the day shift: Skilled Nursing Facility 5th floor was short of one (1) Nurse, Skilled Nursing Facility 8th floor was short of one (1) Nurse, Skilled Nursing Facility 9th floor was short of one (1) Nurse, House Building 4th floor was short of one (1) Certified Nursing Assistant.On 01/26/2026 on the day shift: Skilled Nursing Facility 3rd floor was short of one (1) Nurse, Skilled Nursing Facility 4th floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 5th floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 6th floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 7th floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 8th floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 9th floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 11th floor was short of one (1) Nurse, Skilled Nursing Facility 13th floor was short of one (1) Nurse.On 01/30/2026 on the day shift: Skilled Nursing Facility 8th floor was short of one (1) Nurse, Skilled Nursing Facility 9th floor was short of one (1) Nurse.On 01/31/2026 on the day shift: Skilled Nursing Facility 3rd floor was short of one (1) Nurse, Skilled Nursing Facility 5th floor was short of one (1) Nurse, Skilled Nursing Facility 8th floor was short of one (1) Nurse, House Building 4th floor was short of one (1) Certified Nursing Assistant.On 02/01/2026 on the day shift: Skilled Nursing Facility 3rd floor was short of one (1) Nurse, Skilled Nursing Facility 5th floor was short of one (1) Nurse, Skilled Nursing Facility 7th floor was short of one (1) Certified Nursing Assistant, Skilled Nursing Facility 8th floor was short of one (1) Nurse, Skilled Nursing Facility 9th floor was short of one (1) Nurse, House Building 4th floor was short of one (1) Certified Nursing Assistant.On 02/02/2026 on the day shift: Skilled Nursing Facility 5th floor was short of one (1) Nurse, Skilled Nursing Facility 6th floor was short of one (1) Nurse, Skilled Nursing Facility 9th floor was short of one (1) Nurse.On 02/06/2026 on the day shift: Skilled Nursing Facility 3rd floor was short of one (1) Nurse, Skilled Nursing Facility 5th floor was short of one (1) Nurse, Skilled Nursing Facility 6th floor was short of one (1) Nurse, Skilled Nursing Facility 7th floor was short of one (1) Nurse, Skilled Nursing Facility 8th floor was short of one (1) Nurse, Skilled Nursing Facility 9th floor was short of one (1) Nurse.On 02/07/2026 on the day shift: Skilled Nursing Facility 3rd floor was short of one (1) Nurse, Skilled Nursing Facility 5th floor was short of one (1) Nurse, Skilled Nursing Facility 6th floor was short of one (1) Nurse, Skilled Nursing Facility 7th floor was short of one (1) Nurse, Skilled Nursing Facility 8th floor was short of one (1) Nurse, Skilled Nursing Facility 9th floor was short of one (1) Nurse.On 02/08/2026 on the day shift: Skilled Nursing Facility 3rd floor was short of one (1) Nurse, Skilled Nursing Facility 5th floor was short of one (1) Nurse, Skilled Nursing Facility 6th floor was short of one (1) Nurse, Skilled Nursing Facility 7th floor was short of one (1) Nurse, Skilled Nursing Facility 9th floor was short of one (1) Nurse, Skilled Nursing Facility 10th floor was short of one (1) Certified Nursing Assistant.On 02/09/2026 on the day shift: Skilled Nursing Facility 3rd floor was short of one (1) Nurse, Skilled Nursing Facility 7th floor was short of one (1) Nurse, Skilled Nursing Facility 8th floor was short of one (1) Nurse, Skilled Nursing Facility 9th floor was short of one (1) Nurse.On 02/14/2026 on the day shift: Skilled Nursing Facility 7th floor was short of one (1) Nurse, House Building 3rd floor was short of one (1) Certified Nursing Assistant, House Building 4th floor was short of one (1) Certified Nursing Assistant.On 02/15/2026 on the day shit: Skilled Nursing Facility 3rd floor was short of one (1) Nurse, Skilled Nursing Facility 9th floor was short of one (1) Certified Nursing Assistant, House Building 4th floor was short of one (1) Certified Nursing Assistant.On 02/20/2026 on the day shift: Skilled Nursing Facility 3rd floor was short of one (1) Nurse, Skilled Nursing Facility 5th floor was short of one (1) Nurse, Skilled Nursing Facility 7th floor was short of one (1) Nurse, Skilled Nursing Facility 8th floor was short of one (1) Nurse, Skilled Nursing Facility 9th floor was short of one (1) Nurse.On 02/21/2026 on the day shift: Skilled Nursing Facility 5th floor was short of one (1) Nurse.On 02/22/2026 on the day shift: Skilled Nursing Facility 3rd floor was short of one (1) Nurse, Skilled Nursing Facility 4th floor was short of one (1) Nurse, Skilled Nursing Facility 5th floor was short of one (1) Nurse, Skilled Nursing Facility 6th floor was short of one (1) Nurse, House Building 4th floor was short of one (1) Certified Nursing Assistant.On 02/28/2026 on the day shift: Skilled Nursing Facility 9th floor was short of one (1) Nurse.On 03/01/2026 on the day shift: Skilled Nursing Facility 8th floor was short of one (1) Nurse, Skilled Nursing Facility 9th floor was short of one (1) Nurse, House Building 4th floor was short of one (1) Certified Nursing Assistant.On 03/06/2026 on the day shift: Skilled Nursing Facility 3rd floor was short of one (1) Nurse, Skilled Nursing Facility 5th floor was short of one (1) Nurse, Skilled Nursing Facility 9th floor was short of one (1) Nurse.On 03/07/2026 on the day shift: Skilled Nursing Facility 3rd floor was short of one (1) Nurse, Skilled Nursing Facility 6th floor was short of one (1) Nurse, Skilled Nursing Facility 8th floor was short of one (1) Nurse, Skilled Nursing Facility 9th floor was short of one (1) Nurse.On 03/08/2026 on the day shift: Skilled Nursing Facility 5th floor was short of one (1) Nurse, House Building 4th floor was short of one (1) Certified Nursing Assistant.On 03/15/2026 on the day shift: Skilled Nursing Facility 3rd floor was short of one (1) Certified Nursing Assistant, Skilled Nursing Facility 4th floor was short of one (1) Certified Nursing Assistant, Skilled Nursing Facility 5th floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 6th floor was short of one (1) Certified Nursing Assistant, Skilled Nursing Facility 7th floor was short of one (1) Certified Nursing Assistant, Skilled Nursing Facility 8th floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 9th floor was short of two (2) Certified Nursing Assistants, House Building 3rd floor was short of one (1) Certified Nursing Assistant, House Building 4th floor was short of one (1) Certified Nursing Assistant, House Building 6th floor was short of one (1) Certified Nursing Assistant.On 03/16/2026 on the day shift: Skilled Nursing facility 3rd floor was short of one (1) Nurse, Skilled Nursing Facility 5th floor was short of one (1) Nurse, Skilled Nursing Facility 6th floor was short of one (1) Nurse, House Building 4th floor was short of one (1) Certified Nursing Assistant.On 03/17/2026 on the day shift: Skilled Nursing Facility 5th floor was short of one (1) Nurse, Skilled Nursing Facility 8th floor was short of one (1) Nurse, House Building 4th floor was short of one (1) Certified Nursing Assistant.On 03/18/2026 on the day shift: Skilled Nursing Facility 3rd floor was short of one (1) Nurse, Skilled Nursing Facility 4th floor was short of one (1) Nurse, Skilled Nursing Facility 5th floor was short of one (1) Nurse, Skilled Nursing Facility 6th floor was short of one (1) Nurse, Skilled Nursing Facility 7th floor was short of one (1) Nurse, Skilled Nursing Facility 8th floor was short of one (1) Nurse, Skilled Nursing Facility 9th floor was short of one (1) Nurse, Skilled Nursing Facility 11th floor was short of one (1) Nurse, House Building 4th floor was short of one (1) Certified Nursing Assistant.On 03/20/2026 on the day shift: Skilled Nursing Facility 3rd floor was short of one (1) Nurse, Skilled Nursing Facility 4th floor was short of one (1) Nurse, Skilled Nursing Facility 5th floor was short of one (1) Nurse, Skilled Nursing Facility 6th floor was short of one (1) Nurse, Skilled Nursing Facility 7th floor was short of one (1) Nurse, Skilled Nursing Facility 8th floor was short of one (1) Nurse and one (1) Certified Nursing Assistant, Skilled Nursing Facility 9th floor was short of one (1) Nurse, Skilled Nursing Facility 11th floor was short of one (1) Nurse, Skilled Nursing Facility 13th floor was short of one (1) Nurse, House Building 4th floor was short of one (1) Certified Nursing Assistant, House Building 7th floor was short of one (1) Certified Nursing Assistant.On 03/21/2026 on the day shift: Skilled Nursing Facility 3rd floor was short of one (1) Nurse, Skilled Nursing Facility 6th floor was short of one (1) Nurse, Skilled Nursing Facility 7th floor was short of one (1) Nurse, Skilled Nursing Facility 8th floor was short of one (1) Nurse.On 03/22/2026 on the day shift: Skilled Nursing Facility 3rd floor was short of one (1) Nurse, Skill[TRUNCATED]

Based on record review and staff interviews, the facility did not ensure that each resident's Comprehensive Care Plans were reviewed and revised. This was evident for one (1) resident out of five (5) residents reviewed for Unnecessary Medications out of 38 sampled residents. Specifically, there was no documented evidence that the Seizure Disorder Comprehensive Care Plan was reviewed and revised for Resident #148 after their last quarterly Minimum Data Set assessment was completed.The findings include:The facility policy titled Care Planning Process effective 02/2026 documented that the facility shall have a care planning process that is person centered which includes integrating assessment findings in care planning, developing an interdisciplinary care plan, regularly reviewing and revising the care plan, providing the care, and documenting the care. The care plan is revised by the members of the Interdisciplinary Team after each assessment, including both the comprehensive and quarterly review assessment.Resident #148 had diagnoses including Non-Alzheimer's Dementia and Seizure Disorder.The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #148 had a Seizure Disorder and was prescribed an anticonvulsant medication.The Seizure Disorder Comprehensive Care Plan, effective 05/19/2025, documented that Resident #148 had a Seizure Disorder with involuntary contractions of muscles. The Seizure Disorder Comprehensive Care Plan was last reviewed on 10/18/2025 and there was no documented evidence that that the care plan was reviewed following Resident #148's Quarterly Minimum Data Set assessment on 01/15/2026. On 03/24/2026 at 09:39 AM, Registered Nurse #7 was interviewed and stated that they were a Registered Nurse Supervisor on Resident #148's Unit. Registered Nurse #7 stated that it was their responsibility to update the care plans of residents on their unit on a quarterly basis at the time of the resident's Minimum Data Set assessment. Registered Nurse #7 stated that Resident #148 had a Seizure Disorder and was prescribed an anticonvulsant medication for the Seizure Disorder. Registered Nurse #7 stated that they believed that Resident #148's Seizure Disorder Comprehensive Care Plan was not updated because the facility had recently switched electronic medical record systems and this care plan was missed during the transfer of care plans.On 03/24/2026 at 10:45 AM, the Director of Nursing was interviewed and stated that Comprehensive Care Plans are updated on a quarterly basis by the Registered Nurse Supervisor on the resident's unit. The Director of Nursing stated that Resident #148's Seizure Disorder Comprehensive Care Plan should have been updated in January 2026 with their Minimum Data Set assessment and that it was possible that the care plan was not transferred to the new electronic medical record system that the facility uses and was therefore not updated.New York Codes, Rules and Regulations 415.11(c)(2)(i-iii)

