Every finding on record at Livingston Hills Nursing and Rehabilitation Center

Based on record review and interview during a survey, the facility failed to ensure medical records on each resident were complete and accurately documented for seven (Residents #s 1,2,3,4,5,6 and 7) of seven residents reviewed. Specifically, Certified Nurse Aides tasks were not documented daily during February 2026. This lack of accurate record keeping made it difficult for other staff to know which tasks were completed for residents and what level of assistance was provided.Findings include:Facility Policy and Procedure titled Certified Nurse Aide Documentation, last revised 09/2025, stated documentation of activities of daily living performance will be maintained in the Certified Nurse Aide record area of the electronic medical record. The purpose of documentation was to provide ongoing documentation of the resident's receipt of daily unskilled services and participation, level of support, in addition to other functional and observational data for continuity of record and accuracy of assessment, and to provide accurate data for care planning and medical decision-making. Certified Nurse Aides are expected to document the following items in the electronic medical record each shift: bathing/showers, toileting/bowel movements, eating/meal consumption, dressing, transfers, bed mobility, ambulation, skin condition, safety interventions. It is the responsibility of the Certified Nurse Aide to document care provided for residents upon/following provision of care by Certified Nurse aide but no later than the end of the shift.Resident #1Resident #1 was admitted to the facility with the diagnoses displaced intertrochanteric fracture of the right femur (a type of broken hip occurring in the upper region of the thigh bone), unspecified dementia (when a person has a clear cognitive decline consistent with dementia, but cannot definitively identify the type of dementia), and muscle weakness. The Minimum Data Set (a resident assessment tool) dated 11/12/2025, documented the resident could be understood, understood others, and had severe cognitive impairment.The Comprehensive Care Plan with focus Activities of Daily Living effective 11/14/2025, documented the resident had self-care deficit in the following areas and the level of assistance needed:Bathing- extensive assist times one (when a person needs direct, hands-on weight-bearing physical help from one person to perform an activity);Bed Mobility- extensive assist times oneDressing- extensive assist times oneEating- set upPersonal Hygiene- extensive assist times oneToilet Use- Extensive assist times bed level. Incontinent of bowel and bladderTransfer extensive assist times two (when a person needs direct, hands-on weight-bearing physical help from two people to perform an activity).Record Review of Resident #1's Certified Nurse Aide Documentation Record for February 2026 included tasks such as bed mobility, dressing, locomotion on unit, personal hygiene, transfer, eating, toilet use, Certified Nurse Aide Care provided, and skin check/care. Tasks were to be recorded on the shift they were performed, along with the level of support provided or if the task was self-performed. There was no documentation on the Certified Nurse Aide Documentation Record indicating when these tasks were performed and what level of assistance was provided for the following dates: 02/02/2026, 02/03/2026, and 02/05/2026. Resident #1 was discharged from the facility on 02/13/2026. Resident #3Resident #3 was admitted to the facility with the diagnoses of unspecified dementia, unspecified severity, with agitation (cognitive decline without a defined subtype or stage, accompanied by behavioral symptoms like pacing, restlessness, or physical aggression), hypertension (high blood pressure), and adult failure to thrive (a syndrome characterized by unexplained weight loss, poor appetite, inactivity, and social withdrawal). The Minimum Data Set, dated [DATE], documented the resident could be understood, understood others, and had severe cognitive impairment.The Comprehensive Care Plan with focus Activities of Daily Living effective 11/07/2024, documented the resident had self-care deficit in the following areas and the level of assistance needed:Bathing- Maximal assist times one (when a person performs 25 percent or less of the effort needed for a task, while one caregiver provides 75 percent or more of the physical lifting, guiding, or balancing)Bed Mobility- Limited assist times one (when a person requires physical, hands-on help from one caregiver. The person performs most of the effort, while the caregiver performs non-weightbearing assistance)Dressing- Maximal Assist times oneEating- Maximal Assist times onePersonal Hygiene- Maximal Assist times oneToilet Use- Maximal Assist times on;Transfer Limited assist times one, Rolling Walker.Record Review of Resident #3's Certified Nurse Aide Documentation Record for February 2026 included tasks such as bed mobility, dressing, locomotion on unit, personal hygiene, transfer, eating, toilet use, Certified Nurse Aide Care provided, and skin check/care. Tasks were to be recorded on the shift they were performed, along with the level of support provided or if the task was self-performed. There was no documentation on the Certified nurse Aide Documentation Record indicating when these tasks were performed and what level of assistance was provided for the following dates: 02/01/2026, 02/02,2026, 02/04/2026, 02/05/2026, 02/07/2026 through 02/15/2026, 02/17/2026, 02/18/2026, 02/20/2025, 02/22/2026 through 02/25/2026, 02/27/2026, and 02/28/2026.Resident #4Resident #4 was admitted to the facility with diagnoses of diabetes mellitus, type two (a chronic condition where the body either resists the effects of insulin or does not produce enough to maintain normal glucose levels), chronic obstructive pulmonary disease (a progressive, inflammatory lung disease that restricts airflow and causes breathing difficulties), and congestive heart failure (a chronic condition where the heart does not pump blood as efficiently as it should leading to fluid retention in the lungs and body). The Minimum Data Set, dated [DATE], documented the resident could be understood, understood others, and had intact cognition.The Comprehensive Care Plan with focus Activities of Daily Living, effective 01/24/2025, documented the resident had self-care deficit in the following areas and the level of assistance needed:Bathing/shower- Extensive times oneBed Mobility- Extensive times one for rolling and total dependent to sit upDressing- Extensive times oneEating- Set-Up and SupervisionPersonal Hygiene- Extensive times oneToilet Use- Extensive times oneTransfer - Dependent times two Mechanical LiftRecord Review of Resident #3's Certified Nurse Aide Documentation Record for February 2026 included tasks such as bed mobility, dressing, locomotion on unit, personal hygiene, transfer, eating, toilet use, Certified Nurse Aide Care provided, and skin check/care. Tasks were to be recorded on the shift they were performed, along with the level of support provided or if the task was self-performed. There was no documentation on the Certified Nurse Aide Documentation Record indicating when these tasks were performed and what level of assistance was provided for the following dates: on 02/01/2026 through 02/05/2026, 02/07/2026 through 02/10/2026, 02/13/2026 through 02/15/2026, 02/17/2026, 02/18/2026, 02/20/2026, 02/22/26 through 02/25/2026, 02/27/2026 and 02/28/2026. Interviews:During an interview on 03/10/2026 at 1:46 PM, Certified Nurse Aide #1 stated they documented in a resident's electronic healthcare record when they provided services for a resident. They tried to get their documentation in throughout the day, but sometimes the unit was a little hectic and they completed their documentation by the end of the day. They stated the certified nurse aide that had the resident on their assignment should be the one completing the documentation for that resident.During an interview on 03/10/2026 at 3:17 PM, Certified Nurse Aide #2 stated there were days they were not able to document when they provided care for the residents in the electronic health system because of other responsibilities they had. They stated they put the residents first; they were doing their job, but they were not able to get the documentation done.During an interview on 03/10/2026 at 3:46 PM, Registered Nurse #1 stated certified nurse aide charting (documentation) was not always up to date and at times, they had to ask the certified nurse aides if residents had bowel movements, but if they were gone for the day they were not able to ask them. They stated they had to go by whatever was documented.During an interview on 03/11/2026 at 1:55 PM, Certified Nurse Aide #3 stated they completed documentation for everyone that was on their assignment. Areas they documented on included the percentage of what the resident ate and drank, care provided for completion of activities of daily living, and assistance with toileting. They completed their documentation during a break or at the end of their shift, and they still had to document for the person if their status was independent for those areas. They stated sometimes there was a shortage of staff and they did not have time to document.During an interview on 03/11/2026 at 2:03 PM, Registered Nurse #2 stated certified nurse aides were supposed to document the care they provided for the residents each day and it was supposed to be done for every resident on each shift, but it was not happening. They stated Director of Nursing #1 said they have a big problem with documentation. Registered Nurse #2 was able to look in the computer system and see that certified nurse aides were not documenting care provided to the residents. They stated if there was no documentation, they would not know if the residents had changes.During an interview on 03/11/2026 at 2:15 PM, Director of Nursing #1 stated certified nurse aides should have been documenting on everything they did with the resident and if the resident was independent in status, they were still responsible to document on them. They stated their priority was providing hands on care as opposed to documentation. They also stated any staff should have been able to look in a resident's chart and see the level of care that was provided. Documentation told a story, and if the story was not there, it could cause issues and the communication piece the documentation provided was important. Ideally, the certified nurse aides would document the care they provided in real time, but if they were short staffed, the priority was to get the care done and then document when they had a chance to sit down. They stated they did not know if the nurses spoke with the certified nurse aides about not completing their documentation on care provided for the residents.During an interview on 03/11/2026 at 2:43 PM, Administrator #1 stated staff did not document as well as they would like, but they were providing education to increase clinical competencies. Staff should be documenting on the care they provided as it was a requirement of their job. If there was a lack of documentation, it could not be proven care was provided. They stated the care for the residents was getting done, but the documentation of the care was not what it should be. 10 New York Codes of Rules and Regulations 415.22 (a)(1-4)

Based on observation and interviews conducted during the recertification and abbreviated survey (Case #664249), the facility did not ensure that posted menu items were served, that notification was provided when menu items were substituted and that individual food preferences were honored for five (5) (Resident #'s 11, 14, 40, 47, and 97) of five (5) residents reviewed. Specifically, residents were not served posted menu items, food preferences, or food items that were listed on the meal tray tickets. Additionally, residents were not notified of menu substitutions.this is evidenced by:The Facility Policy titled; Food and Nutrition revised 04/2024 documented that it was the policy of the facility to ensure that facility staff support the nutritional well-being of the residents while respecting an individual's right to make choices about his or her diet. The facility would provide each resident with a nourishing, palatable, well-balanced diet that met their daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Each resident would receive, and the facility would provide at least three meals a day.Resident #11Resident #11 was admitted to the facility with diagnoses of multiple sclerosis (a chronic, often debilitating disease of the central nervous system that disrupts the flow of information within the brain, and between the brain and bod), dysphagia (difficulty swallowing), and type 2 diabetes (a chronic condition where the body either does not produce enough insulin or cannot properly use the insulin it produces). The Minimum Data Set (an assessment tool) dated 6/26/2025, documented the that the resident was cognitively intact, could be understood, and could understand others.During an interview on 7/21/2025 at 12:50PM, Resident #11 stated the menu was sent around, but the meal was never correct. The kitchen served whatever they wanted to serve. They stated they were not given a chance to choose their lunch meal that day. Resident #11 stated when they would ask for an alternate, sometimes they were served something else, sometimes they were not. They stated they had not gotten tea for 8 months as per their preference. They further stated that they had gone to Resident Council and told them about their issues with the food/menu and nothing was done about it.During an observation on 7/21/2025 at 12:50PM, Resident #1 was served their lunch. The meal ticket read tator tots, but they were served mashed potatoes. They were also not served tea, as was indicated on the meal ticket.Resident #40Resident #40 was admitted to the facility with diagnoses of asthma (a respiratory condition marked by spasms in the lungs causing difficulty breathing), gastro-esophageal reflux disease (a condition in which acidic gastric fluid flows backward into the esophagus resulting in heartburn), and dysphagia (difficulty swallowing). The Minimum Data Set, dated [DATE], documented that the resident was cognitively intact, could be understood, and understand others.During Resident Council meeting on 7/22/2025 at 10:32 AM, Resident #40 stated that alternative items were frequently unavailable.During an interview on 7/28/2025 at 12:13 PM, Resident #40 stated that they rarely got a meat or protein item on their food tray. They stated that they had no choice on what they were served. They took what they were given. Resident #40 stated there were no choices and no advance menu. Resident #40 stated that after they were served eggs multiple times, although the resident was not able to eat eggs, they took their tray to the kitchen themselves, made the kitchen staff look at their tray, and their ticket which said, no eggs and asked them to explain why they continued to get eggs. Resident #40 stated the kitchen stopped sending eggs after that.During a tray sampling on 7/28/2025 at 12:05 PM, Resident #40's tray was provided. The meal ticket read peaches however, the mixed fruit cup was made up of both peaches and pears.Resident #47Resident #47 was admitted to the facility with diagnoses of fibromyalgia (a chronic disorder characterized by widespread pain and other symptoms such as fatigue, muscle stiffness, and insomnia), type 2 diabetes, and morbid obesity due to excess calories (a severe form of obesity characterized by an extremely high body mass index). The Minimum Data Set, dated [DATE], documented that the resident was cognitively intact, could be understood, and understood others.During an interview on 7/22/2025 at 12:38 PM, Resident #47 stated that they were told by kitchen staff that the kitchen was having problems with orders. They stated the Dietitian had offered to bring them a new menu to cross out items they did not like, but that never happened. They stated the menu had not changed since December 2024 and that residents could not ask for alternates, because the kitchen would often not have any. Resident #47 stated, you never knew what you would be served. Resident #47's roommate was present during the interview and agreed. During a tray sampling on 7/29/2025 at 8:15 AM, Resident #47's food tray was provided. The meal ticket documented that there would be nondairy creamer, orange juice, and cottage cheese. Coffee was observed to be served separately from the breakfast trays. Apple juice was provided, and there was no creamer or cottage cheese.During an interview on 7/21/2025 at 11:18 AM, Kitchen Director #1 stated the system they used allowed them to put allergies as well as likes and dislikes. It took time to ensure that when an item was listed as an allergy, it really was an allergy. Some residents did not like eggs or milk and were upset when they did not receive cake or baked goods. The system was now in a better place. Kitchen Director #1 stated they always had peanut butter and jelly sandwiches, cold cut sandwiches, burgers, and chicken patties available if a resident did not like what was on the menu.During an interview on 7/23/2025 at 1:27 PM, Kitchen Director #1 stated that they were no longer allowed to order directly from the distributers. Unfortunately, now when an order was placed, they did not know when the distributor was out of something until the order arrived. They stated they had to make changes to the menu on the fly because of this. Kitchen Director #1 further stated that corporate was setting up a procedure with the distributor where corporate would email the distributor to find out if food items were unavailable before the shipment was sent to the facility. If this was arranged, the kitchen would be able to make substitutions at that point. 10 New York Codes, Rules, and Regulation 415.14(c)(1-3)

Based on observations, record reviews, and interviews conducted during the recertification survey, the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. Specifically, the facility nursing staff did not have documentation of completed annual mandatory educations as listed in the Facility Assessment.This is evidenced by:The Facility assessment dated [DATE] documented Staff Training/Education and Competencies that were necessary to provide the level and types of care needed for the resident population: Resident's rights and facility responsibilities; Abuse, neglect and exploitation; Infection control; Culture change; In-service training for nurse aides no less than 12 hours per year, including dementia management training, and training for residents with cognitive impairments; Identification of resident changes in condition; and Cultural competencies.Additionally listed in the Facility Assessment were the Competencies, in parenthesis that it was not an inclusive list: Person-center care; Activities of daily living; Disaster planning and procedures; Infection control; Medication administration, Measurements; Resident assessment and examinations; Caring for persons with Alzheimer's or other dementia; Specialized care; Care for residents with mental and psychosocial disorders.Education records were provided for Licensed Practical Nurse #4, Licensed Practical Nurse #1, Licensed Practical Nurse #5, Certified Nurse Aide #4, Certified Nurse Aide #5, and Registered Nurse #1. All education records were noted to be incomplete for annual educations and varied in the number of educations provided.During an interview on 7/29/2025 at 9:08 AM, Licensed Practical Nurse #3 stated that there was no system in place that triggers the staff to know they have educations due. There was a pile of mandatory educations near the time clock and the staff were supposed to take their education, do the test and sign that they did it. Licensed Practical Nurse #3 stated they had no time to get their educations done. There was no education given for Certified Nurse Aides that separated education for care of demented residents versus residents that had a mental illness as far as they knew. Licensed Practical Nurse #3 stated that it had been a while since they had been educated on the topic. They stated they could not say when the last time they were educated on the topic but the last time it happened, it had been the first time in a long time that it had happened at all.During an interview on 7/29/2025 at 9:30 AM, Staffing Coordinator #1 stated that they were not involved with education of nursing staff but knew that there were baskets full of handouts staff were supposed to take, complete, and return to Director of Nursing #1 who was also the Nurse Educator.During an interview on 7/30/2025 at 10:04 AM, Director of Nursing #1 who also the Nurse Educator, stated that they had been the nurse educator since September 2024. The new Assistant Director of Nursing was being trained to take over as Nurse Educator. Assistant Director of Nursing #1, also the Infection Preventionist, had just completed taking the Preventionist course and now that they had finished that, they were working on getting them ready take over education in the building. They stated When Director of Nursing #1 started, the annual educations that had already been done were unable to be located so they had to start from scratch and create a tracking system. Director of Nursing #1 stated that getting educations organized was their weekend project and provided tracking binders, sporadically filled out, as examples of what the intended end product would look like. Director of Nursing #1 stated that monthly educations were put out near the time clock for staff to do and sign off that they were done. Director of Nursing #1 stated that they did not have time to audit the educations as much as they should and that there were not enough staff to pull them off the units to do education at this time. Director of Nursing #1 stated they had not been at the facility for a year and therefore was unable to speak to yearly evaluations as they had not yet been completed. Educations have been ad hoc based on house wide practices noted to be problematic. They stated they deal with issues as they popped up at this time.Director of Nursing #1 stated they had plans to do education on the difference between caring for residents with mental illnesses versus residents with dementia and Alzheimer's. They stated they also wanted to do training on personal safety when dealing with aggressive residents.During an interview on 7/30/2025 at 11:41 AM, Corporate Administrator #1 stated that the facility needed a lot of work after their last survey and that the staff had been focusing on the major problem areas and creating organization for processes to be implemented. They stated educations would be done. The focus had been working on behavior management and medication reduction. 10 New York Codes, Rules, and Regulations 415.26(c)(1)(iv)

Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for two (2), (South and East Units) of three (3) medication rooms reviewed, and four (4) (East Unit Cart #1; North Unit Cart #1 and #2; South Unit Cart #1) of six (6) medication carts reviewed. Specifically, (a.) one (1) open bottle of purified protein derivative (PPD) had expired; (b.) one (1) vial of COVID 19 vaccine mRNA Comirnaty had expired; (c.) Jevity tube feed formula was stored in resident's room; (d.) pre-poured medication was found stored in medication cart; (e.) one (1) empty inhaler was found in cart. (f.) two (2) open inhalers had no open and or expiration date; (g.) three (3) open bottle of eye drops had no open and or expiration date, and (h.) one (1) bottle of eyedrops belonging to cart #1 found in cart #2.This is evidenced by:The Facility ' s Policy and Procedure titled, Storage of Drugs, effective 3/2023, documented drugs shall be stored in an orderly manner in cabinets, drawers or carts or sufficient size to prevent crowding. All medications and other drugs, including treatment items, shall be stored in a locked cabinet inaccessible to residents and visitors. Drugs shall not be kept on hand after the expiration date on the label, and no contaminated or deteriorated drugs shall be available. Drug storage areas in the medication cart shall not contain non-drug items.The Facility ' s Policy and Procedure titled; administering medications, effective 1/2024, documented a medication must never be left at the bedside or be out of sight of the medication nurse. Administration of Controlled Substances: The medication is prepared or administration at the resident's bedside. Immediately following preparation of the medication for administration, the amount to be administered is recorded on the specific resident's Controlled Substance Inventory form. Medication administration is recorded after the administration of the medication to the resident. If for any reason, the resident refuses, the medication becomes contaminated, or there is a medical reason to withhold the medication, then the medication documentation is entered into the Medication Administration Record indicating not given and the reason why. If the controlled medication is not given, then the medication nurse needs to seek another licensed nurse to witness the appropriate ad irretrievable wasting of the controlled drug. Both nurses' signatures are required as documentation of this event, both on the controlled substance log and in the electronic medication administration record.During an observation on [DATE] at 2:55 PM, the North Unit Medication Room refrigerator contained one (1) open bottle of purified protein derivative (PPD) with open date of [DATE]. A tuberculin PPD vial, once opened, should be discarded 30 days after opening or when it reaches the manufacturer's expiration date, whichever comes first Per Manufacturer's insert A vial of TUBERSOL which has been entered and in use for 30 days should be discarded.During an observation on [DATE] at 3:03 PM, East Unit Medication Cart #2 contained a pre-poured medication cup with one (1) clonazepam 0.5 milligram tablet prescribed for Resident #8. The medication was signed out in narcotic book and in electronic medical record at 1:19 PM. The medication was brought and administered to the resident at 2:26 PM. The cart also contained one (1) empty Atrovent inhaler; one (1) Atrovent inhaler and one (1) Dulera inhaler both had no open and or expiration dates.During an observation on [DATE] at 8:19 AM, North Unit Medication Cart #1 contained three (3) bottles of Latanoprost eye drops with no open and or expiration date. Three (3) open over the counter medications had no open dates (Tylenol, Senna and Multivitamins). During an observation on [DATE] at 8:30 AM, North Unit Medication Cart #2 contained one (1) bottle of Latanoprost eyedrops belonging to cart #1 found in cart #2.During an observation on [DATE] at 11:20 AM, South Unit Medication Room refrigerator contained COVID 19 vaccine mRNA Comirnaty with an expiration date of [DATE].During an observation on [DATE] at 2:18 PM, four (4) bottles of Jevity Tube Feed were at Resident #50's bedside. One (1) of those bottles were opened with approximately 200 milliliters remaining in bottle. During an interview on [DATE] at 03:03 PM, Licensed Practical Nurse #2 stated when the medication was brought to the resident, they were asleep. Licensed Practical Nurse #2 stated they should have awakened resident and given the medication.During an interview on [DATE] at 11:22 AM, Licensed Practical Nurse #3 stated the over-the-counter stock medications should be labeled with an open date. During an interview on [DATE] at 2:41 PM, Director of Nursing #1 stated per the Medication Administration Policy nurses cannot pre-pour medications. If a medication is pre-poured and the resident became unavailable or refused, the medication should be discarded. It is the responsibility of each nurse to ensure their mediation cart is clean and orderly prior to passing medications. They also stated upon opening a multivial medication, the medication should be labeled with open and expiration dates. Director of Nursing #1 stated Tube Feed formula is stored in the medication room. Tube feedings should not be left at the bedside unless it is a continuous feed infusing via pump. 10 New York Codes, Rules, and Regulations 415.18(d)

Based on observation, record review, and interviews conducted during recertification surveys, the facility did not ensure action as a fiduciary (trustee) of the resident's funds and hold, safeguard, manage, and account for the residents' personal funds deposited with the facility. Specifically, seven (7) out of eight (8) residents at a surveyor led Resident Council meeting reported they were not able to get money from their resident funds account because the money in the cash box at the reception desk would be empty, even if the arrangements for withdrawal were made in advance.This is evidenced by:The Facility's Policy titled, Resident Finance dated 9/2024, documented the facility would maintain written records of all financial arrangements with the resident or responsible family member and/or source of payment; copies of monthly statements would be provided to the resident, family, and/or source of payment on request. The facility would provide to the residents the service of holding monies in trust. The facility would maintain an individual resident Personal Income Account ledger recording the deposit and withdrawal of funds which would be available to residents or legal representative at the Reception Desk in the Lobby, seven days a week, 24 hours a day. Written receipts would be given for all personal possessions and funds received or deposited with this facility. Petty cash was only disbursed on the resident's signatures or Power of Attorney. However, if the medical records indicated that the resident was unable to sign, the Nurse or the Social Worker would sign for the resident.The Facility's Policy titled, Resident Personal Income Account, dated 9/2024, documented all Personal Income Account funds were deposited directly into a resident account at a facility designated bank and designated Personal Income Account. A cash reserve would be kept in the Petty Cash fund. Records of the individual resident's account would be maintained. Deposits and withdrawals could be made at the Reception Desk in the Lobby, seven days a week, 24 hours a day.During the surveyor led Resident Council meeting on 7/23/2025 at 9:38 AM, residents stated they had to make arrangements in advance to get their money and frequently when they went to get the money, they were told there was none. The vending machines cost money so the residents could not use the vending machines because they could not get money.During an interview on 7/25/2025 at 10:00 AM, Administrator #1 stated personal funds from corporate were kept in a box at the reception desk. Corporate brings money once a week, which was usually $500 to $600 dollars in $5s and $1s. Sometimes the delivery came every other week. If the box ran out of money and a resident wanted money before the delivery came, Administrator #1 stated that they gave the residents a few bucks because they usually only wanted to use the vending machine. They stated there was an accounting sheet they used to track resident funds. Administrator #1 stated relative of the owner managed accounts off site and their contact information was provided.During an interview on 7/25/2025 at 12:48 PM, Receptionist #1 stated that residents needed to sign out their money. They stated they kept a list of trial balances and the sign out sheet was sent to Corporate Personal Funds Manager #1. Receptionist #1 stated that when they run out of room on the balance sheets, they had to call and ask for a new sheet. Copies of the current sheet at the time of the interview was provided. The sheets provided listed the resident name, their current balance, the resident's monthly allowance amounts, and the resident's account status. The sheets provided had handwritten dates and amounts written under account status and the balances were crossed out and new balance amounts handwritten in next to them (and around them as space allowed) which indicated what the new balances were after withdrawals were made. Receptionist #1 verified the handwritten alterations were written by them at the time of the resident's withdrawal. Receptionist #1 stated that a corporate person came with envelope full of cash, but there was no set time as to when they were coming. The cash envelope got handed to Administrator #1, who gave it to Receptionist #1 who kept it in the locked box. The cash box, drawer the box was kept in and the door to the reception office were all separately locked. During the interview, Receptionist #1 opened the drawer without unlocking it and the lock box was wide open. Receptionist #1 stated that they thought they had the only key to the box. The drawer and door may have had other keys, but they could not say for sure. Receptionist #1 stated that maybe the supervisor had keys. The lock box shown during the interview had about $80 in $20 bills from making change for people, about $100 in $1 dollar bills and $50 in $5 dollar bills. It was noted that these amounts were not exact counts, just quickly calculated based on what Receptionist #1 stated and thumbed through. Receptionist #1 stated that the cash usually lasted about two weeks. If they ran out, it usually took a day or two for the envelope of money to be delivered.During an interview on 7/28/2025 at 10:52 AM, Corporate Personal Funds Manager #1 stated that Receptionist #1 kept the resident funds. The tally list got sent from Receptionist #1 weekly so that they could reconcile the balances. A driver delivered money weekly, sometimes 10 days, sometimes 2 weeks. Corporate Personal Funds Manager #1 stated that they just got the list Monday or Tuesday and that they needed to reconcile. The list provided by Receptionist #1 was dated 7/07/2025. Corporate Personal Funds Manager #1 stated that if they did not get the list after a week or two, they would reach out to the facility. They stated residents should have been able to access their funds 8 AM through 5 PM, Monday through Friday. On the weekends there was a lock box on the unit that the unit manager had access to. Corporate Personal Funds Manager #1' stated to their understanding finances were mostly done when the Receptionist #1 was there. Corporate Personal Funds Manager #1 stated that they had heard that money was running low at times, and it could take a day or two to get it replenished, but they had not heard no money available for residents. If a resident wanted a large sum of money, they would have to arrange it in advance because it would be sent separately from the facility funds so it would not get mixed into the facility pot. They stated residents could not take more than $50 out without advance arrangement and that was discussed with residents when they were admitted and the arrangements for delivery were made with social work. Corporate Personal Funds Manager #1 stated that Receptionist #1 was supposed to call when the cash box was $110 or less.During an interview on 7/30/2025 at 11:41 AM, Corporate Administrator #1 stated that resident financial issues were not known to Corporate Administrator #1, but they stated they would be bringing it to corporate teams. They stated they were big on making processes for improvement but were struggling to have staff to implement the processes, which was why there were staff in management positions contributing to the resident care processes in the facility. 10 New York Code Rules and Regulations 415.3(g)(1)

