Every finding on record at Masonic Care Community of New York

Based on observations, record review, and interviews (iQIES Intake 2722137) the facility failed to ensure routine and emergency drugs and biologicals were provided to two (2) of two (2) residents (Residents #14 and #247) reviewed. Specifically, three (3) doses of Resident #14's alprazolam (used to treat anxiety) were not administered due to the medication not being available from pharmacy; and Resident #247 was not administered five different medications (diltiazem, methimazole, nadolol, hydralazine, and lisinopril) between February 2026 and March 2026 due to the medications not being available from pharmacy. Findings include:The facility policy Medication Administration, revised 10/2025, documented if a medication was not available at the time it was to be administered, the nurse was to notify the neighborhood manager or supervisor. The neighborhood manager or supervisor would explore alternate methods for obtaining the medication such as the emergency medication supply, contacting the pharmacy, or contacting medical for alternate medication. The facility policy Medication Ordering, last reviewed 12/2025, documented all medication nurses were responsible for ordering medications. All new medications and medication refills were ordered electronically through the electronic medical record. The nurse would need to speak to a pharmacist to communicate the status of orders and urgency for medications needed prior to the morning delivery. Orders sent to pharmacy by 9:00 AM were to be delivered on the first pharmacy run; orders sent by 1:00 PM, were delivered on the second run; and orders by 7:00 PM were on the last delivery. The nurse was responsible for monitoring refill requests through General Dashboard Notification Box. If a transmission error appeared, the nurse was to contact the pharmacy regarding need to reorder. If a refill was rejected, the nurse was to review reason. If reason was too soon to fill, the nurse was to review the medication supply. If the medication was needed, the nurse was to contact the pharmacy. All other reasons the nurse should also contact the pharmacy. 1) Resident #247 had diagnoses including atrial fibrillation (irregular heartbeat), hypothyroidism, and congestive heart failure. The 02/13/2026 Minimum Data Set documented the resident was cognitively intact, had no behaviors, and took an antidepressant. The 08/06/2025 comprehensive care plan revised 01/19/2026 documented: - the resident had the potential for complications related to hypothyroidism. Interventions included administering medications as ordered and monitor response. - the resident had cardiovascular disease and had the potential for complications secondary to hypertension, congestive heart failure, and atrial fibrillation. Interventions included to provide medication and treatment per physician's orders and monitor for side effects of medication and inform the physician of concerns. Physician order documented: -on 08/04/2025 one (1) capsule of 120 milligrams of diltiazem extended release (a heart medication) by mouth once daily for atrial fibrillation. -on 8/04/2025 one (1) 5 milligram tablet of methimazole (a thyroid medication) by mouth six (6) times a week Monday-Saturday for thyrotoxicosis (excessive thyroid hormone in the blood stream). -on 08/04/2025 one (1) 80 milligram tablet of nadolol by mouth once daily for hypertension (high blood pressure). -on 12/31/2025 one (1) 50 milligrams tablet of hydralazine for hypertension. -02/06/2026 one (1) 2.5 milligrams tablet of lisinopril (a heart medication) by mouth one time a day for atrial fibrillation. The February 2026 Medication Administration Record documented the resident was not administered the following medications: -on 02/17/2026 at 2:00 PM, one (1) 50 milligram tablet of hydralazine; marked as not administered due to being re-ordered by Registered Nurse Neighborhood Manager #29. -on 02/25/2026 at 8:00 AM, one (1) 120 milligram capsule of diltiazem extended release; marked not administered with the supervisor aware by Licensed practical Nurse #53. -on 02/26/2026 at 8:00 AM, one (1) 120 milligram capsule of diltiazem extended release; marked not administered with the supervisor aware by Licensed Practical Nurse #28. The March 2026 Medication Administration Record documented the resident was not administered the following medications: -on 03/10/2026 at 8:00 AM, one (1) tablet of lisinopril 2.5 milligrams; marked as waiting on pharmacy by Licensed Practical Nurse #57. -on 03/28/2026 at 8:00 AM, one (1) tablet of methimazole 5 milligrams and one (1) capsule of 120 milligrams of diltiazem extended release; marked as not available by Licensed Practical Nurse #58. -on 03/29/2026 at 8:00 AM, one (1) tablet of nadolol 80 milligrams; marked as awaiting delivery by Licensed Practical Nurse #59. The 01/26/2026 Inventory Summary for the facility's emergency medication supply documented hydralazine 25 milligram tablets were kept stocked. The resident's blood pressure was documented on 03/28/2026 at 9:23 AM as 180/82 (high) after their missed dose of diltiazem. There was no documented evidence the provider was notified regarding the resident's missed medications and elevated blood pressure. The 03/29/2026 Registered Nurse Neighborhood Manager #29 progress note documented the resident did not receive nadolol that morning. The resident's adult child was concerned about the missed dose. The resident's blood pressure was 131/84. The resident was going out with their family and the resident's adult child requested the resident's blood pressure be rechecked upon the resident's return. The scheduled dose would be administered the next morning after it was delivered. An email was sent to the medical team. There was no documented evidence a supervisor was made aware of the missed doses of medications on 02/17/2026, 03/10/2026, and 03/28/2026. There was no documented evidence the medical providers were made aware of the missed doses of medications on 02/17/2026, 02/25/2026, 02/26/2026, 03/10/2026, and 03/28/2026. During an interview on 04/02/2026 at 10:05 AM, Licensed Practical Nurse #28 stated if a resident ran out of medications, they should check the emergency medication supply to see if it was stocked. If it was not, they should notify the supervisor and call the pharmacy to see when it would be delivered. The supervisor was responsible for notifying the provider. On 02/26/2026 Resident #247 missed their 8:00 AM diltiazem dose because the medication was out. They informed Registered Nurse Neighborhood Manager #29. They sometimes ran out of medications due to the medication not being reordered and because the pharmacy did not deliver timely. During an interview on 04/02/2026 at 11:55 AM, Licensed Practical Nurse #53 stated non-narcotic medications were reordered by clicking a button in the electronic medical record. The new pharmacy was not great with refilling medications, and the nurses usually had to call and make sure the refill went through. Medications should be ordered within five (5) days of the last dose. Not all the nurses checked the supply left when administering medications. If a resident did not have a medication, the nurse should check the emergency medication dispensing machine to see if there were tablets to equate the dose. If there were not, they should contact the supervisor to discuss next steps as well as call the pharmacy. The supervisor was responsible for notifying the physician. The 02/25/2026 dose of diltiazem for Resident #247 was not available as the medication was out. They called the supervisor, checked the emergency medication supply dispensing machine which did not have it. When they called the pharmacy, they were told the resident's insurance was the issue because it was too early to fill it. There was no alternative given and the resident was not placed on additional monitoring. During an interview on 04/03/2026, Registered Nurse Neighborhood Manager #29 stated medications should be reordered when the resident was down to a three (3) day supply, not the last day. They stated medications were ordered late. If the resident was out of medication, the nurses should check the emergency medication supply dispensing machine. The supervisor or neighborhood manager should be informed. The supervisor or neighborhood manager should call medical if the medication was not available in the emergency supply and see if it was alright for the resident not to receive the medication or if a different medication should be given. A note should be entered into the electronic medical record regarding the missed dose and the provider notification. The nurses ran into issues with ordering medications and medications being delivered timely by the pharmacy. They were only aware of the 03/29/2026 missed dose of the nadolol for Resident #247, not the other missed medications in February 2026 and March 2026. 2) Resident #14 had diagnoses including Alzheimer's disease and anxiety. The 03/11/2026 Minimum Data Set assessment documented the resident had severely impaired cognition and received antianxiety medication. The 10/22/2025 Comprehensive Care Plan, revised 03/23/2026, documented the resident had alteration in mood related to anxiety, depression, and Alzheimer's dementia. Interventions included to give clear, concise explanations regarding impending procedures, assist with decision making as needed, and provide reassurance and comfort. The 01/12/2026 physician order documented alprazolam 0.25 milligram tablet orally four times per day. The January 2026 Resident Medication Administration Record documented alprazolam was not administered to the resident on: - 01/12/2026 at 3:00 PM pending pharmacy by Licensed Practical Nurse #13. - 01/12/2026 at 7:00 PM pending pharmacy by Licensed Practical Nurse #13. - 01/13/2026 at 7:00 AM was not available by Licensed Practical Nurse #52. During an interview on 04/02/2026 at 9:42 AM Licensed Practical Nurse #14 stated the pharmacy was not reliable delivering resident medications and the medications were not always available in the automated medication cabinet. During an interview on 04/02/2026 at 12:40 PM, Licensed Practical Nurse #52 stated when residents returned from the hospital the pharmacy was notified of the readmission and medications were delivered. Resident #14 had alprazolam ordered when they returned to the facility from the hospital. The medication was not available from the pharmacy or in the automated medication cabinet. This was a new pharmacy, and they rarely received medications quickly and had to call the pharmacy frequently. During an interview on 04/03/2026 at 11:29 AM Assistant Director of Nursing #5 stated when residents returned from the hospital orders were reentered into the system. The medication was administered as soon as the pharmacy delivered it. They had deliveries twice a day. There was a complication with getting medications from the pharmacy and from the automated medication cabinet. In January there was a bigger issue with medications being delivered in a timely manner. During an interview on 04/03/2026 at 3:05 PM, the Director of Nursing stated medications should be ordered when there were three (3) or four (4) doses left. The pharmacy was usually quick with the delivery of medications. If they did not have medication for a resident, the nurses should check the emergency medication supply. If the medication was not available there, the physician should be informed to see if there was an alternative. Staff should also call the pharmacy to see when the medication was to be delivered. A progress note should be documented regarding the missed medication and the medical provider being informed. 10 NYCRR 415.18(e)(2)

Based on observations and interviews, the facility failed to ensure each resident had the right to exercise their rights as a resident of the facility and as a citizen or resident of the United States to include sending and receiving mail and to receive letters, packages, and other materials delivered to the facility for all 296 of 296 residents residing in the facility. Specifically, mail was not delivered to residents promptly to include Saturdays.Findings include: The facility policy Resident Mail, last reviewed 9/2025, documented incoming mail would be sorted and distributed daily. The mail was to be given to the resident or placed in a secure location and not opened by staff unless requested or authorized to do so.The facility policy Resident [NAME] of Rights, last reviewed 05/2020, documented residents had the right to send and receive mail promptly and unopened.During an anonymous resident meeting on 03/31/2026 at 3:07 PM, 13 out of 13 anonymous residents stated they only received mail Monday through Friday, and never on Saturdays.During an interview on 04/03/2026 at 10:44 AM, Receptionist #37 stated Mail Clerk #38 was the only one who managed and received the mail in the facility.During an observation and interview on 04/06/2026 at 9:35 AM, Mail Clerk #38 stated they received the mail, separated it by floor into bundles and brought it down to the mail room on the first floor where it is then picked up by the unit clerks to be distributed. They worked Monday through Friday and there was no mail coverage on Saturdays. The receptionist took the mail delivered on Saturdays and locked it up to be picked up on Monday morning. Previously, some receptionists had sorted the mail and distributed it, but they were not supposed to as a lot of errors occurred. They showed the surveyor the cart of mail delivered the previous Saturday they were sorting through to distribute to the units. Residents had previously complained about not receiving their mail on Saturdays. They were aware it was a resident right to receive mail promptly, including on Saturdays.During an interview on 04/06/2026 at 11:59 AM, the Administrator stated on the weekends the receptionist at the front received the mail and the household staff was supposed to come to reception to retrieve it and deliver it to the residents. They were unaware this was not occurring. 10 New York Codes, Rules and Regulations 415.23(e)(2)(i)

Based on observations, record review, and interviews, the facility failed to ensure resident's right to choose activities and health care services consistent with their interests, assessments, and plan of care and the right to participate in social and community activities for two (2) of two (2) residents (Residents #133 and #281) reviewed and for 13 of 13 anonymous residents present at the resident group meeting. Specifically, Residents #133 and #281 and 13 anonymous residents present at the resident group meeting expressed their displeasure with not being able to go outside on facility grounds without supervision.Findings include: The facility policy Resident [NAME] of Rights, last reviewed 05/2020, documented residents had the right to make choices about aspects of their life that were significant to them. The facility would meet their individual needs and preferences to the extent possible, except where health and safety of the residents would be endangered. Residents had the right to participate in the development of their person-centered plan of care. During a resident meeting on 03/31/2026 at 3:07 PM, 13 of 13 anonymous residents stated the facility did not always give them answers regarding their concerns. They felt their rights were not respected by not being able to go outside independently as they were previously able to. They and the staff were not always notified of rules changing in the facility and it led to confusion. Some staff stated residents could not go outside at all and some staff state they could go outside if they stayed right outside the front door. The Resident Council Meeting Minutes documented: - on 11/03/2025 the Administrator reviewed with the residents the new practices put into place which included residents were required to sign out and back in when leaving the household, staff were required to check on the residents who signed off the household every 30 minutes until they returned, and residents were not able to leave the building/go outside unless they were with family or a staff member. - on 12/01/2025 the residents expressed frustration with not being able to go outside by themselves. 2) Resident #133 had diagnoses including diabetes, morbid obesity, and heart failure. The 11/13/2025 Minimum Data Set (a resident assessment tool) documented the resident had intact cognition and felt it was very important to be able to outside to get fresh air when the weather was good. The 02/06/2026 Minimum Data Set documented the resident had intact cognition, used a motorized wheelchair/ scooter, and was independent once seated in their wheelchair/scooter, with ability to wheel at least 150 feet in a corridor or similar space. The Comprehensive Care Plan, initiated 10/31/2024 and revised 02/09/2026, documented the resident was able to independently utilize a personal power vehicle to designated/ supervised areas off the household and throughout the building. They were independent in the pursuit of leisure and social interests. The 01/08/2026 physician order documented the resident was able to independently sit outside when the weather was appropriate. The 01/16/2026 physician order documented the resident was able to independently utilize their personal power vehicle to designated/ supervised areas outside. The 02/09/2026 Elopement Risk Assessment documented the resident needed total assistance, had intact cognition, had no elopement attempts, had no behaviors, had no dementia or any type of mental illness, and was not on any mood-altering medications. The resident's elopement risk was low. During an interview on 03/30/2026 at 4:38 PM, Resident #133 in the presence of their family member, stated they loved to be outside when the weather was nice, and they were no longer able to go outside independently. A staff member/ family member/ or friend had to be with them if they went outside. During an interview on 04/03/2026 at 9:14 AM, Certified Nurse Aide #44 stated residents were only allowed to go outside if they had a staff member/ family member/ or friend with them and they needed to sign in and out when leaving the unit. Resident #133 loved to go outside and had a personal power vehicle. The resident was upset they could no longer go outside independently. During an interview on 04/03/2026 at 09:27 AM, Licensed Practical Nurse #45 stated residents could only go outside with a family member or staff and they needed to be signed in and out when leaving the unit. Resident #133 was independent once they were in their personal power vehicle, they loved to go outside and enjoy the nice weather. The resident recently stated to them they missed being able to go outside when the weather was nice. During a telephone interview on 04/03/2026 at 12:22 PM Registered Nurse Neighborhood Manger #46 stated residents were able to go outside but needed to be supervised and had to sign out prior to leaving and sign in when they returned. Residents needed a medical order to go outside and would also need to have a care plan to do so. Resident #133 was independent and could leave the unit, but if they went outside, they required supervision. During an interview on 04/06/2026 at 10:56 AM Social Worker #47 stated residents needed to be supervised if they went outside and had to sign out when they left the unit. The facility changed the outside process in November 2025. They had not offered any support to residents about the changes made regarding going outside. Resident #133 never expressed any concerns regarding not going outside and had just recently transferred to their unit. During an interview on 04/06/2026 at 11:19 AM Social Worker #48 stated residents were not allowed to go outside independently anymore. They need to be near the reception area and within eyesight of staff. They were not aware if residents were offered support or assessed for mood/ behavior changes following the facility change. Resident #133 used to reside on their unit and loved going outside. 3) Resident #281 had diagnoses including kidney disease, diabetes, and insomnia. The 02/10/2026 Minimum Data Set documented the resident was cognitively intact, had no behaviors, was independent for most of their activities of daily living, and used a motorized wheelchair/scooter. The 02/18/2025 comprehensive care plan documented the resident needed encouragement to attend activities of interest related to impaired psychosocial wellbeing related to diagnosis of depression. Interventions included targeting the resident for movies, music, Happy Hour, and outdoor activities when the weather permitted. On 04/02/2026 residents' preferences will be honored for their daily routine. Interventions included the resident was able to independently utilize their personal power vehicle to designated/supervised areas and they were independent with the use of a scooter style personal protective vehicle and could operate it throughout the health pavilion and on the facility campus. The 11/16/2025 Elopement Risk Assessment documented the resident was fully ambulatory, had intact cognition, had no elopement attempts, had no behaviors, had no dementia or any type of mental illness, and was not on any mood-altering medications. The resident's elopement risk was low. During an interview on 03/30/2026 at 1:15 PM, Resident #281 stated they were previously able to go outside and on the grounds, but they could no longer do that due to one person. They were told it was being worked on, but they did not want to hear it was being worked on anymore, they wanted a solution. They felt locked up in the facility and felt like they were being punished because of one person. Some staff told them they could go as far as the main entrance if they were within eyesight, but other staff would not let them out at all. During an interview on 04/03/2026 at 10:44 AM, Receptionist #37 stated the rule for residents going outside was they could only go outside with family members or facility staff. They were supposed to stop residents from going outside if they were alone. Some residents were unhappy with the new rules. During an interview on 04/03/2026 at 11:57 AM, Certified Nurse Aide #42 stated residents had to sign out of the unit and let staff know they were leaving. Residents were not allowed to go outside independently; only under the supervision of a family member and had to always be with someone. The facility did not have enough staff available to take the residents outside when they wanted. The independent residents were upset about this rule. During an interview on 04/03/2026 at 12:02 PM, Licensed Practical Nurse #43 stated the facility did not have enough staff to take the residents outside and a lot of residents were upset about the rule they could no longer go outside independently. During an interview on 04/06/2026 at 9:19 AM Registered Nurse Neighborhood Manager #12 stated residents were not allowed to go outside independently. The current plan was residents had to be supervised by either family or staff when outside regardless of cognition and mobility level. Independent cognitively intact residents could go all throughout the facility but not outside. Some days they had household attendants who could take residents outside, but some days were better than others for staffing. During an interview on 04/06/2026 at 10:56 AM Social Worker #47 stated residents needed to be supervised if they went outside and had to sign out when they left the unit. The facility changed the outside process back in November 2025. They had not offered any support to residents regarding the changes regarding going outside and had not assessed for mood/ behavior changes following the change. Resident #281 had not complained to them about not being able to go outside, but they knew the resident did enjoy sitting outside. During an interview on 04/06/2026 at 11:59 AM, the Administrator stated residents required a physician's order to go outside independently. Since the cameras were now installed, residents were able to go outside independently into the patio area which was right outside the front door under the supervision of the receptionist, the cameras, and security rounds. Previously residents were not allowed to go outside independently. Family and friends were also allowed to bring residents outside along with facility staff and volunteers to the great lawn for additional outside time. All residents had to be signed in and out of their units, so the facility knew where they were and were allowed to stay out as long as the weather permitted and it was daylight hours. The residents were assessed by the interdisciplinary team to be able to go outside, an order placed, and the information care planned. They received complaints regarding the residents' ability to go outside independently, and they addressed them monthly in resident council. Residents who expressed dissatisfaction or were upset about not being able to go outside anymore were met with individually to address concerns. 10 New York Codes, Rules and Regulations 415.23(b)(1-3)