Based on observation, record review, and interviews, the facility failed to ensure that Minimum Data Set assessments were electronically transmitted to the Centers for Medicare and Medicaid Services Data System within 14 days after assessments were completed. This was evident for 14 ( # 38, #100, #286, #358, #373, #440, #493, #573, #587, #614, #621, #626, #663, #670) of 14 residents reviewed for resident assessment. The findings are:The facility's policy and procedure dated 02/2026 titled Minimum Data Set/Resident Assessment Instrument, Process Completion documented that the Resident Assessment Instrument process will be used to complete initial and periodic Omnibus Budget Reconciliation Act and Discharge Minimum Data Set assessments for all residents in certified beds. Assessments will be completed within the guidelines outlined in the Resident Assessment Instrument manual, including that assessments will be completed in accordance with Center for Medicaid/Medicare requirements.A quarterly Minimum Data Set for Resident #38 with an assessment reference date of 01/31/2026 was completed on 02/09/2026. The resident assessment was submitted on 03/16/2026.A quarterly Minimum Data Set for Resident #100 with an assessment reference date of 01/27/2026 was completed on 02/04/2026. The resident assessment was submitted on 03/16/2026.A quarterly Minimum Data Set for Resident #286 with an assessment reference date of 01/31/2026 was completed on 02/09/2026. The resident assessment was submitted on 03/16/2026.A quarterly Minimum Data Set for Resident #358 with an assessment reference date of 01/28/2026 was completed on 02/05/2026. The resident assessment was submitted on 03/16/2026.A quarterly Minimum Data Set for Resident #373 with an assessment reference date of 01/26/2026 was completed on 02/09/2026. The resident assessment was submitted on 03/16/2026.A quarterly Minimum Data Set for Resident #440 with an assessment reference date of 01/20/2026 was completed on 02/09/2026. The resident assessment was submitted on 03/16/2026.An annual Minimum Data Set for Resident #493 with an assessment reference date of 01/26/2026 was completed on 02/09/2026. The resident assessment was submitted on 03/16/2026.A quarterly Minimum Data Set for Resident #573 with an assessment reference date of 01/28/2026 was completed on 02/05/2026. The resident assessment was submitted on 03/16/2026.An annual Minimum Data Set for Resident #587 with an assessment reference date of 01/29/2026 was completed on 02/09/2026. The resident assessment was submitted on 03/16/2026.A quarterly Minimum Data Set for Resident #614 with an assessment reference date of 01/28/2026 was completed on 02/09/2026. The resident assessment was submitted on 03/16/2026.A quarterly Minimum Data Set for Resident #621 with an assessment reference date of 01/31/2026 was completed on 02/09/2026. The resident assessment was submitted on 03/16/2026.A quarterly Minimum Data Set for Resident #626 with an assessment reference date of 01/31/2026 was completed on 02/06/2026. The resident assessment was submitted on 03/16/2026.A quarterly Minimum Data Set for Resident # 663 with an assessment reference date of 01/28/2026 was completed on 02/05/2026. The resident assessment was submitted on 03/16/2026.A quarterly Minimum Data Set for Resident #670 with an assessment reference date of 01/31/2026 was completed on 02/09/2026. The resident assessment was submitted on 03/16/2026. On 03/20/2026 at 1:04 PM, Minimum Data Set Consultant #3 was interviewed and stated their role is to conduct weekly audits of late or missing Minimum Data Set assessments using the Internet Quality Improvement & Evaluation System. They stated that on 03/16/2026, while doing their weekly audit, they found 14 residents' Minimum Data Sets were not transmitted timely. They stated this was immediately corrected and transmitted on the same day. Minimum Data Set Consultant #3 stated that the person responsible for transmitting these assessments was the former Minimum Data Set Coordinator who is no longer employed at the facility. The facility implemented corrective actions and was found to be in substantial compliance on 03/16/2026, prior to the start of the Recertification Survey on 03/18/2026. The Minimum Data Set assessment of the 14 identified residents was transmitted to the Centers for Medicare and Medicaid Services on 03/16/2026. Validation reports were confirmed to be accepted on 03/16/2026.A full house review of the Minimum Data Set Assessments transmittal process was conducted on 03/16/2026 by the Minimum Data Set Consultant.A Quality Assessment and Performance and Improvement meeting was conducted on 03/16/2026. The facility identified that the root cause for the deficient practice was the former Minimum Data Set Coordinator leaving their position without transmitting the scheduled Minimum Data Set Assessments.The policy was reviewed and the Minimum Data Set Coordinator and assessors received in-service education on timely submission of Minimum Data Set assessments to the Centers for Medicare and Medicaid Services Data System. These were completed on 03/16/2026.The facility implemented daily transmission checks to prevent recurrence. 10 New York Codes, Rules and Regulations 415.11(b)

Based on record review, and interview during the Abbreviated Survey (ID# 2685553) the facility did not develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet each resident's medical, nursing, mental, and psychosocial needs. This was evident in one (1) of six (6) residents (Resident #1) sampled for comprehensive care plan. Specifically, Resident #1 who was receiving medications to prevent constipation did not have a person-centered care plan with interventions in place. The findings are:The facility policy tiled Comprehensive Care Plan effective 12/2023 documented the facility develops and maintains an individualized person-centered comprehensive plan of care to meet identified needs/goals. The Comprehensive Care Plan is initiated on the day of admission and completed within 7 days after Care Area Assessments completion.Resident #1 was admitted to facility with diagnoses including chronic pulmonary embolism ( a blood clot that blocks and stops blood flow to an artery in the lung), coronary heart disease, moderate pericardial effusion (refers to collection of excess fluid in the pericardial sac surrounding the heart) and small cell cancer of the Lung complicated by superior vena cava syndrome (occurs when blood flow through the heart vessels was obstructed, often due to tumors or blood clots, leading to symptoms like swelling and difficulty breathing).The Minimum Data Set, dated [DATE] documented Resident #1 had moderately impaired cognition.A review of Resident #1's Physician's Order dated 09/02/2025, revealed orders for MiraLAX 17 grams oral powder packet daily and Senna 8.6 milligram two times per day as needed for slow transit constipation.There was no documented evidence a person-centered care plan was implemented.During an interview on 12/11/2025 at 12:14 PM, Registered Nurse Supervisor #1 stated the admitting nurse should not have retrieved Resident #1's old care plan dated (12/11/2024) because Resident #1 was a newly added resident. Registered Nurse Supervisor #1 stated Resident #1 did not have an at risk for constipation care plan initiated upon admission. Registered Nurse Supervisor #1 stated the admitting nurse is responsible for initiating new care plans. Registered Nurse Supervisor #1 stated they were not aware Resident #1 did not have a current care plan in place. During an interview on 12/15/2025 at 10:42 AM, the Director of Nursing stated Resident #1 was admitted on [DATE] and the admitting nurse should have initiated a new care plan for at risk for constipation. The Director of Nursing stated that the registered nurses, head nurses, and registered nurse supervisors are responsible for completing the care plans. 10 NYCRR 415.11(c)(1)

The findings are: The facility policy titled 'Consultations' dated 10/2021 documented after consultation is completed, the nurse reviews recommendations and contacts attending physician to report recommendations or changes in treatment plan. Resident #1 was admitted to facility with diagnoses including chronic pulmonary embolism ( a blood clot that blocks and stops blood flow to an artery in the lung), coronary heart disease, moderate pericardial effusion (refers to collection of excess fluid in the pericardial sac surrounding the heart) and small cell carcinoma of the Lung complicated by superior vena cava syndrome (occurs when blood flow through the heart blood vessel is obstructed, often due to tumors or blood clots, leading to symptoms like swelling and difficulty breathing).The Minimum Data Set, dated [DATE], documented Resident #1 had moderately impaired cognition.A review of a Hematology/Oncology consult dated 09/10/2025, documented Resident #1 was seen by the oncologist on 09/10/2025, and the oncologist recommended to stop cyclobenzaprine (muscle relaxant), consider reducing olanzapine ten (10) milligram to five (5) milligram if tolerated and to start Dexamethasone (anti-inflammatory) four (4) milligrams. A Physician's order dated 09/19/2025 revealed Olanzapine ten (10) milligram was changed to five (5) milligrams and Dexamethasone four (4) milligrams were ordered.A review of the nursing progress notes from 09/10/2025 to 09/19/2025, revealed no documented evidence Medical Doctor #1 was notified of the oncologist's recommendations.During an interview on 12/09/2025, Resident #1's adult child #1 stated that they accompanied Resident #1 to an oncology appointment on 09/10/2025 and that the oncologist made some recommendations that the facility did not carry out timely. Resident #1's adult child stated that on 09/19/2025 they accompanied Resident #1 to another oncologist appointment and the oncologist asked them why Resident #1 did not receive the Dexamethasone they prescribed on 09/10/2025. Resident #1's adult child stated that the oncologist called the facility on 09/19/2025 and spoke to them about the medication that was recommended.During an interview on 12/11/2025 at 10:40 AM, Licensed Practical Nurse #2 stated they received the oncology consult dated 09/10/2025, but that they had just looked at the consultation. Licensed Practical Nurse #2 stated that they notified the nursing supervisor (unsure of name), but was do not recall notifying the Medical Doctor.During an interview on 12/11/2025 at 12:14 PM, Registered Nurse Supervisor #1 stated they were not aware of the oncologist recommendations of 09/10/2025. Registered Nurse Supervisor #1 stated that the unit nurses are responsible for reviewing the consults when a resident returned from their appointments. Registered Nurse Supervisor #1 stated that Licensed Practical Nurse #2 should have notified Medical Doctor #1 of the oncologist's recommendations.During an interview on 12/11/2025 at 1:02 PM, Medical Doctor #1 stated they received a call from a facility nurse (unsure of name) on 09/19/2025 stating that the oncologist had recommendations on 09/10/2025 that was not prescribed. Medical Doctor #1 stated that they gave a telephone order on 09/19/2025 for the medication (Dexamethasone) that was ordered by the oncologist on 09/10/2025. Medical Doctor #1 stated they reviewed the oncology consult on 09/22/2025 when they visited the facility. 10 NYCRR 415.12

Based on observation, record review, and interviews conducted during the Abbreviated Survey (Complaint 2588679), the facility did not ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the New York State Department of Health. This was evident for one (1) (Resident #2) of six (6) residents reviewed for accidents. Specifically, Resident #2 had an unwitnessed fall on 07/16/2025 resulting to a laceration to the left eyebrow and eventually was found to have an acute fracture in the humeral neck that was not reported to the New York State Department of Health. The findings include: The facility policy and procedure titled Abuse Prohibition-Prevention and Reporting which was last revised in March 2025 documented all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to New York State Department of Health. Resident #2 was admitted with diagnoses that included Dementia and Breast Cancer. The Minimum Data Set assessment dated [DATE] documented Resident #2's cognition as severely impaired and that resident never/rarely made decisions. The resident required substantial assistance with bed mobility and transfers.A nurse's progress note dated 07/16/2025 at 11:45 PM documented that Resident #2 was observed lying on the floor on their left side against the closet. Resident #2 sustained a 1.5-centimeter laceration on the left eyelid that was bleeding. The physician was notified, and resident was sent to the emergency room for evaluation. A nurse's progress note dated 07/17/2025 at 4:55 PM documented that Resident #2 returned from the emergency room with recommendation to keep the wound on the left eyebrow dry and clean. The note documented that computed tomography scans and x-rays were completed in the emergency room, but no reports were sent with the resident. A nurse's progress note dated 07/20/2025 at 1:44 PM documented that Resident #2 complained of left shoulder pain. X-ray of the left shoulder revealed acute fracture of the humeral neck. There was also decreased bony mineralization suggestive of osteopenia or osteoporosis. The resident was transferred to the emergency room. The undated document titled Root Cause Analysis documented that at about 9:45 PM on 07/16/2025, the staff reported that Resident #2 was found on the floor, with skin laceration on the left eyelid. The resident was transferred to the emergency room and returned on 07/17/2025 with negative scan and x-ray results. On 07/19/2025, the next of kin reported that the resident was guarding their arm. The x-ray report showed acute humeral neck fracture. The facility concluded that it appeared that resident got up from the bed and fell. Resident has impaired vision secondary to the fall. Resident also has bony demineralization with arthritic changes which could have caused the fracture hence non-reporting to the Department of Health.On 10/22/2025 at 11:41 AM, the Director of Nursing was interviewed and stated that they are responsible for reporting allegations to the New York State Department of Health. They stated that Resident #2 had an unwitnessed fall and that the left arm fracture was identified two (2) days after the said fall. The Director of Nursing stated they correlated the fracture from the fall, which was why the incident, and the injury was not reported to the New York State Department of Health. On 10/22/2025 at 12:26 PM, the Administrator was interviewed and stated that Resident #2's fall and fracture were discussed during the morning report. It was not reported because they knew how the fall happened, and that the fracture was correlated with the fall. The Administrator stated, they and Director of nursing are responsible for reporting incidents to the New York State Department of Health. 10 NYCRR 415.4(b)(2)