Based on observations, record reviews, and interviews conducted during the recertification and abbreviated survey (Case # 664249), the facility did not ensure that food and drink were palatable and attractive for seven (7) (Resident #s 6, 14, 19, 40, 47, 87, and 97) of seven (7) residents reviewed for palatable and attractive food and drink. Specifically, Resident #s 6, 14, 19, 40, 47, 87, and 97 complained of food being cold, unattractive, and not palatable. This is evidenced by: Facility Policy titled, Food Safety Requirements Policy, last revised 5/01/2025, documented that it was the policy of this facility to provide safe and sanitary storage, handling, and consumption of all food including food and fluids brought to residents by family and other visitors. Additionally, the facility procures food from sources approved or considered satisfactory by federal, state or local authorities. This included storage, preparations, distribution, and serving food in accordance with professional standard for food service safety.Facility Policy titled, Food and Nutrition Services, last revised 4/2024, documented that it was the policy of the facility to ensure that facility staff supports the nutritional well-being of the residents while respecting an individual's right to make choices about their diet. The facility would provide each resident with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Suitable, nourishing alternative meals and snacks would be provided to residents who wanted to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care.Resident #6Resident # 6 was admitted to the facility with diagnoses of type 2 diabetes (a chronic condition where the body either doesn't produce enough insulin or can't properly use the insulin it produces), severe morbid obesity (a severe form of obesity characterized by an extremely high body mass index), and hypertension (high blood pressure). The Minimum Data Set (an assessment tool) dated 3/24/2025, documented that the resident was cognitively intact, could be understood, and understand others.During Resident Council meeting on 7/22/2025 at 10:32 AM, Resident #6 stated that their food was unappetizing, and that alternative items were frequently unavailable. Additionally, Resident #6 believed that the portions were too small, and the juice had no flavor.Resident #40Resident #40 was admitted to the facility with diagnoses of asthma (a respiratory condition marked by spasms in the lungs causing difficulty breathing), gastro-esophageal reflux disease (a condition in which acidic gastric fluid flows backward into the esophagus resulting in heartburn), and dysphagia (difficulty swallowing). The Minimum Data Set, dated [DATE], documented that the resident had intact cognition, could be understood, and understand others.During Resident Council meeting on 7/22/2025 at 10:32 AM, Resident #40 stated that their food was unappetizing, and that alternative items were frequently unavailable.During an interview on 7/28/2025 at 12:13 PM, Resident #40 stated that they rarely got meat or protein item on their tray. Resident #40 stated that they had no choice on what they were given. Resident #40 stated they took what staff gave them. There were no choices, and no advance menu. Resident #40 stated that after they were served eggs multiple times, and the resident was not able to eat eggs, the resident took their tray to the kitchen themselves, made the kitchen staff look at their tray, and their ticket which said, no eggs and asked them to explain to why Resident #40 continued to get eggs. Resident #40 stated after they did that, the kitchen stopped sending eggs to them.Resident #47Resident #47 was admitted to the facility with diagnoses of fibromyalgia (a chronic disorder characterized by widespread pain and other symptoms such as fatigue, muscle stiffness, and insomnia), type 2 diabetes (a chronic condition where the body either does not produce enough insulin or cannot properly use the insulin it produces), and morbid obesity due to excess calories (a severe form of obesity characterized by an extremely high body mass index). The Minimum Data Set, dated [DATE], documented that the resident had intact cognition, could be understood, and understand others.During Resident Council meeting on 7/22/2025 at 10:32 AM, Resident #47 stated that their food was unappetizing, and that alternative items were frequently unavailable.During an interview on 7/22/2025 at 12:38 PM, Resident #47 stated the food was bad. Food was burnt or raw. Vegetables were overcooked. Resident #47 stated they were supposed to get double protein, but usually only got one serving and were lucky if they got a salad once a month. Resident #47 stated that the kitchen staff stated they were having problems with orders. The facility Nutritionist stated they would bring a new menu to cross out things Resident #47 did not like, but that never happened. The menu had not changed since December 2024. People could not ask for alternates, because the kitchen did not usually have them.During an interview on 7/29/2025 at 8:20 AM, Resident #47 agreed to allow this surveyor to test their tray for temperature and taste, but only if they could see what was on it before it was taken because they did not believe that the kitchen would be able to provide a replacement tray containing the same items.During a lunch observation on 7/21/2025 at 1:29 PM, Resident #13's meal ticket was observed to say coleslaw, however the resident was not served coleslaw. They were served what was observed to look like mechanically soft beans. During a tray sampling on 7/28/2025 at 12:05 PM, Resident #40's tray was provided. The meal ticket documented that there would be coffee available on the tray. No coffee was noted. Resident #40 stated they hand out coffee separately from the trays. Additionally, the tray ticket stated peaches however the mixed fruit cup was peaches and pears mixed. The lunch provided was tested for taste and temperature and the results were as follows: Broccoli 115.9 degrees, macaroni and cheese 140.5 degrees, mixed peaches and pears 77.9 degrees, and reduced fat milk 61.2 degrees. All items had their expected consistency.During a tray sampling on 7/29/2025 at 8:15 AM, Resident #47's tray was provided. The meal ticket documented that there would be nondairy creamer, orange juice, and cottage cheese. Coffee was observed to be served separately from the breakfast trays. Apple juice was provided, there was no creamer or cottage cheese. The breakfast provided was tested for taste and temperature and the results were as follows: Fruit yogurt 66.8 degrees, 2 slices of French toast 103.1 degrees, 2 breakfast sausage links 96.6 degrees, apple juice 68.3 degrees, a pat of butter 78.1 degrees, and skim milk 58.6 degrees. The butter was nearly melted.During an interview on 7/23/2025 at 1:27 PM, Kitchen Director #1 stated that they were no longer allowed to order directly from the distributers. Unfortunately, now when they placed the order, they did not know if the kitchen would be out of anything until the order arrived. When that happened Kitchen Director #1 stated they had to make changes to the menu on the fly. Corporate had said that they were setting something up with the shipping company so that they could email someone before the shipment went out to let the facility know if things would be missing and hopefully after that happened, the facility would be able to make substitutions for residents. 10 New York Code of Rules and Regulations 415.14(d)(1)(2)

Based on observations, record review, and interviews during a recertification survey, the facility did not ensure that each resident received, and the facility provided food that accommodated resident allergies, intolerances, and preferences, and appealing options of similar nutritive value to residents who choose not to eat food that was initially served or who requested a different meal choice. Specifically, seven (7) out of eight (8) residents at a surveyor led Resident Council meeting reported they were not able to get substitutions or an alternative menu option.This is evidenced by: A facility policy titled Food and Nutrition Services, date revised 4/2024, documented that it was the policy of the facility to ensure that facility staff supports the nutritional well-being of the residents while respecting an individual's right to make choices about his or her diet. Under procedures, documented was the following. The facility would provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. 10. Suitable, nourishing alternative meals and snacks would be provided to residents who wanted to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care.Resident #6Resident # 6 was admitted to the facility with diagnoses of type 2 diabetes (a chronic condition where the body either does not produce enough insulin or cannot properly use the insulin it produces), severe morbid obesity (a severe form of obesity characterized by an extremely high body mass index), and hypertension (high blood pressure). The Minimum Data Set (an assessment tool) dated 3/24/2025, documented that the resident was cognitively intact, could be understood, and understand others.During Resident Council meeting on 7/22/2025 at 10:32 AM, Resident #6 stated that their food was unappetizing, and that alternative items were frequently unavailable.Resident #40Resident #40 was admitted to the facility with diagnoses of asthma (a respiratory condition marked by spasms in the lungs causing difficulty breathing), gastro-esophageal reflux disease (a condition in which acidic gastric fluid flows backward into the esophagus resulting in heartburn), and dysphagia (difficulty swallowing). The Minimum Data Set, dated [DATE], documented that the resident was cognitively intact, could be understood, and understand others.During Resident Council meeting on 7/22/2025 at 10:32 AM, Resident #40 stated that that alternative items were frequently unavailable.During an interview on 7/28/2025 at 12:13 PM, Resident #40 stated that they rarely got meat or protein item on their tray. Resident #40 stated that they had no choice on what they were given. Resident #40 stated they take what they gave them. There were no choices, and no advance menu. Resident #40 stated that after they were served eggs multiple times, and the resident could not eat eggs, the resident took their tray to the kitchen themselves, made the kitchen staff look at their tray, and their ticket which said, no eggs and asked them to explain to why Resident #40 continued to get eggs. Resident #40 stated after they did that, the kitchen stopped sending eggs to them.Resident #47Resident #47 was admitted to the facility with diagnoses of fibromyalgia (a chronic disorder characterized by widespread pain and other symptoms such as fatigue, muscle stiffness, and insomnia), type 2 diabetes (a chronic condition where the body either doesn't produce enough insulin or can't properly use the insulin it produces), and morbid obesity due to excess calories (a severe form of obesity characterized by an extremely high body mass index). The Minimum Data Set, dated [DATE], documented that the resident was cognitively intact, could be understood, and understand others.During Resident Council meeting on 7/22/2025 at 10:32 AM, Resident #47 stated that their food was unappetizing, and that alternative items were frequently unavailable.During an interview on 7/22/2025 at 12:38 PM, Resident #47 stated the food was bad. Food was burnt or raw. Vegetables were overcooked. Resident #47 stated they were supposed to get double protein, but usually only got one serving and were lucky if they got a salad once a month. Resident #47 stated that the kitchen staff stated they were having problems with orders. The facility Nutritionist stated they would bring a new menu to cross out things Resident #47 did not like, but that never happened. The menu had not changed since December 2024. They stated residents could not ask for alternate, because the kitchen did not usually have them.During an interview on 7/23/2025 at 1:27 PM, Kitchen Director #1 stated that they were no longer allowed to order directly from the distributers. Unfortunately, now when they placed the order, they did not know if the kitchen would be out of anything until the order arrived. When that happened Kitchen Director #1 stated they had to make changes to the menu on the fly. Corporate had said that they were setting something up with the shipping company so that they could email someone before the shipment went out to let the facility know if things would be missing and hopefully after that happened, the facility would be able to make substitutions for residents. 10 New York Code of Rules and Regulations 415.14(d)(1)(2)

Based on observations, record review, and interviews conducted during the recertification and abbreviated survey (664249), the facility did not ensure provision of sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, the facility did not have the desired staffing levels for Licensed Practical Nurses and Certified Nurse Aides, and Registered Nurses as documented in the Facility Assessment for 13 of 13 days from 7/13/2025 to 7/25/2025. As a result of the insufficient staffing, nursing staff reported that indirect and direct resident care activities were unable to be completed. This included the inability to develop comprehensive care plans and the inability to supervise the implementation of resident-specific care plans. Additionally, multiple residents complained that they were not given care or had to wait excessively long times to get staff assistance.This is evidenced by:Cross Referenced: to F656: Comprehensive Care Plan, F657: Care Plan Timing and Revision, F677: Activities of Daily Living for Dependent Residents, F842: Resident RecordsThe facility census upon entry to the facility on 7/21/2025 was 110.The Facility Assessment last updated 2/26/2025, documented minimum staff required across 3 units. The Facility Assessment documented that the maximum capacity was 120 residents and that the average daily census was 92 percent occupation. The minimum staff documented as required to care for residents in a 24-hour period was 6-9 Licensed Practical Nurses, 9-27 Certified Nurse Aides, and 1 Registered Nurse (required for 8 hours), and that 3 Other nursing personnel e.g. those with administrative duties were required, with no documentation of the required time those 3 other nursing staff would be available.A review of Staffing Sheets dated 7/13/2025 to 7/25/2025 documented the following total staff numbers for a 24-hour period:7/13/2025 - 1 Registered Nurses, 11 Licensed Practical Nurses, 10 Certified Nurse Aides7/14/2025 - 3 Registered Nurses, 5 Licensed Practical Nurses, 10 Certified Nurse Aides7/15/2025 - 3 Registered Nurses, 6 Licensed Practical Nurses, 11 Certified Nurse Aides7/16/2025 - 3 Registered Nurses, 7 Licensed Practical Nurses, 10 Certified Nurse Aides7/17/2025 - 4 Registered Nurses, 4 Licensed Practical Nurses, 10 Certified Nurse Aides7/18/2025 - 3 Registered Nurses, 7 Licensed Practical Nurses, 6 Certified Nurse Aides7/19/2025 - 1 Registered Nurses, 4 Licensed Practical Nurses, 7 Certified Nurse Aides7/20/2025 - 1 Registered Nurses, 8 Licensed Practical Nurses, 7 Certified Nurse Aides7/21/2025 - 3 Registered Nurses, 6 Licensed Practical Nurses, 9 Certified Nurse Aides7/22/2025 - 3 Registered Nurses, 4 Licensed Practical Nurses, 10 Certified Nurse Aides7/23/2025 - 4 Registered Nurses, 6 Licensed Practical Nurses, 13 Certified Nurse Aides7/24/2025 - 4 Registered Nurses, 6 Licensed Practical Nurses, 12 Certified Nurse Aides7/25/2025 - 3 Registered Nurses, 2 Licensed Practical Nurses, 5 Certified Nurse AidesDuring general observations on 7/21/2025 at 11:40 AM, the North unit was noted to have one Licensed Practical Nurse and 2 Certified Nurse Aides on the unit.During general observations on 7/25/2025 at 8:19 AM, the North unit was noted to have one Licensed Practical Nurse and 2 Certified Nurse Aides.During general observations on 7/28/2025 at 9:08 AM, the South unit was noted to have one Licensed Practical Nurse and 2 Certified Nurse Aides.During an interview on 7/21/2025 at 11:54 AM, Resident #97 stated that they had been at the facility for 3 years. Resident #97 stated they did not have agency staff available. House staff were mandated to work frequently. Usually there was only one aide available on the unit. It was shocking that they had two (2) aides today. Sometimes there were no aides at night. Residents did not get to shower, and Resident #97 had not had a shower in two (2) weeks. It was normal for 1 aide on the floor and on the weekends, there were sometimes no nurses available.During an interview on 7/21/2025 at 12:33 PM, Resident #3 stated that the facility did not have enough staff to ask the resident what they needed. They had agency people there sometimes, but when there was one aide or one nurse on the floor, there was not anyone to provide the basic care to any resident. If there was one nurse aide, then it was unsafe. Sometimes there were no nurse on the floor. During an interview on 7/21/2025 at 2:21 PM, Resident #8 stated that there were very little staff, and they needed to wait long times for assistance. Resident #8 stated that there was only 1 aide all the time. During an interview on 7/22/2025 at 10:55 AM, Resident #9 stated that there was not enough staff. That day Resident #9 stated there was 1 unit manager who was passing meds and 2 Certified Nurse Aides. Resident #9 stated that they had not had no morning care as of 10:25 am and stated was sitting in their wet bed since last night.During an interview on 7/22/2025 at 11:31 AM, Resident #16 stated that they needed help to the bathroom and knew they did not have enough workers to answer lights quick enough. Resident #16 stated that sometimes they waited for an hour for assistance.During an interview on 7/22/2025 at 12:34 PM, Resident #11 stated that they had to wait long times for assistance. Resident #11 stated that there was only 1 or 2 staff members for 40 residents. Resident #11 stated that their shower was regularly given late or sometimes skipped all together.During an interview on 7/22/2025 at 1:07 PM, Resident #34 stated that there was usually only 1 aide on, they had to wait long time for an aide most of time.During an interview on 7/23/2025 at 10:00 AM, Resident #86 stated that staff did not answer call lights and questioned if the staff knew how to use the call bell system. Resident #86 stated that they sit near the nursing station so that they would be sure the staff paid attention to them.During an interview on 7/23/2025 at 9:17 AM, Resident #77 stated that the facility did not have enough staff, especially at night. Resident #77 stated that they did not get changed or even checked on at night because there was not enough staff. Resident #77 stated that staff were rude to them because they assumed the resident had dementia. They stated staff hung up the phone when their spouse called the unit.During an interview on 7/24/2025 at 12:13 PM, Certified Nurse Aide #3 stated that they had no time to stop and take a lunch break because they had so much work to do. Certified Nurse Aide #3 stated they might get 15 minutes of a break daily.During an interview on 7/29/2025 at 9:08 AM, Licensed Practical Nurse #3 stated that the Director of Nursing was supposed to update care plans when asked why care plans did not appear to have been updated. Licensed Practical Nurse #3 stated that they struggled to get anything other than resident care done. They did not have time to get their annual educations done, nor could they speak to the educations other what nursing staff had received.During an interview on 7/29/2025 at 9:30 AM, Staffing Coordinator #1 stated that staffing was a significant issue. They were unable to complete a schedule in advance and was frequently working to create a weekend schedule on the Monday of the same upcoming weekend. Staff would be mandated up to 16 hours as needed. It used to be that staff were mandated during emergency situations, like snowstorms, but it was becoming regular practice due to lack of staff in general. Bonuses were given for volunteering to pick up a shift or if the staff member was mandated. The bonus used to be offered only on Fridays, Saturdays, and Sundays. However, for roughly the last two months, the bonus was offered every day. There was also a bonus called the All Alone bonus, which was given when the staff member was the only one for the entire unit. Staffing Coordinator #1 stated that they tried to make deals with staff members by offering to swap shifts when it was possible to do so. Staffing coordinator stated that there were two staffing agencies that the facility employed. When asked if there were agencies that would not work with the facility because they had trouble getting paid, Staff Coordinator stated that it was told that was a corporate problem. There was someone that was supposed to pay the bill and Staffing Coordinator #1 did not know what had happened, but the result was there were agencies that would not work at the facility. There were also issues regarding the remote location of the facility and how agency staff did not want to come out that far or could not, due to lack of public transportation. There were no vans or buses that could pick up staff from the nearest bus stop in town. When shown the Facility Assessment staffing minimum, Staffing Coordinator #1 stated that they had not ever seen the Facility assessment and never had nine (9) nurses and 27 certified nurse aides on any day. Staffing Coordinator #1 stated that they aimed to have 2 nurses and 2 certified nurse aides per unit. Sometimes, they would be able to get a third person on the unit. Staffing Coordinator #1 stated that coordinating with a local school, college or career school to help recruiting efforts was brought up in morning meetings, but they did not know if anything had been done. During an interview on 7/30/2025 at 10:04 AM, Director of Nursing #1 stated that they worked every day. If they only worked Monday through Friday, they would not have time to do all the things they had to do. Director of Nursing #1 stated they worked regularly off hours and on the weekend. Director of Nursing #1 stated that something had changed in the nursing field. The last five (5) interviews for nurses they had scheduled did not show up or call to cancel their interview. Director of Nursing #1 stated that they struggled to get all their work done because there were so many things to do, including helping with resident care. Director of Nursing #1 stated that staff educations were behind because there were not enough staff to pull them off the units to do education. Director of Nursing #1 stated they had not been at the facility for a full year yet and to the best of their knowledge there were a total of six (6) Registered Nurses employed at the building and most of the time, those nurses were working on carts on the units and therefore struggled to do jobs that were specific to Registered Nurses. Director of Nursing #1 stated that they were dealing with issues as they arose and framed educations to fit the problems. Director of Nursing #1 stated that when a new admit comes in during the day, social work did the talking to family about inventorying personal items. When 4 residents that were admitted without items being inventoried was presented, Director of Nursing #1 stated staffing was probably the issue. Director of Nursing #1 stated that working with agencies had been discussed with Administrator #1, and that they were concerned that current facility staff were dedicated to the facility but were starting to look burnt out. Director of Nursing #1 stated that they advocated for their staff often and arranged for bonuses above and beyond the established bonuses. Director of Nursing #1 stated they had also reached out to people they knew that worked in healthcare and there were referral bonuses for any staff member that brought someone in.During an interview on 7/30/2025 at 11:41 AM, Corporate Administrator #1 stated that staffing was an issue everywhere. The facility had ads on various online platforms for positions. It was their expectation that everyone in the facility was in an all-hands-on deck situation. It was expected that everyone needed to pitch in and help each other. If the Certified Nurse Aides were struggling to get people out of bed, Physical Therapists and Occupational Therapists should have been helping them. Resident care was considered top priority and believed that if the therapists were helping, the Certified Nurse Aides would have enough time to complete both resident care and the charting their job required. Corporate Administrator #1 stated that the facility was working on hiring Unit Assistants so that they could learn to be Certified Nurse Aides and grow staff from within the ranks. The facility also relied on word of mouth by staff to refer people to them. Corporate Administrator #1 stated that Administrator #1 shared the same ethos and was very involved in the day-to-day management of the facility. Corporate Administrator #1 believed that it was important for staff to see everyone working together and that it raised the moral of the building. 10 New York Code Rules and Regulations 415.13(a)(1)(i-iii)

Based on record review and interviews conducted during a recertification survey, the facility did not ensure the Quality Assurance and Performance Improvement committee developed and implemented appropriate plans of action to correct identified quality deficiencies as well as opportunities for improvement. Specifically, the facility had repeat deficiencies in the areas of Baseline Care Plan (F655), Develop/Implement Comprehensive Care Plan (F656), Care Plan Timing and Revision (657), staffing (F725), Competent Nursing Staff (726), and Label/store/Drugs and Biologicals (F761).This is evidenced by:The Facility Quality Assurance and Improvement Policy dated 05/2025, documented it is the policy of the facility to evaluate our residents experience of the services facility provides to determine how the experience can be improved, to realize our vision of innovation and continuous improvement in the delivery of care. To accomplish our purpose, we engage all members of each service to evaluate the quality of care we provide to our residents and hold ourselves to the highest standard by continually improving the care of the resident's behalf. Documented in Element III - Feedback, Data Systems and Monitoring, was that following: Pertinent resident care information would be reviewed daily by Interdisciplinary Team; daily morning minutes (running log or needed follow up for each unit) will be reviewed and revised on an ongoing basis by Interdisciplinary Team; any areas that needed immediate Performance Improvement would be identified and followed up by Quality Assurance Steering Committee as indicated; the facility would utilize multiple data sources to monitor performance including Quality Measures, State and National benchmarks as well as tracking and investigating any adverse events affecting residents. Feedback from staff would be encouraged and welcomed via Unit Quality Improvement rounds, regular meetings and open door policy by Department Heads and Administration. Quality Improvement alert would be distributed to each Department Head for staff educations as indicated.During an interview on 7/30/2025 at 10:04 AM, Director of Nursing #1 stated that they had been the nurse educator since September 2024. The new Assistant Director of Nursing who started in March 2025 was in training to take on the role. Assistant Director of Nursing #1 started as the Infection Control Preventionist upon hiring at the facility. That certification had recently been completed and therefore, they would be able to focus on education now. They stated during the onsite survey, there was a particularly high instance of late medications, and because of that, Assistant Director of Nursing #1 was working with the nursing staff to ensure better performance. The gap in the system, which lead to the outcome of a high medication error rate, was not known to the Director of Nursing or the Corporate Administrator until it had occurred while survey was happening. Director of Nursing #1 stated that they had to work on facility related tasks every day, including off hours and weekends because there were so many things that needed to be done. The previous administration and high-level nursing left minimal information and a mess when they left, and the new staff were brought in. Director of Nursing #1 stated they felt supported by their corporate structure, but the culture of nursing care had changed. Director of Nursing #1 stated that their door was always open for residents and staff to come and talk to them regarding issues within the facility. Director of Nursing #1 stated that they had not been employed at the facility for a full year yet and there were so many issues when they arrived, that they started with what they believed to be the most egregious issues and went from there. There were not enough staff currently to be able to pull them off the units to do educations or one on one performance improvement plans. Director of Nursing #1 also stated that they were not able to audit staff educations as often as they should because of the amount of work they needed to do. Educations had been ad hoc based on house wide practices noted to be problematic.During an interview on 7/30/2025 at 11:41 AM, Corporate Administrator #1 stated that they were treating the facility as all hands-on deck. It was expected that everyone in the building needed to pitch in. Quality Assurance Performance Improvement met every three months. Some corporate people came to the meetings; however, the Regional Director of Operations had just left the organization so Corporate Administrator #1 was covering a lot of people's positions. Corporate Administrator #1 stated that they would be at the next Quality Assurance Performance Improvement meeting because they were in the facility for the survey. Performance Improvement Plans were done with people as needed. Working on reducing fall rates, behavior management, and psychotropic medications were the focus when they all started at the facility. Corporate Administrator #1 stated that when issues were identified, the Performance Improvement Plan would start. Some of the issues identified during the survey process were not known to Corporate Administrator #1 prior to being pointed out. Issues like inventorying resident belongings was known because it was brought up by resident council. Food supply issues, and resident financial issues were not known to Corporate Administrator #1, but they stated they would be bringing it to corporate teams. Corporate Administrator #1 offered the information that they were big on making processes for improvement but were struggling to have staff to implement the processes, which was why there were staff in management positions contributing to the resident care processes in the facility. 10 New York Code Rules and Regulations 415.27(a.c)

Based on observation, record review, and interviews conducted during the recertification and abbreviated surveys (Case #664249), the facility did not maintain a pest-free environment and an effective pest control program on two (2) of two (2) resident units. Specifically, insect infestation was found in resident rooms, the main kitchen, and staff areas.This is evidenced by:During observations on 7/21/2025 through 7/30/2025 between 8:00 AM and 5:00 PM fly activity was always identified in the below locations throughout the duration of the survey at various intensities noted in the North Unit activity room which was provided to the team as the survey team meeting area.During initial interviews on 7/21/2025 at 10:58 AM, flies were noted to be in the room of Resident #10.During an interview on 7/21/2025 at 12:22 PM, flies were noted to be in the office of Regional Nursing Coordinator #1.During initial interviews on 7/21/2025 at 1:22 PM, small flying insects were noted in the bathroom of Resident #87.During a test tray observation on 7/29/2025 at 8:16 AM, flies were noted in the room of Resident #47.There was no evidence that the facility maintained a Pest control Management book.During an interview on 7/21/2025 at 12:00 PM, Director of Maintenance #1 stated that the vendor had treated for flies last Friday (7/18/2025) but they had not yet received the report and invoice for the work performed. 10 New York Codes, Rules and Regulations 415.29(j)(5)

Based on record review and interviews conducted during the Recertification survey, the facility did not ensure that residents had the right to send and promptly receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service. Specifically, residents did not receive mail on Saturdays. This impacted all residents within the facility.This is evidenced by: Facility Policy titled, Resident Right-Right to Forms of Communication with Privacy, dated 11/2024, documented residents had the right to send and receive mail, and to receive letters, packages, and other materials delivered to the facility for the residents through a means other than the postal service. During a surveyor led Resident Council Meeting on 7/22/2025 at 10:32 AM, eight (8) of eight (8) residents present reported mail was not delivered to them on Saturdays. During an interview on 7/25/2025 at 10:45 AM, Director of Activities #1 stated mail was delivered to the front desk after lunch time Monday through Friday. A staff member from the activities department sorted the mail according to unit and the mail was then delivered to the unit to be distributed to the residents. Mail was delivered to the residents Monday through Friday. Mail was not delivered to the Residents on Saturdays because there was no one there from the activities department to receive and distribute the mail. During an interview on 7/25/2025 at 10:56 AM, Administrator #1 stated delivery of mail to the residents was completed by the Activities department. They stated they did not know when letters were delivered to the residents and stated they would need to check with Director of Activities #1 regarding when letters were delivered. 10 New York Code Rules and Regulations 415.3(e)(2)(i)

Based on record review and interviews conducted during the recertification and abbreviated survey (Case # 664249), the facility did not maintain medical records in accordance with accepted professional standards and practices, as accurately documented and completed for six (6) (Resident #'s 2, 3, 16, 44, 77, and 97) of the 30 residents reviewed. Specifically, (a.) Resident #2 was observed to be unkempt and in need of assistance to perform activities of daily living, there was no documented evidence of care provided; (b.) Resident #3 medications and monitoring of behaviors were not documented as completed; (c.) Resident #16 did not have weekly skin checks and showers documented as completed; (d.) Resident #44 did not have weekly skin checks and showers documented as completed; (e.) Resident #77 reported they had not received a shower, there was no documented evidence that resident had been given a shower, and an order for skin checks under a wrist brace was not entered correctly into the Treatment Administration Record; and (f.) Resident #97 reported that they were not regularly offered or provided the opportunity to shower, despite being care planned to receive showers twice a week because of a fungal infection. There was no documented evidence that resident was offered showers twice a week.Resident #2Resident #2 was admitted to the facility with the diagnoses of dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), major depressive disorder (a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and a range of other symptoms that significantly impact daily life), and atrial fibrillation ( an irregularly heartbeat). The Minimum Data Set (an assessment tool), dated 7/02/2025, documented the resident was able to understand others, be understood, and was severely cognitively impaired.During a general observation of the unit on 7/21/2025 at 10:52 AM, Resident #2 was still in bed, still sleeping, and did not appear to have been gotten up or cleaned up for the dayResident #2's Comprehensive Care Plan for Activities of Daily Living dated 11/30/2024 documented the resident required daily support of a minimal one assist staff member to shower related to their cognitive status. There was no documented day or shift for the weekly shower.The Treatment Administration Record for July 2025 did not have documented evidence that Resident #2 was provided a shower.The Treatment Administration Records for June 2025 documented Resident #2 received a shower or bath on 6/14/2025, and 6/28/2025.Resident #3 Resident #3 was admitted to the facility with the diagnoses of Parkinson's disease (a progressive neurodegenerative disorder that primarily affects movement), unspecified dementia, and essential hypertension (high blood pressure). The Minimum Data dated 6/30/2025 documented the resident was rarely/never understood by others, could rarely/never understand others, and was severely cognitively impaired. The Medication Administration Record for July 2025 documented the following medications were not documented as administered:- Quetiapine 25 milligrams (an antipsychotic medication) did not have documented evidence as administered on 7/02/2025 at 4:00 PM and 8:00 PM, 7/12/2025 at 4:00 PM and 8:00 PM, 7/16/2025 at 4:00 PM and 8:00 PM- Famotidine 20 milligrams (antacid medication) did not have documented evidence as administered on 7/02/2025 at 8:00 PM, 7/12/2025 at 8:00 PM, 7/16/2025 at 8:00 PM- Acetaminophen arthritis pain 650 milligrams (non-opioid pain medication) did not have documented evidence as administered on 7/02/2025 at 8:00 PM, 7/12/2025 at 8:00 PM, 7/16/2025 at 8:00 PM- Artificial Tears 1.4% eyedrops (for dry eyes) did not have documented evidence as administered on 7/02/2025 at 8:00 PM, 7/12/2025 at 8:00 PM, 7/16/2025 at 8:00 PM- Tamsulosin 0.4 milligram (medication to treat urinary retention) did not have documented evidence as administered on 7/02/2025 at 9:00 PM, 7/12/2025 at 9:00 PM, 7/16/2025 at 9:00 PM- Atorvastatin 10 milligrams (medication to treat high cholesterol) not documented as administered on 7/02/2025 at 8:00 PM, 7/12/2025 at 8:00 PM, 7/16/2025 at 8:00 PM- Behaviors every shift did not have documented evidence as completed on 7/02/2025 3:00 PM-11:00 PM shift, 7/12/2025 3:00 PM-11:00 PM shift, and 11:00 PM-7:00 AM shift, 7/16/2025 3:00 PM-11:00 PM shiftResident #16Resident #16 was admitted to the facility with the diagnoses malignant neoplasm of left kidney (cancerous tumor characterized by uncontrolled cell growth that can invade nearby tissues and spread to other parts of the body), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and heart failure (a condition where the heart can't pump enough blood to meet the body's needs). The Minimum Data Set, dated [DATE] documented the resident could be understood, understand others, and was cognitively intact. During an observation on 7/29/2025 at 8:51 AM, Resident #16 was noted to have a large bruise on their left outer leg, from knee to midcalf. The Certified Nurse Aide Guide documented the resident required one-person physical help in part of bathing activity, one-person extensive assistance for dressing, and one-person extensive assistance with toilet use. The Physical Therapy Treatment Encounter Note dated 7/15/2025 documented Resident #15 reported pain in the left knee. They documented the resident had a bruise that was tender to the touch.The Accident and Incident Report dated 7/15/2025 documented the resident reported a fall on 7/08/2025 or 7/09/2025.The Treatment Administration Record for July 2025 did not have documented evidence of weekly skin checks completed on 7/01/2025 or 7/08/2025 as ordered.The Resident Certified Nurse Aide Documentation Record for July 2025 did not have documented evidence that Resident #16 had been bathed or shower in the month of July 2025.The Resident Certified Nurse Aide Documentation Record for July 2025 documented Certified Nurse Aide care provided for 7/01/2025 7:00 AM - 3:00 PM shift, 7/02/2025 11:00 PM - 7:00 AM shift, 7/03/2025 7:00 AM - 3:00 PM shift and 11:00 PM - 7:00 AM shift, 7/04/2025 11:00 PM - 7:00 AM shift, 7/05/2025 11:00 PM - 7:00 AM shift, 7/06/2025 11:00 PM - 7:00 AM shift, 7/07/2025 11:00 PM - 7:00 AM shift, 7/10/2025 3:00 PM - 11:00 PM shift and 11:00 PM - 7:00 AM shift, 7/11/2025 11:00 PM - 7:00 AM shift, 7/12/2025 11:00 PM - 7:00 AM shift, 7/13/2025 11:00 PM - 7:00 AM shift. This task was ordered to be documented every shift.The Resident Certified Nurse Aide Documentation Record for July 2025 ordered Skin Check/Care every shift. This was documented as completed on 7/01/2025 7:00 AM - 3:00 PM shift, 7/02/2025 11:00 PM - 7:00 AM shift, 7/03/2025 7:00 AM - 3:00 PM shift and 11:00 PM - 7:00 AM shift, 7/04/2025 11:00 PM - 7:00 AM shift, 7/05/2025 11:00 PM - 7:00 AM shift, 7/06/2025 11:00 PM - 7:00 AM shift, 7/07/2025 11:00 PM - 7:00 AM shift, 7/10/2025 3:00 PM - 11:00 PM shift and 11:00 PM - 7:00 AM shift, 7/11/2025 11:00 PM - 7:00 AM shift, 7/12/2025 11:00 PM - 7:00 AM shift, and 7/13/2025 11:00 PM - 7:00 AM shift.There was no documented evidence in the resident's electronic medical records that a bruise was noted during these documented skin checks.During an interview on 7/29/2025 at 12:05 PM, Director of Nursing #1 stated that skin checks should have been completed weekly and signed for. They stated that when the Certified Nurse Aide provided care and found a new bruise or other skin issue, it should have been reported immediately to the charge nurse. Resident #44Resident #44 was admitted with the diagnoses of dementia, major depressive disorder, and hypertension. The Minimum Data Set, dated [DATE], documented the resident was able to be understood, sometimes understand others, and was severely cognitively impaired.Comprehensive Care Plan for Activities of Daily Living, dated 12/20/2024, documented the resident was dependent on an extensive one person assist for activities of daily living related to their cognitive status and physical state.The Physician's Order dated 5/12/2025 documented weekly skin checks on bathing days, enter Medication Administration Record comment/progress note documenting findings every week on Tuesday at 11:00 PM - 7:00 AM.The Treatment Administration Record for July 2025 did not have documented evidence that Resident #44 was provided a shower. There was no documentation related to bathing/shower on 7/01/2025, 7/04/2025, 7/08/2025, 7/11/2025, 7/15/2025, 7/18/2025, 7/22/2025, 7/25/2025, or 7/29/2025. Documentation indicating not scheduled was documented on the rest of the dates in July 2025.The Treatment Administration Records for June 2025 documented Resident #44 received a shower or bath on 6/13/2025, and 6/20/2025. There was no documented evidence of bathing or shower on 6/03/2025, 6/06/2025, 6/10/2025, 6/17/2025, 6/24/2025, and 6/27/2025. Documentation indicating not scheduled was documented on the rest of the dates in June 2025.Resident #77Resident #77 was admitted to the facility with inflammatory spondylopathies (a group of chronic inflammatory diseases that primarily affect the spine and other joints), chronic pain syndrome (persistent pain that lasts weeks to years), and cellulitis of the lower leg (a common bacterial skin infection that can cause redness, swelling, pain, and warmth in the affected area). The Minimum Data Set, dated [DATE] documented the resident was understood, could understand others, and was cognitively intact. The Minimum Data Set documented the presence of one venous or arterial ulcer. The Physician's Order dated 5/17/2025 documented splint to right wrist at all times, remove every shift for skin check and skin care.The Physician's Order dated 6/20/2025 documented weekly skin checks on bathing days: enter Medication Administration Record comment/progress note documenting findings. Follow through with skin report and notification to supervisor if newly discovered after admission every week on Wednesday at 7:00 AM - 3:00 PM.The Treatment Administration Record for May 2025 documented device type - splint right wrist at all times, remove twice daily for skin check and skin care. This order was only scheduled for 5/16/2025 and documented as completed on 5/16/2025 7:00 AM-3:00 PM shift and 3:00 PM - 11:00 PM shift.The Treatment Administration Record for June and July 2025 did not reflect the order and was not entered onto the Treatment Administration Records.The Resident Certified Nurse Aide Documentation Record for June 2025 documented that bathing was provided on 6/12/2025 on 3:00 PM - 11:00 PM shift.The Resident Certified Nurse Aide Documentation Record for July 2025 documented that bathing was provided on 7/03/2025 on 3:00 PM - 11:00 PM shift. During an interview on 7/23/2025 at 9:16 AM, Resident #77 stated they received a shower once a month, if that. They stated they wore the brace on the right wrist all the time for pain.Resident #97Resident #97 was admitted to the facility with the diagnoses of polyneuropathy (a condition where multiple peripheral nerves malfunction, causing various symptoms like numbness, tingling, pain, and muscle weakness), systemic involvement of connective tissue (refers to a group of autoimmune diseases, known as systemic autoimmune rheumatic diseases that affect connective tissues throughout the body), and major depressive disorder. The Minimum Data Set, dated [DATE], documented the resident was able to understand others, be understood, and was cognitively intact. Resident 97's Comprehensive Care Plan for Activities of Daily Living dated 12/16/2024 documented the resident required a one assist to shower in a high back wheelchair. Resident 97's documented preference for safety and comfort was Tuesday and Friday 3 PM to 11PM shift. Resident 97's Treatment Administration Record for July 2025 documented Resident #97 did not have documented evidence that the resident received a shower on the following Tuesdays: 7/01/2025, 7/08/2025, 7/15/2025, or 7/29/2025; or the following Fridays: 7/11/2025, 7/18/2025, or 7/25/2025. Bathing was documented only as being given on 7/04/2025, 7/14/2025, 7/21/2025, and 7/22/2025 for the entire month.During an interview on 7/29/2025 at 10:34 AM, Licensed Practical Nurse stated that all ordered care should be provided for and documented as given.During an interview on 7/30/2025 at 9:28 AM, Certified Nurse Aide #7 stated there was not enough time to document when the unit was staffed with one or two aides per shift. During an interview on 7/30/2025 at 9:34 AM, Licensed Practical Nurse #3 stated that documentation may not be complete because staff did not know how to navigate the documentation system, or they did not have access. The documentation may not be complete because there isn't enough time as well. They stated that all medication should be documented at the time of administration. 10 New York Codes, Rules, and Regulations 415.22(a)(1-4)

