Every finding on record at Kings Harbor Multicare Cente

Number of residents sampled: 39Number of residents cited: N/A Based on interviews and record reviews conducted during the Recertification survey, the facility failed to ensure that the direct care staffing information based on payroll data was submitted based on the schedule specified by the Centers for Medicare and Medicaid Services. Specifically, the facility failed to submit the direct care staffing data for fiscal year Quarter 1 2026 (10/01/2025 - 12/31/2025) timely. The findings include:The Centers for Medicare & Medicaid Services Electronic Staffing Data Submission Payroll-Based Journal, Long Term Care Facility Policy Manual version 2.6 dated 06/2022 documented Section 6106 of the Affordable Care Act requires facilities to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other auditable data. Direct care staffing and census data will be collected quarterly and is required to be timely and accurate. Staffing and census data will be collected for each fiscal quarter. The deadline for submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Time) after the last day in each fiscal quarter in order to be considered timely. The facility policy titled Payroll-Based Journal Submission with a last revised date of 12/04/2025 stated the facility was responsible for ensuring payroll-based journal submissions are complete, accurate, and submitted within required timeframes. The Centers for Medicare and Medicaid Services Payroll Based Journal Staffing Data Report documented that there was no data submitted by the facility for fiscal year Quarter 1 2026 (October 01 - December 31). On 04/01/2026 at 12:09 PM, the Management Information System Technician #1 was interviewed and stated they were responsible for submitting payroll-based journal information for the facility to Centers for Medicare and Medicaid Services, and they were aware of the submission due dates each quarter for the payroll-based journal. The Management Information System Technician #1 also stated they submitted the payroll-based journal data before the due date of 02/14/2026 for fiscal year Quarter 1 2026 (October 1 - December 31). The Management Information System Technician #1 further stated they were not aware they submitted the incorrect quarter payroll-based journal as there was no warning notice, and they received confirmation of the submission. The Management Information System Technician #1 stated they found out they submitted the Quarter 2 2026 (January 01 - March 31) payroll-based journal data instead of Quarter 1 2026 (October 1 - December 31) and reached out to Centers for Medicare and Medicaid Services on 02/18/2026. The Management Information System Technician #1 also stated the Centers for Medicare and Medicaid Services told them the due date was past, and it was too late to submit the Quarter 1 2026 (October 1 - December 31) payroll-based journal data. On 04/01/2026 at 11:50 AM, the Management Information System Manager was interviewed and stated they oversaw the payroll-based journal submission. The Management Information System Manager also stated they knew they submitted the wrong quarter payroll-based journal report, and they were unable to submit correct one because they were past the due date of 02/14/2026. On 04/01/2026 at 12:17 PM, the Administrator was interviewed and stated they were aware the facility submitted the wrong payroll-based journal report to Centers of Medicare and Medicaid for Quarter 1 2026. The Administrator also stated it was the first time this happened, and they did not expect it to happen.10 New York Codes, Rules and Regulations 400.2

Number of residents sampled: 3Number of residents cited: 1 Based on observation, record review, interview, the facility failed to ensure that resident was assessed by an interdisciplinary team to determine their ability to safely self-administer medication when clinically appropriate. This was evident for one (1) of three (3) residents (Resident #439) reviewed for Respiratory Care. Specifically, there were multiple observations of a Ventolin HFA inhaler left unsecured at Resident #439's bedside, and there was no evidence Resident #439 had been assessed by the interdisciplinary team, and a determination made that they could safely self-administer the medication. In addition, there was no documented evidence of a physician's order for this medication.The findings include:The facility policy titled Self-Administration of Medications dated 09/1997, last revised 09/2024, documented those residents deemed capable, and who desire to self-administer their medications, will be permitted to do so, after appropriate counseling/teaching and with the specific order of the resident's physician and the resident will be evaluated to determine if criteria for self-administration is met. The policy also stated the resident is to store the medication in a locked area provided by the facility and understands the necessity to keep locked area. Resident #439 was admitted with diagnoses of Asthma, Cerebrovascular accident with chronic right-side weakness, and Gout.The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #439 was cognitively intact and was able to understand and be understood.During observations on 03/30/2026 at 9:10 AM, 12:43 PM, and 2:00 PM, Resident #439 was seated in a wheelchair next to the bed. A Ventolin HFA inhaler was observed on a resident's bedside table.During an interview on 03/30/2026 at 2:17 PM, Resident #439 stated the inhaler belonged to them which they used for coughing two to three times a day and was always kept at the bedside. Resident #439 also stated that this medication was prescribed from an outside doctor, and they had argued with nurses at the facility in order to keep the inhaler in their room and have used the inhaler since in the facility. The Comprehensive Care Plan with focus Alteration in Behavior as evidenced by holding inhaler in the room do not want to give it up when asked, created 10/30/2025 and updated 03/17/2026, documented resident will demonstrate fewer episodes of unacceptable behavior. Interventions include be calm when interacting with resident, use behavior modification technique, and ensure residents and others are safe.There was no documented evidence in the medical record that Resident #439 had been evaluated and deemed suitable for self-administration of medication.On 04/01/2026 at 11:10 AM, Resident #439 was interviewed and stated that a nurse took their inhaler away and they wanted it back so they could keep it themself. During an interview on 04/06/2026 at 9:56 AM, Certified Nursing Assistant #13 stated they could not recall if Resident #439 had any medication with them and they would report to the nurse or supervisor if a resident possessed any medication. During an interview on 04/06/2026 at 10:07 AM, Registered Nurse #10 stated they had never seen Resident #439 with any medication before, and residents were not allowed to have their own medication. Registered Nurse #10 also stated if nurses observe residents with medication, they should report to supervisor immediately so the resident can be assessed.During an interview on 04/06/2026 at 10:15 AM, Registered Nurse Manager #11 stated that they observed Resident #439 in the afternoon of 03/30/2026 with an inhaler and they informed the doctor, obtained an order, and assessed Resident #439 to see if they demonstrated capability to manage medication. Registered Nurse Manager #11 also stated Resident #439 agreed to have a nurse administer medication as ordered and gave the inhaler to Registered Nurse Manager #11.During an interview on 04/06/2026 at 11:53 AM, the Director of Nursing stated that it is facility policy that a nurse should assess a resident for capacity for self-administration of medication which should include their cognitive status, teaching, and return demonstration. The Director of Nursing also stated that then a physician's order is obtained, and the medication is kept in a locker in the resident's room. The Director of Nursing further stated that when nurses or Certified Nursing Assistants find a resident with any medication, they need to inform the physician to assess if the resident needs that medication or not, and then the interdisciplinary team must assess resident's capacity to self-administer medication.10 New York Codes, Rules and Regulations 415.3(f)(1)(vi)

Number of residents sampled:5Number of residents cited:1Based on record review and interviews, the facility failed to ensure they immediately informed the resident, consulted with the resident's physician and notified the resident's representative when there was a need to alter treatment significantly. This was evident for one (1) of five (5) residents (Resident #630) reviewed for Pain Management out of 39 sampled residents. Specifically, there was no documented evidence that Resident #630 or their designated representative was informed when Dilaudid was initiated and added to their pain management regimen.The findings include:The facility's policy and procedure titled Pain Assessment, Education and Management effective 3/2006 and revised 01/2025 documented information on pain may be obtained from the resident, family members or observation of the resident. The policy also stated the pain assessment will be performed by a Registered Nurse using the pain assessment tool which includes documentation of pain rating, subjective data-the resident's Resident #630 own description of the pain, objective data-staff observation and summary and plan of care based on the information obtained. Resident #630 was admitted to the facility with diagnoses including Hypertension, Schizophrenia, and Bipolar Disorder.The admission Minimum Data Set, dated [DATE] documented Resident #630 had moderately impaired cognition and had no pain/hurting in the last 5 days. The Quarterly Minimum Data Set, dated [DATE] documented Resident #630 had moderately impaired cognition, occasionally experienced very severe pain which rarely affected sleep and occasionally limited their ability to participate in therapy and day to day activities, and they received an Opioid. On 03/30/2026 at 10:36 AM, Resident #630 was interviewed and stated they are given Hydromorphone twice daily and Tylenol has been effective when they have pain due to neuropathy, and they did not know why they are receiving Hydromorphone. Resident #630 also stated they questioned the nurses and did not get a firm answer. The Comprehensive Care Plan for Pain Management initiated 10/21/2025 and revised 03/23/2026 documented resident has pain as evidenced by verbalization related to cardiovascular, bilateral edema upper extremities and burning sensations to bilateral feet. Interventions included administer Gabapentin 100 milligram three times daily, Lidocaine 4% topical patch, Tylenol 325 milligram tablet medication used for pain management, obtain pain history, assess nature intensity, location, duration, and frequency of pain, use a standardized scale to quantify intensity of pain, review/revise pain management plan as needed, and observe for non-verbal cues of pain/discomfort. The Hospital Discharge summary dated [DATE] documented Resident #273 was admitted from 10/09/2025 to 10/21/2025 with diagnoses of septic shock secondary to infectious colitis and acute kidney injury. Discharge medications included Tylenol 325 milligrams, two (2) tablets every eight (8) hours as needed for pain.The Physician Order initiated on 10/21/2025 and discontinued on 10/22/2025 documented Tylenol 325 milligrams, two (2) tablets every eight (8) hours as needed for pain.The Physician Order initiated on 10/22/2025 and renewed on 03/08/2026 documented Tylenol 325 milligrams, tablet two (2) tablets every eight (8) hours for pain at 06:00 AM, 02:00 PM, and 10:00 PM. The Pain assessment dated [DATE] documented Resident #630 did not verbalize pain; current therapy is Tylenol 650 milligram tablet every eight (8) hours is effective.The Nursing Note dated 10/22/2025 documented Resident #630 admitted and monitoring for pain management. Tylenol 325 milligrams, two (2) tablets every eight (8) hours secondary to pain. New as needed medication; Dilaudid two (2) milligrams tablet every four (4) hours as needed secondary to pain. Resident #630 denies any pain or discomfort.The Medical Note dated 10/22/2025 documented Resident #630 was admitted for long term placement. Resident #630 is awake, alert, conversant but confused at baseline. Resident #630 with bilateral upper extremity pain and swelling but no intervention done during hospitalization. Start Tylenol scheduled and will likely need strong pain medications, consider starting narcotics at low dose with close monitoring.The Physician Order initiated on 10/22/2025 and discontinued 03/02/2026 documented Dilaudid two (2) milligrams tablet every four (4) hours as needed for pain in right hand.The Medication Administration Record dated 10/22/2025 to 12/18/2025 revealed Tylenol 325 milligrams two (2) tablets were administered as ordered and Resident #630 received Dilaudid two (2) milligrams tablet as needed on eight (8) occasions (10/25/2025,10/25/2025, 10/26/2025, 10/28/2025, 11/09/2025, 12/05/2025, 12/08/2025, 12/15/2025).The Nursing Notes dated 12/05/2025, 12/08/2025, and 12/15/2025 documented Resident #630 complained of pain to right thigh. Dilaudid two (2) milligrams tablet as needed was given.The Nursing Note dated 12/09/2025 documented Resident #630 reported pain to lower buttocks but stated that Dilaudid is not as effective, and they would like Icy Hot patch to help with pain relief.The Treatment Order dated 12/10/2025 documented apply Icy Hot 5% topical patch once daily as needed, place on affected joints for pain.The Treatment Administration Record dated 12/15/2025 documented Resident #630 was treated with Icy Hot 5% topical patch.The Physician Order initiated 12/19/2025 and discontinued on 03/30/2026 documented Dilaudid two (2) milligrams tablet twice daily for pain.The Medication Administration Record dated 12/19/2025 to 03/30/2026 revealed Tylenol 325 milligrams x 2 tablets were administered three times daily as ordered, Dilaudid 2 milligrams tablet was administered twice daily as ordered, and Dilaudid 2 milligrams tablet was administered as needed on four (4) occasions (01/15/2026, 01/29/2026, 02/15/2026, 02/20/2026).The Nursing Note dated 12/19/2025 documented monthly physical reviewed and renewed by Medical Director. No medication or treatment changed. Will continue with current care. The Pain assessment dated [DATE] documented Resident #630 did not verbalize pain or discomfort.Review of the medical record dated 10/21/2025 to 03/29/2026 revealed there was no documented evidence that Medical Doctor informed Resident #630 or their designated representative when Dilaudid was initiated and added to pain management regimen.On 04/03/2026 at 09:17 AM, the Medical Director stated that on return from the hospital in October 2025, Resident #630's bilateral upper extremities were observed very tender and sensitive with swelling. Hospital records showed that Resident #630 reported pain, and Tylenol was given as needed for the pain. Discharge pain medications to the facility were Lidocaine patch topical as needed, Tylenol 325 milligrams x 2 tablets every 8 hours as needed. The Medical Director also stated the wound doctor assessed Resident #630 upon admission and observed their right wrist was swollen and warm to touch and they initiated Dilaudid 2 milligrams as needed as a proactive approach on 10/22/2025. The Medical Director further stated later on they spoke to unit staff and rehab therapists who revealed Resident #630 was not participating in daily care/tasks, wanted to stay in bed due to pain, and reported tightness and pain in the hands. The Medical Director stated they changed Dilaudid 2 milligrams tablet from an as needed medication to twice daily for pain management on 12/19/2025. The Medical Director also stated they are aware that cognitively intact residents and their representatives are informed about any changes in the medication regimen, and they recalled speaking to Resident #630 about all the changes in their treatment/medication but could not locate any documented evidence that Resident #630 or their representative was informed about the changes. 10 New York Codes, Rules and Regulations 415.3(e)(2)(ii)(b)