Based on observations and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for five (5) of eleven (11) medication carts ([NAME], [NAME], Westchester, Manhattan, and Placid Neighborhoods) reviewed. Specifically, the Placid Neighborhood narcotic box contained 30 morphine (opiate) syringes and 57 lorazepam (anti-anxiety) syringes belonging to a deceased resident; the Manhattan Neighborhood medication cart contained one (1) morphine syringe without a resident's name on the label; the Westchester Neighborhood medication cart contained three (3) pre-poured medication cups; the [NAME] Neighborhood medication cart contained expired eye drops and a nasal spray that was not labeled with an open date; and the [NAME] Neighborhood medication cart had expired and undated nasal sprays.Findings included: The facility policy Medication Administration, revised 10/2025, documented controlled medications were placed in the double locked drawer in the medication cart just before medication pass. Nurses ensured the resident was available prior to preparing medications for administration. Expiration dates were checked prior to administration and expired medications were returned to the pharmacy. Expired narcotics must be collected by the Director of Nursing for destruction. The policy did not include directions for collection of medications and narcotics belonging to deceased residents. [NAME] NeighborhoodDuring an observation and interview on 04/02/2026 at 9:42 AM, the top drawer of the medication cart had fluticasone nasal spray with an open date of 01/16/2026 and Afrin nasal spray with an open date of 02/02/2026. Licensed Practical Nurse #14 stated nasal spray should be dated when opened and expired 30 days after being opened. They stated the expired nasal sprays needed to be disposed of and should not have been in the cart. They were not sure why the nasal sprays were still in the cart or why they were not dated when opened. [NAME] NeighborhoodDuring an observation and interview on 04/03/2026 at 12:00 PM, the first drawer of the medication cart had an opened, undated allergy nasal spray. Licensed Practical Nurse #13 stated the nasal spray should be labeled, and they needed to discard it. There were Refresh eye drops opened 12/19/2025 with the instructions to discard after 90 days. Licensed Practical Nurse #13 stated that the eye drops were expired as it was long past 90 days. They were unsure why there was expired or undated medication in the cart as it was not their main neighborhood. They did not check the cart when they started their shift.During an interview on 04/03/2026 at 11:29 AM, Assistant Director of Nursing #5 stated they were supervising the [NAME] and [NAME] neighborhoods, as there was no registered nurse neighborhood manager. Nasal sprays and eye drops were good for 28 days after they were opened and should always be labeled. Consultants came once a month and looked through medication carts to ensure they were accurate. When a resident expired or was discharged their medication should not be kept in the medication cart and should be sent back to the pharmacy on the next medication delivery. Narcotics were gathered for destruction by the Director of Nursing. Nurses called the Director of Nursing and told them they had narcotics that needed to be picked up and they would dispose of them in the pharmacy disposal box. Westchester NeighborhoodDuring an observation and interview on 04/02/2026 at 3:46 PM, the first drawer of the medication cart had three (3) cups of pre-poured medication. Licensed Practical Nurse #32 stated they poured the medications, but the residents were not present in the neighborhood at the time, and they did not want to waste anything. They put the names of the residents on the medication cups, so they did not confuse them. They did not let anyone in their cart, so they knew the residents received the right medications.During an observation and follow-up interview on 04/02/2026 at 3:55 PM, the locked narcotic box contained ten packs of eleven, and one (1) pack of seven (7) morphine syringes belonging to a deceased resident. Licensed Practical Nurse #32 stated the resident passed about a month ago and they emailed the Director of Nursing to collect the remaining narcotics. When a resident expired or was discharged the Director of Nursing or Assistant Director of Nursing were supposed to come and collect medications. Manhattan NeighborhoodDuring an observation and interview on 04/02/2026 at 4:14 PM, the locked narcotic box within the medication cart had an unlabeled morphine syringe. Licensed Practical Nurse #33 stated they knew who the syringe of morphine was for. They always took the syringe out of the medication bag from the locked narcotic box and put it in the medication cart.During an interview on 04/06/2026 at 9:19 AM, Registered Nurse Neighborhood Manager #12 stated nurses took out of the locked narcotic only the narcotics they needed for the day and placed them into the medication cart. Morphine syringes came in a bag; individual morphine syringes were not labeled, only the bag they came in was labeled. The syringes were not labeled so the whole bag of morphine syringes should have gone in the cart. Placid NeighborhoodDuring an observation and interview on 04/02/2026 at 3:54 PM, the Placid Neighborhood narcotic box contained 57 syringes of lorazepam and 30 syringes of morphine belonging to a resident who expired in January of 2026. Licensed Practical Nurse #11 stated the Director of Nursing came to the neighborhoods to collect medications and dispose of them. Nurses informed the Director of Nursing through voicemail or email that medications were discontinued, expired, or when a resident expired so they could come to the neighborhood and dispose of the medications.During a follow-up interview on 04/06/2026 at 10:10 AM, Registered Nurse Neighborhood Manager #12 stated the Director of Nursing disposed of medications and narcotics. Licensed practical nurses called the Director of Nursing to let them know medications needed to be collected. The nurses continued to count the narcotics when residents were no longer in the neighborhood until they were disposed of by the Director of Nursing. The nurses had emailed the Director of Nursing regarding the narcotics of the expired resident still in the narcotic box.During an interview on 04/03/2026 at 3:05 PM, Director of Nursing #36 stated they were the only person who picked up narcotics that were no longer required. If a resident expired or was discharged , they counted and signed the narcotics out of the logbook and placed them in a double locked box. When that was full, they placed them in a safety box and had it picked up. Narcotics should not be in the neighborhood for a resident that was discharged from the facility in January or February. 10 NYCRR 415.18(d)

Based on observations, record review, and interviews, the facility failed to ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for two (2) of two (2) test trays (the 03/30/2026 lunch meal and the 04/01/2026 lunch meal), 13 of 13 anonymous residents during a resident meeting, and one (1) resident (Resident #11) reviewed. Specifically, food was not served at palatable and appetizing temperatures during lunch meals on 03/30/2026 and 04/01/2026; 13 anonymous residents during a resident council and Resident #11 stated the food was cold. Additionally, multiple meal trays were observed sitting for 30-60 minutes prior to resident consumption; and the facility did not have a procedure in place to ensure food was properly re-heated on the resident units to the required temperatures. Findings include: The facility policy Taste and Temperature Control, revised 05/2023, documented cold food such as milk, juice, and ice cream, should be refrigerated or on ice during meal service to maintain proper temperature. There was no documentation regarding appropriate temperatures of foods when served to the residents.During an observation on 03/30/2026 at 11:47 AM, Resident #19's lunch meal was tested, and a replacement meal was ordered. Food temperatures were measured and verified by Certified Nurse Aide #15 as follows: roasted sweet potatoes were 129.6 degrees Fahrenheit, apple crisp was 51.6 degrees Fahrenheit, cranberry juice was 52.2 degrees Fahrenheit. The apple crisp was bland with hard apples, and the cranberry juice tasted lukewarm. During an interview on 03/30/2026 at 12:30 PM, Resident #11 stated the food was often cold.During an observation and interview on 03/30/2026 at 2:11 PM Residents #205 and #206 were out of the budling for the lunch meal and their meal trays were sitting on a table in the dining room The trays contained potentially hazardous foods, including roasted turkey breast and milk. Licensed Practical Nurse #16 stated they left the trays out for the residents and would serve the trays to them when they returned to the facility. During an observation on 04/01/2026 at 12:37 PM, Resident #235's lunch meal was tested. The resident was out of the building. Food temperatures were measured and verified by Licensed Practical Nurse #18 as follows: pork loin was 135.2 degrees Fahrenheit, bread stuffing was 134.2 degrees Fahrenheit, chocolate milkshake 56.7 degrees Fahrenheit, water 54 degrees Fahrenheit. The pork loin was very hard to chew, and the milkshake tasted lukewarmDuring a continuous observation on 04/02/2026 between 8:00 AM and 12:00 PM: -at 8:29 AM, Food Service Worker #8 started passing breakfast trays. Four (4) residents were in the dining room and were served, including Resident #15. The doors to the cart were left open and the remaining resident trays were left in the cart;-at 8:50 AM, many residents were still in bed. Licensed Practical Nurse #35 stated they usually came out to the dining room by 9:00 AM. The food cart was sitting with the doors open, and seven trays were still in cart;-at 9:01 AM, Certified Nurse Aide #15 re-heated the pancakes for Resident #15 and assisted them with their meal. There was no evidence the temperature of the food was checked after being reheated. -at 9:11 AM, six (6) breakfast trays remained in the meal cart with the doors open and untouched; -at 9:24 AM, Residents #39 and #235 came into the dining room and were served their breakfast meal from the open cart without re-heating the food. Resident #39 requested their meal be heated up and Certified Nurse Aide #17 put the plate in the microwave for 30 seconds There was no evidence the temperature of the food was checked after being reheated. Resident #235 ate their breakfast meal without staff re-heating it.-at 9:52 AM, three (3) breakfast trays were unpassed and left in the meal cart with the door opened. The milk carton on one tray and a milkshake on another tray felt warm to touch. Certified Nurse Aide #19 pulled the meal trays out of the cart and set them out on the counter and stated they were going to serve them to the residents if they got up to eat. -at 10:00 AM Resident #280 entered the dining room and Certified Nurse Aide #19 heated up pancakes for the resident. There was no evidence the temperature of the food was checked after being reheated. -at 11:45 AM, three resident trays remained on the counter untouched. The residents were still in bed at that time.During an interview on 04/02/2026 at 9:35 AM, Certified Nurse Aide #17 stated there was no formal procedure to re-heat meal trays. They reheated the resident's meal trays in the microwave at 30 second intervals until the plate felt warm. They did not have a thermometer on the unit to check the temperature of the food.During an interview on 04/02/2026 at 10:05 AM, Certified Nurse Aide #19 stated there was no formal procedure to re-heat meal trays. They reheated the resident's meal trays in microwave at 30 second intervals until the plate felt warm. They did not have a thermometer on the unit to check the temperature of the food and did not know what temperature food should be reheated to. Hard boiled eggs and dairy items should not be served to the residents if they were left in an open meal cart for almost two hours. If residents were sleeping during meal service nursing staff did not wake them up. During an interview on 04/02/2026 at 10:15 AM, Licensed Practical Nurse #35 stated they re-heated resident's meal trays for 30 seconds and did not know what temperature to heat the food items to. There was no thermometer on the unit to check the temperature of the food once it was reheated. Eggs and milk should not be left out at room temperature for two hours. During an interview on 04/03/2026 at 9:52 AM Certified Nurse Aide #20 stated nursing staff assisted the residents with their meals. Food items stayed hot for one (1) hour, after one (1) hour they reheated the food and served the residents. There was no formal procedure on how to re-heat meal trays. They put the plate in the microwave for 30 second intervals until the plate felt warm. They did not have a thermometer on the unit to check the temperature of the food. Meal trays that sat on the counter were discarded if the resident refused the meal. Unconsumed breakfast trays should not be left out on the counter at 11:45 AM. During an interview on 04/03/2026 at 10:31 AM, Food Service Director #6 stated food service staff delivered the meal carts to the units and passed out the meal trays in the dining room. They did not deliver meal trays to the resident's rooms if a resident was sleeping to prevent the meal trays from getting cold while they slept. Food service staff removed unconsumed trays out of the meal cart and placed them on the counter in the kitchenette. Meal trays should be served within one (1) hour from the start of the meal. They were unsure how long the plate warming base kept the food warm. Meal trays containing meat and eggs should not be left sitting in the meal cart or on the counter for over two (2) hours. The units all had a thermometer to test the temperatures of the food after staff reheated the meal trays. Breakfast meal trays should not be left sitting out on the counter at 11:45 AM, because the food had been in the temperature danger zone too long. They did not know what the process was for reheating food on the units. The nurse educator educated the nursing staff on how to reheat food in the microwave and what the temperature food items should be heated to. During an interview on 04/03/2026 at 11:10 AM, Registered Nurse #29 stated food service staff brought the breakfast meal trays to the unit around 8:25 AM, and passed out all the trays, including room trays. They held any unconsumed meal trays for residents in case they want them later. The meal trays could be served for one (1) hour after the meal cart arrived on the unit. After one (1) hour the food needed to be reheated in the microwave for one (1) minute. Any unconsumed breakfast meal trays should not sit out on counter until 11:45 AM. During an interview on 04/06/2026 at 9:23 AM, Licensed Practical Nurse #18 stated they were not sure of the official process, but thought food service staff served the meal trays to all residents and nursing staff assisted the residents with eating. They thought the meal trays could be served up to 75 minutes from when they arrived on the unit. Meal trays that were on the counter should be taken back to the kitchen if unconsumed. Meal trays containing meat and dairy that were on the counter past 75 minutes should not be served. 10 New York Codes, Rules and Regulations 415.14(d)(1)(2)

Based on observations and interviews, the facility failed to ensure proper sanitation and food handling practices to prevent the outbreak of foodborne illness in one (1) of one (1) main kitchen. Specifically, the main kitchen had unlabeled/undated prepared and leftover food; and dishwashing machine temperatures were not monitored routinely. Findings include:The facility policy Mechanical Wear (ware) washing, revised 05/2023, documented warewashing temperatures would be taken and recorded in the supervisor monitoring log during each meal period. Food Storage During an observation and interview on 03/30/2026 at 9:56 AM, the following was observed in the main kitchen:-two pans of prepared and cooked food in the reach-in cooler, identified by Food Service Director #6 as leftover hashbrowns and ground chicken, were not labeled or dated; -one pan of prepared and cooked food in the walk-in cooler, identified by Food Service Director #6 as leftover kielbasa, was not covered, labeled, or dated; -three pans of prepared and cooked food in the walk-in cooler, identified by Food Service Director #6 as leftover fish, cooked beef, and garlic bread, were not labeled or dated. Dinnerware Sanitization and Storage During an observation and interview on 04/01/2026 at 11:09 AM, the Weekly High Temperature Mechanical Warewashing Log was reviewed for March 2026, and the following entries were missing:-03/01/2026: Breakfast, Lunch, and Dinner;-03/02/2026: Breakfast, Lunch;-03/03/2026: Breakfast, Lunch, and Dinner;-03/04/2026: Lunch;-03/05/2026: Breakfast, Lunch;-03/06/2026: Breakfast, Lunch;-03/09/2026: Breakfast, Lunch;-03/10/2026: Breakfast, Lunch;-03/11/2026: Breakfast, Lunch;-03/12/2026: Breakfast, Lunch;-03/13/2026: Breakfast, Lunch, and Dinner;-03/14/2026: Breakfast, Lunch, and Dinner;-03/15/2026: Breakfast, Lunch, and Dinner;-03/16/2026: Breakfast, Lunch;-03/17/2026: Breakfast, Lunch;-03/18/2026: Breakfast, Lunch;-03/19/2026: Breakfast, Lunch, and Dinner;-03/20/2026: Breakfast, Lunch;-03/21/2026: Breakfast, Lunch;-03/22/2026: Breakfast, Lunch;-03/23/2026: Breakfast, Lunch;-03/24/2026: Breakfast, Lunch;-03/25/2026: Breakfast, Lunch;-03/26/2026: Breakfast, Lunch;-03/27/2026: Breakfast, Lunch;-03/28/2026: Breakfast, Lunch, and Dinner;-03/29/2026: Breakfast, Lunch, and Dinner;-03/30/2026: Breakfast, Lunch, and Dinner;-03/31/2026: Breakfast, Lunch, and Dinner.During an interview on 04/01/2026 at 11:30 AM, Food Service Director #6 stated the dish machine temperatures were recorded three times a day at mealtimes by a kitchen supervisor and recorded on the Weekly High Temperature Mechanical Warewashing Log. The missing temperatures were a concern, and they were unsure why so many were missing. The dish machine temperatures were monitored to ensure dishes were sanitized properly. Prepared and cooked food should be covered in the cooler to prevent contamination and should be labeled and dated to identify what the food was and when it needed to be used or discarded by.During an interview on 04/01/2026 at 11:51 AM, [NAME] #7 stated they worked in the kitchen at the facility for over a year. They stated leftover prepared and cooked food was sealed in a bag or container and labeled and dated prior to going in the refrigerator. The food should be covered to prevent contamination and labeled and dated to identify what the food was and to ensure the oldest product was used first. 10 NYCRR 415.14(h)

Based on observations, record review and interviews, the facility failed to ensure residents who were fed by enteral means (tube feeding, delivery of nutrition directly to the stomach or small intestine) received the appropriate treatment and services to prevent complications of enteral feeding for one (1) of one (1) resident (Resident #4) reviewed. Specifically, Resident #4's hung tube feeding was not dated during multiple observations.Findings include: The facility policy Gravity, Tube Feeding, Enteral, Gastrostomy, or Jejunostomy, revised 06/2023 did not document dating and timing of tube feedings when administered. The manufacturer details for Nepro tube feeding formula, last updated 2025, documented unless a shorter hang time is specified by the set manufacturer, hang product for up to 48 hours after initial connection when clean techniques and only one new set are used. Otherwise hang for no more than 24 hours. Resident #4 had diagnoses including dysphagia (difficulty swallowing), chronic kidney disease, and cerebral infarction (stroke). The 02/27/2026, Minimum Data Set (a resident assessment tool) documented the resident had severely impaired cognition, did not eat by mouth, weighed 196 pounds, and received nutrition through a feeding tube.Physician orders documented:-03/18/2025 nothing by mouth, may have popsicles.-12/09/2025 hold tube feeding from 05:00 AM and restart at 07:30 AM.-12/17/2025 provide Nepro (tube feeding formula) at 45 milliliters an hour for 21.5 hours for total volume of 967.5 milliliters daily via gastrostomy tube (a feeding tube inserted through the abdomen into the stomach). The March 2026 Medication Administration Record documented Nepro at 45 milliliters an hours for 21.5 hours for a total daily volume of 967.5 milliliters.The following observations were made:-on 03/31/2026 at 8:42 AM and 4:00 PM, the resident was in their recliner chair seated upright. Their tube feeding pump was on and functioning. The pump indicated the tube feeding was infusing at 45 milliliters per hour. There was no documented evidence of the day/ time the tube feeding was opened and hung.-on 04/01/2026 at 9:18 AM, the resident was in bed with the head of the bed positioned greater than 30 degrees. Their tube feeding pump was on and functioning. The pump indicated the tube feeding was infusing at 45 milliliters per hour. There was no documented evidence of the day/ time the tube feeding was opened and hung.During an interview on 04/01/2026 at 12:20 PM Licensed Practical Nurse #39 stated tube feedings should be dated when hung. Resident #4's tube was on hung on the evening shift. They had not noticed it was not dated but checked to make sure the correct formula was hung, and it was infusing during their shift. Tube feedings should be dated so staff knew how long it was hung for, as it was only supposed to be hung for 24 hours.During an interview on 04/01/2026 at 12:41 PM Registered Nurse Neighborhood Manager #12 stated the nurse who hung the tube feeding should date it, so staff knew when it was hung.During a telephone interview on 04/01/2026 at 1:26 PM Licensed Practical Nurse #11 stated Resident #4's tube feeding was hung on the evening shift as it ran for 21.5 hours. They should date the tube feeding when it was hung, but they were terrible with dating, they were busy and did not think about it. 10 New York Codes, Rules and Regulations 415.12(g)(2)