Based on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed 5 percent for Four (4) (Resident #33, 36, 76, and 11) of four (4) residents observed during medication administration with 25 observations. This resulted in a medication error rate of 84 percent.This is evidenced by:The Facility's Policy and Procedure titled; Administering medications, effective 1/2024, documented a licensed nurse will be responsible for passing medications to residents in accordance with techniques approved for use in the facility, in compliance with New York State Codes, rules and regulations ad with other applicable Federal and State Laws. Medications will be administered using the six rights of medication administration: right resident, right medication, right dose, right time, right route, right documentation. If medication supply is found to be equal or less than 7 days, the refill icon should be clicked to initiate resupply. Medication administration must be charted in the Medication Administration Record (MAR) immediately before going on to the next resident, as follows: Documentation to indicate medication was given as ordered.Resident #36Resident #36 was admitted with a diagnoses of chronic obstructive pulmonary disease (a group of lung diseases characterized by persistent and progressive airflow obstruction and chronic respiratory symptoms), polyneuropathy (a condition where multiple peripheral nerves in the body are damaged, leading to a range of symptoms due to impaired nerve function), lower extremity gangrene (a condition where tissue dies due to a lack of blood supply), status post amputation. The Minimum Data Set (an assessment tool) dated 4/28/2025 documented the resident's cognition was intact and could understand and be understood by others.Resident #36 Medication Administration Record dated July 2025 documented, Gabapentin 300 milligram capsule: Give 1 capsule (300 milligram) by oral route 2 times per day at 8:00 AM and 8:00 PM Breo Ellipta 100 micrograms-25 microgram/dose powder for inhalation: Inhale 1 puff by inhalation route once daily at 9:00 AM Ensure Plus (Strawberry) 240 milliliters at 9:00 AM Slow-Mag 71.5 milligram tablet delayed release: Take 1 tablet by oral route once daily at 9:00 AM Pro Stat 30 cubic centimeters orally twice daily at 9:00 AM Multivitamin with minerals-ferrous fumarate 15 milligram iron tablet: Give1 tablet by oral route once daily at 9:00AM Potassium chloride ER 20 milliequivalent tablet: Give 1 tablet (20 milliequivalent) by oral route 2 times per day with food at 8:00 AM and 8:00 PM Furosemide 40 milligram tablet: Give 1 tablet (40milligrams) by oral route once daily at 9:00 AM Docusate sodium 100 milligram capsule: Give 1 capsule (100 milligrams) by oral route 2 times per day at 8:00 AM and 8:00 PM Carvedilol 6.25 milligram tablet: Give 1 tablet (6.25 milligram) by oral route 2 times per day with food at 8:00 AM and 8:00 PM. Aspirin 81 milligram tablet, delayed release: Give 1 tablet (81 milligram) by oral route once daily for 10 days Start Date: 04/22/2025 7:07 AM Amlodipine 10 milligram tablet. Give 1 tablet (10 milligram) by oral route once daily at 9:00 AM During an observation on 7/29/2025 at 10:35 AM, Registered Nurse #1 administered the following medications prescribed for 8:00 AM at 10:35 AM: docusate sodium 100 milligram capsule Carvedilol 6.25 milligram tablet Potassium chloride ER 20 milliequivalent tablet Gabapentin 300 milligram capsuleDuring an observation on 07/29/2025 at 10:35 AM, Registered Nurse #1 administered the following medications prescribed for 9:00 AM at 10:35 AM: Pro Stat 30 cubic centimeters Amlodipine 10 milligram tablet. furosemide 40 milligram tablet Multivitamin with minerals-ferrous fumarate 15 milligram iron tabletDuring an observation on 7/29/2025 at 10:35 AM, Registered Nurse #1 administered Aspirin 81 milligram tablet, delayed release after its 10-day order expiration date, without obtaining order clarification or renewal order: The Physician order documented Give 1 tablet (81 milligram) by oral route once daily for 10 days Start Date: 4/22/2025 7:07 AM. During an observation on 7/29/2025 at 10:35 AM, Registered Nurse #1 did not administer Breo Inhaler Ellipta 1 Puff as order at 9:00AM, and Ensure supplement as ordered for 9:00 AM. Initially Breo inhaler medication was not available; then Resident #36 stated to Registered Nurse #1 that they did not take this medication or supplement anymore. Registered Nurse #1 did not verify orders; did not re-order medication, instead withheld medication and supplement. Both Breo Inhaler and Ensure Nutritional Supplement were signed as given on previous day by Registered Nurse #2.During an observation on 7/29/2025 at 10:35 AM, Registered Nurse #1 did not administer Slow-Mag 71.5 milligram tablet delayed release as ordered for 9:00AM. Registered Nurse #1 stated the medication was not available and was unable to give. Resident #76Resident #76 was admitted to the facility with diagnoses of cerebral palsy (group of disorders that affect movement, balance, and posture due to damage to the developing brain), muscle weakness, and major depressive disorder (a common and serious mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities). The Minimum Data Set, dated [DATE] documented the resident was cognitively intact, could be understood, and be understand by others.Resident #76 Medication Administration Record dated July 2025 documented, Hydromorphone 4 milligram tablet: Give 1 tablet (4 milligram) by oral route every 6 hours at 3:00AM; 9:00AM; 3:00PM and 9:00PM. Lokelma 10-gram oral powder packet: Give 1 packet (10 gram) mix in 45 milliliters of water and drink immediately by oral route once daily rinse glass with water and drink for full dose Omeprazole 40 milligram capsule, delayed release: Give 1 capsule (40 milligram) by oral route once daily before a meal at 7:30 AM. Lorazepam 1 milligram tablet: Give 1 tablet (1 milligram) by oral route 3 times per day for 14 days as needed: Start Date: 7/09/2025 06:22 PM Baclofen 10 milligram tablet. Give 1 tablet (10 milligram) by oral route every 4 hours for 30 days as needed Start Date: 7/08/2025 8:13 AMDuring an observation on 7/29/2025 at 9:45 AM, Registered Nurse #1 stated Hydromorphone 4 milligram drug was not available. They stated it was last given at 9:00 PM the previous evening. Registered Nurse #1 stated they were told in report that the physician had not signed off on the order yet. Resident #76 observed from outside room asking Registered Nurse #1 for their pain medication. Registered Nurse #1 entered Resident # 76's room, they did not knock on door prior to entering, nor did they introduce themselves. Registered Nurse #1 informed Resident #76 that Hydromorphone 4 milligram drug was not available, then asked resident what they thought would help? Resident #76 asked for Baclofen and Lorazepam. Registered Nurse #1 then asked resident how they take medication, example: whole, pudding, etcetera? Resident replied whole.During an observation on 7/29/2025 at 9:49 AM, Registered Nurse #1, poured Lorazepam 1 milligram tablet and Baclofen 10 milligram tablet into medication cup without verifying order how to take medication. During an observation on 7/29/2025 at09:49 AM, Registered Nurse #1, administered Omeprazole one (1) 40 milligram capsule, delayed release. The order was to give 1 capsule (40 milligram) by oral route once daily before a meal at 7:30 AM. Resident #76 had completed breakfast. During an interview on 7/29/2025 at 9:49 AM, Registered Nurse #1, stated they would use a disposable plastic drinking cup to mix Lokelma 10-gram oral powder packet and was unsure of how many ounces the cup held. The order was to mix in 45 milliliters of water or drink. Registered Nurse #1 asked Activities Aide #1 how many ounces did the plastic drinking cup hold? Activities Aide #1 stated they were not sure. Registered Nurse #1 was then prompted to use a medicine cup, which was a small, cylindrical container specifically designed for measuring liquid medications. Registered Nurse #1 stated they did not think of doing that, and stated they were not trained in this position.Resident #118Resident #118 was admitted with a diagnoses Parkinson's disease (a progressive neurological disorder that primarily affects movement, but can also impact mental health, sleep, and pain), chronic obstructive pulmonary disease (a group of lung diseases characterized by persistent and progressive airflow obstruction and chronic respiratory symptoms), and anxiety disorder (a group of mental health conditions characterized by excessive, persistent worry and fear that interfere with daily life). The Minimum Data Set, dated [DATE] documented the resident was cognitively intact, could be understood and understand others.Resident #118's Medication Administration Record dated July 2025 documented, Carbidopa 25 milligram- levodopa 100 milligram tablets: Give 2.5 tablets by oral route every 3 hours at 2:00 AM; 5:00 AM; 8:00 AM; 11:00 AM; 2:00 PM; 5:00 PM; 8:00 PM; 11:00 PM Ferrous sulfate 325 milligram (65 milligram iron) tablet, delayed release: give 1 tablet by oral route once daily at 9:00 AM Docusate sodium 100 milligram capsule: Give 1 capsule (100 milligram) by oral route once daily at 9:00 AM Eliquis 5 milligram tablet: Give 1 tablet (5 milligram) by oral route 2 times per day at 8:00 AM and 8:00 PMDuring an observation on 7/24/2025 at 10:21AM, Registered Nurse #1 administered two and a half (2.5) Carbidopa 25 milligram- levodopa 100 milligram tablets: and one (1) Eliquis 5 milligram tablet both due at 8:00 AM, given at 10:21 AM. Registered Nurse #1 administered one (1) Ferrous sulfate 325 milligram (65 milligram iron) tablet and one (1) Docusate sodium 100 milligram capsule both due 9:00 AM at 10:21AM. During an interview on 7/29/2025 at 10:50 AM, Registered Nurse #1 was asked what their next steps were when medication was not available or if there was a discrepancy. Registered Nurse #1 stated they were not there to pass medications. They were called in by Director of Nursing #1 to assist with supervision. Upon their arrival they were assigned a medication cart after 9:00 AM. Registered Nurse #1 stated they were previously a Licensed Practical Nurse for seven (7) years. They had been a Registered Nurse for one (1) year and had been supervising staff. Registered Nurse #1 stated they had no training at this facility of their supervisory role or role as a Registered Nurse. Registered Nurse #1 stated they were not aware that they should notify the physician or nurse practitioner when medications were held or late.During an interview on 7/29/2025 at 11:40 AM, Director of Nursing #1 stated all nurses completed a competency skills checklist specific to task, in addition to medication administration training and audit prior to passing medications. If a medication was late, the physician must be made aware, and it was documented in progress notes. If a medication was missing from the medication cart, it was the responsibility of the medication nurse to first look in bottom drawer for overflow medications; check the medication room to see if it was delivered; call pharmacy for status or re-order. Furthermore, the facility had a pyxis machine that dispensed several narcotics as well as other routine medications. The nurse should contact supervisor and or check pyxis for medication availability. They further stated, the nurse must notify physician that medication could not be given until pharmacy delivered medication. The pharmacy generally delivered on the same day order was sent. The physician then may give new orders or advise to wait for medication. They stated Hydromorphone 2 milligram tablets were stocked in the Pyxis machine. Registered Nurse #1 should have given two (2) Hydromorphone 2 milligram tablets to Resident #76 to comply with order to give Hydromorphone 4 milligram tablet. 10 New York Codes, Rules, and Regulations 415.12 (m)(1)

Based on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure residents were aware of the grievance process. Specifically, (1.) residents on South Unit did not have the option to file a grievance anonymously; and (2.) seven (7) out of eight (8) residents at a surveyor led Resident Council meeting reported they did not know the process by which to file a grievance.This is evidenced by:Facility Policy titled, Grievance Reporting and Response, last revised 7/01/2022 documented it was the policy of the facility to investigate and respond to all resident grievances in a timely manner. The procedure to file a grievance included filling out a grievance form and giving it to the Director of Social Services or put it in the grievance box located by the social work office. Grievances could also be filed verbally with the Director of Social Services or Administrator. Grievances may be named or anonymous when put in the drop box.During a surveyor led Resident Council meeting on 7/22/2025 at 10:32 AM, seven out of eight residents present stated they were unsure how to file a grievance within the facility. The residents stated they could take their complaint to the resident council president, and the resident council president could follow up with whom they needed to follow up with. All eight residents present during this meeting were unaware of who the grievance official was in the facility. During an observation on 7/22/2025 at 11:50 AM, a suggestion/grievance box in which grievance forms could be deposited anonymously were seen on North Unit and East Unit on the wall across from the nurse's station. There was no suggestion/grievance box for depositing anonymous grievances on the South Unit. There was no suggestion/grievance box by the social work office as noted in the facility policy. There were no other suggestion/grievance boxes in common areas such as the lobby, by the dining room, or by the therapy gym.During an interview on 7/25/2025 at 9:56 AM, Director of Social Services #1 stated they were the grievance official in the facility. They stated there was a sign posted on the bulletin board of each unit with their email address and phone number that stated they were the grievance official. They stated they verbally notified residents they were the grievance official upon admission to the facility, but it was not noted in the admission paperwork provided to the resident that they were the grievance official. They stated a resident on the South Unit tried to rip the suggestion/grievance box f of the wall, so it was removed and there were no suggestion/grievance boxes in common areas or outside of the social services office for them to file a grievance anonymously.During an interview on 7/25/2025 at 10:56 AM, Administrator#1 stated grievances went to the social services department, but they try to keep all residents happy. When asked if all residents could file a grievance anonymously, they stated the residents could call the Department of Health anonymously to file a grievance or the resident could fill out a grievance form and not sign it. Administrator #1 stated they were not aware where the suggestion/grievance boxes were off the top of their head, but they thought they were located on the units.During an interview on 7/29/2025 at 11:34 AM, Director of Nursing #1 stated all grievances went through the social services department and they were discussed during morning report. If a resident wanted to file a grievance anonymously, there were supposed to be boxes on all the units for them to do so, and they assumed there were boxes on all the units. 10 New York Codes Rules and Regulations 415.3(c)(1)(i)

Based on observation, record review, and interviews conducted during the recertification and abbreviated survey (Case #664249), the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming, personal and oral hygiene for six (6) (Resident #s 2, 47, 50, 71, 77, and 97) of ten (10) residents reviewed. Specifically, (a.) Resident #2 was observed to be unkempt and in need of assistance to perform activities of daily living; (b.) Resident #47 did not receive twice weekly showers as per the resident's plan of care; (c.) Resident #50 was observed on 7/22/2025 at 1:41 PM, 7/24/2025 at 1:10 PM, 7/28/2025 at 10:00 AM, and 7/29/2025 at 11:22 AM, in their room with door closed, temperature warm and sweltering, disheveled appearance, clothing soiled, unshaven, hair unkempt with strong urine odor; (d.) Resident #71 was not regularly offered or provided the opportunity to get of bed and was not given a bed bath or shower in accordance with their plan of care; (e.) Resident #77, the resident stated they were not being bathed; and (f.) Resident #97 reported that they were not regularly offered or provided the opportunity to shower, despite being care planned to receive showers twice a week because of a fungal infection.This is evidenced by:The facility's Policy and Procedure titled; Activities of Daily Living, dated 5/2024, documented the facility would ensure a resident is given the appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living. The facility would provide care and services for the following activities of daily living: (a.) Hygiene - bathing, dressing, grooming and oral care. (b) mobility - transfer and ambulation including walking (c) elimination - toileting (d) dining; eating, including meals and snacks; communication including speech, language and other functional communication systems. A resident who is unable to carry out activities of daily living would receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene.Resident #47 Resident #47 was admitted to the facility with diagnoses of fibromyalgia (a chronic condition that causes widespread musculoskeletal pain, fatigue, and sleep disturbance), type 2 diabetes (a chronic condition where the body either doesn't produce enough insulin or cannot properly use the insulin it produces, leading to high blood sugar levels), and morbid obesity (a severe form of obesity characterized by a Body Mass Index (BMI) of 40 or higher). The Minimum Data Set, dated [DATE], documented the resident was cognitively intact, could be understood, and understand others.The Comprehensive Care Plan dated 12/06/2024 titled; Activities of Daily Living documented that Resident #47 required extensive assist of 1 for bathing. Their shower days were Sunday and Thursday on the evening shift. Interventions included weekly shower per preferences/schedule and as needed. The Resident Certified Nurse Aide Documentation Record dated July 2025 for Resident #47 documented the resident's bathing schedule was Tuesday and Fridays on the morning shift.Review of Resident Certified Nurse Aide Documentation Record dated July 2025 for Resident #47, there was no documented evidence that resident received a shower on the following dates: 7/01/2025, 7/11/2025, 7/15/2025, 7/18/2025, and 7/28/2025. During an interview on 7/22/2025 at 12:38 PM, Resident #47 stated they were supposed to get a shower twice a week but were lucky if they got a shower once a week or even once every 3 weeks. They stated they were always told by staff that they were shorthanded. Resident #47 stated they needed to shower because they had skin breakdown. During an observation on 7/24/2025 at 2:25PM, Resident #47's hair was noted to be greasy and there was strong smell of urine present. During an interview on 7/24/2025 at 2:25PM, Resident #47 stated their showers were scheduled for Sunday and Thursdays on the evening shift. They stated they usually had to beg for a shower on the day it was scheduled and then they might get it.During an interview on 7/28/2025 at 12:42 PM, Director of Nursing #1 reviewed Resident #47's care plan and verified they should receive a shower on Monday and Thursday evenings. The care plan was correct, and the Certified Nurse Aide tasks were incorrect. They stated nursing had put the task in incorrectly and then updated the task. When asked if they were aware of any issues with residents not getting shower, Director of Nursing #1 stated a few residents had not gotten showers. They stated they had now informed staff that they needed to document better, like writing a note if a resident refused showers. They stated if there were staffing struggles, they would try to make up the shower if it was missed.Resident #71Resident #71 was admitted to the facility with diagnoses of morbid obesity (a severe form of obesity characterized by a Body Mass Index (BMI) of 40 or higher), major depressive disorder (a serious mental health condition characterized by persistent sadness, loss of interest, and other symptoms that significantly impair daily life), and generalized anxiety disorder (mental health condition characterized by excessive fear or anxiety that interferes with daily activities). The Minimum Data Set, dated [DATE], documented the resident was understood, could understand others, and had moderately impaired cognition.During an interview on 7/22/2025 at 9:42 AM, Resident #71 stated the mechanical lift for obese people was broken and they had not been able to get out of bed. They thought it had been about two and half weeks since they were out of bed. They stated staff had no other way to get them out of bed. They stated staff told them that they were worried about using the other mechanical lift on the unit to get them out of bed because of how the lift was composed and the piece that comes out to hold them, might not hold their weight and they could fall. Resident #71 stated they have been living 24 hours a day in their bedroom. They had not been able to go to activities in a while because they could not get out of bed. Resident #71 stated when they were in bed for over 2 weeks, they became agitated and depressed.During an interview on 7/25/2025 at 10:35 AM, Director of Maintenance #1 reported that the bariatric mechanical lift was functioning. They stated it only needed a new battery, which was ordered and replaced after a week ago.During an interview on 7/25/2025 at 11:17 AM, Certified Nurse Aide #3 stated the bariatric mechanical lift was broken and the other mechanical lift was not capable of getting Resident #71 up due to their weight. They stated they got the bariatric mechanical lift back a few weeks ago. Certified Nurse Aide #3 stated the resident used to get up all the time. During an interview on 7/25/2025 at 11:39 AM, Licensed Practical Nurse #1 stated the bariatric mechanical lift was down for a week. It needed a new battery, maintenance was made aware, and it was replaced. The bariatric mechanical lift was working now. Resident #71 got up yesterday. They stated Resident #71 did not get up every day. It depended on how they felt. They stated bariatric mechanical lift was basically only used for Resident #71. During an interview on 7/28/2025 at 11:27 AM, Licensed Practical Nurse #1 stated Resident #71required a mechanical lift with 3-person assist. There were days due to staffing, Resident #71 was not gotten out of bed as there were not enough staff to assist.During an interview on 7/29/2025 at 1:15 PM, Director of Nursing #1 stated that they believed their mechanical lifts were standard bariatric. They stated they have a lot of bariatric residents at the facility. They stated Resident #71 was often panicky and anxious during care which may be why Resident did not get up often.During an interview on 7/30/2025 at 9:08 AM, Certified Nurse Aides #'s 1 and 2 stated they did not feel safe using the other mechanical lift on the unit with Resident #71 because it was old, and they were afraid to use it because of resident's shape and size. Certified Nurse Aide #'s 1 and 2 stated Resident #71 only liked to get up on the days when there was Bingo activity or when there was a larger event planned. Certified Nurse Aides #'s 1 and 2 stated they did not have a shower chair that Resident #71 fits in. They stated a former Certified Nurse Aide would shower Resident #71 in their wheelchair. They stated they usually provided Resident #71 with a bed bath. During an observation on 7/30/2025 at 9:48 AM Resident #71 was observed lying in bed, saturated in urine with 5 flies flying around them.During an interview on 7/30/2025 at 9:48 AM, Resident #71 stated they had not received care yet. Resident #71 stated they would prefer to have a shower once a week if they could instead of a bed bath. They stated a former Certified Nurse Aide would put them in their wheelchair and gave them a shower on a nice day. Then the Certified Nurse Aide would bring their wheelchair outside to dry. Resident #71 stated that they received a bed bath daily but had not had a shower in over a month. Resident #71 stated prior to the mechanical lift not working, 80% of the time staff would get them out of bed. They stated they wanted to get out bed at least every other day. Resident #71 stated staff did not offer to get them out of bed, they had to ask. During an interview on 7/30/2025 at 9:15 AM, Licensed Practical Nurse #1 stated the facility did have a bariatric shower chair. It's shared among the units.During an interview on 7/30/2025 at 10:06 AM, Director of Nursing #1 reviewed Resident #71's Comprehensive Care Plan and the Certified Nurse Aide Documentation Record. They stated Resident #71 could have a bed bath or a shower per their care plan. In the Certified Nurse Aide Documentation Record, it was scheduled for Tuesday and Fridays on the 7-3 shift. They stated the Certified Nurse Aide Documentation Record does not clarify if a bath or a shower was provided. Director of Nursing #1 stated they must have a bariatric shower chair. They believed they did and would have to track it down. During an interview on 7/30/2025 at 11:18 AM, Certified Nurse Aide #3 stated they thought Resident #71 was last up about a week ago. During a subsequent interview on 7/30/2025 at 11:29 AM, Director of Nursing #1 confirmed that they did have a bariatric shower chair. It was on the east unit and was shared among the units. Resident #50Resident #50 was admitted to the facility with diagnoses of multiple sclerosis (a chronic, often debilitating disease that affects the central nervous system (brain and spinal cord); Dysphagia (difficulty or discomfort in swallowing) and major depressive disorder (a common and serious mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities). The Minimum Data Set (an assessment tool) dated 06/05/2025 documented the resident's cognition was intact and could understand and be understood by others.The Comprehensive Care Plan titled; Activities of Daily Living dated 5/27/2025 documented Resident has self-Care Deficit in the following areas: Bathing- Setup Supervision/Shower supervision. Personal Hygiene-Set up. which is related to: Cognitive status/Dementia. Intervention: Resident will improve Activity of Daily Living performance as evidenced by requiring less support to complete tasks over course of review period. Encourage maximal independence, assist to complete cares only as needed. During an observation on 7/22/2025 at 1:41 PM, 7/24/2025 at 1:10 PM, 7/28/2025 at 10:00 AM, and 7/29/2025 at 11:22 AM, Resident #50 observed in room, in bed, fully clothed with door closed, temperature warm and sweltering, disheveled appearance. Resident and room had strong urine odor on all days. Several flies were circling the room; floor was sticky. Review of Certified Nurse Aide Documentation for dates 7/21/2025 through 07/29/2025 were Not Documented all shifts including bathing; certified nurse aide care provided; dressing; locomotion on and off unit; nutrition; personal hygiene and skin check care. During an interview on 7/28/2025 at 10:45 AM, Assistant Director of Nursing #1 stated Certified Nurse Aide documentation should be completed every shift. They stated Certified Nurse Aide documentation for 7/21/2025 through 7/27/2025 was not done. They stated they would follow up with staff and educate on documentation requirements. 10 New York Codes, Rules, and Regulations 415.12(a)(2)

Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being for three (3) (Resident #'s 34, 50, and 71) of four (4) residents reviewed. Specifically, Resident #'s 34, 50, and 71 did not consistently attend meaningful, accommodating activities to maintain their highest practicable quality of life. This is evidenced by:The Facility Policy titled; Activity Programs, last revised 5/2024, documented (a.) activity programs were designed to encourage maximum individual participation and were geared to the individual resident's needs; (b.) the activity programs consisted of individual, small, and large group activities that were designed to meet the needs and interests of each resident; (c.) individual and at least 4 group activities were offered per day; and (d.) individualized and group activities were provided that: reflect the schedules, choices and rights of the residents and reflect the cultural and religious interests, hobbies, life experiences, and personal preferences of the residents. Resident #34Resident #34 was admitted to the facility with diagnoses of paraplegia (paralysis of the legs and lower body) without sensation below the waist, chronic osteomyelitis (a bone infection) of the pelvic bones, and neurogenic bladder (condition where the nerves that control the bladder function abnormally, leading to problems with urination). The Minimum Data Set (an assessment tool) dated 6/05/2025, documented the resident's cognition was intact, could be understood and understand others.A review of Resident #34's Comprehensive Care Plan did not include a plan titled or related to Activities. On 7/28/2025, during the recertification survey, the Comprehensive Care Plan was updated as follows: resident presents with an inability to participate in activities due to personal choice, physical limitations. Resident is invited to come to activities on a weekly basis but declines.During an observation on 7/22/2025 at 1:10 PM, Resident #34 was observed in bed wearing a hospital gown. They were watching television. A wheelchair was observed in the bathroom.During an interview at this time, Resident #34 stated they rarely got out of bed due to staffing shortages. They stated they were able to self-transfer from their bed to their wheelchair, but their wheelchair was in the bathroom. Resident #34 stated they would have to call for assistance to get the wheelchair and due to staffing shortages, they did not want to bother the staff. They stated they generally stayed in bed all day with the hope of discharging home. Resident #34 stated they did not really attend any activities.A review of the Activity Log dated July 2025 for Resident #34, documented a one-on-one (1:1) social visit on 7/05/2025. The remaining dates for the month of July 2025 were blank.Resident #50Resident #50 was admitted to the facility with diagnoses of multiple sclerosis (a chronic, often debilitating disease that affects the central nervous system, brain and spinal cord), dysphagia (difficulty or discomfort in swallowing), and major depressive disorder (a mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities). The Minimum Data Set, dated [DATE], documented the resident was cognitively intact, could be understood and understand others.The Comprehensive Care Plan dated 6/23/2025 titled, Activities documented the resident did not participate in any activities offered due to personal choice. Resident will receive one-to-one (1:1) visits, sensory stimulation at least one (1) time per week to maintain communication.The Comprehensive Care Plan dated 1/17/2025, titled, Mood, documented problem as depressed; anxious. Interventions included to provide recreational activities; encourage participation in religious services.During observations on 7/22/2025 at 1:41 PM; 7/24/2025 at 1:10 PM, 7/28/2025 at 10:00 AM, and 7/29/2025 at 11:22 AM, Resident #50 was observed in their room, in bed, fully clothed, with the door closed. A review of the Activity Log dated July 2025 for Resident #50, documented a one-to-one (1:1) social visit on 7/06/2025. The remaining dates for the month of July were blank.During an interview on 7/24/2025 at 1:20 PM, Resident #50 stated they did not come out of room because ‘they, the people in charge,' would not let them out. Resident #50 was asked if they would like to attend an activity and they reiterated, the people in charge would not let them out. During an interview on 7/24/2025 1:30 PM, Director of Nursing #1 stated Resident #50 ambulated independently in and out of their room; and that Resident #50 chose not to attend activities.Resident #71Resident #71 was admitted to the facility with diagnoses of morbid obesity (a severe form of excess weight characterized by a Body Mass Index of 40 or higher), major depressive disorder (a mental health condition characterized by persistent sadness, loss of interest, and other symptoms that significantly impair daily life), and generalized anxiety disorder (mental health condition characterized by excessive fear or anxiety that interferes with daily activities). The Minimum Data Set, dated [DATE], documented the resident could be understood, understand others, and had moderately impaired cognition.The Comprehensive Care Plan titled, Activities, dated 7/17/2025, documented that Resident #71 would receive one-to-one (1:1) visits and sensory stimulation at least two (2) times per week to maintain social skills and independence. Intervention included providing supplies/materials as needed.During an observation and interview on 7/22/2025 at 9:42 AM, Resident #71 stated they had not gone to activities in a while since they could not get out of bed. Activity staff offered them coloring books, but they were not interested in coloring. They stated they would rather do word searches. Resident #71 stated they have not received any one-to-one (1:1) visits from activities. There were no books, magazines, or word searches observed in Resident #71's room.A review of the Activity Log dated July 2025 for Resident #71, documented Resident #71 received one-to-one (1:1) social visits on 7/05/2025, 7/06/2025, 7/11/2025, and 7/20/2025. The remaining dates for the month of July were blank. During an interview on 7/28/2025 at 11:27 AM, Licensed Practical Nurse #1 stated Resident #71 required a mechanical lift with three (3)-person assist. There were days that Resident #71 was not gotten out of bed as there were not enough staff to assist. During an interview on 7/30/2025 at 9:08 AM, Certified Nurse Aide #1 stated Resident #71 only liked to get up on days when Bingo was the activity or other larger events were planned. They stated they had not really seen Resident #71 do any activities in their room other than watching television.During an interview on 7/30/2025 9:48 AM, Resident #71 was lying in bed and stated they liked going to the activities offered and would go more if they got out of bed more often. They stated there were not many activities that the activity staff can provide to them with the way they are positioned in bed. Resident #71 stated Director of Activities #1 brought in magazines for them to look at which they enjoyed. They stated they did not really receive one-to-one (1:1) visits from staff.During an interview on 7/28/2025 at 10:30 AM, Director of Activities #1 stated for those residents who were unable to attend group activities or choose not to attend group activities, one-to-one (1:1) activities were provided once a week. They stated activities may include bringing residents magazines to read among other things. Director of Activities #1 stated some residents were not able to attend group activities due to staffing shortages. They stated, for example, Resident #71 would ask to attend a group activity, but on several occasions could not because they were not dressed and out of bed in time for the activity. During an interview on 7/30/2025 at 10:00 AM, Regional Administrator #1 stated Activities Director #1 was new to the facility and to the role of Activities Director. They stated Activities Director #1 was not familiar with documentation and would be paired with a seasoned Activities Director for training. They stated that in addition, when there were unexpected staffing shortages, all staff members should assist with care. They stated Physical Therapy, Occupational Therapy, the Directors of Nursing, the Assistant Director of Nursing and Administrator #1 could assist with patient care, particularly assisting with getting residents out of bed to attend activities. 10 New York Codes, Rules, and Regulations 415.5(f)(1)h

This is evidenced by:The policy and procedure titled, Comprehensive Care Plans, last revised 5/2024, documented interdisciplinary comprehensive care plans would identify problems and needs, reflecting the resident's strengths, limitations, and goals.Resident #2Resident #2 was admitted to the facility with the diagnoses of dementia, major depressive disorder, and atrial fibrillation (irregular heartbeat). The Minimum Data Set (an assessment tool) dated 7/02/2025, documented the resident was able to understand others, be understood, and was severely cognitively impaired.During a general observation of the unit on 7/21/2025 at 10:52 AM, Resident #2 was still in bed, still sleeping, and did not appear to have been gotten up or cleaned up for the day. The resident was noted to have floor mats next to their bed, call bell on the floor.Resident #2's Comprehensive Care Plan for Risk for Falls, dated 11/30/2024, documented to keep the resident's environment safe and clutter free, call bell within reach and encourage use. The care plan was revised 1/17/2025 to include a raised edge mattress.There was no documented evidence of the use of floor mats in any of Resident #2's comprehensive care plan care areas.There was no documented evidence of provider's order to use floor mats in Resident #2's room.Resident #16Resident #16 was admitted to the facility with the diagnoses malignant neoplasm of left kidney (cancerous tumor characterized by uncontrolled cell growth that can invade nearby tissues and spread to other parts of the body), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and heart failure (a condition where the heart can't pump enough blood to meet the body's needs). The Minimum Data Set, dated [DATE] documented the resident was understood, could understand others, and was cognitively intact.The Comprehensive Care Plan titled, Edema did not have documented evidence of goals or interventions. During an interview on 7/28/2025 at 12:10 PM, Director of Nursing #1 stated that comprehensive care plans should have goals and person-centered interventions addressing each area of care.Resident #77Resident #77 was admitted to the facility with inflammatory spondylopathies (a group of chronic inflammatory diseases that primarily affect the spine and other joints), chronic pain syndrome (persistent pain that lasts weeks to years), and cellulitis of the lower leg (a common bacterial skin infection that can cause redness, swelling, pain, and warmth in the affected area). The Minimum Data Set, dated [DATE] documented the resident was understood, could understand others, and was cognitively intact. The Minimum Data Set documented the presence of one venous or arterial ulcer.A Physician's Order dated 7/14/2025 documented to cleanse left lower extremity with wound cleanser, pat dry, apply xeroform to open areas (cut to size), urea cream to scabbed areas, cover with dry dressing and kerlix, then apply Coban dressing from toes to knee three times weekly on shower days.A Progress note dated 6/25/2025 documented the resident was seen on wound rounds, wound was measured, and resident would continue to be followed on wound rounds.A Progress Note dated 7/14/2025 documented the resident was seen on wound rounds with a treatment order change and would continue to be followed by wound care.Review of resident's medical record did not include documented evidence of a comprehensive care plan for wounds, open areas, or impaired skin integrity.During an interview on 7/28/2025 at 11:48 AM, Regional Nursing Coordinator #1 stated they would expect a care plan for any open area that was being tracked and treated.During an interview on 7/28/2025 at 12:37 PM, Director of Nursing #1 stated there should have been a care plan in place to address the wound. 10 New York Codes, Rules, and Regulations 415.11(c)(1)

Based on observations, record review, and interviews conducted during a recertification survey, the facility did not ensure residents were assessed by an interdisciplinary team to determine their ability to safely self-administer medication when clinically appropriate for three (3) (Residents #'s 10, 29, and 47) of three (3) residents reviewed for self-administration of medication. Specifically, (a.) Resident #'s 10 and 29 were observed with unprescribed medications on their nightstands; and (b.) Resident #47 was noted to have discontinued Clindamycin Phosphate cream in their nightstand. There was no documented evidence that Resident #'s 10, 29, and 47 were assessed by an interdisciplinary team to determine their ability to safely self-administer medications, and there was no physician order for self-administration of medications.This is evidenced by:The Facility Policy titled, Resident Self-Administration of Medication, created 7/2020, documented that residents who expressed a wish to self-administer medications would be assessed by nursing and by rehabilitation services for their ability to do so safely. This assessment would include parameters of cognitive ability, awareness of dosing times, understanding of purpose for medication and awareness of potential outcomes if not completed, manual dexterity, ability to understand and observe any applicable infection control practices, ability to maintain storage safely and securely and ability to report to nursing when re-supply was needed. The physician would issue the appropriate medical order for residents who met the criteria for self-administration. Residents who were not fully able to meet all of the above criteria but were cognitively eligible would be facilitated in self-administration of medications with the appropriate level of staff support.Resident #10Resident #10 was admitted to the facility with diagnoses of multiple sclerosis (a chronic, often debilitating disease of the central nervous system that disrupts the flow of information within the brain, and between the brain and body), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and tachycardia (a condition where the heart beats faster than normal, typically more than 100 beats per minute). The Minimum Data Set (an assessment tool) dated 7/22/2025, documented the resident was understood, able to understand others, and was cognitively intact.During an observation and interview on 7/21/2025 10:58 AM, Resident #10 was lying in bed. An unopened box of Nasacort Allergy 24 Hour Spray was noted on their nightstand. There was no name on the box. Resident #10 stated they were unsure where the nasal spray came from, but it had been there for a while.During an observation on 7/28/2025 at 11:48 AM, the unopened box of Nasacort nasal spray was noted on Resident #10's nightstand.A review of Resident #10's medical record did not include documented evidence that the resident was assessed for their ability to self-administer their medications. A review of Resident #10's Comprehensive Care Plan did not include documented evidence that the resident could self-administer their medications.A review of the physician orders for Resident #10 dated 4/21/2025, documented Fluticasone Propionate 50 microgram/actuation nasal spray, suspension. 2 sprays (100 micrograms) to be inhaled by nasal route once daily at bedtime for other seasonal allergic rhinitis.A review of the physician orders for Resident #10 did not include an order for the use of Nasacort Allergy 24 Hour Spray.During an interview on 7/25/2025 at 11:39AM, Licensed Practical Nurse #1 stated family must have brought in the nasal spray found on Resident #10's nightstand.Resident #29Resident #29 was admitted to the facility with diagnoses of type 2 diabetes (an endocrine dysfunction causing unregulated blood glucose levels), chronic obstructive pulmonary disease, and acute on chronic diastolic (congestive) heart failure (a sudden worsening of symptoms of a pre-existing condition of weakened heart muscles). The Minimum Data Set, dated [DATE], documented the resident could be understood, understand others, and had moderate cognitive impairment.During an observation and interview on 7/21/2025 at 11:48 AM, Resident #29 was lying in bed. There was a bottle of Hydrocortisone cream on their nightstand with no name, dated 5/11/2025. Resident #29 stated the cream was used for a rash that developed under their breasts and in their folds at times. They stated they did not put the cream on by themselves.During an observation on 7/22/2025 at 9:38 AM, the same bottle of hydrocortisone cream was on Resident #29's nightstand.A review of Resident #29's medical record did not include documented evidence that the resident was assessed by an interdisciplinary team for their ability to self-administer their medications. A review of Resident #29's Comprehensive Care Plan did not include documented evidence that the resident could self-administer their medications.A review of the physician orders for Resident #29 did not include an order for the use of Hydrocortisone cream.During an interview on 7/25/2025 at 11:39 AM, Licensed Practical Nurse #1 stated Resident #29's family must have brought in the Hydrocortisone cream. They stated Resident #29 did not have an order for Hydrocortisone cream.During an observation and interview on 7/25/2025 1:15 PM, the bottle of Hydrocortisone cream was still observed on Resident #29's nightstand. Resident #29 stated they did not recall where the cream came from, but it had been there for a while, and they still used it.Resident #47 Resident #47 was admitted to the facility with diagnoses of fibromyalgia (a chronic condition that causes widespread musculoskeletal pain, fatigue, and sleep disturbance), type 2 diabetes, and morbid obesity (a severe form of obesity characterized by a Body Mass Index (BMI) of 40 or higher). The Minimum Data Set, dated [DATE], documented the resident was cognitively intact, could be understood, and understand others. During an observation and interview on 7/22/2025 at 12:38 PM, Resident #47 stated they had a fungal rash and pulled a ziploc bag out of their nightstand with a bottle of Clindamycin Phosphate gel. The bag had their name on it and read: Refill on 6/21/2025. Resident #47 stated staff would put it on them after a shower if needed. They were unable to put it on themselves due to pain in their shoulders and inability to lift their right arm. A review of Resident #47's medical record did not include documented evidence that the resident was assessed for their ability to self-administer their medications. A review of Resident #47's Comprehensive Care Plan did not include documented evidence that the resident could self-administer their medications. A review of the physician orders for Resident #29 dated 12/17/2024, documented clindamycin one (1) percent topical gel, apply by topical route two (2) times per day. Apply to areas of cellulitis; buttocks, skin folds of trunk/axilla for diagnosis of cellulitis of buttock. The order was discontinued on 7/08/2025. During an interview on 7/25/2025 at 11:39 AM, Licensed Practical Nurse #1 stated they thought Resident #47 could self-administer the clindamycin gel, but they were not sure if there was an order for it. During an interview on 7/25/2025 at 11:48 AM, Licensed Practical Nurse #1 stated residents should not have medications, including over-the-counter medications in their rooms unless they could self-administer their medications and have an order to self-administer their medications. They stated they believed only one (1) resident on the unit was able to self-administer medications. Licensed Practical Nurse #1 stated it was likely that families brought over-the-counter medications into the facility or residents purchased them online. During an interview on 7/28/2025 at 12:42 PM, Director of Nursing #1 stated for a resident to have medications in their room, the resident needed to be screened, educated, have an assessment completed, and a doctor's order to self-administer medications. There should be no medications at the bedside unless a resident was screened to self-administer medications. They stated there were only two (2) residents in the building that were able to self-administer medications. 10 New York Codes, Rules, and Regulations: 415.3(f)(1)(vi)

Based on observations, record reviews, and interviews conducted during the recertification survey, the facility did not ensure that residents had the right to be treated with respect and dignity to retain and use personal possession, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents for one (1) (Resident #14) of five (5) residents reviewed for personal property. Specifically, (a.) for Resident #14 was observed at nurses' station, in a common area, wearing a hospital gown. Resident #14 stated they were wearing a hospital gown because their clothing was not returned to them from the off-site laundry facility. This is evidenced by: The Facility's Policy titled; Resident Rights last reviewed 7/2022 documented resident have the right to keep and use their personal belongings and property as long as they did not interfere with the rights, health, or safety of others.Resident #14 was admitted to the facility with diagnosis of Parkinson's Disease (a progressive neurological disorder that primarily affects movement, but can also impact mental health, sleep, and pain), major depressive disorder (a common and serious mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities. and Schizophrenia unspecified (a chronic mental health condition characterized by disruptions in thought processes, perceptions, emotions, and behavior). The Minimum Data Set (an assessment tool) dated 5/04/2025 documented the resident was severely cognitively impaired, usually could be understood, and understand others.During an observation on 7/21/2025 at 11:45 AM and 7/23/2025 at 12:30 PM, Resident #14 was observed sitting in wheelchair at nurses' station along with other residents in the common area, wearing a hospital gown, untied in back. During an interview on 7/21/2025 at 11:45 AM, Resident #14 stated they were wearing a hospital gown because they had no clothing. Their clothing had not been returned from laundry, which happens all the time. During an interview on 7/21/2025 at 1:30 PM, Regional Social Worker #1 stated missing laundry was reported. Laundry was sent to an outside service; it was sent out in a bag labeled patient room and returned clean in same bag. There were times articles of clothing or other laundry was missed and later relocated. If not found, facility would replace items, if the resident filed a grievance.During an interview on 7/30/2025 at 9:55 AM, Regional Administrator #1 stated they were aware of missing laundry items. The facility used an outside service for laundry. The process was each resident had a mesh bag. Once mesh bag was full, it goes into a bundle then to the laundry service. The laundry was returned in the same bag once cleaned, which was usually on the next delivery day. Regional Administrator #1 stated they would investigate why laundry was not returned timely. 10 New York Code of Rules and Regulations

This is evidenced by:The Facility Policy titled, Resident Right- Right to Survey Results/Advocate Agency Information, last reviewed 11/2024, documented it was the policy of the facility to inform residents of survey results and advocate agencies in such manner to acknowledge and respect resident rights. The facility will post in a place readily accessible to residents, family members, and legal representatives of residents the results of the most recent survey of the facility. The facility will post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public.During a surveyor led Resident Council Meeting on 7/22/2025 at 10:32 AM, eight (8) of eight (8) anonymous residents present stated they did not know where survey results were located for them to read.During a walkthrough of the facility on 7/22/2025 at 11:50 AM, a white binder with survey results was observed on the second shelf of a shelving unit in the lobby. There was a sign listing visiting hours taped to the shelf above the binder. The sign hung down directly in front of the binder, obstructing it from view. There were no signs in the lobby that indicated survey results were available to view. There were no survey binders or signs stating the results of surveys were available for viewing on East, North, and South units or in hallways that connected the units. During an interview on 7/25/2025 at 10:56 AM, Administrator#1 stated results of most recent surveys were kept in a binder in their office, and there was also a copy kept in a binder in the shelving unit in the lobby. They stated there were no signs posted that listed where the results of the surveys were located for residents or visitors to view.During an observation on 7/29/2025 at 9:54 AM, the binder that contained the survey results was not on the shelving unit in the lobby where it was previously kept. It was not located anywhere in the lobby.During an interview at this time, Receptionist #1 stated there were always a binder that contained survey results in the shelving unit, but that it was not there now. They stated they would have to ask Administrator #1 where it was.During an interview at this time, Corporate Administrator #1 stated the binder was in the office of Administrator #1 and they went to retrieve it.During an interview on 7/29/2025 at 11:34 AM, Director of Nursing #1 stated survey results were to be kept in a binder in the front of the building so any resident or visitor could access them. They stated they did not know if there was a sign posted noting the availability of survey results but should be. 10 New York Code Rules Regulations 415.3 (d)(1)(v)

