Every finding on record at Massena Rehabilitation & Nursing Center

Based on observations, record review, and interviews, the facility failed to provide proper supervision to residents to prevent elopement and respond appropriately to wander alert alarms resulting in residents having access to unsafe areas and/or to exit the building undetected for three (3) of three (3) residents (Residents #2, #3, and #4) reviewed. Specifically, on 08/24/2025 Resident #2 had known wandering behaviors, exited the building undetected by staff, and was found by a visitor in the parking lot, asking for a ride. Resident #3, had known exit-seeking behaviors and exited the building undetected by staff on 10/06/2025 and 10/23/2025 and was found across a four-lane highway in a shopping plaza, after an undetermined period of time. Resident #4 had known wandering behaviors, and on 02/21/2026 was found in an unsecured, non-resident administrative area where there was construction and electrical equipment and floors that were not finished. This resulted in Immediate Jeopardy and Substandard Quality of Care to Residents #2, #3, and #4, and placed other residents with cognitive impairment at risk for the likelihood of serious injury, serious harm, serious impairment, or death. Findings include:The 04/05/2022 facility policy Out on Pass - Therapeutic Leave, documented a medical order was obtained for no out on pass, out on pass independent, or out on pass with responsible party based on the resident's needs and abilities at the time. A nurse would verify the medical order for current [out on pass] status. The receptionist would notify the nursing supervisor if a resident attempts to or leaves the facility without authorization. The undated facility policy Elopement Procedure, documented to immediately notify the Administrator and Director of Nursing if an elopement occurred. Initially upon inability to easily locate a resident, a page for please locate (resident's name) was completed three times. All staff would search their work area for the resident. If the resident was not located within five minutes, the supervisor would page code brown and a location three times. A complete search of the facility including the basement and roof would be conducted. The search must include all locked doors as well; it should not be assumed that a resident would not be behind a locked door. After a search of the interior of the facility, the search would extend to the outside grounds including looking in and under parked cars. Staff would search the surrounding neighborhood (one block radius). A photograph was in the wander alert device books on the units and the main office. 1). Resident #2 had diagnoses including dementia, anxiety, and depression. The 06/12/2025 Minimum Data Set assessment (a resident assessment tool) documented the resident had severe cognitive impairment, wandering behaviors for one to three days out of seven days, independent with mobility, and had a fall since their last assessment. The 12/13/2024 comprehensive care plan, revised 01/08/2025, documented Resident #2 had out on pass with responsible party privileges. Interventions included resident/representative would sign the resident out and indicate the anticipated return time. The 06/10/2025 comprehensive care plan, revised 09/12/2025 documented Resident #2 was at risk for elopement related to cognitive impairment, dementia, and voiced intentions to leave the facility; the resident often packed their belongings and sat in front of the nurse's station. The interventions included checking the function of the wander alert device per facility protocol, checking the placement of the wander alert device, and engaging in activities or tasks to keep the resident occupied. On 08/24/2025, Resident #2 eloped from the building into the parking lot and walked across the street. The 07/30/2025 Elopement Risk Evaluation completed by the Assistant Director of Nursing documented Resident #2 had prior elopement history or was currently exit seeking; wandered aimlessly; and voiced desires to leave or discontent with placement. Resident #2's total score was 36 (elopement risk is identified when there is a score greater than 10). The intervention was a wander alert device. The 08/24/2025 unsigned Facility Investigative Summary documented on 08/24/2025, at approximately 12:15 PM, Resident #2 was observed in the parking lot of the facility by a visitor. After review of the statements, it was concluded Resident #2 likely got on the elevator as visitors were arriving to the unit. When the resident got down to the first floor, visitors were entering the building, and because the wander alert system at the elevator was alarming, the visitors required assistance from the receptionist (Certified Nurse Aide #1) to enter the code (to disarm the alarm). While the receptionist was assisting the visitors, Resident #2 went out the sliding front door, unobserved. The 08/24/2025 Statement by Certified Nurse Aide #1 documented at approximately 12:20 PM, they went to the elevator to enter the code because the alarm was going off. When they were heading back, a visitor asked them to put the elevator code in so they could go upstairs. Then they heard the entrance door alarm. They went over and turned that alarm off, because they thought the alarm was due to another resident that was by the door. Then [the visitor that wanted to go upstairs earlier] came running to tell the receptionist there was a resident outside about to cross the road, and to call the unit for help. Staff came down to help and they were told to call the Assistant Director of Nursing to tell them what happened. Staff brought the resident back into the facility. The 08/26/2025 at 12:42 PM Assistant Director of Nursing progress note documented they were alerted Resident #2 was across the road. They went out to retrieve Resident #2. The resident was pale in color, shaking, and continuously stating they were sorry. During an interview on 05/06/2026 at 11:47 AM, Resident #2's family stated the facility notified them the resident exited the building (on 08/24/2025). The facility did not tell them the resident made it across the street until later when a staff member told them. The resident wore a wander alert device and they did not understand how the resident could leave with the device on. They stated the resident did not know how to take off the device nor did they try. During an interview on 05/06/2026 at 12:20 PM, Licensed Practical Nurse #14 stated the front entrance had alarms for when residents with wander alert devices got too close to the door. Residents could not just leave on their own. They were working on the day Resident #2 made it out of the building and all the way to the hotel parking lot across the street. Resident #2 had eloped a number of times but only made it to the parking lot. The resident packed up all their belongings every day and told them they were leaving. 2). Resident #3 had diagnoses including stroke, communication disorder, and weakness. The 08/19/2025 Minimum Data Set assessment documented the resident was cognitively intact, did not have wandering behaviors, and was independent with mobility. The 08/27/2024 Comprehensive Care Plan, revised 01/29/2026, documented Resident #3 had a care plan for their behavior problem, agitation, was aggressive at times, wandered, was exit seeking, and attempted to throw furniture. Interventions included assisting the resident with the use of the food delivery service application on their tablet, could utilize the elevators to freely move between the first and second floor, and if they were observed wearing their coat and hat, approach the resident to determine their unmet need and redirect them away from any exit doors. The 08/26/2024 physician order documented Resident #3 may go out on pass with a responsible party. The 06/06/2025 Out on Pass Determination form completed by Registered Nurse #3 documented the resident could go out on pass with a responsible party. The resident could move freely through the building and go outside without supervision. The resident could become impulsive regarding food and enjoyed fast food. A physician order was placed for out on pass. The Comprehensive Care Plan initiated 01/09/2025 documented Resident #3 had a care plan for their out on pass with responsible party privileges. Interventions included: the resident/representative will sign the resident out; refer to interdisciplinary team and social worker for concerns regarding out on pass status; and obtain out on pass order. On 06/15/2025, interventions were updated to include re-evaluate if the resident could go out on pass alone. There was no documented evidence Resident #3 was re-evaluated for out on pass privileges alone. The 09/24/2025 at 7:10 PM, Registered Nurse #2 progress note documented they were paged to the reception area where the receptionist saw Resident #3 walking out the front door. Registered Nurse #2 caught up with the resident in the front parking lot just before the road. The resident expressed anger about not having milk with their meal and not enough to eat. They had a handwritten grocery list as they were going to walk to the grocery store across the street to buy food. The resident was re-directed back into the building and onto their unit. The 10/06/2025 at 9:17 AM Social Worker #11 progress note documented they were called to help with Resident #3's behavior, as they were upset about not having the correct items on their breakfast tray. The resident did not want to wait for the social worker to fix the situation, so they left the building and went across the road to the grocery store. Social Worker #11, along with other staff went and found the resident. The social worker stayed with the resident at the grocery store, while the resident obtained their grocery items. The 10/07/2025 at 10:20 AM Registered Nurse #3 progress note documented Resident #3 was upset regarding breakfast. The resident packed their backpack, put on a coat and hat, and went downstairs. Social worker #11 spoke with the resident and returned them to their room. Registered Nurse #3 left the unit after the resident returned to their room. Resident #3 left the building shortly after and the Code Brown was called by reception. Registered Nurse #3, along with other staff, located Resident #3 in the grocery store parking lot. The 10/08/2025 Out on Pass Determination signed by Social Worker #11, Registered Nurse #3, and the Director of Rehabilitation Therapy documented Resident #3 could go out on pass with a responsible party. Resident #3 would go out shopping with a responsible party once per week as scheduled. The resident was deemed to have capacity to make their own decisions, however, if they did not follow the schedule and left the building without staff, privileges of shopping would be revoked. The 10/14/2025 Facility Reported Incident Five-Day Submission documented Resident #3 departed the facility on 10/06/2025 at approximately 9:20 AM and walked to the grocery store without notifying the charge nurse or signing out at the receptionist desk. The facility called a Code Brown and searched the facility and outside for the resident. Resident #3 was located on the sidewalk at the strip mall diagonally across from the facility at approximately 9:30 AM. Resident #3 could not effectively communicate their wants and needs verbally due to the disabling effect after their stroke. The resident would at times leave the facility without a family/staff member present and was care planned for being at risk for elopement. The resident did not wear a wander alert device due to being cognitively intact and generally leaving with a destination in mind such as a grocery store or fast-food restaurant. The Comprehensive Care Plan revised 10/12/2025 documented Resident #3 had a care plan for out on pass with responsible party privileges. Interventions included to remind the resident the privilege of scheduled shopping trips could be revoked if the policy they signed was not followed. The Comprehensive Care plan initiated 08/27/2024 and revised 10/12/2025 documented the resident had a care plan for their behavior problem, agitation, and aggression at times, wandering, and exit-seeking. Interventions included activities (staff) will bring the resident to the grocery store and fast-food restaurants at least weekly. The Nursing Home Facility Incident Report submitted on 10/23/2025 at 5:34 PM by the Administrator documented the allegation type was other, and the incident was not an elopement. The facility investigation was complete with care plan violations. The incident occurred on 10/23/2025 at 3:15 PM and the facility staff were made aware on 10/23/2025 at 4:15 PM. Resident #3 was seen by staff who were driving by in the parking lot to the shopping plaza across the street. The resident was returned to the facility in a staff vehicle. The immediate response and plan to prevent recurrence was to meet with the interdisciplinary team on 10/24/2025 to determine if the resident should be allowed to go out on leave of absence to the shopping plaza by themselves since they had shown the ability to safely navigate the crosswalk, shop independently, and had purpose. There were no progress notes in the electronic medical record related to Resident #3's exit seeking behaviors or exiting the building on 10/23/2025. There was no documented evidence that the resident was reassessed for their ability to leave the facility alone. During an observation on 05/04/2026 at 7:20 PM, the facility was located on a side street without a sidewalk. To get to the sidewalk, an individual would have to cross the street without a crosswalk between the facility and a hotel located directly across the street. The sidewalk went downhill to a large five-lane state highway. Once across the highway, there was a road and access to multiple parking areas for multiple businesses, with no sidewalk. The road and businesses within the shopping plaza were all at a downhill slope to access. The grocery store