Based on observations, record review, and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to include services provided to maintain the resident's highest practicable physical well-being for two (2) of two (2) residents (Residents #77 and #16) reviewed. Specifically, Resident #77's person-centered comprehensive care plan did not include the use of oxygen; and Resident #16's person-centered comprehensive care plan did not include the use of psychotropic (used to treat mood/ behaviors) medications.Findings include:The facility policy Interdisciplinary Comprehensive Care Plans, revised 09/2025, documented a person-centered care plan would be developed by the interdisciplinary care team to ensure services were being provided to assist the resident in achieving/maintaining their highest practicable physical, mental, and psychosocial wellbeing. The person-centered Interdisciplinary care plan would be completed in conjunction with the medical data set assessment by day fourteen from admission and would be reviewed and revised quarterly, annually, and as needed. 1) Resident #77 had diagnoses including pneumonia, respiratory failure with hypoxia (low levels of oxygen in body tissues), and pulmonary hypertension (high blood pressure in the arteries of the lungs). The 03/04/2026 Minimum Data Set (a resident assessment tool) documented the resident had intact cognition; had shortness of breath with exertion and while lying flat; and was on continuous oxygen therapy. The 03/03/2026 physician order documented oxygen at four (4) liters/minute continuous by nasal cannula (tube in nose). There was no documented evidence the comprehensive care plan included an individualized respiratory care plan with the use of oxygen. The resident profile (care instructions) did not include the use of oxygen. During an interview on 04/06/2026 at 10:26 AM, Certified Nurse Aide #9 stated they were unsure if oxygen use should be included in the care plan but thought it should so they would know if Resident #77 was supposed to use oxygen continuously or as needed and to monitor and ensure the resident was using it as ordered. During an interview on 04/06/2026 at 10:31 AM, Licensed Practical Nurse #3 stated registered nurses were responsible for initiating and updating care plans. Resident #77 used oxygen continuously since admission. They thought oxygen should be included in the care plan, so staff knew how many liters per minute the resident was on, if the resident required continuous or as needed oxygen, to monitor the resident's breathing, and to ensure the resident was wearing and receiving oxygen as ordered. During an interview on 04/06/2025 at 10:42 AM, Registered Nurse/Charge Nurse #10 stated registered nurses were responsible for initiating and updating resident care plans and the care plan should include everything about the resident's care. Resident #77 should have oxygen therapy on their care plan, so staff knew how many liters per minute were ordered, if the resident needed continuous or as needed oxygen, when to check the resident's oxygen levels, and to monitor for shortness of breath or other respiratory issues. 2) Resident #16 had diagnoses including Alzheimer's disease and adult failure to thrive (overall physical decline). The 02/14/2026 Minimum Data Set (resident assessment tool) documented the resident had severely impaired cognition; had no depressive symptoms or behaviors; had no psychiatric/mood disorders; and received both an antipsychotic and an antidepressant with an indication noted. The Care Area Assessment Summary documented psychotropic drug use was triggered, and care planning was necessary. The 10/14/2025 physician order documented 0.5 milligram tablet of risperidone (antipsychotic) by mouth two times a day for dementia with anxiety. The 11/02/2025 physician order documented 25 milligram tablet of sertraline (an antidepressant) once a day for dementia with anxiety. There was no documented evidence of a care plan related to the resident's psychotropic medication use or interventions for any history of behaviors and depression The 03/06/2206 Physician #41 progress note the resident had advanced major neurocognitive disorder likely a mixed type of vascular and Alzheimer's type. The resident was started on risperidone as well as sertraline to help with their mood and anxiety. The resident recently had been much better with their behaviors. The 03/16/2026 Nurse Practitioner #40 Psychiatric Consultation documented the resident was seen for an initial evaluation due to their anxiety by facility staff request. The resident had outpatient behavioral health services in the past. The recommendations were to continue the risperidone 0.5 milligram tablet twice a day for agitation from dementia and the sertraline 25 milligram tablet once a day for depression and anxiety. Staff were to reinforce coping skills and non-pharmacological measures and monitor changes in mood, behaviors, and medication side effects. There was no documented evidence of a care plan addressing the resident's anxiety and use of non-pharmacological measures. During an interview on 04/03/2026 at 10:15 AM, Certified Nurse Aide #26 stated behaviors were documented on the care plan, but they were unsure if interventions for behaviors were also there. Resident #16 had behavioral symptoms which included hitting/swinging out at staff and verbal aggression. The resident became agitated when they were in bed or asleep and pulled the soft boots, socks, and bandages off their feet and blankets off their body. The resident had swung at them this morning. They tried to approach Resident #16 calmly and if that did not work, and the resident was in a safe position, they left the resident alone and documented on it. During an interview on 04/03/2026 at 10:59 AM, Licensed Practical Nurse #27 stated behavioral interventions should be listed on the resident's care plan. Resident #16 had verbally aggressive behaviors. When Resident #16 had verbally aggressive behaviors, they left the resident alone to calm down and then reapproached. During an interview on 04/03/2026 at 2:16 PM, Registered Nurse Neighborhood Manager #29 stated care plans were an interdisciplinary team effort, but psychotropic and behavior care plans were done by them. Psychotropic medications should be addressed on the resident's comprehensive care plan. Resident #16 should have a care plan addressing their sertraline and risperidone use. The resident had behaviors in the past, but they were not aware of any recent behaviors. Recurrent behaviors should be addressed on the resident's care plan. 10 New York Codes, Rules and Regulations 415.23(c)(1)

Based on observations, record review, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of one (1) resident (Resident #312) reviewed. Specifically, Food Service Worker #2 entered Resident #312's room, who was on enteric precautions (measures to prevent the spread of pathogens transmitted through feces), without donning personal protective equipment or performing hand hygiene upon exit. Findings included:The facility policy Transmission Based Precautions, last reviewed 11/2025, documented it was the responsibility of all personnel who had direct contact with residents to follow transmission-based precautions. Enteric precautions were contact precautions specifically for difficult to treat infections such as clostridium difficile, enterohemorrhagic Escherichia coli (severe intestinal infection), shigella (contagious intestinal infection), hepatitis A, or rotavirus (a highly contagious virus). Contact precautions required the use of gowns and gloves on every person entering the resident's room. A brown enteric precaution sign was placed outside the resident's room with personal protective equipment available. All staff were to wash hands with soap and water or use hand sanitizer before donning gloves. Staff were to wear gowns and gloves when entering the resident's room. Prior to leaving the room staff were to remove their gown and gloves and perform hand hygiene with soap and water.Resident #312 had diagnoses including enterocolitis (inflammation of intestines) due to clostridium difficile (a highly contagious bacteria) and diarrhea. The 03/26/2026 Minimum Data Set (a resident assessment tool) documented the resident had enterocolitis due to clostridium difficile.The 03/23/2026 Care Plan documented the resident had a clostridium difficile infection. Interventions included to maintain enteric contact precautions for the remainder of the infection.The 03/20/2026 physician order documented the resident was on enteric precautions.During an observation on 03/30/2026 at 11:42 AM, Resident #312's room had an enteric precaution sign outside the door. Food Service Worker #2 entered the resident's room to deliver their lunch tray without removing their gloves worn in a different residents' room. Food Service Worker #2 did not perform hand hygiene or put on a gown and new gloves. While in the room they moved the resident's wheelchair out of the way and pulled the over bed table closer to the resident's lap for lunch. Food Service Worker #2 left the room without removing gloves or performing hand hygiene.During an interview on 03/30/2026 at 11:47 AM, Food Service Worker #2 stated they did not know when residents were on precautions or what that meant. After looking at the enteric precaution sign they stated they did not know what the sign meant or what information it provided. When they brought food carts to units, they washed their hands and donned gloves before entering the unit. They did not remove their gloves until they finished passing out all meal trays. Just before they left the unit, they removed their gloves and used hand sanitizer. They did not remember if they had education on infection control or transmission-based precautions.During an interview on 04/03/2026 at 11:29 AM, Assistant Director of Nursing #5 stated they were the Infection Prevention nurse for the facility. Different types of precautions included enhanced barrier, contact, droplet, airborne, and enteric. Enteric precautions were mostly for clostridium difficile infection or any infection where alcohol-based products were not effective. It was required by all staff who entered a resident's room on enteric precautions to perform hand hygiene, don a gown and gloves before entering the room, remove gown and gloves before exiting the room, and perform hand hygiene with soap and water inside the room. Food service workers were required to wear personal protective equipment when entering an enteric precaution room. The same pair of gloves should not be worn when moving between resident rooms.During an interview on 04/03/2026 at 2:51 PM, Certified Nurse Aide #4 stated when residents were on transmission-based precautions there was a sign outside their door which told them what kind of precaution it was. Enteric precautions were for someone who had an infection or a catheter. The sign told staff what personal protective equipment to wear. The infection prevention nurse hung the signs and told us what type of precautions residents were on.During an interview on 04/03/2026 at 2:58 PM, Licensed Practical Nurse #3 stated staff knew when residents were on precautions because there were a sign and personal protective equipment outside their room. Enteric precautions were used for residents who had catheters and open areas on their bodies. They had to wash their hands before and after being in the residents' room and wear gowns, gloves, and sometimes a mask. If staff did not know what personal protective equipment was required, they looked at the sign and it told them what they needed. No one should go into an enteric precaution room without donning personal protective equipment. Resident #312 was on enteric precautions, and they had a sign and personal protective equipment bin outside their room. They were educated on transmission-based precautions on orientation and annually. 10 NYCRR 415.19(a)(b)

Based on observations, record review, and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure ulcers and promote healing of pressure ulcers for two (2) of five (5) residents (Residents #16 and #304) reviewed. Specifically, Resident #16's and Resident #304's pressure relieving interventions were not implemented as planned; and Resident #16 had conflicting wound care orders signed off as completed and wound care recommendations by the wound care provider were not implemented. Findings include: The facility policy Skin and Wound Care Policy and Procedure, reviewed 8/2025, documented the facility established a comprehensive, interdisciplinary approach for prevention, assessment, treatment, and monitoring of all wound types. Certified Nurse Aides were responsible for floating heels and managing offloading devices per the resident's care plan. The licensed practical nurses were responsible for implementing wound and prevention orders, performing ordered dressing changes within scope, and documenting wound observations. Registered nurses/Wound Nurse was responsible for initiating individualized interventions and obtain provider orders for treatment, recommended diagnostics, and consults. 1) Resident #16 had diagnoses including Alzheimer's disease and adult failure to thrive (overall physical decline). The 02/14/2026 Minimum Data Set (a resident assessment tool) documented the resident had severely impaired cognition; required maximum assistance or was dependent for most activities of daily living; was at risk of developing pressure ulcers; had a Stage 4 pressure ulcer (full thickness tissue loss with exposed tendon or muscle) and two (2) unstageable (full thickness tissue loss in which the base of the ulcer is covered by dead tissue) pressure ulcers with one (1) presenting as a deep tissue injury (purple/maroon localized area of discolored intact skin due to underlying tissue damage); had pressure reducing devices to the bed and chair; and had wound care and applications of dressings to their feet. The 02/25/2026 Comprehensive Care Plan, revised 03/11/2026, documented the resident was at high risk for skin breakdown. Interventions included to wear Prevalon boots (cushioned boots that alleviate pressure) while in bed. Physician orders documented the following: -10/13/2025 offload heels at all times and wear Prevalon boots in bed. -01/23/2026 apply Betadine (an antiseptic) to the left heel twice a day and leave open to air. -01/30/2026 apply Betadine to the right heel unstageable ulcer, apply heel cup (protective covering), cover with dry gauze and kerlix and change daily. -02/01/2026 apply Betadine 10% topical solution to bilateral heel ulcers, cover with dry gauze and kerlix and change daily. The 3/20/2026 Nurse Practitioner #22 Wound Care Follow Up Note documented the resident had a Stage 4 pressure injury and bilateral heel unstageable pressure injuries. The treatment history outline documented: -on 02/06/2026 and 02/13/2026 nursing staff were to apply Betadine and a dry dressing to both heels, secure the dressing with kerlix. Heel cups were not to be used as the gauze bunching under the foam may cause a skin injury. -on 03/06/2026 and 3/20/2026 nursing staff were to continue with the current plan. The left heel was to be painted with Betadine and left open to air. The right heel was to have the eschars (dead tissue) painted with Betadine then apply Betadine moistened gauze over the area and secure with kerlix (cotton rolled dressing). Foam heel cups were to be used, and the dressings changed daily. There was no documented evidence the 3/6/2026 and 3/20/2026 Nurse Practitioner #22's recommendations for right heel to have the eschar painted with Betadine then apply Betadine moistened gauze over the area and secure with kerlix was implemented. The 04/03/2026 Nurse Practitioner #22 progress note documented the resident's treatments to their heels were to paint the left heel with Betadine and leave open to air. The right heel eschar was to be painted with Betadine, apply dry gauze, secure with kerlix. The dressing was to be changed daily, and staff could continue to use foam heel cups. The March 2026 and April 2026 Treatment Administration Records documented the following orders as completed: -01/23/2026 apply Betadine (an antiseptic) to the left heel twice a day and leave open to air. -01/30/2026 apply Betadine to the right heel unstageable ulcer, apply heel cup (protective covering), cover with dry gauze and kerlix and change daily. -02/01/2026 apply Betadine 10% topical solution to bilateral heel ulcers, cover with dry gauze and kerlix and change daily. The orders to cover bilateral heels ulcers with dry gauze and kerlix conflicted with the order to apply betadine to the left heel and leave open to air. The March 2026 and April 2026 Treatment Administration Records documented the 01/23/2026 left heel wound care order, the 01/30/2026 right heel wound care order and the 02/01/2026 bilateral heel order were all signed as completed. The March 2026 and April 2026 Treatment Administration Records documented the order to offload the resident's heels at all times with Prevalon boots in bed was signed as completed every shift except for the nightshift on 03/05/2026 and dayshift on 03/29/2026 when there was no documentation and the dayshift of 03/19/2026 and the nightshift of 03/30/2026 when the resident was out of bed. The resident was observed on: - 03/31/2026 at 2:46 PM, asleep in bed not wearing Prevalon boots. The Prevalon boots were on top of a basket. - 04/01/2026 at 11:35 AM and 2:27 PM, asleep in bed on their left side not wearing Prevalon boots. The Prevalon boots were on top of a basket. During an interview on 04/01/2026 at 2:30 PM, Certified Nurse Aide #26 stated if a resident was supposed to be wearing offloading boots in bed it was documented in the resident's chart. They stated Resident #16's family did not want the resident wearing the offloading boots because the resident refused to wear them as they made the resident uncomfortable. Resident #16 became agitated and would take off the offloading boots and the bandages on their foot. The staff on the unit and the nurse manager know the resident's family stated not to put the boots on the resident. During an interview on 04/02/2026 at 2:48 PM, Licensed Practical Nurse #28 stated residents who should wear Prevalon boots in bed had orders on their Treatment Administration Record. They did not know if Resident #16 had orders for Prevalon boots while in bed. The order on the Treatment Administration Record was meant to make the nurse aware of the boots needing to be on the resident and signing off on the order meant the nurse knew of the order. The Treatment Administration Record listed all wound treatment orders. They followed the individual heel orders for Resident #16; leaving the left heel open to air after Betadine and wrapping the right heel after Betadine with heel cup in place. The orders needed to be fixed as sometimes they were confusing. During an interview on 04/03/2026 at 10:59 AM, Licensed Practical Nurse #27 stated if a resident was supposed to have Prevalon boots on in bed it should be on their Treatment Administration Record. When the order was signed off as completed it meant the nurse had verified the certified nurse aide put the boots on the resident. Resident #16 did not wear their Prevalon boots because they did not like anything on their feet. On 04/01/2026 the resident was not wearing their Prevalon boots. Licensed Practical Nurse #27 stated they did not remember signing off on the Treatment Administration Record the resident was wearing their boots on 04/01/2026 but it was one of those things that was just a click of a button. During an interview on 04/03/2026 at 2:16 PM, Registered Nurse Neighborhood Manager #29 stated Resident #16 was care planned to wear Prevalon boots in bed, but they refused them. They were not aware the resident's refusals were not being documented. The licensed nursing staff should not be signing off the Prevalon boots order as completed if the resident refused to wear them. The resident should have their refusals of the boots care planned and the provider should have been notified. They were unaware Resident #16's family did not want the resident wearing the Prevalon boots since they agitated the resident. Wound care orders were entered by the neighborhood managers in the past, but Registered Nurse #30 assisted with wound rounds and placing the orders. The wound care orders should match the recommendations made by the wound care nurse practitioner. If there were conflicting orders for wound care the licensed nursing staff should contact the provider and find out which orders were correct, and they should not sign off all the orders as completed. They were unaware Resident #16 had multiple orders for the heel wounds and stated the previous orders must not have discontinued when new ones were ordered. During an interview on 04/06/2026 at 9:53 AM, Registered Nurse #30 stated they put in the wound care orders from wound rounds. The wound care orders should match the recommendations of the Wound Care Nurse Practitioner. They only discontinued the previous orders if the Wound Care Nurse Practitioner's new orders indicated to do so. If the previous order was put in by a different provider than the Wound Care Nurse Practitioner, they did not discontinue the previous orders. During an interview on 04/06/2026 at 10:55 AM, Wound Care Nurse Practitioner #22 stated they expected the facility to follow their recommendations for wound care orders. Old wound care orders should be discontinued when new orders were entered. Resident #16 should have the order for the bilateral heels discontinued as both heels had an individual treatment. They were just made aware on 04/03/2026 Resident #16 was not wearing their Prevalon boots while in bed. The resident should have an order for the Betadine moistened gauze to the right heel as that was their treatment recommendation prior to when they saw the resident on 04/03/2026. 2) Resident #304 had diagnoses including Alzheimer's disease, adult failure to thrive (overall physical decline), and history of venous thrombosis and embolism (formation of blood clots). The 07/19/2026 Minimum Data Set (a resident assessment tool) documented the resident had severely impaired cognition, did not refuse care, required substantial assistance for most activities of daily living and transfers, and was at risk for developing pressure ulcers. The 08/23/2024 Comprehensive Care Plan, revised 07/21/2025, documented the resident had a skin condition following a deep vein thrombosis. Interventions included frequent repositioning. On 01/25/2026 the care plan was updated and documented the resident was at a mild risk for skin breakdown. Interventions included refer to basic needs and preferences for cushions, positioning devices, specialty mattresses, and lifting devices. The 03/14/2025 physician order documented Spenco boots (pressure relieving boots) while in bed. The 08/19/2025 care card (care instructions) documented the resident had Spenco boots while in bed. The March 2026 Treatment Administration Records documented Spenco boots on while in bed and was signed off as completed every shift. The following observations were made of Resident #304: - on 03/30/2026 at 2:07 PM, asleep in bed, lying flat on their back. The resident was not wearing Spenco boots. The Spenco boots were on their recliner. - on 03/31/2026 at 4:06 PM, the resident was lying in bed flat on their back. The resident was not wearing Spenco boots. The Spenco boots were on their recliner. During an interview on 04/02/2026 at 2:03 PM, Licensed Practical Nurse #14 stated Resident #304 was at risk of developing pressure injuries and should wear pressure relieving boots every time they were in bed. It was the responsibility of the certified nurse aide who put the resident to bed to ensure they were placed on the resident. Certified Nurse Aide #51 was assigned to Resident #304 on 03/30/2026 and 03/31/2026. During an interview on 04/02/2026 at 3:01 PM, Certified Nurse Aide #51 stated pressure relieving boots were an intervention to reduce the risk of pressure injuries. Resident #304 did have pressure relieving boots and did not refuse care. They stated they put the resident back to bed on 03/30/2026 and 03/31/2026 but did not remember if they placed the boots on the resident. During an interview on 04/03/2026 at 11:29 AM, Assistant Director of Nursing #5 stated pressure relieving boots were an intervention utilized to reduce the risk of developing pressure injuries. If pressure relieving boots were ordered, were on the resident's care plan, or on the certified nurse aide care instructions, they expected the boots to be placed on the resident when they were in bed. 10 New York Codes, Rules, and Regulations 415.12(c)(1)