Based on observations, record review, and interviews during an abbreviated survey (Case # NY00325764), the facility failed to ensure the resident environment remained as free of accident hazards as possible for 7 (Resident #'s 2, 3, 20, 21, 22, 25, and 26) of 7 residents reviewed. Specifically, the facility (A) failed to provide meals to Resident #'s 2, 20, 21, 22, 25 and 26 who required a modified diet (provides foods that have a texture that is easier to eat), with meal items that were consistent with the physician ordered food texture, and (B) did not ensure that kitchen and nursing staff knew how to properly and consistently prepare and identify modified diets that were safe for residents. Subsequently, this put all residents with modified diets at risk for choking. This resulted in Immediate Jeopardy to resident health and safety and Substandard Quality of Care for Resident #'s 2, 20, 21, 22, 25 and 26, and had the likelihood to affect all 36 residents in the facility who required modified diets. Additionally, (C) the facility failed to ensure Resident #3, with a history of aggression towards others and self-harm, did not have sharp objects in their room and that behavioral interventions were followed for safety; and (D) Resident #2's care plan was not updated, or new interventions implemented after the resident had multiple falls with injuries. This is evidenced by: Cross-referenced to: F600: Abuse Prohibition, F610: Investigate/Prevent/Correct Alleged Violations, F725: Sufficient Nursing Staff. The undated Policy and Procedure titled Meal Tray Preparation and Tray Pass documented it was the policy of the facility's Dietary Department to identify the process followed to deliver food in a safe, accurate, effective, and timely manner to resident consistent with physician prescribed diets. It documented a diet order must be received prior to a meal being accepted. All food/beverage requests were entered into the Meal Service Program, meal production sheets were printed, and meals would be prepared accordingly. Menu items were placed on a tray and prior to loading, all items were checked against the meal ticket for accuracy. (A) The facility failed to provide meals to Resident #'s 2, 20, 21, 22, 25 and 26 who required a modified diet, with meal items that were consistent with the physician ordered food texture, and (B) did not ensure that kitchen and nursing staff properly and consistently knew how to prepare and identify modified diets that were safe for residents. Resident #20 Resident #20 was admitted to the facility with diagnoses of, hypoglycemia (low blood sugar), generalized muscle weakness, and dementia of unspecified severity with psychotic disturbance. The Minimum Data Set (an assessment tool) dated 2/10/2024, documented the resident had moderate cognitive impairment, could understand others, and be understood by others. Comprehensive Care Plan for Significant Weight Loss, revised 2/17/2023, related to inadequate nutritional intake relative to needs, as evidenced by significant weight loss and was at risk for malnutrition. Interventions documented staff were to monitor/document/report as needed any signs/symptoms of dysphagia (difficulty swallowing): pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, and appears concerned during meals. Order Summary Report dated as of 4/01/2024, documented an order dated 2/18/2023 for a regular diet; mechanical soft (food) texture. During an observation on 4/09/2024 at 12:12 PM, Resident #20, who was ordered to have a mechanical soft diet, was served a hamburger patty and kernel corn instead of creamed corn, per the meal ticket. Licensed Practical Nurse #6 was observed cutting the hamburger patty into pieces and then walked away from the resident. At 12:26 PM, Resident #20 was observed not eating their lunch and Licensed Practical Nurse #6 verbally encouraged Resident #20 to eat. At 12:31 PM, Resident #20 was observed using their walker to exit the dining area while crying, and the resident did not eat the meal. Resident #20's meal ticket for the lunch tray dated 4/09/2024, documented mechanical soft (diet). It documented ground #8 beef enchilada casserole and creamed corn. During an interview on 4/09/2024 at 12:34 PM, Registered Dietician #1 inspected Resident #20's lunch tray and stated Resident #20's hamburger patty should have been served with a ground texture instead of cut. Registered Dietician #1 stated Resident #20 was served whole kernel corn instead of creamed corn as it was listed on resident's meal ticket. Resident #21 Resident #21 was admitted to the facility with diagnoses of gastro-esophageal reflux disease without esophagitis (acid reflux disease without erosion of the esophagus), muscle wasting and atrophy (decrease in size or wasting away of a body part) and unspecified dementia with unspecified severity with agitation. The Minimum Data Set, dated dated dated [DATE], documented Resident #21 had severe cognitive impairment, could understand others, and be understood by others. Comprehensive Care Plan for Underweight for Age, revised 2/19/2024, related to inadequate PO (oral) intake, documented the resident had impaired swallowing function and was to have a mechanically altered diet. Interventions documented staff were to instruct the resident to eat slowly and chew each bite thoroughly. Comprehensive Care Plan for Oral/Dental Health Problems, revised 2/20/2024, related to poor nutrition, poor oral hygiene, and edentulous (no teeth); has upper dentures. Interventions documented diet as ordered. Order Summary Report dated as of 4/01/2024, documented an order dated 8/01/2023 for a regular diet, mechanical soft texture. During an observation on 4/11/2024 at 12:49 PM, Resident #21's plate was observed to have a sliced turkey meat sandwich cut into 4 (four) pieces. Resident #21's meal ticket was on the tray and indicated the resident was ordered a mechanical soft diet. During observation of the lunchtime meal on 4/11/2024 at 1:05 PM, Registered Dietician #1 was observed talking to Resident #21 at their lunch table. Registered Dietician #1 was heard offering to bring Resident #21 an egg salad sandwich if it would be easier to chew. Resident #21 was observed to pull a long segment of partially chewed, yet still intact, turkey deli meat out of their mouth. Registered Dietician #1 asked Resident #21 whether they had teeth or dentures in their mouth. Resident #21 opened their mouth slightly. Resident #21 was observed to be edentulous (without teeth). Registered Dietician #1 indicated they would get Resident #21 an alternative to the turkey sandwich. The facility was not able to print the lunch meal ticket dated 4/11/2024 for Resident #21. An untitled, undated report provided by the facility documented that on 4/11/2024, Resident #21 was to receive a turkey salad sandwich. During observation of the dinner meal on the South unit, on 4/11/2024 at 5:10 PM, Resident #21's meal ticket documented they were to receive a mechanically soft diet and to be served 6 ounces of chicken noodle soup pureed. Resident #21 was observed to have received a bowl of chicken noodle soup of regular consistency, not pureed. The facility was not able to print the dinner meal ticket dated 4/11/2024 for Resident #21. An untitled, undated report provided by the facility documented that on 4/11/2024, Resident #21 was to receive pureed chicken noodle soup. Resident #22 Resident #22 was admitted to the facility with diagnoses of cerebral infarction (stroke), chronic kidney disease (stage 4), and dementia. The Minimum Data Set (an assessment tool) dated 3/01/24 documented Resident #22 had mild impaired cognition, resident could understand others, and could be understood by others. Comprehensive Care Plan for Has a Swallowing Problem, revised 3/26/2023, related to complaints of difficulty or pain with swallowing, coughing, or choking during meals. Interventions documented all staff were to be informed of the resident's special dietary and safety needs, diet was to be followed as prescribed, instruct resident to eat slowly and chew each bite thoroughly, and the resident was to eat only with supervision. Order Summary Report dated as of 4/01/2024, documented an order dated 7/13/2023, for a no-salt added diet, mechanical soft texture. Observations of the lunchtime meal on the South unit on 4/11/2024 were made between 12:41 PM and 1:18 PM. At 12:41 PM, the kitchen staff were observed delivering the lunch cart to the unit. The facility's Minimum Data Set Coordinator #1 was observed checking resident trays against the meal tickets prior to handing them to staff to deliver and serve to the residents. During an interview on 4/11/2024 at 12:58 PM, Minimum Data Set Coordinator #1 stated the broccoli was tough in texture and needed to be cut. Minimum Data Set Coordinator #1 informed staff to cut the broccoli florets which had already been served. On 4/11/2024 at 1:10 PM, Registered Dietician #1 went into Resident #22's room to check on their lunch. Resident #22 was unsupervised and was observed propped up in bed eating lunch from the tray on the over the bed table. Resident #22's lunch included a side of uncut broccoli florets which appeared uneaten. Registered Dietician #1 asked Resident #22 about the broccoli and Resident #22 replied, not eating it. Registered Dietician #1 asked Resident #22 if the broccoli was too tough for them and Resident #22 stated yes. Resident #22's meal ticket was on the tray and indicated they had a physician's order for a chopped diet. The facility was not able to print the lunch meal ticket dated 4/11/2024 for Resident #22. An untitled, undated report provided by the facility documented that on 4/11/2024, Resident #22 was to receive buttered broccoli. The consistency of the broccoli was not documented. Additional Interviews: During a follow-up interview on 4/11/2024 at 1:13 PM, Registered Dietician #1 indicated mechanical soft and chopped diets do not require sides to be chopped or cut before being served to the resident if the items were soft enough in texture. Registered Dietician #1 indicated Resident #22's broccoli florets should have been cut into quarter inch pieces. Registered Dietician #1 indicated mechanical soft and chopped diets required sandwiches to be served quartered (cut into 4 equal parts). During an interview on 4/12/2024 at 4:02 PM, Registered Dietician #1 stated there were 3 components of a diet order: therapeutic (renal, regular, no sugar and/or no salt), liquid (viscosity), and consistency (chopped, mechanical, regular). Registered Dietician #1 indicated the facility would be switching to a different standard of defining food consistencies because the current system was confusing. Registered Dietician #1 indicated they were auditing past records to be sure diets were currently correct. Registered Dietician #1 stated they did an audit in March 2024 focusing on chopped diets and found mistakes that were being made by kitchen staff. Registered Dietician #1 stated they then educated the kitchen supervisor, who was to train kitchen staff. Registered Dietician #1 stated the facility held large classes as part of their orientation for food safety which included information on cutting sandwiches into quarter pieces. During an interview on 4/12/2024 at 5:00 PM, Administrator #1 stated they indicated the first line in ensuring correct resident diets is the education of the kitchen staff. Administrator #1 indicated they are working on facility-wide education of the facility nursing staff and certified nursing assistants. Administrator #1 indicated they are doing meal audits for 7 (seven) days or as long as it takes to reach 100% accuracy of meal trays. Administrator #1 indicated meal accuracy would be added to the reviews done by their quarterly quality assurance committee. Administrator #1 indicated outside vendors for speech and dietary will be consulted to ensure the in-house dietary education is the way it should be to help get a process together that is less confusing. Administrator #1 indicated a kitchen staff supervisor was in the facility every day to ensure accurate resident textures and consistencies and nursing staff should be the second line of defense in catching meal tray mistakes if those mistakes were to make it out of the kitchen. During an interview on 4/14/2024 at 7:30 AM, Administrator #1 indicated the dietary electronic system for generating meal tickets was not integrated with the electronic medical record used by the facility; therefore, any changes, including new admissions, discharges, and/or changes in resident diets made in the electronic medical record must be manually entered into the dietary system used by the kitchen. Administrator #1 indicated they were catching some meal tickets that were incorrect. Administrator #1 also indicated they discovered that when an alternative meal option is requested in the dietary electronic system for residents with a mechanical soft diet, it lists club sandwich - chopped as an allowable alternative option which was not right. Administrator #1 indicated, now, when they catch mistakes on meal tickets, they are marking the tickets for follow-up corrections to be done in the dietary system. Administrator #1 indicated, from a corporate level, they would be changing to a different dietary electronic system. During a subsequent interview on 4/14/2024 at 5:45 PM, Administrator #1 indicated the Food Director was the person responsible for checking the tickets and ensuring they were correct before the food cart with meal trays were delivered to the units. During an interview on 4/15/2024 at 7:18 AM, Regional Director of Nursing #1 was interviewed and indicated the problems of inaccurate meal trays was coming from the kitchen because the facility had a Food Director who they have since replaced. Regional Director of Nursing #1 indicated the facility anticipated a big improvement with the new Food Director. During an interview on 4/15/2024 at 3:48 PM, interim Director of Speech Pathology #1 was interviewed and indicated they had worked in the facility for about 3 (three) weeks and focused on individual diets and treatments. Director of Speech Pathology #1 indicated they were currently asked to look at the menus and make sure they were correct for all the modified diets. Director of Speech Pathology #1 indicated some of the categories of mechanically altered diets used at the facility (mechanically soft, chopped, and pureed) were outdated and often caused confusion for kitchen and unit staff. They indicated the facility would be shifting to a new, internationally accepted standard for dysphagia diets, but this would be done gradually as residents with physician-ordered mechanically altered diets need to be reassessed for tolerance of new diet guidelines for mechanical soft. Director of Speech Pathology #1 indicated the residents who were currently prescribed a mechanically soft diet would be downgraded to a ground diet for their safety until they could be reassessed by a speech therapist, diet orders reviewed by physician, and all staff trained. Director of Speech Pathology #1 gave the facility a list of the new standardized dysphagia diet levels that included items allowed or prohibited in each diet and the various sizes that were described. Director of Speech Pathology #1 indicated they would be checking daily to ensure meals were served correctly. Director of Speech Pathology #1 indicated Registered Dietician #1 was making a new menu with their consultation. During an interview on 4/17/2024 at 11:30 AM, Director of Nursing #1 was interviewed and indicated meals were to arrive on the unit as ordered per diet from the kitchen. Director of Nursing #1 indicated unit nursing staff should be consulted if a diet texture or size did not look accurate to staff. They indicated the unit nurses must judge whether that current food is appropriate, needs to be cut up or should be returned to the kitchen. Director of Nursing #1 indicated it was the Food Director's responsibility to educate the kitchen staff. Director of Nursing #1 indicated 36 residents in the facility out of 113 residents had physician-ordered mechanically altered diets. Director of Nursing #1 indicated that of the 36 residents, 7 (seven) residents had physician-ordered mechanical soft diets and of those residents, 4 (four) residents needed their care plans updated. Director of Nursing #1 indicated that in total, all 36 residents on a mechanically altered diet had their diets and care plans reviewed and 8 residents had diets changed and care plans updated. During an interview at 4/30/2024 at 3:47 PM, Medical Director #1 indicated physician's orders for mechanically altered diet was intended to reduce resident risk for choking or aspiration. Medical Director #1 indicated a resident who receives food of a size or texture contrary to the physician's order would be at an increased risk for choking. Medical Director #1 indicated they were unsure how the kitchen double checked food on meal trays to ensure the appropriate textures for the diet ordered. Medical Director #1 indicated Registered Dietician #1 should know what a mechanically altered diet was. Medical Director #1 indicated the unit nursing staff should check for accurate diets before passing out the meal trays. They stated they did not know if the nurses received training on diet textures and consistencies. Medical Director #1 reiterated that an altered diet would be less of a choking/aspiration risk for a resident with swallowing difficulties or at risk for aspiration and stated a wrong texture contrary to the physician's order would increase the risk for choking. Medical Director #1 indicated, for that reason, they expect nurses to ensure the meals are served as ordered. (C) The facility did not ensure Resident #3, with a history of aggression towards others and self-harm, did not have sharp objects in their room and that behavioral interventions were followed for safety. Resident #3 Resident #3 was admitted to the facility with diagnoses which included severe intellectual disabilities, schizoaffective disorder (a mental health condition with symptoms of both schizophrenia and mood disorders), and cerebral palsy (a condition marked by impaired muscle coordination). The Minimum Data Set, dated dated [DATE], documented the resident could be understood and could understand others, with a Brief Interview of Mental Status score assessed to be 7/15 indicative of cognitive impairment for decisions of daily living. The Policy and Procedure titled Resident Right-Safe/Clean/Comfortable/ Homelike Environment, last revised 9/2023, read in part that it was the policy of the facility to provide a safe, clean, comfortable, homelike environment in such a manner to acknowledge and respect resident rights. The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Comprehensive Care Plan for Behavioral Symptoms: History of Self-Harm, initiated on 10/04/2023, documented Resident #3 had a history of self-harm by cutting themselves and was documented to have cut themselves with a razor earlier this year (2023) at a different skilled nursing facility. Regular rooms checks were to be performed to ensure the resident did not have access to sharp objects. During an observation on 2/11/2024 at 6:20 PM, Resident #3's room was observed to have a thick, metal safety-pin shaped object which was approximately eight inches long and was unfastened, open, and had a sharp metal end. Additionally, there was a metal fork in the trash bin in the room. During an interview on 2/11/2024 at 6:37 PM, Assistant Social Worker #1 stated they worked with Resident #3 and the resident was treated with medication for their psychiatric diagnosis and behaviors. They stated staff would observe the resident for behaviors. Assistant Social Worker #1 observed the sharp metal object on the floor of the resident's room and stated that it was used to fasten laundry bags in the resident's closet. They were unaware of interventions implemented in the resident's care plan that staff should monitor the resident's room for sharp objects. During an interview on 2/27/2024 at 3:31 PM, Certified Nursing Aide #1 stated that Resident #3 had regularly exhibited aggressive behaviors directed at staff and other residents. They stated the resident had multiple altercations with other residents and had spit at them and punched another resident in the leg during a recent incident. They stated that the former Director of Nursing had instituted a daily schedule for the resident each day which was signed off to keep their day structured and help with behaviors. They stated the resident's daily schedule was no longer in place, that no safety checks for sharp objects in resident's room had ever been done, and they were unaware of safety interventions having been implemented. They stated each time the resident would get in an altercation with another resident, the facility would send the resident out to the hospital. The hospital would send them back and nothing would change. They stated they asked Assistant Social Worker #1 about the behaviors and expressed concern for safety of the staff and other residents; however, they were told that referrals to group home settings had been made, but the resident had not been accepted and there was nothing that could be done. During an interview on 4/24/2024 at 10:44 AM, Director of Social Work #1 stated Resident #3 was not a typical nursing home resident due to their psychiatric diagnosis, history, and cognitive limitations. They stated they had verbalized on numerous occasions that staff should be trained to deal with the resident's behaviors and emotional needs. They stated the resident could be easily triggered, but it was all about how the resident was approached and that they were aware some staff were more reactive to the resident's behaviors, which would further exasperate the resident. They stated that staff should monitor the resident's environment for hazards such as sharp objects. They stated Resident #3 did not have safety awareness and had behaviors that could be triggered by others. During an interview on 4/30/2024 at 3:16 PM, Director of Nursing #1 stated staff should be monitoring Resident #3's room for any safety concerns due to the resident's diagnosis and history of behaviors. They stated Resident #3 should not have access to items that could potentially be a danger to themselves or others. (D) The facility did not ensure that Resident #2's care plan was updated, and new interventions implemented after the resident had multiple falls with injuries. The Policy and Procedure titled, Resident Right-Safe/Clean/Comfortable/ Homelike Environment, last revised September 2023, read in part that it was the policy of the facility to provide a safe, clean, comfortable homelike environment such a manner to acknowledge and respect resident rights. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The Policy and Procedure titled, Resident Falls, last revised September 2023, read in part that each resident would be evaluated for fall risk upon admission, readmission significant change in status and with occurrence of fall event. Care planning should be individualized for the specific resident and will represent input from multiple disciplines. Each resident fall should be managed in a manner that maximizes well-being and safety including assessment for injury with appropriate follow up. The follow up procedure should determine causative/contributory factors, root cause, interventions to prevent recurrence or, in event that recurrence is highly likely, means to prevent major injury from falls. Anytime a resident had a fall the Nursing Supervisor should be notified immediately. The Nursing Supervisor should complete an assessment immediately. Resident #2 Resident #2 was admitted to the facility with diagnoses of unspecified dementia (condition characterized by progressive or persistent loss of intellectual functioning) with agitation, contusion (bruise) of lower back and pelvis and muscle weakness. The Minimum Data Set (an assessment tool) dated 1/18/2024, documented the resident could be understood and could sometimes understand others with a Brief Interview of Mental Status indicating severe cognitive impairment for decisions of daily living. The Resident Care Plan, initiated 4/21/2023, documented Resident # 2 was at risk for falls related confusion, incontinence, psychoactive drug use and inability of the resident to recognize safety needs. The care plan documented that the resident had a fall on 5/22/2023, a fall 6/1/2023 which resulted in a hematoma and the resident being sent to the emergency room , a fall on 10/21/2023 with injury, a fall on 11/9/2023 which resulted in injury and sent to the hospital, falls on 12/6/2023, 1/25/2024 and on 2/1/2024 was noted with a laceration to the back of their head which was documented to be an unknown injury. On 2/18/2024 the resident was sent to the emergency room after being found in bed with blood on their face and clothing and multiple bruises. Review of the care plan revealed that new interventions were not implemented based on fall/incident investigations to prevent recurrence of falls and injuries. A Health Status Note dated 1/25/2024 at 3:06 PM written by Licensed Practical Nurse #6 documented that at 1:45 PM, a Certified Nurse Aide notified them that they had heard a bang and that Resident #2 was on the floor next to another resident. Resident #2 was documented to be lying on their back with their pants around their ankles and next to another resident. The resident was documented as able to move all extremities without signs or symptoms of pain or discomfort and vital signs were obtained. The resident was documented to have been assisted from the floor, by two nursing staff. The supervisor, physician and resident representative were documented as having been notified. A Health Status Note dated 2/1/2024 at 6:57 AM written by Licensed Practical Nurse #9 documented Resident #2 was noted to have been walking on the unit that morning and a Certified Nurse Aide noted that the back of their head looked pink. The writer was documented to assess the resident and discovered a small laceration. The resident's neuro checks were documented to be within normal limits. Review of the facility record revealed the resident last fell on [DATE], however no injuries were noted. A Health Status Note dated 2/2/2024 at 2:52 PM written by Licensed Practical Nurse #6 documented the resident was on follow up for a fall, on day 2 out of 3, a small laceration to back of head, which cleansed and bacitracin was applied. The resident was documented to have no signs or symptoms of discomfort and indicated that staff would continue to monitor. There was no documentation of the resident having a fall and the investigation into the injury did not determine the cause of the injury No new interventions were not identified/implemented to prevent recurrence. A Health Status Note dated 2/18/2024 documented the resident had been found lying in their bed with blood on the right side of their face, nose and on clothing. The resident was noted to have swelling on their nose. Bruising was noted on the right of the resident's face as well as bilateral upper and lower extremities. A Health Status Note dated 2/18/2024 documented a new order was received to transfer resident to the hospital to evaluate for a fall earlier in the day. Resident #2 was transferred to hospital by emergency medical services. The resident complained of pain on the right side of their face which was documented as not an abnormal complaint of this resident. Multiple hematomas noted on face at different stages of healing that were associated with resident's history of crawling on floor. During an interview on 2/27/2024 at 3:31 PM, Certified Nurse Aide #1 stated that Resident #2 had numerous falls at the facility and had been sent out to the hospital multiple times. They stated the facility did not implement new interventions after the resident would fall. They stated they were told to just try to get the resident to stay seated. They stated the resident was always on the floor and constantly had bruising on their body. They stated that the facility did not have enough staff to properly supervise the residents. They stated the resident was frequently found on the floor and that neurological checks should be completed with each fall, whether the resident was observed to hit their head or when they had an unwitnessed fall where it could not be determined whether they had hit their head. During an interview on 4/24/2024 at 10:44 AM, Director of Social Work #1 stated that incident/fall investigations should be conducted to look at the environment in the room and what might have caused injury or contributed to the incident and implement new interventions to prevent recurrence. They stated that there was not enough 'eyes on' residents who required supervision to prevent falls/accidents due to insufficient staffing levels and that they were very concerned for the residents at the facility. During an interview on 4/30/2024 at 3:16 PM, Director of Nursing #1 stated that each time a resident had a fall, and they were unable to state what happened, the fall should be investigated to determine the root cause of the fall/injury and the care plan should be updated with new interventions to prevent recurrence. They stated that interventions should be implemented based on what occurred and those interventions should be added to the resident's care plan. 10 New York Codes Rules and Regulations 415.12(h)(1)

Based on record review and interview during an abbreviated survey (Case #NY 861), the facility failed to ensure all residents were free from abuse, neglect, and mistreatment when allegations of sexual abuse by Resident #4 were reported. Specifically, on 7/26/2022 at 1:30 AM, Certified Nursing Assistant (CNA) #3 observed Resident #4, who had severely impaired cognition, standing next to the bedside of Resident #2, who had moderately impaired cognition. Resident #2's sheets were off and hospital gown was pulled up. CNA #3 removed Resident #4 from the room. On the same day, 7/26/2022 at 4:45 AM, Resident #4 wandered into the room of Resident #3, who was cognitively intact and reported to CNA #3 and Registered Nurse (RN) #1 that they were sexually assaulted by Resident #4. Resident #3 stated they woke up to Resident #4 fondling their breast and inner thigh. Resident #3 has a history of Post-Traumatic Stress Disorder ([CONDITION(S)]) after being sexually assaulted as a child and reported experiencing increased anxiety as a result of this incident with Resident #4. As a result, the facility did not collect evidence to determine what occurred or what actions or systems were necessary to prevent sexual abuse by Resident #4 from reoccurring and failed to provide a safe environment to residents. This resulted in, or had the likelihood for, psychosocial harm that is Immediate Jeopardy and Substandard Quality of Care to resident health and safety and had the likelihood to affect all residents in the facility. The Immediate Jeopardy was lifted on 9/16/2022. This is evidenced by: The Policy and Procedure (P&P) titled Resident Abuse Prevention and Reporting dated 5/2022, documented that all residents would be treated with respect and dignity, would be free from abuse, and all residents would be protected and provided a safe environment. The Nursing Home Incident Intake Form dated 7/27/2022 at 9:38 AM, documented on 7/26/2022 at 4:45 AM, it was reported Resident #4 had gone into Resident #2 and Resident #3's rooms and touched them inappropriately. The investigation was on-going, and the facility's immediate response was to continue 15-minute checks with close supervision. Incident #1: On 7/26/2022 at 1:30 AM, the facility failed to implement interventions to maintain the safety of all residents after Certified Nursing Assistant (CNA) #3 observed Resident #4 standing next to the bedside of Resident #2. Resident #2's sheets were off and hospital gown was pulled up. CNA #3 removed Resident #4 from the room. Resident #4: Resident #4 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- an assessment tool) dated 5/7/2022, documented the resident had severely impaired cognition, could usually understand others, and could usually make themselves understood. The Comprehensive Care Plan (CCP) for Activities of Daily Living, last revised 5/2/2022, documented Resident #4 required intermittent supervision without an assistive device throughout the facility for ambulation and was independent with transfers and toilet use. The CCP did not include person centered care plans with individualized interventions to ensure Resident #4 was supervised and monitored by staff due to the resident's history of wandering on the unit and in and out of other residents' rooms. A care plan for wandering was initiated on 8/2/2022. Resident #2: Resident #2 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- an assessment tool) dated 5/4/2022, documented the resident had moderately impaired cognition, could understand others, and could make themselves understood. The CCP for At Risk for Being Targeted, dated 4/25/2022, documented Resident #2 was at risk for being targeted physically or verbally by a co-resident secondary to impaired physical mobility. Interventions included: Observe for any co-resident ramping up and to remove the co-resident from harm's way immediately, and to seat/position the resident away from co-residents who were known to be aggressive to others. The CCP did not include person centered care plans with individualized interventions to ensure the safety of Resident #2's physical and psychosocial well-being related to the incident with Resident #4 on 7/26/2022 at 1:30 AM. The Incident and Accident report (I&A) dated 7/26/2022, initiated by Registered Nurse (RN) #1, documented Resident #4 had inappropriate contact with another resident (Resident #2). The immediate action to protect resident safety was to maintain 15-minute checks for Resident #4. Situational factors included: there was only one aide and one nurse on the unit for the duration of 11 PM - 7 AM shift. The RN documented the resident was last seen at 4:30 AM and was wandering into other resident rooms. A staff statement dated 7/26/2022 at 1:30 AM, written by CNA #3, documented Resident #4 was found in Resident #2's room near their bed. When CNA #3 walked into the room and asked what was going on, Resident #2 stated they were making love with Resident #4. Resident #2's sheets were off and hospital gown was pulled up. CNA #3 removed Resident #4 from the room. The CCP and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Progress notes documented on: -7/26/2022 at 1:21 AM, Resident #4 was awake and hovering around nursing station beginning of shift. Then began wandering and peering into other patients' rooms. When redirected Resident #4 stated they would not disturb the other residents. Resident #4 began entering rooms. The resident startled the resident in bed by the door and chose to keep returning to that room and became threatening to staff when they attempted to distract and remove Resident #4 from the room. -7/26/2022 at 1:28 AM, Resident #2 was awakened when another resident entered their room and had to be removed. Resident #2 began yelling help and when asked what they needed Resident #2 stated nothing and told staff to leave the room. -7/26/2022 at 3:47 AM, Resident #4 would not remain in bed nor in their room. Resident was napping in chair by nursing station. There was one incidence of trying to enter someone's room and became threatening both verbally and physically brandishing their fists. Resident #4 returned to chair by the nursing station. -7/26/2022 at 6:17 AM, Resident #2 stated to the aide on duty that they were making 'love' with the Resident #4. -7/26/2022 at 8:32 AM, the Attending Physician was updated at 6:30 AM. -7/26/2022 at 8:35 AM, Resident #2 confided that they did not want Resident #4 to get into trouble. Resident #2 did not understand why they were not allowed to 'make love'. The Skin Observation Tool dated 7/26/2022 at 2:31 PM, documented Resident #2 did not have injuries or any bruised/open areas. The medical record for Resident #2 did not include a Registered Nurse (RN) Assessment to assess for physical and psychosocial harm after the incident with Resident #4 on 7/26/2022. During an interview on 9/14/2022 at 11:45 AM, RN #1 stated Resident #4 was wandering around the unit and in and out of residents' rooms on the night of 7/26/2022. Resident #4 was on 15-minute checks, but it would have been impossible for the RN to constantly keep an eye on Resident #4. The RN stated after the resident went into the room of Resident #2, there were no other interventions were implemented except to maintain the 15-minute checks that the resident was already on. During an interview on 9/14/2022 at 4:30 PM, the Director of Resident and Family Services (DRFS) stated they were not made aware of the incident between Resident #4 and Resident #2 on 7/26/2022. The DRFS stated that Resident #4 was at risk for elopement and that was why they had been on 15-minute checks prior to 7/26/2022. The DRFS did not know if the resident had a care plan for the 15-minute checks or a care plan to address the resident's wandering. The DRFS stated they were not responsible for investigating the incident or updating care plans of Resident #2 and Resident #4 after an incident. That was deferred to nursing. During an interview on 9/15/2022 at 10:27 AM, the Staffing Coordinator, who also worked as a CNA, stated when there was one nurse and one aide working on a unit and it would be impossible to do 15-minute checks on a resident. During a subsequent interview on 9/15/2022 at 11:10 AM, RN #1 stated the progress note on 7/26/2022 at 1:30 AM, was about Resident #4 being in Resident #2's room. Resident #4 was in Resident #2's room standing at beside the bed. The RN stated they observed Resident #4 was trying to climb into Resident #2's bed with one knee in air and their hands were on the bed supporting themself to get into the bed. The RN stated they told Resident #4 they were not supposed to be in the room and assisted the resident out of the room to the nursing station where the RN had a clear view of the resident. The RN stated at 6:00 AM on 7/26/2022, CNA #3 reported Resident #2 and Resident #4 had contact with each other. Resident #4 was reportedly fondling Resident #2. When the RN went in to talk to Resident #2 after that had been reported, Resident #2 stated to the RN that they were a couple with Resident #4 and the touching was not an issue. The RN was under the impression the two residents wanted to be together. The RN did not notify Administration until after 6:00 AM on 7/26/2022 of the incident because they did not know the resident's had contact with each other until the CNA #3 reported it at 6:00 AM. The RN stated they had found Resident #4 close to other residents when they wandered in and out of resident rooms. Resident #4 had the opportunity to touch other residents, but the RN did not know if Resident #4 had in fact touched other residents. The RN stated Resident #4's behaviors were inappropriate and dangerous. During an interview on 9/15/2022 at 11:50 AM, the Assistant Director of Nursing (ADON) stated RN #1 was supposed to call them or the Director of Nursing immediately after an incident occurred. The ADON stated their understanding of the incident was that CNA #3 was rounding and found Resident #4 in Resident #2's room on top of Resident #2 in the bed. When the ADON was asked further about Resident #4 being on top of Resident #2, the ADON stated well, maybe I have it wrong. The ADON stated it was reported that Resident #4 was standing next to Resident #2's bed. Resident #2's sheet was down, and their gown was up above their belly button, exposing their abdomen and incontinence brief. The ADON stated Resident #2 screamed at the CNA to get out because they were about to make love. The ADON stated they became aware of the incident with Resident #2 and #4 the next morning, but they should have been called by the RN immediately after it had happened. During an interview on 9/16/2022 at 11:46 AM, the Nurse Practitioner (NP) stated they knew Resident #4 had behaviors but was not told about the resident's wandering in and out of other resident rooms. The NP was not the on call the night of the incident with Resident #2 and Resident #4 and was not made aware of the incident. The NP stated the RN should have assessed the resident after the incident and called the provider at the time. The NP stated they knew that Resident #4 paid attention to Resident #2 and would push Resident #2 in their wheelchair. When the NP would see Resident #2 and Resident #4 sitting and holding hands, Resident #2 would say Resident #4 was their boyfriend. These interactions were seen in passing and were not documented. The NP stated that on 8/3/2022, Resident #2 asked for a room change so that Resident #4 could not find her. During an interview on 9/16/2022 at 1:20 PM, the Administrator stated the DON (define) informed them of the incident. Resident #4 was on 15 minutes checks but after the incident at 1:30 AM, the resident should have been assigned 1:1 supervision but was not. During an interview on 9/20/2022 at 2:30 PM, CNA #3 stated they did not know Resident #4 was a wanderer and stated I guess they were on 15-minute checks. The CNA stated on 7/26/2022 between 1:00 AM and 2:00 AM, they could not find Resident #4 and when they found the resident, they were in Resident #2's room. When CNA #3 saw Resident #4 on top of Resident #2 in Resident #2's bed, the CNA stated they turned the light on to make sure they were seeing what they thought they were seeing and saw that Resident #4 was on top of Resident #2 in the bed. Resident #4 was in between Resident #2's legs with both feet off the floor and fully on the bed on top of Resident #2. Resident #4 was pulling up Resident #2's gown above their belly button and Resident #2 was tugging at their incontinence brief in a motion to pull off the brief. The CNA stated they called to the RN they were working with that night and removed Resident #4 from Resident #2's room. Resident #2 became agitated and was cursing and saying they were interrupted. CNA #3 stated they reported it to RN #1 and RN #1 did not do anything different after this incident with Resident #4. Resident #4 was brought out the nurses' station but there were no new interventions put in place. The CNA stated later that same night, Resident #4 had another incident with a resident. Resident #3 reported they were touched by Resident #4. Incident #2: On the same morning, 7/26/2022 at 4:45 AM, Resident #4 wandered into the room of Resident #3 who reported to CNA #3 and Registered Nurse (RN) #1 that they were sexually assaulted by Resident #4. Resident #3 stated they woke up to Resident #4 fondling their breast and inner thigh. Resident #3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] #4. Resident #3: Resident #3 was admitted with post-traumatic stress disorder ([CONDITION(S)]), [CONDITION(S)] disorder, and [CONDITION(S)] with [CONDITION(S)]. The Minimum Data Set (MDS- an assessment tool) dated 6/10/2022, documented the resident was cognitively intact, could understand others and could make themselves understood. The Comprehensive Care Plan (CCP) for Alteration in Psychosocial Well-being, last revised 9/6/2020, documented to attach a Velcro Stop Sign barrier to the door frame for the resident's feeling of safety and security. The Stop Sign intervention was dated 7/27/2022. The CCP did not include person centered care plans with individualized interventions to ensure the safety of Resident #3's physical and psychosocial wellbeing related to the sexual assault by Resident #4 on 7/26/2022. The Incident and Accident (I&A) report dated 7/29/2022, initiated by the Director of Nursing (DON) documented Resident #4 entered the room of Resident #3 without authorization. The I&A did not document the date and time of the incident. The immediate action to protect resident safety was that the wandering resident was placed on 15-minute checks and close supervision by the supervisor. A staff statement dated 7/26/2022 at 4:45 AM, written by RN #1, documented Resident #4 was due for their 15-minute check when Resident #3 told the RN that Resident #4 had touched Resident #3's breasts and was moving their hand down Resident #3's leg. Progress notes documented on: -7/26/2022 at 4:45 AM, Resident #3 told RN #1 that Resident #4 had touched their breasts and moved their hand down to Resident #3's leg. -7/26/2022 at 8:25 AM, the Attending Physician was updated at 6:30 AM. -7/26/2022 at 10:20 AM, Resident #4 remained on 15-minute checks, continued to wander in the hallway and peer into rooms. The resident was redirected many times and will continue to monitor. -7/26/2022 at 2:45 PM, Resident #3 continued to talk in calm manner to few staff and residents about incident. The resident requested as needed (prn) [MEDICATION(S)] (antihistamine used to treat anxiety) in the morning with effect. -7/26/2022 at 10:52 PM, Resident #4 was wandering all over in other residents' rooms. The resident did not respond at first when redirected out of room. The resident had to be told again and guided out. The other residents were upset. -7/26/2022 at 11:20 PM, Resident #3 mentioned the other resident (Resident #4) at end of the shift. Resident #3 expressed anxiety and was given [MEDICATION(S)] ([MEDICATION(S)]). The resident's representative called and was concerned for Resident #3's safety. -7/27/2022 at 10:40 AM, the Nurse Practitioner (NP) documented Resident #3 had a recent episode with a resident with dementia also increasing the resident's anxiety. Resident #3 had previously refused/stopped using their Stop Sign across doorway and was now using it and allowed staff to place it across their door. -7/29/2022 at 10:48 AM, Resident #3 still concerned over past incident and will reach out to mental health today. The medical record did not include documentation the facility assisted the resident with obtaining psychological or psychiatric services after the incident on 7/26/2022. The Skin Observation Tool completed on 7/26/2022 at 2:36 PM, documented Resident #3 had no injury, no bruising, and no open areas on their body. The medical record did not include a Registered Nurse (RN) Assessment to assess for physical and psychosocial harm after the alleged incident with Resident #4 on 7/26/2022. The facility did not notify law enforcement of the alleged sexual assault. During an interview on 9/14/2022 at 11:00 AM, Resident #3 stated on 7/26/2022 at 4:45 AM, they were sleeping and woke up to Resident #4 standing next to their bed close to the side rail of the bed. Resident #3 stated Resident #4 had their hand under Resident #3's gown and was rubbing their breast and Resident #4's other hand was rubbing Resident #3's upper thigh toward their private area. Resident #3 stated they rang their call bell and CNA #3 came in and removed Resident #4. CNA #3 called for RN #1. Resident #3 stated CNA #3 said not again when removing Resident #4. Resident #3 stated the next day staff put up a stop sign on their bedroom door. During an interview on 9/14/2022 at 11:45 AM, RN #1 stated at 4:45 AM on 7/26/2022, Resident #4 was found in the Activity Room next to Resident #3's room. Resident #4 was wandering around in and out of rooms during the night and RN #1 stated they did not know what to do with the resident. The RN stated there were no other interventions implemented in addition to Resident #4 already being on 15-minute checks after the initial incident with Resident #2 and nothing else was implemented after the incident with Resident #3. RN #1 stated Resident #3 told them what happened with Resident #4 and after that the RN kept the resident up by the nurses' station and was more aware of where the resident was for the remainder of the shift. The RN stated Resident #4 was quick and went room to room when they were wandering. RN #1 stated they did not complete a physical assessment of Resident #3 and the resident did not seem to be shaken up at the time. RN #1 stated they did not put a stop sign up on Resident #3's door after the incident was reported to them. The RN called administration in the morning and did not report the incident right after it happened. During an interview on 9/15/2022 at 11:50 AM, the Assistant Director of Nursing (ADON) stated they became aware of the incident with Resident #3 and Resident #4 the next morning. The ADON stated they saw Resident #3 that morning and did not do an assessment, did not start an investigation, and did not initiate a care plan for either resident. During an interview on 9/15/2022 at 3:25 PM, the Director of Nursing (DON) stated RN#1 did not notify them of the incident immediately after it happened, and they wished they had been called at the time of the incident because they would have instructed the RN #1 to implement a 1:1 with Resident #4. The DON stated they would have come in to do the 1:1 themselves if there were not staff in building to do it. The DON stated the RN did not start a care plan and should have. The DON stated the Nurse Practitioner (NP) went to assess the Resident #3 the next day and the DRFS was also supposed to see the resident. The DON stated after the incident a care conference was held for Resident #4 on 7/30/2022 to discuss a room change, but the family did not want the resident moved to South Unit, the designated dementia unit. During an interview on 9/16/2022 at 11:46 AM, the NP stated they heard about the incident the next day and had physically assessed Resident #3 with no findings. The NP assessment was not documented. Resident #3 had reported to the NP that Resident #4 walked into their room and thought the resident had touched them. Resident #3 stated they were ok but did not want Resident #4 in their room. The NP stated Resident #3 had reported an increase in anxiety related to the incident with Resident #4 and Resident #3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP stated they were not the attending provider for the North Unit, but if they had been notified of the incident, they would have sent Resident #3 out to the hospital for evaluation and placed Resident #4 on a 1:1 or continued the 15-minute checks. The NP stated, but with 15-minute checks you have to think to yourself what the resident is doing with the 14 minutes in between each 15-minute check. The NP stated immediate interventions should have been implemented to keep Resident #4 safe and the other residents safe. The NP stated the RN should have assessed Resident #3 after the incident and called the provider at the time. Law enforcement was not called according to the NP's knowledge. During an interview on 9/16/2022 at 1:20 PM, the Administrator stated Resident #4 was on 15 minutes checks but after the incident at 1:30 AM, Resident #4 should have been assigned a 1:1 for supervision. At 4:45 AM, Administration should have been called immediately after Resident #3 reported Resident #4 touched them. If Administration had been called, they would have given the staff direction. The RN should have assessed the resident and written a note. The Administrator stated they read in the progress notes after the incident and realized then Resident #3 had increased anxiety and the psych referral should be made. The DRFS should have been involved after the incident. The Administrator stated Resident #4 should have been placed on 1:1 and the 1:1 would have continued until the next day and would not have been removed until the resident was reassessed and was moved to South Unit. During an interview on 9/16/2022 at 4:19 PM, Licensed Practical Nurse (LPN) #11 stated there was no set plan for Resident #4 and they wandered at will. The resident wandered into rooms and would just stand there or use the other residents' bathrooms. Resident #4 would go in any room. LPN #11 stated they saw Resident #3 after the incident on 7/26/2022 but did not write a note. LPN #11 stated Resident #3 said that Resident #4 had touched them, and the supervisor had taken care of it, but Resident #3 was upset. Resident #3 talked about how it brought back past trauma that they had, and they were scared. Resident #4 remained on 15-minute checks, and Resident #3 had a stop sign put up in their doorway. Prior to the incident, Resident #3 had a stop sign because Resident #4 would wander down there. LPN #11 had told Resident #3 to contact their mental health provider as the resident had their direct number. During an interview on 9/20/2022 at 2:30 PM, CNA #3 stated Resident #3 reported Resident #4 touched them. Resident #3 became very upset and called their family because they were scared. The resident stated that Resident #4 felt them up. Resident #4 touched Resident #3's thigh and the CNA stated they thought the resident reported their breast was also touched. The CNA went to check on Resident #3 and the resident was distraught and crying. The CNA and RN put the stop sign barrier up on the resident's door. The CNA stated after this incident, Resident #4 was not placed on a 1:1. The resident remained on 15-minute checks. Incident #3: On 8/4/2022, Resident #4 had unwanted contact with Resident #3. During an interview on 9/15/2022 at 5:40 PM, Resident #3 stated on 8/4/2022 they were wheeling down the hallway in their wheelchair and Resident #4 had their arm extended with their hand on Resident #2's shoulder. Resident #3 stated that they could not get by and said excuse me and tried to go around both of them. Resident #4 put their hand on Resident #3's shoulder to prevent them from going around. Resident #3 stated they pulled away and then Resident #4 punched them in the left forearm leaving a bruise. The resident stated they reported this to a nurse who wrote said they would file a grievance on it. The facility did not provide an Investigation, I&A report, or grievance form for the alleged physical incident on 8/4/2022 involving Resident #3 and Resident #4. Progress notes documented on: -8/3/2022 at 2:15 AM, Resident #4 continued on every 15-minute checks for safety. -8/3/2022 at 11:38 PM, the NP documented Resident #4 had increasing behaviors and observed reaction/behavior to delusions related to another resident (Resident #2) they believed to be their spouse. Redirection was occasionally effective, but as the delusion increased in intensity, Resident #4 was less likely to be redirected and was becoming more aggressive. The other resident (Resident #2) had confided they were not comfortable with keeping company and asked for a room change so Resident #4 could not visit them. Resident #4 was observed wheeling the other resident in their wheelchair while they were objecting. Staff and this writer intervened on numerous occasions. Room change to be accommodated to provide security to the other resident. Room change to take place in the morning. -8/4/2022 at 5:12 PM, Resident #4 was being physically assaultive and verbally aggressive. Resident #4 became attached to another resident and taken on a protector role. The NP was notified and ordered that a 1x dose of [MEDICATION(S)] (antipsychotic medication) for Resident #4. After the nurse retrieved the medication from the emergency kit, the resident was trying to get back to the aforementioned resident and again attempted to punch staff. Family agreed to allow the facility to move Resident #4 to South Unit tomorrow which will hopefully be less overstimulating. -8/10/2022 at 9:31 PM, Resident #4 was wandering in and out of other residents' rooms and going through their things. When redirecting the resident, they became very combative towards staff and redirection ineffective. Resident #4's behavior continues. -8/11/2022 at 10:40 PM, Resident #4 was wandering in and out of residents' rooms. At one point, Resident #4 was attempting to get into other residents' beds with them in it. Redirection was very difficult as the resident became very agitated and striking out. Resident #4 wandered to the North Unit several times and again, it was difficult to assist them back to (South) unit. Resident #3's medical record did not include documentation of the alleged unwanted physical contact with Resident #4 on 8/4/2022. Resident #3's medical record did not include a completed Skin Observation Tool or a Registered Nurse Assessment to assess for physical and psychosocial harm after the alleged incident with Resident #4 on 8/4/2022. During an interview on 9/14/2022 at 1:40 PM, Licensed Practical Nurse (LPN) #1 stated they had no idea there had been an alleged sexual assault involving Resident #4. The LPN stated they knew Resident #4 had been moved to South Unit due to escalated behaviors. On North Unit, Resident #4 had gotten the other residents upset by going in and out of their rooms. The LPN's fear was that there would be a confrontation when Resident #4 went into other residents' rooms and because Resident #4 did not know boundaries. The LPN stated there were no appropriate interventions implemented for Resident #4 to keep them safe or other resident's safe. The LPN stated even when there were 2 CNAs and 1 LPN on the unit, it was impossible to do 15-minute checks on Resident #4. The CNAs would be providing care to residents behind closed doors and the nurse would be passing medications. No one could see where Resident #4 was. During an interview on 9/14/2022 at 4:30 PM, the Director of Resident and Family Services (DRFS) stated a care plan for Resident #4's wandering was not updated and there were no interventions in place for the resident's wandering other than 15-minute checks. The interdisciplinary team had a care plan meeting on 7/30/2022 with Resident #4's family and it was discussed that the resident would be transferred to the South Unit as it would be more appropriate given the resident's recent behaviors. Resident #4's family did not want the resident transferred off North Unit. The DRFS stated Resident #4 did not get moved off North Unit at the family's request and the decision not to move the resident put the rest of the residents at risk. The DRFS stated on 8/4/2022, the family of Resident #3 called them and told them that there had been a repeat incident with Resident #4. The DRFS was not sure what a repeat incident meant but the DRFS was on their way to give Resident #3 a grievance form to report the repeat incident with Resident #4 when DRFS was distracted by Resident #2 who was screaming. The DRFS stated Resident #4 wheeled Resident #2 outside and Resident #2 did not want to go so they were screaming. The DRFS did not follow up with Resident #3 about the alleged unwanted contact on 8/4/2022, did not file a grievance for the resident, and did not notify Administration on 8/4/2022. DRFS stated Resident #4 was moved to South Unit on 8/5/2022, due to the incident with Resident #2 screaming, not because of the reported 2nd incident with Resident #3. During an interview on 9/15/2022 at 3:45 PM, the DON stated they were aware there was another incident on 8/4/2022 with Resident #3 and Resident #4 but was made aware after the fact. They did not complete an A&I report after finding out or investigate it further. The DON did not know about the alleged bruise. The DON just knew that an incident took place between the 2 residents. The DON stated the facility did not move Resident #4 to the South Unit before 8/5/2022 because family kept refusing. The facility should not have appeased the family and the resident should have been moved due to their behaviors. The DON stated after the incident on 8/4/2022, when Resident #4 was wheeling Resident #2 outside, was when they put their foot down and the resident was transferred off the North Unit to the South Unit. The DON stated Resident #4 was still able to ambulate without a walker on South Unit. During an interview on 9/16/2022 at 1:30 PM, the Administrator stated they did not know about the 8/4/2022 incident with Resident #4 and Resident #3. The Administrator stated there were no grievance forms or I&A reports completed for the incident on 8/4/2022. The Administrator stated the incident on 8/4/2022 with Resident #4 would not have happened if the first incident on 7/26/2022 had been handled appropriately. The Administrator stated an I&A and investigation should have been completed for the alleged incident with Resident #3 on 8/4/2022 that was reported to the DRFS. The Administrator stated family choice and preference should not override the safety of the residents in the facility. The family of Resident #4 should have been called and told that Resident #4 was being moved for their safety and the safety of other residents. The resident should have been moved immediately and placed on a 1:1 for supervision after the 1st incident. The Administrator stated no new interventions were implemented after the incidents with Resident #4 on 7/26/2022 and 8/4/2022 and care plans were not initiated or updated for these residents. The whole process fell through from implementing safety interventions to investigating the incidents. During an interview on 9/16/2022 at 3:00 PM, the Attending Physician (AP) stated they were not aware of the incidents with Resident #s 4, 3, and 2. They had not been called about the incidents and would expect that another provider was called, t [TRUNCATED]