was at the far end of the shopping plaza with multiple parking areas and driving lanes. During an interview on 05/06/2026 at 9:43 AM, Certified Nurse Aide #12 stated they worked with Resident #3 and were very familiar with them. The resident was known to elope and had a wander alert device for a while, but they took it off and hid it in the ceiling tiles. The resident would get upset about the food or something and just leave. Most of the time, they could catch the resident in the parking lot and they would walk with them and bring them back to the building. Resident #3 would take advantage of the busy staff and leave. There were a few times they were unable to catch the resident. They called a Code Brown and searched for the resident, and they were found at the shopping plaza across the street. Resident #3 was never on one-to-one supervision, someone would just stay alert to their room. During an interview on 05/06/2026 at 9:59 AM, Certified Nurse Aide #13 stated the resident was exit seeking since admission. They were on one-to-one supervision when they first got to the facility, then had a wander alert device. The resident learned how to take the wander alert device bracelet off and hide it. Staff found bracelets in the ceiling. Resident #3 exited the building a number of times before they made it to the grocery store. There was a time when they were found two streets over in the back parking lot by the gate, but it was still considered on the property. When they did not know where Resident #3 was, they would go out and walk the building to find them. The resident was fast and they found them in the back parking lot and staff walked with them around the front of the building and came back inside. When the wander alert device was discontinued, Resident #3 was not put on one-to-one supervision or safety checks. The day Resident #3 went to the grocery store for the first time, they were down in the lobby very upset about their breakfast. They were able to get Resident #3 back to their room and they thought they were calm with a new breakfast tray coming. They went to assist with another resident when they came out of that resident's room they heard the code for a missing resident. During an interview on 05/06/2026 at 12:12 PM, Registered Nurse #3 stated they were the Unit Manager at the time of Resident #3 elopements. Resident #3 had poor impulse control and exit seeking behaviors. Another staff member and themselves went to the grocery store to get Resident #3 one time, but social work stayed at the store and took them shopping. Resident #3 would stay in the lobby, wait for the receptionist to get busy with another resident or visitor, and just walk out. The doors were an automatic system and Resident #3 would just walk out. The receptionist would finish what they were doing and see the resident in the parking lot, but they had already left by that point. Resident #3 usually left on the evening shift. During an interview on 05/06/2026 at 12:20 PM, Licensed Practical Nurse #14 stated Resident #3 used to run out all the time. They had to chase them down with a van. The residents were not allowed to go out on their own. During an interview on 05/06/2026 at 4:39 PM, Registered Nurse Supervisor #2 stated Resident #3 had exit seeking behaviors, it was random or because the meal tray was wrong. There was a time or two they would meet Resident #3 in the parking lot. There was another time Resident #3 went across the street. They would put the resident on an unofficial one to one supervision for the shift if they saw behaviors. 3). Resident #4 had diagnoses including dementia with agitation and major depression. The 01/04/2026 Minimum Data Set documented the resident had significant cognitive impairment, exhibited wandering behaviors for one to three days out of seven days, and was independent with mobility. The Comprehensive Care Plan initiated on 12/21/2023 and revised 02/22/2026, documented Resident #4 was an elopement risk due to dementia and mobility. Interventions included a wander alert device, check the function of the wander alert device, and check the placement of alert device every shift. The 10/29/2025 Comprehensive Care Plan documented the resident was at risk for self-directed or other directed harm. Interventions included if the resident wandered or was pacing, initiate visual supervision during acute episode. The 04/28/2025 Physician Order documented to check the functionality of the wander alert device every shift for safety.The 05/01/2025 Elopement Assessment documented Resident #4 was at risk for elopement based on being fully ambulatory, wandering aimlessly, and exhibiting hallucinations/delusional thinking/confusion/paranoia, or was unpredictable. There were no attempts of elopement. The 02/21/2026 at 6:41 PM Nursing Supervisor #5 progress note documented Resident #4's spouse was unable to the locate resident, so they asked staff help look for the resident. Resident #4 was found in the building's classroom, down a wing where the door should be locked. The receptionist spoke with staff and the resident's spouse that a registered nurse helped the receptionist earlier to turn off an alarm for the door, but that was it. The resident's wander alert device set the alarm off for the door leading down that hallway even though it is unlocked, and the registered nurse had not gone down the hall to look for a resident. The Assistant Director of Nursing and Maintenance were notified and statements were collected. The above 02/21/2026 at 6:41 PM Nursing Supervisor #5 progress note was struck out on 02/22/2026 at 2:11 PM with a note in error. The 02/21/2026 at 7:01 PM Assistant Director of Nursing progress note created on 02/22/2026 at 1:16 PM documented the resident's spouse came to see resident and was unable to locate them. Staff began looking for the resident. The resident was found in the classroom, down the hall in the business office area by a certified nurse aide. The resident was sitting in a calm manner on a bed, unharmed. Their spouse was at their side. The resident's skin remained intact with no new areas of concern, no bumps, lumps or bruising. The resident was able to ambulate per baseline and had no verbal/nonverbal indications of pain or discomfort. The 02/21/2026 unsigned facility investigation documented Resident #4's spouse came to see the resident and was unable to locate them. Staff began looking for Resident #4. The resident was found in the business office area, by Certified Nurse Aide #9, in the education room. The area was secured with a keypad (and an alarm to activate against wander alert device). Registered Nurse #8, who was covering the reception area, noted Resident #4 was wandering in the front lobby area, which they did often before dinner, waiting for their spouse to come in. Registered Nurse #8 noted prior to the incident, an alarm was activated, and it was not the front door. Registered Nurse #8 notified Licensed Practical Nurse #6. Licensed Practical Nurse #6 cleared the alarm on the administration wing by entering the code. Licensed Practical Nurse #6 was not engaged to check the area as nobody was around when they looked down the hall and the alarm would sound if a resident with a wander alert device got close to the alarm. At the instruction of the Administrator, Environmental Services completed a system check on the door in question and it was determined the door was not locking when the system was engaged. The keypad was serviced and the system was back in working order to lock when the wander alert device engaged it. The doorway that led to the old business office was not used by staff. Witness Statements included with the investigation documented: - by Registered Nurse #7, Resident #4's spouse asked if they saw Resident #4 as they were unable to locate them. They notified the surrounding staff to help look for the resident. When they went to the front reception area, Registered Nurse #8 stated they saw the resident walking towards the dining room earlier. - by Registered Nurse #8, shortly after arriving to the front reception area for their shift, they observed Resident #4 standing in the front lobby. When the resident approached the white railing, the door alarm sounded. After they reset the door code, Resident #4 headed down the hallway towards the dining room. They did not see Resident #4 return to the front lobby. The front door alarm sounded a second time when a visitor attempted to push the door open. They were able to reset the alarm, five minutes later, they heard the door alarm again, Licensed Practical Nurse #6 entered the area, and tried to reset the alarm to no avail. Licensed Practical Nurse #6 went down the C-1 hallway, and Registered Nurse #8 did not visualize Licensed Practical Nurse #6, but heard them say, oh, it's this door alarm. I shut it off. Approximately, 30-45 minutes later, a staff came to reception area to inquire if they had seen Resident #4.- by Licensed Practical Nurse #6, while they were downstairs, on their way up to B2 unit, Registered Nurse #8 asked them if they could help them, and they walked over to the front door main entrance. Registered Nurse #8 was trying to shut off the alarm that was going off. They listened and walked towards the alarm noise. They told Registered Nurse #8, oh, it was this door by the Administrator's office. To their knowledge that door was always locked and to get in you had to put in a code. So, they put the code in and went back up to their assigned unit.- by Certified Nurse Aide #9, they walked by the door to the old business wing and saw Resident #4 down the hallway. They went and got help to get Resident #4. They found the resident unharmed. During an interview on 05/06/2026 at 12:07 PM, Registered Nurse #10 stated Resident #4 wandered all the time. For example, Resident #4 was just on the unit on the other side of the building and the unit manager called the unit to let Registered Nurse #10 know. They knew Resident #4 was safe on that unit, so they just kept track of Resident #4's location with each other. During a telephone interview on 05/06/2026 at 2:17 PM, Registered Nurse Supervisor #5 stated they recalled Resident #4. The resident was usually nonsensical (medical term used for senseless or irrational) and could not follow directions. They wandered and picked up things along the way. They were working the night Resident #4 got into the old business office area. They knew the door did not lock, everyone used it to get back to the classroom, or the back side of the front desk area. They were not provided training for their position and were not taught how to use the work order system. The supervisor computer did not have an icon for work orders. Resident #4 wore a wander alert device. The wander alert device would alarm, but there was no way to tell where it was coming from, they just had to walk around and find where the noise was coming from. They were not sure how the resident got back there, but figured they just opened the door and walked in. Registered Nurse Supervisor #5 was not there when the resident was found. Registered Nurse Supervisor #5 had only gone back to that area a few times on other nights. The area has a long hallway that ended with multiple rooms. There was construction and electrical equipment back there and floors that were not finished. Resident #4 was known to grab doors and anything they could. During an interview on 05/05/2026 at 8:52 AM, Receptionist #28 stated residents could sign out in the binder with a friend or family. They could not sign themselves out. Residents were allowed to sit on the patio, and they would watch them when they were out there. If a resident could not be located, they thought they would call the supervisor, but they were not sure. They had never had that happen, so they were not sure what would happen. During an interview on 05/05/2026 at 5:15 PM, Certified Nurse Aide #29 stated they were a certified nurse aide on the unit and went on transports with residents primarily, but they also picked up the 4:00 PM to 8:00 PM front desk coverage to help out. If a resident wanted to leave on their own, they would ask where they were going first. They were not sure if residents could leave alone. If a resident was an elopement risk, they would wear a wander alert device. They did not have a book of residents that were at risk of elopement or a book of residents in the building for identification. During an interview on 05/06/2026 at 3:51 PM, Assistant Director of Nursing stated elopement was when a resident went out one of the doors without staff knowing or without a witness. They generally had a full-time receptionist and a weekend person, but certified nurse aides that knew how to answer the phone could cover the front desk area. They were given a list of extensions. When a staff member was covering the front desk, they knew the at-risk residents by wander alert devices being a part of their in-service training, and they knew the codes for a missing resident. They stated they printed the supporting documents, so they must have been the one that did Resident #2's elopement investigation. Whoever completes the accident and incident report was the person that did the investigation. Resident #2 eloped on 08/24/2025. Based on the investigation, they did not know who the resident was in the lobby near the door when the receptionist turned off the alarm. They were unable to outline how the resident was able to exit the building. They stated that some families had the code to stop the alarm, so they did not have to bother the staff when they wanted to take residents downstairs or out for a visit. They stated there was a book with all the residents with a wander alert device and elopement risk residents. Certified Nurse Aide #1 was covering the front desk and should have known Resident #2 as they worked on that unit. When the Assistant Director of Nursing got to the resident outside on 08/24/2025, they were pale and shaking, they were scared. They did not know what to do once they were