Based on observation, interview, and record review conducted during the survey the facility failed to ensure that a resident was free from physical restraints for purposes of discipline or convenience and that are not required to treat the resident's medical symptom. This was evident for one (1) of two (2) residents (Resident #642) reviewed for Physical Restraints out of 39 total sampled residents. Specifically, Resident #642 was observed, on multiple occasions, in bed with two (2) upper half side rails raised on both sides. The siderail assessments were incomplete, the physician order documented use of a one (1) half side rail as an enabler, there was no documentation of the medical necessity for use of the side rails, and Resident #642 was not able to lower the bed rails voluntarily.The findings include:The facility policy titled Side Rails, last reviewed on 06/2025, stated that it is the policy of the facility to provide residents with side rails in a manner that promotes resident safety and dignity based on individual patient assessments and clinical judgement. The policy also states side rails will be provided to residents as an enabler to assist with bed mobility and will be monitored for safety and prevention of entrapment. The policy further stated residents will be assessed for use of side rails on admission, readmission, quarterly, and when there is a change in the resident's condition. The policy stated a medical order will be obtained for residents who require side rails and has informed consent, will include the type of side rail and use as an enabler. The policy also stated that the resident or resident representative will be provided with education regarding the use of side rails to assist with bed mobility and informed consent will be obtained prior to use.The facility policy titled Physical Restraints, last revised 10/2021, stated it is the policy of the facility that all residents have the right to be free from any physical restraints imposed for purposes of discipline or convenience and not required to treat the residents' physical symptoms. The policy also stated upon admission/readmission the resident will be assessed for the need for a physical restraint, and all residents with restraints are to be evaluated at least quarterly by the Comprehensive Care Plan Team Members for need of continued use (more often if the resident's condition warrants). The policy further stated physical restraint use will be initiated after a medical order has been obtained for a specific type of restraint and the medical symptoms requiring its use. In addition, the policy stated that prior to the application of a restraint, written acknowledgement must be obtained from the resident or designated representative to include discussion of benefits and risks. Resident #642 was admitted to the facility with diagnoses including stroke with paralysis (loss of ability to move part of the body) of the right dominant side and Non-Alzheimer's dementia.The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #642 was severely cognitively impaired, had limitations in range of motion on both sides of the upper and lower extremities and required dependent assistance of staff with transfer, bed mobility and bathing, and bed rails were not in use in bed.On 03/30/2026 at 11:20 AM, Resident #642's bed was observed with two (2) upper side rails attached that were lowered and Resident #642 was not in the bed. On 04/01/2026 at 9:19 AM, Resident #642 was observed in bed sleeping. Two (2) upper side rails were raised. On 04/02/2026 at 12:30 PM, Resident #642 was observed in bed alert, lying on their left side. Two (2) upper side rails were raised. On 04/03/2026 at 2:25 PM, Resident #642 was observed in bed. Two (2) upper-enabler side rails were raised. Licensed Practical Nurse #11 asked Resident #642 to hold on to the rails while being turned and Resident #642 was able to follow the instruction. Registered Nurse #13 then asked Resident #642 to lower the side rails, but they were not able to do so. Siderail Use Assessments completed on 08/29/2025 and 09/15/2025 documented Resident #642 was able to follow commands, required assistance with bed mobility and was using the side rail for positioning and support. The Siderail Use Assessment also revealed the side rail recommendations was incomplete, and sideral location was documented as bilateral (both sides). Siderail Use Assessments completed on 10/20/2025 and 12/10/2025 documented Resident #642 was able to follow commands, required assistance with bed mobility and was using the side rail for positioning and support. The Siderail Use Assessment also revealed the side rail recommendations documented siderails indicated and serve as an enabler to promote independence, and side rail location was documented as bilateral (both sides). A Siderail Use assessment dated [DATE] documented Resident #642 was able to follow commands, required assistance with bed mobility and was using the side rail for positioning and support. The Siderail Use Assessment also documented the side rail recommendations was incomplete, and side rail location was documented as bilateral (both sides). A Physician Order initiated 11/14/2025 and renewed 03/14/2026 documented the use of one (1) half side rail as enabler. The Care Plan Activity Report with focus Non Restraint Wheelchair Seatbelt/Siderails effective 08/29/2025 and updated 02/12/2026 documented that Resident #642 was provided with two halves side rails as enabler and Resident #642's current bed mobility is dependent of two (2) for bed scooting, extensive assistance of two (2) for bed rolling, and transfer status is total assistance of two (2) via Hoyer lift.The Care Plan Activity Report with focus Fall documented that on 8/23/2025 at 8:50 PM, Resident # 642 was observed on the floor by unit Licensed Practical Nurse. Resident was observed lying on the floor, to the right side of the bed on their left side in a fetal position with back toward the air conditioner and head toward the top of the bed. Wheelchair was in locked potion at the foot of the bed. The note also sated Resident #264 was assessed on the floor and had swelling to the left side of their forehead and blood coming from their mouth with a slight cut to their lip. The note further documented that upon interview Resident #642 was unable to give an account of incident due to severe impairment in cognition. The Care Plan Activity Report with focus Fall documented that on 9/06/2025 at 11:54 PM, Resident #642 was observed on the floor, and was unable to state what happened due to cognitive impairment. Resident #642 complained of pain to left hip, and there was mild bleeding to inner upper lip and was evaluated at the hospital.Siderail Use Assessments completed on 08/29/2025 and 09/15/2025 documented Resident #642 was able to follow commands, required assistance with bed mobility and was using the side rail for positioning and support. The Siderail Use Assessment also documented Resident/Family did not consent to the use of side rails as enablers, the side rail recommendations was incomplete, and sideral location was documented as bilateral (both sides). There was no documented evidence that a medical symptom that requires the use of bed rails was identified for Resident #642, and there was no Physician's order for the use of two (2) upper side rails. On 04/03/2026 at 8:34 AM, an interview was conducted with Certified Nursing Assistant #14 who stated Resident #642 has two (2) upper side rails in place to hold onto while they are providing care. Certified Nursing Assistant #14 also stated the side rails support Resident #2 during turning and positioning when they are instructed to hold on. Certified Nursing Assistant #14 further stated they have observed Resident #642 lying on their side holding on to the side rail. Certified Nursing assistant #14 stated the side rails may prevent the resident from falling when they move in bed in a scooting position, but Resident #642 was found on the floor near the bed, and the side rails did not keep Resident #642 from falling. On 04/03/2026 at 8:50 AM, an interview was conducted with Licensed Practical Nurse #10 who stated that side rails are used to transfer residents from the wheelchair to the bed by instructing the resident to hold on to the device so they can pivot to sit on the bed and can also help with positioning residents in bed. Licensed Practical Nurse #10 also stated Resident #642 requires two (2) persons to transfer them with the Hoyer lift as they cannot stand and pivot, so in their case the side rails helps them to turn and helps them to stay on their side while care is being provided. Licensed Practical Nurse #10 further stated that there is a risk that the Resident #642's fingers or face can get stuck or caught in the side rail , so they try to keep Resident #642 in the middle of the bed with wedges, but they still move. Licensed Practical Nurse #10 stated that Resident #642 had an unwitnessed fall out of bed once with the side rails in place. On 04/06/2026 at 12:41 PM, an interview was conducted with Registered Nurse #12 who stated that Resident #642 cannot make decisions on their own. Registered Nurse #12 also stated the risks for Resident #642 is that if they are not able to use the side rails on their own, they can hit their head, and the side rails can be considered a restraint because this resident moves on their own, they could get stuck in it and injured. Registered Nurse #12 further stated they completed a side rail assessment on 01/27/2026 and determined Resident #642 was an appropriate candidate for side rail use as they were able to hold on to the side rails when instructed and their family wanted to have the side rails in place. Registered Nurse #12 further stated that it was an oversight when they left the assessment form blank on areas where it asks if the family/resident are aware of the risks of side rails use and gives consent to the side rails. On 04/06/2026 at 1:05 PM, an interview was conducted with Assistant Director of Nursing #2 who stated Resident #642 had unwitnessed falls from the bed before side rails use and after side rails use because Resident #642 moves in the bed. The Assistant Director of Nursing #2 also stated side rails are an enabler and help Resident #642 to hold their position in place when they are asked to turn from side to side. The Assistant Director of Nursing #2 further stated staff reported that Resident #642 can move in the bed independently and that is why they fall, but they cannot put the side rails down by themself. The Assistant Director of Nursing #2 there is a risk if a resident is not able to use the side rail, as they can hit their head, so side rails could be viewed as a restraint and there could be an entrapment risk because Resident #642 can they move on their own and could get caught in the rails and be injured. The Assistant Director of Nursing #2 also stated the nurse should have ensured that the physician order was correct.On 04/06/2026 at 1:22 PM, an interview was conducted with the Director of Nursing who stated the nurse completes the side rail assessment and residents should be assessed quarterly for appropriateness of the side rail. The Director of Nursing also stated if a resident can follow the directions for use, they do receive enablers even if they have impaired cognition as an enabler can assist with the resident's bed mobility if the resident can hold on to the enabler while receiving care and side rails are not used for fall prevention. The Director of Nursing further stated that some possible risk for residents with enabler use is entrapment. The Director of Nursing stated the documentation in the side rails assessment should have been complete and the physician's order should have been correct. 10 New York Codes, Rules, and Regulation 415.4(a)(2-7)

Number of residents sampled: 3Number of residents cited: 1Based on record review and interviews conducted during the survey the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to the state agency. This was evident for one (1) of three (3) residents (Resident #273) reviewed for Accidents out of total 39 sampled residents. Specifically, the facility did not report Resident #273's incident of unknown origin, resulting in a nasal fracture, to the New York State Department of Health. The findings include: The facility's policy and procedure titled Abuse Reporting reviewed 05/2025 documented incidents suspected of abuse, neglect and exploration or misappropriation and serious injury of unknown origin that is suspicious in nature must be reported within two (2) hours after forming the suspicion to the New York State Department of Health. All other incidents must be reported within 24 hours. Resident #273 was admitted to the facility with diagnoses that included Cerebrovascular Accident, Seizure Disorder, and Parkinson's Disease.The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #273 had severely impaired cognition and was dependent for toileting, roll left and right. The Nursing Note initiated 01/07/2026 and completed on 01/24/2026 documented on 01/07/2026 at approximately 05:30 PM, Licensed Practical Nurse #6 was conducting rounds and observed Resident #273 lying on the bedroom floor. Registered Nurse Supervisor #7 was notified. Resident #273 was noted with uncontrolled tremors and a small laceration on the bridge of their nose with active bleeding, and a small laceration to their mid forehead. The area was cleaned, pressure and ice pack applied. Resident #273 was unable to give details of the event. Medical Doctor and family were notified. Resident #273 was transferred to hospital for further evaluation. The Hospital Discharge summary dated [DATE] documented Resident #273 was admitted after fall incident in the nursing home facility. X ray was done and result showed fractures of the bilateral nasal bones and nasal septum. Resident #273 was also noted to have resting tremors during the hospitalization.The Nursing Note dated 01/08/2026 documented Resident #273 returned to facility around 12:44 AM, following hospital evaluation. The Fall/Occurrence Report documented on 01/07/2026 at 05:30 PM, Resident #273 was observed lying on the bedroom floor between bed A and B. Resident #273 has severely impaired cognition and was unable to give details of the event. The occurrence was a fall incident (not witnessed). Pain and skin assessments were done. Neuro check and treatment was given. Resident #273 was transferred to hospital on [DATE] and readmitted with nasal fracture and contusion to the forehead following the hospital evaluation.The facility's Summary of Investigation initiated 01/07/2026 documented that at 05:30 PM, Licensed Practical Nurse #6 was conducting rounds and observed Resident #273 lying on bedroom floor between bed A and bed B. Resident's head was towards the head of the bed; their legs extended towards the foot of their bed. Resident #273 was observed with uncontrollable tremors, and a pillow was under their head. Resident #273 was unable to state what happened. Resident #273 was assessed while on the floor and observed with a small superficial laceration on the bridge of their nose and mid forehead measuring 0.5 centimeter each with active bleeding. Doctor and family were notified, and resident was transferred to hospital for evaluation. Resident #273 returned to the unit on 01/08/2026 with hospital diagnosis of a nasal fracture. The facility concluded that Resident #273 was having tremors due to Parkinson's disease and may have rolled out of bed onto the floor. The investigation has revealed that there is no evidence to support that any alleged resident abuse, neglect, or mistreatment may have occurred. The incident was not reportable to Department of Health. There was no documented evidence that Resident #273's incident resulting in nasal fracture and lacerations to forehead and bridge of the nose was reported to the New York State Department of Health. On 04/02/2026 at 10:57 AM, the Assistant Director of Nursing was interviewed and stated Resident #273 was assessed immediately by Registered Nurse Supervisor and was observed having uncontrollable tremors. The Assistant Director of Nursing also stated Resident #273 may have rolled out of bed due to their unpredictable movement, or possibly seizure episode due to their diagnoses. The Assistant Director of Nursing further stated they were notified on 01/07/2026 when Resident #273 was being sent out to the hospital, and they found out about Resident #273's nasal fracture on the following morning on 01/08/2026. The Assistant Director of Nursing #2 stated that they did not suspect abuse or neglect occurred for Resident #273, so the fall was not considered reportable. On 04/03/2026 at 2:12 PM, the Director of Nursing was interviewed and stated investigation of all incidents is conducted by a Registered Nurse Supervisor, and the Assistant Director of Nursing is responsible for reviewing and reporting the incident to Director of Nursing and Risk Manager. The Director of Nursing also stated that they and the Administrator will decide if this is reportable to the state agency. The Director of Nursing further stated this incident was not reported to the New York State Department of Health because the facility did not suspect any abuse or neglect occurred for Resident #273. On 04/06/2026 at 12:24 PM, the Administrator was interviewed and stated they did not report this incident to the New York State Department of Health because it was determined not reportable. The Administrator also stated Resident #273 was found on the floor and was having an epileptic seizure which is likely to cause an injury, so they concluded very quickly that it was not an abuse incident. 10 New York Codes, Rules and Regulations 415.4(b)