Based on record review and interviews during an abbreviated survey (Case #NY 681) the facility failed to thoroughly investigate allegations of abuse for 2 (Resident #2 and #3) of 2 residents reviewed for abuse. Specifically, on 7/26/2022 at 1:30 AM, Certified Nursing Assistant (CNA) #3 observed Resident #4, who had severely impaired cognition, standing next to the bedside of Resident #2, who had moderately impaired cognition. Resident #2's sheets were off and hospital gown was pulled up. CNA #3 removed Resident #4 from the room. On the same day, 7/26/2022 at 4:45 AM, Resident #4 wandered into the room of Resident #3, who was cognitively intact and reported to CNA #3 and Registered Nurse (RN) #1 that they were sexually assaulted by Resident #4. Resident #3 stated they woke up to Resident #4 fondling their breast and inner thigh. Resident #3 has a history of Post-Traumatic Stress Disorder ([CONDITION(S)]) after being sexually assaulted as a child and reported experiencing increased anxiety as a result of this incident with Resident #4. The facility failed to complete a thorough investigation of the allegation of sexual abuse by Resident #4 that occurred on 7/26/2022. The facility did not report allegations of sexual abuse to law enforcement, and the facility did not submit an incident report to the department until 7/27/2022, 29 hours after the reported incident. As a result, the facility did not collect evidence to determine what occurred or what actions or systems were necessary to prevent sexual abuse by Resident #4 from reoccurring and failed to provide a safe environment to residents. This resulted in, or had the likelihood for, psychosocial harm that is Immediate Jeopardy and Substandard Quality of Care to resident health and safety and had the likelihood to affect all residents in the facility. The Immediate Jeopardy was lifted on 9/16/2022. This is evidenced by: The Policy and Procedure (P&P) titled Resident Abuse Prevention and Reporting dated 5/2022, documented that upon receiving a report of suspicion of abuse of any kind, mistreatment, neglect or misappropriation of property, the supervisory/administrative staff were required to immediately initiate an investigation into the alleged incident. The investigation would proceed per the criteria on the investigative report, with documentation of all actions taken on an ongoing basis for the duration of the investigation. All abuse investigations would be reviewed by the Administrator, Medical Director, and Director of Nursing. Incident #1: The facility failed to complete a thorough investigation for Resident #2 after Resident #4 was removed from the bedside of Resident #2 where Resident #2 was observed by Certified Nursing Assistant (CNA) #3 in bed with their sheet down, and hospital gown up, exposing their incontinence brief and abdomen on 7/26/2022 at 1:30 AM. Resident #4: Resident #4 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- an assessment tool) dated 5/7/2022, documented the resident had severely impaired cognition, could usually understand others, and could usually make themselves understood. Resident #2: Resident #2 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- an assessment tool) dated 5/4/2022, documented the resident had moderately impaired cognition, could understand others, and could make themselves understood. The Incident and Accident (I&A) report dated 7/26/2022, initiated by RN #1, documented Resident #4 had inappropriate contact with another resident (Resident #2). The immediate action to protect resident safety was to maintain 15-minute checks for Resident #4. Situational factors included: there was only one aide and one nurse on the unit for the duration of 11 PM - 7 AM shift. The RN documented the resident was last seen at 4:30 AM and was wandering into other resident rooms. The medical record for Resident #2 did not include a Registered Nurse Assessment to assess for physical and psychosocial harm after the alleged incident with Resident #4 on 7/26/2022. The facility did not provide documentation that immediate measures were put in place to ensure that further potential abuse, neglect, exploitation, or mistreatment did not occur and did not provide documentation that a thorough investigation of the alleged violation was completed. During an interview on 9/15/2022 at 11:10 AM, Registered Nurse (RN) #1 stated they wrote up an I&A and got a statement from CNA #3 after the incident but did not start an investigation. During an interview on 9/15/2022 at 11:50 AM, the Assistant Director of Nursing (ADON) stated that they heard about the incident on 7/26/2022 between Resident #4 and #2 but they did not start an investigation. During an interview on 9/15/2022 at 3:25 PM, the Director of Nursing (DON) stated they were not aware of the incident with Resident #4 and Resident #2 until 7:00 AM, the morning of the incident and had not started an investigation on this incident. During a subsequent interview on 9/16/2022 at 3:07 PM, the DON stated the procedure for an investigation would be to get staff statements, care plans be established with new interventions and to see if the monitoring was effective. The DON stated that they should have gotten an interview with CNA #3 but did not. The DON stated they still had not done an investigation of the incident. During an interview on 9/16/2022 at 3:15 PM, the Administrator (ADM) stated that they were made aware of the incident on 7/26/2022 by a text message from the DON. The ADM stated they did not investigate the incident, and it was the responsibility of whoever was in charge at the time of an incident to start an investigation. The ADM stated that Resident #4 was on 15-minute checks and the ADM was told everything was done. That was the extent of their follow-up. Incident #2: For Resident #3, the facility failed to complete a thorough investigation for an allegation of sexual abuse by Resident #4 that was reported to CNA #3 and Registered Nurse (RN) #1 on 7/26/2022 at 4:45 AM. Resident #4 wandered into the room of Resident #3 who alleged to staff that they were sexually assaulted by Resident #4 when they woke to Resident #4 fondling their breast and inner thigh on 7/26/2022 at 4:45 AM. Resident #3: Resident #3 was admitted with post-traumatic stress disorder ([CONDITION(S)]), [CONDITION(S)] disorder, and [CONDITION(S)] with [CONDITION(S)]. The Minimum Data Set (MDS- an assessment tool) dated 6/10/2022, documented the resident was cognitively intact, could understand others and could make themselves understood. The I&A report dated 7/29/2022, initiated by the Director of Nursing (DON) documented Resident #4 entered the room of Resident #3 without authorization. The A&I did not document the date and time of the incident. The medical record for Resident #3 did not include a Registered Nurse Assessment to assess for physical and psychosocial harm after the alleged incident with Resident #4 on 7/26/2022. The facility did not provide documentation that immediate measures were put in place to ensure that further potential abuse, neglect, exploitation, or mistreatment did not occur and did not provide documentation that a thorough investigation of the alleged violation was completed. During an interview on 9/14/2022 at 11:00 AM, Resident #3 stated they did not think the facility investigated the incident because they had not heard anything in response to the incident on 7/26/2022. During an interview on 9/14/2022 at 11:35 AM, Registered Nurse (RN) #1 stated they worked 7/26/2022 and they did not write an I&A report or start any investigation after Resident #3 alleged sexual abuse by Resident #4 because they had other priorities. During an interview on 9/15/2022 at 3:25 PM, the Director of Nursing (DON) stated they were aware of the incident with Resident #4 and Resident #3 on 7/26/2022 and had not started an investigation on this incident. During an interview on 9/16/2022 at 11:46 AM, the Nurse Practitioner (NP) stated they were aware of Resident #4's aggressive behaviors but unaware of their wandering. The NP stated these issues could have been addressed had they been investigated. The NP stated law enforcement was not called to their knowledge but should be with any allegation of sexual abuse. During an interview on 9/16/2022 at 1:00 PM, the Administrator (ADM) stated they had not started an investigation and had not called the police. Incident #3: The facility did not complete a thorough investigation when Resident #4 had unwanted contact with Resident #3 on 8/4/2022. During an interview on 9/15/2022 at 5:40 PM, Resident #3 stated on 8/4/2022 they were wheeling down the hallway in their wheelchair and Resident #4 had their arm extended with their hand on Resident #2's shoulder. Resident #3 stated that they could not get by and said excuse me and tried to go around both of them. Resident #4 put their hand on Resident #3's shoulder to prevent them from going around. Resident #3 stated they pulled away and then Resident #4 punched them in the left forearm leaving a bruise. The resident stated they reported this to a nurse who wrote said they would file a grievance on it. The facility did not provide an Investigation, Incident and Accident (I&A) report, or grievance form for the alleged physical incident on 8/4/2022 involving Resident #3 and Resident #4. Resident #3's medical record did not include documentation of the alleged unwanted physical contact with Resident #4 on 8/4/2022. Resident #3's medical record did not include a completed Skin Observation Tool or a Registered Nurse Assessment to assess for physical and psychosocial harm after the alleged incident with Resident #4 on 8/4/2022. During an interview on 9/14/2022 at 4:30 PM, the Director of Resident and Family Services (DRFS) on 8/4/2022, the family of Resident #3 called them and told them that there had been a repeat incident with Resident #4. The DRFS was not sure what a repeat incident meant but the DRFS was on their way to give Resident #3 a grievance form to report the repeat incident with Resident #4 when DRFS was distracted by Resident #2 who was screaming. The DRFS stated Resident #4 wheeled Resident #2 outside and Resident #2 did not want to go so they were screaming. The DRFS did not follow up with Resident #3 about the alleged unwanted contact on 8/4/2022, did not file a grievance for the resident, and did not notify Administration on 8/4/2022. During an interview on 9/15/2022 at 3:45 PM, the DON stated they were aware there was another incident on 8/4/2022 with Resident #3 and Resident #4 but was made aware after the fact. They did not complete an I&A report after finding out. The DON did not know about the alleged bruise. The DON just knew about an incident taking place and did not know the details and did not investigate. During an interview on 9/16/2022 at 1:30 PM, the Administrator stated they did not know about 8/4/2022 incident with Resident #4 and Resident #3. The Administrator stated there were no grievance forms or I&A reports completed for the incident on 8/4/2022. The Administrator stated the incident on 8/4/2022 with Resident #4 would not have happened if the first incident on 7/26/2022 had been handled appropriately. The Administrator stated an I&A and investigation should have been completed for the alleged incident with Resident #3 on 8/4/2022. The resident should have been moved immediately and placed on a 1:1 for supervision after the first incident. The Administrator stated no new interventions were implemented after the incidents with Resident #4 on 7/26/2022 and 8/4/2022 and care plans were not initiated or updated for these residents. The whole process fell through from implementing safety interventions to investigating the incidents. During an interview on 9/16/2022 at 3:00 PM, the Attending Physician (AP) stated they were not aware of the incidents with Resident #s 4, 3, and 2. The AP stated had they been called and informed of the incident, they could have given instructions or guidance on what to do for the resident. During an interview on 9/19/2022 at 2:10 PM, the Medical Director stated they were not informed of the incidents on 7/26/2022 or 8/4/2022 with Resident #s 4, 3, and 2. The MD stated the resident should have had an RN assessment and if the staff had called them, they would have had the resident sent to the hospital for an evaluation. The MD stated that an investigation should have been done. The MD expected an investigation would have been done with details of what the problem was and how they fixed it. The Administrator was informed of the Immediate Jeopardy and provided the Immediate Jeopardy Template on 9/15/2022. On 9/16/2022, the facility submitted an allegation letter for the Removal of the Immediate Jeopardy. On 9/17/2022, an onsite survey was conducted, and the following corrections were taken by the facility: The facility implemented one to one supervision of Resident #4 that would be ongoing. The resident would be re-evaluated prior to removing the one-to-one supervision. The Policy and Procedure (P&P) titled Resident Abuse Prevention and Reporting dated 5/2022 was updated. Staff education as of 9/17/2022, was at a 92% completion rate with 97 of 102 employees and 6 of 8 agency staff were in-serviced by the DON and ADON. A packet on the new P&P was given and discussed with the employees before the start of their shift. Law enforcement was called, and a report will be filed regarding the sexual assault allegation. A thorough investigation for the incidents on 7/26/2022 and on 8/4/2022 will be substantially underway. All residents who wander and who were at risk for sexual misconduct or aggression or at risk for victimization due to cognitive status or past trauma were assessed. Specific education was rendered to the RN on duty at the time of events, identified deficient practice and appropriate actions that should have taken place. The RN was educated on abuse prevention, reporting, providing an immediate and appropriate intervention to keep residents safe. As a result of this survey, it was determined that the Immediate Jeopardy for F610 was abated as of 9/16/2022, prior to the exit date of 9/20/2022. 10 NYCRR 415.4(b)

Based on staff interview and medical record review during a complaint investigation (Case #NY 659) the facility did not ensure that the resident environment remained as free of accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #124) of two resident's reviewed. Specifically, on 3/17/14 Resident #2 was admitted to the facility. She was evaluated by the Physical Therapist and it was determined she required one assist, contact guard/close supervision for ambulation. Resident #124's Care Card (a document used by staff to know what care a resident required) documented that she was independent with ambulation. That evening, at 6:10 pm the resident was found on the floor in her room with right hip deformity with external rotation of her right leg. The resident was transferred to the emergency room (ER) and the hospital medical record documented that the resident was admitted with a right intertrochanteric hip fracture. This resulted in actual harm that is not immediate jeopardy. This was evidenced by: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Nursing History and Assessment assessed the resident as having impaired judgment and poor short term memory. The Hospital and Community Patient Review Instrument (HC-PRI) dated 3/11/14 documented under Mobility: walks with constant one to one supervision and/or constant physical assistance. The physician's orders [REDACTED]. The Rehabilitation PT/OT Screening Form dated 3/17/14 documented the resident required a contact guard/close supervision for ambulation. It further documented the resident was to ambulate with a wheeled walker, one assist for now until further evaluation by PT on 3/18/14. The Fall Risk assessment dated [DATE] documented the resident was at high risk for falls related to intermittent confusion, balance problem while standing/sitting, balance problem while walking, use of a walker, and taking 3-4 specific medications currently or within the past 7 days. The Care Plan, entitled Falls and dated 3/17/14, documented the Resident was at risk for falls or injury related to confusion, wandering, and unaware of safety needs. Approaches/Interventions included to transfer and ambulate per PT and/or OT recommendations. The Care Plan, entitled ADLs (Activities of Daily Living) dated 3/17/14 documented the resident was independent with ambulation and required one assist for toileting. The Care Card, undated, documented the resident was independent with ambulation and required one assist with toileting. The Nurses Notes dated 3/17/14 at 2:00 pm documented evaluation by therapy-resident to ambulate on unit with rolling walker. The Accident and Supervision Report: Fall dated 3/17/14 at 6:10 pm documented while ambulating with walker in her room, the resident turned and fell on her right side. The fall was unobserved. Where the report questions when the resident was last toileted it is documented indep or independent. It further documented the resident had right hip deformity with external rotation of the right leg. She was transferred to the ER. During an interview on 3/23/15 at 1:50 pm the Licensed Practical Nurse (LPN) stated that when a new admit arrives they would be evaluated by nursing at first, and then would be screened by PT for activities of daily living. She stated once PT completed their screen, staff would go by their recommendations. She stated PT should verbalize this to nursing and also file their screen in the chart so the resident's care plan could be adjusted accordingly. During an interview on 3/23/15 at 1:55 pm the Registered Nurse (RN), who completed the resident's Care Card 3/17/14, stated that when a resident is admitted they are evaluated by therapy and staff follow their recommendations for activities of daily living. She stated prior to therapy's assessment, nursing would go by the PRI (Patient Review Instrument) or hospital paperwork. When therapy completed their evaluation they would complete a Rehabilitation Changes Notice to alert staff that their care plan had changed, or therapy could update the resident's care card on their own to reflect the changes. She stated she recalled the resident and she thought she was seen by therapy the day she was admitted . She stated from what she could remember the resident fell in her room, so it would not matter if she could ambulate independently or required one assist. She stated the resident had gotten up on her own, therefore the end result would not have been different. During a repeat interview on 4/13/15 at 7:45 am the RN stated she admitted the resident and the family provided information on the resident. She stated the resident knew who she was but was confused to time and place. She stated she could not recall why she put Independent on the Care Card for ambulation but remembered the family saying the resident could walk. She stated she usually would not make a person Independent on admission, she would err on the side of safety. She stated that if a resident needed supervision to ambulate that would mean in the room also. She stated she did not remember if the resident was oriented to the call bell use, she did not know if the resident would remember that later. During interview on 3/23/15 at 11:30 am the Physical Therapist (PT) who completed the resident evaluation/screen stated that with a new admission therapy would evaluate the resident for activities of daily living. She stated she would complete her screen and give it to her assistant to file in the resident's chart. She stated nursing staff would not necessarily see that screen that day, however, they should be told verbally so they could update the Care Plan or the therapist could change the resident's Care Card on their own. She stated based on her evaluation the resident should have been a one assist, contact guard/close supervision with wheeled walker for ambulation. She stated because this resident had been admitted over a year ago, she could not remember if she verbally updated nursing regarding her ambulation status. She stated she did not understand why the resident's Care Plan and Care Card documented that she was independent with ambulation. She stated usually prior to her evaluation, nursing would make a resident at least a one assist for safety. She further stated the resident's Care Card should have been updated to reflect her recommendations for ambulation. During repeat interview on 4/10/15 at 2:57 pm the PT stated that contact guard meant hands on the resident and close supervision meant right next to the resident. She stated she wanted one Assist for ambulation as more of a general guide for nursing. She stated that the independent transfer status meant that the resident could go from chair to bed or bed to chair if the chair was right next to the bed. She stated she would normally let the resident know she would need assist when walking, but she did not document talking with this resident. She stated that if the nurses did the Care Card she would have told them about the changes she recommended verbally. She stated the resident was supposed to use the rolling walker when walking in her room. She also stated she had no documentation form for the changes needed to the resident's Care Card. During an interview on 3/23/15 at 2:15 pm with the Director of Nursing (DON) and Administrator present, the DON explained that upon admission a resident would be evaluated by therapy for activities of daily living and nursing would follow their recommendations. She stated prior to therapy's assessment, nursing would use their judgment in making this decision, and should make the resident at least an assist of one for precautionary purposes. She stated once the resident was screened by therapy, the therapist could make appropriate changes directly on the resident's care card. She further stated therapy could also notify nursing and have them adjust the care plan. 10 NYCRR 415.12 (h)(1)

Based on staff interview and medical record review during a complaint investigation ( Case #s NY 511 and NY 709) the facility did not ensure that each resident's drug regimen was adequately monitored for one (Resident #1) of eight residents reviewed for unnecessary medications. Specifically, for Resident #1 the facility did not complete laboratory blood testing to monitor the efficacy of anticoagulant therapy. Resident #1 was on [MEDICATION NAME] and [MEDICATION NAME] (both anticoagulants, blood thinning medications), which required laboratory blood testing monitoring. The [MEDICATION NAME] time (PT) and international normalized ratio (INR) ordered by the physician were not completed and/or results were not reported. Subsequently, Resident #1's PT and INR results were critically elevated (normal range for PT 10.4-13, and therapeutic range for INR 2-3), which required acute care hospital admission. This resulted in actual harm for Resident #1 that is not immediate jeopardy. This was evidenced by: Resident #1 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a standardized assessment tool) dated 2/26/14 assessed the resident as having moderately impaired cognition. The Hospital Transfer Summary dated 2/17/14 documented to recheck the resident's PT/INR in 48 hours, [MEDICATION NAME] 4 mg by mouth daily, and [MEDICATION NAME] 80 (mg) subcutaneously twice a day until INR is therapeutic. The Physician's Discharge Orders from the hospital dated 2/19/14 documented to recheck the resident's PT/INR on 2/20/14 and to discontinue the [MEDICATION NAME] once the INR was greater than 2. The Admission physician's orders [REDACTED]. The orders did not include laboratory blood testing to check the resident's PT/INR on 2/20/14. The Medication Administration Record [REDACTED]. Document Injection Site. Until INR therapeutic. The MAR indicated [REDACTED]"one" mg. The MAR indicated [REDACTED]. The following information was recorded: 2/19/14 8:00 pm-blank 2/20/14 8:00 am-abd (abdomen) 2/20/14 8:00 pm through 2/21/14 8:00 pm: blank 2/22/14 8:00 am-abd 2/22/14 8:00 pm-blank 2/23/14 through 2/24/14 8:00 am and 8:00 pm-abd (all 4 times/injections) 2/25/14 8:00 am-blank 2/25/14 8:00 pm through 2/27/14 8:00 pm-abd (all 5 times/injections) 2/28/14 8:00 am-right (illegible) handle 2/28/14 8:00 pm what appears to be initials, not injection site 3/1/14 8:00 am-right (illegible) handle 3/1/14 8:00 pm-left (illegible) handle 3/2/14 8:00 am-blank 3/2/14 8:00 pm-LA (left arm) 3/3/14 8:00 am-abd. The physician's orders [REDACTED]. It further documented Routine Labs PT/INR weekly (next PT/INR due by 3/1/14). The Laboratory Telefax Activity Report dated 2/22/14 at 2:30 pm documented the resident's PT/INR were 21.6/1.9 There was no documented evidence the physician was made aware of the resident's PT/INR results on 2/22/14. The following day 2/23/14, the Nurses Notes (day shift) documented the resident's INR was 1.9 on 4 mg ([MEDICATION NAME]). New Order per MD ([MEDICATION NAME]) 4.5 mg by mouth daily, INR Wednesday (2/26/14). The physician's orders [REDACTED]. Record review revealed an Accident and Supervision Report (ASR) dated 2/25/14 at 12:30 pm was completed for Resident #1. The ASR documented that Resident #1 had an "injury of unknown origin" to the left flank/trunk area. The area was described as a bruise measuring 20 cm in length X 8 cm in width. It was further documented the resident was on both Aspirin 81 mg and [MEDICATION NAME] 3 mg ( Resident was actually on [MEDICATION NAME] 4.5mg). There was no mention that the resident was also receiving [MEDICATION NAME] injections twice daily. The Nurses Notes dated 2/25/14 at 3:00 pm documented Resident #1 noted with bruise to left flank. Resident is on both Aspirin 81 mg and [MEDICATION NAME] 3 mg daily (Resident actually receiving [MEDICATION NAME] 4.5mg). Resident unable to remember or state reason for bruise. There was no mention that the resident was also receiving [MEDICATION NAME] injections twice daily. There was no documented evidence of an order to recheck Resident #1's PT/INR 2/26/14. A Physician notification form, titled The Accident and Supervision Report: Non Fall MD Progress Note dated 2/27/14 documented "Nurse Explain Occurrence: Bruise noted to L (left) flank area receives ASA (aspirin) 81 mg & [MEDICATION NAME] 3 mg." The physician then wrote "Exam: as above" and signed the document 2/28/14. There was no mention that the resident was also receiving [MEDICATION NAME] injections twice daily. There was no documented evidence Resident #1's PT/INR was rechecked on 3/1/14 per the order for weekly PT/INRs written 2/21/14. The Daily Skilled Nurse's Note dated 3/3/14 day shift documented Resident #1 was noted with a bloody nose. The Laboratory Inquiry Report documented Resident #1's PT/INR was not rechecked until 3/3/14. Resident #1's PT and INR were both critically elevated, with a PT of 134 and an INR of 11.7. The physician's orders [REDACTED]. It also documented an order for [REDACTED]. The physician's orders [REDACTED]. There was no documented evidence that blood for a PT/INR was drawn on 3/4/14. The physician's orders [REDACTED]. The Laboratory Telefax Activity Report dated 3/5/14 documented Resident #1's PT and INR were still both critically elevated, with a PT of 60.7 and an INR of 5.3. The Nurses Notes dated 3/5/14 at 10:15 am documented Resident #1 alert and pleasant denies any pain or distress but reacts to palpation of large bruise to left side. Several status [REDACTED]. Abdomen soft, non-tender upon palpation. Call placed to rescue squad, en route. An entry on the bottom of the Laboratory Telefax Activity Report dated 3/5/14 documented resident admitted to hospital with [MEDICAL CONDITION] and abdominal hematoma. During an interview on 3/5/14 at 1:20 pm Licensed Practical Nurse (LPN) #1 stated that all residents on anticoagulation therapy should have their PT/INR checked at least weekly. She stated some residents who need to be more closely monitored, for example those also receiving antibiotics, are checked even more frequently at 3 times per week. During an interview on 3/5/14 at 8:55 am the Registered Nurse Manager (RNM) stated that anticoagulant orders are patient specific and she has not noticed any problems regarding the lab drawing PT/INRs or issues with the resident's PT/INR results. In a subsequent interview with the RNM on 3/5/14 at approximately 10:30 am the RNM stated the resident was being sent to the ER for a hematoma to her abdomen. She stated she did not know if it was related to the [MEDICATION NAME] injections the resident had been receiving. The History and Physical from the hospital dated 3/5/14 documented Resident #1 was transferred to the ER for bruising to the abdominal wall and abdominal pain. The Discharge Summary from the hospital dated 3/7/14 documented Resident #1 was admitted to the hospital and was found to have left psoas muscle hematoma, a retroperitoneal bleed and [MEDICAL CONDITION] both secondary to over anticoagulation. Resident #1's hemoglobin was noted to be 5.7 (normal range 12.3-15.5) and hematocrit 18.1 (normal range 37.5-45.9) requiring a transfusion of 3 units of packed red blood cells. During an interview on 3/5/14 at 2:55 pm the Director of Nursing (DON) stated about one month ago, the facility identified an issue with tracking PT/INRs. She stated there was an issue with the lab not drawing blood work, requiring the facility to have to call them and get them to come back in. She stated the physician's currently working in the facility had different theories regarding [MEDICATION NAME] therapy. During an interview on 3/27/14 at 10:30 am the Physician stated that [MEDICATION NAME] therapy was very unpredictable. She stated that diet can effect PT/INR levels and it takes about 3-5 days to have a change noted in the PT/INR when adjusting dosage. She first stated when she changes the dosage of [MEDICATION NAME] she would recheck the PT/INR in 2 to 3 days, but later in the interview stated she would recheck it in one week. She stated there was no real indication when to order Vitamin K, that this is a gray area and up to the discretion of the physician. She stated maybe she was thinking one way this day, and differently the next in reference to ordering the Vitamin K on 3/4/14 and not 3/3/14. She further stated that Resident #1 had bled while on anticoagulant therapy, and it was unfortunate. During a second interview on 3/27/14 at 12:30 pm the DON stated she was unaware of any concerns with Resident #1's care at the facility and that the resident had been discharged after being sent to the hospital on [DATE]. 10 NYCRR 415.12(l)(1)