Based on observations, record review, and interviews conducted during the Recertification and Complaint (NY00315735 & NY00330475) survey from 03/26/24 to 04/02/24, the facility did not ensure there was sufficient numbers of nursing assistants available to provide nursing care to all residents in accordance with the resident's plan of care. This was evident during review of the Sufficient and Competent Nurse Staffing task. Specifically, 1) Review of facility par level revealed short staffing on 9 of 9 weekends reviewed, 2) Resident #175 did not receive scheduled showers during the Months of December 2023 and January 2024 due to shortage of staff, 3) Resident #210 required two persons assistance for Activities of Daily Living to get out of bed and was not consistently taken out of bed due to short staffing, 4) During Resident Council meeting 10 of 10 residents in attendance reported the facility is consistently short staff and they had to wait between 20 minutes and 4 hours before the staff responded to the call device, and 5) Multiple staff complained of short staffing which affected their ability to provide care according to the resident's plan of care. The findings include but are not limited to: 1. The Facility Assessment revised June 2023 documented a census of 611. The Staffing Plan included in the Facility Assessment documented an average of 328 nurses aides and 116 nurses were needed to provide direct care. The Facility Assessment did not document the specific staffing needs per resident unit or per shift. The undated document with heading Par provided by the Staffing Coordinator documented the total Certified Nursing Assistants needed daily as follows: Day=68 Evening=66 Night=44 Review of weekend staffing from 2/3/24 to 3/30/24 documented less than the par level of Certified Nursing Assistants on the following dates: 2/3/24 Day shift minus 11, Evening minus 11.5, Night minus 7 2/4/24 Day shift minus 14, Evening minus 19, Night minus 9 2/10/24 Day shift-minus 12, Evening minus 8.5, Night minus 5 2/11/24 Day shift minus 13, Evening minus 9.5 2/17/24 Day shift minus 12, Evening minus 11.5, Night minus 15 2/18/24 Day shift minus 13, Evening minus 11.5, Night minus 7 2/24/24 Day shift minus 14 2/25/24 Day shift minus 27, Night minus 7 3/2/24 Day shift minus 20.5, Evening minus 10.5, Night minus 10 3/9/24 Day shift minus 16, Evening minus 13 3/10/24 Day shift minus 24, Evening minus 16, Night minus 10 3/16/24 Day shift minus 18, Evening minus 5, Night minus 4 3/17/24 Day shift minus 19.5, Evening minus 17.5, Night minus 9.5 3/23/24 Day shift minus 10, Evening minus 13.5 3/24/24 Day shift minus 19, Evening minus 12 3/30/24 Day shift minus 6 Evening minus 12.5 2. Resident #175 diagnoses included Cancer, Heart failure, and Non-Alzheimer's Dementia. The Admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that Resident #175 was cognitively intact, and required the physical assistance of two staff for bathing and toileting. During an interview on 03/27/24 at 10:06 AM, Resident #175 stated that they did not receive any showers in December 2023 and January 2024 due to shortage of staff. During an interview on 03/27/24 at 10:12 AM, the complainant (NY00330475) stated that in December 2023 and January 2024 the staff were not assisting Resident #175 with showers due to shortage of staff. Resident #175 is supposed to be showered twice a week and did not start receiving showers until February 2024. The Certified Nursing Assistant Accountability Records dated December 2023 and January 2024 contained no documented evidence that Resident #175 received showers. On 04/01/24 at 12:00 PM, Certified Nursing Assistant #13 stated that the assignment for Certified Nursing Assistants varies and there are times when there are only 3 of 4 Certified Nursing Assistants on the floor. When there are only 3 Certified Nursing Assistants, each Certified Nursing Assistant will have 15 or more residents on their assignment and we try our best. The Certified Nursing Assistants work together to get the work done. We ensure that residents who are scheduled to be showered for the day receive their showers as scheduled. Certified Nursing Assistant #14 also stated that there are times it is impossible to take a lunch break. If we have to give showers on a day we are short, we may have to change the resident's shower days and we let the residents know first. On 04/01/24 at 04:07 PM, Registered Nurse #4 stated Resident #175 is alert and oriented and is scheduled to receive showers twice a week. When we are short of staff, the resident may have to wait to get assistance. Registered Nurse #4 also stated that they do not always have 4 Certified Nursing Assistants on the unit, and when there are only 3 Certified Nursing Assistants it is very difficult to ensure all residents scheduled for showers are able to be showered. Registered Nurse #4 further stated that there are over 20 residents on the unit who require total care, so it is really hard for them. 20 out of 45 residents need assistance with feeding. Registered Nurse #4 also stated that residents are scheduled for showers twice a week and the staff try their best to ensure all residents receive showers on their scheduled days. Registered Nurse #4 stated that they do have floaters on the unit sometimes, and it is possible that not all residents have received showers on their scheduled shower days. On 04/02/24 at 10:03 AM, Registered Nurse #13 stated that they supervise six units. Residents are supposed to be showered twice a week. We do check with the nurses to ensure all residents scheduled to be showered are showered on scheduled days. Registered Nurse #13 also stated that they try to offer the showers on a later day if, for some reason, the showers cannot be provided. We do rounds twice per shift and check on all of the residents. We check on all units and we ensure all residents are receiving care. 3. Resident # 210 diagnoses include Heart Failure, Cerebrovascular Accident, and Dementia. The Annual Minimum Data Set 3.0 assessment dated [DATE] documented Resident #210's cognitively was severely cognitively impaired and required maximal assistance for eating, toileting, upper and lower body dressing. The Minimum Data Set 3.0 assessment also documented that Resident #210 had impairment on one side of the upper extremities, both sides of the lower extremities, and used a walker for ambulation. The complaint intake summary (NY00315735) dated 05/01/23 documented that the complainant stated that they asked staff to change Resident #210 and they were told there was not enough staff and they would have to wait till the next shift. The complainant also stated that Resident #210 was left in bed all day since they did not have the staff to get them up. On 03/26/24 at 10:34 AM, 03/27/24 at 10:25 AM, 03/28/24 at 10:36 AM, 03/29/24 at 10:57 AM, 04/01/24 at 12:27 PM and 04/01/24 at 04:25 PM, Resident #210 was observed in bed. On 03/29/24 at 10:59 AM, Certified Nursing Assistant #18 stated that there are only 3 of 4 Certified Nursing Assistants on the unit today, and they had 15 residents on their assignment today. Certified Nursing Assistant #18 also stated that most of the resident need assistance of two staff for activities of daily living care. Certified Nursing Assistant #18 further stated that it is hard to get everyone out of bed when they are short staffed because most of the residents need assistance of two staff persons for transfers. Certified Nursing Assistant #18 further stated that Resident #18 is usually in bed and does not refuse care. On 04/01/24 at 04:27 PM, Certified Nursing Assistant #19 stated that Resident #210 requires total care, is supposed to be taken out of bed during the day, and does not refuse to come out of bed. If the regular Certified Nursing Assistants are not on the unit, the aides available do not take the residents out of bed. Certified Nursing Assistant #19 also stated that most of the staff on the day shift are floaters. Certified Nursing Assistant #19 further stated that when there are 3 Certified Nursing Assistants instead of 4 Certified Nursing Assistants on the unit they have to take care of 15 residents and it is hard. Certified Nursing Assistant #19 stated that they are not able to take their break when they are assigned 15 residents. On 03/29/24 at 11:15 AM, Registered Nurse #11 stated that they usually have 3 Certified Nursing Assistants on the unit and it is supposed to be 4 Certified Nursing Assistants. Registered Nurse #11 also stated that if there are a lot of call outs they work short. On 04/01/24 at 04:33 PM, Registered Nurse #12 stated Resident #210 needs to be out of bed after they are assisted with care and does not refuse care. On the evening shift, there are usually 3 Certified Nursing Assistants on the unit for 45 residents. We have residents with dementia and residents who needs extensive assist to total dependence. The residents on the unit need to be always supervised. Registered Nurse #12 also stated that they are the only nurse on the floor and it is very hard to pass medications to 45 residents. Registered Nurse #12 further stated that when there are only 3 Certified Nursing Assistants on the unit instead of 4, they have to respond to every call for assistance while passing medications. There are times, the 3 Certified Nursing Assistants are in the rooms assisting residents. Registered Nurse #12 stated that they are unable to take their lunch break on most days. 44843 4. The Resident Council minutes dated 12/19/23 documented nursing staff was discussed, and more nursing staff were needed. The Resident Council Meeting Minutes dated 2/16/24 documented the response time of call device was slow, and the residents must wait for assistance until their assigned Certified Nursing Assistant comes back from break. The Resident Council Meeting Minutes dated 3/19/23 documented call bell response was still a concern, and the residents were not able to tell who their assigned Certified Nursing Assistant or nurse was. On 03/27/24 at 11:12 AM, during the Resident Council Meeting, 10 out of 10 residents in attendance stated that staffing was an issue at the facility, and staff took too long to respond to call bells. The residents stated that they sometimes had to wait up to four hours for someone to respond to the call bells or they have to wait for the next shift to have somebody answer the call bell. Resident # 470 stated the lunch tray stayed in their room until 4 PM and they had to take it out themselves sometimes. Resident #113, Resident 287, Resident 371, and Resident 571 stated there was only 1 Certified Nursing Assistant for day shift on Sunday sometimes. They did not get assistance they needed for the day or had to wait a long time before getting any assistance. 41709 5. On 04/02/24 at 12:09 PM, an interview was conducted with Licensed Practical Nurse #5 who stated that the staffing is very bad. They are responsible for administering medications and treatments, and must help the Certified Nursing assistant at the same time because of short staff. Licensed Practical Nurse #5 stated they leave at 7 pm at nights to ensure all the medications or treatments are given to the residents. If there are only 3 Certified Nursing Assistant on the unit, with no extra staff for the resident on 1:1 monitoring, they must help the Certified Nursing Assistants with feeding the residents as there are a lot of residents who need assistance with feeding on the 9th floor. There was a meeting with management and a meeting with the union, but there has been no change in the staffing. Licensed Practical Nurse #5 also stated there were only 2 Certified Nursing Assistants on the unit yesterday unit to provide morning care with a resident who was on 1:1 monitoring. An aide come in at 10 :00 am to do the 1:1 monitoring. Licensed Practical Nurse #5 further stated Sunday night into Monday morning there was one Certified Nursing Assistant on the floor to start the shift and the staff assigned to the resident on 1:1 monitoring arrived at 1:00 am. On Monday morning most of the residents were wet, because the one Certified Nursing Assistant was not able to change all the residents. Licensed Practical Nurse #5 stated on the floor today there was 1 regular staff and 3 agency staff. On 04/02/24 at 10:30 AM, an interview was conducted with Certified Nursing Assistant #8 who stated they are short of staff sometimes during the week but the weekends are the worst. There used to be 3 aides on the unit, but now there is a resident on 1:1 monitoring and they have not been given additional staff, so only two Certified Nursing Assistants are on the floor to give care. Certified Nursing Assistant #8 also stated they do not take a break until they finish their shift, because the residents will not get care, and they feel rushed, hurried, and are constantly going to get everything done. Certified Nursing Assistant #8 further stated that staff has gotten worst, staff just do their best, but it is an impossible task. During an interview on 04/02/24 at 10:23 AM, Certified Nursing Assistant #9 stated that they work on the morning and evening shift and every weekend and came in to help out this weekend because the staffing was not good. The evening shift had two Certified Nursing Assistant and one person for 1:1 supervision on the unit which had 45 residents. Certified Nursing Assistant #9 stated they feel rushed to do everything because of the short staff, and do not get to take breaks so eats after they finish work as they are about to go home. On 04/02/24 at 10:14 AM, an interview was completed with Certified Nursing Assistant #10 who stated the staffing is terrible, with one weekend good and the other weekend not good. When working we prioritize the quadriplegics and the tube feeders to ensure they get care first. Certified Nursing Assistant #10 also stated that every other weekend and they are still on the unit at this time to help colleagues and they stayed to help give showers to the residents before leaving. Certified Nursing Assistant #10 further stated they worked overnight with two Certified Nursing Assistant and there was a resident on 1: 1 monitoring on the unit. On 03/26/24 at 11:57 AM, an interview was completed with Certified Nursing Assistant #4 who stated the staffing is very bad and was cut from 3 to 4 staff down to 2 aides only. When there are only 2 Certified Nursing Assistants it is hard to give showers and answer call bells. During an interview on 04/02/24 at 12:05 PM, the Staffing Coordinator stated that document titled Par is the guide the Staffing Coordinators use to determine staff needed for each unit and was provided to them by Nursing Administration. When there are residents who require 1:1 monitoring, additional staff is given to cover the one to one. The challenge here is the call outs which happen every day, on every shift. Staff say they are ill and can't make it in today. Weekends are also a challenge to get staff, they call out or do not show up to work. Staffing Coordinators also work on weekends and stay until 10pm on evenings to make sure there are staff to cover. We use our regular staff and will reach out to staff to come into their shift earlier. The Staffing Coordinator also stated that one weekend does have less staff than the other, but we have to give notice when we need to change the weekend schedule to even it out. We also have a few people out on medical leave on every shift. The Staffing Coordinator further stated that we try to meet the Par level for each unit and the Par level has been the same for the past year. The Staffing Coordinator stated that they do have a referral process and offer sign on bonuses to attract new employees. The Staffing Coordinator also stated that staff are required to take their breaks. On 04/02/24 at 01:07 PM, the Director of Nursing was interviewed and stated we started a Certified Nursing Assistant school so they can recruit more Certified Nursing Assistants. We hired two new recruiters to assist us with recruiting nursing staff and nurse managers. We have incentives such as sign on bonuses, referral bonuses. The Director of Nursing also stated we have thirteen agencies assisting us to obtain staff at all levels, and we contact the agencies if they have a lot of call outs. We do call regular staff to see if they can work extra hours. The Director of Nursing further stated that all of the department heads are constantly meeting to ensure that we have adequate staffing. We do discuss keeping the census at the same level. We are looking closely at prospective residents to determine the level of staff needed to take care of them. During an interview on 04/02/24 at 02:34 PM, the Administrator stated we have been consistent with the census, and the census is going to stay the same. We are trying to increase staffing to ensure we have adequate staff to meet the needs of the residents. The staffing issues goes up and down. We are working with at least ten agencies and we hired two new recruiters to help us with recruiting staff. Sometimes when the staff call out, it set us back. The Administrator also stated that we started a Certified Nursing Assistant school and are on our seventh class. We are trying to hold class every six weeks and are working on getting another educator to be able to teach two classes at the same time. We also provide financial incentives to all new staff and we have referral programs. Some of the agency's staff are joining us as well. The Administrator further stated that their staffing coordinators work seven days a week to obtain staff when needed. We do want to increase staffing and we are constantly recruiting and actively working on improving staffing. 415.13(a)(1)(i-iii)