Number of residents sampled: 3Number of residents cited: 1Based on record review and interviews, the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. This was evident for one (1) of three (3) residents (Resident #696) reviewed for Hospitalization out of 39 sampled residents. Specifically, Resident #696 had a change of condition and Urinalysis/Polymerase Chain Reaction testing (method to detect and identify pathogens (things that cause disease) was ordered on 02/09/2026 and results were not received until 02/19/2026 which confirmed that Resident #696 had a urinary tract infection. In addition, there was no documented evidence that the Medical Doctor and Resident #696's representative were notified when Resident #696 refused to provide a urine sample.The findings include:The facility's policy and procedure titled Resident Change in Condition effective date 03/2026 documented that it is facility's policy to establish a standardized process for early recognition, timely notification and appropriate intervention. The goal is to prevent decline, ensure timely medical treatment and maintain the highest practicable level of resident well-being. The facility's policy and procedure titled Diagnostic Service Laboratory Services reviewed 01/2024 documented laboratory services are performed to ensure that residents receive appropriate clinical laboratory services. That the values are communicated for follow up in an efficient manner. Resident #696 was admitted to the facility with diagnoses that included Hypertension, Diabetes Mellitus, and Chronic Kidney Disease. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #696 had moderately impaired cognition, required dependent assistance for toileting, and was always incontinent of urine. The Care Plan for Alteration in Bowel and Bladder Elimination initiated 06/12/2025 documented interventions which included provide brief change/check every two (2) to four (4) hours and as needed, monitor labs as scheduled, and encourage proper hand washing. The Care Plan for Fever/Hyperthermia initiated 02/12/2026 documented interventions which included assess/identify source of increased body temperature, lab tests as per physician order, monitor temperature/vital signs, offer ample fluids and monitor intake. The Physician Order entered 02/09/2026 at 01:03 PM and discontinued on 02/09/2026 at 03:03 PM documented Urine Sample for Urinalysis/Urine Polymerase Chain Reaction one time for fever. The Nursing Note dated 02/09/2026 at 02:36 PM documented Resident #696 was observed with increased temperature of 101.9-degree Fahrenheit during wound rounds. Vitals signs were checked. Medical Doctor was notified and ordered tests to rule out respiratory viruses and urinary tract infection. Tylenol Extra Strength 500 milligrams two (2) tablets every eight (8) hours as needed for fever. Resident #696's family was notified and updated on their status. Staff will continue to monitor and report changes accordingly. The Physician Orders entered 02/09/2026 at 03:03 PM for Urine Sample for Urinalysis/Urine Polymerase Chain Reaction one time for fever was documented as discontinued on 02/13/2026 at 03:16 PM after completion.The Diagnostic Result for Complete Blood Count dated 02/10/2026 documented [NAME] Blood Count level of 12.56 milligrams per deciliter (Reference Range 4.23-9.07), Blood Urea Nitrogen level of 42 milligrams per deciliter (Reference Range 9-23) and Creatinine level of 2.62 milligrams per deciliter (Reference Range 0.70-1.30) were abnormal.The Nursing Note dated 02/10/2026 at 04:22 PM written by Licensed Practical Nurse #11 documented no urine obtained on tour.The Nursing Note dated 02/10/2026 at 10:30 PM documented Resident #696 is alert and responsive, was to have urine collected but was uncooperative. Nursing Supervisor was informed and directed to collect another sample. The Nursing Note dated 02/11/2026 at 06:51 AM documented unable to obtain urine sample. The Nursing Note dated 02/12/2026 at 03:55 PM written by Licensed Practical Nurse #11 documented no urine obtained on tour.There was no documented evidence that the Medical Doctor was notified when the specimen for urinalysis was not collected. In addition, there was no documented evidence that staff attempted to obtain urine specimen on the following shifts: 02/09/2026 from 7:00 AM to 3:00 PM, 02/09/2026 from 3:00 PM to 11:00 PM shift, 02/10/2026 from 11:00 PM to 7:00 AM, 02/11/2026 from 7:00 AM to 3:00 PM, 02/11/2026 from 3:00 PM to 11:00 PM, and on 02/12/2026 from 11:00 PM to 7:00 AM.The Nursing Note dated 02/12/2026 at 10:16 PM documented urine sample collected and placed in refrigerator.The Nursing Notes dated 02/13/2026 at 11:45 AM, documented Resident #696's family was called and informed of the negative results for COVID-19/Respiratory Influenza and urine result is pending. The Nursing Progress Notes dated from 02/14/2026 to 02/17/2026 did not contain any ongoing monitoring and assessment of resident's condition.The Nursing Note dated 02/17/2026 at 10:35 PM, documented received call from lab to send another urine sample. Lab was unable to perform test. Urine collected and placed in refrigerator. There was no documented evidence that the Medical Doctor was informed of the delayed Urinalysis/Polymerase Chain Reaction test result. The Nursing Note dated 02/18/2026 at 07:37 AM documented urine was collected by the laboratory staff.The Nursing Note dated 02/18/2026 at 02:43 PM documented Resident #696 was observed with poor appetite, breakfast and lunch input was observed less than 25%; offered alternative and refused. Upon responding to the room, the resident noted to be alert and verbally responding, in no noted distress, denies any pain and no clinical signs observed. Vital signs, temperature were taken. Medical Doctor notified and gave no new orders. Resident #696's family was updated on the status. Staff will continue to monitor and report changes accordingly.The Nursing Note dated 02/18/2026 at 03:50PM documented staff reported that resident refused to eat his breakfast and lunch intake very poorly. Vital signs taken. Medical Doctor was made aware.The Nursing Note dated 02/19/2026 at 06:59 AM documented Resident #696 noted with elevated temperature during shift 101.3 degrees Fahrenheit and Tylenol 325 milligrams two(2) tablets administered as prescribed. Subsequent reassessment revealed temperature returned to within normal limits with no signs of acute distress. Will continue to monitor and follow plan of care. Vitals within residents' trend. The Medical Note dated 02/19/2026 at 09:24 AM documented Resident #696 with altered mental status and fever. Spoke to Resident #696's family that given decreased mentation, low blood pressure, fever and hypoxemia, family understands Resident #696 could be septic. Resident #696's family requested transfer to the hospital. The Transfer to Acute Hospital Form completed on 02/19/2026 documented Resident #696 was transferred to the hospital due to low blood pressure, hypoxemia, fever, to rule (low levels of oxygen in the blood) out sepsis (a life-threatening illness that develops when an existing infection causes an extreme immune response in the body). The Urine Polymerase Chain Reaction Test ordered 02/09/2026 documented it was collected on 02/17/2026 at 3:00 PM and results received on 02/19/2026 at 8:12 AM which documented that the test was positive for Streptococcus group B and Candida. Licensed Practical Nurse #11 was unavailable for interview as they were on leave. On 04/06/2026 at 11:18 AM, Registered Nurse #6 was interviewed and stated on 02/09/2026 they received a report that Resident #696 was having a fever, so they checked vital signs and notified the Medical Doctor immediately who ordered urinalysis, blood tests, chest x ray, COVID 19, Influenza, Respiratory Syncytial Virus testing and that Tylenol was to be given for fever. Registered Nurse #6 also stated rapid testing was conducted which was negative for COVID-19 and Influenza and swab was also collected/placed in the refrigerator for PCR test on 02/09/2026. The urine sample collection was also attempted by them but could not be collected because Resident #696 could void at that time. Chest x ray showed no irregularities. Registered Nurse #6 further that on 02/10/2026 they attempted to collect urine using a condom catheter, but urine could not be collected. Registered Nurse #6 stated that after three refusals and after three days of failed collection they will notify the Medical Doctor, and nurses were also checking vital signs including temperature every shift until Resident #696 to rule out any suspected infection. Registered Nurse #6 stated they expect nurses to communicate with the nurse on the incoming shift and to document if urine collection could not be done until it was completed.On 04/01/2026 at 02:45 PM, Centers Laboratory Staff were interviewed over the phone and stated a lab technician visits the facility daily at 4:00 AM to draw blood for tests that were ordered. The lab technicians will also review the urine test order form in the binder indicating that urine was collected and placed in the refrigerator for the technician to pick up, and they will initial when it is picked up. The Centers Laboratory Staff also stated that the urine test results take two (2) days to become available, and the lab technician picked up the urine on 02/13/2026 so they would have known by 02/15/2026 if there was any issue. The Centers Laboratory Staff further stated they will reach out to the facility's supervisor immediately if there was any issue with the sample and if another urine sample needed to be collected. The Centers Laboratory Staff stated an attempt was probably made to inform the facility that the test needed to be repeated on 02/15/2026, but they could not explain why facility staff could not be reached on 02/15/2026 and 02/16/2026 and were not contacted until 02/17/2026. The Centers Laboratory Staff stated a technician picked up another urine sample on 02/18/2026 and the result was sent to the facility electronically on 02/19/2026.On 04/06/2026 at 11:59 AM, Licensed Practical Nurse #4 who worked on 02/09/2026 during the 7:00 AM to 3:00 PM shift, was interviewed and stated the wound nurse made the team aware of Resident #696's change in condition. Licensed Practical Nurse #4 also stated that after the tests were ordered, they tried collecting urine, but Resident #696 could not void urine. Licensed Practical Nurse #4 further stated they and Licensed Practical Nurse #11 tried the condom catheter method on 02/09/2026 but urine could not be collected. Licensed Practical Nurse #4 stated they did not know why there was no documentation in the medical record regarding the urine not being obtained due to Resident #696's refusal or not being able to void urine, however, the urine was sent out to the laboratory a few days later. Licensed Practical Nurse #4 also stated they did not notify the nursing supervisor and Medical Doctor until Resident #696 had refused to cooperate with the urine collection for three (3) days. On 04/01/2026 at 03:15 PM, Licensed Practical Nurse #7 was interviewed over the phone and stated they can only recall that they collected the urine sample on 02/12/2026 during the 3:00 PM to 11:00 PM shift and placed it in the refrigerator. Licensed Practical Nurse #7 stated they found out that the urine sample was picked up for processing when they came back to work, and they do not recall what occurred after that.On 04/04/2026 at 01:55 PM, Licensed Practical Nurse #5 was interviewed and stated that they were a floating nurse when they were told to collect urine specimen and swab for COVID 19 for Resident #696 during on 02/10/2026 during the 3:00 PM to 11:00 PM shift. Licensed Practical Nurse #5 also stated Resident #696 was incontinent and was receiving care and they explained the urine collection process, but Resident #696 refused to give urine. Licensed Practical Nurse #5 further stated they informed Registered Nurse Supervisor #5 of Resident #696's refusal on 02/10/2026 during the 3:00 PM to 11:00 PM shift.On 04/02/2026 at 11:15 AM, Registered Nurse Supervisor #5 stated they are often the covering Supervisor during the 3:00 PM to 11:00 PM shift, and Licensed Practical Nurse #5 called them and reported that urine could not be collected for Resident #696 because of their refusal on 02/10/2026 during the 3:00 PM to 11:00 PM shift. Registered Nurse Supervisor #5 also stated they attempted to collect urine twice during the 3:00 PM to 11:00 PM shift on 02/10/2026, but Resident #696 refused. Registered Nurse Supervisor #5 further stated they are aware that the Medical Doctor should be notified of a residents' refusal of urine collection, and it should be documented in the progress notes, so the Medical Doctor can address the concerns and consider an alternative method like using straight catheterization. Registered Nurse Supervisor #5 stated the family is notified of refusal as well because they can assist with the process, however they did not notify the family of Resident #696's refusal on 02/10/2026. On 04/06/2026 at 10:52 AM, the Assistant Director of Nursing was interviewed and stated if the resident refused or staff is not able to collect urine for three (3) days then the doctor and family should be notified.On 04/03/2026 at 2:34 PM, the Director of Nursing was interviewed and stated the urinalysis order was a one-time order, not an immediate order, so the night shift nurse should have collected the urine during their shift and placed it in the refrigerator for pick up the next morning. The Director of Nursing also stated the nurses should have documentation about the progress of the collection and any concerns in the progress notes. The Director of Nursing further stated that the Medical Doctor and family are notified after three days of attempting urine collection. 10 New York Codes, Rules, and Regulations 415.12

Based on observations, interviews, and record review, the facility did not ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident on one (1) of 17 resident units (Unit 5 East), and one (1) of five (5) residents (Resident #683) reviewed for Pressure Ulcer/Injury out of a total sample of 39 residents. Specifically, 1). Housekeeping Aide #1 was observed in the room of a resident on contact/droplet precaution clostridium difficile (bacterial infection that affects the colon) and was not wearing a gown and did not perform hand washing before exiting the room, and 2). During a wound care observation, Resident #683's sacral (a bone located at the base of the lower back and between the hip bones) pressure ulcer was observed undressed and covered with wash cloths, gauze pads were not opened in a manner to maintain cleanliness, Registered Nurse #9 did not change their gloves and or perform hand hygiene after cleansing the wound and before applying the treatment, applied potentially contaminated gauze to wound after cleaning, and returned supplies taken into Resident # 683's room to the treatment cart after wound care. The findings include: The facility's policy titled Clostridium Difficile Protocol revised on 05/2024 stated gloves and gown are to be used when entering resident's room and during resident care. The policy also stated hand washing is to be performed after removing gloves. Use of alcohol hand rub is not to be utilized. 1.Resident #225 had diagnoses of enterocolitis (intestines are irritated and inflamed) due to clostridium difficile (bacterial infection that affects the colon), cancer (body's cells do not grow normally), and heart failure (heart is too weak or stiff). The admission Minimum Data Set assessment (a resident assessment tool) dated 02/12/2026 documented Resident #225 had moderately impaired cognition and was dependent for toileting. The hospital Discharge summary dated [DATE] documented Resident #225 was found to be positive for clostridium difficile. The Physician's Order revealed that Resident #225 was placed on Contact/Isolation Precautions for clostridium difficile on 03/27/2026. The Nursing Note dated 03/28/2026 documented Resident #225 is positive for clostridium difficile and contact precautions maintained. During an observation on 03/31/2026 at approximately 10:35 AM, Housekeeping Aide #1 was observed without a gown in Resident #225's room. Housekeeping Aide #1 took a garbage bin from the room to a housekeeping cart in the hall, removed the garbage bag, placed it in the soiled bin in the cart, placed a new bag in the room garbage bin, and returned it to Resident #225's room. Housekeeping Aide #1 then returned to the cart, removed their gloves, used hand sanitizer, applied clean gloves, and re-entered Resident #225's room. Housekeeping Aide #1 removed a clear bag of soiled personal protective equipment gowns from Resident #225's room and disposed of the bag in the soiled utility room down the hallway. Housekeeping Aide #1 returned to the cart, removed their gloves, used hand sanitizer, did not wash their hands, and then proceeded to another resident's room across the hall. On 03/31/2026 at 10:43 AM, Housekeeping Aide #1 was interviewed and stated they were aware of the contact precaution signage on Resident #225's door and that they should wear a gown before they enter Resident #225's room. Housekeeping Aide #1 also stated they had been instructed to wash their hands before leaving residents' rooms. Housekeeping Aide #1 further stated they forgot to wear a gown and wash their hands because the State Surveyor was observing them. On 03/31/2026 at 11:39 AM, the Housekeeping Director was interviewed and stated Housekeeping Aide #1 has been in-serviced on the required personal protective equipment to wear for those rooms that have contact precautions signage, and they have also received in-services instructing them to wash their hands with soap and water for 20 seconds before exiting resident rooms. On 04/01/2026 at 2:08 PM, the Assistant Director of Quality Assurance/Performance Improvement/Infection Preventionist was interviewed and stated the Housekeeping Director provides their staff education on the interpretation of different precaution signage. The Assistant Director of Quality Assurance/Performance Improvement/Infection Preventionist also stated nursing staff are also instructed to report if they see staff breaking infection control procedures. The Assistant Director of Quality Assurance/Performance Improvement/Infection Preventionist further stated the housekeeping aide should have worn a gown in Resident #225's room and should have washed their hands prior to exiting the room. On 04/06/2026 at 12:39 PM, the Director of Nursing was interviewed and stated that housekeeping staff receive in-service training from the staff educator, as well as from their supervisor and director. The nursing educator addresses infection control concerns and provides additional in-service education as needed. The Director of Nursing also stated that hand sanitizer is not effective against clostridium difficile. The Director of Nursing further stated Housekeeping Aide #1 should have worn a gown as indicated by the contact precaution signage and should have washed their hands with soap and water, scrubbing for at least 20 seconds, prior to exiting Resident #225's room. 2. The facility policy titled Aseptic (Clean-No Touch) Dressing Technique dated 01/1997, last revised 10/2012 documented that all dressing/treatment be under aseptic technique in accordance with medical orders. The policy further stated in procedure from #20 to #23 (page 2 of 3), Nurse will wash hands and change gloves before applying the treatment. Resident #683 was admitted with diagnoses of Polyneuropathy, Unspecified stage of pressure ulcer, Hypertension. The admission Minimum Data Set, dated [DATE] documented Resident #693 was at risk for developing pressure ulcers and had one unhealed unstageable pressure ulcer. The Physician's Order dated 03/25/2026 documented wash with Dakin 0,25%, dry, apply Santyl, apply Dakin's moist gauze, foam cover changes every day on sacral area for pressure ulcer. On 04/03/2026 at 10:18 AM, a wound care observation was conducted for Resident #368 with Registered Nurse #9. Registered Nurse #9 entered Resident #683's room, donned gloves and cleaned the overbed table before placing a drape sheet on it. Registered Nurse #9 gathered a box of 4x4 gauze pads, a bottle of Dakins 0.25% solution, a tube of Santyl ointment, and gloves and placed the items on the drape sheet. Registered Nurse #9 then left the room, washed their hands, donned a gown and gloves and returned to the bedside. Registered Nurse #9 then proceeded to tear the gauze packets horizontally across the top edge, removed gauze pads from the wrappers with gloved fingers, then poured Dakins 0.25% solution onto some of the gauze pads and removed the tube of Santyl ointment from a plastic bag. Registered Nurse #9 assisted Certified Nursing Assistant #12 with repositioning Resident #368 onto their right side. Certified Nursing Assistant #12 opened Resident #368's incontinent brief and the sacral wound was observed without a dressing and was covered with two wash cloths. Registered Nurse #9 performed hand hygiene and proceeded to clean the wound with the Dakins moistened gauze pads and patted it dry. Registered Nurse #9 then applied the Santyl ointment to a dry gauze pad and applied the treatment to the wound. Registered Nurse #9 then opened more gauze pads by tearing the wrapper horizontally, placed them on the drape sheet and applied Dakins 0.25% solution to the gauze pads. Registered Nurse #9 then applied the remaining Dakins soaked gauze pad that was used for cleaning the wound over the treatment, covered this with the newly prepared Dakins soaked pads, and applied the foam dressing. Registered Nurse #9 then removed gloves, performed hand hygiene and then returned the Dakins 0.25% solution, Santyl, and a box containing one wrapped gauze pad to the treatment cart. The Clean (Non-Sterile) Dressing Competency Assessment dated 01/28/2026 documented Registered Nurse #9 demonstrated proficiency during treatment pass observations. The facility failed to ensure that Resident #683's wound was dressed appropriately and not covered with wash cloths, gauze pads were opened in a manner to maintain cleanliness, Registered Nurse #9 changed their gloves and perform hand hygiene after cleansing the wound and before applying the treatment, did not apply potentially contaminated gauze to the wound after cleaning, and that Registered Nurse #9 did not return supplies taken into Resident # 683's to the treatment cart after wound care. On 04/03/2026 at 12:00 PM, Certified Nursing Assistant #12 was interviewed and stated Resident #368 was soiled and the dressing was also soiled and was already falling off the wound into the incontinence brief. Certified Nursing Assistant #12 also stated that they notified Registered Nurse that the dressing was soiled and had come off. Certified Nursing Assistant #12 further stated that after cleaning Resident #368, they covered the sacral wound with wash cloths because they did not have access to gauze pads. Certified Nursing Assistant #12 stated they know the wound is supposed to be covered with gauze and not wash clothes and this is why they notified the nurse that the dressing was off. On 04/03/2026 at 12:06 PM, Registered Nurse #9 was interviewed and stated that they were not informed that Resident #368's wound dressing was soiled and off by Certified Nursing Assistant #12. Registered Nurse #9 also stated that the nurse is supposed to assess a resident's wound when the resident is soiled or the dressing is off, as the wound should always be covered by gauze. Registered Nurse #9 further stated the dressing is not done using sterile technique, so it was not an issue if the gauze pads were touched by their hands when removing them from the wrappers. Registered Nurse #9 stated that after cleaning the wound with Dakin moistened gauze, their hands were still clean, so they did not change gloves or wash hands before applying the treatment. Registered Nurse #9 also stated that they ran out of gauze, so they used the remaining Dakin's gauze used to clean wound to apply over the treatment. Registered Nurse #9 further stated that they received in-service for dressing change from the nursing educator. On 04/03/2026 at 01:38 PM, the Staff Development Lead was interviewed and stated that they were involved in monitoring nurses performing wound treatment, and they complete competencies for new nurses which included competencies for wound care. The Staff Development Lead also stated that when performing wound care, the nurse should set up separate sections for wound dressing cleaning supplies and treatment supplies. The Staff Development Lead further stated that the nurse must remove gloves and perform hand hygiene before applying the treatment, gauze used to clean the wound should never be used for packing, and gauze pads should not be touched when supplies are being prepared. The Staff Development Lead stated that the Certified Nursing Assistant is supposed to inform the nurse when a dressing is soiled, then put 4x4 gauze on the wound in the interim. The Staff Development Lead also stated that clean techniques should be used throughout, and a competency was completed with Registered Nurse #9 when they were hired. On 04/06/2026 at 9:33 AM, the Infection Preventionist was interviewed and stated that the wound nurse and nurse educator are more involved with monitoring pressure ulcer for infection control to prevent cross contamination. The Infection Preventionist also stated that a wound should not be covered with wash cloths, and the Certified Nursing Assistant should know this, and the nurse should know how to handle wound care to prevent further infection. The Infection Preventionist further stated that Registered Nurse #9 should have prepared two separate areas of supplies for cleaning and wound care treatment and must wash hands and change gloves before applying a treatment after cleaning a wound. 10 New York Codes, Rules and Regulations 415.19(a) (1-3) (b)(4)