outside, they were just scared. They were not sure that Resident #3 eloped as they were of sound mind. The interdisciplinary team would discuss and agree if a resident was able to go out on pass, and then there would be a physician order for it. The interdisciplinary team had to agree that the resident was safe to go out on pass. There was an out on pass assessment, they thought nursing staff and a medical provider had to sign the assessment and it was done on admission. The Assistant Director of Nursing stated they would have to ask the Administrator if residents could leave without supervision. If the out on pass assessment documented the resident could leave on pass with a responsible party, they would not be able to leave alone. Resident #3's care plan documented their out on pass privileges would be reassessed if they went out alone again. They did not know if the resident was re-assessed after the second elopement. Resident #4 was found in the old business office area. The area was supposed to be locked, but it was not locked at the time. The keypad was not working. The door allowed the resident to go in, but the wander alert system alarmed. During a telephone interview on 05/07/2026 at 9:59 AM, the Medical Director stated out on pass privileges were nurse driven privileges if the resident had decision-making capacity. They did not sign the out on pass assessments. Resident #2 left in the middle of the night; they had an underlying dementia diagnosis. They were found at a motel next door. They did not think Resident #2 could leave without supervision; there was a risk to this resident. Resident #3 had a brain injury and was at risk for elopement. They had fluctuating behavior with poor impulse control; they nearly needed one to one supervision. They would wait for the receptionist not to be looking and then they would leave. They were not safe to leave without supervision. They were at high risk of being assaulted in public due to their behavior. They should have been on a closed unit. They were not familiar with Resident #4, however, stated Resident #4 could not leave without supervision. All three residents had underlying dementia or cognitive disorder, which put them at risk for negative outcomes such as harm to self and harm to others. They did not take part in investigations, but only if it were a recurring issue, then it would come to the Quality Assurance meetings. During an interview on 05/07/2026 at 11:58 AM, the Administrator stated any resident had the ability to go out on pass. If they lacked capacity, they could go out with a health care proxy. They had to tell the nurse and sign the book in the lobby. There was a form in the computer that was completed, but they did not sign that form as part of the process. Residents could go out on the patio and they did not have to sign out for that. Elopement was when someone left the building and did not have the mental capacity and they did not know where they were. Resident #2 could not leave without supervision they did not have capacity. However, they consistently packed up to leave. They were moved to the second floor and had a wander alert device. If a resident with a wander alert device entered the elevator, the doors would stay open, and it would not function. They were not sure how Resident #2 got downstairs. Families might know the code for the elevator and they did have families that visited daily that had the code. They had resident assistants, certified nurse aides, medical records staff, or activities staff that would help at the front desk. They did not get any specific training for working the front door. They had the wander alert device and elopement training on hire and annually. There was a book that identified the residents at risk for elopement. There was no book with information about residents with out on pass privileges, nothing to identify the residents that needed a responsible party, could go alone, or did not have pass privileges. Resident #3 was previously identified as not being able to go out on their own, they took off the wander alert device, and Resident #3 went shopping with activities staff. They only went out one time without notifying anyone. Resident #3 should have told the nurse and receptionist when they left. They could leave without supervision because they had decision-making capacity. They had an elopement in June 2025, they were not aware of any attempts in September 2025 and they did not think there were any elopements in October 2025. When reminded of

Based on observations and interviews (iQIES Intake), the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met their daily nutritional needs for two (2) of two (2) meals (the 05/04/2026 lunch and dinner meals) and for one (1) of four (4) kitchenettes reviewed. Specifically, the 05/04/2026 lunch and dinner meals were not served at palatable and appetizing temperatures, were not flavorful, and had missing food items; and the Unit A2 kitchenette was not stocked with sufficient snack items available to residents. Findings include:The facility policy Food Temperature, dated 09/2018, documented the policy was to ensure safe and quality food items. The facility would obtain and record temperatures of food items prior to serving the residents. The policy did not document the appropriate serving temperatures for hot and cold food items. The facility policy Food Preparation and Service, dated 08/2025, documented food is cooked in a manner to conserve nutritive value, flavor, appearance, and texture. The danger zone for food temperatures is between 41 F and 135 F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illnesses. Hot foods are held at 135 F or higher on the steam table. Cold foods are held at 41 F or lower. Potentially hazardous foods include meat, poultry, seafood, cut melon, eggs, milk, yogurt and cottage cheese. Potentially hazardous foods must be maintained below 41 F or above 135 F. The facility policy Frequency of Meals, revised 08/2025, documented nourishing snacks would be available for resident who needed or desired additional food between meals. Evening snacks would be available routinely to all residents. Nourishing snacks were items from the basic food groups, offered either separately or with each other. The facility would choose the snacks that were offered at bedtime. However, the dietitian and food services manager would solicit input from the residents and/or the resident council. The undated facility weekly par level for unit snacks documented 1/3 box of graham crackers, 6 boxes of fig bars, 8 packages of peanut butter crackers, 5 boxes of gingerbread cookies, 1/3 box of animal crackers, 1/3 box of cream of mushroom soup, 1/2 box of chicken rice soup, 1/2 box of chicken noodle soup, 1/2 box of vegetable soup, 1 box of tomato soup, 18 orders of ice cream. Snack Availability:On 05/05/2026 at 9:09 AM, the following was observed in the A2 kitchenette: 9 packets of graham crackers, 2 packs of peanut butter crackers, 1/2 open bag of mini marshmallows, 5 chocolate pudding cups, one 18-ounce jar of peanut butter, 1 1/2 loaves of wheat bread, 5 English muffins, hot chocolate packets, tea, condiments, sugar and sugar substitute. Refrigerated items included several containers of thickened liquids, milks, Mighty Shakes, 2 gallons of whole milk, other various juice containers, 3 sandwiches labeled PBJ. Freezer items included multiple cups of sherbert, 1 ice cream sandwich, 2 quarts of ice cream, and 5 cups chocolate ice cream. On 05/08/2026 at 10:03 AM, the following was observed in the A2 kitchenette: 23 cups of ice cream/sherbert, 2 packets of two graham crackers, 1 bag of graham cracker cookies, and an open jar of peanut butter. Meal Observations:During an interview on 05/04/2026 at 12:20 PM, Resident #36's family stated food was the biggest concern. Meals were late, not palatable, and hot meals were always cold. The meals were not good with few options. They frequently brought food in for Resident #36. During an observation and interview on 05/04/2026 at 12:55 PM, the A2 tray cart left the kitchen. Dietary Aide #33 stated the tray carts did not usually leave the kitchen with the insulated covers on, but they were using them today. During a meal observation and interview on 05/04/2026 at 1:10 PM, Resident #9's was served their lunch tray. Their lunch tray was tested, and a replacement was requested. Licensed Practical Nurse #18 observed and verified the temperatures for the meal tray at 1:11 PM. The fish was 118 degrees Fahrenheit, mashed potatoes were 121 degrees Fahrenheit, mixed vegetables were 134 degrees Fahrenheit, fruit cup was 70 degrees Fahrenheit, and the coffee was 128 degrees Fahrenheit. The fish was dry, with a jerky like texture, and the fruit cup was room temperature. Licensed Practical Nurse #18 stated beverages were normally served on the trays, but they were not served on the trays for lunch on 05/04/2026. During an observation and interview on 05/04/2026 at 1:10 PM, Certified Nurse Aide #16 stated the meals could be small and were often missing items. If items were missing or the resident wanted an alternative they had to go downstairs for it. Resident #45's meal ticket documented 1/2 cup of potatoes, 3 ounces of baked fish, 4-ounce Mighty Shake (nutritional supplement), 1 serving of peanut butter and crackers, 8 ounces of cola, 1/2 cup of gelatin, and 1 package of margarine. These items were not included on the tray. During an observation and interview on 05/04/2026 at 1:13 PM, Resident #43 stated they were served sandwiches for supper on most nights. Recently, they were served sandwiches for supper 5 days in a row. They were supposed to get double portions and did not usually get them. The portions were very small, and items were often missing or were wrong. Resident #43's meal ticket documented double portions. During an observation on 05/04/2026 at 1:13 PM, Resident #10's meal ticket documented 4-ounce Mighty Shake and 8-ounces of water. These items were not present on the tray. During an observation and interview on 05/04/2026 at 1:20 PM, Resident #42 stated the food was not good and the portions were small. They were supposed to get double portions but did not usually get double portions. They stated they did not drink coffee but was served coffee. For the 05/04/2026 lunch meal tray they were missing their pudding. Resident #43's meal ticket documented double portions. During an observation on 05/04/2026 at 1:21 PM, Resident #12's meal ticket documented 4-ounce Mighty Shake, 8-ounces nectar thickened water, 4-ounces nectar thickened milk, and 8-ounces nectar thickened apple juice. These items were not present on the tray. During a meal observation and interview on 05/04/2026 at 5:45 PM, Resident #23 was served their dinner tray. Their dinner tray was tested, and a replacement was provided. Certified Nurse Aide #34 observed and verified the temperatures for the meal tray. The sausage was 103 degrees Fahrenheit, the green beans were 101 degrees Fahrenheit, peppers and onions were 99 degrees Fahrenheit, milk in the carton was 53 degrees Fahrenheit, and coffee was 120 degrees Fahrenheit. Their tray was missing water and margarine. The rice was in a semi-circle scoop form, was plain white rice with no flavor or seasoning, slightly mushy, and lukewarm. The green beans were bland canned beans, lukewarm, with no seasoning. The tray had a very small portion of peppers and onions; they were barely lukewarm, overcooked and mushy. During an interview on 05/04/2026 at 5:47 PM, Resident #23 stated they liked their margarine, but typically never got it. They were often missing items from their tray, or the items did not match the tickets. They bought their own snacks and drinks and kept them in their room, because snacks were often not available. During a dinner meal observation and interviews on 05/04/2026 at 5:57 PM, Resident #42, did not receive a brownie, double portions, water, or margarine on their meal tray. The resident stated the food was okay, but not very warm. The rice was not good; it was bland and mushy with no flavor. Resident #43 stated they got their double portion, but the food was only lukewarm and did not taste good. They did not receive any margarine, and the rice and green beans had no flavor. Resident #44 stated the rice was too sticky/mushy, all in one clump, it was lukewarm at best, and the sausage was okay. During an interview on 05/05/2026 at 8:23 AM, Resident #11 stated the hot food was always served cold. The following was observed during the breakfast meal on 05/05/2026:-at 9:20 AM, Resident #9's meal ticket documented 8 ounces prune juice, 8 ounces orange juice, 4 ounces whole milk and 4 ounces cream of wheat. These items were not present on the tray.