Based on observations, interviews, and record review the facility failed to ensure the interdisciplinary team determined a resident's ability to safely administer their own medications, if clinically appropriate, for one (1) of one (1) resident (Resident #299) reviewed. Specifically, Resident #299 had a large bottle of acetaminophen (pain reliever), a tube of Neosporin (antibiotic ointment), a bottle of antacids, loperamide gel capsule (antidiarrhea medication), and a medication cup with several different pills in their room. There was no documented evidence of assessments and/or physician orders for the resident to safely self-administer medications. Findings included:The facility policy Medication Administration, revised 10/2025, documented nurses were to remain with the resident until medications were swallowed. They were not to leave medication with the resident to be taken later unless it was ordered by medical and care planned. The facility policy Self-Administration of Medication Program, last reviewed 12/2025, documented if a resident requested to self-administer medications an assessment would be completed and reviewed by the interdisciplinary team. The interdisciplinary team determines if self-administration was clinically appropriate for the resident and would document it in the medical record and on the resident's care plan. A physician's order was needed prior to the initiation of a self-administration program specifying the specific medications the resident was to be self-administrating. The interdisciplinary team will re-evaluate the self-administration program on a quarterly basis, with any significant changes and as needed to ensure it is clinically appropriate. Resident #299 had diagnoses including dementia, left sided weakness following a stroke, and anxiety. The 01/03/2026 Minimum Data Set documented the resident had intact cognition and required set up or was independent for most activities of daily living. There was no documented evidence of a comprehensive care plan related to self-administration or storage of medication in their room. There was no documented evidence of a medication self-administration assessment or a physician order for self-medication. The resident was observed on:- 03/30/2026 at 11:10 AM sitting in their rocking recliner in their room watching television. There was a tube of Neosporin with their name and a bottle of antacid on the overbed table and a large bottle of acetaminophen on their nightstand.- 03/31/2026 at 2:19 PM asleep in their recliner chair. There was a bottle of antacid on their over bed table next and a large bottle of acetaminophen on their nightstand. During an observation and interview on 04/01/2026 at 9:07 AM, the resident was sitting in the recliner chair. There was a bottle of acetaminophen on their nightstand. There was a bottle of antacid, a small blue gel pill (loperamide) sealed in cut up packaging, and a medicine cup with several unidentified pills on their overbed table. The medicine cup contained two (2) small white pills, one (1) oblong tan pill, one (1) large oblong white pill, one (1) yellow gel pill, one (1) light orange round pill, one (1) pink smaller oblong pill, one (1) half white pill, and one (1) small round pill. The resident stated there should be about nine (9) pills in the medicine cup which included a blood thinner and a seizure pill. The resident stated they believed the small blue pill in the packaging was loperamide their adult child brought to them, but they were not sure. They stated they took the antacids if their stomach was bothering them or if they had heartburn. They had sneaked the acetaminophen in, but they did not take it very often, only when they had headaches. The medication cup was left by the nurse that morning because they did not like to take the medications on an empty stomach, so they waited to take them until they had a few bites to eat. During an interview on 04/01/2026 at 9:22 AM, Licensed Practical Nurse #49 stated they only occasionally left medications with two residents. Resident #299 did not have an order for their medications to be left at bedside but when they sat with the resident waiting for them to take the medications, the resident would not take them, so they left the medications in the room. They stated the resident did well with taking their medications after they had a little bit of food, as taking them on an empty stomach made the resident sick, so they left the resident with the medications so they could eat first. They were unaware of the bottle of antacids, acetaminophen, and loperamide gel capsule in the resident's room. They stated the resident had an order for acetaminophen three times a day so they should not need more. The resident did not have an order for loperamide. They stated the resident's family probably brought the medications in for them. During an interview on 04/03/2026 at 2:00 PM, Registered Nurse Neighborhood Manager #50 stated medications should not be left at a resident's bedside unless they were care planned that way. The nurse should watch the resident to make sure the medication was administered. The nurse should not leave medications at the resident's bedside even if the resident was taking a lot of time to take their medications. Resident #299 was not assessed for a medication self-administration program. The resident should not have personal over the counter or nurse administered medications at their bedside. 10 New York Codes, Rules and Regulations 415.23(f)(1)(vi)

Based on observations, record review, and interviews, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of their quality of life for three (3) of three (3) residents (Residents #30, #190, and #288) reviewed. Specifically, staff stood over Residents #30, #190, and #288 while assisting them with feeding.Findings include:The facility policy Resident Dignity, revised 09/2025, documented the facility ensured all residents were treated with dignity and provided residents with a dignified dining experience. 1) Resident #30 had diagnoses including Alzheimer disease and dysphagia (difficulty swallowing). The 12/31/2025 Minimum Data Set (a resident assessment tool) documented the resident had severely impaired cognition, required substantial/ maximum assistance with eating, and received a mechanically altered diet. The Comprehensive Care Plan, initiated 08/13/2024 and revised 03/31/2026, documented the resident required substantial/ maximum assistance with eating.The 01/15/2025 physician order documented the resident was on a regular puree diet with thin liquids.During an observation on 04/01/2026 at 8:09 AM Resident #30 was seated at a table for the breakfast meal. Certified Nurse Aide #23 was standing while assisting Resident #30 with their meal. 2) Resident #190 had diagnoses of Alzheimer's disease and dysphagia (difficulty swallowing). The 02/26/2026 Minimum Data Set (a resident assessment tool) documented the resident had severely impaired cognition, was dependent with eating, and received a mechanically altered diet.The 01/23/2026 physician order documented the resident was on a puree diet with nectar consistency liquids.The Comprehensive Care Plan, initiated 09/24/2025 and revised 02/25/2026, documented the resident was dependent with eating.During an observation on 04/01/2026 at 8:09 AM Resident #109 was seated at a table for the breakfast meal. Certified Nurse Aide #23 was standing while assisting Resident #109 with their meal. 3) Resident #288 had diagnoses of Alzheimer's disease and dysphagia (difficulty swallowing). The 02/16/2026 Minimum Data Set (a resident assessment tool) documented the resident had severely impaired cognition, was dependent with eating, and received a mechanically altered diet.The 03/30/2026 physician order documented a regular puree thin liquid diet.The Comprehensive Care Plan, initiated 06/25/2025 and revised 03/25/2026, documented the resident was dependent with eating.During a meal observation on 03/30/2026 at 12:22 PM, Resident #288 was seated at a table for the lunch meal. Certified Nurse Aide #25 was standing while assisting Resident #288 with their meal. During a meal observation on 04/01/2026 at 8:09 AM, Resident #288 was seated at a table for the breakfast meal. Certified Nurse Aide #23 was standing while assisting Resident #288 with their meal. During an interview on 04/01/2026 at 02:22 PM, Certified Nurse Aide #23 stated they assisted residents at meals and was trained to offer bites of food and alternate with sips of liquids. They were supposed to be seated at eye level when assisting residents at meals for dignity reasons. The facility had enough chairs to be seated during meals, but the unit had several residents who needed assistance at meals, so they stood while assisting all the residents during the meal. They stated it was not dignified to stand while assisting the residents with their meals. During an interview on 04/01/2026 at 2:31 PM Licensed Practical Nurse #24 stated staff should be seated while assisting residents with meals.During an interview on 04/06/2026 at 10:04 AM Registered Nurse Neighborhood Manager #12 stated staff should be seated when assisting the residents at meals. Standing while assisting residents with their meals was not dignified.10 New York Codes, Rules and Regulations 415.23(c)(1)(i)

Based on observations, record review, and interviews conducted during the abbreviated (iQIES incident #2607732) survey, the facility failed to ensure residents received adequate supervision to prevent accidents for two (2) of five (5,) residents (Residents #1 and #3) reviewed for accidents. Specifically, Resident #1 was at risk for elopement and exited the facility undetected on 09/03/2025 and 10/25/2025; and Resident #3 left the facility grounds on 07/25/2025, undetected, on their motorized scooter and was found two (2) hours later at a fast-food restaurant approximately four (4) miles away. This resulted in Immediate Jeopardy and Substandard Quality of Care to Resident #1 and #3 and placed all 59 residents with exit-seeking behaviors at risk for serious harm, serious injury, serious impairment, or death. The facility policy Elopement Risk Screen, revised 07/2011, documented staff would monitor a resident's whereabouts to ensure they remained within the facility. In the event of an elopement or elopement attempt, staff notified the Nurse Manager or supervisor. The policy did not include procedures for disarming the sounding alarm.The facility policy Missing Resident: Code Yellow, revised 12/2015, documented when a resident was missing from the unit, the unit staff members were to immediately notify the supervisor, alert the receptionist, and a formal announcement (overhead) was made. All unit staff initiated a search of all areas on the unit and report the results to the receptionist. Ancillary staff and one (1) staff member from each unit conducted a search of other assigned areas within the facility. 1) Resident #1 had diagnoses including Alzheimer's dementia, repeated falls, and difficulty walking. The 06/19/2025 Minimum Data Set (a resident assessment tool) documented the resident had severely impaired cognition, did not exhibit wandering behavior, required supervision for walking, received daily antipsychotic and antidepressant medications, and used a wander detection device.The 09/30/2024 admission Elopement Screen documented the resident's scored a 16 out of 28. A score greater than 10 indicated an elopement risk. The Comprehensive Care Plan initiated 10/12/2024 documented the resident was at elopement risk as per Elopement Risk Data Collection. Interventions included: complete elopement risk screen; gather history of wandering/elopement attempts; observe and identify behavior/patterns of mobility such as pacing, searching, etc.; wander detection device to right ankle, check three (3) times a day on day, evening, and night shifts. On 02/06/2025 at 11:00 AM, the resident was found on the second step on the stairwell after the alarm sounded. A stop sign was added to the stairwell door as well as a red barrier gate, and the wander alert device range was extended. On 04/10/2025, the resident surpassed the wander alert alarm and was found at the bottom of the stairwell. On 06/01/2025, the resident's wander alert device was alarming in the stairwell. A certified nurse aide found the resident at the bottom of the stairwell trying to push on the door to go into the hallway near the lobby. Approaches included continue interventions. On 06/08/2025, the resident was found on the first-floor landing in the stairwell with their wander alert device alarming. Approaches included continue interventions. On 06/28/2025, the stairwell was alarming, and the resident was not seen in the stairwell. The resident was found in the front lobby. Interventions included continue with wander alert device, stop signs, and consider room move. The 09/2025 Medication Administration Record documented 15-minute checks for frequent falls with a start date of 01/03/2025. The 15-minutes checks were documented as completed on 09/03/2025 during the 3:00 PM-11:00 PM shift by Licensed Practical Nurse #4. There was no documented evidence of actual times when 15-minute checks were completed. The 09/03/2025 at 4:50 PM progress note by Licensed Practical Nurse #7, documented the resident was wandering on and off the unit constantly, was redirected with short term effect, 15-minute checks were done, and staff were to continue to monitor the resident.The 09/03/2025 incident report completed by Registered Nurse Supervisor #3, documented Resident #1 eloped on the evening shift and was found outside. Registered Nurse Supervisor #3 was called to the resident's unit at 7:33 PM, as the resident had been found outside by security. The resident went down the back stairwell and out the exit door making their way to the grounds fence near a main road. Registered Nurse Supervisor #3 and Licensed Practical Nurse #4 went outside to get the resident. The resident was wearing a wander detection device, and the alarms sounded. The investigation determined the apparent timeline was the resident pushed the unit stairwell door open at 6:55 PM, exited an outside stairwell door sometime between 6:55 PM and 7:05 PM, a visitor went to the front desk at 7:13 PM and stated there was a [person] standing against the fence near the road. Security was called and found the resident on the corner of the facility property. Unit staff were notified to come get the resident, while security monitored the resident. Staff arrived at 7:22 PM with a wheelchair and brought Resident #1 back into the facility. The resident was assessed by Registered Nurse Supervisor #3 and there were no injuries. The resident had a nightgown and socks on, the outside temperature was about 70 degrees Fahrenheit. The Medical Director and family were notified. An elopement risk screen was completed, and a team meeting was needed to review the incident and plan of care. -The 09/03/2025 Certified Nurse Aide #5 witness statement documented they heard an alarm sounding about 7:05 PM after completing care on another resident. They went to check the exterior stairwell door, which was open, peeped outside, and did not see anyone. They shut the door and went back inside.-The 09/03/2025 Certified Nurse Aide #6 witness statement documented they were providing care to another resident at the time of the incident. The resident was found outside wearing a nightgown and socks. The wander detection device was on the resident and functioning.-The 09/03/2025 Licensed Practical Nurse #4 witness statement documented the resident was last seen at 7:00 PM on the unit. The resident was found by the fence near the road in front of the facility. The resident had socks and a wander detection device on.-The 09/03/2025 Certified Nurse Aide #7 witness statement documented they and another aide (unidentified) were putting a resident who required assistance of two (2) to bed when the other aide opened the room door. The unit stairwell exit door was sounding and the other aide went to see who left the unit. Certified Nurse Aide #7 continued to provide care to the resident they were with and assisted with looking for the resident who sounded the alarm when the care was done.The 09/03/2025 Wander Detection Device Activity Report documented Resident #1's wander alert device set off the unit exterior stairwell door alarm at 6:47 PM and was cleared at 6:50 PM. The unit elevator alarm sounded for Resident #1 at 7:30 PM and was cleared at 7:31 PM.The 09/03/2025 updated comprehensive care plan documented the resident was found outside at 7:13 PM. There were no documented additional interventions put in place after the incident.The 09/03/2025 Elopement Risk Screen completed by Registered Nurse Supervisor #3 documented there was a new attempt to elope, or exit seek. The resident wandered aimlessly, had made one (1) or more attempts, and was a high elopement risk.During an observation on 10/20/2025 at 9:52 AM, Resident #1 was sitting in the unit dining room area. The resident frequently stood from their wheelchair and attempted to ambulate. The unit stairwell door at the end of the hallway had an orange foldable barrier and a stop sign banner across the doorway. The doorway had a keypad on the left side wall. At 9:56 AM, Resident #1 pushed on the hallway double doors separating the unit from an adjacent unit. The double doorway alarm sounded throughout the unit. Unit staff intervened and redirected the resident back onto the unit.During an observation on 10/20/2025 at 4:35 PM, Receptionist #14 showed the surveyor the computer screen at the desk and explained how the wander detection device displayed a banner if a door alarm sounded. The banner displayed which door was alarming and the resident's name.The 10/25/2025 incident report completed by Registered Nurse Supervisor #24 documented Resident #1 eloped from the facility at 4:24 PM. The resident exited the unit via a stairwell, down a flight of stairs, and went out the exit door heading towards the parking lot. The resident was wearing a wander detection device. The stairwell door alarmed when the resident pushed the door at 4:22 PM. Certified Nurse Aides #20 and #21 were providing care to another resident in their room. As soon as the certified nurse aides made sure that resident was safe, they immediately responded to the alarming door, and checked the stairwell. Certified Nurse Aide #22 heard the exterior door alarming, went through the stairwell door, and did not see a resident. Certified Nurse Aides #23 and #25 were returning from a break and saw Resident #1 on the ground between the exit door and the parking lot. They immediately responded and notified the Registered Nurse Supervisor. Security was notified by the receptionist about the alarming door, and they responded at 4:28 PM. The resident sustained abrasions to their palms and knees.The 10/25/2025 at 6:20 PM New York State incident report submitted by the Director of Nursing documented the facility's immediate response to the elopement was to provide 1:1 supervision for the resident every shift throughout the weekend. A team meeting would be held on 10/27/2025 to discuss further interventions and evaluate the 1:1 status. A 10/25/2025 at 11:02 PM, Registered Nurse Supervisor #4 progress note documented at 4:25 PM, Resident #1 was found outside in the parking lot. They arrived at the scene immediately and assessed the resident. The resident was brought back to the unit in a wheelchair. The resident was placed on 1:1 related to high fall and elopement risk. The resident was already on frequent checks. The Comprehensive Care Plan revised 10/26/2025 documented the resident eloped on 10/25/2025 and interventions included frequent 15-minute checks. There was no documented evidence the resident was placed on 1:1 supervision as planned. During an observation on 10/28/2025 at 8:45 AM, Resident #1 was sitting at a table in the unit dining room with an aide who stated they were providing 1:1 supervision to the resident. The orange barrier and stop sign remained across the unit stairwell doorway. There were three (3) certified nurse aides and a nurse on the unit.During an interview on 10/20/2025 at 1:07 PM, Licensed Practical Nurse #4 stated Resident #1 had exit seeking behaviors in the past. On 09/03/2025 at about 7:00 PM, Resident #1 was sitting in the unit dining room. Licensed Practical Nurse #4 stated they were on another unit helping a staff member when Certified Nurse Aide #19 called and said they could not find Resident #1. They told the aide to do a unit search, and the aide called them back and told them the resident was not found. They told the aide to check the stairwells and was told the stairwell alarm was sounding but there was no one in the stairwell. Licensed Practical Nurse #4 stated they called other units and the receptionist to find out if a resident set off the alarm. The receptionist informed them Resident #1 was found outside. They and Certified Nurse Aide #19 went outside to get the resident, who was found near a property fence by the main road and was brought into the building. Registered Nurse Supervisor #3 was called and assessed the resident. The resident had a wander detection device on and had no injuries. They stated normal staffing was one (1) aide dedicated to the unit, one (1) aide that was split between two (2) units, and a nurse who was assigned two (2) to three (3) units. Door alarms were supposed to sound at the reception desk. They stated no one other than unit staff made them aware the alarms had sounded or that the resident was missing.During an interview on 10/20/2025 at 2:58 PM, Certified Nurse Aide #6 stated they worked a split assignment (worked on two (2) different units) on 09/03/2025. They and Certified Nurse Aide #19 were transferring another resident using a mechanical lift and the room door was closed. They did not hear the stairwell door alarming until they opened the door. They asked Certified Nurse Aide #19 what that sound was, and Certified Nurse Aide #19 told them to turn off the alarm. They turned the alarm off, took accountability of the unit's residents, and informed certified Nurse Aide #19 that Resident #1 was not found. Certified Nurse Aide #6 stated they took the elevator to the unit one (1) floor below and Certified Nurse Aide #19 went down the stairwell. They returned to the unit and Certified Nurse Aide #19 continued to look for the resident. They stated when Resident #1 was not found, they informed Licensed Practical Nurse #4 and the nursing supervisor. During an interview on 10/20/2025 at 3:18 PM, Certified Nurse Aide #19 stated Resident #1 ambulated quickly and frequently went toward the stairwells. Each stairwell and exit door had a 15-second egress for fire safety reasons. This meant once the open bar was held for 15-seconds, the door automatically released and can be opened. On 09/03/2025, Resident #1 was sitting at a unit dining room table when both they and Certified Nurse Aide #6 went into another resident's room to transfer them to bed with a mechanical lift. When they opened the room door, they heard a stairwell door alarming. They stated they told Certified Nurse Aide #6 to check the door and Certified Nurse Aide #6 asked what the alarm code was; they did not tell Certified Nurse Aide #6 to turn the alarm off. Certified Nurse Aide #6 went down the stairwell to the unit below, came back to the unit, and told them Resident #1 was not downstairs. Certified Nurse Aide #19 then went downstairs and was told by unit staff they had not seen the resident. They returned to their unit and told Licensed Practical Nurse #4 the resident was missing. There were no alarms sounding during that time frame, so they did not think to look outside. The unit was searched, and the resident was not located. Licensed Practical Nurse #4 told Certified Nurse Aide #19 that Resident #1 was found outside. They stated the resident was gone from the unit for about 15 minutes.During an interview on 10/20/2025 at 3:44 PM, Registered Nurse Supervisor #3 stated they were on duty 09/03/2025 when Resident #1 eloped. Unit staff turned the door alarms off, which stopped the alarm at the reception desk. Staff should have notified them when it was determined the resident was missing. They were not notified until the resident was brought back to the unit. During an interview on 10/20/2025 at 4:35 PM, Receptionist #14 stated when a resident set off a stairwell or exit door, a banner showed on the computer screen at the reception desk. The banner included what door was sounding and the resident near it, if they were wearing a wander detection device. If staff shut the door alarm off, the banner stopped showing at the reception desk. The receptionist was unable to go back to see what alarm was sounding once the alarm was shut off. Not all doors in the facility had cameras. During an interview on 10/21/2025 at 11:18 AM, Certified Nurse Aide #5 stated exterior door alarms were much louder than interior stairwell door alarms. On 09/03/2025, they heard the stairwell exit door sounding at about 7:05 PM, went to look, saw the exterior door open and the alarm sounding, looked around outside the exit door while standing holding the door open, and did not see any residents. They then closed the exterior door, silenced the alarm, and went back to their unit as they were the only staff on that unit at the time. A certified nurse aide from the upstairs unit asked if they saw Resident #1, they told them no, and the certified nurse aide immediately left the area before they could tell them to call the supervisor. Certified Nurse Aide #5 stated they did not inform the supervisor, as they thought staff had already done so.During an interview on 10/24/2025 at 10:02 AM, the Director of Nursing stated if a door alarm sounded, the receptionist received a message on their computer screen letting them know which door it was, and which resident set it off. Security also received a message on their phone. Security was to check on the situation and the receptionist was to call and inform the nearest unit. The alarms were loud enough to be heard throughout the unit. Unit staff were to immediately respond to the alarm and look in the stairwell. If it was an exit door, they were to check the area within visual distance from just outside the doorway. The alarms should be turned off when beginning the search near the area of the door. Staff should have another staff member monitor the unit if a resident's care was to take over 10 minutes. Resident #1's unit staff did not do so both times Resident #1 eloped. The staff responded appropriately to the alarms on 09/03/2025, but when they found the exit door ajar, they should have expanded the outside search further and they did not immediately notify the supervisor.During an interview on 10/24/2025 at 11:03 AM, the Administrator stated expectations of staff when a door alarm was sounding was to respond to the alarm, check the area such as the stairwell up and down, check the immediate area if an exterior door was alarming, and account for all unit residents. If a resident was not on the unit, they were considered a missing resident. They were then to call the receptionist. The receptionist was to notify the supervisor, and a code yellow was called. All exterior doors alarmed to the receptionist's computer and security, and security checked areas outside the alarming door. Alarms should not be turned off based on the situation. The receptionist's computer displayed what door was alarming and the resident's name if they wore a wander detection device. If staff were providing care when the alarm sounded, they should ensure the safety of that resident and then respond to the alarm. If staff were to be providing care for a significant amount of time, they were to ensure there was another staff member monitoring the unit until they were done. The Administrator stated a significant amount of time varied based on the needed care. Staff responded appropriately to the alarm on 09/03/2025 when Resident #1 eloped from the facility building. Staff were taking accountability of the unit when the visitor reported the missing resident outside. No harm came to the resident.During an interview on 10/24/2025 at 3:02 PM, Registered Nurse Unit Manager #17 stated Resident #1 was a high risk for elopement and had a wander detection device in place both times they eloped from the building. They expected staff to respond to a door alarm by running to the door and checking the stairwell prior to silencing an alarm. They should check the area first, clear the stairwell or exit door prior to turning off the alarm, do a unit resident accountability, notify the supervisor if the resident was not found on the unit, and immediately expand the search if the resident was not found. If they found the alarming door ajar, they should look in all directions and immediately notify the supervisor and security. If staff were occupied performing care for resident, they should notify the unit nurse so the unit could be monitored. They stated staff should have immediately notified the supervisor and not have turned off the door alarms until they were told to do so.During an interview on 10/27/2025 at 4:13 PM, Certified Nurse Aide #20 stated they worked on Resident #1's unit on 10/25/2025. They and Certified Nurse Aide #21 were assisting another resident to bed via mechanical lift with the room door closed. Resident #1 entered the room and was directed to leave for resident privacy. While transferring the resident, they heard the unit stairwell door alarming. Certified Nurse Aide #21 stated once the resident was safe, they left the room to investigate. The alarm was still sounding when they left the room. The unit phone was ringing when staff were responding to the alarm. The unit nurse was on another unit when the event occurred. Shortly after they left the room, Certified Nurse Aide #21 returned to the unit with Resident #1. Resident #1 was not on 1:1 monitoring at the time of the incident but did have a wander detection device.During an interview on 10/27/2025 at 4:32 PM, Certified Nurse Aide #22 stated they heard a door alarming sounding on 10/25/2025, looked out the hallway window and exit door and did not see a resident. As they were going to the unit phone, it rang, and the receptionist informed them Resident #1 had sounded the door alarm. They stated they went out the exit door and saw the resident sitting on the grassy area near the closest parking lot to the building. When they reached the resident, Certified Nurse Aide #23 was coming out the front lobby doors towards them, along with another aide and security.During an interview on 10/28/2025 at 12:05 PM, the Medical Director stated Resident #1 had severely impaired cognition, and there were concerns about staff response and supervisor notification with the 09/03/2025 incident. The system worked well when the resident got out of the building on 10/25/2025, but the resident still got out of the building. The resident only sustained some minor abrasions on 10/25/2025 but otherwise there was no harm. 2) Resident #3 had diagnoses including repeated falls, polyneuropathy (damaged nerves in the hands or feet), diabetes, congestive heart failure, poor circulation in the extremities, and chronic kidney disease. The 06/23/2025 quarterly Minimum Data Set documented the resident had severely impaired cognition, utilized a walker or wheelchair, required supervision with transfers and walking 10 to 50 feet, used a motorized wheelchair/scooter independently at least 150 feet, was always incontinent of urine, and received anticoagulant (blood thinner), diuretic (water pill), and hypoglycemic (diabetic) medications daily.The 06/28/2024 Occupational Therapist #46 progress note documented the resident received a new motorized scooter, was trained on its use, and was able to independently utilize it.The 01/02/2025 Comprehensive Care Plan documented the resident was independent with motorized scooter use throughout the facility and on the campus. There was no documented evidence of a plan to account for the resident's whereabouts when they left the building in their motorized scooter. The 03/27/2025 and 06/20/2025 Resident #3 elopement risk screens documented the resident was a low risk for elopement.The 07/25/2025 incident report completed by Registered Nurse #11 documented at 7:30 PM, Resident #3's family called the facility and notified them the resident had wandered via motorized scooter to a [fast food restaurant] about four (4) miles from the facility and they would return the resident to the facility. The resident arrived back at the facility at approximately 9:00 PM. The resident had no injuries. The resident stated they were just riding around and was going to return to the facility. The resident stated they believed the battery on their scooter was dying so they went to the fast-food restaurant and someone at the restaurant called the police who then called their daughter. The Certified Nurse Aide #27 witness statement documented the resident was last seen eating supper at a unit dining room table (no time documented). The Licensed Practical Nurse #10 witness statement documented the resident normally rode the scooter around the facility building and campus, returned to the unit when ready, and there were no restrictions in place. The resident was last seen at 5:00 PM in the unit dining room. The resident did not have a wander detection device at the time of the incident.During an observation on 10/24/2025 at 9:30 AM, Resident #3 was sitting in their room in a manual wheelchair. There was a red motorized scooter near the foot of their bed plugged into the wall charging. During an interview on 10/24/2025 at 1:55 PM, Registered Nurse Manager #16 stated unit managers were responsible for completing elopement risk screens quarterly, annually, and as needed. Therapy performed the motorized scooter assessments and training. Any resident allowed a motorized scooter also had to sign a contract with the rules of use. Resident #3 understood the rules of their scooter use and was expected to let staff know when they left the unit and where they were going. Registered Nurse Manager #16 did not know what the staff monitoring expectations were when the resident was off the unit. The facility was responsible for resident well-being and safety at all times. Unit staff were expected to check scooter battery levels prior to the resident leaving the unit. The resident had never made attempts or voiced they were going to leave the facility property in the past. The facility grounds were about 400 acres with ponds and wildlife. Any resident that was cleared for scooter use should have it included it in their care plan. During an interview on 10/24/2025 at 10:02 AM, the Director of Nursing stated Resident #3 had a cognition level of moderate impairment but when talking to them, the resident was more alert and oriented than scored. The resident was assessed and trained for independent motorized scooter use throughout the building and on facility grounds. The resident exercised that independence without concern prior to the 07/25/2025 incident and always carried a cell phone with them. The facility had no specific monitoring plan for independent residents throughout the grounds. The facility determined incident reporting by using the New York State Department of Health Incident Reporting Guidelines manual. The resident was low risk for elopement, knew where they were going, and had intentions of returning to the building and therefore, the facility determined it was not elopement. The resident did not tell any staff member they were going to leave facility grounds. During an interview on 10/24/2025 at 11:03 AM, the Administrator stated Resident #3 was assessed to be independent on facility grounds with a motorized scooter for primary means of mobility. There were no set monitoring timeframes as the resident never expressed a desire to leave the grounds and always returned to the unit within an appropriate period. The resident usually carried a cell phone, and informed staff when they were leaving the unit and where they were going. The facility used the New York State Department of Health Incident Reporting Guidelines manual to determine if an incident needed to be reported. The resident was not a risk for elopement, was cognizant to make their own decisions, and had the intent to return to the facility. The facility decided they did not elope as the resident did not meet that criteria. The resident did not follow the policy for being out-on-pass as Resident #3 decided to leave facility grounds spontaneously. The resident was assessed upon return and sustained no harm.During an interview on 10/28/2025 at 12:05 PM, the Medical Director stated Resident #3 had mild to moderate cognitive deficits but was functional and safe to make their own decisions. They felt the resident was not unsafe to be independent in their motorized scooter on facility grounds. The resident had a higher potential for harm leaving the facility grounds. The facility had no indication the resident would decide to do so. The resident carried a cell phone with them. They stated no harm had come to the resident when they were off facility grounds. During an interview on 10/28/2025 at 12:57 PM, Resident #3 stated they did not remember notifying staff that they were going outside on 07/25/2025, did not have to sign out, and did not remember what made them go off-campus. The resident stated they thought they were still on facility grounds, realized they were not, and went into the fast-food restaurant for directions to return to the facility.During an interview on 10/28/2025 at 1:00 PM, Certified Nurse Aide #27 stated they were working the unit on 07/25/2025 when Resident #3 left facility grounds. The resident did not have to notify staff or sign off the unit at the time, as they were independent with their motorized scooter mobility on facility grounds. The resident left the unit many times in the past without issues. They stated they were made aware the resident left grounds when staff received a call the resident was found off campus. The resident told them when they returned, they just went out for a ride.10 NYCRR 415.12(h)(1)(2)An Immediate Jeopardy in F-689 was issued to the Administrator and Corporate Administrator on 10/28/2025 at 3:45 PM. The facility performed the following steps to lift the Immediate Jeopardy in F-689, issued 10/28/2025 at 3:45 PM:- As of 10/28/2025 at 8:44 PM the facility's immediate plan was reviewed and accepted.-As of 10/30/2025 at 12:50 PM, 85% of staff had been educated on elopement risk and wander detection device door alarm response. The remaining staff will be educated prior to the start of their next shift or upon return from their leave.-Staff education was verified onsite during interviews on 10/30/2025. Multiple staff including nursing, maintenance, housekeeping, and activities were interviewed. -Staff were able to report content of education, confirmed the day they received the education, and the facility staff who presented the education