Number of residents sampled: 3Number of residents cited: 3 Based on record review and staff interview conducted during the survey, the facility failed to ensure that residents and/or their designated representatives were fully informed of their right to an expedited review of a service termination. This was evident for three (3) of three (3) sampled residents (Resident #635, Resident #637, and Resident #701) reviewed for Beneficiary Protection Notification out of 39 sampled residents. Specifically, there was no documented evidence that written notices were mailed to the designated representatives of Resident #635, Resident #637, and Resident #701 on the same day that telephone notification was made.The findings include:The facility policy titled Notification of Medicare A Non-Coverage effective 5/2009 and revised 02/2024 stated that if the provider is unable to personally deliver a notice of non-coverage to a person legally acting on behalf of a beneficiary then the facility will telephone the representative to advise them when the beneficiary's services will no longer be covered. The policy also stated the telephone contact is confirmed by written notice mailed on the same date or via email. and confirm by written notice mailed the same day or sent via email.1.Resident #635 was discharged from skilled services on 11/7/2025 with 26 days remaining and remained in the facility. A note placed on the Notice of Medicare Non-Coverage stated Resident #635's representative was notified of coverage ending on 11/07/2025 by telephone on 11/05/2025 at 2:00 PM.2. Resident #637 was discharged from skilled services on 03/02/2026 with 16 days remaining and remained in the facility. A note placed on the Notice of Medicare Non-Coverage stated Resident #637's representative was notified of coverage ending on 03/03/2026 by telephone on 02/27/2026 at 9:30 AM.3. Resident #701 was discharged from skilled services on 11/24/2025 with 54 days remaining went home. A note placed on the Notice of Medicare Non-Coverage stated Resident #701's representative was notified of coverage ending on 11/24/2025 by telephone on 11/20/2025 at 2:40 PM.There was no documented evidence that written notices were mailed to the designated representatives of Resident #635, Resident #637, and Resident #701 on the same day that telephone notification was made.On 04/06/2026 at 9:27 AM, the Assistant Director of Social Work was interviewed and stated that the forms are prepared by the Resident Assessment department and sent to Social Work. The Assistant Director of Social Work also stated if the resident is cognitively impaired, the family is contacted by phone, with date, time, and phone number documented on the form. The Assistant Director of Social Work further stated they were not aware that mail is required the same day as the phone call.On 04/06/2026 at 9:47 AM, the Director of Social Work stated that if the family is not on-site, the Notice of Medicare Non-Coverage and the Skilled Nursing Facility and Advanced Beneficiary Notice of Non-coverage forms may be sent via email or fax or are reviewed over the phone. The Director of Social Work also stated they document on the form when telephone notification was made and were not aware that documents were to be mailed out when telephone notification was made. The Director of Social Work further stated certified mail is sent if telephone contact could not be made. The Director of Social Work stated they could not obtain documentation that the notices had been sent to the resident's representatives via email. 10 New York Codes, Rules, and Regulations 415.3(g)(2)(i)

Based on record reviews, and interviews conducted during a survey, the facility failed to ensure that each resident receives treatment and care in accordance with professional standards of practice. This was evident in one (1) of three (3) residents sampled (Resident #1). Specifically, facility's investigation dated 02/17/2026 at 5:04 PM, documented Resident #1 vomited undigested foods and there was no documented evidence that Resident #1's vital signs were done, or the Registered Nurse Supervisor #1 or the medical doctor were notified that Resident #1 vomited after dinner.The findings are:The facility's policy titled Notification of Changes dated 12/2024, documented it is the policy of the facility to immediately inform the resident, consults with resident's physician, and if known, notify the resident's legal representative or an interested family member when there is an accident or incident involving the resident, upon significant change in status or condition, or regarding changes in resident's rights. The members of the interdisciplinary team should address any changes in resident condition/status as appropriate.The facility's policy titled Falls/ Occurrences dated 04/2024, documented all Occurrence will have supportive documentation in interdisciplinary notes describing the occurrence, the vital signs, full physical assessment and therapeutic interventions provided. The note will include notification to the physician, family, Social Work, OT/PT and Maintenance, as applicable.Resident #1 was admitted to the facility with diagnoses including subdural hematoma (a collection of blood in the brain), hydrocephalus (abnormal buildup of fluid in the brain with increased pressure on the skull), and dementia.The Minimum Data Set (a resident assessment tool) dated 12/17/2025, documented Resident #1 had severely impaired cognition.A review of activities of daily living care plan dated 12/13/2025, documented Resident #1 required total assistance of one person with eating and required maximal assistance (helper does more than half the effort) of two persons for bed mobility. The care plan was updated on 02/02/2026, Resident #1 required maximal assistance of one person in bed mobility. On 02/09/2026 that Resident #1 required maximal assistance of one person with eating.A nursing notes dated 02/17/2026 at 9:06 PM by Licensed Practical Nurse #1 documented during dinner time at approximately 4:35 PM, Resident #1 ate dinner in their room assisted by Certified Nursing Assistant #2. During which Resident #1 vomited a small amount of undigested food. Resident #1 remained alert with no distress. At approximately 5:45 PM, Licensed Practical Nurse #1 was called to Resident #1's room and was told Resident #1 accidentally hit their left forehead on the closet when daily care was provided and their clothes were changed. Licensed Practical Nurse #1 attended Resident #1 and observed a laceration to left forehead with no active bleeding. Resident #1 was nonverbal, responsive to touch and their eyes were open. Licensed Practical Nurse #1 notified Registered Nurse Supervisor #1. Registered Nurse Supervisor #1 documented on 02/17/2026 at 5:45 PM, they were called to the unit by Licensed Practical Nurse #1. Resident #1 was observed in bed with a laceration on the left side of their forehead. No active bleeding was noted. Both eyes were open. Resident #1 was alert to tactile stimuli and remained nonverbal. Registered Nurse Supervisor #1 conducted a neurological assessment and noted Resident #1 had changes in communication and mental status. The vital signs were assessed, and the blood pressure was 58/36, heart rate was 59 beats per minute, respiration rate 14 and temperature 98 degrees. Registered Nurse Supervisor #1 immediately called 911 and activated an overhead page for a medical emergency. Resident #1 became unresponsive and pulseless. Cardiopulmonary resuscitation was initiated until the emergency services 911 arrived (at 5:57 PM) and assumed responsibility. Resident #1 pulse was achieved, and Resident #1 was transported by ambulance at 6:07 PM to the emergency room.A review of investigative statement of Licensed Practical Nurse #1 dated 02/17/2026 documented at approximately 5:07 PM, Licensed Practical Nurse #1 was informed by staff that Resident #1 vomited. Licensed Practical Nurse #1 responded and observed Resident #1 sitting upright in their bed. Licensed Practical Nurse #1 saw a small amount of vomitus on Resident #1's clothing and moderate amount of vomitus on Resident #1's bed linen. Resident #1 was alert and not in distress. Vital signs were collected.A review of Resident #1's medical record revealed there was no documented evidence that vital signs were taken and recorded, and the nursing supervisor or the medical doctor were notified that Resident vomited after dinner.During an interview on 02/26/2026 at 11:50 AM, Certified Nursing Assistant #1 stated on 02/17/2026, Licensed Practical Nurse #1 told them that Resident #1 vomited and need to be clean up. Certified Nursing Assistant #1 stated when they entered Resident 1's room they observed Resident #1 was seated upright, alert, and responsive. Certified Nursing Assistant #1 stated they observed vomitus on Resident #1's clothing and bed linens. Certified Nursing Assistant #1 stated when they turned Resident #1 to the right side towards the closet, they heard a sound, and they turned Resident #1 on to their back and noticed a small laceration to Resident #1's forehead. Care was stopped and Licensed Practical Nurse #1 was informed. Certified Nursing Assistant #1 stated they did not apply unusual force when Resident #1 was turned to their right side. Certified Nursing Assistant #1 stated they used draw sheet underneath when Resident #1 was turned to change the bed linens. Resident #1' s bed was close to the closet.During an interview on 02/26/2026 at 5:50 PM, Certified Nursing Assistant #2 stated they worked on 02/17/2026 in the evening shift (3:00 PM-11:00 PM). Certified Nursing Assistant #2 stated they were assigned to feed Resident #1. Resident 1 ate everything without a problem, was fine and kept talking. Certified Nursing Assistant #2 stated they left Resident #1 seated upright. Certified Nursing Assistant #2 stated when they were picking up trays at approximately 5:04 PM they observed Resident #1 vomited undigested food. Licensed Practical Nurse #1 was called and told they were told to keep the head of Resident's bed elevated.During an interview on 02/26/2026 at 12:16 PM, Licensed Practical Nurse #1 stated on 02/17/2026 at approximately 4:35 PM Resident #1 ate dinner and at approximately 5:07 PM, staff notified them that Resident #1 vomited undigested foods. Licensed Practical Nurse #1 stated they went to the room and observed Resident #1 seated upright, not in distress and they were talking. Licensed Practical Nurse #1 stated the vital signs were stable but not documented. Licensed Practical Nurse #1 stated they knew that if there was any change in condition, they must notify the nursing supervisor and the medical doctor. Licensed Practical Nurse #1 stated they did not notify Registered Nurse Supervisor #1 right away because when they checked Resident #1, they were not in distress and not in an emergency at that time. Licensed Practical Nurse #1 stated at approximately 5:45 PM, Certified Nursing Assistant #3 told them that Resident #1's head hit the closet in their room. Licensed Practical Nurse #1 stated they checked Resident #1 and observed Resident #1 lying in bed with a small laceration to forehead and called the Registered Nurse Supervisor #1 to assess Resident #1.During an interview on 02/26/2026 at 12:31 PM, Registered Nurse Supervisor #1 stated Licensed Practical Nurse #1 informed them Resident #1 hit their head on the closet on 02/17/2026 at 5:45 PM. Registered Nurse Supervisor #1 stated Resident #1 was assessed and had a laceration and hematoma to forehead. Neurological assessments were done there were changes in communication and mental status. Registered Nurse Supervisor #1 stated they took vital signs. Resident #1 suddenly had no pulse and was unresponsive, cardiopulmonary resuscitation was initiated and 911 called. Emergency Medical Services arrived at 5:57 PM and took over. Resident #1's pulse was regained, and Resident #1 was transferred to the emergency room at 6:07 PM.A follow up interview on 03/04/2026 at 12:46 PM, Registered Nurse Supervisor #1 stated they did not receive report from Licensed Practical Nurse #1 that Resident #1 vomited after dinner on 02/17/2026 prior to the incident. Registered Nurse Supervisor #1 stated that when residents' condition changes the protocol is to notify the supervisor, and they will come to the unit to assess the resident. Registered Nurse Supervisor #1 stated once they assessed resident, then they will notify the medical doctor. Registered Nurse Supervisor #1 stated Licensed Practical Nurse #1 should have notified them when Resident #1 vomited. Registered Nurse Supervisor #1 stated they found out from Certified Nursing Assistant #1 when they entered the room that Resident #1 vomited after dinner.During an interview on 02/27/2026 at 12:52 PM, Director of Nursing stated on 02/17/2026 at approximately 6:03 PM, they were notified by the assistant director of nursing that Resident #1 sustained laceration and hematoma to their left forehead when Resident #1 was turned to their right side in bed. The Director of Nursing stated Resident #1 vomited a small amount of undigested foods and was checked by Licensed Practical Nurse #1. Director of Nursing stated Resident #1 was not in acute distress. The Director of Nursing stated they investigated the incident together with assistant director of nursing and they conducted two (2) separate days of reenactments of events and interviewed Certified Nursing Assistant #1 three (3) times, and they were consistent with the sequence of events. Director of Nursing stated during the reenactments Certified Nursing Assistant #1 demonstrated correct standard practice in turning and positioning Resident #1 while in bed during bed linen changes. Director of Nursing stated they did not identify the closet or dressers as potential hazards for residents with similar conditions. Director of Nursing stated the facility concluded the occurrence was accidental and not purposeful or deliberate.A subsequent interview on 03/04/2026 at 9:23 AM, Director of Nursing stated they interviewed Licensed Practical Nurse #1 and stated Resident #1 was stable after they vomited and vital signs were taken but not documented. Director of Nursing stated when Resident #1 had vomited, the Licensed Practical Nurse #1 should have documented the vital signs in their nursing notes and notified the registered nurse supervisor. The nursing supervisor will then assess Resident #1 and notify the medical doctor.During an interview on 03/02/2026 at 10:40 AM, Medical Director stated they reviewed the documentation and interviewed staff and that Resident #1 was not in distress after they vomited, there was no indication of aspiration or trouble breathing. The Medical Director stated if Resident #1 aspirated there would be signs and symptoms, and it would not be a sudden change in mental status. The Medical Director stated they do not think the injury was the reason, given Resident #1 with multiple vascular risk factors leading to cardiac events, the incident was not intentional. The Medical Director stated that this was likely cardiac related because the changes with Resident #1 occurred suddenly. 10 New York Codes, Rules, and Regulations: 415.12