Based on observations, interviews, and record review conducted during the Recertification survey from [DATE] to [DATE], the facility did not ensure food was stored in accordance with professional standards for food service safety. This was evident during kitchen observation and in 1 (9th floor) of 18 pantries. Specifically, 1) the kitchen walk-in refrigerator contained expired, opened, and undated food and drink items, 2) the 9th floor pantry refrigerator was 44 degrees Fahrenheit and contained undated, unlabeled food, and 3) Dietary staff were observed not wearing head coverings in the food preparation area of the kitchen The findings are: The facility policy titled Food Storage from Deliveries dated ,d+[DATE] documented opened, stored leftover food should be labeled and dated. Opened items should be discarded after 48 hours. Expired food should be discarded immediately. The Food Service supervisor ensures foods are labeled, dated, and not expired. The facility policy titled Food Storage on Units dated ,d+[DATE] documented all items to be stored on the units are to be labeled with resident name, room number, dated, and stored at a refrigerator temperature of 40 degrees Fahrenheit or less. The charge nurse, Nursing supervisor or designee ensures that food items are labeled, dated, and stored appropriately and discarded per policy. 1) On [DATE] at 09:23 AM, Food Service Director #1 was present when the kitchen walk-in refrigerator was observed with 4 facility-prepared 4-ounce containers labeled diced pineapples with a use-by date of [DATE], 1 undated and unlabeled bag containing 6 wheat tortillas with no expiration date, 1 undated plastic bag containing 6 slices of white bread with no expiration date, an open and undated 64-ounce container of orange juice, and a quarter-sheet pan of sliced corned beef dated [DATE]. 2) On [DATE] at 09:22 AM, Registered Nurse #1 was present during observation of the 9th Floor pantry refrigerator. The refrigerator was observed with an unlabeled and undated bag containing 1 bowl of rice and noodles and half of a cucumber. The refrigerator thermometer was observed at a temperature of 44 degrees Fahrenheit. 3) On [DATE] at 11:28 AM, Dietary Worker #1 and Food Service Director #2 were observed without hair nets or head coverings and were in the kitchen preparing the lunch meal. On [DATE] at 05:45 PM, Dietary Worker #2 and Dietary Worker #3 were observed on the tray line in the kitchen during dinner service and were not wearing hair nets or head coverings. On [DATE], Food Service Director #1 was interviewed and stated the kitchen walk-in refrigerator contained expired food items because of inconsistent food dating and that staff were supposed to label food with the preparation date and a date the food should be discarded. Food Service Director #1 stated all Dietary staff should label food with a discard date that is 48 hours after the food was prepared and/or opened. Dietary staff were not responsible for the food kept in the pantry refrigerators on the resident units. On [DATE] at 09:30 AM, Registered Nurse #1 was interviewed and stated all resident food kept in the pantry refrigerators should be labeled and dated by staff that place the food in the refrigerator. The unit staff were responsible were checking the refrigerator temperatures daily to ensure they remain below 40 degrees Fahrenheit. 10 NYCRR 415.14(h)

Based on observation, record review, and staff interviews conducted during the recertification survey from 3/26/2024 to 4/2/2024, the facility did not ensure infection control practices and procedures were maintained. This was evident for 1 (Unit 10W) of 18 resident units during medication pass and during infection control review. Specifically, 1) infection control policies were not reviewed annually, and 2) License Practical Nurse #4 did not sanitize a blood pressure cuff in between resident use or perform hand hygiene during medication administration. The findings are: 1) The facility policy titled Operating Procedures - Infection Control was dated 12/2022, Influenza Vaccination Requirements - Health Care Workers was dated 4/12/2017, Mandatory COVID-19 Vaccination Program was dated 12/14/2021, and Antibiotic Stewardship Program was dated 09/2022. There was no documented evidence the policies related to infection control were reviewed and revised annually. On 04/02/2024 at 01:45 PM, the Director of Nursing was interviewed and stated the Infection Control Preventionist was not available for interview. Infection control policies were supposed to be updated annually and the Nursing department was not responsible for reviewing and updating the polices. 41709 2) The facility policy titled Equipment - Cleaning/Disinfection of Instruments/Equipment dated 5/2023 documented equipment used for more than one resident is cleaned and disinfected after use and prior to use on another resident according to manufacturer guidelines. The facility policy titled Hand Hygiene dated 1/2024 documented hands must be washed before and after contacts with residents and when handling contaminated equipment and supplies. On 03/27/2024 at 09:39 AM, Licensed Practical Nurse #4 was observed on Unit 10W applying a blood pressure cuff to Resident #785's arm without sanitizing the blood pressure cuff prior to application. Licensed Practical Nurse #4 did not sanitize the blood pressure cuff, entered Resident #339's room, and placed the blood pressure cuff on Resident #339's right arm. Licensed Practical Nurse #4 did not sanitize the blood pressure cuff and placed the blood pressure cuff of Resident #308's arm. On 03/27/24 at 09:53 AM, Licensed Practical Nurse was observed on Unit 10W at the medication cart and touched the medication cart, grabbed a pen to document a resident's vital signs, handled the computer mouse to check Physician Orders, grabbed keys to open the medication cart, did not perform hand hygiene and dispensed medication from blister packs, grabbed a bottle of cranberry juice to pour into a cup, entered Resident #785's room and administered medication to the resident without performing hand hygiene. On 03/27/2024 at 10:42 AM, an interview was conducted with Licensed Practical Nurse #4 who stated they should have sanitized the blood pressure cuff in between each resident use but forgot. Licensed Practical Nurse #4 stated they also should have performed hand hygiene when administering medications to residents and was unable to provide a reason they did not perform hand hygiene before administering medications to Resident #785. On 03/27/2024 at 10:43 AM, an interview was conducted with Registered Nurse #7 who stated blood pressure cuffs were sanitized in between each resident use to promote infection control. Sanitizing wipes were available on the units for nurses to wipe down the cuffs before and after resident use. Registered Nurse #7 monitored the Licensed Practical Nurses by performing rounds on the units to ensure they follow infection control practices and reminded nurses during morning report to adhere to infection control policies. Registered Nurse #7 was unable to explain Licensed Practical Nurse #4's failure to sanitize blood pressure cuffs in between each use and perform hand hygiene when administering medications. On 03/29/2024 at 03:42 PM, an interview was conducted with the Infection Control Preventionist who stated all staff were provided with ongoing education regarding appropriate infection control practice. Competency evaluations were also performed to ensure staff were knowledgeable and practicing infection control. The Infection Control Preventionist stated sanitizing wipes, hand sanitizers, and soap were readily available on all units to ensure staff performed hand hygiene and sanitized equipment in between each resident use. The Infection Control Preventionist performed rounds on the units and has not observed any infection control breaches. NYCRR 415.19(b)(4)

Based on observation, interview, and record review conducted during the Recertification survey from 3/26/2024 to 4/2/2024, the facility did not ensure that notice of the availability of the survey results was posted in prominent areas accessible to the public. This was evident for 10 (Resident #s 60, 410, 571, 74, 113, 611, 287, 371, 470, and 250) of 10 resident attendees during Resident Council Meeting. Specifically, notification of survey result availability was not posted in prominent areas of the facility accessible to the public. The findings are: The facility policy titled Resident Rights and Responsibilities dated 7/2022 documented residents and their representatives are informed of their rights. During observation of the facility on 3/26/2024 at 9:00 AM and 3/29/2024 at 11:00 AM, notification of survey result availability was posted in the lobby entrance of the main building. There were no observations of the notification posted on the 18 residential units or 1st floor frequented by residents, staff, and visitors. On 03/27/2024 at 11:12 AM, Resident Council Meeting was held with Resident #s 60, 410, 571, 74, 113, 611, 287, 371, 470, and 250. All attendees stated and agreed they did not know where the survey results were posted in the facility and have not seen a notification regarding location of posted survey results. On 03/29/2024 at 11:52 AM, the Administrator was interviewed and stated the state survey results were in a [NAME] located in the lobby by the entrance to the facility. The signs posting notification regarding location of the survey results were posted throughout the facility in prominent locations. The Administrator stated they were not aware the residential units did not have signs posting information regarding the location of the facility's survey results. 10NYCRR 415.3(d)(1)(v)