Based on record review and interviews during the recertification survey conducted 5/13/2024 -5/17/2024, the facility did not ensure they had a process in place for residents to have their grievances addressed appropriately for 6 of 8 anonymous residents. Specifically, 6 anonymous residents present at the Resident Council meeting stated they did not know how to file a grievance. Additionally, the facility did not have a process for residents to file a grievance anonymously. Findings include: The facility policy Resident Grievances, dated 11/2016, documented every resident of the facility and/or their resident representative had the right to voice grievances to the facility without fear of reprisal or discrimination. Grievances included those with respect to care and treatment which had been provided as well as those which had not been provided, the behavior of staff and of other residents, and other concerns regarding their stay at the facility. The facility would make prompt efforts to resolve a grievance. All complaints and/or grievances presented by a resident and/or the resident representative would be forwarded to the Director of Social Services as the designated Grievance Official and documented on the Resident Grievance Form. The form would be completed by the staff involved in the grievance which included the resolution. The facility policy did not state how residents were informed of their right to file a grievance or how to do so anonymously. The grievance log for year 2024 documented one grievance in total for the facility. On 5/14/2024 at 10:44 AM the grievance policy was observed in the front lobby inside a locking glass wall case in the upper right top corner which was above head height when standing. During a Resident Council Meeting on 5/13/2024 at 3:33 PM, 6 anonymous residents stated they did not know how to file a grievance. They had verbalized concerns to the social workers in the facility regarding whether their unit had a process to file a grievance. 2 anonymous residents stated they did not hear back about a resolution to their concerns or questions. During an interview on 5/16/2024 at 10:39 AM, the Social Services Director stated they did not have too many formal complaints in the facility. Formal complaints were considered grievances, so many concerns did not always come directly to them. Grievances or concerns were a team approach. If a grievance was received, the Administrator reviewed the grievance which then got distributed to the appropriate parties. The social services department was responsible for interviewing alert and oriented residents residing on the households. They were unaware of how residents were educated on the grievance process. If there was a concern, they informed the resident and/or resident's family the process of a grievance investigation. Nursing was responsible for any action in regards to concerns with the nursing staff, and did not always know the outcome. A concern did not always rise to the level of a grievance; it would still be investigated but not documented on a formal grievance form. If a resident wanted to file an anonymous grievance, they could call the Department of Health. Any staff member could provide that number to a resident. They were not aware of any internal process to file an anonymous grievance. During an interview on 5/17/2024 at 9:27 AM, Licensed Practical Nurse #13 stated they were unsure of the process for residents to file a grievance but knew there was a form that would be filled out. They thought residents had to speak with the Ombudsman as part of the process of filing a grievance. During an interview on 5/17/2024 at 9:30 AM, Certified Nurse Aide #12 stated they were unsure of how a resident filed a grievance. They thought residents would have to speak to the nurse manager or the social worker. During an interview on 5/17/2024 at 9:32 AM, the Administrator stated they had two different processes for addressing resident grievances in the facility. The first process was for formal written grievances, which were addressed with a letter provided to the complainant stating the outcome. The second process was for family and resident concerns, such as a family member wanting a resident to attend more activities, which did not rise to the level of a grievance. They had never had a resident file an anonymous grievance. If a resident had an anonymous grievance they wanted to file, they were encouraged, during resident council meetings, to call the Ombudsman. They would have to check with the admissions department to see if the right to file grievances was addressed in the admission packet. If it was not addressed in the admission packet, they would have to check with the social workers to see if it was reviewed during the admission meeting. 10NYCRR 415.3(C)(1)(ii)

Based on observation and interview during the recertification surveys conducted 5/13/2024-5/17/2024 the facility did not ensure an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment was established and maintained to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #15) reviewed. Specifically, Resident #15 had a urinary catheter bag resting on the floor without a barrier for multiple days of survey. Findings include: The undated facility policy Catheter Care - Nurses Aides Role documented the external catheter tube needed to be kept as clean as possible. The drainage bag should never touch the floor. Resident #15 had diagnoses including urinary retention and a history of urinary tract infections. The 4/27/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, was dependent with toilet hygiene, was dependent with transfers, and had an indwelling urinary catheter (a tube inserted into the bladder to collect urine). The 11/8/2023 updated comprehensive care plan documented the resident had a suprapubic urinary catheter (a type of urinary catheter surgically inserted through the skin to the bladder), needed assistance with daily care, was non-ambulatory, and was on long-term antibiotics for urinary tract infection prevention. Interventions included keep the drainage system below bladder level, monitor for symptoms of urinary tract infection, maintain cleanliness and dressing around catheter site, two staff assist with mechanical lift transfers, ensure the drainage bag was emptied at the end of every shift, and provide toileting assistance after meals and as needed. Resident #15 had the following physician orders: - 8/1/22: change catheter drainage bag every 2 weeks and as needed, and catheter care every shift and as needed. - 3/23/23: 16-French (size) with 10 milliliter balloon suprapubic catheter. - 4/26/23: enhanced barrier precautions due to indwelling urinary catheter. - 12/17/23: cleanse suprapubic catheter site with normal saline, apply antibiotic ointment and cover with a 2 x 2 gauze and border dressing; and, - 3/7/24: registered nurse only to change the suprapubic catheter every 6 weeks. When interviewed on 5/13/24 at 11:03 AM, Resident #15 stated the suprapubic catheter caused a burning feeling around the site. The site was covered with a dry 4 x 4 gauze dressing. There were mucous shreds observed in the catheter tubing. The drainage bag was hanging from the door side of the recliner the resident was sitting in, the bag was uncovered, and the bottom of the drainage bag was resting on the bare floor. During follow-up observations at 11:54 AM and 1:30 PM, the resident continued sitting in the recliner and the bottom of the drainage bag remained on the bare floor. On 5/14/24 at 9:02 AM and 1:52 PM, Resident #15 was sitting in a recliner in their room. The catheter drainage bag was hanging from the door side of the recliner and the bottom of the bag was resting on the bare floor. There was no barrier between the catheter drainage bag and the floor. On 5/15/2024 at 9:31 AM and 1:13 PM, Resident #15 was sitting in a recliner in their room. The catheter drainage bag was hanging from the door side of the recliner and the bottom of the drainage bag was again resting on the floor without a barrier. When interviewed on 5/16/2024 at 10:45 AM, Certified Nurse Aide #6 stated catheter drainage bags were to be covered with a privacy bag for dignity, below bladder level, and should not touch the floor at any time to prevent infection. The drainage bags had a port on the bottom that staff cleansed with alcohol wipes to prevent infection prior to and after emptying the bag. Staff usually put a plastic container under the drainage bag in the event it leaked and used as a barrier from the floor. Staff hung the bag from the side of the recliner or bed, and the aide did not realize the bag was touching the floor. The aide stated it was an infection risk if the bottom of the bag rested on the bare floor as germs could travel from the port, into the bag, up the tube and into the body. When interviewed on 5/16/2024 at 11:13 AM, Licensed Practical Nurse #7 stated catheter drainage bags were supposed to hang in a privacy bag, not touching the floor, and below bladder level. The privacy bags were to prevent contamination and ensure dignity. The nurse was not sure if the privacy bags were permeable or non-permeable. The catheter tubing was not supposed to touch the floor for infection control purposes. The nurse noticed on 5/16/2024 that the bottom of the bag was resting on the floor, so they put the drainage bag in a privacy bag and set that in a plastic container. The resident had a history of urinary tract infections. Staff received infection control training yearly that included catheter care. If the bottom of the drainage bag was on the floor without a barrier, it was possible that germs from the floor could enter the bag and travel into the body causing an infection. When interviewed on 5/16/2024 at 3:15 PM, the Registered Nurse Infection Preventionist stated they had heard a resident did not have their catheter bag in a privacy bag, which was permeable. Catheter drainage bags were to hang from a non-moveable area, off the floor, and in a privacy bag. Infection control education was done yearly and included catheter care. The drainage bags were not supposed to touch the floor, as they could potentially leak. If they touched the floor, germs could enter from the opening, travel up the tube, and enter the body thereby causing an infection. All unit nursing staff should check drainage bag positioning when performing resident care. 10NYCRR 415.12(d)(1)