Based on staff observation, interviews and record review conducted during an abbreviated survey (NY00333408), the facility did not ensure that pain management was provided to a resident who required such services consistent with professional standards of practice. This was evident in one out three residents (Residents #1) sampled. Specifically, Resident #1 reported to Certified Nursing Assistant #1 on 02/09/2024 at 10:10 AM that they were unable to stand and that they had pain. Resident #1 was transferred, by Licensed Practical Nurse #1 and Certified Nursing Assistant #1, before being assessed by Registered Nurse Supervisor #1 and before pain medication was administered. Resident #1 was transferred to the hospital on 02/09/2024 and was diagnosed with an acute Pelvic fracture. There was no documented evidence of pain assessment or that pain medication was administered on 02/09/2024 prior to Resident #1 being transferred to the hospital. The findings include: The facility Policy and Procedure title Pain Assessment, Education and management dated on 05/2024, documented it is the policy of the facility to assess and manage resident's pain upon admission/readmission and continually throughout their stay to assure the highest level of pain control and resident comfort. Pain assessment should be performed by a Registered Nurse using the Pain Assessment Tool. Resident #1 was admitted to the facility with diagnoses of Dementia, Anxiety and Anemia. The Minimum Data Set (MDS, an assessment tool) dated 12/08/2023 documented Resident #1 had Severe Impaired Cognition. Resident #1 was independent in bed mobility and transfer. A Physician's Order dated 02/09/2024 at 12:23 PM, revealed an order for Tylenol 325 milligram, give 2 tablets (650) milligram every 8 hours and as needed for pain. Review of the Medication Administration Record dated 02/09/2024 revealed no documented evidence Resident #1 received Tylenol for pain. There was no documented evidence of pain assessment. The facility's Summary of Investigation dated 02/12/2024, revealed Certified Nursing Assistant #1 provided care to Resident #1 on 02/09/2024 at approximately 10:30 AM. Resident #1 was unable to stand when Certified Nursing Assistant #1 was assisting them to stand up. Certified Nursing Assistant #1 immediately notified Licensed Practical Nurse #1, who responded and notified Registered Nursing Supervisor #1. Registered Nursing Supervisor #1 went to Resident #1's room and Resident #1 was observe sitting on a chair. On assessment Resident #1 was unable to bear weight on their left lower extremity. Resident #1 complained of pain in their left hip and groin area. Resident #1 left lower extremity was kept immobilized. Resident #1 was transferred (back) to bed and a completed body assessment was done. Resident #1 had a slight swelling to their left hip area. Resident #1 was transferred to the hospital for further evaluation. A Hospital Record dated 02/10/2024 revealed a Computed Tomography Scan was done in the hospital and showed an acute Pelvic fracture. The facility's investigation concluded there was no evidence to support abuse, neglect, or mistreatment. The investigation also concluded Resident #1 is independent and moves about frequently, therefore, Resident #1 could have fractured their pelvis during an unassisted transfer. Resident #1 has a history of osteopenia and prior falls with status post left femur fracture. A Nursing Progress note, by Registered Nursing Supervisor #1, dated 02/09/2024 at 12:25 PM documented they were notified, by Licensed Practical Nurse #1, Resident #1 had difficulty standing. Assessment revealed Resident #1 had difficulty bearing weight and expressed pain to their left hip and groin area. Resident #1 denied falling. Resident #1 was lifted manually from standard chair and was put back in bed. The Medical Doctor was notified and ordered Tylenol 650 milligram by mouth every hour as needed and a STAT x-ray to bilateral hip and pelvis. A Transfer Note dated 02/09/2024 at 2:24 PM, by Registered Nurse #1, documented Resident #1 was being transferred to the hospital to ruled out fracture to bilateral hip. Resident #1 was unable to bear weight. Family notified. A hospital Inpatient Discharge Summary dated 02/15/2024 documented Resident #1 was admitted on [DATE]. A Computed Tomography Scan was done on 02/09/2024 of the abdomen and pelvis. The result showed the bones were osteopenic (a lower-than normal bone mass or bone mineral density). Acute fractures of the left superior and inferior pubic ramus (a pair of bone at the front of the pelvis that make up part of the hip). Acute, minimally displaced position of the right superior pubic ramus. Also documented - the bones appeared to be demineralized, limiting evaluation. There was a chronic posttraumatic deformity of the proximal left femur. A long intramedullary nail (a metal rod forced into the medullary cavity of a bone) with distal interlocking screw in place in the left femur. No acute displace fracture or dislocation in the hips. There were degenerative changes of the hips. During an interview on 12/03/2024 at 12:00 PM, Certified Nursing Assistant #1 stated at approximately 10:35 AM on 02/09/2024 they asked Resident #1 to stand and while Resident #1 was attempting to stand up, Resident #1 reported that they are feeling pain and pointed towards their left knee. Resident #1 also reported they were unable to put weight on their left leg. Certified Nursing Assistant #1 stated they assisted Resident #1 to sit on the bed and immediately called Licensed Practical Nurse #1. Certified Nursing Assistant #1 stated Licensed Practical Nurse #1 came to Resident #1's room and spoke with Resident #1 in Spanish. Certified Nursing Assistant #1 stated Licensed Practical Nurse #1 instructed them to assist them (Licensed Practical Nurse #1) in transferring Resident #1 from the bed to the chair. Certified Nursing Assistant #1 stated Licensed Practical Nurse #1 notified Registered Nurse Supervisor #1 after Resident #1 was transferred to the chair. During an interview on 12/02/2024 at 12:30 PM, Licensed Practical Nurse #1 stated on 02/09/2024 at approximately 10:30 AM Resident #1's assigned Certified Nursing Assistant #1 called them to Resident #1's room stating Resident #1 was not themself and that Resident #1 complained of pain to their left leg and was unable to stand. Licensed Practical Nurse #1 stated when they arrived in Resident #1's room, Resident #1 was sitting on the edge of their bed and bed linen was wet. Licensed Practical Nurse #1 stated they assisted Certified Nursing Assistant #1 to transfer Resident #1 to sit on the chair in their room. Licensed Practical Nurse #1 stated that Resident #1 was rubbing their left hip and thigh area and complained of pain. Licensed Practical Nurse #1 stated they checked Resident #1's feet but did not see anything. Licensed Practical Nurse #1 stated they did not check Resident #1's hip because Resident #1 was wearing pants. Licensed Practical Nurse #1 stated they immediately notified Registered Nurse Supervisor #1. Licensed Practical Nurse #1 stated they transferred Resident #1 from the bed to the chair before calling Registered Nurse Supervisor #1. Licensed Practical Nurse #1 stated the Medical Doctor was notified Tylenol 325 milligram two tablets to give STAT and then 325 milligram three times a day. Licensed Practical Nurse #1 stated they gave Resident #1 the pain medication but did not sign for the medication at the time of administration. During an interview on 12/02/2024 at 1:12 PM, Registered Nurse Supervisor #1 stated on 02/09/2024 at approximately 10:35 AM, Licensed Practical Nurse #1 notified them that Resident #1 was unable to bear weight on their left leg. Registered Nurse Supervisor #1 stated they went to Resident #1's room and observed Resident #1 sitting on a chair pointing to their hip. Registered Nurse Supervisor #1 stated they put Resident #1 back in bed and immediately assessed Resident #1 whose left hip was swollen. Registered Nurse Supervisor #1 stated there were no discoloration or bruising on Resident #1's hip. Resident #1 stated they did not fall and did not bump on any objects. Registered Nurse Supervisor #1 stated the Medical Doctor was informed and ordered an x-ray of the hip. Registered Nurse Supervisor #1 stated Resident #1 refused to have the x-ray done in the facility and was transferred to the hospital for further evaluation. Registered Nurse Supervisor #1 stated Licensed Practical Nurse #1 told them they administered pain medication to Resident #1. During an interview on 12/02/2024 at 1:35 PM, the Risk Manager stated that on 02/12/2024 the facility received a Patient Review Instrument from the hospital with primary diagnosis of Pelvic Fracture. The Risk Manager stated the fracture was investigated and abuse was rule out based on Resident #1 prior history of multiple falls at home with prior fracture which put Resident #1 at risk for further fractures. The Risk Manager stated they became aware of Resident #1 history of fractures after receiving Resident #1's Patient Review Instrument from the hospital. The Risk manager stated during the investigation, they became of aware that Licensed Practical Nurse #1 and Certified Nursing Assistant #1 transferred Resident #1 from the bed to the chair before Registered Nurse Supervisor #1 assessed the resident. During an interview on 12/27/2024 at 1:30 PM, the Director of Nursing stated they were notified that Resident #1 was transferred to the hospital for further evaluation. The Director of Nursing stated they became aware of Resident #1's fracture after receiving and reviewing the Patient Review Instrument from the hospital. The Director of Nursing stated Licensed Practical Nurse #1 explained that Resident #1's bed linen was soiled and that was why they moved Resident #1 from the bed to the chair. The Director of Nursing stated Resident #1's pain was new, and that the resident should have been assessed and the medical doctor notified before Resident #1 was moved. The Director of Nursing stated they in-serviced the nursing staff on preventing and managing accidents and suspected incident. 10NYCRR 415.12

Based on interviews and record review conducted during the Recertification/Complaint survey (NY00349608) from 12/02/2024 to 12/09/2024, the facility did not ensure all alleged violations involving resident to resident physical abuse were reported immediately, but not later than 2 hours after the allegations were made, to the State Survey Agency. This was evident for 2 (Resident # 193 and # 325) of 5 residents reviewed for Abuse out of sample size 38 residents. Specifically, the facility did not report Resident # 325 hit Resident # 193 on the right shoulder with a grabber to the New York State Department of Health within 2 hours after the allegation was made The findings are: The facility policy titled Abuse - Prohibition Protocol, Types of Abuse, Response/Reporting with effective date 10/97 and last revision date 5/23, documented in the section Response/Reporting under abuse that the persons observing an incident of resident abuse or suspecting resident abuse must attempt to stop the abuse and must immediately report such incident to their immediate supervisor or administrative staff. The policy also documented that long term care facilities must report abuse, neglect, and misappropriation within 24 hours after reasonable cause threshold in concluded. 1) Resident #193 was admitted to the facility with diagnoses which included End stage renal disease, Cerebral infarction, and Polyneuropathy. The Quarterly Minimum Data Set 3.0 assessment dated [DATE] documented Resident #193 was cognitively impaired in cognition and had no behavioral symptoms towards others. 2) Resident #325was admitted to the facility with diagnoses which included Other Alzheimer's disease, Unspecified dementia without behavioral disturbance, and Major depressive disorder. The Quarterly Minimum Data Set 3.0 assessment dated [DATE] documented Resident #325 was severely impaired in cognition and had no behavior symptoms towards others. The facility investigation report documented the occurrence happened at approximately 1:40 PM on 07/28/2024. It also documented Resident # 193 and Resident #325 shared a room. The report documented Certified Nursing Assistant # 7 heard loud noises from Resident #193 and Resident #325's room while they were walking in the hallway. It also documented Certified Nursing Assistant #7 went to the room, observed Resident #325 holding a cup and standing by the sink next to Resident #193's bed and Resident # 193 was trying to take the cup from Resident # 325. It further documented Certified Nursing Assistant # 7 called for help, took the cup away from Resident #325, and proceeded to escort Resident #325 out of the room. It documented Resident #325 got the grabber from Resident #193's bed, flailed it, and hit Resident #193's right shoulder. The New York State Department of Health Aspen Complaint Tracking System intake documented the incident happened on Sunday 07/28/2024 at 13:40. The intake also documented the Administrator was first made aware of the incident on Sunday 07/28/2024 at 13:55. The auto reply email from New York State Department of Health to Assistant Director of Nursing # 1 documented the facility submitted the report to Department of Health on 07/29/2024 at 12:31. On 12/02/2024 at 09:51 AM, Resident # 193 was interviewed and stated they recalled they were taped by something on the right shoulder by Resident #325 on the day the incident happened. Resident #193 also stated they were not injured. On 12/03/2024 at 12:23 PM, Certified Nursing Assistant # 7 was interviewed and stated they witnessed the incident that Resident #325 took the grabber from Resident #193's bed and hit Resident # 193's right shoulder when they tried to escort Resident #325 out of the room. Certified Nursing Assistant # 7 also stated they reported what they observed to Registered Nurse #4 upon their arrival to the unit. On 12/03/2024 at 12:08 PM, Registered Nurse # 4 was interviewed and stated they reported the incident that happened on the unit immediately to Assistant Director of Nursing and Director of Nursing. Registered Nurse # 4 also stated they had cell phone numbers of Assistant Director of Nursing and Director of Nursing and was able to call them at anytime to report. Registered Nurse # 4 further stated they called Assistant Director of Nursing # 1 immediately to report the resident-to-resident alteration between Resident # 193 and Resident # 325 after they knew what happened from Certified Nursing Assistant # 7. On 12/04/2024 at 11:24 AM, Assistant Director of Nursing #1 was interviewed and stated the Assistant Director of Nursing, Performance Improvement Director, Director of Nursing, and Administrator had access to Health Commerce System to report allegations to Department of Health. Assistant Director of Nursing #1 stated Registered Nurse # 4 reported the resident-to-resident alteration between Resident # 193 and Resident # 325 to them on the day the incident happened. Assistant Director of Nursing #1 also stated they had to report the allegation to Department of Health as it was considered as allegation of abuse. Assistant Director of Nursing #1 further stated they knew they had to report allegation of abuse to Department of Health within 2 hours after making aware of the allegation. Assistant Director of Nursing #1 stated they reported the allegation to Director of Nursing. Assistant Director of Nursing #1 also stated they did not obtain the instruction from Director of Nursing to report the incident to Department of Health until next day on 07/29/2024. On 12/04/2024 at 11:53 AM, the Director of Nursing was interviewed and stated Assistant Director of Nursing # 1 called them and reported the allegation on 7/28/2024. The Director of Nursing also stated the incident was considered as allegation of abuse and they had to report it to Department of Health within 2 hours after they were made aware of it. The Director of Nursing stated they discussed with the Administrator about the allegation and decided it was a reportable incident. The Director of Nursing also stated the staff who had access to Health Commerce System can submit the report to Department of Health at anytime and anywhere as long as they had access to a computer. The Director of Nursing stated they did not recall when they instructed Assistant Director of Nursing # 1 to submit the report to Department of Health. On 12/04/2024 at 12:09 PM, the Administrator was interviewed and stated the Director of Nursing called and discussed with them if the incident that happened on 07/28/2024 was reportable to Department of Health. The Administrator also stated the facility had to report all allegations of abuse to the Department of Health within 2 hours after they were making aware of it. The Administrator further stated they did not recall the details of the incident and why it was not reported to Department of Health until next day on 07//29/2024. 10 NYCRR 415.4(b)(2)