-at 9:32 AM, Resident #29's meal ticket documented 1/4 cup pureed sausage patty. The item was not present of the tray. During an observation on 05/08/2026 at 12:32 PM, an unknown resident was eating lunch at the B2 nurse's Station. The lunch for the day was fish, baked potato, and spinach. The fish was tan in color and had the same dry, jerky appearance as the fish on 05/04/2026. During an interview on 05/04/2026 at 2:51 PM, Dietary Aide #36 stated the food that was ordered by the residents was not always what they received for their meals. The unit also ran out of snacks to offer the residents. During an interview on 05/04/2026 at 5:52 PM, Certified Nurse Aide #34 stated meal trays were often missing items and the tray items did not match the meal ticket. They often bought snacks on their own for the residents because they did not have them in the evening. They were told by the facility not to, and they were not reimbursed, but they felt bad for the residents. During an interview on 05/06/2026 at 12:20 PM, Licensed Practical Nurse #14 stated hot food was served cold, and cold food was served at room temperature. The meals tickets did not usually match the meal tray, and missing items were usually condiments. The milk was expired, but the staff caught that before it was served. The snacks were limited, because the staff helped themselves with the snacks in the unit or the items were still frozen solid when they were brought to the unit. During an interview on 05/08/2026 at 10:05 AM, Certified Nurse Aide #12 stated the residents complained the food was cold when it should be hot, and it did not have flavor. The meal tickets sometimes did not match what the resident received. If the facility was out of oatmeal, the resident just did not get it on their tray. If they were missing a beverage, they could sometimes replace it with another beverage. The trays sometimes were missing a side dish or snack, and they tried to replace them if they could. For example, the ticket would say goulash, but the resident would get meatloaf because the kitchen did not have pasta for the goulash. During an interview on 05/08/2026 at 10:30 AM, Licensed Practical Nurse #18 stated the hot food was not served hot, and the food did not follow the menu. The kitchen staff did not pay attention to the meal tickets. They would send up regular consistency trays for resident that needed pureed food. The unit staff caught those, and they would have to call for another tray. Diabetic residents got sugary items, they did not give double portions, and the food was flavorless. The weekends were the worst. They served sandwiches for two meals in a row. They never had snacks for the residents. They needed a manager or assistant manager in the kitchen. During an interview on 05/20/2026 at 9:01 AM, [NAME] #38 stated per diem Food Service Director #41 came in 2 days a week and did the ordering. They used the 4-week menu for ordering food items. They ordered food, and it was not received. The food order was reviewed by Corporate, and they would take things off the order, especially if the order was over budget. They had snacks in the facility now, but they did not for a while. If an item was needed for a meal and they did not have it, sometimes the Administrator would go to the store and buy it. They were told by the former cook that serving temperatures were between 175 and 190 degrees Fahrenheit for hot food, and between 32 and 38 degrees Fahrenheit for cold food. The fruit for the fruit cup did not come in cold. It had to be served in bowls and then the bowls went into the cooler to be chilled. The serving of the fruit was not usually done until meal service time, so they did not always have time to go in the cooler. The fish, potatoes, mixed vegetables, fruit cup, sausage, green beans, peppers and onions, or milk served at the temperature they were served at was not appropriate. Milk should not be served that warm. The last dietary aide on the service line was responsible for checking to ensure all items listed on the ticket were on the tray. During an interview on 05/20/2026 at 1:14 PM, former Food Service Director #40 stated per diem Food Service Director #41 did the food ordering now. They did it when they worked there. The food was ordered based on the 4-week menu. The order would go to a third-party company that would remove items as they saw fit, especially if the order was over the $6 per resident per day allotment. They would remove items like pasta, chicken, and ice cream. It was random what was removed. They did not know what food they were going to get until it arrived at the facility. They were not allowed to speak with the food distributor directly; they could only communicate with the third-party company. When food was missing from the order, the third-party company would say that the facility did not order it. They knew they ordered it, because they kept their own record of what the original order included. They spent their own money at the grocery store to make sure residents had what they needed. The food that was ordered was low grade food to fit the low budget of $6 to create 3 meals, 2 desserts, snacks, and beverages. They also had to order the thickened beverages within the same budget. The food they got in the orders was frequently pre-packaged low-grade food. Hot food should be served to the residents at over 160 degrees Fahrenheit, and cold food should be served under 40 degrees Fahrenheit. Any hot food served under 160 degrees Fahrenheit was not acceptable. Milk should not be 53 degrees Fahrenheit, and a chilled fruit cup would not be considered chilled if it was 70 degrees Fahrenheit. The dietary aides on the line were responsible for ensuring the meal trays had everything the meal ticket included. The last person on the food line was supposed to do a review of the whole tray to ensure accuracy. A third of a box of graham crackers are approximately 20 packages of 2 crackers, 8 packages of peanut butter crackers were approximately 64 servings, and a third of a box of animal crackers was approximately 33 packages of crackers. During an interview on 05/21/2026 at 9:00 AM, the per diem Food Service Director stated they were responsible for ordering food for meals, beverages, and snacks. They used the menu and ordered based on a full census of 162 residents. The order was reviewed by a third party company to find the cheapest price. If the order was within the budget the orders were placed. If the order was over budget, the third party contacted them to remove or try to change the items for a cheaper option. They did not know what the budget was, and the corporation would not tell them the budget number. They would just say how much they were over budget. Corporate got to decide if the overage would be paid, or if more cuts needed to be made. They could only order to the approved par levels. During an interview on 05/21/2026 at 11:33 AM, the Registered Dietitian #43 stated they did not provide meal oversight. The meal ticket and meal tray should match, if they did not there should be an equivalent item to replace it. They were not notified of tray accuracy issues. To their knowledge the facility had never run out of food or the main menu item. They were not aware of any issues with food service in the facility. No one informed them that meals were not following the approved menu. They were not aware of sandwiches being served regularly instead of the menu. Sandwiches were on the menu, but they would not be served twice a day, nor 5 days in a row. During an interview on 05/21/2026 at 1:12 PM, the Administrator stated their current census was 136 residents but could be up to 162 residents. Per diem Food Service Director #41 was responsible for ordering food and determining the par level of food for the facility. They placed the orders, and sometime things were back ordered but they were not notified of back orders until they did not show up at delivery. They stated they sometimes had to go to the store to get milk because it did not come with the delivery. The third-party company would let them know that the food order was over budget. They stated they were almost always over budget. The budget came from Corporate. The par list did allow for enough snacks for the residents. The staff on the units would come down about 2:00-2:30 PM to get snacks for the residents. They were not aware of every running out of snacks for the residents. They stated they were responsible for ensuring food was good quality. The cooks should not send out food that was not warm or cooked properly. The appropriate serving temperature for hot food was over 120 degrees Fahrenheit, and cold food was under 50 degrees Fahrenheit. Milk should not be greater than 38 degrees Fahrenheit and milk at 53 degrees Fahrenheit was not appropriate. The last dietary aide on the service line was supposed to check over the trays. Everything listed on the meal ticket should be located on the tray with the exception of cold beverages. Cold beverages were served on the unit by the unit staff, so they did not get warm on the meal cart. The kitchen ran out of the main dish before, and the item was substituted. The registered dietitian should be notified when items were substituted, but that was not always happening. There was a time the kitchen did not notify them of a change in the menu. They stated they started looking into it about 2 months ago, because the residents were sending them photos of their meals. 10 New York Codes, Rules and Regulations 415.14(d)(1)(2)10 New York Codes, Rules and Regulations 415.14(f)(3)(4)

Based on observation, interview, and record review (iQIES intake 2793248), the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services. Specifically, the facility did not have a Food Service Director to manage the kitchen and food service; the full-time dietetic technician did not have the required credentials for the position of Food Service Director, and the registered dietitian worked remotely and was not available on site. Refer to citations (F800 - Food and Nutrition Services and F812 - Food Safety Requirements). Findings include: The 05/04/2026 Facility Assessment documented Former Food Service Director #40 was the current Food Service Director on Medical Leave; and the Per Diem Food Service Director was Per Diem Food Service Director #41. The Current Staff List provided by the facility documented Nutrition Assistant #39 was a Dietetic Technician. The undated Food Service Director Job Description documented the purpose of the position was to develop, plan, coordinate, and execute food service for all residents, personally or through delegation of duties to dietary staff. They provided leadership, support, and guidance to ensure food quality standards, inventory levels, food safety guidelines, and customer service expectations were met. They provided overall direction and coordination of the department including direct supervisor of dietary staff. The 03/01/2014 Dietetic Technician Job Description documented the dietetic technician obtained all information necessary for nutritional care planning. Duties included interviewing all new admissions for a dietary history and recording all the information; writing monthly progress notes on appropriate residents and ensuring that care plans were implemented; monitoring meal intake on all residents and calculating food intakes when necessary; and verifying physician diet orders or changes and documenting them in the medical record. They must be a graduate of a 2-year college with associates of applied science in dietetic technology and registered or registration eligible with Commission on Dietetic Registration and membership in Academy of Nutrition and Dietetics was preferred. During an interview on 05/04/2026 at 12:18 PM, the Ombudsman Coordinator stated food was the biggest issue at the facility. The kitchen staff had no management. During an interview on 05/04/2026 at 5:47 PM, Resident #23 stated no one from dietary ever came to check on their preferences or updated their meal plan with them. During an interview on 05/04/2026 at 2:46 PM, [NAME] #42 stated there was no kitchen manager for at least the last two weeks. They stated Per Diem Food Service Director #41 came in to train new kitchen managers and ordered food and supplies while they were without a kitchen manager. Per Diem Food Service Director #41 had previously worked there a long time ago. During an interview on 05/04/2026 at 2:51 PM, Dietary Aide #36 stated staffing was good for the day shift, but the night shift for dinner usually only had 2 or 3 staff total. During an interview on 5/20/2026 at 9:01 AM, [NAME] #38 stated the kitchen did not have a supervisor. They tried to get the staff to help, but they just ignored them. They did not have the ability to write up staff for not doing their job. They stated they were kind of acting in a manager role because the kitchen duties had to get done. They stated they thought the facility had a registered dietitian; however, they had never seen them. During an interview on 05/20/2026 at 1:14 PM, Former Food Service Director #40 stated they had not worked in the facility since December 2025. They had since hired Per Diem Food Service Director #41, and another full-time food service director since they left. Per Diem Food Service Director #41 was only responsible for ordering food. The facility had a Registered Dietitian on record; however, they were never in the facility, and they never met or spoke with them. During an interview on 05/21/2026 at 9:00 AM, Per Diem Food Service Director #41 stated they were in the building once a week to review inventory and order supplies and food. They were not responsible for making food, cleaning the kitchen, or the accuracy of the meals. They did not oversee the kitchen. The facility had a registered dietitian on staff who worked remote only and they never met them personally. They did not have a contact phone number for the registered dietitian. The facility had Nutrition Assistant #39, but they were currently unavailable. During an interview on 05/21/2026 at 11:33 AM, the Registered Dietitian #43 stated they were hired to provide remote dietetic support. The facility had a dietary liaison, Nutrition Assistant #39, that was full time at the facility and provided oversight. Registered Dietitian #43 stated they did nutrition assessments and followed wounds, tube feeding, and dialysis residents. If they made a recommendation, the nurse practitioner would approve it, and the nutrition assistant would add it to the meal ticket. The facility was in between Food Service Directors, and the nutrition assistant did not have any certifications or degrees in dietary or nutrition sciences. The nutrition assistant performed clerical tasks and interviewed residents for admission intake and preferences; they did not do any clinical tasks or chart on the residents. They referred to Nutrition Assistant #39 as a Dietary Aide when documenting. During an interview on 05/21/2026 at 1:12 PM, the Administrator stated they were currently responsible for managing the day-to-day kitchen operations. The last Food Service Director left about a month ago. They had a consultant registered dietitian that worked remotely and was responsible for approving menus, menu substitutions, and monitoring weights of residents and dietary notes. Nutrition Assistant #39 was the diet technician, and they communicated with the registered dietitian. Nutrition Assistant #39 was not a registered dietetic technician; they carried the title at the facility of dietary technician. They did not have any certifications or credentials in nutrition. They were previously a certified nurse aide. 10 New York Codes, Rules and Regulations 415.14(a)(1)(2)