Based on observation, medical record review and staff interviews the Quality Assurance (QA) program did not have a program that readily identified issues that had the potential to cause serious harm to residents during an abbreviated survey (NY 586). Specifically, for twelve residents reviewed the QA program did not ensure residents wishes for advanced directives were accurately identified, and that staff was aware of the meaning of the indicators of cardiopulmonary resuscitation (CPR) and do not resuscitate (DNR) status. In addition, Review found multiple inconsistencies among the various references used to identify the residents code status to include inaccurate physician orders, resident status incorrectly identified on wrist bands and other direct care lists and records. This resulted in no actual harm, with the potential for more than serious harm that is Immediate Jeopardy for the residents health and safety. This has the potential to effect all of the residents in the facility. This was evidenced by: Refer to F 155 - Resident Rights- Scope and Severity - L During an interview on [DATE] at 12:30 pm the Director of Nurses (DON) stated she was fairly new in the position and had plans to look at the CPR/DNR protocol in the near future, although she had no idea that the issues identified were that extensive. DON was present for one Quality Assurance (QA) Meeting since her start as DON. There was no CPR/DNR discussion at that meeting although Code Blues( resuscitative measures) were discussed, given the recent code that took place in the facility with Resident # 7. During an interview on [DATE] at 1:20 pm the Administrator stated he new they had to review the DNR/CPR protocol, that the QA Registered Nurse (QARN) mentioned it a few weeks ago in the Quality Assurance Meeting because she found a wrist band to be wrong. Administrator stated that the QA RN was responsible to monitor for issues that needed attention and she would work to fix the problems. He stated that a house audit was done in January by the Social Work(SW) assistant and he was told there were no issues. Administrator had not read the DNR/CPR Policy & Procedure, although the previous Administrator had reviewed DNR/CPR with him when he started as the new Administrator. The QA Committee meets quarterly and the attendees include the department heads and the nurse managers. Adjunct groups meet on an as needed basis. During an interview on [DATE] at 3:30 pm the Medical Director (Med Dir) stated he was not aware of problems with advance directives, and that it had to be addressed. My role as Med Dir there is also to look at QA. I want to know about problems and I want to fix problems. I'm present in the building and I am accessible by phone. My own QA, I look at residents that have been transferred out, at random to be sure that residents that go out to the emergency room /hospital are appropriate transfers. 10 NYCRR 415.27(a-c)

Based on observation, record review and interview during an abbreviated survey (NY 586) the facility failed to accurately identify the residents wishes for Advance Directives (AD), and to ensure staff is aware of the residents wishes for Advance Directives. The nursing home has a multi-layered system that begins with the advanced directive form and includes physician orders, a color coded sheet in the chart, wristbands with colored dots, full code lists and entries on the Certified Nurse Aide (CNA) Care Card, review found multiple inconsistencies among these various references. In addition, all staff did not know the action to be taken based on the color indicator on the wrist band and do not routinely check that bracelets are in place. Specifically, for 12 residents reviewed (#'s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12) the multiple indicators for Advance Directive status were not consistent with one another. Interviews revealed the facility staff were unable to identify the wishes of the residents for Do Not Resuscitate (DNR) and Cardiopulmonary Resuscitation (CPR) status. This resulted in no actual harm, with the potential for more than serious harm that is Immediate Jeopardy for the residents health and safety. This has the potential to effect all of the residents in the facility. Policy & Procedure (P&P) entitled Advance Directives (AD) and dated as revised on [DATE] documented the facility will comply with New York State regulations regarding policies and procedures for Advance Directives and Basic Life Support. Procedure included; Resident AD status will be identified on the day of admission; Director of admissions/designee will obtain AD documents, copies of the documents will be given to the director of Social Work (SW) and RN, Unit Manager (RNUM). RNUM or supervisor will: review the documents for completeness and ensure the documents are placed in the medical record; will obtain physician order [REDACTED]. Admissions Director will maintain a current roster of FC residents, the roster will be kept on emergency cart located in the dining room. The nursing secretary will distribute updated rosters as changes occur. On evening, night and weekend shift the RN Supervisor (RNS) will manually update and distribute this roster, at a minimum the roster will be updated every time a resident is admitted , and when any resident is readmitted after a hospital admission, and when there is a change in the AD status and so ordered by physician. Changes in resident AD wishes the RNUM/RNS and SW will ensure proper changes with physician orders, FC roster, care card and care plan. Resuscitative status information will be reviewed frequently and reported to QA committee to ensure that it is up to date and each method of information is consistent. All facility staff, including non-direct care employees and temporary agency staff, and volunteers will be aware of what to do if they encounter an unconscious resident. The Code Phrase will be Code Blue. It is the responsibility of the licensed nurse to immediately establish the resuscitative status of resident upon initiation of a " Code Blue " . Observation on [DATE] of the Full Code List obtained from the Medication Cart on Unit East and the Crash Cart in the main dining room of the facility revealed conflicting information. The Full Code List from the medication cart was dated [DATE], the Full Code List from the dining room Crash Cart was dated [DATE] and the Residents listed on the two lists did not match. Resident # 1: Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident was alert and oriented with a BIMS score of 15 according to the MDS dated [DATE]. Resident # 1's records revealed a DNR status documented on the Advance Directive form, physician orders, Care Card, and the Resident was not listed on the Full Code list. Full Code status was documented in the Physician Periodic Medical Evaluation, and the Resident had no facility wristband on her person indicating advance directive status. Advance Directive form dated [DATE] and signed by the Resident and Physician documented the Resident was with capacity, and was a DNR status. Resident Care Card dated [DATE] documented under Code Status: DNR. Physician Periodic Medical Evaluation dated [DATE], and [DATE] and signed by physician had an entry noting the Resident was a full code. Physician orders [REDACTED]. Full Code List located in the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident Identification Bracelet on [DATE] revealed there was one hospital identification bracelet on each wrist. There was no facility identification bracelet on the Resident's person. Review of the care plan revealed there was no documentation of the resident's advance directive wishes. During an interview on [DATE] at 1:45 pm Resident # 1 stated that she was a DNR status, but had never been given a facility identification bracelet. During an interview on [DATE] at 4:20 pm LPN # 6 stated that a resident who was DNR would have a blue dot on their name band, and there was a list of full code residents in the front of the Medex. LPN would always go to the chart to double check a status before trusting that the other things are all correct. During an interview on [DATE] at 4:30 pm the nursing secretary stated that she was responsible for typing the Full Code List once the SW assistant gave her the list that was based on the monthly audit. Stated the last list was done on [DATE]. Nursing secretary stated that she did not know who was responsible to update the list with daily changes, but that it was supposed to be updated by hand. During an interview on [DATE] at 9:40 am, the Certified Occupational Therapy Assistant (COTA) stated that to identify a resident who was DNR there would be a blue dot on their bracelet. Stated the Full Code List was on the Crash Cart in the dining room and stated it was supposed to be checked daily for correctness. During an interview on [DATE] at 11:15 am CNA # 4 stated that if a resident was a DNR it would be found on the wristband. It would be blue for DNR, and red if resident was a full code. Resident # 3: Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident was alert and oriented according to the nursing progress notes dated [DATE]. There was no Minimum Data Set (MDS) available for review. Resident # 3's records revealed a DNR status documented on the Advance Directive form, the Care Card, and Resident verbalized his desire to be DNR on admission. Full Code status was documented on the Full Code list, physician orders, physician history and physical and the Resident's wristband indicated Full Code. Full Code List located in the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Advance Directive form located in the medical record, dated [DATE] and signed by the Resident and Physician documented the Resident was with capacity, and was a DNR status. Nursing Progress note dated [DATE] and signed by a Registered Nurse documented Patient admitted via ambulance and stretcher. Patient alert and oriented X 3 (person, place & time). Resident states he is a DNR status and has a Health Care Proxy (HCP). Physician History and Physical dated [DATE] and signed by physician had an entry noting the resident was a full code. Physician orders [REDACTED]. Resident Care Card dated [DATE] documented under Code Status: DNR. Resident Identification Bracelet on [DATE] revealed there was no blue dot on the bracelet, indicating a full code status for Resident # 3. Review of the care plan revealed there was no documentation of the resident's advance directive wishes. During an interview on [DATE] at 1:45 pm Licensed Practical Nurse (LPN) # 1 stated that to identify a Residents DNR status the arm band would be checked, and that maybe it was a red dot on the band to indicate DNR. If the Resident was unresponsive the LPN would check for the written DNR form in the chart, to be certain of code status. During an interview on [DATE] at 2:40 pm CNA # 1 stated that a Resident who was DNR would have a blue dot on their identification bracelet, but was not sure if it would be on the care card. During an interview on [DATE] at 2:50 pm CNA # 2 stated that to identify a Resident who is DNR would be to check the identification band which should be purple which means they are DNR. During an interview on [DATE] at 12:00 pm LPN # 7 stated that to identify a resident's code status there would be a pink or blue sheet in the chart, a list on the MAR. LPN #7 was not sure if there was a care plan for Advance Directive status. LPN # 7 stated that the wrist band would be blue for DNR status and red for a full code status. Resident # 6: Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident is alert and oriented with a BIMS score of 14 according to the MDS dated [DATE]. Resident # 6's records revealed there was no Advance Directive Form completed on admission. Full Code List located in the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Advance Directive form in Resident's medical record had Resident # 6's name and medical record written on the top of the form and was undated. The remainder of the form was not completed which included the following entries; Resident capacity, wishes to be resuscitated, wishes to be DNR, surrogate information, attending physician determination, resident's signature, physician's signature, witness signature. Physician orders [REDACTED]. Physician History and Physical dated [DATE] and signed by physician had an entry noting the resident was a Full Code. Resident Care Card dated [DATE] documented under Code Status: Full Code. Resident Identification Bracelet on [DATE] revealed there was no blue dot on the bracelet, indicating a full code. Review of the care plan revealed there was no documentation of the resident's advance directive wishes. During an interview on [DATE] at 2:10 pm LPN # 2 stated that to identify a person ' s DNR status she would look for the blue paper in the chart that had DNR on it. A list of people who are DNR are on the medication carts and the code cart. LPN # 2 stated that she could also look at the MOLST form in the Resident chart. During an interview on [DATE] at 3:25 pm LPN # 4 stated that the Resident who is a DNR had a blue dot on the bracelet, and would have a pink FC sheet or blue DNR sheet in the chart. LPN stated that to be honest, she would only rely on checking the chart to be certain of a code status. During an interview on [DATE] at 11:00 am CNA # 3 stated that a resident could be identified for their code status by looking at the wristband, and DNR was a blue dot. CNA# 3 did not know if the code status would be on the care card in the resident room. During an interview on [DATE] at 3:00 pm the Social Worker stated that Nursing would do the Advance Directive Form on admission, and that SW would look and be the back-up to make sure it was done. The facility does not use MOLST at this time but she recently had an education on how to use the MOLST. SW did not know how the Full Code list gets updated in between the SW assistant updating it monthly, following an audit of all residents. The Nurse Managers were responsible to update the Care Cards. SW was not aware that the DNR protocol in the facility was this bad. During an interview on [DATE] at 3:00 pm the SW assistant stated the she does an audit of all residents on a monthly bases. She stated the last audit was done [DATE]. The results of the audits with an updated list of Full Code Residents was given to the Nursing Secretary to type and distribute. The Nursing Secretary should be given changes to be made, in order to have the Full Code sheet updated. During an interview on [DATE] at 2:20 pm the ADON stated that in order to identify a Resident DNR status, the nurses could check the chart, the wrist band indicates DNR status and the ADON thinks the DNR had a red dot on the wrist band. During an interview on [DATE] at 2:30 pm the East Unit Secretary stated that she was responsible for placing wrist bands and that the blue dot indicates DNR. The SW assistant is responsible to complete audits of all residents to assure the code status of all the residents are correct. The full code list is updated and sent to the units. During an interview on [DATE] at 12:30 pm the DON stated that the evening prior ([DATE]) the facility checked all name bands against the AD form and physician orders. They added AD care plans to the resident charts and they were noted to be absent in many resident charts. DON stated she did have a concern with having the care cards being in the resident rooms and in the CNA binder, which meant they would both have to be updated with changes. DON was fairly new in the position and had plans to look at the CPR/DNR protocol in the near future, although she had no idea that the issues identified were that extensive. DON stated that the staff are inserviced on DNR/CPR as part of the mandatory inservice. A new Registered Nurse Inservice Coordinator began working for the facility in the past month. Prior to the new person starting the ADON was responsible for Inservice education. DON was present for one Quality Assurance Meeting since her start as DON. There was no CPR/DNR discussion at that meeting although codes were discussed given the recent code that took place in the facility. During an interview on [DATE] at 1:20 pm the Administrator stated he new they had to review the DNR/CPR protocol, that the QA nurse mentioned it a few weeks ago in the Quality Assurance Meeting because she found a wrist band to be wrong. Administrator stated that the QA RN was responsible to monitor for issues that needed attention and she would work to fix the problems. He stated that a house audit was done in January by the SW assistant and he was told there were no issues. Administrator stated that a former DON had told the SW assistant to stop the audits he thought it was not done for one month prior to January. Administrator had not read the DNR/CPR P&P, although the previous Administrator had reviewed DNR/CPR with him when he started as the new Administrator. The first thing that the staff would do in the case of an unresponsive resident would be to grab the chart, in Administrators opinion the physician orders [REDACTED]. During an interview on [DATE] at 3:30 pm the Medical Director (Med Dir) stated he was not aware of problems with advance directives, and that it had to be addressed. We need to update the P&P and it needs to be put into place and we need to follow it. We need to audit to make sure it is being followed. I was not aware that staff were unfamiliar with the process, we will fix this as soon as possible, I will see to it. 10 NYCRR 415.3(e)(1)(ii)

Based on observation, medical record review and interviews during an abbreviated survey (Complaint # NY 586), the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the Administration failed to ensure residents wishes for advanced directives were accurately identified, and that staff was aware of the meaning of the indicators of cardiopulmonary resuscitation (CPR) and do not resuscitate (DNR) status. In addition, Review found multiple inconsistencies among the various references used to identify the residents code status to include inaccurate physician orders, resident status incorrectly identified on wrist bands and other direct care lists and records. This resulted in no actual harm, with the potential for more than serious harm that is Immediate Jeopardy for the residents health and safety. This has the potential to effect all of the residents in the facility. Interviews revealed the facility staff were unable to identify the correct indicators for DNR and full code (FC) status. These staff members included direct care staff such as Certified Nurse Aides (CNA), Licensed Nurses, and administrative nursing staff. This was evidenced by: Refer to F 155 - Resident Rights- Scope and Severity - L During an interview on [DATE] at 2:20 pm the Assistant Director of Nurses (ADON) stated that in order to identify a Resident DNR status, the nurses could check the chart, the wrist band indicates DNR status and the ADON thinks the DNR had a red dot on the wrist band. During an interview on [DATE] at 12:30 pm the Director of Nurses (DON) stated that the evening prior ([DATE]) the facility checked all name bands against the Advanced Directive(AD) form and physician orders. They added AD care plans to the resident charts and they were noted to be absent in many resident charts. DON stated she did have a concern with having the care cards being in the resident rooms and in the CNA binder, which meant they would both have to be updated with changes. DON was fairly new in the position and had plans to look at the CPR/DNR protocol in the near future, although she had no idea that the issues identified were that extensive. DON stated that the staff are inserviced on DNR/CPR as part of the mandatory inservice. A new Registered Nurse Inservice Coordinator began working for the facility in the past month. Prior to the new person starting the ADON was responsible for Inservice education. DON was present for one Quality Assurance (QA) Meeting since her start as DON. There was no CPR/DNR discussion at that meeting although codes were discussed given the recent code that took place in the facility. During an interview on [DATE] at 1:20 pm the Administrator stated he new they had to review the DNR/CPR protocol, that the QA Registered Nurse (QA RN)nurse mentioned it a few weeks ago in the QA Meeting because she found a wrist band to be wrong on a resident. Administrator stated that the QA RN was responsible to monitor for issues that needed attention and she would work to fix the problems. He stated that a house audit was done in January by the Social Work (SW) assistant and he was told there were no issues. Administrator stated that a former DON had told the SW assistant to stop the audits he thought it was not done for one month prior to January. Administrator had not read the DNR/CPR P&P, although the previous Administrator had reviewed DNR/CPR with him when he started as the new Administrator. The first thing that the staff would do in the case of an unresponsive resident would be to grab the chart, in Administrators opinion the physician orders [REDACTED]. 10NYCRR 415.26

Based on medical record review and staff interviews during a complaint investigation (complaint #NY 586) it was determined that for one (Resident # 7) of 13 residents reviewed, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psycho social well-being, in accordance with established policies and procedures and standards of practice. Specifically, when Resident # 7 was noted to have a potassium level of 2.3Meq/L at 10:08am on [DATE], the physician was not notified in a timely manner; the resident was not sent out to the emergency department for treatment of [REDACTED]." At approximately 12:50pm the resident was found on the bathroom floor, not breathing and required cardiopulmonary resuscitation. Additionally, the resident did not receive the potassium each day as originally ordered by the physician. This resulted in actual harm for Resident #7 that is not immediate jeopardy. This is evidenced by the following: Resident # 7 The resident was admitted to the nursing home on [DATE] with [DIAGNOSES REDACTED]. On admission the resident was assessed to be alert with periods of confusion. A review of physician's (MD) orders for Resident #7 revealed an order entered on [DATE] for [MEDICATION NAME] ( a diuretic that removes excess fluid and potassium ) 20mg every Monday, Wednesday and Friday and a second order dated [DATE] for KCL (potassium) 20Meq once a day, starting on [DATE]. A review of the Resident #7's medical record reveals there was no care plan for administration of [MEDICATION NAME] or potassium supplements for hypokalemia. A review of Resident #7's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A basic metabolic panel was drawn from Resident #7 each day from [DATE] to [DATE] with the following K (potassium) levels; on [DATE] the K was 2.6 Meq/L, on [DATE] the K was 2.7, on [DATE] the K result was 3.0. On [DATE] a blood specimen, that included a potassium level, was collected from Resident # 7 at 6:30am and received in the laboratory at 10:08am. The lab result of the potassium level (which was 2.3 Meq/L (millequivalents per liter) was called to Livingston Hills, East Wing to nurse Melissa on [DATE] at 10:53am. The notation documenteds that Nurse (name) read the lab results back to the caller. On the report under the 2.3 Meq/L result is written, "Critical value." The lab report also reveals that a second call was made to Livingston Hills East Wing on [DATE] at 11:27am and the critically low potassium level of 2.3 was read to Nurse (DON). The laboratory then faxed a copy of the lab result to Livingston Hills on [DATE] at 11:33am. A supervisor at the performing laboratory stated on [DATE] at approximately 12:30pm, that the comment section on the computer for this particular critical Potassium documents that the results of the residents potassium level was called to the facility twice on [DATE]. A copy of a rescue squad report dated [DATE], the EMT (emergency medical technician) documented that a call was received to respond to a [MEDICAL CONDITION] at Livingston Hills Nursing Home on [DATE] at 12:57pm. The chief complaint entered on the report was documented to be "[MEDICAL CONDITION] and a critical potassium level of 2." The report also revealed that upon arrival at the nursing home EMTs noted that CPR was in progress and the nursing staff had delivered one shock to Resident # 7. During an interview on [DATE] at approximately 12:30pm, the facility Director of Nursing (DON) stated that there had been a "code" (resuscitation) called on a resident on the east wing in mid-January and the resident (Resident #7) had been successfully resuscitated and sent out to the hospital but later died of unknown complications. The DON stated that she was not aware that the laboratory had called or faxed a critically low potassium level (2.3Meq/L) result to the facility on the morning of [DATE] (the day Resident # 7 was resuscitated) and that she was only just learning of the low potassium level from the state surveyor during this current interview. The DON agreed that with potassium level as low as 2.3 Meq ' s/L, it was possible that Resident #7 might have developed an arrhythmia which caused his [MEDICAL CONDITION]. After reviewing Resident #7's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview on [DATE] at approximately 3:30pm, the facility Medical Director (Med Dir) stated that he was not aware that Resident # 7 was reported to have a critically low potassium level on [DATE], the day he was sent out to the hospital. The Med Dir stated that he had not reviewed this particular resident's death or the resuscitation performed on the resident while at the nursing home because prior to this conversation, no one had informed him of the resident's death or his critically low potassium level. The Med Dir stated he reviewed most deaths and transfers out of the building as his own system of quality assurance to ensure that residents were transferred out when it is appropriate. The Med Dir stated that although there was no way to be certain, a potassium level of 2.3 might very well have caused the resident to develop an arrhythmia that resulted in the resident's [MEDICAL CONDITION] and added that with a GFR (estimated glomerular filtration rate, a test to determine kidney function) of 76.0, Resident#7 would have been a candidate to receive intravenous potassium at the hospital as a form of treatment to raise the resident's potassium to a normal level. The Med Dir stated that it seemed that MD#1 was not real aggressive treating the resident's low potassium and he would have to discuss the case with MD #1. During an interview on [DATE] at approximately 11:00m a licensed practical nurse (LPN#8) stated that she was working the day shift on [DATE] and heard a loud noise and then a visitor scream for help. LPN #8 went to the Resident # 7's room and found the resident on the bathroom floor and then noted the resident was unresponsive and not breathing. After calling out for someone to call a "code" LPN#8 and staff began resuscitation maneuvers on the resident. An AED was placed gave instructions to administer a shock to the resident. The rescue squad arrived, prepared the resident for transport and as they were leaving for the hospital the resident was breathing on his own. LPN # 8 recalled that she received a fax earlier in the day on [DATE] and the resident's potassium level, drawn that morning at 6:00am was 2.3Meq/L, a critically low number. The physician (MD#1) was contacted and he instructed the LPN to increase the resident's potassium supplement (KCL 20Meq's) from once a day to twice a day. LPN#8 stated that during her phone conversation with MD # 1, he did not discuss sending the resident out to the emergency department for intravenous treatment and did not instruct her to give the next dose of potassium "stat" (immediately). LPN# 8 stated she did not ask the doctor if he would consider either of these options and added that she and some of the other nurses generally did not suggest things like that to MD # 1 because when they did, he tended to "go in the other direction" meaning that MD#1 did not like nurses suggesting what to do for a resident and would order the opposite of what the nurse suggested. At around 12:45pm as LPN#8 was getting off the phone with MD#1, she heard Resident #7's visitor yell for help and responded and started resuscitation. LPN #8 stated that as the EMTs were taking Resident # 7 out to the hospital, she made sure that they had a copy of the lab report so doctors in the emergency room would be aware of the resident's low potassium level. During a second interview on [DATE] at approximately 11:30am, the facility DON stated that she recalled receiving a call late in the morning on [DATE] from the laboratory, informing her that Resident # 7 had a critically low potassium level of 2.3. The DON stated that she immediately informed LPN # 8 of the lab results and instructed her to call MD#1 immediately. The DON recalled that she received these results of the potassium level on the day that Resident # 7 had a [MEDICAL CONDITION]. During a second interview at 11:45am on [DATE], LPN #8 stated that on [DATE] at approximately 11:00am she received notification from the lab that Resident # 7's potassium level was critically low at 2.3meg/L. LPN#8 stated that she immediately she called MD #1's office and told the office secretary that she was calling about a resident's critically low potassium level and needed to speak to the MD. LPN# 8 recalled that MD #1 had still not returned her call at 11:30am when the DON came to her with the same report of Resident #7's low potassium level. At that time LPN#8 placed a second call to MD#1's office at that time and it was not until approximately 12:45pm, when MD#1 returned that call. LPN # 8 stated that at that time, MD#1 gave her an order to increase the resident's KCL 20 Meq to twice a day. MD #1 did not discuss sending the resident out to the ER and did not discuss giving the extra dose of potassium for that day as a "stat "dose. LPN #8 stated that she had just hung up the phone after speaking with MD#1 when she heard a "loud thud" and then a visitor yelling for help. Resident # 7 was found on the bathroom floor and CPR was started on the resident. LPN # 8 stated that she had been having problems with MD#1 returning her calls when they were placed to him when she needed orders and this was not new and it had been going on for some time. LPN # 8 stated that she had not personally informed the Medical Director of the problem but she had reported it to the DON and the assistant DON in the past. During an interview on [DATE] at approximately 11:00am, the physician (MD#1) in change of Resident #7 's care stated that the resident had low potassium levels noted early after admission to the facility and he was not sure what might have caused the hypokalemia (low potassium levels). MD#1 recalled the resident had potassium levels in the first few days at the facility of 2.5, 2.7, 3.0 and finally, 2.3Meq/L on [DATE] the same day the resident suffered a [MEDICAL CONDITION] and was resuscitated and admitted to the hospital. MD#1 stated that while at the hospital, the cardiologist had seen the resident and determined that the resident ' s [MEDICAL CONDITION] was most likely caused by an arrhythmia that developed because of the resident's hypokalemia. MD#1 responded, when asked if he had considered sending the resident to the emergency roiagnom on [DATE] for IV administration of potassium, by saying that the resident had already arrested when he was informed of the resident's potassium level of 2.3. It was explained to MD # 1 that nursing staff at the facility had reported to the state surveyor that they had called his office twice on [DATE] and reported to his secretary that Resident # 7 had a critically low potassium level and they needed to speak with the MD. Nursing had also reported that the first call was made at 11:00am and the second at 11:30am and that he had not returned the calls until 12:45pm on [DATE] and the resident suffered a [MEDICAL CONDITION] minutes after that call. In a follow-up phone call at [DATE] at approximately 11:10am, MD #1 stated that his office staff documented all calls made to his office in a log book. Documentation in the book included the person and /or facility that called and the nature of the call. MD#1 added that there was no notation in the log book for Resident # 7 or a critically low potassium level on [DATE]. During an interview on [DATE] at approximately 2:30pm, a secretary at MD#1's office stated that every call that comes from a hospital, nursing home, pharmacy's etc. is entered into a log book in the office and all information that is given to the office staff member taking the call is documented in the log book. The secretary stated that if the caller asks to speak to the doctor "right away or immediately" their call is placed on hold and the doctor is called to the phone. If the office staff is told what the call is for (i.e. blood work, a patient's name, a change in medication) any information that is given to the office staff is entered into the log book. On a copy of a log book from MD # 1's office the MD's staff documented phone calls from the facility and the information that was given to them on each call. On [DATE] at 10:55am, LPN #8 called from Livingston Hills East regarding resident RT. On [DATE] at 11:51am, staff (no name given) from Livingston Hills East wing called (call back) (no resident name given). On [DATE] at 12:45pm, staff (no name given) from Livingston Hills East wing called (call back) (no resident name given). On [DATE] at 1:35pm staff from Livingston Hills East called regarding Resident PA, [MEDICATION NAME]. There was no written evidence the facility called in "critical lab values." 10NYCRR 415.12

Based on observation, record review and staff interview during complaint investigation (NY# 648), the facility did not insure that 1 (Resident #1) of 2 residents had care planned safety devices implemented to prevent accidents. Specifically, Resident #1 was assessed as a high fall risk and was care planned for bilateral bolsters on the bed. The resident fell while ambulating in her room and sustained a pelvic fracture. This resulted in actual harm that is not immediate jeopardy as evidenced by: Resident #1 was admitted to the facility on [DATE] diagnosed with [REDACTED]. The Rehabilitation Screen Request dated 7/22/13 documented that the resident fell from bed on 7/21/13 and the Registered Nurse (RN) documented a request for bilateral bolsters for Resident #1's bed which was approved by Occupational Therapy on 7/23/13. The Comprehensive Care Plan for Falls last updated on 8/13/13 documented that Resident #1 was at risk for falls due to impaired short term memory, impaired judgement, impulsive behaviors, incontinence and failure to recognize limitations. Care plan interventions included, a bed alarm, offer toileting with each care round and bilateral bolsters to the bed. The Resident Activities of Daily Living (ADL) Care Card (undated) documented that the Resident #1 had safety devices including a bed alarm and bed bolsters. The facility's Investigative Summary (undated) documented that Resident #1fell on [DATE] and sustained a pelvic fracture. The facility investigation revealed that Resident #1's room was changed on or about 9/4/13; however, Resident #1's bolsters were not moved to her new room and were not present on the resident's bed at the time of her fall. Hospital Records documented that Resident #1 was admitted on [DATE] for a nondisplaced superior pubic ramus fracture (pelvic fracture). During an interview on 10/10/13 at 9:10 am, the Administrator stated that the facility investigation revealed that Resident #1's bolsters on each side of her bed were not transferred when the resident's room was changed on or about 9/4/13. The Administrator stated that the facility took immediate action to insure that all safety devices were in place for all facility residents. During an interview on 10/10/13 at 11:30 pm, the Registered Nurse Manager (RNM) stated that due to the renovations, it has been pretty chaotic moving residents from one room to another. The RNM stated that after obtaining approval from resident's and families, the housekeeping department was notified of the move and would move all of the resident's belongings to the new location. The RNM stated that she did not check the resident's room after the move to insure all of the resident's safety devices were moved. The RNM stated "at that time, we didn't have anything in place to check to make sure that safety devices were in place, nor were we doing walking safety rounds at the change of shift." The RNM stated "walking safety rounds were instituted about 2 weeks ago." During an interview on 10/10/13 at 12:40 pm, the Director of Nursing (DON) stated that she had been the DON for approximately one month and had identified that the facility did not have a policy and procedure in place to complete safety rounds as a part of shift change. The DON stated that has since written a policy and procedure and began inservicing staff as of 10/10/13. 10NYCRR 415. 12(H)(1)(2)