Based on Record reviews and interviews during the Recertification survey from 12/02/2024 to 12/09/2024, the facility did not ensure that all completed resident assessments were submitted and transmitted into the Quality Improvement Evaluation Assessment Submission and Processing in a timely manner. Specifically, 9 (Resident #10, Resident #76, Resident #83, Resident #326, Resident #345, Resident #355, Resident #420, Resident #493, and Resident #572) of 9 Minimum Data Set submissions reviewed for Resident Assessments were not submitted to Centers for Medicaid and Medicare Services system within 14 days of completion. The findings are: The facility's policy and procedure titled Minimum Data Set 3.0 Submission revised 1/2024 documented it is the policy of [NAME] Harbor Multicare Center to ensure timely submission of all Minimum Data Sets to Centers for Medicare and Medicaid Services via Internet Quality Improvement and Evaluation System. Resident #10's quarterly Minimum Data Set 3.0 with assessment reference date of 10/23/2024 and completion date of 10/29/2024. The assessment was not submitted as of 12/06/2024. Resident #76's quarterly Minimum Data Set 3.0 with assessment reference date of 10/24/2024 and completion date of 10/30/2024. The assessment was not submitted as of 12/06/2024. Resident #83's quarterly Minimum Data Set 3.0 with assessment reference date of 10/23/2024 and completion date of 10/29/2024. The assessment was not submitted as of 12/06/2024. Resident #326's quarterly Minimum Data Set 3.0 with assessment reference date of 10/24/2024 and completion date of 10/30/2024. The assessment was not submitted as of 12/06/2024. Resident #345's quarterly Minimum Data Set 3.0 with assessment reference date of 10/18/2024 and completion date of 11/1/2024. The assessment was not submitted as of 12/06/2024. Resident #355's quarterly Minimum Data Set 3.0 with assessment reference date of 10/19/2024 and completion date of 10/25/2024. The assessment was not submitted as of 12/06/2024. Resident #420's quarterly Minimum Data Set 3.0 with assessment reference date of 10/12/2024 and completion date of 10/25/2024. The assessment was not submitted as of 12/06/2024. Resident #493's quarterly Minimum Data Set 3.0 with assessment reference date of 10/11/2024 and completion date of 10/24/2024. The assessment was not submitted as of 12/06/2024. Resident #572's quarterly Minimum Data Set 3.0 with assessment reference date of 10/23/24 and completion date of 10/29/24. The assessment was not submitted as of 12/06/2024. On 12/09/2024 at 12:30 PM, the Assistant Director of Nursing #3 who is also responsible for Resident Assessments was interviewed and stated, the batch that was scheduled for a 11/06/2024 submission was accidentally missed. They were not aware that the assessments were not submitted until it was pointed out by the surveyor. The Assistant Director of Nursing #3 also stated they just checked the validation report which showed the batch was cued on 11/06/2024 and wasn't submitted. The Assistant Director of Nursing #3 stated Information Technology Support submits the batch once it is cued. The Assistant Director of Nursing #3 further stated the assessments were submitted today. On 12/09/24 at 12:44 PM, the Information Technology Support person was interviewed and stated, they had two files to submit and accidentally one single file was submitted twice. They received two reports and one report indicated duplicate submission and they did not spot the error at that time. The Information Technology Support person further stated they didn't realize this until today that the assessments weren't submitted. On 12/09/24 at 1:03 PM, the Administrator was interviewed and stated, this is the first time this has been an issue. The Information Technology Support person sent the same batch twice. The Administrator further stated it was an honest mistake that happened. 10 NYCRR 415.11

Based on observations, interviews, and record review during the Abbreviated Survey (NY 00351995), the facility failed to protect residents' rights to be free from physical abuse by nursing home staff. This was evident in one out of six residents (Resident #1) reviewed for abuse. Specifically, on 08/20/2024 at approximately 4:45 PM, Certified Nursing Assistant #2 reported to Registered Nurse Supervisor #1 that at 6:53 AM, Certified Nursing Assistant #2 assisted Certified Nursing Assistant #1, in the care of Resident #1. During care, Resident #1 held on tightly to Certified Nursing Assistant #1's hand, sinking their fingers into Certified Nursing Assistant #1's arm. Certified Nursing Assistant #1 raised their hand and with a deliberate, forceful slap to Resident #1's face between their forehead and eyes. The findings are: The Facility's Policy and Procedure titled Combative Resident with revision date 08/2023, documented it is the policy of the facility to maintain the safety of residents and staff during resident combative behavior/outburst. Any physical or verbal behavior/outburst from residents is to be reported to the Registered Nurse Manager or Nursing Supervisor immediately. The Facility's Policy and Procedure titled Abuse Reporting with revision date 12/2023, documented the residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. All personnel must promptly report any incident or suspected incident of resident abuse, including injury of unknown source. An Occurrence Note dated 08/20/2024 at 05:12 PM, written by the Assistant Director of Nursing, documented that Certified Nursing Assistant #2 reported on 08/20/2024 at approximately 4:45 PM, they witnessed during care, Resident #1 held on tightly to Certified Nursing Assistant #1's hand, sinking their fingers into Certified Nursing Assistant #1's arm. Certified Nursing Assistant #1 raised their hand and with a deliberate, forceful slap to Resident #1's face between their forehead and eyes. Resident #1 responded by letting go immediately of the Certified Nursing Assistant #1's hand. Resident #1 did not scream or try to fight back. Resident #1 was assessed with no apparent injury. Facility Summary of Investigation dated 08/20/2024, documented Law Enforcement was called, but no arrest was made. Certified Nurse Assistant #1 neither admitted nor denied slapping Resident #1. Certified Nursing Assistant #1 was suspended and terminated. The facility concluded that abuse may have occurred during the time Certified Nursing Assistant #1 cared for Resident #1. Resident #1 was admitted to the facility with diagnoses including Dementia, Alcohol Abuse, and Delirium. A Minimum Data Set (a resident assessment tool) dated 05/31/2024, identified that Resident #1 had a Brief Interview of Mental Status and scored 0/15 indicating Resident #1 was cognitively impaired. Resident #1 required supervision or touching assistance with bed mobility, transfer, and toileting. A Care Plan Titled Resident Abuser/Victim initiated on 02/22/2024, documented interventions to separate the victim from the abuser and affirm appropriate behavior. A Care Plan Titled Alteration in Behavior effective date 02/22/2024, documented interventions to maintain a calm environment, and use behavior modification techniques. The care plan notes from 05/09/2024 to 08/20/2024, documented Resident #1 was physically aggressive and resisted care at times. Nursing progress notes from 05/01/2024 to 08/20/2024, documented that Resident #1 was observed to be physically aggressive toward staff, resisting care, hitting staff, and yelling at staff at times. A New York Police Department Omni form System-Complaint dated 08/20/2024, documented the classification of the occurrence as Harassment and no arrest. During an interview on 08/27/2024 at 12:17 PM, Assigned Certified Nursing Assistant #1 stated that they provided care to Resident #1 on 08/20/2024 at around 6:30 AM. Certified Nursing Assistant #1 stated that they knew that Resident# 1 might be combative when trying to change them. Certified Nursing Assistant #1 stated that the nurse on the unit told them to get help when they were going to provide care to Resident #1. Certified Nursing Assistant #1 stated they asked Certified Nursing Assistant #2 to assist them. Certified Nursing Assistant #1 stated that when they attempted to change Resident #1, Resident#1 put their fingernails on Certified Nursing Assistant #1's arm in the wrist area. Certified Nursing Assistant #1 stated it was hurting, and Certified Nursing Assistant #1 released Resident #1's hand. Certified Nursing Assistant #1 stated they did not hurt Resident #1. Certified Nursing Assistant #1 also stated that they did not slap Resident #1 in the face. They moved Resident #1's hand and continued to provide care. Certified Nursing Assistant #1 stated that they should have notified the nurse that Resident #1 was combative. During an interview on 08/27/2024 at 12:53 PM, Certified Nursing Assistant #2 stated that on 08/20/2024 around 6:50 AM, Certified Nursing Assistant #1 asked them to assist with Resident #1 care. Certified Nursing Assistant #2 stated that when they went to the room, they observed Resident #1 hitting Certified Nursing Assistant #1 over the upper body with both hands while they were changing Resident #1. Certified Nursing Assistant #2 stated Certified Nursing Assistant #1 stopped providing care and asked them to help turn Resident #1. Certified Nursing Assistant #2 stated they helped to turn Resident #1, but the resident was still fighting and moving their hands toward Certified Nursing Assistant #1. Certified Nursing Assistant #2 stated that they should stop providing care and call the nurse if the resident resisted or was fighting, but in Resident #1's case, they did not want to leave them unchanged. Certified Nursing Assistant #2 stated that when Certified Nursing Assistant #1 was washing Resident #1's back, Resident #1 held Certified Nursing Assistant #1 's hand around the wrist area and sank their fingernails in their skin. Certified Nursing Assistant #2 stated that Certified Nursing Assistant #1 gave Resident #1 a forceful slap in the face between the eye and forehead. During an interview on 08/27/2024 at 11:44 PM, Licensed Practical Nurse #1 stated they worked on 08/20/2024 11 pm-7 am shift, and no staff reported any abuse. Licensed Practical Nurse #1 also stated that no staff had reported to them that Resident #1 was resistant to care and combative. During an interview on 08/27/2024 at 3:50 PM, Registered Nurse Manager #1 stated they were responsible for updating the care plan and Resident Nursing Instructions. Registered Nurse Manager #1 stated that Resident #1 was resistant and combative at times, when the resident moves/transfers. Registered Nurse Manager #1 stated that staff was instructed that when Resident #1 became resistant, they should stand back, report to the nurse or supervisor, and get help from another staff member. Registered Nurse Manager #1 stated that it should be documented in Resident Nursing Instructions to notify the nurse and get a second person if the resident became combative, and it was omitted. Registered Nurse Manager #1 also stated staff cannot retaliate if the resident hits or hurts the staff. During an interview on 08/28/24 at 2:56 PM, the Risk Manager #1 stated that Resident Nursing Instructions should include instructions to the Certified Nursing Assistants on what they should do if Resident #1 resists care or is combative/ aggressive. During an interview on 08/29/2024 at 12:25 PM, Assistant Director of Nursing #1 stated they were informed about the alleged abuse on 08/2024 at 4:45 PM and investigated the incident. Assistant Director of Nursing #1 stated Certified Nursing Assistant #2 reported witnessing Certified Nursing Assistant #1 slapped Resident #1 in the face at 6:53 AM. Assistant Director of Nursing #1 stated they interviewed Certified Nursing Assistant #1 over the phone, and they did not acknowledge or deny if they slapped Resident #1. Assistant Director of Nursing #1 stated according to Certified Nursing Assistant #1, Resident #1 was combative and hit them. Assistant Director of Nursing #1 stated Certified Nursing Assistant #1 was supposed to stop providing care and report to the nurse immediately. Assistant Director of Nursing #1 stated that calling the nurse or having a second person assist was not documented in Resident#1's instructions prior to the incident. Assistant Director of Nursing #1 stated that Certified Nursing Assistant #1 was terminated for abuse based on an incident witnessed by Certified Nursing Assistant #2. During an interview on 08/29/2024 at 2:29 PM, the Administrator stated that they were notified immediately and were physically present. The Administrator stated they met with the Director of Nursing and Risk Manager to discuss the incident and concluded that abuse may have occurred. The Administrator stated that law enforcement came to the facility, no arrest was made, and Certified Nursing Assistant #1 was terminated. 10 NYC RR 415.4(b)(1)(i)