Based on record review and interviews during the recertification survey conducted 5/13/2024 - 5/17/2024 the facility did not ensure that residents were free of any significant medication errors for 1 of 1 residents (Resident #28) reviewed. Specifically, Resident #28 did not receive four consecutive doses of carbidopa - levodopa (brand name Rytary, used to treat Parkinson's Disease) on 5/11/2024 -5/12/2024 as physician ordered. Findings include: The 5/2024 revised Medication Administration policy documented if medication was not available at the time it was to be administered, the nurse was to notify the Nurse Manager/Supervisor. The Nurse Manager/Supervisor would explore alternative methods for obtaining medication such as the backup medication storage (Omnicell), contacting the pharmacy or contacting medical for an alternate medication. Resident #28 was admitted to the facility with diagnoses including Parkinson's Disease. The 4/10/2024 Minimum Data Set assessment documented the resident was cognitively intact, used a walker and wheelchair for mobility, and required partial to moderate assistance with upper and lower body dressing, personal hygiene, and ambulation. A 4/25/2024 physician order documented carbidopa - levodopa 23.75 milligrams - 95 milligrams capsule extended release; give two capsules by mouth three times daily at 8:00 AM, 1:00 PM and 6:00 PM. The May 2024 Medication Administration Record documented carbidopa - levodopa 23.75 milligrams - 95 milligrams was not administered due to being unavailable on: - 5/11/2024 at 6:00 PM. - 5/12/2024 at 8:00 AM. - 5/12/2024 at 1:00 PM. - 5/12/2024 at 6:00 PM. Interdisciplinary progress notes documented: - On 5/11/2024 at 10:23 PM by Licensed Practical Nurse #9: Carbidopa - levodopa 23.75 milligrams - 95 milligrams capsule extended release was out. Pharmacy called, awaiting delivery, supervisor aware. - On 5/11/2024 at 10:37 PM by Registered Nurse Supervisor #10: Resident missing last dose of carbidopa - levodopa 23.75 milligrams - 95 milligrams that evening. Pharmacy notified. Medication not provided on last run of pharmacy. - On 5/12/2024 at 1:52 PM by Registered Nurse Supervisor #11: Call placed to pharmacy because resident had still not received their carbidopa -levodopa 23.75 milligrams - 95 milligrams. Per pharmacy a new prescription was sent out and the medication would arrive on the next pharmacy run. There was no progress note by nursing documenting that medical was notified of the missed doses of carbidopa -levodopa 23.75 milligrams - 95 milligrams. During an interview on 5/14/2024, Licensed Practical Nurse #18 stated medications were reordered by the nurses as needed. Residents should not run out of medication; sometimes if a pill was dropped or wasted, they may run out of medicaton. If a medication was not available, pharmacy needed to be called. They would check and see if it was available in the backup medication storage (Omnicell), then notify the supervisor. The supervisor was supposed to communicate with medical for instructions. Parkinson's Disease medications were supposed to be given to prevent worsening of tremors, rigidity, and difficulty moving. During an interview on 5/14/2024 at 2:05 PM, Registered Nurse Unit Manager #3 stated medications were reordered by the nurses when they noticed them getting low. The medications came in 30-days at a time and pharmacy was supposed to automatically refill. If a nurse noticed a medication was low, they should reorder right on the Medication Administration Record. If a medication was unavailable, they needed to call the pharmacy to get the medication there as soon as possible. The medication carbidopa -levodopa 23.75 milligrams - 95 milligrams for Resident #28 was not available in the backup medication storage. If a resident was going to miss a dose, medical should have been notified. If that medication was missed for a dose or more than one dose, it could potentially worsen symptoms such as tremors or movement difficulty. Pharmacy sometimes made emergency medication runs. Medical should have been notified of Resident # 28 not receiving their carbidopa -levodopa 23.75 milligrams - 95 milligrams. Physician # 17 was on call, and they were not sure if they were notified. During an interview on 5/14/2024 at 2:40 PM, Physician #17 stated they were on call the weekend of 5/11/2024 - 5/12/2024. If a resident missed a medication, they should have been notified. They were not notified of Resident #28 missing doses of their Parkinson's Disease medication. Missing four doses consecutively of a medication for Parkinson's' Disease could have caused difficulty swallowing, movement difficulty, or increased tremors. It could have negatively affected the resident's quality of care and life. During an interview on 5/14/2024 at 2:47 PM, Registered Nurse Supervisor #11 stated they were the weekend supervisor 5/11/2024 - 5/12/2024. If a resident was missing medications, they would have checked the backup medication storage, then called pharmacy. Medical should be notified of any medications missed. They were notified the morning of 5/12/2024 that Resident #28 missed their medication for Parkinson's Disease for two doses. They called pharmacy and were notified that the dosage had changed, pharmacy fixed the error, and it would be delivered the evening of 5/12/2024. They did not notify medical. Medical should have been notified of the missed doses as they may had wanted to change orders or give further instructions. They were not aware of the effects the carbidopa - levodopa 23.75 milligrams - 95 milligrams was supposed to have on the resident. They believed it was facility policy to notify medical of missed medications. During an interview on 5/15/2024 at 9:18 AM, Licensed Practical Nurse #9 stated all nurses were responsible for making sure medications were available. Resident #28 had enough carbidopa -levodopa 23.75 milligrams - 95 milligrams for 2 doses on 5/11/2024. They notified the nursing supervisor and wrote a note. On 5/12/2024 at 6:00 PM there was still no carbidopa -levodopa 23.75 milligrams - 95 milligrams for Resident #28. There was a progress note that a supervisor had called pharmacy, but no physician recommendations were documented. The medication was for Parkinson's' Disease and helped decrease Resident #28's tremors. If they did not receive the medication as ordered, their tremors could worsen. Medical should have been notified of the missed medication. The 5/12/2024 6:00 PM dose was not given. The evening supervisor was aware and stated they would administer a one-time dose when it came in. There was no dose documented as being given on 5/12/2024 evening shift. 10 NYCRR 415.12(m)(2)

Based on observation, record review, and interview during the recertification survey conducted 5/13/2024 -5/17/2024, the facility did not ensure residents were assessed for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative, or obtain informed consent prior to the installation of bed rails for 1 of 1 residents (Resident #40) reviewed. Specifically, for Resident #40, there was no documented evidence of a bed rail assessment prior to bed rail installation, that the risks and benefits of bed rails were explained to the resident or their representative, or that consent was obtained prior to bed rail installation. Findings include: The undated facility policy Bed Rail Policy documented the facility would utilize approaches to identify and reduce safety risks and hazards commonly associated with bed rail use, including individual bed rail evaluations. Residents would be screened upon admission, readmission or change of condition. Prior to the installation of bed rails the following would be done: - The resident would be assessed for risk of entrapment from bed rails. Bed rails would not be used when a resident could not raise and lower them easily and would not be used for staff convenience or discipline. - If the Interdisciplinary Team had determined that bed rails were safe and appropriate for use, the risks and benefits of bed rail use would be reviewed with the resident and/or resident representative, and informed consent would be obtained and documented. - A physician order would be obtained for bed rail use, including the medical symptom contributing to the need. - Use of the bed rail would be indicated on the care plan. 1) Resident #40 had diagnoses including polyneuropathy (nerve damage impacting sensation and coordination), vascular dementia, and morbid obesity. The 4/25/2024 Minimum Data Set assessment documented the resident was cognitively intact, had functional limitation with range of motion with impairment of one arm, was dependent for rolling side to side, sit to lying, lying to sitting on edge of the bed, and transfers, and did not use bed rails. The 11/1/2021 admission bed rail assessment documented the rationale for potential use of bed rails and included the resident was non-ambulatory due to a left above-the-knee amputation and a right below-the-knee amputation. Assist rails on both sides of the upper bed were recommended to increase the resident's independence. There was no current, documented bed rail assessment for the use of half bed rails and no informed consent for use of half bed rails. The 5/13/2024 comprehensive care plan documented the resident was dependent of two-person hands-on assistance with rolling from left to right. Staff could use a slide sheet for repositioning. There was no documentation in the care plan for bed rail use. There were no physician orders for the use of bed rails. Resident #40 was observed: - On 5/13/2024 at 10:58 AM, in bed with half bed rails up on both sides of the bed. - On 5/14/2024 at 8:52 AM, in bed with half bed rails up on both sides of the bed. - On 5/15/2024 at 11:04 AM, in bed with both half bed rails up on both sides of the bed. When interviewed, the resident stated they did not use the bed rails very often and they were used to keep them from falling out of bed. During an interview on 5/15/2024 at 9:45 AM, Certified Nurse Aide #5 stated Resident #40 had bed rails to pull themselves up in bed and to keep them from falling out of bed. They believed bed rails were documented in the care plan and there was an order for them. Bed rails could be dangerous. If the resident got stuck they could break a bone. During an interview on 5/15/2024 at 9:53 AM, Registered Nurse Unit Manager #3 stated bed rails were utilized for repositioning, enhanced mobility, and independence. Physical therapy completed and documented the assessment for bed rails, and then maintenance installed them. Bed rails were documented in the care plan and did not require a physician order. They required consent by either the resident or their representative after risks and benefits were discussed with the resident as bed rails could cause entrapment, strangulation, skin tears, broken bones, or bruising. An admission assessment had been completed on 11/1/2021 for assist rails, and they were not sure if a periodic reassessment was required by nursing or physical therapy. The facility used two types of bed rails: assist rails and half bed rails. Resident #40 had half bed rails for positioning and had a bed rail assessment completed for assist rails. The manager stated that half bed rails carried a bigger risk for injury than assist rails. During an interview on 5/15/2024 at 10:27 AM Assistant Director of Nursing #2 stated bed rails were used to increase bed mobility and independence after being assessed by physical therapy. Physical therapy assessed the ability of a resident to use the bed rails safely and the bed rails had to increase a resident's function. The risks and benefits were reviewed with a resident or their representative and a consent form was to be signed prior to usage. Bed rails could cause injuries such as skin tears and entrapment. Bed rails were documented on a resident's care plan and were reassessed quarterly, on readmission, and with any change in condition for continued ability and necessity. During an interview on 5/15/2024 at 10:50 AM Director of Physical Therapy #4 stated each resident was screened on admission to determine if bed rails were appropriate for turning and positioning. If it was determined bed rails were appropriate, they would notify the nurse manager. They reviewed with the resident or their representative the risks of the bed rails which included injuries or entrapment. If bed rails were appropriate, they would be added to the care plan by nursing. There was a specific form in the electronic health record that they filled out for the bed rail assessment. Residents were reassessed quarterly or with change of condition to make sure bed rail use was still appropriate. The risk/benefit and consent was required by regulation and half bed rails carried a greater risk than a hand assist rail due to size. 10NYCRR 415.12(h)(1)(2)

Based on observation, record review, and interview during the recertification survey conducted 5/13/2024-5/17/2024, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 1 of 4 residents (Resident #106) reviewed. Specifically, Resident #106 was ordered to have bilateral heel float boots on 4/29/2024 and did not receive the left boot until 5/12/2024. The undated facility policy Skin Assessment for Admissions or Change of Condition: Skin Prevention Protocol documented there were three categories for a resident's skin that required physician orders and care plan interventions: high risk, moderate risk, and a skin tear. High risk included orders for a pressure guard mattress, specialty cushion, heel float boots (brand name Skil-Care) to bilateral feet when in bed, skin prep to heels, and an occupational therapy referral to recommend positioning aides. Interventions geared towards skin and skin protocol would be documented on the care plan. Moderate risk orders included a standard gel wheelchair cushion, physical and occupational evaluation for moderate skin risk, barrier cream and lotion to skin. The undated facility policy Resident Care Guide: AOD Point of Care documented the resident care guide would be reviewed by the assigned caregiver prior to delivery of care to a resident. Staff would provide care in accordance with the resident care guide located on the kiosk and in the resident's room. Any care that was not given would be reported to the nurse and the reason documented in the resident's chart. The resident's care guide would include resident-specific skin care interventions, which included pressure relieving devices. Resident #106 diagnoses included peripheral vascular disease (a circulation disorder), diabetes mellitus type 2 with diabetic neuropathy, and heart failure. The 4/17/2024 Minimum Data Set assessment documented the resident was cognitively intact, was dependent for toileting, lower body dressing, putting on/taking off footwear, and transfers, had one or more pressure ulcers: one was unstageable, and one was an unstageable deep tissue injury, was at risk for developing pressure ulcers, and had two venous and arterial ulcers. The resident had a pressure-reducing device for the wheelchair and the bed, nutrition/hydration intervention, pressure ulcer/injury care, application of non-surgical dressings, applications of medications/ointments, and application of dressings to feet. The comprehensive care plan initiated 3/18/2024 documented the resident was at high risk for skin breakdown related to decreased mobility, obesity, and comorbidities. Interventions included heel protection by having heels propped up by pillows and heel float boots to left and right foot on at all times except for hygiene. The care plan also documented the resident's basic care needs and preferences for daily routine would be honored. Interventions included a pressure-relieving cushion in their chair for comfort and positioning and was dependent on one assist for footwear. The 4/29/2024 wound care follow-up consult note documented the left heel deep tissue injury was stable in size and appeared to be resolving. There was no sign of on-going pressure injury. The recommendation for the left heel was for skin prep and bilateral heel float boots (brand name Skil-Care) while in bed. Further instructions documented heel cup for protection and support bandage (brand name Tubigrip) daily to the left heel. The 4/29/2024 physician's order by Nurse Practitioner #19 documented the resident was to have bilateral lower extremity heel float boots (brand name Skil-Care) on at all times except for during the skin checks on every shift. The May 2024 Medication Administration Record nursing comments documented the following for the resident's order for bilateral heel float boots: - On 5/1/2024 on the 11:00 PM to 7:00 AM shift by Licensed Practical Nurse #21: The resident had only the right one on and the left one was not found. - On 5/6/2024 on the 11:00 PM to 7:00 AM shift by Licensed Practical Nurse #21: The resident had only the right one on and the left one was not found - On the 5/10/24 on the 11:00 PM to 7:00 AM shift by Licensed Practical Nurse #22: The resident only had the right one on. The resident stated they had never had a second one. The supervisor was notified. A 5/11/2024 at 7:16 AM interdisciplinary progress note by Registered Nurse Supervisor #20 documented the resident had an order for bilateral heel float boots but only had one boot for the lower right extremity. They were unable to locate another heel float boot in the nursing emergency storage closet. During an observation and interview on 5/13/2024 at 12:33 PM, Resident #106 was observed wearing bilateral blue, soft heel float boots. They stated they had gone to a wound clinic appointment a few weeks ago (4/29/2024) for their foot wound. It took the facility two weeks to get the heel float boot for their left foot that was recommended by the wound care clinic. They had received the second boot this past weekend (5/12/2024). A 5/14/2024 at 4:26 PM interdisciplinary progress note by Registered Nurse Unit Manager #15 documented that during the resident's skin check it was noted the resident's left heel had a 0.1 centimeter x 0.1 centimeter yellow, sloughing (dead/dying tissue) dry scab, the left great toe had a small, yellow fluid-filled blister, and there was fresh blood draining from the skin between the toes. A new order for a protecting cream (brand name Eucerin) was obtained. During an interview on 5/16/2024 at 2:53 PM, Licensed Practical Nurse #14 stated the resident received their heel float boot for the right foot right away but did not receive their left heel float boot until a couple of days ago. They were unsure why the resident had not received the left heel float boot sooner. They and the other nurses had marked the resident had bilateral heel float boots in place in the medication administration record when they should not have, as the resident had only had one heel float boot. They should have charted the resident only had the right heel float boot. The resident told them they had been asked by a couple of managers why they only had one heel float boot, but no one had provided the second heel float boot. The nurse managers usually provided the heel float boots to the nursing staff for the residents who had them ordered. They were aware the heel float boots were kept in the nursing storage room on the second floor but had not gone to get a second heel float boot for the resident. During an interview on 5/16/2024 at 3:16 PM, Registered Nurse Unit Manager #15 stated the heel float boots were in the clean utility room and in the laundry room. If there were no heel float boots available, the unit secretary would order more from central supply, and they would be delivered to the unit the same day. Resident #106 needed two heel float boots as that was the order they had entered. They did not always go and retrieve the heel float boots when they entered the order as they expected the floor nurses to obtain them for the resident. They received an electronic message on 5/11/2024 from the floor nurse that stated the resident had still not received the left heel float boot from when the order was entered on 4/29/2024. They retrieved a heel float boot on 5/12/2024 from the second floor storage room as the supervisor on duty on 5/11/2024 was unable to locate one. The nurses should not have been signing off that the resident had both heel float boots when the resident only had the right heel float boot. They should had documented the resident only had the right heel float boot and then gone and retrieved a left heel float boot. The resident had bad skin and was highly susceptible to new skin issues and breakdown. The resident was on their radar for skin issues and went to the wound clinic regularly. During an interview on 5/17/2024 at 8:32 AM, Nurse Practitioner #16 stated it was an issue if a resident had an order entered on 4/29/2024 for bilateral heel float boots but did not receive the left heel float boot until 5/12/2024. They expected to be notified if there was a delay in obtaining the heel float boots. They performed medical rounds once weekly so there was opportunity for it to be discussed with nursing. Resident #106 was at risk for skin breakdown without wearing the second heel float boot that was ordered. Medical orders needed to be followed. If there was a reason why they could not be followed, a medical provider needed to be notified. During an interview on 5/17/2024 at 9:02 AM, Assistant Director of Nursing #2 stated it was an issue if an order for bilateral heel float boots was entered on 4/29/2024 but the resident did not receive one of the heel float boots until 5/12/2024. The resident could potentially have skin breakdown or the wound worsening on the heel that did not have the heel float boot. If a heel float boot was not available, the nursing staff should have notified the nurse manager, or the nurse supervisor during an off-shift, so they could get the ordered heel float boot. 10NYCRR 415.12(c)(1)

Based on record review and interview during the recertification survey conducted 5/13/2024 - 5/17/2024, the facility did not ensure a comprehensive, person-centered care plan was developed and implemented to meet a resident's medical and nursing needs for 1 of 5 residents (Resident #170) reviewed. Specifically, Resident #170 did not have a comprehensive, person-centered care plan that included anticoagulant (blood thinner) therapy. Findings include: The facility policy Interdisciplinary Comprehensive Care Plans (IDCP), reviewed 2/2022, documented a person-centered interdisciplinary care plan would be developed by the Interdisciplinary Care Team to identify a resident's problems, strengths and needs, and incorporate their personal and cultural preferences. The interdisciplinary care plan would be used to ensure services were provided to assist the resident achieve or maintain their highest practicable physical, mental, and psychosocial well-being. Resident #170 had diagnoses that included long-term use of anticoagulants, personal history of other venous thrombosis (blood clot) and embolism (block in blood flow due to clot), and personal history of pulmonary embolism (blocked lung artery). The 2/28/2024 Minimum Data Set assessment documented the resident was cognitively intact, was on an anticoagulant with an indication noted, and was supervision to independent for most activities of daily living. The comprehensive care plan, dated 11/21/2022, documented the resident was at low risk for falls. The interventions included to monitor the environment for fall hazards, to encourage non-skid socks and to assist to the bathroom at 4:00 AM daily. The comprehensive care plan did not include the resident received anticoagulant medication or any interventions related to the anticoagulant medication use. Physician orders dated 2/1/2022 and renewed 4/16/2024 documented the resident took one apixaban (brand name Eliquis, a blood thinner) 2.5 milligram tablet by mouth two times per day related to a personal history of other venous thrombosis and embolism. During an interview on 5/16/2024 at 12:29 PM, Certified Nurse Aide #12 stated they knew how to care for a resident based on their plan of care, which was located in a resident's electronic health record. There was also a copy of the care plan posted in a resident's closet. Residents on anticoagulant medication needed to be monitored for bruising. The nurse manager was responsible for the plans of care which were then distributed to the staff so they knew how to care for a resident. During an interview on 5/16/2024 at 12:39 PM, Licensed Practical Nurse #13 stated staff knew how to care for a resident based on their care plan, which was located in the certified nurse aide book and in each resident room in a resident's closet. If a resident was on anticoagulant medication, they were to monitor with routine labs and monitor for bruising. They were unsure if anticoagulant interventions were on Resident #170's plan of care. During an interview and record review on 5/16/2024 at 3:16 PM, Nurse Manager #15 stated they were responsible for ensuring the development of and the updating of comprehensive care plans with input from other departments in the facility. The care plan was a snapshot of the specific care needs of a resident. Care plans were reviewed annually to verify if the interventions were still appropriate. If a resident was on anticoagulant therapy, it would be a part of the care plan. There was a specific template for an anticoagulant therapy care plan in the electronic medical record that they utilized. Nurse Manager #15 then reviewed Resident #170's plan of care and stated the template for anticoagulant therapy had not been initiated, which meant there was no care plan related to anticoagulant therapy. Resident #170 should have had a care plan for anticoagulant therapy. During an interview on 5/17/2024 at 9:02 AM, Assistant Director of Nursing #2 stated the purpose of a resident's care plan was to inform the staff of what they needed to know about a resident and how to care for that resident. If a resident was on anticoagulant therapy, they should have had a care plan that addressed it. Care plans were updated quarterly and as needed, and should always be accurate and up-to-date. If a care plan was not up-to-date or accurate, the resident could be provided the wrong care. 10NYCRR 415.11(c)(1) 48632 49831