Based on observations and interviews (iQIES Intakes 2607654 and 2985855), 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 spoiled food; an unclean freezer; unclean surfaces; a steamer oven was in disrepair; and the box compactor room was piled with empty boxes.Findings include:The facility policy Kitchen Sanitization, dated 08/2025, documented food service should be maintained in a clean and sanitary manner. All utensils, counters, shelves and equipment should be kept clean and maintained in good repair. Between uses, cloths and towels used to wipe kitchen surfaces will be soaked in containers filled with approved sanitizing solution. Sanitizing solution would be changed at least once per shift or if solution becomes cloudy or visibly dirty. The Food Service Manager was responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff would be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment.Electronic communication with the Administrator on 05/19/2026 documented the facility did not have kitchen cleaning logs for May 2026. There was no documented evidence of work orders from 04/15/2026 to 05/04/2026 for kitchen maintenance or repairs for the streamer oven or walk-in freezer. The following observations were made in the main kitchen on 05/04/2026: -at 11:24 AM, the walk-in cooler contained moldy cucumbers.-at 11:30 AM, the walk-in freezer had water dripping from the condenser with ice built up on the boxes below and on the floor. [NAME] #38 stated they had a freezer truck parked behind the facility with frozen food. The food in the walk-in freezer was removed and placed in the freezer truck when the condenser was repaired last week. However, the condenser began dripping water again.-at 11:32 AM, the utensil container was soiled.-at 11:35 AM, there were numerous drain flies by the juice system and dish washing areas.-at 11:37 AM, the wheeled garbage can bases were heavily soiled.-at 11:47 AM, there was built up food debris in the reach-in refrigerators and freezers.-at 11:48 AM, there was built up debris under and behind kitchen equipment throughout the kitchen.-at 11:52 AM, there were two sanitizer buckets for the entire kitchen; one with a very soiled cloth and liquid. The wiping cloths were disintegrated.-at 12:10 PM, the steamer oven door seal was in disrepair and boiling liquid leaked out consistently while in use. The floor drain did not have a smooth transition from the tile to the grate which puddled the liquid instead of allowing it to flow down the drain. During an observation and interview on 05/04/2026 at 3:00 PM, there were boxes piled up around the box compactor. The boxes were piled to the height of the compactor in a semi-circle around the machine. The Environmental Services Director stated the box compactor did not work for approximately a week and a half. It was repaired on 04/22/2026 and numerous empty boxes built up around it as of 05/04/2026. During an interview on 05/04/2026 at 11:41 AM, [NAME] #38 stated the old juice dispensing nozzle had maggots in it, but management changed it out the previous week, and the dispensing nozzle was new without any problems. During an observation and interview on 05/04/2026 at 2:51 PM, Dietary Aide #36 stated staff brought in their own cloths for wiping and cleaning since the facilities cloths were disintegrated. During an interview on 05/20/2026 at 9:01 AM, [NAME] #38 stated cleaning responsibilities for the kitchen were divided. The cook side was the cook's responsibility, and the side of the line was the dietary aide's responsibility and included the cooler, freezer, and stand-up refrigerators. During an interview on 05/20/2026 at 1:14 PM, the Former Food Service Director #40 stated the dietary staff was responsible for cleaning the kitchen, however, the Corporation only allowed for 30 minutes post food services for cleaning, which included all the dishes. They got in trouble for staying over or using overtime. The kitchen did not get cleaned. They hired people to clean one time, but basically the kitchen got cleaned once a year. The kitchen was cleaned last due to a previous state citation. They had put in multiple work orders for repairs to the kitchen and equipment but were asked if the repairs were in the budget. The repairs were never done unless the state cited them for it. During an interview on 05/21/2026 at 9:00 AM, the Per Diem Food Service Director stated Dietary Aides were responsible for cleaning the kitchen, and cooks were responsible for cooking areas such stove and flat top. They had a job posting that documented what should be done every shift and by who for cleaning tasks and kitchen responsibilities. There was no direct supervisor for the kitchen. Two years ago, they had cleaning logs, but they did not think they were being done now. The staff told them they did not have to complete the logs; they just made sure everything was clean. During an interview on 05/21/2026 at 12:51 PM, the Director of Environmental Services stated the cardboard [NAME] was repaired. The facility lacked a Food Service Director to train people on how to use the machine. Only a few people could use it. They got a lot of freight, nearly every other day and the boxes piled up fast. During an interview on 05/21/2026 at 1:12 PM, the Administrator stated kitchen cleanliness was their responsibility at the moment. The dietary aides had a job description for cleaning, and the cooks were responsible for the cooking side of the kitchen. The staff was not documenting the cleaning tasks. The kitchen staff should advise when equipment was broken or had issues. They knew the steam tables drains were not working correctly, and the streamer oven was looked at and would probably need to be replaced. The walk-in freezer broke again, but they were still using the freezer truck in the back. If the box compactor was in working order the boxes should not be piled up in that room. There was an inservice, and all kitchen staff knew how to use it. 10 New York Codes, Rules and Regulations 415.14(h)

Based on observations, record review, and interviews (iQIES Intake 2638730), the facility failed to ensure a clean, comfortable, and homelike environment for three (3) of four (4) resident units (A1, A2, and C2 units) reviewed. Specifically, A1, A2, and C2 units had strong urine odors and unclean walls and floors; and the A2 unit had several trash cans with fluid from a leaking ceiling.Findings include: The facility policy Quality of Life – Homelike Environment, revised 12/15/2025, documented the facility staff and management should maximize the characteristics of the facility that reflect a personalized, homelike setting. The characteristics included a clean, sanitary, and orderly environment; clean bed and bath linens that were in good condition; and pleasant, neutral scents. Cleaning logs were not provided by the facility for C1 and B2 units as requested. The Daily Room Cleaning Log for 05/04/2026 was not provided as requested. No Daily Room Cleaning Log was provided for A2 unit. Terminal Cleaning Logs for the Common Areas for 05/02/2026 and 05/03/2026 for A2 unit were not provided as requested. The following observations were made: A1 Unit: -on 05/04/2026 at 9:15 AM, there was a strong odor of urine present immediately upon entering the unit. C1 Unit: -on 05/04/2026 at 9:33 AM, there were trails of a brown substance on the floor near the nurse's station. -on 05/04/2026 at 9:34 AM, the baseboards and walls in the area across from Central Bath 109 had several white marks leading from the floor up the wall. -on 05/04/2026 at 10:03 AM, room [ROOM NUMBER] Bath had a pile of soiled linens near the shower, and a garbage bag tied near the door. There was discoloration on the shower floor and the ramp leading to the shower. -on 05/04/2026 at 10:06 AM, room [ROOM NUMBER] had debris/garbage and substance/discoloration on the floor. The hallway and unit smelled of urine. The hallway outside room [ROOM NUMBER] had a dried brown substance on the floor with footprints from the area of the substance. -on 05/04/2026 at 10:08 AM, room [ROOM NUMBER], had debris and discoloration on the floor. -on 05/08/2026 at 11:48 AM, there was a strong odor of urine at the nurse's station. A2 Unit: -on 05/04/2026 at 11:15 AM, upon entry to the unit there was a strong odor of urine. -on 05/04/2026 at 11:46 AM, there was a large blue cylindrical bucket against the wall across from room [ROOM NUMBER], the ceiling tile above the bucket had two holes in it. The bucket was collecting fluid leaking from ceiling and there was no yellow hazard sign. There was a large white bucket directly in front of room [ROOM NUMBER]. The bucket was a quarter of the way full of broken ceiling tiles and brown water. The ceiling was actively dripping. -on 05/04/2026 at 1:02 PM, upon entry to the unit there was a strong odor of urine. -on 05/05/2026 at 11:59 AM, the ceiling had leaks near resident rooms [ROOM NUMBERS], the Director of Environmental Services stated the air conditioner compressor was leaking in the ceiling and at two spots along the duct work. The air conditioning unit was turned on recently, either 04/30/2026 or 05/01/2026. They stated the vendor would be evaluating the leak on 05/06/2026 for repair. The water in the catch receptacles should be drained out daily. -on 05/06/2026 at 9:05 AM, there was a black trashcan in the hallway in front of room [ROOM NUMBER]. The ceiling tiles above the trashcan were missing, and fluid was actively dripping into the black trashcan. -on 05/06/2026 at 9:33 AM, there were three buckets in the hallway near room [ROOM NUMBER]. A large capacity clear bucket was nearly half full of brown water constantly dripping from a missing ceiling tile. The bucket contained broken pieces of ceiling tile and had a foul odor. A black garbage was catching a slow drip of water from the ceiling above. A blue can was collecting drips from the ceiling above. -on 05/07/2026 at 11:24 AM, the hallway near room [ROOM NUMBER] had a clear large capacity bucket about 1/4 full of dirty brown water that slow dripped from the ceiling (no ceiling tile seen over bucket). There was a black garbage can containing water dripping from the ceiling. The black bucket had barely any water in the bottom. -on 05/08/2026 at 9:50 AM, there was a strong odor of urine when entering the unit, the odor continued down through the unit to the nurse's station area. -on 05/08/2026 at 10:58 AM, room [ROOM NUMBER] had a dinner plate sized stain in the ceiling on the A side. The resident in room [ROOM NUMBER] A stated they were getting dripped on the previous night. They pointed to the area of discoloration and stated it was coming from that area. The B side had a mattress without linens. There was a large yellow/brown stain in the middle of the mattress. Licensed Practical Nurse #18 stated the mattress was dark blue, but the amount of urine from that resident over time had bleached and stained the mattress. Work orders should be put in the system, but nothing was done because it was not broken. During an interview on 05/06/2026 at 8:52 AM, Housekeeping Aide #44 stated they tried to mop some of the areas, but they thought the floor workers got floor stripping chemical on the new floors because they could not get the boot prints off the floor when they mopped. They stated they did their best just to keep their unit clean, but they were only there during the day. They started with the common areas first, and they had a room of the day that would get a more thorough cleaning. During an interview on 05/08/2026 at 10:30 AM, Licensed Practical Nurse #18 stated the environment was not clean. There were trash bins in the hallway for days, and it was getting worse. The leak was spreading down the hall. During an interview on 05/21/2026 at 12:51 PM, the Director of Environment Services stated they had five housekeepers on staff and were onboarding two more. They were short staffed for a while but were finally able to fill a few spots. They stated that the week the surveyors were in the building three housekeepers were not on the schedule. A homelike environment meant a clean area free of holes and debris and no widespread odors. The housekeepers had daily cleaning logs they completed each day. The expectation for a soiled/stained mattress was that a work order was put in and it would be replaced. They reviewed the work order system and did not find a work order for room [ROOM NUMBER]'s mattress. During an interview on 05/21/2026 at 1:12 PM, the Administrator stated the facility environment should be homelike. A homelike environment included cleanliness and painting. There should not be any odors. If there were odors staff should determine the origin of the odor. Bed maintenance was done by the general maintenance staff. If a mattress needed to be replaced the expectation was a work order would be placed. 10 New York Codes, Rules and Regulations 415.5(h)(4)