Based on record review and interview conducted during the Recertification survey from 3/26/2024 to 4/02/2024, the facility did not ensure that appropriate notices were provided to Medicare beneficiaries when they were discharged from skilled services. This was evident for 2 (Residents #311 and #554) of 3 residents reviewed for Beneficiary Notification out of 39 total sampled residents. Specifically, a copy of the Notice of Medicare Non-Coverage was not mailed to the resident's representative on the same date that the telephone notification was made. The findings are: The facility policy titled Notice of Medicare Non-Coverage (NOMNC) dated 11/2023 documented that the MDS Coordinator/Designee will issue the NOMNC to the patient and/or responsible party. A copy of the signed NOMNC will be given to the patient and a copy will be kept in the clinical compliance office. The MDS Coordinator must ensure that the beneficiary or responsible party signs and dates the NOMNC to demonstrates that the beneficiary or representative received notice and understands that the termination decision can be disputed. If the Designated Representative is unable to be reached via phone a proof of mail delivery must be secured in the patient's medical record. The Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 documented the requirement that notification of changes in coverage for an institutionalized beneficiary/enrollee who is not competent be made to a representative. The instructions also documented that if the provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise him or her when the enrollee's services are no longer covered. The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date. 1. The Notice of Medicare Non-Coverage form dated 1/8/2024 issued for Resident #311 documented that the last covered day for Medicare Part A service was 1/10/24. The Notice of Medicare Non-Coverage form also documented that the significant other was provided telephone notification from the staff designee on 01/8/2024 at 11:33 AM. There was no documented evidence that a Notice of Medicare Non-Coverage form had been mailed out on the same date that notification was made. 2. The Notice of Medicare Non-Coverage form issue for Resident #554 dated 11/27/2023 documented that the last covered day for Medicare Part A service was 12/1/23. The Notice of Non-Coverage form also documented that the family member was provided telephone notification from the staff designee on 11/27/2023 at 2:40 PM. There was no documented evidence that a Notice of Medicare Non-Coverage form had been mailed out on the same date that notification was made. During an interview on 4/1/24 at 4:06 PM, the Minimum Data Set Coordinator stated that once a date of discharge is determined, they contact the resident or their representative and explain the Notice of Medicare Non-Coverage and provide LIVANTA's contact information that they can call to appeal the discharge. The Minimum Data Set Coordinator also stated that if they provided telephone communication, they fill out the telephone notification area on the form with the time, date and sign it. If the resident or resident representative understand all the information, we mail the notification. The Minimum Data Set Coordinator further stated that they send notices by certified mail notification to the resident's representative if they were not able to reach them by phone. The Minimum Data Set Coordinator stated that they do not mail or email notices when telephone notification is made so was not able to provide any evidence that this was done. 10 NYCRR 415.3(g)(2)(i)

Based on observation, interviews, and record review conducted during the Recertification and Complaint (NY00315735 & NY00330475) Survey from 3/26/2024 to 4/2/2024, the facility did not ensure residents unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene. This was evident for 2 (Resident #175 and Resident #210) of 9 residents reviewed for Activities of Daily Living out of 38 total sampled residents. Specifically, 1) Resident #175 did not receive staff assistance and was unable to shower in 12/2023 and 1/2024, and 2) Resident #210 was not provided with physical assistance necessary to transfer out of bed. The findings are: 1) Resident # 175 had diagnoses of anemia and heart failure. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #175 was cognitively intact and required the physical assistance of two people for bathing. On 03/27/2024 at 10:06 AM, Resident #175 was interviewed and stated staff did not provide them with the necessary assistance to shower in 12/2023 and 1/2024 due to staffing shortages. Resident #175 stated they did not receive the twice weekly scheduled showers until 2/2024. The Certified Nursing Assistant Accountability Record for 12/2023 and 1/2024 documented Resident #175 was provided with assistance for bathing. The record did not document a shower schedule for Resident #175 or that Resident #175 received showers. There was no documented evidence Resident #175 was provided with assistance to have showers in 12/2023 and 1/2024. On 04/01/2024 at 12:00 PM, Certified Nursing Assistant #13 was interviewed and stated there were only 3 staff on the unit to provide assistance to residents to perform activities of daily living. The staff did their best to address each resident's needs and ensure that residents were showered according to their shower schedule. On 04/01/2024 at 04:07 PM, Registered Nurse #4 was interviewed and stated Resident #175 was scheduled for showers twice weekly. It was difficult to residents who required total assistance with scheduled showers when the unit was short of staff. There were residents who were not showered on their scheduled shower days. 2) Resident #210 had diagnoses of heart failure and hyperlipidemia. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #210 was severely cognitively impaired and required maximal staff assistance to transfer out of bed. On 03/26/24 at 10:34 AM, on 03/27/24 10:25 AM , on 03/28/24 10:36 AM, on 03/29/24 10:57 AM, on 04/01/24 12:27 PM and on 04/01/24 04:25 PM, resident #210 was observed in bed. The Certified Nursing Assistant Accountability Record for 5/2023 did not document that Resident #210 was transferred out of bed. There was no documented evidence staff provided Resident #210 with the assistance necessary to be transferred out of bed. On 03/29/24 at 10:59 AM, Certified Nursing Assistant #18 was interviewed and stated most residents on the unit require 2 staff to transfer them out of bed and there were only 3 staff members working on the unit. Resident #210 did not refuse to come out of bed but usually remained in the bed because it was difficult for staff to address all the needs of the residents on the unit. On 04/01/24 04:27 PM, Certified Nursing Assistant # 19 was interviewed and stated Resident #210 was supposed to come out of bed during the day but most of the staff assigned to the unit were not regularly assigned to the unit and did not transfer resident #210 out of bed. On 04/02/24 at 01:07 PM, the Director of Nursing was interviewed and stated the Registered Nurses were responsible for ensuring unit staff addressed resident needs and they made rounds twice daily to observe resident care. Residents were supposed to be provided with the assistance to shower according to their schedule and be transferred out of bed daily. 10 NYCRR 415.12(a)(3)

Based on observation, record review, and interviews conducted during the Recertification Survey from 3/26/2024 to 4/2/2024, the facility did not ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This was evident for 1 (Resident #210) of 3 residents reviewed for limited range of motion out of 38 total sampled residents. Specifically, Resident #210 had a right-hand contracture and was observed without a carrot splint per Physician Order. The findings are: Resident #210 had diagnoses of dementia and cerebral vascular accident with right hemiplegia. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #210 was severely cognitively impaired and had functional limitation in range of motion on 1 side of their upper extremities. Between 03/26/2024 at 10:34 AM and 4/1/2024 at 4:25 PM, there were multiple observations of Resident #210 with a right-hand contracture and without a carrot splint in their right hand. The Physician Order initiated 3/10/2023 and last renewed 2/29/2024 documented Resident #210 was ordered to always wear a carrot splint in their right hand and to remove the carrot splint during range of motion, hygiene care, and skin checks. The Comprehensive Care Plan related to contractures initiated 4/5/2023 and last reviewed 3/28/2024 documented a Resident #210 always wore a carrot splint in their right hand to prevent new contractures. On 03/29/2024 at 10:59 AM, Certified Nursing Assistant #18 was interviewed and stated they usually applied Resident #210's carrot splint to their right hand after providing the resident with care. Certified Nursing Assistant #18 stated they did not know the reason Resident #210 did not have their carrot splint in place. The carrot splint should have been applied to Resident #210. On 03/29/2024 at 11:15 AM, Registered Nurse #11 was interviewed and stated they conducted rounds every 30 minutes to ensure residents were receiving proper care. Resident #210 was ordered to always wear a carrot splint in their right hand. On 04/02/2024 at 01:07 PM, the Director of Nursing was interviewed and stated the Registered Nurses were responsible for conducting rounds on the resident units twice per shift to ensure care was provided by the Certified Nursing Assistants. All splints should be applied per Physician Order. 10 NYCRR 415.12(e)(2)

Based on observation, interview, and record review conducted during the Recertification and Complaint (NY00327086) Survey from 3/26/2024 to 4/2/2024, the facility did not ensure a resident remained free of accident hazards. This was evident for Resident #494 reviewed for accidents out of 38 total sampled residents. Specifically, The findings are: The facility policy titled Microwave - Reheating of Food Items dated 11/2023 documented Nursing and Nutrition staff were responsible for microwaving food and testing the internal temperature until it reaches 165 degrees Fahrenheit. Resident #494 had diagnoses of diabetes mellitus and anemia. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #494 had mild cognitive impairment and required 1 person to assist with activities of daily living. The Comprehensive Care Plan related to impaired skin integrity initiated 5/10/2023 documented to assess Resident #494's skin every shift and assess risk factors on an ongoing basis. activity report last reviewed on 11/16/2023 documented Resident # 494 will be injury free. The Comprehensive Care Plan related to fall risk initiated 5/10/2023 documented to provide a safe environment and encourage Resident #494 to ask for assistance. The Comprehensive Care Plan related to activities of daily living and self-care deficit initiated 5/11/2023 documented to anticipate Resident #494's needs. The care plan did not specify activities of daily living, or the level of assistance Resident #494 needed. The Comprehensive Care Plan related to vision, and sensory perception alteration initiated 5/18/2023 documented nursing was responsible for assisting with and supervising Resident #494's activities of daily living to ensure the resident remained injury free. The Comprehensive Care Plan related to dementia initiated 7/6/2023 documented Resident #494 had cognitive loss and their needs should be anticipated. The Nursing Situation Background Assessment and Recommendation Form dated 10/28/2023 documented Resident #494 sustained right and left upper thigh burns on 10/25/2023 and did not report the burns to staff. Resident #494 was not in pain. The Nursing Note dated 10/28/2023 documented Resident #494 reported they warmed their water in the microwave located in the unit dining room and spilled the water on their lap while self-propelling back to their room resulting in bilateral upper thigh burns. The Medical Doctor Note dated 10/28/2024 documented Resident #494 was evaluated for a burn on their left thigh from spilling tea on themselves a few days ago. Resident #494 had some discomfort but declined hospital transfer. The left thigh wound appeared as a large medical eschar with surrounding redness and cellulitis. Silvadene and Keflex antibiotic were ordered for Resident #494. The Wound Care Doctor Note dated 10/31/2023 documented Resident #494 was evaluated for a right upper thigh burn measuring 2.5 centimeters by 1.8 centimeters and left upper thigh burn measuring 5.5 centimeters by 7.8 centimeters. Both burns were draining serous fluid, presented with tunneling, had unstable surrounding skin, and had suboptimal potential to heal. MediHoney Gel treatment was ordered. The facility Incident Investigation initiated 10/28/2023 and completed 11/2/2023 documented Resident #494 was alert and oriented, was able to independently perform their activities of daily living, tended to refuse skin checks, and did not report burning their bilateral upper thighs with a hot liquid after using the microwave. There was no documented evidence Resident #494 was provided with the necessary supervision when using the dining room microwave resulting in the resident sustaining bilateral upper thigh burns on 10/25/2023. On 04/01/2024 at 11:50 AM, Certified Nursing Assistant #20 was interviewed and stated, prior to Resident #494's burn incident, unit staff informed facility Administration the microwave in the dining room needed to be removed because it was easily accessible to all residents on the unit. On 04/01/2024 at 11:11 AM, Registered Nurse #14 was interviewed and stated the Certified Nursing Assistant assigned to Resident #494 on 10/28/2023 reported the resident had burn marks on their bilateral upper thighs. Resident #494 reported they burned themselves on 10/25/2023 with hot water they warmed in the dining room microwave. Resident #494 did not report the burns to staff and none of the unit staff were aware Resident #494 used the microwave and sustained burns. On 04/01/2024 at 12:41 PM, the Director of Nursing was interviewed and stated unit staff were not aware Resident #494 used the dining room microwave without assistance and sustained burns. Residents were no supposed to use microwaves without staff assistance. 10 NYCRR 415.12(h)(1-2)