Based on observation, record review, and interview during the recertification survey conducted 5/13/2024 -5/17/2024, the facility did not ensure a resident's ability to safely self-administer medications was clinically appropriate for 2 of 6 residents (Residents #96 and #155) reviewed. Specifically, Resident #96 was observed with prescribed eye drops and nasal sprays at their bedside and there was no documented evidence the resident had an assessment or order to self-administer the medications. Additionally, Resident #155 was observed with prescribed eye drops at their bedside and did not have an assessment or order to self-administer the medications. Findings include: The facility policy Self-Administration of Medication Program reviewed 11/2016 documented the interdisciplinary team would determine if a resident was clinically appropriate for self-administration of medications, and reviewed on a quarterly and significant change basis. That decision would be documented in the resident's record. A physician order was needed prior to initiation of the program specifying the specific medications the resident would be self-administering. Resident education would be done. The unit nurse would monitor at all times if the medications were taken and document accordingly. 1) Resident #96 had diagnoses including Parkinson's disease, bipolar disorder, and chronic obstructive pulmonary disease. The 12/28/2023 Minimum Data Set assessment documented the resident understood and was able to make self-understood, wore corrective lenses, had full cognition, choice was important, used a walker or wheelchair, and was set-up only for eating. The 11/10/2023 through 5/3/2024 vision consults documented the resident was seen for previous cataract surgeries. Eye drops were ordered. There was no documentation the resident was able to self-administer the eye drops. The 1/23/2024, 3/13/2024 and 4/1/2024 30/60 day physician progress notes by the Medical Director did not document the resident had the ability to self-administer medications. The 3/23/2024 physician orders by Nurse Practitioner #16 documented: - Fluticasone propionate (steroid medication) 50 micrograms per actuation nasal spray, instill 1 spray by nasal route daily in each nostril for allergic rhinitis; and, - Cough drops 2.7 milligrams give 1 by mucous membrane as needed and may leave at bedside to be used as needed. There was no order to leave fluticasone propionate at the bedside for self-administration. The 3/23/2024 comprehensive care plan documented the resident was non-compliant, had Parkinson's Disease, had impaired vision, had cataract removal, had bipolar disease, refused medications at times, could self-administer polyethylene glycol 3350 (brand name, Miralax, a laxative) and would self-administer nebulizer treatments safely. Interventions included provide supervision as appropriate, eyeglasses, give medications as prescribed, may keep post-operative eye drops at bedside and self-administer per instructions, educate on importance of medication consistencies, encourage to take medications, report concerns to medical provider, prepare laxative per order for self-administration, set up nebulizer machine for resident to self-administer nebulizer treatment, and follow up 30 minutes post self-administration to ensure all medication administered. The care plan did not document the resident could self-administer nasal spray or eye drops. The 3/27/2024 Nurse Practitioner #16 readmission after elective surgery note did not document the resident was able to self-administer medications. The 5/3/2024 physician orders by the Medical Director documented: - FML Liquifilm 0.1% eye drops instill one drop in each eye 2 times per day for macular degeneration (loss in the center of field of vision). - Muro 128 5% eye ointment instill in each eye once daily at bedtime to lower lid for macular degeneration. - Refresh celluvisc 1% eye gel in dropperette instill one drop in each eye once daily for dry eye syndrome; and, - Zaditor 0.025% (0.035%) eye drops instill 1 drop in each eye 2 times per day for macular degeneration. There was no order to leave at bedside for self-administration. The April 2024 and May 2024 Medication Administration Records documented the eye drops were administered as ordered. On 5/13/2024 at 12:04 PM, Resident #96 was observed in their room with eye drops on the bedside table. On 5/15/2024 at 8:48 AM, the resident was observed sitting in their recliner with multiple prescription nasal sprays and eye drops on the bedside table. The resident stated they self-administered the eye drops and nasal sprays. During a follow-up observation at 10:41 AM, the resident was not in their room. The eye drops and nasal sprays remained on the bedside table next to the recliner. On 5/16/2024 at 9:25 AM, the resident was again observed to have eye drops and nasal sprays left on the bedside table. When interviewed on 5/16/2024 at 10:20 AM, Licensed Practical Nurse #14 stated they were not sure if the resident was allowed to self-administer medications, was not sure if there was a physician order, and had informed the nurse manager they needed one. The nurse would ask the resident if they took the eye drops and nasal sprays, and then would sign in the Medication Administration Record as given. During a follow-up interview at 2:48 PM, Licensed Practical Nurse #14 stated they asked the resident why the eye drops and nasal sprays were in the room. The resident had then thrown them in the garbage. They should have removed the medications from the room instead of letting the resident throw them away. The resident would not give the medications to the nurse. The resident had a lot of home medications delivered to them and staff had to check to ensure the resident did not have any in the room. When interviewed on 5/16/2024 at 3:16 PM, Registered Nurse Manager #15 stated any resident wishing to self-administer medications needed a physician order specifically for that medication. An assessment was done for competency. Resident #96 had a post-operation order to self-administer the eye drops that was discontinued. The manager did not know why the nurses were leaving the nasal sprays and eye drops in the room and did not know the resident preferred to self-administer them. 2) Resident #155 had diagnoses including dementia and glaucoma. The 4/20/2024 Minimum Data Set assessment documented the resident had difficulty seeing, wore corrective lenses, had moderately impaired cognition, and required moderate to maximum assistance with most activities of daily living. The 4/5/2024 physician orders by the Medical Director documented: - Lumigan 0.01% eye drops instill 1 drop in each eye at bedtime for high ocular pressure and please wait 5 -10 minutes between administering other eye drops. - Rhopressa 0.02% eye drops instill 1 drop in each eye at bedtime for high ocular pressure and please wait 5 - 10 minutes between administering other eye drops. - Timolol Maleate 0.5% eye drops instill 1 drop in each eye twice a day for high ocular pressure and please wait 5 - 10 minutes between administering other eye drops. - Patanol 0.1% eye drops instill 1 drop in each eye twice a day for high ocular pressure and please wait 5 -10 minutes between administering other eye drops. - Pilocarpine 1% eye drops instill 1 drop in each eye four times a day for high ocular pressure and please wait 5 - 10 minutes between administering other eye drops; and, - Nurse to administer all eye drops. Please do not leave eye drops at bedside. The 4/5/2024 comprehensive care plan documented the resident had impaired vision and had glaucoma. Interventions included report visual changes, wore corrective glasses, refer to eye specialist if needed, administer eye medication per orders, and could keep eye drops at bedside with nursing to observe resident taking them as prescribed. The 4/1/2024 30/60 day physician progress note by the Medical Director documented the resident was upset they were not allowed to self-administer eye drops. The Medical Director had explained the difficulty of administering the eye drops appropriately. The resident's cognition was getting worse. The resident was not accepting the reality of their decline. The plan was for nursing to continue administering the eye drops. The 4/8/2024 30/60 day physician progress note by the Medical Director documented the resident had short-term memory deficits, denied vision changes, and was on multiple eye drops. The note did not document the resident could self-administer eye drops. The April 2024 and May 2024 Medication Administration Records documented all eye drops were administered as ordered. The 5/5/2024 at 7:31 AM interdisciplinary progress note by Licensed Practical Nurse #23 documented the resident had eye drops in their nightstand drawer and was not allowed to have them there or self-administer them. They tried to remove them from the drawer on evening and night shifts and were unsuccessful due to the resident's refusal. The nurse did administer the eye drops. When interviewed on 5/15/2024 at 10:52 AM, Resident #155 stated they used to have their eye drops in the room. The nurse took them out and now they did not know their scheduled administration times. When interviewed on 5/16/2024 at 10:20 AM, Licensed Practical Nurse #14 stated the resident was not allowed to have medications in their room. The resident was allowed to have the eye drops in the room in the past but was getting more confused. They were not allowed to keep medicatons in their room starting about 2 - 3 months ago. They were not sure how the resident got the eye drops in their room but the resident would not give them back to nursing. They administered the eye drops to the resident and sometimes left them in the room. Sometimes they let the resident self-administer the eye drops when they were agitated, but only under supervision. They knew they were not supposed to do that as there was no order for self-adminstration of the eye drops. When interviewed on 5/16/2024 at 3:16 PM, Registered Nurse Manager #15 stated any resident wishing to self-administer medications needed a physician order specifically for that medication. An assessment was done for competency. Currently, Resident #155 did not have an order to self-administer eye drops. The unit nurse should not leave them bedside without an order to do so. The care plan should not contain reference to self-administer the eye drops if the resident did not have a current order to do so. When interviewed on 5/17/2024 at 8:32 AM, Nurse Practitioner #16 stated they could assess the resident and determine if they were capable to self-administer medications. An order was then entered into the electronic medical record allowing the self-administration of that particular medication. When interviewed on 5/17/2024 at 9:02 AM, Assistant Director of Nursing #2 stated care plans should be accurate and up-to-date. Care plans were reviewed quarterly and with significant changes. Resident #155's care plan should have been updated as it was confusing as to whether the resident was able to self-administer the eye drops or not. No medications should be left at bedside unless the resident had a self-administration order for that specific medication, as another resident could enter the room and take the medication not prescribed them. There was also no way of knowing if the resident was taking the medication as ordered. 10NYCRR 415.3(e)(1)(vi)

Based on record review and interview conducted during the recertification and abbreviated surveys (NY 729), the facility did not ensure 1 of 38 residents reviewed for advance directives (Resident #557) had their advance directives honored. Specifically, Resident #557 was resuscitated despite a do not resuscitate (DNR, withhold cardiopulmonary resuscitation, CPR, when the heart stops beating) order in the resident's medical record. This resulted in actual harm for Resident #557 that is not immediate jeopardy. Findings include: The facility's Advance Directives policy, updated ,[DATE], documented it was the right of residents to establish advance directives. Advance directives were to be discussed on admission and verbal physician orders [REDACTED]. Resident #557 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident was admitted from the hospital where he was diagnosed with [REDACTED]. The resident signed a Medical Orders for Life-Sustaining Treatment (MOLST) on [DATE] at 5:05 PM documenting that he wanted a do not resuscitate (DNR) order. The form was also signed by registered nurse (RN) #1. A verbal physician's orders [REDACTED].#2) documented the resident had a DNR order. The attending physician signed the verbal order at 7:25 PM. The [DATE] RN #1's progress note at 9:20 PM, documented at 8:50 PM, the resident was found unresponsive. Cardiopulmonary resuscitation (CPR) was started, one shock was administered via the AED (automated defibrillator, device to shock the heart), and the resident resumed breathing on his own. The physician and paramedics were called and at 9 PM, the resident was transported to the hospital. The [DATE] nursing progress notes documented: - At 2 AM, the hospital reported the resident requested to be extubated (removed from artificial ventilation) and sent back to the facility on comfort care only. Upon return to the facility, the resident complained of the worst possible chest pain and was medicated. - At 6:22 AM, the resident was sent back to the hospital as chest pain was uncontrolled by medication. - At 6:50 AM, the resident expired at the hospital. The facility's investigation dated [DATE] and signed by Assistant Director of Nursing (ADON) ADON #5 documented: - The resident was alert and oriented, able to make health care decisions, and discussed advance directive wishes with RN #1 shortly after admission. The resident and RN #1 signed the MOLST for a DNR. - Certified nurse aide (CNA) #15 found the resident unresponsive, RN #1 responded to the room, and directed staff to start CPR. - Six staff members performed CPR on the resident throughout the 8 minutes until spontaneous pulse and respirations resumed. - RN #1 made the decision to start CPR and stated she thought the resident's advance directives were unclear as no documentation of his wishes came with him from the hospital, the MOLST was not yet signed by the physician, and she had not performed the second check of the resident's orders in the electronic medical record at the time that he was found unresponsive. - RN Supervisor #3's statement documented when she arrived at the room, CPR was in progress. She saw the resident's MOLST documented DNR but saw it did not have a second witness signature or the physician's signature. She circled DNR status on the hospital transfer form and wrote MOLST not completed on the form. - RN Supervisor #4's statement documented when she entered the room, CPR was in progress. She attempted to obtain information about the resident and noticed the MOLST was not signed by the physician, did not have a second witness signature, and she assisted with CPR. On [DATE] at 11:46 AM, RN Manager #2 stated in an interview, on the day the resident was admitted , she reviewed the MOLST that the resident completed with RN #1 and entered the DNR order into the medical record. She stated she left the facility at a little after 6 PM and when she left, she told RN #1 she obtained the resident's orders from the physician and entered them into the electronic medical record. RN Manager #2 stated the resident expressed his wish for a DNR and those wishes should have been honored. On [DATE] at 12:53 PM, RN #1 stated in an interview: - She completed the MOLST with the resident when he was admitted . The resident told her he just had heart surgery and the hospital required him to be a full code for the surgery but that he wanted to resume his DNR order at the facility. The resident signed the MOLST and so did RN #1. RN Manager #2 entered the DNR order into the medical record. - As she was completing paperwork, someone told her the resident was not responsive. She assessed the resident, tried to arouse him, and when he did not arouse she realized it was the new admission and he had just had cardiac surgery. She had staff start CPR. - She started CPR because she thought the resident wanted to live. She stated if he did not want to live, he would not have had a cardiac procedure with stents placed a few days prior. - She also intervened because the resident looked like he was in pain and she wanted to help him. - She did not check his MOLST and did not remember completing a MOLST with him earlier in the shift. - She stated time was heart and brain muscle and she could not stop to check paperwork when someone needed CPR. On [DATE] at 3:47 PM, RN Supervisor #3 stated in an interview, when she got to the resident's room, CPR was in progress and because there were so many people in the room, she went to the desk to get the paperwork ready for the hospital. She saw the resident's MOLST on the desk with RN #1 and the resident's signatures and noticed the MOLST was not signed by the physician or a second witness. She stated RN #1 told her the resident rescinded his DNR for the cardiac surgery, she completed a new MOLST with him, and she had not entered his orders into the electronic medical record yet. RN Supervisor #3 stated since the MOLST was not signed by 2 witnesses or the physician, she did not know if it was valid. She stated she did not send the MOLST to the hospital with the resident as it was incomplete and she was not aware the resident had an order for [REDACTED].>On [DATE] at 4:20 PM, RN Supervisor #4 stated in an interview, she responded to the unit when the code was called and tried to determine the resident's code status. She was told by RN #1 that she was in the process of working on the resident's admission, the orders had not been double checked yet, and the MOLST was not witnessed or signed. She stated RN #1 did not tell her that she did the MOLST with the resident a few hours before and RN #4 did not know the resident had an order for [REDACTED].>On [DATE] at 2 PM, the attending physician stated in an interview, he saw the resident about an hour after admission. The resident had a cardiac procedure that went well and he was sitting up talking to the physician. He did not talk to the resident about advance directives on admission but knew the resident signed a MOLST later that evening. He stated he signed the DNR order entered by RN Manager #2 as he knew the resident was alert and oriented and able to make advance directive decisions. He stated the resident expressed his wish for DNR so that should have been honored and he did not believe that the 2 witness signatures were needed on the MOLST since the resident was able to state his wishes. The attending physician stated when he was called, the resident was breathing on his own and he did not immediately recall the DNR order. He stated the next morning at around 3 AM, the resident wanted to come back to the facility on comfort care so he gave the order and when he returned, they could not control his pain, and he was sent back to the hospital and expired. 10NYCRR 415.3(e)(1)(ii)