Based on observations, record review, and interviews (iQIES Intake 2607654), the facility failed to ensure a system of records and accounts of all controlled drugs was maintained for five (5) of five (5) residents (Residents #37, #38, #39, #40, and #41) reviewed. Specifically, Unit C1 had all the scheduled narcotic medications signed off at the beginning of the day, prior to the medication administration time.Findings include: The facility policy Controlled Substance Log, revised 11/2025, documented a record of all controlled substances would be maintained in the facility to ensure accountability and security of controlled substances. The facility's system would account for the receipt, usage, wastage, return to the pharmacy, disposition, and reconciliation of all controlled medications. The policy did not document the process for documenting medication administration of a control substance on the log. During an observation and interview on 05/04/2026 at 10:31 AM, the Unit C1 narcotic medication book was requested. Licensed Practical Nurse #30 provided the book and stated it was going to be wrong as they already signed off all the narcotic medication in the book for the entire day. The narcotic book was signed in advance for residents' controlled medications as follows:- Resident #37's oxycodone/acetaminophen (opioid) 7.5/325 milligram tablet was signed for the 05/04/2026 1:00 PM dose. - Resident #38's clonazepam (antianxiety) 0.5 milligram tablet was signed for 05/04/2026 12:00 PM dose. - Resident #39's hydrocodone/acetaminophen (opioid) 5/325 milligram capsule was signed for the 05/04/2026 12:00 PM dose. - Resident #40's oxycodone/acetaminophen (opioid) 5/325 milligram tablet was signed for the 05/04/2026 12:00 PM dose. - Resident #41's tramadol (opioid) 50 milligram table was signed for the 05/04/2026 12:00 PM dose. During an interview on 05/08/2026 at 11:50 AM, Licensed Practical Nurse #30 stated the narcotic medication book should be signed when the medications were given. The narcotic medication book should not be signed ahead of time. That was not how they were trained, and they did not normally do that, but they were the only nurse on the unit, and they were trying to get ahead of the workday. They were the only nurse for 40 residents, including 23 diabetics, many on regular insulin that required glucose monitoring several times a day. They were thankful they did not have many treatments on the unit, but it was a very heavy assignment for just one person. During an interview on 05/08/2026 at 12:02 PM, Registered Nurse Unit Manager #10 stated nurses were all taught to open the narcotic medication book, check the counts, compare the book and the medication card, open the medication, make sure the medication was taken, then sign the narcotic medication book. Nurses should not sign the narcotic medication book ahead of time. The whole shift of medications should not be signed for at the beginning of the shift, only after the medication was given. 10 New York Codes, Rules and Regulations 415.18

Based on observations, record review, and interviews (iQIES intake 2610975), the facility failed to ensure they were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for one (1) of four (4) resident rooms observed. Specifically, Resident #9's call bell did not function as designed.Findings include: The facility policy Resident Call System, revised 02/2025, documented the facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized work area from each resident's bedside and toilet and bathing facilities. The availability of the call system or alternative method for communication was mandatory by the facility. The following observations were made of Resident #9's call bell:-on 05/05/2026 at 8:43 AM, the resident was lying in bed and stated they were wet from urine. When they pushed the call bell button the light above their door did not illuminate. They pushed their call bell button two more times and the light above the door did not illuminate. The surveyor pushed the call button and the light above the door did not illuminate. No audible beeping sound was heard at the nursing station. -on 05/05/2026 at 2:45 PM, 05/06/2026 at 9:33 AM, and 05/07/2026 at 11:24 AM the resident's call bell button was pushed, and the light did not illuminate over the door. No audible sound was heard from the nursing station to indicate the call bell was activated. During an observation and interview on 05/07/2026 at 11:30 AM, Certified Nurse Aide #23 stated they knew a resident had a request or needed assistance when the call bell light was pushed by the resident. Certified Nurse Aide #23 was asked to push the call bell button and the light above the door illuminated with one push. The aide turned the call bell off, and the surveyor pushed the call bell button 3 times with strength and was unable to get the light to illuminate. Certified Nurse Aide #23 stated sometimes you have to push really hard. They stated they were not aware the resident's call bell was not working. During an interview on 05/08/2026 at 10:30 AM, Licensed Practical Nurse #18 stated a lot of the resident call lights on the unit did not work properly. Resident #9's call light had issues since 08/2025. Maintenance fixed it once and then the problem continued without being resolved. Resident #9 could use the call bell when they were having a good day. During an interview on 05/08/2026 at 10:35 AM, the Director of Environmental Services stated the call bell system functioned when a resident pushed the call bell button and it sent a signal to the nursing station to show which resident needed assistance. They typically received a work order or by resident report if a call bell was not working. They were not notified the resident's call bell was not functioning. 10 New York Codes, Rules and Regulations 415.29

Based on observations, record review, and interviews during the recertification survey conducted 8/11/2025-8/15/2025, the facility did not ensure sufficient support personnel to safely carry out the functions of the food and nutrition services for the main kitchen and for 3 of 4 units (Units A1, B2, and C1) reviewed. Specifically, meal trays for Units A1, B2, and C1 were delivered an hour after the scheduled mealtimes, and concerns were identified with the effectiveness of meal preparation and other foot and nutrition services. Additionally, deficiencies related to food and nutrition services were identified in the areas of: Menus Meet Resident Needs/ Prepare in Advance/ Followed (F 803); Nutritive Value/ Appearance, Palatable/ Prefer Temperature (F804); and Food Procurement, Store/ Prepare Serve-Sanitary (F 812).Findings include:The facility policy, Food and Nutrition Services, revised 12/2024, documented meals and/or nutritional supplements would be provided within 45 minutes of either the resident request or scheduled mealtime, and in accordance with the resident's medication requirements. Meals were scheduled at regular times to assure that each resident received at least 3 meals per day. Breakfast downstairs began at 7:30 AM, upstairs at 8:00 AM; lunch downstairs began at 11:45 AM, upstairs at 12:15 PM; dinner downstairs began at 5:15 PM and upstairs at 5:45 PM. The Resident Listing Report, dated 8/10/2025, documented the facility's resident census was 138 residents. The facility dietary employee schedule documented the scheduled staff including staff who called off work the week of 8/11/2025-8/15/2025. The schedule documented the following day shift staffing:-On 8/11/2025 there were 5 staff including the cook and there was one call off.-On 8/12/2025 there were 5 staff including the cook and there was one call off.-On 8/13/2025 there were 3 staff including the cook and one staff who left at 9:00 AM.-On 8/14/2025 there was 1 staff, no cook and one staff who left at 10:00 AM. -On 8/15/2025 there was 4 staff including the cook. The following meal delivery time observations were made:-On 8/11/2025 at 12:44 PM, Unit C1 hallway trays arrived and were passed.-On 8/11/2025 at 1:03 PM, Unit A1 lunch trays arrived in the dining room.-On 8/13/2025 during a kitchen observation, lunch trays left the kitchen for Unit A1 at 1:24 PM and Unit C1at 1:36 PM, dining room cart for A1 and C1 left the kitchen at 1:50 PM. -On 8/14/2025 at 8:57 AM, there was an overhead page Unit B2 breakfast trays arrived.-On 8/14/2025 at 1:05 PM, there was an overhead page Unit A1 lunch trays arrived.-On 8/14/2025 at 1:24 PM, there was an overhead page Unit C1 trays arrived.During an interview on 8/13/2025 at 11:18 AM, Dietary Aide #42 stated they were behind with service because of call ins.During an interview on 8/13/2025 at 11:23 AM, [NAME] #41 stated they were running behind with meal service because of call ins. They stated the kitchen should function with six staff, but they usually ran it with three.During an interview on 8/13/2025 at 1:55 PM, Dietary Aide #31 stated lunch was behind because they were short staffed. During an interview on 8/13/2025 at 2:18 PM, the Food Service Director stated lunch was very slow today. There were call ins and new staff that were not quite up to par. During a follow up interview on 8/14/2025 at 10:08 AM, the Food Service Director stated the cook called in, so they were cooking today and there were only two dietary aides due to call ins. There was an activities aide helping and another staff member who they were not sure of their normal role in the facility. During an interview on 8/14/2025 at 11:55 AM, Certified Nurse Aide #35 stated they informed Licensed Practical Nurse #10 they called down to the kitchen and the kitchen was behind. They did not know if they could get a lunch tray to Resident #63 before their appointment. During an interview on 8/15/2025 at 11:13 AM, Registered Nurse Unit Manager #26 stated the past few days meals were late. They thought it may have to do with kitchen call ins. They stated residents deserved to have their meals on time; it caused disruptions to their schedule and throws them off. 10NYCRR 415.14(b)(1)(2)

Based on observations, record review, and interviews during the recertification survey conducted 8/11/2025- 8/15/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for one (1) of (1) main kitchen reviewed. Specifically, the main kitchen had unclean floors, walls, and equipment, uncovered food, the sanitizer solution in the 3-bay sink was not tested, recipes were not followed for pureed items, a food scoop was left in a thickening agent bag, there was ice buildup in the walk in freezer, there were missing ceiling tiles, hand hygiene was not performed between dish washing and food services, there were no temperature logs for the tray line or the dishwasher, no kitchen cleaning logs, or sanitization logs. Findings include:The facility policy Kitchen Sanitization, revised 6/2025, documented the food service area was maintained clean and in a sanitary manner. All kitchens, kitchen areas, and dining areas were kept clean. All utensils, counters, shelves, and equipment were kept clean, maintained in good repair and were free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. All equipment, food contact surfaces and utensils were washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/ or chemical sanitizing solutions. Between uses, cloths and towels were used to wipe kitchen surfaces and soaked in containers filled with approved sanitizing solution. Cutting boards were washed and sanitized between uses. Kitchen surfaces not in contact with food were cleaned on a regular schedule and frequently enough to prevent the accumulation of grime. The Food Service Manager was responsible for scheduling staff for regular cleaning of kitchen and dining areas. There was documented evidence of completed kitchen cleaning logs, food temperature logs, dishwasher temperature logs, and sanitizer logs.On 8/11/2025 between 9:58 AM and 10:11 AM, the following was observed in the main kitchen area:-a pan of blueberry cobbler on a wheeled cart unattended and uncovered.-the kitchen walls were not clean. -the fryers had grease build up on the sides.-the ovens had built up grime on the sides.-the stove top had built up grime on the burners and the sides. -the floors underneath the stove, ovens, and fryers had built up grime. -the freezer condenser was dripping on the left side and there was a 2-foot by 2-foot area with ice buildup on the freezer floor dripping in between two metal racks containing frozen food in boxes.On 8/12/2025 between 1:32 PM and 2:10 PM, the following was observed in the main kitchen area:-standing water and food debris between the dish machine and the drying racks. -a mouse trap under the 3-bay sink.-the wall behind the 3-bay sink was dirty. -standing pink liquid in the prep sink.-stove top had burnt crusty debris on the top and sides. -the oven and the fryer had crusted on debris.-walls behind the large kitchen equipment had food debris.-there was caked on debris on the floor underneath the large kitchen equipment.-the steam table contained food that was left unattended and uncovered after the meal service was done.-the freezer condenser was leaking on the left side and there was a 2-foot by 2-foot area a few inches thick of ice buildup on the freezer floor dripping in between two metal racks with frozen food in boxes.