Based on observation, record review, and staff interviews conducted during the Recertification survey from 03/26/2024 to 04/2/2024, the facility did not ensure psychotropic drugs were not given to residents unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. This was evident for 2 (Resident #190 and #141) of 5 residents reviewed for Unnecessary Medications out of 38 total sampled residents. Specifically, 1) Resident #190 was prescribed Risperdal without documented evidence of behavior or staff attempts to use nonpharmacological interventions, and 2) there was no documented evidence Resident #141 displayed behavior, nonpharmacological interventions were used, or a medical assessments was done prior to placing Resident #141 on psychotropic medication. The findings are: The facility policy titled Psychotropic Medications dated 05/2023 documented psychotropic medications require proper indications for use, alternatives when appropriate, appropriate dosage and duration of use, and effective monitoring for effectiveness and side effects. Prior prescribing psychotropic medication, staff must consider and use appropriate nonpharmacological interventions. The Medical Doctor must assess the resident with new or worsening behavioral symptoms for underlying medical causes. 1) Resident #190 was admitted with diagnoses which included Alzheimer's disease, Dementia, Depression, and insomnia. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #190 had severely impaired cognition and did not display behaviors. The Patient Review Instrument assessment dated [DATE] documented Resident #190 was diagnosed with dementia. There was no documented evidence Resident #190 had a severe mental illness or received psychotropic medication prior to their admission to the facility. The Psychiatry note dated 12/6/2023 documented Resident #190 did not have behavioral disturbances, was not agitated, and denied visual hallucinations. The Psychiatry note dated 01/19/2024 documented Resident #190 had dementia with severe psychotic disturbance, was verbally disruptive, and was paranoid and delusional. The Psychiatrist recommended ordering Resident #190 Risperdal 0.25 milligrams for psychosis due to visual hallucinations and delusions. The Physician Order dated 01/25/2024 documented an order for Resident #190 to receive Risperdal 0.5 milligrams daily at bedtime due to unspecified psychosis. There was no documented evidence from 11/1/2023 to 1/19/2024 that Resident #190 displayed behaviors, delusions, or hallucinations. There was no documented evidence of nonpharmacological interventions were attempted or assessment for underlying medical causes was done prior to ordering Risperdal for Resident #190. On 04/01/2024 at 03:53 PM, Certified Nursing Assistant #17 was interviewed and stated Resident #190 did not display inappropriate behavior. On 04/01/2024 at 04:07 PM, Registered Nurse #4 was interviewed and stated that Resident #190 had some episodes of anxiety and crying in the evenings related to their desire to be discharged to their home in the community. Resident #190 was not aggressive and was ordered Risperdal to address their crying and screaming. During an interview on 04/02/2024 at 10:03 AM, Registered Nurse #13 stated nursing staff were responsible for documenting a resident's behavior in daily behavior progress notes. Nonpharmacological interventions should be attempted to address a resident's behavior prior to placing a resident on psychotropic medications. On 04/02/2024 at 01:07 PM, the Director of Nursing was interviewed and stated a resident's behaviors and nonpharmacological interventions must be documented in the medical record prior to placing a resident on psychotropic medications. On 04/02/2024 at 11:18 AM, the Psychiatrist was interviewed and stated Resident #190 was admitted to the facility on Seroquel because they displayed hallucinations. The Seroquel was discontinued, and Resident #190 began hallucinating again due to their diagnosis of dementia. Resident #190 cried and screamed and was ordered Risperdal. The Psychiatrist stated the dose of Risperdal was too low to cause cardiac issues. Resident #190 began pointing and talking to someone that was not there during the Psychiatry consult in 1/2024 and the Psychiatrist decided to place the resident on Risperdal to address the hallucinations. On 04/02/2024 at 01:26 PM, Medical Doctor #1 was interviewed and stated Resident #190 was prescribed Risperdal because they were agitated, cursing, and screaming daily claiming their family abandoned them in the facility. Medical Doctor #1 agreed with the Psychiatrist and ordered Resident #190 to receive Risperdal to address their hallucinations. Gradual dose reductions of psychotropic medications were only attempted with residents receiving high doses of medication for at least 6 months. 49081 2) Resident #141 was admitted to the facility with diagnoses that included Heart Failure, Atrial Fibrillation, Malnutrition and Osteoporosis. The Admission Assessment 5 Day Scheduled Minimum Data Set, dated dated dated [DATE] documented resident was moderately impaired cognition, had no behavioral symptoms and no antipsychotic medications were received. The Annual Assessment Minimum Data Set, dated dated dated [DATE] documented resident was severely cognitively impaired and had no behavioral symptoms. Diagnoses included Non-Alzheimer's Dementia, and Psychotic Disorder. The Minimum Data Set documented resident received antipsychotic, gradual dose reduction was clinically contraindicated, and date physician documented was 11/24/2023. A Comprehensive Care Plan Titled Dementia Cognitive Loss dated 10/05/2023 and revised 01/17/2024 had a goal of sustain current level of cognitive functioning. Interventions included anticipate needs, maintain calm environment, and use direct/simple instructions and cues. A Comprehensive Care Plan Title Psychoactive drug use with diagnosis of Psychosis and Depression dated 01/09/2024 had interventions which included evaluate behavior pattern daily, evaluate effectiveness of medications, monitor for changes in behavior or moods and psychiatry consultation. On 03/28/2024 at 09:54 AM, Resident #141 was observed in bed with bilateral floormats on both sides of bed. Resident #141 observed with calm mood. On 04/01/2024 at 09:41 AM, Resident #141 was observed in bed eating breakfast. Resident #141 mood was pleasant and answered simple questions. Resident #141 displayed no behaviors. On 04/02/2024 at 09:06 AM, Resident #141 was observed eating breakfast, replied to surveyor when asked with simple questions but with some confusion. No restless or agitation observed. Resident #141 observed in good mood. At 11:47 AM, Resident #141 observed sleeping in bed with the television on and bilateral floormats observed on both sides of bed. From 03/28/2024 through 04/02/2024 during multiple observations, Resident #141 was observed in bed, no activities being provided. Resident #141 displayed no behaviors. A Medical progress note dated 10/05/2023 documented Resident #141 was alert, awake, frail looks with chronological age. Psychiatry: normal mood and affect Resident #141 with anorexia to continue with Remeron 30 mg at bedtime. A Psychiatry progress note dated 10/19/2023 documented Resident #141 was for psychiatric evaluation with history of Aphasia and Subsequent Dementia with Depression, on psychotropic medications. As per staff Resident #141 had been without behavioral disturbances, no significant agitation, although recent reported Resident #141 with restlessness and agitation. Resident #141 denied Depression, no signs, and symptoms of Depression and positive confusion. Resident #141 denied psychotic signs and symptoms but recent reported of visual hallucinations. Resident #141 had positive memory deficits. Resident #141 was on psychotropic medications of Remeron 15 mg at bedtime and Melatonin 10 mg at bedtime. Diagnoses included Vascular Dementia with Depression. No gradual dose reduction was attempted, Resident #141 was unstable. A Psychiatry progress note dated 10/25/2023 documented for follow up, Resident #141's history of present illness with severe memory deficit, behavioral problem-periodic restlessness and agitation, labile and depressed mood, psychosis- visual hallucinations and insomnia. Psychotropic medications were Remeron 15 mg by oral route at bedtime and Melatonin 10 mg by oral route at bedtime. Resident #141 mental status documented awake, alert and calmed, mood depressed, hallucinations visual type, affect full/labile. Plan: please start Risperdal 0.25 mg by oral route at bedtime for Visual Hallucinations/Psychosis, support provided, monitor behavior and mood. A Medical progress notes dated 10/31/2023 documented Resident #141 was seen by psychiatrist had some visual hallucination and psychiatrist consult recommended Risperdal in low dose. Resident #141 with anxiety with visual hallucinations and adding Risperdal 0.25 mg at bedtime. A Nursing progress note dated 11/25/2023 at 02:41 AM documented Resident #141 had behavior of crawling onto the floor mats attempting to go to the bathroom. A Nursing progress notes dated 11/25/2023 at 10:32 PM documented Resident #141 had behavior of crawling onto the floor mats attempting to go to the bathroom. A Nursing progress note dated 01/10/2024 at 10:32 PM documented Resident #141 was monitored for insomnia. Received Resident #141 in chair awake, alert and verbal at 11:30 PM. At 12:35 AM Resident #141 observed dozing in chair. Certified Nursing Assistant put Resident #141 back to bed and floor mats placed on floor for safety as Resident #141 had a habit of coming out from bed. At 12:45 AM, Resident #141 observed crawling from mattress on the floor and shifted Resident #141 back to chair with assistance of two staff, and placed Resident #141 in front of nurse's station for constant observation and safety. There were no other nursing notes documented for Resident #141's behavior. The Medication Administration Record dated 10/01/2023 to 10/31/2023, documented Resident #141 was started on Risperdal (Risperidone) 0.5 mg tablet once daily for Generalized Anxiety Disorder on 10/31/2023. The Medication Administration Record dated from 10/01/2023 to 03/31/2024, documented no tapering or discontinuation of the medication Risperidone 0.25 mg once daily. Review of Physician's order dated 11/13/2023 Risperidone 0.25 mg tablet order for diagnosis of Generalized Anxiety Disorder, observed changed diagnosis to Unspecified Psychosis not due to a substance or known physiologic condition and Visual Hallucinations. The Medication Regimen Review progress note dated 11/25/2023 documented Resident #141 currently receiving Risperidone (Risperdal) 0.25 mg at bedtime which can increase risk for falls. Evaluate considering tapering dose or implementing alternative treatment if necessary. Currently receiving low dose Risperidone (Risperdal) for a diagnosis other than an approved chronic psychiatric condition, please evaluate continued need and efficacy and consider discontinue, if appropriate. Physician responded disagreed, Resident #141 with psychosis with hallucinations. The Medications Regimen Review progress note dated 02/25/2024 documented Resident #141 currently receiving Risperidone. Per order, use is for diagnosis other than an approved psychiatric condition. Please evaluate accuracy of diagnosis is inaccurate and the resident currently is using this medication for an approved use such as Schizophrenia, Bipolar Disorder, or other chronic enduring psychiatric condition, please update the medication order accordingly. If no approved chronic enduring psychiatric diagnosis exists, please consider implementing gradual dose reductions and discontinuing currently. Physician responded and disagreed with note that Resident #141 had dementia with psychotic disturbance including hallucinations. The Resident Certified Nursing Assistant Documentation History Detail documented that on 10/08/2023 and 10/18/2023 Resident #141 had 1 occasion of intrusive wandering and 1 occasion of repetitive physical movements, on 11/23/2023 and 11/25/2023 1 occasion of repetitive physical movements, 1 occasion of wandering and 1 occasion of abusive language. There was no documented evidence that Resident #141 displayed signs of psychosis prior to being prescribed antipsychotic medication. There was no documented evidence of a medical workup to rule out underlying medical conditions before Resident #141 was prescribed antipsychotic medication. There was no documented evidence that non-pharmacological interventions were attempted for Resident #141 prior to the administration of antipsychotic medications. During an interview on 04/02/2024 at 09:04 AM, Certified Nursing Assistant #4 stated that Resident #141 would try to get up and walk to go to the bathroom or go outside the room. Resident #141 sometimes would scream when they were in the hallway because Resident #141 wanted to get up and then they would try to hit the staff. To keep Resident #141 calm, we give food that Resident #141 likes, and try to divert their attention. Certified Nursing Assistant #4 also stated that now that Resident #141 is on contact isolation, they do not take them out of bed but when Resident #141 starts to get up, they take them out of bed because Resident #141 was high risk for fall and had an incident before. During an interview on 04/01/2024 at 09:45 AM, Registered Nurse #21 stated that Resident #141 was alert and confused and sometimes they get upset, argue with other staff, become restless and agitated if staff would give them a bath. Resident #141 would chase the staff away but did not scream or yell. Registered Nurse #21 also stated that the only behavior Resident #141 had was that they tried to get up from bed without calling for assistance. Resident #141 was provided with recreational activities and liked coloring, painting, watching television especially the Spanish channel. During an interview on 04/02/2024 at 11:56 AM, the Director of Nursing stated that they provided nonpharmacological intervention such as redirection, recreation activities and they explore the background of residents. The Director of Nursing also stated that Resident #141 had a few falls and at some point, they placed Resident #141 on one to one because of behavior like restlessness, kicking, and constant getting up and was not easily redirected. The Director of Nursing further stated that they would assess if the medication was effective by showing that Resident #141 had experienced fewer behavioral symptoms. The Director of Nursing stated that they had behavior notes and the Certified Nursing Assistants document behaviors also. The Director of Nursing was only able to provide 3 behavior nursing notes dated 11/25/2023 (2 notes) and 01/10/2024. During an interview on 04/02/2024 at 03:06 PM, the Psychiatrist stated that the medication Risperidone 0.25 mg tablet was ordered because Resident #141 had Dementia with Psychotic behavior features with hallucinations. The Psychiatrist said that Resident #141's hallucinations were like hearing somebody in their room and hearing their daughter's voices. The Psychiatrist said that Resident #141 was bothered by these hallucinations, but now, Resident #141 was better, there was no behavior, no agitation and there were no hallucinations anymore. The Psychiatrist said that they tried to discontinue the medication twice but was not successful and could not recall when they discontinued the medication. Hallucinations came back, and they started the medication again. The Psychiatrist said that usually they follow up with Resident #141 every eight weeks and Risperidone 0.25 mg tab was the right medication because it was only a small dose and that would not affect Resident #141's heart or cause a heart attack. During an interview on 04/02/24 at 03:12 PM, Medical Doctor #1 stated that Resident #141 hallucinated but cannot tell exactly when this occurred and they would have to check the medical record. Medical Doctor #1 also stated that they saw Resident #141 on the unit and they knew that Resident #141 with an episode of intermittent depression, lack of appetite and weight loss. Medical Doctor #1 further stated that Resident #141 hallucinated in the past and Risperdal was recommended by the psychiatrist. 10 NYCRR 415.12(1)(2)(i)