Based on record review and interviews conducted during the abbreviated survey (NY00341680) on 08/27/2024-08/29/2024, the facility failed to ensure the resident was free of significant medication errors. This was evident for one out of five sampled residents (Resident #2). Specifically, on 05/08/2024 at approximately 10:50 PM, Registered Nurse # 1 administered 24 units of insulin Lantus (long-acting insulin) to Resident #2, who was not on insulin therapy. The Medical Doctor was made aware and immediately ordered dextrose 5 % and 0.45 % sodium chloride intravenous solution to be infused at 70 ml/hour for 24 hours. Fingerstick Blood Sugar and vital signs (blood pressure, pulse, and temperature), monitor every four hours for 24 hours. The findings are: The facility Policy and Procedure titled, Administration of Insulin Injection and Preparation with revision date 01/2018, documented it is the facility policy to administer insulin preparations safely and appropriately. The nurse responsibility included. Review medication order, identify resident, explain procedures, and follow the rights for medication administration. Resident #2 was admitted to the facility with a diagnosis of Type 2 Diabetes Mellitus, Peripheral Vascular Disease, and chronic kidney disease. The Minimum Data Set (an assessment tool) dated 04/13/2024, documented that Resident #2 had intact cognition. A Physician Order Activity Detail Report dated 05/01/2024 to 05/08/2024, revealed there were no Physician Order for insulin Lantus. A Care Plan Alteration in Blood Glucose Level effective date 05/03/2023, documented interventions, including monitoring blood glucose levels as ordered and notifying the Medical Doctor of changes. The Facility's Fall/Occurrence Report dated 05/08/2024, documented at 10:50 PM, License Practical Nurse #1 reported to Registered Nurse Supervisor #1 that Resident #2 was given insulin in error. A complete assessment was done. Emotional support was provided. The Medical Doctor and family were notified. Intravenous fluid was administered as ordered by the Medical Doctor. A Medication Error Incident Report dated 05/08/2024, documented that Licensed Practical Nurse #1 asked Registered Nurse # 1 to administer Lantus to Resident #3. Registered Nurse #1 failed to identify the resident prior to administering the medication and inadvertently administered 24 units of Lantus to Resident #2, who has a diagnosis of Diabetes, but is not on insulin therapy. Resident #2 remained asymptomatic. Registered Nurse #1's employment was terminated. A Situation Background Assessment Recommendation Note dated 05/09/2024 at 02:55 AM, written by Registered Nurse #1 documented that on 05/08/2024 at approximately 10:50 PM, they incidentally administered Insulin to Resident #2. Registered Nurse #1 immediately told Licensed Practical Nurse #1, who called Registered Nurse Supervisor #1. Resident #2 was alert and responsive. Resident #2 was not in any acute distress with Blood Sugar 136 milligram/deciliter, Blood Pressure 165/81, Pulse 94, Respiration 19, Temperature 98.0, Oxygen saturation 95% Room Air. The Medical Doctor was made aware immediately and ordered dextrose 5 % and 0.45 % sodium chloride intravenous solution infuse by intravenous route 70 ml per hour for 24 hours. Monitor Fingerstick Blood Sugar and vital signs every 4 hours for 24 hours. The orders were implemented. The vital signs were re-checked at 11:25 PM and were within normal limits. The Blood Sugar was 136 milligram/deciliter. A Situation Background Assessment Recommendation Note dated 05/09/2024 at 01:49 AM, written by Registered Nurse Supervisor #1 documented that Registered Nurse #1 incidentally administered insulin Lantus 24 units to Resident #2 at 10:50 PM. Resident #2 stated in an interview that the nurse gave them insulin injection, and they know they don't get any insulin. A Physician Order Activity Detail Report dated 05/09/2024, documented the orders for dextrose 5 % and 0.45 % sodium chloride intravenous solution, infuse 70 milliliters by intravenous route immediately 70 ml/hour for 24 hours. Fingerstick Blood Sugar every 4 hours for 24 hours. Call the Medical Doctor for blood sugar below 75 mg/dl. A Medical Interim Progress Note dated 05/15/2024 at 12:05 AM, documented Resident #2 received a dose of long-acting insulin by error last week. Today, 05/15/2024, the resident states that they did not feel too well yesterday, which could have been secondary to the sustained effect of the long-acting insulin dose. During a telephone interview on 08/28/2024 at 1:49 PM, Resident #2 stated that the incident happened around 11:00 PM, and they were dosing off. Resident #2 stated that the room was dark, and they felt someone uncovering them and saying something, but they were wearing masks, and they did not hear what the staff said. Resident #2 stated that they thought it was a nurse administering cream for the rash on their tummy, and they allowed to uncover them. Resident #2 stated that they felt that the nurse injected something in their tummy, woke up fully, and asked what they were doing. Resident #2 stated the nurse said it was their insulin. Resident #2 stated that they told the nurse that they were not taking insulin, and the nurse said, yes. Resident #2 stated that after they convinced the nurse that they had the wrong resident, the nurse left. Resident #2 stated a Licensed Practical Nurse #1 came into the room and said everything would be all right and checked their blood pressure and glucose. Resident #2 stated that they texted their adult child and notified them of what happened. During an interview on 08/28/2024 at 2:05 PM, Licensed Practical Nurse #1 stated that the incident happened on 05/08/2024 during the 3-11 shift, they asked Registered Nurse #1 to give Resident #3 their insulin. Licensed Practical Nurse #1 stated they already prepared the insulin with a pen and told Registered Nurse #1 the name of the resident and showed them the Medication Administration Record for Resident #3. Licensed Practical Nurse #1 stated that later Registered Nurse #1 told them that they thought they made a mistake by giving insulin to the wrong resident. Licensed Practical Nurse #1 stated they notified the supervisor and Medical Doctor. During an interview on 08/28/2024 at 2:38 PM, Registered Nurse #1 stated on 05/08/2024, around 10:30 PM -10:45 PM, Licensed Practical Nurse #1 asked them to administer insulin to Resident #3 and said it had already been prefilled. Registered Nurse #1 stated that they were very busy and fixated on another resident under their care and had a lot of pressure in their head. Registered Nurse #1 stated that they did not check the Electronical Medical Administration Record as they were supposed to and went to the wrong room. Registered Nurse #1 stated that the room was dark and they did not open the light, and they did not check the resident's wristband as they were supposed to. Registered Nurse #1 stated that after the resident told them that they were not taking insulin, they realized that they had administered the insulin to the wrong resident. Registered Nurse #1 stated that they immediately told the Licensed Practical Nurse #1, Nursing Supervisor and called the Medical Doctor. During an interview on 08/29/2024 at 11:19 AM, Registered Nurse Supervisor #1 stated they were called to the unit by Registered Nurse #1, who notified them that they administered insulin to the wrong resident. Registered Nurse Supervisor #1 stated that they assessed and interviewed Resident #2. Registered Nurse Supervisor #1 stated Resident #2 told them that they got injections, and they were not receiving any insulin. Emotional support was provided. Registered Nurse Supervisor #1 stated they did not observe any adverse reaction, vital signs were normal, and the Medical Doctor was notified. Registered Nurse Supervisor #1 stated Registered Nurse #1 did not follow the five rights of medication administration and assumed that it was the right resident without checking the resident's wristband as a part of identification. During an interview on 08/28/2024 at 1:22 PM, the Medical Doctor stated Resident #2 had no order for insulin. The Medical Doctor stated they evaluated Resident #2 after the incident on 05/08/2024. The Medical Doctor stated that Resident #2 did not sustain any harm, emotional or physical, due to the one-dose injection of the insulin Lantus. Resident #2 was monitored and received dextrose 5% intravenously, and it was discontinued due to the increase in blood glucose level. During an interview on 08/29/2024 at 2:36 PM, the Administrator stated that they were informed about Registered Nurse #1 not following facility policy on medication administration, which resulted in administering insulin to the wrong resident. The Administrator stated Registered Nurse #1 and was terminated from employment. 10 NYCRR 415.12 (m)(2)

Based on observation, record review, and interview conducted during the Recertification and Complaint (NY00312479) survey from 04/27/23 to 05/04/23, the facility did not ensure a person-centered Comprehensive Care Plan (CCP) was developed and implemented to meet resident needs. This was evident for 3 (Residents #193, #513, and #936) of 41 total sampled residents. Specifically, 1) a CCP related to abuse prevention was not developed for Resident #193 following a substantiated abuse allegation, 2) a CCP related to dialysis treatment was not developed for Resident #513 who receives dialysis, and 3) a CCP related to fractures was not developed for Resident #936 following a left rib fracture. The findings are: The facility policy titled CCP last revised 4/2022 documented the CCP should be kept current by all disciplines on an ongoing basis. Disciplines will be responsible for updating the plan of care when there is a new problem that requires that discipline to intervene. The care plan will be revised to reflect the resident's current status, need, and achievements. 1) Resident #193 had diagnoses of osteoarthritis and osteoporosis. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #193 had mild cognitive impairment and was totally dependent on 2 people for toileting and bed mobility. On 05/02/2023 at 9:00 AM and 05/02/2023 at 3:09 PM, Resident #193 was observed with the ring finger (RF) on their left hand swollen and resting in a straight position. Resident #193 attempted to bend their left RF and was unable to complete the task without wincing and grimacing in pain. The Nursing Note dated 3/11/2023 documented Resident #193 was assessed for a complaint of left RF pain, swelling, and discoloration. Resident #193 stated they are unable to move the finger. The Investigation Report dated 03/11/2023 documented the nurse responded to Resident #193's call light and the resident complained of pain to their left RF and was observed with discoloration extending to the palm of their hand. The registered nurse supervisor (RNS) was notified, and Resident #193's left RF was found swollen, discolored (purplish), and tender to touch. The Medical Doctor (MD) was notified, x-ray ordered, and no fracture was noted. The facility investigated Resident #193's allegation that CNA #1 provided care without a 2nd staff member present and grabbed the remote from the resident's hand during care. The report documented the facility concluded the abuse allegation was substantiated. The MD Note 3/13/2023 documented Resident #193's left RF sustained trauma after being bent backwards and had pain, swelling, ecchymosis extending to the palm of the hand, tenderness over the metacarpophalangeal joint, and motor restriction from edema. X-ray of Resident #193's left hand was negative for fracture. The MD documented a plan to ice Resident #193's finger as tolerated, repeat x-ray, and obtain an orthopedic consult. The MD also documented Resident #193 had a questionable fracture versus ligament tear versus unreadable fracture due to degenerative joint disease and osteopenia. The MD Note dated 3/15/23 documented Resident #193 continued to have pain in their left hand and was unable to flex their left RF. Pain is controlled with Tylenol and the MD was awaiting the orthopedic consult. MD Order dated 3/15/23 documented Resident #193 was ordered to have an orthopedic consult following trauma to the left RF and repeat left hand x-ray. On 3/16/23, ice was ordered to be applied to Resident #193's left RF for 10 minutes as tolerated for 3 days. The Medication Administration Record (MAR) for March 2023 documented Resident #193 received ice to their left RF for 10 minutes every shift from 3/13/23 to 3/15/23. There was no documented evidence a CCP related to abuse treatment and prevention was developed and implemented following a Resident #193's substantiated allegation of abuse on 3/10/23. During an interview on 05/02/2023 at 12:47 PM, the Social Service Director (SSD) stated the social services and nursing department assess the residents and determine whether to initiate an abuse prevention CCP. Resident #193 did not have an abuse prevention CCP in place because the resident is alert and able to make their needs known. During an interview on 05/03/2023 at 1:30PM, the Director of Nursing (DON) stated the nursing and social services department initiate abuse prevention CCPs upon admission, quarterly, significant changes and during annual assessments. A CCP related to abuse prevention was not initiated for Resident #193 because the resident is alert, oriented, and able to make their needs known. 44864 Resident #513 had diagnoses of end stage renal disease (ESRD) and diabetes mellitus. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #513 was cognitively intact and received dialysis treatment. The Physician's Orders renewed 04/21/23 documented Resident #513 had dialysis treatment on Tuesday, Thursday, and Saturday. The resident's permacath site was ordered to be checked for signs and symptoms of infection and bleeding. A Nursing Note dated 4/27/23 documented pre- and post-dialysis assessments of Resident #513 permacath site dressing before and after dialysis treatment. There was no documented evidence a CCP related to ESRD and dialysis treatment was developed and implemented for Resident #513. On 05/03/23 at 12:02 PM, the Registered Nurse (RN) #2 was interviewed and stated Resident #513 did not have a CCP related to ESRD. The admitting RN was responsible for initiating the CCPs for residents and the RN should check to see if a new CCP should be done. On 05/03/23 at 04:36 PM and 05/04/23 at 09:54 AM, the Assistant Director of Nursing (ADNS) was interviewed, and stated the RNs are responsible for initiating the CCPs upon a resident's admission and readmission. Resident #513 was previously diagnosed with ESRD but only began receiving dialysis treatment upon readmission and the CCP should have been updated to reflect the resident's change in condition. The CCP related to ESRD was included in Resident #513's initial admission to the facility. The CCP was not initiated again upon Resident #513's readmission to the facility from the hospital. 39908 Resident #936 had diagnoses of chronic obstructive pulmonary disease (COPD) and diabetes mellitus. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #936 was severely cognitively impaired. The Medical Doctor (MD) Note dated 11/17/2022 documented Resident #936 had volume depletion, was positive for cough, the MD ordered a chest x-ray, and the resident was started on Levaquin for pneumonia. The Radiology Report dated 11/19/2022 documented Resident #936's chest x-ray findings of visualized osseous structures that demonstrated degenerative changes and fracture deformities of multiple left ribs. The Nurse Practitioner (NP) Note dated 11/19/22 documented Resident #936's chest x-ray result showed degenerative changes and fracture deformities of multiple left ribs and left lower lobe consolidation. The plan documented to continue with Levaquin, encourage oral fluid intake, and continue monitoring for adverse reaction. There was no documented evidence a CCP related to Resident #936's left rib fractures was developed and implemented. During an interview on 05/01/2023 at 2:24 pm, Registered Nurse (RN) #1 stated they did not initiate a care plan for rib fracture because they were not aware of the fracture prior to Resident #936's hospitalization on [DATE] and was not the nurse manager on the resident's unit upon readmission from the hospital. During an interview on 05/01/2023 at 1:40 pm, the Program Director (PD) was interviewed and stated they were responsible for readmitting Resident #936 to the facility. The PD did not initiate a CCP related to left rib fractures because they did not know Resident #936 was diagnosed with rib fracture when they were readmitted . If they knew about the resident's rib fractures, the PD could have developed a CCP to address Resident #936's rib fractures. During an interview on 05/04/2023 at 1:04 pm, the Director of Nursing (DON) stated a care plan related to Resident #936's rib fractures should have been initiated by the RN. 415.11(c)(1)

Based on interviews and record review conducted during an abbreviated survey (NY00307515), the facility did not ensure that all alleged violation of abuse, including injuries of unknown source, were thoroughly investigated. This was evident in 1 (Resident #936) of 41 sampled residents. Specifically, Resident #936 was found to have multiple left rib fractures of unknown origin without evidence of an investigation to rule out abuse. The findings are: The facility policy titled Investigations dated 2/2022 documented all injuries of unknown origin will be investigated to determine abuse or mistreatment. Resident #936 had diagnoses of chronic obstructive pulmonary disease (COPD) and diabetes mellitus. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #936 was severely cognitively impaired. The Medical Doctor (MD) Note dated 11/17/2022 documented Resident #936 had volume depletion, was positive for cough, the MD ordered a chest x-ray, and the resident was started on Levaquin for pneumonia. The Radiology Report dated 11/19/2022 documented Resident #936's chest x-ray findings of visualized osseous structures that demonstrated degenerative changes and fracture deformities of multiple left ribs. The Nurse Practitioner (NP) Note dated 11/19/22 documented Resident #936's chest x-ray result showed degenerative changes and fracture deformities of multiple left ribs and left lower lobe consolidation. The plan documented to continue with Levaquin, encourage oral fluid intake, and continue monitoring for adverse reaction. There was no documented evidence the facility investigated Resident #936's left rib fractures of unknown origin. During an interview on 05/04/2023 at 1:04 pm, the Director of Nursing (DON) stated that they briefly reviewed the case on Resident #936's left rib fractures and that an investigation should have been conducted. During an interview on 05/04/2023 at 1:21 pm, the Administrator stated that based on their policy, Resident #936's rib fractures should have been investigated to rule out abuse, neglect, or mistreatment. 10 NYCRR 415.4 (b)(3)

Based on record review and interviews conducted during the recertification and abbreviated survey (NY00307515) from 4/27/23 to 5/4/23, the facility did not ensure the resident's representative was notified of a significant change in the resident's condition and a need to alter treatment. This was evident in 1 (#936) out of 5 residents reviewed for Notification of Change of 41 total sampled residents. Specifically, Resident #936's representative was not notified after the resident sustained a rib fracture. The findings include: The facility policy titled Notification of Changes, revised 09/2022, documented the resident, physician, and legal representative or family member should be immediately notified when there is an accident or incident involving the resident, a significant change in status or condition, or changes in resident's rights. Resident #936 had diagnoses of chronic obstructive pulmonary disease (COPD) and diabetes mellitus. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #936 was severely cognitively impaired. The Medical Doctor (MD) Note dated 11/17/2022 documented Resident #936 had volume depletion, was positive for cough, the MD ordered a chest x-ray, and the resident was started on Levaquin for pneumonia. The Radiology Report dated 11/19/2022 documented Resident #936's chest x-ray findings of visualized osseous structures that demonstrated degenerative changes and fracture deformities of multiple left ribs. The Nurse Practitioner (NP) Note dated 11/19/22 documented Resident #936's chest x-ray result showed degenerative changes and fracture deformities of multiple left ribs and left lower lobe consolidation. The plan documented to continue with Levaquin, encourage oral fluid intake, and continue monitoring for adverse reaction. There was no documented evidence that Resident #936's designated representative was notified when the resident's chest x-ray showed left rib fractures. During an interview on 05/04/2023 at 12:44 pm, LPN (Licensed Practical Nurse) #1 stated they informed the NP of Resident #936's left rib fracture when they received the chest x-ray report. During an interview on 05/01/2023 at 1:55 pm, the NP stated that Resident #936 was started on an antibiotic, and a chest x-ray was ordered because the resident had a cough that kept coming back and a chest x-ray result on 11/19/2022 showed rib fractures. The NP stated that they did not call the resident's family to notify them of the rib fractures, and that it is usually the nursing supervisor who notifies the family. During an interview on 05/01/2023 at 1:08 pm, the MD stated that they were the attending physician for Resident #936. The MD stated that they do not recall speaking with the family about the rib fractures, and if they did, they would have documented it in the progress notes. The MD states that the NP should have been the one that communicated the rib fractures to the family when they reviewed the x-ray report. During an interview on 05/04/2023 at 1:04 pm, the Director of Nursing (DON) stated that the MD and the nurse should have immediately notified Resident #936's family of the rib fractures upon identification. During an interview on 05/04/2023 at 1:21 pm, the Administrator stated that Resident #936's family should have been immediately notified by the NP or the MD as soon as they saw that the x-ray report suggested rib fracture. 415.3(f)(2)(ii)(b)