-there were six missing ceiling tiles in between the dishwasher and drying racks with exposed wires hanging down below the level of the ceiling. During an interview on 8/12/2025 at 2:10 PM, the Food Service Director stated they were not sure if the chemical concentration in the 3-bay sink was checked or even where the strips were located. They asked Dietary Aide #47 who was actively washing dishes in the 3-bay sink, and they stated they never checked the chemical concentration and did not know where the test strips were located. The kitchen had years of buildup. The cleanliness was a lot better but there was still a long way to go. The walls were dirty, the kitchen equipment was dirty, the floors under the cooking equipment were sticky, there should not be standing water on the floor, but it happened especially after dishes were cleaned if they did not squeegee it. Everything should be clean. They were coming up with a cleaning list for the staff. They had purchased many items for a big clean of the kitchen but were waiting on casters to move the big equipment. The ice buildup was a battle they had been fighting. The condenser needed a part and was fixed but had been broken again for about 4 weeks. They had not seen any evidence of pests. They needed more time and equipment to adequately clean the kitchen. During an observation and interview on 8/12/2025 at 2:40 PM, the Food Service Director found test strips for the 3-bay sink. They dipped the strip in the soapy water bay that contained pot and pan detergent and not the sanitizer bay sink. The blue color on the strip was not a color on the indicator key of the strip container. They stated that did not make any sense and the strips came from the company that supplied the chemicals, and the test strip did not really tell them anything about the chemical concentration. On 8/13/2025 the following was observed during the lunch meal preparation and service:-at 11:23 AM, Dietary Aide #56 was washing dishes. They took a plastic pitcher to scoop the standing water with food debris from the garbage disposable sink to the drain of the dish machine. There was a large area with white/ grayish frothy liquid with food debris on the floor underneath the dish machine. They stated the garbage disposal sink did not work and the dish machine ran constantly. -at 11:59 AM, [NAME] #41 was washing the dishes in the 3-bay sink while waiting on baked beans to cook. They were wearing the same gloves they had on during the food preparation. At 12:00 PM, they took their gloves off and washed the prep surfaces and blender with a cloth that was pulled from a red bucket containing liquid. At 12:06 PM, they turned off the alarm on the oven and went back to washing dishes. At 12:13 PM, they pulled the baked beans out of the oven. At 12:15 PM, they put on disposable gloves, obtained a spoon, stirred the baked beans, opened the oven door and put the beans back in. At 12:22 PM, they pulled the baked beans from the oven and put them in the steam table for service. There was no hand hygiene performed in between food service and dish services. -at 12:28 PM, [NAME] #41 spooned baked beans into the blender and stated they were making the pureed baked beans. The amount was not measured. At 12:29 PM, they dispensed hot water from the machine into a clear plastic pitcher. The amount of water was not measured. At 12:30 PM, they opened a black plastic tub under the prep sink and scooped out a white granulated substance they called thickener, out of a plastic bag with a paper cup that was left in the bag. There was also a blue plastic coffee mug in the plastic bag. At 12:31 PM, they used the paper cup to scoop some more thickener out. The thickener was not measured. They stated approximately a cup went into the pureed items until it looked like the right consistency.During a follow up interview on 8/14/2025 at 10:08 AM, the Food Service Director stated there was a recipe for each pureed item, and they all required different amounts of thickener, so it needed to be measured. The cook was expected to follow the recipes. Scoops, whether they were disposable cups or the blue coffee mug that was in the thickener container, were not supposed to be there, it was a cleanliness issue. Staff should also be washing their hands as it was also a cleanliness issue. 10NYCRR 415.14(h)

Based on observations, record review, and interviews during the recertification survey conducted 8/11/2025-8/15/2025, the facility did not ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for two (2) of two (2) meals reviewed (lunch meals on 8/12/2025 and 8/13/2025). Specifically, food was not served at palatable and appetizing temperatures during the lunch meals on 8/12/2025 and 8/13/2025. Findings include:The facility policy Food and Nutritional Services, effective 5/2019 documented each resident was provided with a nourishing, palatable, well-balanced diet that met their daily nutritional and special dietary needs, taking in the preferences of each resident. The undated facility policy Temperature Maintaining Equipment, documented the facility would hold and maintain the temperature of hot and cold food items during meal service inside the dietary department, dining rooms, and during transportation to resident units. During an interview on 8/11/2025 at 10:44 AM, Resident #98 stated the food was not good, the portions were too small, they were often missing items, and the food was never hot.During an observation on 8/11/2025 at 12:29 PM, Resident #49's meal tray was tested (a replacement was provided) in the presence of Certified Nurse Aide #39. Food temperatures were measured as follows: hot pork sandwich with gravy 122.4 degrees Fahrenheit, milk 63.3 degrees Fahrenheit, and mashed potatoes with gravy 117.8 degrees Fahrenheit. The pork and potatoes were bland and not hot, and the milk was warm.During a meal observation on 8/13/2025 at 12:51 PM, Resident #98's meal tray was tested (a replacement was provided) in the presence of Minimum Data Set Coordinator #45. Food temperatures were measured as follows: cheeseburger on bun 110.5 degrees Fahrenheit, milk 65.8 degrees Fahrenheit, baked beans 127.9 degrees Fahrenheit, and coffee 127.6 degrees Fahrenheit. Minimum Data Set Coordinator #45 stated the cheeseburger did not look appetizing. The burger was missing cheese and was half brown and half dark brown and crispy looking. The burger was crunchy, the oatmeal cookie was too hard to bite, and the milk was warm. During an interview on 8/13/2025 at 10:37 AM, Certified Nurse Aide #29 stated residents complained about the food all the time saying it does not taste good and was tough to chew. During an interview on 8/14/2025 at 12:19 PM, Certified Nurse Aide #24 stated residents complained about the food all the time stating it was cold, did not taste good, and was hard to chew.During an interview on 8/14/2025 at 2:21 PM, Registered Nurse #11 stated residents were always complaining about the food saying it was cold and tough to chew.During an interview on 8/13/2025 at 2:07 PM Dietary Aide #47 stated the hamburger was 116.4 degrees Fahrenheit and should be 169 degrees or above. Cold food should be served above 32 degrees Fahrenheit. It was important for hot foods to be hot and cold foods to be cold because residents wanted a good meal. During an interview on 8/14/2025 at 10:08 AM, The Food Service Director stated they did not document temperatures of the food. The cook called out sick, so they were cooking. Hot food should be over 145 degrees Fahrenheit. 10NYCRR 415.14(d)(1)(2)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00372537) surveys conducted 8/11/2025-8/15/2025, the facility did not ensure a safe, clean, comfortable, and homelike environment for the main lobby area, common areas, and four (4) of four (4) units (Units A1, A2, B2, and C1) reviewed. Specifically, the facility did not maintain comfortable temperatures on nursing units A1, A2, B2, and C1, A2 and B2 dining rooms, and the A1 and C1 atriums; and Units A1, A2, B2, and C1, and the main lobby were unclean and in disrepair. Findings include:The facility policy Quality of Life- Homelike Environment, revised 12/15/2025, documented residents were provided with a safe, clean, comfortable, and homelike environment. Characteristics that reflected a homelike setting included a clean, sanitary, and orderly environment; inviting colors and decor; comfortable and safe temperatures (71 degrees Fahrenheit- 81 degrees Fahrenheit); and comfortable noise levels. Temperatures:The resident council meeting minutes documented on 6/16/2025 the air conditioning was not working and on 7/28/2025 there were still issues with the air conditioning.The July 2025- August 2025 Maintenance log documented open requests for broken air conditioning units as follows:-On 7/14/2025 for B2 Unit rooms 214, 219, 226; and A2 Unit room [ROOM NUMBER]. -On 7/30/2025 B2 Unit rooms 206, 207, 214, 215, 219, 222, 226, and 245.-On 7/31/2025 A1 Unit rooms [ROOM NUMBERS]; and the second-floor dining room.-On 8/11/2025 Unit C1 room [ROOM NUMBER]. During an anonymous resident group meeting on 8/11/2025 at 1:35 PM, seven of seven residents stated the facility was too hot in the summer. The following temperature observations were made on 8/11/2025:-Unit A1 at 3:07 PM, the hallway outside room [ROOM NUMBER] was 82 degrees Fahrenheit; at 3:10 PM, the hallway outside room [ROOM NUMBER] was 81.5 degrees Fahrenheit; and at 3:18 PM, the atrium on the first floor by the couch in front of the television was 84 degrees Fahrenheit.-Unit A2 at 3:05 PM, the dining room was 88.9 degrees Fahrenheit. Resident #59 was in the dining room and stated they could not handle it; it was so hot. The nurse's station was 87.8 degrees Fahrenheit; the television/ laundry room was 85.5 degrees Fahrenheit; the hallway on the lower number side was 85.3 degrees Fahrenheit; and the hallway with the higher number side was 83.8 degrees Fahrenheit. -Unit B2 at 3:10 PM, the hallway outside room [ROOM NUMBER] was 83.7 degrees Fahrenheit; the hallway outside room [ROOM NUMBER] was 81.7 degrees Fahrenheit; the hallway outside room [ROOM NUMBER] was 82.4 degrees Fahrenheit; the hallway outside the therapy department was 83.1 degrees Fahrenheit; and the dining room was 86 degrees Fahrenheit. -Unit C1 at 3:03 PM, the hallway outside room [ROOM NUMBER] was 82.5 degrees Fahrenheit; at 3:04 PM, the hallway outside room [ROOM NUMBER] was 82 degrees Fahrenheit; at 3:10 PM, the shaded area of the atrium measured 83.4 degrees Fahrenheit and a sunny area in the middle of the atrium was 87.4 degrees Fahrenheit. The following temperature observations were made on 8/12/2025: -Unit A1 at 11:12 AM, the nurse's station was measured at 82.2 degrees Fahrenheit. At 11:54 AM, the dining room was 83.6 degrees Fahrenheit, and many residents were seated waiting on the lunch meal. Resident #62 stated it was hot in there and they did not want to fix it. At 4:16 PM, the hallway outside room [ROOM NUMBER] was 83.8 degrees Fahrenheit; the nurse's station was 82.8 degrees Fahrenheit; the temperature in the middle of the atrium was 90.0 degrees Fahrenheit; and the dining room was 88.7 degrees Fahrenheit where Resident #62 was seated.-Unit A2 at 11:05 AM, the dining room was 82.9 degrees Fahrenheit and the nurse's station was 81.7 degrees Fahrenheit. At 12:03 PM, residents were being brought to the dining room for lunch, and the temperature was 85.3 degrees Fahrenheit. At 1:51 PM, the dining room was empty, two wall vents were not blowing any air and two were blowing warm air. One vent's air exhaust was measured at 97.2 degrees Fahrenheit and the dining room measured at 90.1 degrees Fahrenheit. At 3:54 PM, the short hall was 82 degrees Fahrenheit, the long hall was 85.3 degrees Fahrenheit, and it was 85.8 degrees Fahrenheit across from the nurse's station. The television area was 88 degrees Fahrenheit, and the dining room was 91 degrees Fahrenheit. -Unit B2 at 4:07 PM, the dining room was 86.2 degrees Fahrenheit; the hallway outside room [ROOM NUMBER] was 82.2 degrees Fahrenheit; the hallway outside room [ROOM NUMBER] was 81.3 degrees Fahrenheit; and the hallway outside room [ROOM NUMBER] was 83.9 degrees Fahrenheit.-Unit C1 at 11:30 AM, the atrium was 82.4 degrees Fahrenheit, and five residents were seated there; the atrium measured 84.9 degrees in a sunny area; the hallway outside room [ROOM NUMBER] was 81.5 degrees Fahrenheit; and the hallway outside room [ROOM NUMBER] was 81.6 degrees Fahrenheit. At 4:16 PM the dining room was 84.2 degrees Fahrenheit, and the atrium was 84.9 degrees Fahrenheit. At 4:17 PM, a resident walked in and stated it was hot in there. At 4:22 PM, in the hallway outside room [ROOM NUMBER] the temperature was 82.7 degrees Fahrenheit; and at 4:24 PM, in the hallway outside room [ROOM NUMBER] the temperature was 83.3 degrees Fahrenheit.During an interview on 8/11/2025 at 12:24 PM, Resident #9's representative stated the air conditioning had not worked in the hallways or the atrium all summer. During an interview on 8/12/2025 at 12:29 PM, Certified Nurse Aide #30 stated the dining room was always hot. There used to be fans, but they did not know where they went. They stated Resident #144 often complained that it was hot but many of the residents on unit A2 were unable to voice their complaints. During an interview on 8/12/2025 at 1:28 PM, Dietary Aide #31 stated the air conditioner was always broken. It was broken a while ago and they were told it was fixed but the past two weeks it did not seem like it was working. It was so hot in the facility. During an interview on 8/12/2025 at 1:58 PM, Licensed Practical Nurse #10 stated they were told to take Resident #40's blood sugar because the resident was sweating profusely in the dining room. The resident's blood sugar was fine, and they thought they were probably sweaty because it was so hot on the unit. During an interview on 8/12/2025 at 4:16 PM, the Director of Nursing stated the air conditioning company came out earlier today and stated the air conditioning was fixed. They called them again because the temperatures were not getting cooler. The company was on their way. The dining room for the A2 unit was warm today when they were up there. They stated the dining room was going to be closed until the temperature was cooler. They were going to let residents eat in the atrium if they wanted to. During the bingo activity today, that was held in the dining room, they walked around and told the residents they could leave if the area was too warm. During an interview on 8/15/2025 at 2:36 PM, Maintenance Technician #2 stated there was a heating ventilation and air conditioning (HVAC) unit in each resident room. They were aware of a broken one on A1 and a broken one on A2. They thought new units were on order but had not arrived yet. All the units were fed from a unit on the roof. On Monday (8/11/2025) they went onto the roof and noticed the system that controlled the air conditioning was set to 77 degrees Fahrenheit, so it was not kicking on and that was why the building was warm. They changed this setting to 70 degrees but then they realized a fuse was blown and the air conditioning company was called and came out the same day. On Tuesday night, they noticed another fuse was broken and again the air conditioning company was called and came out. They stated they checked temperatures in the common areas and the highest temperature they got was 80 degrees Fahrenheit. They were not sure if the residents were being monitored. Areas Unclean and in Disrepair:The following observations were made on Unit A1:-On 8/11/2025 at 12:51 PM, the bathroom sink in room [ROOM NUMBER] was one third full of standing water with black flecks. Resident #116 stated staff knew the sink was clogged and nothing was done about it. -On 8/11/2025 at 4:16 PM, room [ROOM NUMBER] had sticky floors, and the bathroom sink was half full of standing water with black flecks. Resident #9's representative stated the sink was that way for a week or longer and the floors were always dirty. They stated staff filled a basin in that sink to provide hygiene care to Resident #9. -On 8/12/2025 at 11:26 AM, the bathroom sink in room [ROOM NUMBER] was half full of standing water with black flecks. Resident #116 stated staff used the sink to fill a basin for hygiene purposes. They asked to speak with maintenance, but they had not been in. -On 8/12/2025 at 11:41 AM, room [ROOM NUMBER]'s floors were sticky and had black scruff marks. The bathroom sink was half full of standing water with black flecks. -On 8/12/2025 at 2:30 PM, in the kitchenette the drawer labeled lids had coffee grounds and coffee stains in it, the ice machine had a locked-out tag on it, the face of the cabinet doors had brown streaks, and the cabinet door under the drawer labeled lids was not secured to the hinges. -On 8/13/2025 at 9:10 AM in the high side hallway shower room the shower handle only moved down to the dependent position so there was no way to add cold water. The water temperature measured at 113 degrees Fahrenheit in the presence of Certified Nurse Aide #4. Certified Nurse Aide #4 stated the whirlpool tub in that shower room also did not work and the reservoir did not fill.