Based on record review, observation, and interview conducted during the abbreviated survey (NY 123), it was determined for 1 of 4 residents (Resident #4) reviewed for [MEDICATION NAME] ([MEDICATION NAME], a blood thinner) use, the facility did not ensure provision of adequate medical supervision/management in terms of care and monitoring of the resident's INR (international normalized ratio, a laboratory test used to monitor blood clotting) in relationship to her medications. Resident #4's [MEDICATION NAME] was not restarted after her INR was no longer elevated, but was within therapeutic range. Resident #4's INR became subtherapeutic, and she was transferred to the hospital with the admitting [DIAGNOSES REDACTED].#4 that was not immediate jeopardy. Findings include: Resident #4's primary [DIAGNOSES REDACTED]. The physician order dated 10/9/2015 contained standing orders that documented to obtain the resident's PT ([MEDICATION NAME] time) and INR (both lab tests used to monitor anticoagulation status/blood clotting) twice a week. The physician renewal orders dated 4/19/2016 contained standing orders that documented to obtain the resident's PT/INR twice a week, and once on 5/31/2016. Documentation on the resident's Diagnostic Result from the lab, dated 5/2/2016, included documentation of clinical indications with associated therapeutic range values for INR as follows: - [MEDICAL CONDITION]: INR 2-3; and - [MEDICAL CONDITION]: INR 2-3. The 5/2016 Medication Administration Record [REDACTED]. The resident's INR was subtherapeutic (according to lab recommended ranges) at 1.9 on 5/2/2016, subtherapeutic at 1.6 on 5/5/2016, and subtherapeutic at 1.2 on 5/9/2016. The 5/2016 MAR indicated [REDACTED]. The resident's INR was subtherapeutic at 1.6 on 5/12/2016, subtherapeutic at 1.9 on 5/16/2016, and subtherapeutic at 1.8 on 5/19/2016. The 5/2016 MAR indicated [REDACTED]. The MAR for 5/21/2016 had the nurse's initials with an asterisk under her initials. The comment section of the 5/2016 documented 3 mg [MEDICATION NAME] was not administered on 5/21/2016, as awaiting delivery. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognition. She required extensive assistance, with assist of 2 for transfers, bed mobility, toileting, dressing, and personal hygiene. The resident required limited assistance with eating. She did not have functional limitations in her range of motion. The resident's INR was therapeutic at 2.3 on 5/23/2016. The 5/2016 MAR indicated [REDACTED]. The 5/2016 MAR indicated [REDACTED] - 5/24/2016 at 8:00 PM; - 5/25/2016 at 8:00 AM and 8:00 PM; and - 5/26/2016 at 8:00 AM. The resident's INR was elevated at 4.7 on 5/26/2016. The physician order dated 5/26/2016 documented to discontinue 3 mg [MEDICATION NAME] and Bactrim DS 800 mg-160 mg. The resident's INR was therapeutic at 2.3 on 5/31/2016. There was no documented evidence in the resident's medical record that the [MEDICATION NAME] was restarted. The resident's INR was subtherapeutic at 1.8 on 6/2/2016. There was no documented evidence in the resident's medical record that the [MEDICATION NAME] was restarted. The resident's INR was subtherapeutic at 1.2 on 6/6/2016. The 6/2016 MAR indicated [REDACTED]. The nursing progress note dated 6/7/2016 documented the resident was noted to have difficulty eating, slightly slurred speech, loss of peripheral vision on the left, and left sided [MEDICAL CONDITION] (weakness). The progress note documented Physician #1 assessed the resident, and the resident was to be sent to the emergency room for a possible embolic stroke. The hospital Discharge Summary dated 6/10/2016 documented the CT (computed tomography) imaging study of the resident's head showed right parietal changes that were new since 5/19/2016. The discharge [DIAGNOSES REDACTED]. The Discharge Summary documented, The stroke occurred due to subtherapeutic INR on [MEDICATION NAME] ([MEDICATION NAME]). The resident was observed on 6/16/2016 at 9:30 AM in the dining area of the unit. The resident was positioned in a positioning chair, with a pillow behind her head, and her feet were elevated. The resident was being fed oatmeal and honey-thick apple juice by the Speech-Language Pathologist. The resident was observed on 6/16/2016 at 10:15 AM in bed. The resident had the call bell in her right hand. The resident answered basic questions, but did not initiate or continue conversation. During an interview with the Administrator on 6/16/2016 at 9:00 AM, she stated she was notified by the QA (Quality Assurance) Coordinator on 6/13/2016 that the resident was transferred to the hospital on [DATE] due to an embolic stroke. The Administrator stated the resident had an increased INR on 5/26/2016 of 4.7, and the [MEDICATION NAME] was discontinued by Physician #7. The INRs were repeated per the resident's schedule of 2 times per week. The Administrator stated that the resident's INR on 5/31/2016 was approximately 2.4 (therapeutic), and was reviewed by Physician #1. The resident's INR on 6/2/2016 was 1.8 (subtherapeutic), and was reviewed by nurse practitioner (NP) #8. The resident's INR on 6/6/2016 was 1.2 (subtherapeutic), and was reviewed by Physician #1 and NP #8; the [MEDICATION NAME] was then restarted. The Administrator stated a new plan of action was begun after the resident's hospitalization , and a policy was developed that each time a PT/INR lab result is reviewed in the electronic system by medical staff, a notation indicating review of the current anticoagulation order will be documented in the comment section. During interviews with licensed practical nurses (LPNs) #9 and 10 on the morning of 6/16/2016, they stated they do not notify the physician of lab results, as the lab sends the results to the physicians electronically via the computer system. During an interview with registered nurse (RN) #11 on 6/16/2016 at 10:00 AM, she stated that medical providers were no longer able to put meds on hold. She stated hopefully when a PT/INR comes back low and the resident was not on [MEDICATION NAME], the provider would check and reinstate the medication. During an interview with the resident's attending Physician #1 on 6/16/2016 at 11:20 AM, he stated he had cared for the resident since she was admitted to the facility. Physician #1 stated he placed the resident on a three day course of Bactrim, as the resident had a diagnosed UTI (urinary tract infection) and staff reported the resident was not acting right. Physician #1 stated the resident's PT/INR was drawn twice a week, as her INRs were variable. Physician #1 stated that the resident's INR was elevated to between 3-4 and he stopped the [MEDICATION NAME] ([MEDICATION NAME]). The physician stated he remembered that this was on a holiday weekend and the resident's INR would not be drawn until Tuesday (5/31/2016). Physician #1 stated he kept a sheet of paper with him that identified residents he needed to see, and Resident #4 was not on the list. Physician #1 stated that on Tuesday (5/31/2016) he signed off on the resident's PT/INR, and her INR was 2.3. He stated he should have had a system to remind him that the resident was not receiving [MEDICATION NAME]. Physician #1 stated two days later (6/2/2016), the resident had another INR done, and it remained therapeutic (1.8). Per the provider that signed off on the INR (NP #8), this did not seem like a significant change. The following Monday (6/6/2016), the resident's INR was 1.2 and [MEDICATION NAME] was restarted. Physician #1 stated that he assumed the resident had a stroke from not being on [MEDICATION NAME]. Physician #1 offered clarification and stated when the resident's INR came back elevated and the [MEDICATION NAME] was discontinued, he did not create a system for himself (when reviewing future lab results) to trigger awareness the resident was not on [MEDICATION NAME]. During a second interview with the Administrator on 6/16/2016 at 12:10 PM, she stated that there was an interface between the laboratory and the computer software system the nursing home utilized. When the lab results come in, the medical providers go directly into the computer software system and review alerts; the providers review the labs and sign off the labs were reviewed electronically. The medical providers have access to the computer software system on and off site. During an interview with the Director of Nursing (DON) on 6/6/2016 at 1:55 PM, she stated an investigation was initiated. She did not think there was a system problem, as there was an order for [REDACTED]. During an interview with NP #8 on 6/16/2016 at 2:30 PM, she stated that on 6/2/2016, the computer system alerted her the resident's INR was 1.8. She reviewed the resident's INRs and saw that the INR was 2.3 on 5/31/2016. NP #8 stated that she saw two therapeutic INRs, and she did not look to see how much [MEDICATION NAME] the resident was on. The NP stated that on 6/6/2016, the computer system alerted her that the resident's INR was 1.2, and that was when she noticed the resident was not on [MEDICATION NAME]. NP #8 stated she does not routinely review the resident's medications in the computer system when she signs off for labs, as it depended on what the lab was for, such [MEDICATION NAME] (heart medication) or [MEDICATION NAME] ([MEDICAL CONDITION] medication). NP #8 stated an INR of 1.8 was within the therapeutic range; she did not have a documented reference source for that information. NP #8 stated that with an INR of 1.8, she does not increase the [MEDICATION NAME]. During an interview with the Medical Director #3 on 6/23/2016 at 9:05 AM, she stated her role in the facility included assisting with policy decisions and oversight of the medical staff. The Medical Director stated an INR result during anticoagulation treatment was used for [MEDICATION NAME] adjustment. She would expect a practitioner to look at the [MEDICATION NAME] dose (when reviewing an INR result). The Medical Director stated it was difficult to say if a INR of 1.8 (such as the resident's on 6/3/2015) was therapeutic, especially for those with an increased risk for bleeding, such as the elderly. The Medical Director stated she was aware the resident sustained [REDACTED]. 10NYCRR 415.15(b)(1)(i)(iii)

Based on observation, record review, and staff interview conducted during the standard and abbreviated survey (Complaint #NY 944), the facility did not ensure 3 of 30 sampled residents (Residents #3, 18 and 24) and 1 out of sample resident (Resident # 45) received the necessary care and services to attain and maintain the highest practicable physical well-being. Specifically, for Resident #18 the facility did not recognize the resident had a change in condition following a fall (persistent complaints of pain, new onset of anxiety and restlessness), did not follow a radiologist's recommendation that the resident undergo additional radiologic studies, and did not accurately and timely report the resident's injuries/death to the Department of Health. For Resident #3, the facility did not ensure physician's orders [REDACTED]. For Resident #24, the facility did not ensure the care planned device for pressure relief was implemented consistently and timely, when the resident requested it. For Resident #45, the facility did not ensure a pressure relieving cushion was provided in her chair as care planned. This resulted in actual harm that is not immediate jeopardy for Resident #18; and for Residents #3, 24, and 45, this resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Findings include: 1) Resident #18 had [DIAGNOSES REDACTED]. physician progress notes [REDACTED]. The physician noted the resident dresses herself, takes care of her own hygiene, and went to the TV room, dining room and bathroom independently. The physician documented the resident had no sleeping, pain, or breathing problems, and had no mood difficulties. A nursing progress note dated April 23, 2012 documented the resident was sent to the hospital on April 22, 2012 for confusion and visual problems. She returned to the facility on [DATE] with mild confusion, needing assistance of 2 to ambulate and left sided neglect with a [DIAGNOSES REDACTED]. A nursing progress note dated April 24, 2012 documented the resident was found on the floor of the bathroom. She was assessed for injuries and none were identified. A physician's progress note dated April 24, 2012 at 9:15 AM documented the resident was previously independent with transfer and mobility, with some left sided neglect present, was found on floor of bathroom and would need a therapy evaluation. Nursing progress notes documented: - on April 25, 2012 at 10 AM, the resident was "crying out in pain with movement" and was given Tylenol for right rib pain; - on April 26, 2012 at 12 AM, nursing notes the resident was given Tylenol for pain of right ribs at 11 PM. - on April 28, 2012, Tylenol was given for right rib pain. The resident was awake most of the night, frequently ringing the call light, sitting up in wheelchair; and -on April 29, 2012, the resident had multiple bruises on right rib area and right thigh and the Supervisor was aware. On April 30, 2012, there was a physician's orders [REDACTED]. A radiology report from a pelvic x-ray taken April 30, 2012 documented there was "no acute pelvic fracture; however there does appear to be some pelvic ring deformity with completely different projections in the frontal view of the right pubic rami as compared to the left." Additional imaging studies were recommended. Review of the resident's record from April 30, 2012 to May 14, 2012 (when she was sent out to the hospital) revealed no additional radiologic studies were performed until May 14, 2012. Additional nursing progress notes documented: - on May 1, 2012 the resident was awake most of the night; - on May 2, 2012 at 10:30 PM she was given Tylenol for complaints of discomfort with good effect; and - on May 3, 2012 the resident complained of right thigh pain, left sided weakness; she was unable to stand/ambulate without extensive assistance. The Supervisor was notified. A physician's progress note dated May 3, 2012 at 1 PM documented "events of last 12 hours reviewed in chart and with nurses. Resident coherent, eating, and denying any problems. Cannot recall difficulty standing this AM. ... " The note does not include any reference to the resident's April 30, 2012 pelvic x-ray or documented complaints of pain. Nursing progress notes documented on; -May 4, 2012 the resident rang the call bell throughout the night requesting to be turned and positioned. She did not sleep; -May 5, 2012 the resident was found lying on the floor. She attempted to transfer herself off the toilet and into the wheelchair and fell to the floor. No apparent injuries; -May 6, 2012 the resident was medicated with Tylenol for complaints of right knee arthritic pain. She was awake all night because of restlessness and was found sitting up on the side of the bed several times. She complained of left leg and back pain and increased confusion was noted; and -May 7, 2012 the resident was very uncomfortable and nervous. The certified nurse's assistant (CNA) informed the nurse. The resident was yelling, fidgeting and screaming in pain. The Vanderlift was used to reposition the resident with her head up and a pillow under her legs which quieted her. A Nurse Practitioner (NP) progress note dated May 7, 2012 documented the resident had been anxious and not easy to redirect since she was at the hospital. [MEDICATION NAME] 0.25 milligrams (mgs) twice a day was ordered. The resident's April 30, 2012 pelvic x-ray results and complaints of pain are not documented in this progress note. Nursing progress notes documented on: -on May 8, 2012 the resident was confused and screaming. The son came in and talked with her without success. The resident complained of overall discomfort and received Tylenol and [MEDICATION NAME] for anxiety. She complained of neck discomfort; - on May 9, 2012 the resident received Tylenol and [MEDICATION NAME] for increased anxiety and general complaints of discomfort. At 9:30 PM she complained of being cold, wanted a blanket and her legs rubbed; - on May 10, 2012 the resident had been awake all night, was very restless, complained of pain on her left side and received Tylenol; -on May 12, 2012 the resident complained of overall discomfort and received Tylenol at 4:30 PM with good effect. The resident screamed in pain when the CNA went to put her to bed. The nursing supervisor was notified. The resident received Tylenol again at 9:35 PM. - on May 13, 2012, a new order for [MEDICATION NAME] 5/325 mg (one dose) was given at 10 PM; and - on May 14, 2012, the resident was repositioned numerous times and Tylenol was given at 12:30 AM for generalized discomfort. At 3 AM the resident was transferred back to bed and complained of hurting. At 8:30 AM the resident complained of mild pain of the right thigh and left flank pain. This area was described as purple/red ecchymosis approximately 16 centimeters (cm) X 9 cm in a cluster with 2 abrasions in the area approximately 5 cm long. Respirations noisy/dry at 28 and lung sounds diminished. At 11:45 AM, the resident was screaming in pain and given Tylenol was given. The physician spoke with the family, ordered Narco5/325 mg (one dose) and sent the resident to the hospital. The hospital x-ay report, dated May 14, 2012, documented the resident's ribs were obtained due to a history of a fall and shortness of breath. The hospital discharge summary dated May 16, 2012 documented the resident went into [MEDICAL CONDITION] secondary to possible aspiration with the possibility that it was also related to medications and her recent [MEDICAL CONDITION]. The resident had a history of [REDACTED]. There were multiple [MEDICATION NAME] and lumbar spine compression fractures. The resident was noted to be in significant pain; [MEDICATION NAME] and a [MEDICATION NAME] were needed and she went into [MEDICAL CONDITION]. The resident required mechanical ventilation and resuscitation. The family decided to take her off of the ventilator and she passed away. On May 31, 2012 the Director of Nursing (DON) was interviewed over the telephone by staff from the Department's Case Resolution Bureau. The DON stated that the resident's family informed her on May 16, 2012, that the resident had fractured ribs. During an interview with the resident's primary CNA on June 13, 2012 at 11:45 AM she stated the resident was in more pain in the last 2 weeks than in the past. There were times her pain was significantly worse. The CNA stated she let the nurses know and informed the registered nurse (RN) Nurse Manager (NM). The RN NM did not do anything except he said to use warm packs, which she did. During an interview with a licensed practical nurse (LPN) on June 13, 2012 at noon she stated she was with the resident when she was sent out to the hospital. She stated the hospital said the resident had a [MEDICAL CONDITION] (TIA) but the facility doctor was certain she had [MEDICAL CONDITION] of the residual. After [MEDICAL CONDITION] wasn't able to walk on her own. She stated the resident had vision loss and drift after the [MEDICAL CONDITION]. The LPN stated the resident complained of pain after her fall, and then sustained a second fall. After the second fall, she would occasionally complain of pain and received Tylenol. During an interview with the RN Nurse Manager on June 15, 2012 at 2:45 PM, he stated on a Sunday late in April the resident went out to the hospital and came back 24 hours later with a [DIAGNOSES REDACTED]. The first night back from the hospital she fell . From late April to early May she had what we thought was [MEDICAL CONDITION] which she improved then declined again. On either May 9 or May 10, 2012 she took another fall and over the next few days had an increase in anxiety and restlessness. On that Sunday, May 12 or 13, 2012, there were family members present one of which is a physician and he thought the resident's [MEDICAL CONDITION] was worse. The following day (Monday) extensive bruising with scratches were found on the resident's left side and she had abnormal lung sounds. A chest x-ray was ordered and she was sent out to the hospital. The resident did get Tylenol on occasion for pain mostly at night. The first week of May she had increased weakness and required two people to help her transfer. The RN NM stated it was assumed she had another mild stroke. During an interview with the DON on June 13, 2012 at 10 AM and July 10, 2012 at 4:45 PM, she stated that facility nursing leadership did not know the resident was in pain. She stated that there is a process in place for nursing to bring change in condition issues like pain to daily report but it was not done for this resident. The DON stated when she reviewed the resident's record after her death she saw that the resident had pain for about two weeks. The x-ray on May 14, 2012 did not reveal any fractures but did reveal pleural effusions which was why the resident was sent out. The family returned to the facility and said the resident had multiple fractures. In summary, Resident #18 experienced actual harm as the facility did not recognize the resident had a change in condition following a fall (persistent complaints of pain, new onset of anxiety and restlessness), did not follow a radiologist's recommendation that the resident undergo additional radiologic studies, and did not accurately and timely report the resident's injuries/death to the Department of Health. 2) Resident #3 had [DIAGNOSES REDACTED]. A consultation done on June 6, 2012 by the dermatologist documented on physical exam the resident had a violaceous (color violet) patch that extends from the upper buttock down to the inferior peri-anal area. The resident had ulcers eroding through the dermis on the superior portions and the violaceous patch on the peri-anal area. The physician recommended the treatment be changed to a mixture of [MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME], anti-fungal cream with steroidal component) cream, [MEDICATION NAME] (silver [MEDICATION NAME], an antibacterial skin cream) and a crushed 100 milligrams (mg) tablet of [MEDICATION NAME] ([MEDICATION NAME]). Everything was to be mixed evenly into 1 tablespoon (tbsp) of petroleum jelly, applied to the area and covered with a [MEDICATION NAME] dressing. This was to be changed every other day. The physician's orders [REDACTED]. - cleanse with soap and water; - empty and crush one capsule of [MEDICATION NAME]; - mix with 1 tbsp of petroleum jelly, [MEDICATION NAME] cream and [MEDICATION NAME], and apply to open ulcer; - cover with [MEDICATION NAME] dressing (open areas only); and - change every day and as necessary. The Minimum Data Set, dated dated dated [DATE] documented the resident had moderately impaired cognition. The Treatment Administration Record (TAR) dated July 2012 documented "coccyx/sacrum/buttocks (whole area-including plaque area) cleanse with soap and water; empty and crush one capsule of [MEDICATION NAME], mix together with 1 tbsp Vaseline, [MEDICATION NAME] cream, and [MEDICATION NAME]. Apply to whole area. Cover with [MEDICATION NAME] dressing, change every day and as needed (prn)." On July 11, 2012 at 10:50 AM, a surveyor observed the resident's treatment as done by a licensed practical nurse (LPN). The LPN stated the pharmacy sent the facility 100mg capsules of the [MEDICATION NAME] and that was what was used. The LPN placed four 30 cc (cubic centimeter) plastic cups on top the treatment cart and emptied 1 crushed capsule of [MEDICATION NAME] into one cup. She emptied 2 small packages of Vaseline into one cup and placed the [MEDICATION NAME] on top of the Vaseline. The LPN then squeezed [MEDICATION NAME] and [MEDICATION NAME] cream in to 2 separate medicine cups. She said she had to "eyeball" the dose but when flattened out it would be 1 tablespoon. The LPN mixed the [MEDICATION NAME] and [MEDICATION NAME] in with the Vaseline using the back of a plastic spoon. The mixture filled the 30 cc plastic medicine cup. During an interview on July 11, 2012 at 12 PM with the attending physician, he stated he did not specify a dose for the [MEDICATION NAME] in the physician's orders [REDACTED]. During an interview on July 11, 2012 at 12:30 PM with the supervising pharmacist, the pharmacist stated that nurses could not compound medications and it was pharmacy's responsibility. She stated she did not know how that was missed on the monthly pharmacy review and stated she would look into it. In summary, the facility did not ensure physician's orders [REDACTED]. 3) Resident #24 had [DIAGNOSES REDACTED]. The May 8, 2012 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, required extensive assistance with activities of daily living (ADLs), was at risk for developing pressure ulcers, and did not have a pressure ulcer. The resident had a pressure reducing device for the bed and received ointments to the skin. The physician orders [REDACTED]. The comprehensive care plan (CCP) dated June 27, 2012 documented the resident was at moderate risk for skin breakdown per the Braden Scale. Interventions included a cushion in his chair. Observations on July 11, 2012 included: - at 9:42 AM, the resident was sitting in a dining room chair without a cushion, complaining he was uncomfortable and asked staff for his cushion; - at 9:46 AM, he asked for his cushion and staff responded "I'll be right back;" - at 9:50 AM, the resident asked where his cushion was and the licensed practical nurse (LPN) stated the certified nurse aide (CNA) was getting his cushion; - at 10:00 AM, the resident asked for the cushion and the LPN stated "we're looking for one;" - at 10:08 AM, the resident asked for a cushion; - at 10:15 AM, the CNA stated she was going to his room to find a cushion; - at 10:16 AM, the CNA placed a cushion in a recliner near the dining room and assisting the resident in transferring to the recliner. On July 12, 2012 at 12:30 PM, the resident was observed in the dining room waiting for lunch. The resident was sitting in a chair with a cushion. The resident stated, "Ohhhhh, my fanny is sore." On July 13, 2012 at 11:30 AM, the CNA stated in an interview, the resident's buttocks was red and he stated it was sore and he liked a cushion in the chair. She stated he was supposed to have a cushion in the chair for comfort and the nurses applied a cream to his buttocks. On July 13, 2012 at 1:30 PM a skin observation was done on the resident. The resident's buttocks/sacrum and coccyx were bright red, blanchable with no open areas noted. In summary, for Resident #24, the facility did not ensure the care planned intervention of a cushion was consistent implemented and implemented timely when the resident requested it. 10NYCRR 415.12