Based on observation, record review, and interviews conducted during an Abbreviated Survey (NY00322374 & NY00327956), the facility did not ensure that an alleged violation involving abuse was reported immediately but not later than two hours after the allegation was made if the events that caused the allegation involve abuse or result in serious bodily injury to New York State Department of Health (NYSDOH). This was evident for two out of eight residents (Resident #2 & Resident #3) sampled for abuse. Specifically, 1) Resident #2 reported to Licensed Practical Nurse (LPN) #1 on 10/16/23 at approximately 11:30 am (as per the facility's investigation), that two females (identified as Certified Nursing Assistant #1 and #2) gabbed Resident #1 by their left wrist and ripped off their disposable brief. Resident #1 also complained of pain to their left wrist. The facility did not report the alleged allegation of abuse within two hours, the facility reported the allegation of abuse to NYSDOH on 10/17/23 at 01:22 pm. 2) Resident #3 reported to Registered Nurse Supervisor (RNS) #1 on 11/09/23 at approximately 07:30 pm that a man touched Resident #3 on their private area. The facility reported the alleged sexual assault to NYSDOH on 11/10/23 at 05:14 pm. The findings are: The facility Policy and Procedure entitled, Abuse Prohibition-Prevention and Reporting, with the last reviewed date 12/2022, documented all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but not later than 2 hours after the allegation is made. Resident #2 was admitted to the facility with diagnoses including Altered Mental Status and Hemiparesis following cerebral infarction. The Minimum Data Set (MDS, a resident assessment tool) dated 10/01/23 documented that Resident #2 had a Brief Interview of Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) and scored 15 out of 15, associated with intact cognition. A Root Cause Analysis investigation dated 10/16/23 documented that on 10/16/23 at approximately 11:30 am, Resident #2 reported to LPN #1 that they were having pain in their left wrist. Resident #2 also reported that two black females (CNA #1 and CNA #2) grabbed their left hand and ripped off their disposable brief while they were changing them on the night shift several weeks ago. A Webform Submission from Nursing Home Facility Incident Report documented that the incident report was submitted to NYSDOH on 10/17/23 at 01:22 pm. Resident #3 was admitted to the facility with diagnoses including Schizophrenia and Dementia. Resident #3 was Legally Blind. The MDS dated [DATE] documented that Resident #3 had a BIMS score of 15 out of 15 indicating intact cognition. A Nursing Note dated 11/10/23 at 12:53 am, written by Registered Nurse Supervisor (RNS) #1 documented that Resident #3 told them that they remembered vaguely, but that someone touched their private pare overnight last week. Resident #3 was interviewed but was not able to identify or describe the perpetrator. Resident #3 was observed with normal behavior, was comfortable, and had no complaints of pain. No visible injury on observation and on assessment. A Root Cause Analysis investigation dated 11/09/23 documented that on 11/09/23 at approximately 7:30 pm, RNS #1 responded to a report from the nurse stating that Resident #3 was verbalizing suicidal ideation and stated that someone touched Resident #3 private parts (perineal and breasts). Resident #3 stated that a black male staff touched their private part overnight some days ago. A Webform Submission from Nursing Home Facility Incident Report documented that the facility reported the incident to NYSDOH on 11/10/23 at 05:14 pm. During an interview on 12/19/23 at 05:00 pm, the Director of Nursing (DON) stated that they reported the allegation of abuse for Resident #2 and Resident #3 late because two hours was not enough time to investigate the incident. During an interview on 12/27/23 at 03:05 pm, the Administrator stated that they oversee the DON to make sure incidents are reported to NYSDOH timely. The Administrator stated that the DON, the supervisor, and the Administrator all have access to reporting. The Administrator stated that prior to the survey, their understanding was that only incidents involving injury required a two-hour reporting time frame. The Administrator stated that they are now aware that any alleged abuse allegations must be reported to NYSDOH within two hours. 10 NYCRR 415.4(b)(2)

Based on record review and interviews during the Recertification survey conducted from 12/11/2022 to 12/16/2022, the facility did not ensure a surety bond was purchased to assure the security of all personal funds of residents deposited with the facility. This was evident for 367 residents with personal funds accounts (PFA) out of 632 residents. Specifically, the facility's PFA for 367 residents exceeded the facility's surety bond amount. There are 367 residents with personal fund balances amounting to a total of $935,493.32 held by the Facility and the amount of bond to assure residents against loss was only $100,000. The findings are: The facility policy titled Resident PFA last revised 11/2018 documented the facility must purchase a Surety Bond, or otherwise provide satisfactory assurance to assure the security of all personal funds of residents deposited with the facility. The Resident's Personal Funds Trust Fund Bond dated 08/01/2018 documented the facility obtained a surety bond for $100,000. The facility Patient Cash Worksheet dated 12/12/2022 documented a total balance of $935,493.94. The facility did not ensure a surety bond was obtained to cover the total value of residents funds held by the facility. On 12/14/22 at 10:55 AM, the Resident Fund Authorized Person (AP) was interviewed and stated they are not aware of the amount needed for the surety bond to be adequate. The facility has a corporate officer that knows the details of the surety bond and PFA. On 12/14/22 at 11:41 AM, the Administrator was interviewed and stated the facility's surety bond is expected to be enough to cover the PFA. A corporate officer was responsible for handling the facility's surety bond and the Administrator was not aware the amount of the surety bond was less than the PFA. 415.26(h)(5)(v)

Based on observations, record review, and interviews conducted during the recertification survey from 12/11/2022 to 12/16/2022, the facility did not ensure a safe, clean, comfortable, and homelike environment was maintained for residents. This was evident for 6 of 18 resident units. Specifically, 1) resident bathrooms on Unit H-7 had a strong smell of urine and were stained and 2) medication carts, linen carts, wheelchairs, and a Hoyer lift from Units SNF-4, SNF-5, SNF-6, SNF-7, and SNF-8 were dirty and stained. The findings are: Facility policy and procedure titled Environment of Care Rounds, dated 11/2016, revised 01/2020 documented, the purpose is to conduct regular environmental care rounds of all areas of the facility to effectively manage and maintain the facility as well as to identify and correct hazards to which may exist to residents, staff, and visitors. 1) On 12/11/2022 at 7:22 AM, Unit H-7 was observed with a pungent odor of urine in resident bathrooms of room [ROOM NUMBER], #721, and #726. Each of the bathrooms had brownish stained areas on the floor near the toilet. On 12/12/2022 at 11:49 AM and 12/13/2022 at 1:44 PM, the bathroom in room [ROOM NUMBER] was observed with a pungent urine odor and dried urine on the floor. On 12/15/2022 at 11:15 AM, CNA #6 was interviewed and stated Unit H-7 is a dementia unit with current census of 34 residents, approximately 11 to 12 residents per each of the 3 CNAs on the day shift. The CNAs do their best to check resident bathrooms and call the housekeeper when they are dirty. There is no time to check if the housekeepers cleaned the bathrooms because the CNAs have so many residents on their assignment. On 12/14/22 at 02:49 PM, Housekeeper #9 was interviewed and stated the bathroom in #721 has a urine smell and the floor tiles have brownish stain especially around the toilet. The bathrooms in #720 and #726 had a urine smell but were cleaned earlier. The bathroom floors are old and have several broken tiles. Even though they were cleaned with a cleaning solution, the solution does not clean the floor very well and the smell is still there. Housekeeper #9 made the Director of Housekeeping (DH) aware of this issue. On 12/14/22 at 03:36 PM, the DH was interviewed and stated there is a pungent odor of urine in the bathroom of # 721. The bathroom floor tiles were broken and need to be fixed. The DH will refer the issue to Administration to obtain new tiles. On 12/16/22 at 12:17 PM, the Administrator was interviewed and stated they are aware there isa problem with some resident bathrooms smelling of urine on Unit H-7. This is one of the challenges they are focusing on solving because Unit H-7 is the dementia unit. The Administrator must collaborate with the Housekeeping, Maintenance, and Nursing Departments to provide a clean and comfortable environment for residents. The facility will find more effective cleaning solution to use in cleaning the bathrooms and will fix bathroom broken and discolored bathroom tiles. 19546 2.) On 12/14/22 at 8:48 AM, an observation of SNF-7 was made, and the medication cart base was heavily layered with dust and imbedded with a black substance. The base of the blood pressure stand was heavily layered with dust. On 12/14/22 at 9:15 AM, an observation of SNF-6 was made, and the medication cart base was layered with dust and imbedded with a black substance. The base of the blood pressure stand was layered with dirt and dust. On 12/14/22 at 9:37 AM, an observation of SNF-5 was made, and the medication cart base was layered with dust and imbedded with a black substance. On 12/14/22 at 9:43 AM, an observation of SNF-8 was made, and the medication cart base was heavily layered with dust and imbedded with a black substance. On 12/16/22 at 9:14 AM, an observation of SNF-4 was made, and the medication cart base was encrusted with dirt and debris. There were 2 clean linen cart covers that were torn and tattered. A wheelchair in the corridor outside room [ROOM NUMBER] had a metal crossbar beneath the seat and wheel spokes heavily layered with dirt and dust. The Hoyer lift base was layered with dirt and dust. The SNF-4 nurse, Licensed Practical Nurse (LPN) #9 was interviewed on 12/16/22 at 10:22 AM and stated the wheelchair located in the corridor was ready for resident use and was not placed there to be cleaned. On 12/16/22 at 10:28 AM, Housekeeper (HK) #9 located on SNF-4 was interviewed and stated they are regularly assigned to SNF-4 and there are HKs located on every unit. The HK is not responsible for cleaning wheelchairs and the nurse cleans the medication carts. If the wheelchairs or medication carts are heavily soiled, then the nurse would inform the Director of Environmental Services (DES). The DES was interviewed on 12/16/22 at 2:46 PM and stated the DES makes daily environmental rounds with the Assistant DES to address environmental issues such as repair needs, cleanliness of environment, and address safety concerns. Housekeeping and Nursing are responsible for the general cleanliness of the medication carts. The DES recently took on the responsibility of cleaning wheelchairs when the previous employee retired and there is a wheelchair cleaning schedule. Cleanliness of blood pressure stands, and all other equipment is the responsibility of the DES. The facility purchased a high pressure heated steamer to clean resident equipment earlier in the year. The cleaning of this equipment is done during the day shift. 415.5(h)(2)