Based on observation, record review, and interviews conducted during a Recertification and Abbreviated survey (NY00312479), the facility did not ensure a resident was free from abuse. This was evident for 1 (Resident #193) of 41 total sampled residents. Specifically, Resident #193 picked up the call bell remote after telling Certified Nurse Assistant (CNA) #1 to stop providing care without a 2nd staff member present to assist. CNA #1 grabbed the call bell remote from Resident #193's hand. Resident #193 sustained trauma and pain to the left-hand 4th finger (ring finger), and they continue to have pain and functional limitations in the left-hand ring finger. The findings are: The facility policy titled Abuse Prohibition Protocol dated 02/2023 documented every resident has the right to be free from abuse, mistreatment, neglect, misappropriation of property and to be free from abuse facilitated or caused by the facility's staff. Resident #193 had diagnoses of osteoarthritis and osteoporosis. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #193 had mild cognitive impairment and was totally dependent on 2 people for toileting and bed mobility. On 05/02/2023 at 9:00 AM and 05/02/2023 at 3:09 PM, Resident #193 was observed with a swollen left-hand ring finger (RF) resting in a straight position. Resident #193 attempted to bend their left RF and was unable to do so without wincing and grimacing in pain. Resident #193 was not able to fully bend the finger. During the observation, Resident #193 was interviewed and stated on 3/10/23, Certified Nursing Assistant (CNA) #1 came into their room to provide care after Resident #193 had a bowel movement. CNA #1 did not have another staff member in the room to assist with care. Resident #193 asked CNA #1 to get the nurse, and CNA #1 told them they will get the nurse after they are finished providing care. Resident #193 told CNA #1 to stop providing care and not to touch them, but CNA #1 continued to give them care. Resident #193 stated they picked up the call bell/television remote in their hand to call the nurse. CNA #1 grabbed the remote out of Resident #193's hand, bending the resident's left RF back in the process. Resident #193 stated they sustained swelling, discoloration, limitation in mobility, and persistent pain that still has not resolved. Resident #193 noticed the discoloration on 3/11/23 and reported the incident to the nurse. The Employee File of CNA #1 documented mandatory in-service related to abuse was provided to CNA #1 on 07/27/2022. The CNA Documentation Record from 03/01/2023 to 03/31/2023 documented Resident #193 required 2 people to assist with bed mobility and toilet use. The Nursing Note dated 3/11/2023 documented Resident #193 was assessed for a complaint of left RF pain, swelling, and discoloration. Resident #193 stated they were unable to move the finger. The Investigation Report dated 03/11/2023 documented Licensed Practical Nurse (LPN) #1 responded to Resident #193's call light, and Resident #193 complained of pain to their left RF. Resident #193 was observed with left RF discoloration extending to the palm of their hand. Registered Nurse Supervisor (RNS) #1 was notified, assessed Resident #193, and determined the resident's left RF was swollen, discolored (purplish), and tender to touch. The Medical Doctor (MD) was notified, an x-ray ordered, and no fracture was noted. The facility investigated Resident #193's allegation that CNA #1 provided care without a 2nd staff member present and grabbed the remote from the resident's hand during care. The report documented the facility concluded the abuse allegation was substantiated. The MD Note 3/13/2023 documented Resident #193's left RF sustained trauma after being bent backwards with pain, swelling, ecchymosis extending to the palm of the hand, tenderness over the metacarpophalenageal joint, and motor restriction from edema. The X-ray result for Resident #193's left hand was negative for fracture. The MD documented a plan to ice Resident #193's finger as tolerated, repeat x-ray, and obtain an orthopedic consult. The MD documented Resident #193 had a questionable fracture versus ligament tear versus unreadable fracture due to degenerative joint disease and osteopenia. Radiology Reports dated 3/12/23 and 3/13/23 documented the x-rays determined there was no fracture to Resident #193's left RF. The Employee Disciplinary Action dated 03/13/2023 documented CNA #1 was terminated from the facility. The MD Note dated 3/15/23 documented Resident #193 continued to have pain in their left hand and was unable to flex their left RF. The pain was controlled with Tylenol, and the MD was awaiting the orthopedic consult. The MD Order dated 3/15/23 documented orders for an orthopedic consult following trauma to the left RF and repeat left hand x-ray. The MD Order dated 3/16/23 documented orders for ice to be applied to Resident #193's left RF for 10 minutes as tolerated for 3 days. The Medication Administration Record (MAR) for March 2023 documented Resident #193 received ice to their left RF for 10 minutes every shift from 3/13/23 to 3/15/23. Gabapentin 100mg was administered once daily to Resident #193 starting 3/30/23 for chronic pain. Tylenol extra strength 1000mg was administered to Resident #193 three times a day from 3/1/23 to 3/21/23 for unspecified pain. The Radiology Report dated 5/1/23 documented Resident #193 had an x-ray of the left hand due to swelling and no fracture was noted. During an interview on 05/02/2023 at 4:45 PM, CNA #1 stated on 3/10/23 they were assigned to Resident #193 on the 3 PM-11 PM shift. During their shift, Resident #193 was soiled and requested to be changed. CNA #1 stated they were providing care to Resident #193 when the resident requested to see the nurse. CNA #1 told Resident #193 they were in the middle of providing care and will notify the nurse once care is completed. CNA #1 left the room after they were finish providing Resident #193 with care and informed the nurse the resident wanted to see them. Resident #193 never expressed any pain or discomfort. CNA #1 did not observe any discoloration of swelling of Resident #193's left RF. CNA #1 never asked any staff members for help to change Resident #193. Resident #193 is alert and can turn themselves. CNA #1 stated they were aware that Resident #193 required two people to assist with toileting and bed mobility. CNA #1 denied the allegation of abuse involving Resident #193 and received in-services on abuse prevention. During an interview on 05/03/2023 at 12:44 PM, LPN #1 stated they worked on 3/11/23 and responded to Resident #193's call bell. Resident #193 reported the incident involving CNA #1 and left RF pain. LPN #1 reported the allegation to RNS #1. During an interview on 05/03/2023 at 1:00 PM, RNS #1 stated they assessed Resident #193's left RF swelling and pain on 3/11/23. Resident #193 reported on 03/10/2023, CNA #1 was attempting to take the call bell/TV remote from them and hurt the resident's finger. Resident #193 had discoloration, swelling, and pain, and they were unable to bend their finger. The MD was informed, and an x-ray was ordered. During an interview on 05/03/2023 at 1:30PM, the Director of Nursing (DON) stated they were informed of Resident #193's allegation involving CNA #1 on 03/11/2023. Resident #193 was interviewed and reported CNA #1 was rough with them and tried to grab the call bell away from them. Resident #193 was immediately assessed, the MD was made aware, and psychiatry and psychology consults were obtained. CNA #1 denied the allegation and was terminated. The DON stated that they were aware that the incident must be reported to the police, and they are not sure why it was not reported. An abuse prevention care plan is initiated upon admission, quarterly and annual assessment by nursing and social services. There was no abuse prevention care plan in place for Resident #193 because the resident is alert, oriented, and able to make their needs known. 415.4(b)

Based on observation, interview, and record review conducted during the recertification and complaint survey (NY00293108 and NY00312479) from 4/27/23 to 5/4/23, the facility did not ensure that all allegations of abuse, involving an injury of unknown source, were reported to the New York State Department of Health and suspicion of a crime was reported to the New York Police Department (NYPD. This was evident for 2 (Resident #937 and #193) of 41 sampled residents. Specifically, 1) Resident #937 sustained a left hip fracture of unknown origin that was not reported to the NYSDOH and 2) a substantiated allegation of abuse involving CNA #1 and Resident #193 was not reported to the NYPD. The findings are: The facility policy titled Abuse - Prohibition Protocol dated 2/2023 documented any alleged violations abuse, including injuries of an unknown source, must be reported to the Administrator, an investigation must be made, and the findings of such investigation must be reported within 24 hours of occurrence/discovery. 1) Resident #937 had diagnoses of dementia and benign prostatic hyperplasia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #937 was severely cognitively impaired. Nursing Note dated 03/19/2022 documented the Certified Nursing Assistant (CNA) reported Resident #937 had left hip pain and swelling when the CNA was providing activities of daily living (ADL) care to the resident. The Licensed Practical Nurse (LPN) and Registered Nurse Manager (RNM) were notified, Resident #937 left hip was assessed, and the resident left lower extremity (LLE) was observed pronated inward. Resident #937 grimaced in pain during range of motion (ROM) of the LLE. MD was notified, Tylenol 650 mg every 6 hours was ordered, and Stat x-ray of bilateral hips was ordered. Resident #937 was unable to state what occurred due to cognitive impairments. The Radiology Report dated 03/19/2022 documented the x-ray findings that Resident #937 had an acute moderately displaced left intertrochanteric fracture present with mild displacement resulting in varus angulation. The facility Summary of Investigation dated 03/24/2022 documented the CNA immediately notified the LPN on the unit when Resident #937 expressed pain on 3/19/22. X-ray findings were likely pathological in nature and there was no evidence to support abuse or neglect. The incident was not reported to the NYSDOH. During an interview on 05/04/2023 at 1:10 pm, the Director of Nursing (DON) stated there was no abuse and Resident #937's left hip fracture was probably pathological in nature secondary to osteoporosis. This was an injury of unknown origin and should have been reported to the NYSDOH. During an interview on 05/04/2023 at 1:16 pm, the Administrator stated a fracture of unknown origin must be investigated and reported to the NYSDOH. 43285 2) Resident #193 had diagnoses of osteoarthritis and osteoporosis. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #193 had mild cognitive impairment and was totally dependent on 2 people for toileting and bed mobility. The Investigation Report dated 03/11/2023 documented the nurse responded to Resident #193's call light and the resident complained of pain to their left RF and was observed with discoloration extending to the palm of their hand. The registered nurse supervisor (RNS) was notified and Resident #193's left RF was found swollen, discolored (purplish), and tender to touch. The Medical Doctor (MD) was notified, x-ray ordered, and no fracture was noted. The facility investigated Resident #193's allegation that CNA #1 provided care without a 2nd staff member present and grabbed the remote from the resident's hand during care. The report documented the facility concluded the abuse allegation was substantiated. The Employee Disciplinary Action dated 03/13/2023 documented CNA #1 was terminated from the facility. During an interview on 05/04/2023 at 12:14 PM, the Risk Manager (RM) stated Resident #193's allegation of abuse was investigated, and CNA #1 was interviewed. CNA #1 denied the allegation and the incident was not reported to the NYPD. During an interview on 05/03/2023 at 1:30PM, Director of Nursing (DON) stated they were informed Resident #193's allegation of abuse on 03/11/2023. CNA #1 was rough and was trying to grab the call bell and television remote away from the resident. The DON stated that they are aware the incident should have been reported to the NYPD, but they are not sure why it was not reported. 10 NYCRR 415.4(b)

Based on observation, record review, and interviews conducted during the Recertification and Complaint (NY00311511) survey from 04/27/23 to 05/04/23, the facility did not ensure a resident was treated with respect and dignity. This was evident for 1 (Resident #402) of 6 residents reviewed for Activities of Daily Living (ADL) out of 41 total sampled residents. Specifically, Resident #402 was served and ate lunch while waiting for incontinence care after having a bowel movement. The findings are: The facility policy titled Toileting last revised 04/18 documented all residents are brought to the toilet regardless of continence status, unless physically or medically contraindicated. Resident #402 had diagnoses of diabetes mellitus and non-Alzheimer's dementia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #402 was cognitively intact, always incontinent of bowel, and required 1 person to assist with transfers and toilet use. On 05/01/23 at 12:02 PM, Resident #402 was observed sitting in their wheelchair in the hallway on their unit. Resident #402 stated they have been having diarrhea for a few days due to recent antibiotic use, bowel movement, and they are waiting to be put back to bed to have their incontinent brief changed. Resident #402 was in the dining room preparing to have lunch with other residents and left to sit in the hallway once they realized they had a bowel movement. At 12:10 PM, Licensed Practical Nurse (LPN) #1 was interviewed and stated they were aware Resident #402 needed to have their incontinence brief changed. Resident #402's room is being cleaned and the staff are serving lunch so Resident #402 will be changed when lunch service is done. Certified Nursing Assistant (CNA) #1 assigned to Resident #402 is on break. At 12:15 PM, CNA #1 was observed walking up and down the hallway on the unit. On 5/1/23 at 12:40 PM, Resident #402 was observed in their room in the wheelchair feeding themselves lunch from the tray in front of them. Resident #402 stated they still had a bowel movement in their incontinence brief that needed to be changed. Staff have not provided incontinence care yet. On 05/01/23 at 12:45PM, Registered Nurse (RN) #1 was observed entering Resident #402's room. On 05/01/23 at 3:00PM, Resident #402 was interviewed and stated the nursing staff eventually changed their incontinence brief earlier. Resident #402 stated they understand it always takes a while to get changed. The Comprehensive Care Plan (CCP) related to ADL - Toilet Use, initiated 05/06/20 and last reviewed 4/19/23, documented Resident #402 was unable to transfer to the toilet and required extensive assistance of 1 person to be toileted. Nursing Note dated 4/30/23 documented Resident #402 was receiving Sulfamethoxazole 400mg twice daily for 10 days for a urinary tract infection. Nursing Note dated 05/01/23 at 3:49 PM documented Resident #402 completed antibiotic therapy and was noted with loose bowel movements. Staff will continue to assist the resident as needed. On 05/01/23 at 02:39 PM, CNA #1 was interviewed and stated they were assigned to Resident #402 and CNA #1 cleaned the resident's bowel movement this morning before taking them out of bed at 11:20 AM. Resident #402 was taken out of the room so staff could clean the room. Resident #402 can wheel themselves and the resident chose where they went after leaving their room. CNA #1 stated they served lunch in the dining room earlier and were not aware Resident #402 needed their incontinence brief changed. CNA #1 then went to lunch from 12:30 PM to 1:00 PM. Another staff member placed Resident #402 back in bed and performed incontinence care while CNA #1 was on lunch. On 05/01/23 at 02:51 PM, a follow up interview was conducted with LPN#1 who stated if a resident needs assistance, any CNA can be assigned to assist the resident. The unit usually uses a buddy system to address the issue of residents who require ADL care while their CNA is on break. LPN#1 stated the Social Worker informed LPN #1 that Resident #402 had a bowel movement and required incontinence care. CNA #1 was on lunch when Resident #402 needed to be changed and then LPN #1 stated they went on lunch at 12:15 PM. On 05/03/23, at 11:08 AM, LPN#2 stated LPN #1 mentioned Resident #402 needed to be changed and LPN #1 looked for CNA #1 to change the resident. LPN #2 found that CNA #1 was on break. RN #1 was notified, and 2 other CNAs were tasked with changing the resident. If there is any issue where a resident needs assistance, LPN #2 would pull a CNA from another assignment to attend to the resident in need. On 05/01/23 02:58 PM, RN#1 was interviewed and stated the unit has a buddy system where a CNA covers the assignment of the CNA going on lunch. RN#1 stated the delay in ADL assistance for Resident #402 could have been avoided if RN #1 was made aware. The delay should not have occurred, and RN #1 had another CNA change Resident #402 right away once RN #1 was made aware. On 05/04/23, at 09:03 AM, the Program Director was interviewed and stated they are familiar with Resident #403 and knows that the resident requires assistance. Staff are responsible for finding someone available to address the resident's needs. The facility uses a buddy system to address concerns with ADL care like this. A resident may wait a few minutes to be toileted, but the resident should not be waiting for 45 minutes to get staff assistance. 415.12(a)(3)