Based on medical record review and staff interviews during a complaint investigation, (Complaint # NY 071) it was determined that the facility failed to ensure that 12 ( #'s- 1, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 and 15) of 29 residents identified to be at risk for unsafe wandering, were adequately supervised; failed to have interventions in place to prevent elopement. The facility failed to adequately assess and care plan for residents identified to be at risk for unsafe wandering; failed to operationalize the policy and procedure related to elopement (pictures, lists, drills and documentation) and failed to adequately investigate and report incidents of resident elopement. Additionally, the facility failed to reassess residents who eloped for interventions to prevent further elopement, and failed to identify system failures related to residents who are at risk for unsafe wandering. Specifically, two residents (#'s 1 and 5), who were identified as at risk for unsafe wandering and wore wanderguards, left the building on three occasions in May and June. Staff responded inappropriately by either failing to react to the alarm or by first re-setting the alarm and notifying other staff the resident had eloped before attempting to retrieve the resident. In two instances, the residents were retrieved in close proximity to a busy road. No investigation into the elopements was conducted and no interventions were implemented to prevent future elopements. Additionally, there was no evidence that missing persons drills have been conducted; 8 of 29 care cards ( used by the certified nurses aides to provide care) lacked care planning for unsafe wandering; pictures and lists of potential wanderers were not accurate; staff were signing for alarm checks for residents who had been discharged or were no longer considered an elopement risk; the enunciator panel signaled the incorrect door alarming; and staff did not have an understanding of elopement policies. This had the potential to effect all 29 residents with exit seeking behaviors. This resulted in Immediate Jeopardy and Substandard Quality of Care to resident's health and safety. This is evidenced by the following: The facility's policy and procedure stated that those at risk for wandering are identified by black dots that are placed on the residents' wristbands and spines of the charts. The policy also stated that when an alarm sounds, staff are to call a Missing Person Code and conduct an immediate head count. The facility was not compliant with that policy. Head counts were not being conducted and there are no black dots on either the wristbands or the spines of the charts as indicated in the facility's policy. The facility failed to ensure that residents identified to be at risk for unsafe wandering, were adequately supervised. Additionally, the facility failed to adequately investigate and report incidents of elopement. Resident #1 The resident was admitted to the facility with [DIAGNOSES REDACTED]. A facility policy titled Missing Resident - Emergency procedure dated 7/09, documented that when a door alarm goes off at the facility, a staff person will be assigned by the charge nurse on the unit where the door alarm was triggered, to go outside and walk around the building, searching for the resident. An accident/incident report (A/I), provided by the facility indicated that at 7:30 pm on 5/29/11, Resident # 1 was noted outside of the facility near the beauty shop. A document titled Facility Internal Review Quality System Analysis Assurance Quality/Improvement Process, not dated and signed by the Director of Nursing (DON), documented that a review of the incident (5/29/11 at 7:30 pm) on the facility camera revealed there were two residents noted at the alarmed delayed egress door at the time the resident exited. Staff responded to the alarm and reset the alarm based on seeing a (single) resident at the door, however Resident # 1 had already stepped a few feet outside of the door. The author goes on to document, "Failure Mode Analysis revealed a potential degree of human error on one staff member's part." During an interview on 6/30/11 at approximately 11:30am a Certified Nursing Assistant #1 (CNA) stated that on 5/29/11 at around 7:30pm she was outside in the facility center courtyard having a cigarette when she looked through a glass corridor and could see Resident # 1 on the other side of the glass corridor, outside of, and walking away from the building. CNA #1 realizing the resident was a wanderer and that it was not safe for the resident to be outside unsupervised, ran into the building to the south unit and yelled to a second CNA (CNA #3) for help to bring Resident #1 back inside. CNA' s # 1 and 3 then ran to the exit door at the end of the corridor, went outside and saw Resident #1 walking down the hill, toward the highway (approximately 15-20 yards from the corner of the building). CNA # 1 stated that when she caught up to the resident, she came along easily with the two CNAs. During an interview on 7/5/11 at approximately 2:00pm a CNA (CNA # 3) stated that on 5/29/11 she was in a resident's room on south unit when she heard CNA #1 yell to her, saying Resident # 1 was outside and she needed help to bring the resident back inside the building. CNA # 3 ran behind CNA # 1 who exited the building through the door at the end of the corridor and as she stepped outside CNA # 3 saw Resident # 1 headed down the grassy slope toward the highway. When CNA # 1 called to Resident # 1, the resident stopped and turned around and came back toward the two CNAs. During an interview on 6/29/11 at approximately 2:00pm the DON stated that she had reviewed the videotape of Resident #1's exit from the building on 5/29/11 at 7:30pm and although the camera didn't' show the door and the alarm reset keypad, she could assume from what she could see on the videotape that a member of the nursing staff heard the alarm and went to the door near the beauty salon and saw one resident (Resident #5) and thought that was the resident who had pushed on the door, setting off the alarm. The employee didn't realize that Resident # 1 had already exited through the door and was walking along the outside of the building. The DON stated that the employee should have opened the door and looked outside. An A/I report, provided by the facility DON, dated 5/30/11 at 3:10 pm, (one day after Resident #1's first unsupervised exit from the building) documented that Resident # 1, "was found attempting to go outside the facility through the front entrance and was "caught" by CNA # 2." A statement attached to the A/I report, written by CNA # 2 documented that CNA # 2 heard the front door alarm and observed Resident # 1 standing outside the building at the front door and brought her back inside. During an interview on 6/30/11 at 11:30am a CNA (CNA # 2) stated that on 5/30/11 as she was leaving the building at the end of her shift, she neared the lobby of the building and heard an alarm ringing. CNA # 2 realized at the time there was no receptionist on duty in the lobby, at the front door. As CNA # 2 walked into the lobby she saw Resident # 1 outside, trying to get back into the building through the front doors. The doors would not open because the resident had a secure care alarm on her ankle, which was locking up the doors. CNA # 2 reset the alarm, opened the doors, walked out and called to Resident # 1 who was now standing at the bottom of a stairway leading up to the driveway. The resident willingly came back inside the building and CNA # 2 walked the resident down the hall and handed the resident off to the registered nurse supervisor (RNS#1) and explained where she had found her. CNA# 1 stated that a couple of days later she had a conversation with the DON and Assistant-Director of Nursing (ADON) and explained to them that when she found the resident on 5/30/11, that the resident was not trying to go out of the building but that she was actually outside the building and was trying to get back inside. During an interview on 7/1/11 at approximately 3:30pm the facility DON stated that she had given the DOH her entire investigation into the incident and it consisted of an A/I report (filled out by RNS # 1) and a written statement from CNA # 2. The DON stated that it had been her understanding that Resident # 1 was stopped as she attempted to exit the building and she did not know that the resident had been out of the building and was trying to get back inside. When asked if she had viewed the videotape of the incident, she said she had not. When asked if she had asked for statements from anyone else on duty at the time of the incident other than CNA #2, the DON stated that she had not. The DON stated she didn't feel it was necessary to get additional statements from staff because she felt she had all the information. The DON stated the south unit was not a locked unit and she didn't see the need for further investigation into the Resident # 1's attempt to exit the building. She did not report the elopement to the Department of Health (DOH). The videotape of the facility exit doorways was reviewed by the DOH investigators and revealed that on 5/30/11 at approximately 2:58 pm, Resident # 1 exited the South Unit unnoticed, behind an employee, through the alarmed double doors at the entrance to the unit. A male employee is then seen walking into view of the camera and appears to enter a code on the key pad (used to deactivate the alarm) next to the alarmed double doors. The male employee does not look outside of the double doors to see if a resident has passed through the doors. Resident # 1 is next observed on the videotape at 2:59 pm, at the front main entrance to the building, where she exits the building through both sets of double doors by following behind a male visitor as he exits the building. Resident # 5 The resident was admitted with [DIAGNOSES REDACTED]. The most recent MDS on 4/18/11 assessed the resident to have long and short term memory impairment and severely impaired cognitive skills for decision making. An A/I report dated 6/24/11 at 2:00pm documented that Resident # 5 was found in her room at the facility removing the screen. She had apparently thrown her purse out the window and stated that she didn't' want to be there anymore. A document provided by the facility DON (not dated or signed), who described it as an investigation of events involving the resident's exit from the building revealed that Resident # 5 was found on 6/24/11 standing by a window in her room and had pulled the screen out and thrown her purse out the window, stating she did not want to be there anymore. The resident's medications were adjusted and she was placed on 1:1 monitoring and 15 minute checks. On 6/26/11 at 8:15 am the door was alarming and Resident # 5 was found outside the building by a CNA. She was redirected back to the unit and again placed on 1:1 supervision and 15 minute checks. During an interview on 7/1/11 at 10:45 am a CNA (CNA # 4) stated that on 6/26/11 at approximately 8:15 am she was caring for a resident in his room on the south unit at the facility when she heard the delayed egress alarm sounding. She could not immediately respond to the alarm because the resident she was caring for was standing and he was not safe to be left alone. CNA #4 stated she seated the resident and made him safe and then responded to the alarm. When she got to the alarming door, she looked outside and saw Resident #5, who was headed down the hill toward the highway. She first turned and yelled to a nurse down the hall that Resident #5 was outside and then she exited the building and ran down the hill, chasing the resident. She called to Resident # 5 and when the resident turned and saw CNA # 4 coming after her the resident started moving faster. CNA # 4 stated she didn't call her name again because she was afraid the resident would start to run. CNA #4 eventually caught up to the resident on the shoulder of the highway. During an interview on 6/30/11 at approximately 11:00am LPN #1 stated that on 6/26/11 at around 8:15am she was in room 203 on south unit, passing medications when she heard a door alarm ringing. She left the room and went to the alarm panel in the hallway, where she met RNS #1 who had just walked on the unit. Together they noted that the panel indicated the alarm ringing was the exit door in the "OT " (occupational therapy) room; a room off of the unit and next to the main dining room. RNS #1 headed for the OT room and LPN # 1 stood for a few seconds and as she listened, determined that the alarm was coming from the opposite direction and was actually coming from the door at the end of the south corridor. As she approached the door, she heard CNA #4 call out that Resident # 5 was outside. LPN # 1 followed behind CNA #4 out the door, and saw that Resident # 5 was halfway down the grassy hill and the CNA was chasing her. CNA # 4 caught up to the resident at the edge of the highway. During an interview on 6/30/11 at approximately 12:30pm Registered Nurse Supervisor ( RNS #1) stated that she was walking onto the South Unit on 6/26/11 at approximately 8:15am, when she heard an alarm ringing. She went to the alarm panel on the wall, near the nurses' station and it indicated that the alarm was ringing on the "OT door." RNS # 1 ran off the unit, to the OT door and when she didn't see anyone around she went outside and walked around the building to make sure that no resident had gotten outside. She did not see Resident # 5 outside because she was on the opposite side of the building. During an interview on 7/1/11 at approximately 11:00am, a registered nurse unit manager (RNUM) stated that it was her responsibility to assess residents periodically for risk of wandering and elopement. She used the "elopement risk status" form to complete this assessment quarterly or more frequently if necessary. The RNUM placed secure care alarms on residents if it was indicated by the assessment or based on her nursing judgment. She stated secure care alarm placement was also discussed by the interdisciplinary team. The RNUM could not provide specific dates for when each resident had their secure care alarms applied. She stated there was no one specific place to find that information but that it could be in a number of places; in nurses notes, assessment forms, care plans, doctors' orders, treatment sheets, etc. When a secure care alarm was placed on a resident it should be added to the treatment sheet and the treatment nurse should check for placement each shift; and it should be added to the supervisor's book and they checked the alarms each night-shift for function. The resident's name was also placed on a wanderguard list on the unit, along with a picture to identify each resident and these pictures were kept on each unit and at the receptionist desk in the main lobby. The facility failed to adequately assess and develop a care plan with interventions for residents identified at risk for unsafe wandering, Additionally the facility failed to reassess residents who had eloped for additional interventions to prevent future elopements. Resident #5 A physician's orders [REDACTED]." An "Elopement Risk Assessment," for Resident #5, dated 4/20/11, instructs that if a yes is checked for any starred question on the form, the resident is at immediate risk and a "wanderguard" should be applied. Question # 6 on this form is checked in the "yes" column indicating the resident is at immediate risk and should have a Wander Guard applied. An A/I report dated 6/24/11 at 2:00pm documented that Resident # 5 was found in her room at the facility removing the screen. She had apparently thrown her purse out the window and stated that she didn't want to be there anymore. A second A/I report and attached statements, documented that on 6/26/11 at approximately 8:15am, Resident # 5 exited the building, unsupervised and was observed walking toward the highway. The care plan for elopement for Resident # 5 is dated 6/29/11, three days after she exited the building and 10 months after the physician's orders [REDACTED]. There is no reassessment for elopement after the resident exited the building on 6/26/11. The facility was not able to provide a care plan for unsafe wandering prior to 6/29/11. Resident # 6 The resident was admitted to the facility with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] assessed the resident to have long and short term memory impairment and severely impaired cognitive skills for decision-making. An A/I report with attached employee statements dated 6/10/11 at 8:00 am, documented that Resident # 6 was returned to the facility by an LPN after she exited the building, unsupervised, setting off the door alarm. There is no RN assessment documented and no RN signature on the document to indicate that an assessment was done. Nurses notes documenting the event are signed by LPN's. A document provided by the facility, titled "Elopement Risk Assessment," assessing Resident # 6, dated 6/13/11, (three days after the resident exited the building unsupervised) instructed that if a "yes" is checked for any starred question on the form, the resident is at immediate risk and a Wander Guard should be applied. Question # 7 on the form asks, "Does the resident have a history of leaving the facility without needed supervision?" The RN assessing Resident # 6 answered "no" to this question. The care plan for elopement for Resident # 6 is dated 6/29/11, nineteen days after the resident exited the building. There are no additional interventions added. The facility was not able to provide a care plan for unsafe wandering prior to 6/29/11. The facility failed to operationalize the policy and procedure related to elopement (pictures, lists, drills and documentation). During interview on 6/29/11 at approximately 11:30am, the DON stated that the functionality of secure care bracelets and alarmed doors were checked each night by the night shift supervisor and the treatment nurses checked each shift to ensure that secure care bracelets were on each of the appropriate residents. When the facility DON was asked for a copy of the current policy/procedure (P&P) for management of wandering residents, she provided a copy of a P&P dated June 2006. The policy directed staff to apply black dots to resident name bands and the spines of the resident ' s medical record if they were at risk. During an interview on 7/1/11 at approximately 5:00pm the facility Administrator stated that the policy from June 2006 had been revised and that black dots had been eliminated from the procedure. The "Wandering Resident" P&P dated 7/07 documented that pictures of residents at risk for elopement will be kept at the receptionist desk, nursing stations, recreation and dietary departments. On 6/29/11 at 5:00pm a list provided to the DOH by the facility indicated that six residents on the east wing had secure care bracelets in place. A review of pictures at the receptionist desk at that time revealed there were four pictures posted for east wing residents. Two of the four residents whose pictures were posted, had been previously discharged , leaving four residents who were at risk without pictures. The list also indicated there were 7 resident's on the north wing with secure care bracelets. Of the seven residents only five had pictures at the receptionist's desk. A list of resident's names taken from the supervisor's secure care binder (used for checking function of wanderguard's at night) indicated there were 15 residents on the south wing with secure care bracelets. Of the fifteen residents on the supervisor's list, ten did not have pictures at the receptionist desk. A review of three lists of names of residents with secure care bracelets, obtained from three different sources (one taken from the wall in the nurse's station on south unit, one taken from the supervisors secure care bracelet binder in the supervisors office and a third received from the evening supervisor, being used as an audit tool revealed multiple inconsistencies with all lists. The facility failed to identify system failures related to residents who are at risk for unsafe wandering. During an interview on 6/30/11 at approximately 2:30pm the facility administrator stated that the facility had not conducted a "missing person drill" during the last year. Resident # 7 During an interview on 6/29/11 at approximately 11:15am, the RNUM stated that she could not recall exactly when Resident #7 had her secure care bracelet discontinued but it was more than "several weeks ago." A review of the treatment sheet for the month of June 2011 for Resident # 7, revealed that the placement of the resident's secure care bracelet was verified daily on all three shifts, through 6/29/11. Resident # 8 The resident was admitted to the facility [DIAGNOSES REDACTED]. The most recent MDS, dated [DATE] assessed the resident to have long and short-term memory impairment and severely impaired cognitive skills for decision-making. A nurses note dated 6/14/11, no time entered, documented that Resident # 8 is taken outside daily by his son and has not made an attempt to leave the unit or the facility unsupervised and the wander guard was discontinued and removed. A review of the treatment sheet for Resident # 8, for the month of June 2011, revealed that the placement of the secure care bracelet was verified by nursing personnel on all three shifts from June 14, 2011 through June 17, 2011. A review of the supervisor's sheet for checking the function of the resident's wanderguard documented that the device was checked every night by a supervisor from 6/14/11 through 6/29/11. During an interview on 7/5/11 at approximately 4:30pm, RNS #2 stated that each night that she works, she checks the wanderguard alarm functionality of any resident who has a sheet in the supervisor's log book. She recalled that Resident # 8 was one of a couple of residents who would repeatedly remove their wanderguard's and she would replace them when she found them missing. RNS # 2 insisted that if she documented that she had checked Resident # 8's wanderguard for function, then she had actually done it because she would never document something that she had not done. She could not explain why it was documented in the nurse's note that it was removed on 6/14/11 and the function was checked through 6/29/11. 10 NYCRR 415.12(h)(1)(2)

Based on observation, record review and staff interview during a complaint investigation (Complaint # NY 071) it was determined the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The Administration failed to ensure that resident's care was provided in a safe, secure and supervised environment for residents at risk for unsafe wandering and elopement. Specifically, the facility's administration failed to ensure that effective systems to maintain residents safety were utilized, failed to ensure residents were supervised to prevent accidents and failed to thoroughly investigate an incident of elopement. This resulted in no actual harm that is Immediate Jeopardy to resident's health and safety. This is evidenced by the following: Refer to Quality of Care - Accidents, F-323 scope/severity - K The facility failed to provide adequate supervision for residents who were identified to have dementia, and to be at risk for elopement. Additionally, the facility failed to have an effective system to identify residents who were at risk for elopement and to ensure that electronic monitoring systems were operating effectively. Refer to Quality Assurance, F-520 scope/severity - K The facility failed to implement an effective Quality Assurance (QA) program that readily identified deficiencies in the implementation of its policy for wandering/elopement behaviors; failed to ensure that new interventions were initiated after incidents of elopement. Additionally the QA program failed to ensure that incidents of elopement were thoroughly investigated and reported to the State Agency. During an interview on 6/30/11 at approximately 2:30pm the facility Administrator stated that the facility had not conducted a "missing person drill" during the last year. During an interview on 7/1/11 at approximately 1:30 pm, the Administrator stated that the facility's QA Program had not looked at unsafe wandering/elopement recently because they had focused on areas that had been the subject of prior deficiencies. During an interview on 7/1/11 at approximately 4:00 pm, the Administrator stated he was not told of the resident elopements by the Director of Nurses. 10 NYCRR 415.26

Based on medical record review and staff interviews during a complaint investigation (Complaint # NY 071) it was determined that the facility did not have a quality assurance (QA) program which effectively identified problems and established corrective actions for the management of unsafe wandering/elopement behaviors for twelve of twenty-nine residents reviewed with exit seeking behaviors. Specifically, the QA Program failed to develop a policy on prevention of elopement/unsafe wandering that clearly defined the process for management of residents with exit seeking behavior; failed to ensure residents identified to be at risk for elopement/unsafe wandering were supervised to prevent elopement; failed to ensure that comprehensive care plans that identified individualized needs were developed, actions and/or interventions to prevent/protect residents who were identified to be at risk for elopement/unsafe wandering. This had the potential to effect all 29 residents with exit seeking behaviors. The failure of the QA Program to assure safe outcomes for residents resulted in no actual harm that is Immediate Jeopardy to resident's health and safety. This is evidenced by the following: The findings were as follows: Refer to Quality of Care-F 323 scope/severity K Refer to Administration- F 490 scope/severity K On 6/29/11 at approximately 11:30am, the facility Director of Nurses (DON) was asked for a copy of any current policy/procedure (P&P) addressing the management of wandering residents, she provided a copy of a P&P dated June 2006, titled "Protocol of Care, Wandering Resident Management Elopement Prevention," a second P&P titled "Missing Resident-Emergency Procedure" dated July 2009 and a third P&P titled "Secure Care Alarm System", dated August 2006. During an interview on 7/1/11 at approximately 5:00 pm the facility Administrator stated that the policy from June 2006 was not the facility's current policy. He stated the policy had been revised and some procedures had changed. When the DON was again asked on 7/5/11 for a copy of a current P&P, she provided the DOH investigator with a policy revised in June 2007, titled "Wandering Resident Elopement Risk Assessment." A review of the facility's current policy revealed there is no instruction on monitoring of secure care devices and no procedure to be followed when a secure care alarm or a door alarm sounds. During an interview on 7/1/11 at approximately 1:30 pm, the Administrator stated that the facility's QA Program had not looked at unsafe wandering/elopement recently because they had focused on areas that had been the subject of prior deficiencies. 10NYCRR 415.27(a-c)

Based on record review, and staff interview during a complaint investigation (case #NY 055), it was determined the facility did not ensure 1 (Resident # 1)of 3 sampled residents received sufficient fluids to maintain adequate hydration and health. Specifically, the facility did not ensure that a resident's fluid intake was monitored and interventions to prevent dehydration were implemented in a timely manner. The resident required admission to the hospital for dehydration . This resulted in actual harm that was not Immediate Jeopardy. This was demonstrated by the following: Resident #1: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident's cognitive status to be moderately impaired. It was also documented that the resident had poor appetite nearly every day. The Comprehensive Care Plan (CCP) for Nutrition, dated 3/9/10 documented that the resident had an alteration in nutrition due to his medical condition. Goals documented on the CCP included: the resident would consume more than 75% of all food and fluid provided to him, and that he would not experience signs and symptoms of dehydration. Interventions included to update his food preferences and intolerance as needed, monitor his daily intake, and encourage resident to drink fluids. The Policy and Procedure for Meal Consumption Tracking dated 12/4/09, documented that its purpose was to identify residents at risk for weight loss, dehydration and/or [MEDICAL CONDITION] related to poor appetite and/or less than adequate food intake. Certified Nurses Aides (CNA's) were to notify the charge nurse for any resident who consumed less than 50% of their meal. A resident who consumed less than 50% of their meal was to be offered alternatives. If a resident consumed less than 50% of meals for a 48 hour period, a WHIP form (a form to be completed for all residents who had alteration in bowel, weight or hydration status) was to be completed to alert dietary and the interdisciplinary team. The physician was also to be notified. The unit manager or designee was to monitor the meal consumption sheets daily. A Dietary Progress Note dated 10/19/10 documented that the resident's Blood Urea Nitrogen (BUN) level was 16. BUN is a blood value that indicates the level of hydration, normal levels range from 7 to 18. Levels higher than 18 may indicate dehydration. The resident's Creatinine level was 1.0. Creatinine is another blood value that indicates the level of hydration, normal levels range from 0.6 to 1.3. Levels higher than 1.3 may indicate dehydration. The Meal Consumption Tracker form dated 11/26/10 documented that the resident ate less than 25% of food and drank 360 milliliters (ml) of fluid for breakfast; none of his food and 120 ml of fluid for lunch and none of his food and 120 ml of fluid for dinner. The resident's food and fluid intake was not documented on the 24 Hour Report dated 11/26/10. The 24 Hour Report was reviewed by the interdisciplinary team during morning reports and was used as a tool for communication of staff from shift to shift. There was also a section on the 24 Hour Report for reporting if a resident had low fluid and/or food intake for three consecutive shifts. The Meal Consumption Tracker form dated 11/27/10 documented that the resident ate no food and drank 120 ml of fluid for breakfast; none of his food and 60 ml of fluid for lunch and none of his food and 120 ml of fluid for dinner. The resident's food and fluid intake was not documented on the 24 Hour Report dated 11/27/10. The Meal Consumption Tracker form dated 11/28/10 documented that the resident ate 25% of his food and drank 120 ml of fluid for breakfast; 25% of his food and 120 ml of fluid for lunch and 50% of his food and 240 ml of fluid for dinner. The resident's food and fluid intake was not documented on the 24 Hour Report dated 11/28/10. The Meal Consumption Tracker form dated 11/29/10 documented that the resident ate none of his food and drank 240 ml of fluid for breakfast; none of his food and the fluid section of the form was blank for lunch, and he ate none of his food and 240 ml of fluid for dinner. The resident's food and fluid intake was not documented on the 24 Hour Report dated 11/29/10. A WHIP Communication Alert form, which was used to report a change in weight and/or hydration status, dated 11/30/10 documented that this resident had a 16 pound weight loss in the past 30 days. The section titled "Hydration" did not include documentation regarding the resident's hydration status. Review of the Nurses Notes dated from 11/18/10 through 11/29/10 revealed that no nurses notes were written regarding the resident's food and/or fluid intake. A Nurses Note dated 11/30/10 documented that the Nurse Practitioner (NP) assessed the resident for increased weakness, lethargy and poor food and fluid intake and weight loss. A Dietary Progress Note dated 11/30/10 documented that the dietician had received notice that date of the resident's weight loss. It was also documented that the resident's diet was to be modified and monitored and that an appetite stimulating medication was to be considered. A Nurses Note dated 12/2/10 at 4:00 pm documented that the resident had a large amount of black liquid in his [MEDICAL CONDITION] bag, was lethargic, pulse was weak and thready and unable to obtain a blood pressure. The physician was notified and the resident was transferred to Hospital #1. A Nurses Note dated 12/2/10 at 9:40 pm, documented that a physician from Hospital #1 had called and reported that the resident had an upper [MEDICAL CONDITION] (upper GI bleed), kidney failure and dehydration. The resident was in critical condition and required [MEDICAL TREATMENT], and was being transferred to Hospital #2. An untimed Nurses Note dated 12/2/11 documented that the resident was admitted to Hospital #2 with a GI bleed and dehydration. The Hospital #2 Emergency Department Admission summary dated 12/2/10 documented that the resident arrived from Hospital #1 in acute kidney failure. The resident's BUN was 186 and his creatinine was 8. It appeared that the acute kidney failure was due to dehydration. The Transfer Summary from Hospital #2 dated 12/15/10, documented the course of events and treatment since transferring from the nursing home on 12/2/10. The resident was transferred to Hospital #1 on 12/2/10 and was found to have acute kidney failure. Hospital #1 began treating the kidney failure then transferred the resident to Hospital #2. Upon arrival to Hospital #2 the resident continued to receive intravenous (IV) fluids due to the acute kidney failure caused by dehydration. The resident received urgent [MEDICAL TREATMENT] (a method for removing waste products such as creatinine and urea, as well as free water from the blood when the kidneys are in [MEDICAL CONDITION]) on 12/3/10 and 12/4/10. It was determined that the resident's acute kidney failure was likely due to his decreased food and fluid intake over the past several days to weeks. Upon discharge from Hospital #2 the resident's BUN was 13 and his Creatinine was 1.1. During an interview with Certified Nursing Assistant (CNA) #1 on 1/20/11 at 12:35 pm, she stated that if a resident ate less than 50% of a meal she would notify the charge nurse. She also stated that she could not recall this resident's appetite in November 2010, but that he had been declining in health for several weeks prior to going to the hospital on [DATE]. CNA#1 reviewed the Meal Consumption tracking sheets for this resident and stated that she likely would have reported the resident's poor appetite to the nurse but could not specifically recall if she had or not. During an interview with the Assistant Director of Nursing (ADON) on 1/20/11 at 1:39 pm, she stated that if a resident ate less than 50% of meals for 2 days, a WHIP Event Communication Alert form was to be completed by the charge nurse or Registered Nurse Manager (RNM). This form would be reviewed by the interdisciplinary team (IDT) for care plan interventions. A WHIP Event Communication Alert form was completed on this resident on 11/30/10 because he had been weighed and found to have a significant weight loss. The ADON stated that prior to reviewing this form on 11/30/10, she was not aware that the resident had a low food and fluid intake and that a WHIP form should have been completed sooner. She also stated that the RNM's were responsible for reviewing the Meal Consumption Tracker forms every day. The RNM for this resident's floor on 11/10/10 was no longer employed by this facility. During an interview with the Dietician on 1/20/11 at 3:16 pm, she stated that she was not aware of this resident's poor appetite until she learned of his significant weight loss on 11/30/10. After reviewing the Meal Consumption tracking sheets for this resident, the Dietician stated that a WHIP Event Communication Alert form should have been completed sooner than 11/30/10. She stated that everyone was responsible for reviewing Meal Consumption tracking sheets and that somehow, this resident's declining appetite was not noticed in a timely manner. During an interview with the Director of Nursing (DON) on 1/21/11 at 2:05 pm, she stated that it was the RNM's responsibility to review the Meal Consumption tracking sheets every day and that after 2 days of poor or no appetite a WHIP Event Communication Alert form should have been completed. She also stated that the resident's poor appetite should have been documented on the 24 Hour Report, but in this case that was not done. During an interview with the physician on 1/21/11 at 3:20 pm, he stated that this resident's poor food and fluid intake should have been reported to him prior to 11/30/10. He stated that common sense would say that if a resident had poor intake for two days, a physician should be notified. The physician stated that the resident having poor food and fluid intake for several days prior to 12/2/10, and having a BUN of 180 and a creatinine of 8, that this would indicate a clear association with acute kidney failure and severe dehydration. The physician stated that he should have been notified sooner that the resident was not eating or drinking sufficiently. 10 NYCRR 415.12(j)