Based on observation, record review, and interviews conducted during the Recertification survey from 12/11/22 to 12/16/22, the facility did not ensure person-centered comprehensive care plans (CCP) was developed and implemented to address resident medical, physical, mental, and psychosocial needs. This was evident for 6 (Resident #116, #219, #95, #115, #600, and #207) of 38 total sampled residents. Specifically, 1) a CCP related to contractures was not developed for Resident #116, 2) a CCP related to contractures was not developed for Resident #219, 3) a CCP related to antipsychotic medication was not developed for Resident #95, 4) a CCP related to vision impairment was not developed for Resident #115, 5) a CCP related to wandering/elopement was not developed for Resident #600, and 6) a CCP related to anticoagulant therapy was not developed for Resident #207. The findings are but not limited to: The facility policy titled CCP last reviewed May 2022 documented the facility develops and maintains an individualized person-centered CCP to meet identified needs/goals. 1) Resident #116 had diagnoses of hemiplegia to the right dominant side following cerebral infarct and aphasia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #116 was cognitively intact, required extensive assistance for activities of daily living, and had functional limitation in range of motion on one side of the upper and lower extremities. On 12/11/22 at 09:53 AM, Resident #116 was observed in bed with right hand contracture and no handroll in place. At 11:00 AM, Resident #116 was interviewed and stated staff used to place a device before and the resident did not know why the staff don't apply it anymore. There were multiple observations of Resident #116 without right handroll from 12/12/22 at 9:27 AM to 12/13/22 at 11:00 AM. On 12/13/22 at 11:55AM, Resident #116 was interviewed and stated in the presence of the Licensed Practical Nurse (LPN) that they have not been refusing the right handroll. Staff are not applying it. Physician's order initiated 3/21/22 and renewed 11/21/22 documented right handroll to be worn at all times, as tolerated, and remove every shift during ROM, hygiene, and skin checks. The Occupational Therapy (OT) Discharge Summary dated 11/09/22 documented Resident #116 receive right handroll splint, 4 hours on/4 hours off. There was no documented evidence a CCP related to contractures was developed for Resident #116. On 12/13/22 at 11:49 AM, Registered Nurse (RN) #1 was interviewed and stated they are responsible for reviewing CCPs but have not been able to check and review the CCP status of Resident #116. 2) Resident #219 had diagnoses of left side hemiplegia following cerebral infarct and non-Alzheimer's dementia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #219 was severely cognitively impaired, required extensive assistance with activities of daily living, and had ROM limitation on one side of upper and lower extremities. Multiple observation of Resident #219 was observed multiple times between 12/11/22 at 09:28 AM and 12/13/22 at 11:30 AM in bed with no left handroll in place. Physician's order initiated 10/27/21 and last renewed 12/5/22 documented rolled gauze to Resident #219's left hand each shift every day. There was no documented evidence a CCP related to contracture was developed for Resident #219. On 12/13/22 at 11:49 AM, Registered Nurse (RN) #1 was interviewed and stated they are responsible for reviewing CCPs but have not been able to check and review the CCP status of Resident #219. 44843 3) Resident # 95 had diagnoses of vascular dementia with behavioral disturbance and delusional disorder. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident # 95 was severely cognitively impaired and received antipsychotic medication. Physician order dated 10/14/22 documented Resident #95 received Quetiapine 50 mg once daily at bedtime. The psychiatry note dated 10/23/22 documented Resident # 95 was on Quetiapine 50 mg for delusional disorder. The Medication Administration Record documented Resident # 95 was administered Quetiapine 50 mg daily since 10/14/22. There was no documented evidence a CCP related to antipsychotic medication use was developed for Resident # 95. On 12/14/22 at 03:31 PM, Licensed Practical Nurse (LPN) # 2 was interviewed and stated Resident # 95 was on antipsychotic medication Quetiapine at bedtime. The Registered Nurse (RN) supervisor was responsible to create and update the care plan. On 12/14/22 at 03:43 PM, RN # 3 was interviewed and stated the RN always creates and updates the care plans. A CCP is required for residents receiving antipsychotic medications and was unable to provide an explanation Resident #95 did not have a CCP related to antipsychotic medication use. On 12/14/22 at 11:28 AM and 03:58 PM, Director of Nursing (DON) was interviewed and stated RN manager, nursing supervisor, and RN on the unit create CCPs. Residents receiving antipsychotic medication or with a recommendation for a device should have a care plan created. Nursing initiates the CCP, and this might be overlooked. The DON did not have an explanation for CCPs not being developed for Resident #116, #219, and #95. On 12/14/22 at 11:41 AM, the Administrator was interviewed and stated Administration was not aware of issues with development of CCPs but has already implemented a check of the whole house to ensure CCPs in place reflect the care being provided to the residents. 415.11(c)(1) 41709 45988

Based on observations, record review, and interviews conducted during the Recertification survey from 12/11/22 to 12/16/22, the facility did not ensure residents with limited mobility receive appropriate equipment to maintain or improve mobility. This was evident for 2 of 2 residents (#116 and #219) reviewed for Limited Range of Motion (ROM) out of 38 total sampled residents. Specifically, 1) there were multiple observations of Resident #116 without right handroll in place and 2) there were multiple observations of Resident #219 without left hand gauze roll in place. The findings are: The facility policy titled Splint/Brace/Assistive Devices last revised 01/2022 documented Certified Nursing Assistant (CNA) applies splint/brace as per instructions and Registered Nurse (RN) assures appropriate documentations by all clinical team members. 1) Resident #116 had diagnoses of hemiplegia to the right dominant side following cerebral infarct and aphasia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #116 was cognitively intact, required extensive assistance for activities of daily living, and had functional limitation in range of motion on one side of the upper and lower extremities. On 12/11/22 at 09:53 AM, Resident #116 was observed in bed with right hand contracture and no handroll in place. At 11:00 AM, Resident #116 was interviewed and stated staff used to place a device before and the resident did not know why the staff don't apply it anymore. There were multiple observations of Resident #116 without right handroll from 12/12/22 at 9:27 AM to 12/13/22 at 11:00 AM. On 12/13/22 at 11:55AM, Resident #116 was interviewed and stated in the presence of the Licensed Practical Nurse (LPN) that they have not been refusing the right handroll. Staff are not applying it. Physician's order initiated 3/21/22 and renewed 11/21/22 documented right handroll to be worn at all times, as tolerated, and remove every shift during ROM, hygiene, and skin checks. The Occupational Therapy (OT) Discharge Summary dated 11/09/22 documented Resident #116 receive right handroll splint, 4 hours on/4 hours off. On 12/13/22 at 10:56 AM, CNA #1 was interviewed and stated Resident #116 has a right-hand cone, but CNA #1 has not seen it recently when giving the resident care. Resident #116 refused to wear the cone in August when CNA #1 was previously assigned to them. CNA #1 used to report the resident's refusal to the nurse but does not look for the hand cone because of Resident #116's history of refusing to wear it. CNA #1 did not provide Resident #116 with the right handroll/cone yesterday or today. On 12/13/22 at 11:26 AM, LPN #1 was interviewed and stated Resident #116 sometimes refuses to wear device for right hand contracture. Resident #116 just returned from being quarantined on another unit and LPN #1 is unsure if the right handroll is still in the resident's room. 2) Resident #219 had diagnoses of left side hemiplegia following cerebral infarct and non-Alzheimer's dementia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #219 was severely cognitively impaired, required extensive assistance with activities of daily living, and had ROM limitation on one side of upper and lower extremities. Multiple observation of Resident #219 was observed multiple times between 12/11/22 at 09:28 AM and 12/13/22 at 11:30 AM in bed with no left handroll in place. Physician's order initiated 10/27/21 and last renewed 12/5/22 documented rolled gauze to Resident #219's left hand each shift every day. On 12/13/22 at 11:20 AM, CNA #2 was interviewed and stated they have never seen a device for Resident #219's contracted arm. Resident #219 always keeps their contracted arm tight when CNA #2 is providing care. On 12/13/22 at 11:26 AM, Licensed Practical Nurse (LPN) #1 was interviewed and stated Resident #219 has a left-hand contracture and is ordered to have left handroll. The CNA is responsible for giving the handroll to the resident as indicated on the CNA Accountability Record (CNAAR). The CNAs check the CNAAR to know what to do for the resident and the CNA signs at the end of care. LPN #1 makes rounds on the unit, but it is difficult to monitor the CNAs. On 12/14/22 at 10:11 AM, The Rehab Director was interviewed and stated residents receive devices after a physician's order and updates to the CNAAR. Rehab staff give the staff on the unit training on devices and screen residents every 3 months for devices. The nursing staff monitors that devices are applied daily. The Rehab Director was not aware that Resident #116 and Resident #219 were not provided with devices as ordered. On 12/14/22 at 11:28 AM, the Director of Nursing (DON) was interviewed and stated the CNA ensures devices are placed as per physician order and nurses on the unit check that devices have been applied. If the resident refuses to have a device, the nursing staff must document and reevaluate the resident. 415.12 (e)(2).

Based on observation, interview and record review during an abbreviated survey, the facility did not ensure that residents were free of significant medication errors. Specifically, Resident #2 received a total of 7 medications that were prescribed to Resident #1. Resident #2 was subsequently transferred to the hospital for lethargy and unresponsiveness. The resident was monitored for 24 hours in the hospital and treated for [REDACTED]. Additionally, staff did not follow accepted professional standards of practice during medication administration. Staff was observed leaving medications unattended on the medication cart and pre-pouring medications. This resulted in actual harm that is not Immediate Jeopardy as evidenced by 1 out of 9 sampled residents (Resident # 2). For Residents #1, 3 and 4 this resulted in no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. NY 5273 and NY 163 The findings are: Resident #1 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment 3.0 dated 3/4/11 identified that the resident had moderate impairment in cognitive skills for daily decision making. The resident required extensive assistance with Activities of Daily Living (ADL ' s). According to the Medication Administration Record, [REDACTED]. A review of the Medication/Treatment Error Form, dated 3/23/11 stated that at 9:47AM Resident #2 received medications that were intended for Resident #1. Licensed Practical Nurse (LPN) #1 gave the medications to the Certified Nurse's Aide (CNA) to administer to Resident #1. The CNA administered the medications to Resident #2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS 3.0 dated 3/4/11 identified that the resident had moderate impairment in cognitive skills for daily decision making. The resident required assistance in performing all ADL ' s. The Physician's Notes dated on 3/23/11 documented that resident was noted with lethargy; vital signs were taken and the physician ordered to hold all medications dated 3/23/11. A second Physician's Note dated 3/23/11 stated that the resident was not arousable and ordered transfer to the hospital. The Transfer Notice, dated 3/23/11 stated that the resident was sent to the hospital due to lethargy and unresponsiveness secondary to a medication error. The nursing notes, dated 3/23/11 stated that at 10:45AM LPN #1 reported that she gave the wrong medication to the resident with the CNA ' s help. At 11:30AM Resident #2 was assessed and noted to be drowsy, but opened her eyes when her name was called. The MD was notified and ordered to hold all medications. At 12:50 PM the resident was noted as unresponsive to verbal stimuli and responsive to painful stimuli. The MD ordered intravenous (IV) fluid with normal saline solution. A nursing note dated 1:05PM stated that the IV fluids were started. The resident was transferred to the hospital at 2:40PM. On 3/23/11 at 10:00AM a telephone interview was conducted with the CNA. She stated that she saw that the LPN #1 was having a hard time administering medication to Resident #1. The LPN asked her for assistance with the medication administration. The CNA stated that the LPN gave her medications and asked her to administer them to Resident #2. She stated that she administered the medications to Resident # 2. On 3/25/11 at 1:48PM an interview was conducted with the LPN #1. The LPN stated that Resident #1 refused to take medication that day and the CNA offered to help. She stated that she gave the medication to the CNA and stated to please give it to the resident (Resident #1). The CNA gave it to the wrong resident (Resident #2). The LPN stated that later she realized that they made a mistake and reported it immediately to the supervisor. The LPN stated " it was my mistake I should not have allowed a CNA to administer medication to that resident. " Subsequently, Resident #2 was transferred to the hospital for lethargy and unresponsiveness. Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS 3.0 documented that resident has impaired cognitive skills for daily decision making. The resident required limited to extensive assistance in performing ADL ' S. The physician's order [REDACTED]. On 4/4/11 at 10:00AM LPN #2 was observed during medication administration for Resident #3. The LPN was observed pre-pouring liquid medication for 6 residents, including Resident # 3 ' s medication. The LPN was also observed leaving the medication cart unattended with all the pre-poured medications sitting on top of the cart. On 4/4/11 at 11:58AM LPN #2 was interviewed. The LPN stated that she pre-poured the medications because there are so many residents and all of these residents were on pro stat medications. LPN #2 stated " yes I am well aware of medication administration policy, but if we follow those rules we will never finish giving medications. " Resident # 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Integrated Admission Assessment, dated 3/10/11 identified that the resident was alert, but not oriented to person, place or time. The Physician Orders, dated 4/8/11 documented that the resident was prescribed [MEDICATION NAME] R Insulin 100 units/ml vial with sliding scale coverage at 11:45AM for Diabetes. On 4/4/11 at 11:55AM during an observation of the medication administration for Resident #4, LPN #3 was observed leaving the medication cart open and unattended. The top of the cart contained medications and 4 vials of [MEDICATION NAME] R Insulin for Resident #4 and three other residents. On 4/4/11 at 12:01PM an interview was conducted with LPN #3. LPN #3 stated " I prepared all of this on the cart and I should not leave it unattended. " 415.12(m)(2)