-On 8/14/2025 at 11:21 AM, the headboard of the bed in room [ROOM NUMBER] was bent towards the mattress at a 45-degree angle. During an interview on 8/13/2025 at 8:37 AM, Certified Nurse Aide #33 stated the sinks in rooms [ROOM NUMBERS] had standing water in them the past week and a half. They told the Regional Director of Nursing about it and was told to put an electronic request in the system, but they did not have access. They had also told Registered Nurse Unit Manager #26. Both Residents #9 and #116 were dependent for hygiene needs and they filled a basin in the sink and then dumped it in the toilet. There was not a housekeeper assigned to the unit. The floors were not really mopped, and it had probably been a week or more since room [ROOM NUMBER] was mopped. The sinks and the floor were not clean. During an interview on 8/13/2025 at 8:57 AM, Certified Nurse Aide #32 stated the sinks in room [ROOM NUMBER] and 134 were disgusting. Everyone knew about it, but nothing was being done. During an interview on 8/13/2025 at 9:13 AM, Environmental Services Aide #28 stated former Director of Maintenance #17 quit and so did the housekeeper for the unit. They cleaned rooms [ROOM NUMBERS] today and called a plumber because the sinks did not work and were disgusting. Resident rooms and bathrooms should be clean because it was the residents' home. Resident rooms should be cleaned every day. They did not know there was nobody covering Unit A1 until they were made aware on 8/11/2025. During an interview on 8/13/2025 at 9:55 AM, Licensed Practical Nurse #27 stated the resident rooms should be clean for their well-being and to prevent infection. They stated they barely had room above the standing water in the sink to rinse Resident #116's urinal after it was emptied. During an interview on 8/15/2025 at 10:57 AM, Registered Nurse Unit Manager #26 stated the housekeeper had quit. Even before the housekeeper quit there were dirty floors because they only worked part time. They were not sure how long the sinks were clogged in rooms [ROOM NUMBERS] but it was brought to their attention on 8/11/2025 and they put in an electronic maintenance request. The residents should have a clean environment as it was their home. The kitchenette was a shared responsibility between housekeeping and maintenance. They knew the kitchenette was dirty with coffee stains. The ice machine had been down for a least 3 months and they had to go to the kitchen to get ice. Broken headboards were also maintenance's responsibility. They should be in good repair to prevent injury. The following observations were made on Unit A2:-On 8/11/2025 10:05 AM the floor across from the nurses' station had various debris including pieces of crackers, other wrappers and various debris that continued down the hall. -On 8/11/2025 at 10:12 AM room [ROOM NUMBER]-B's bed footboard was dangling on one side. -On 8/11/2025 at 10:15 AM room [ROOM NUMBER]-B's bed footboard was tilted outward and not attached tightly.-On 8/11/2025 at 10:36 AM room [ROOM NUMBER]-A had no bed footboard. -On 8/11/2025 at 11:04 AM Resident #35 was seated in their wheelchair in the television room. The left armrest of the wheelchair was peeling with exposed foam underneath.-On 8/11/2025 at 11:20 AM there was brown [NAME] debris in the hall in the upper 20's rooms. -On 8/11/2025 at 11:22 AM room [ROOM NUMBER]-B's footboard was not on the bed and was resting up against the dresser. A nut and bolt were on the floor under the foot of the bed. There was a moderate amount of brown food like debris on the floor. -On 8/11/2025 at 11:31 AM room [ROOM NUMBER]-A there were pieces of donut scattered on the floor with a large area of dried fluid under the bed and a large area of yellow dried material at the foot of the bed.-On 8/11/2025 at 11:45 AM room [ROOM NUMBER]-A the top drawer of the nightstand was on the floor near the foot of the bed, and the face of the drawer was on the floor in front of nightstand. There was dried on brown debris on the floor between the bed and wall.-On 8/11/2025 at 1:45 PM room [ROOM NUMBER]-A there the metal strip on the door was lifted from the bottom of the door frame creating a sharp edge. The heater pulled away from the wall about 6 inches. -On 8/12/2025 at 11:16 AM the floors had brown debris at the start of the hall for higher number rooms. -On 8/12/2025 at 11:46 AM room [ROOM NUMBER]-B's bed footboard was loose. -On 8/13/2025 at 1:19 PM room [ROOM NUMBER]-B's footboard was flat on the floor. There was food debris on the left side of the bed.-On 8/14/2025 at 11:47 AM room [ROOM NUMBER]-A the room smelled of urine and the floor was slippery.-On 8/14/2025 at 11:48 AM room [ROOM NUMBER]-B had food debris (crackers) and brown scattered debris on the floor. The left enabler bar had dried crusty debris on it.During an interview on 8/13/2025 at 9:13 AM, Environmental Services Aide #28 stated resident rooms and units were cleaned every day. This was the residents' home, and it should be clean. During a follow up interview on 8/14/2025 at 12:01 PM, they stated it was common for the headboards and footboards to be bent or broken because staff leaned on them. There should be an electronic request so maintenance could repair or replace the items. There should be routine bed checks. During an interview on 8/14/2025 at 1:52 PM, Certified Nurse Aide #21 stated some footboards were missing and they reported it. They were also aware of some that were not yet reported. Footboards should not be missing or loose. During an interview on 8/14/2025 at 2:26 PM Licensed Practical Nurse #20 stated they went through the unit and wrote down all the missing footboards and gave them to Registered Nurse Unit Manager #19 who was currently on vacation. The following observations were made on Unit B2:-On 8/12/2025 at 11:06 AM, there were 5 discolored and cracked floor tiles across from the nurse's station.-On 8/12/2025 at 11:30 AM, the soffit across from room [ROOM NUMBER] had an area approximately 18 inches long that was peeling off. There were 3 ceiling tiles missing from this area. During an interview on 8/13/2025 at 10:37 AM, Certified Nurse Aide #29 stated maintenance was called for discolored floor or ceiling tiles. The archway where the soffit was peeling off had a leak about a month ago. Maintenance was aware and they did not know why it was not fixed. During an interview on 8/14/2025 at 2:21 PM, Registered Nurse #11 stated maintenance looked at the soffit last week and said they were working on it. It was not a homelike environment for the residents. The following observations were made on Unit C1:-On 8/11/2025 at 12:15 PM room [ROOM NUMBER]-A, there was a hole in the wall about upper shin height to the right of the head of the bed frame.-On 8/12/2025 at 10:58 AM the kitchenette had a sign documenting the ice machine was broken.-On 8/14/2025 at 10:07 AM there were food crumbs/particles on the floor under the overbed table and stationary chair parallel to the nurses' station outside the patient lounge.-On 8/14/2025 at 12:49 PM there was food debris in front of the chair parallel with the nurse's station. The following observations were made in the main lobby area:-On 8/12/2025 at 11:00 AM there was an alarm sounding coming from the stairwell. -On 8/13/2025 at 8:00 AM, to the left of the front entrance sliding door, the panel was broken and in a position that allowed entry. The water fountain was leaking with a red bucket underneath to catch the water.-On 8/13/2025 at 5:15 PM, the entrance door was broken and ajar. The water fountain was leaking and had a red bucket underneath. The alarm in the stairwell was sounding while an unidentified resident and visitor were conversing in the main lobby. -On 8/14/2025 at 12:14 PM, the alarm was sounding in the stairwell in the main lobby. During an interview on 8/15/2025 at 11:50 AM, Maintenance Technician #2 stated their boss quit on Friday, and they were the only person working in the maintenance department. Their job was to respond to broken items. They did not have access to the electronic maintenance request system, so they only knew if something needed fixed if it was verbalized to them. They were aware of broken headboards and footboards throughout the facility, but they were not easy to replace as it took a long time to get replacement parts. They were unaware of the metal coming out of the doorframe in room [ROOM NUMBER] or any holes in the walls in the facility. There was a water leak in the soffit, and they just replaced the ceiling tiles on B2. They were not aware of cracked floor tiles. They were made aware of the broken sinks in rooms [ROOM NUMBERS] on 8/8/2025 but did not know who to call but apparently Environmental Services Aide #28 had called a plumber a couple days ago. They did not know the shower handle, or the whirlpool tub needed repair. The ice machines were a known issue and to their understanding corporate had ordered new units, but they were waiting for them to come in. They fixed the alarm in the stairwell yesterday as a staff from another facility had come to help them. They did not know how to fix the front entrance. The water fountain was out of order because the drain needed to be snaked. They fixed wheelchairs if it was reported to them but again, the staff entered requests into the electronic system they did not have access to. Everything in the facility should be in good repair as it was the residents' right to feel at home. During an interview on 8/15/2025 at 12:23 PM the Administrator stated the Maintenance Director walked off the job the previous Friday. Maintenance Technician #2 did not have access to the electronic work orders, and they were working on that. They stated the floor scrubber was broken. They just stripped and waxed all the common areas. Some of the tiles were replaced and not pretreated. The floors had not been maintained. They stated the housekeeper quit last week on A1 after being educated on how to properly clean. 10NYCRR 415.29(j)(1)

Based on observations, record review, and interviews during the recertification survey conducted 8/11/2025-8/15/2025, the facility did not ensure prompt grievance resolution for one (1) of one (1) resident (Resident #138) or provide information on how to file a grievance or complaint for six (6) of seven (7) anonymous residents present at the group meeting. Specifically, Resident #138 had missing dentures and did not receive timely follow up on their grievance; and 6 residents present at the group meeting did not know how to file a grievance, grievance forms were not available to residents, and the facility lacked a process for residents to file an anonymous grievance. Findings include:The facility policy Grievances, revised December 2024, documented residents were afforded the right to voice grievances without fear of discrimination or reprisal. The Director of Social Work Services, designee, or resident social worker was identified as the grievance official and was responsible for acting as the resident advocate. A copy of the grievance policy was to be provided to residents upon admission.The facility policy Missing Items and Ruling Out Misappropriation of Personal Property, revised 12/15/24, documented staff must immediately report any resident complaint of a missing item to the Charge Nurse or Supervisor. A missing items report was to be completed; the resident and staff interviewed and determine if misappropriation was a reasonable suspicion. Items were to be returned to the resident and document the return. If the item remained missing, assist with an insurance claim as appropriate. Updates were to be provided the resident and the responsible party.The facility Policy Resident Rights, revised 3/2025 documented the residents had the right to have received contact information for filing grievances or complaints concerning any suspected violation of state or federal nursing facility regulations, which had included, suspected abuse, neglect, exploitation, misappropriation of funds, or resident property.Resident #138 had diagnoses including stroke and anxiety disorder. The 6/6/2025 Minimum Data Set assessment documented the resident had moderately impaired cognition and had no natural teeth or tooth fragments. The 6/12/2024 comprehensive care plan documented the resident had a self-care performance deficit and limited physical mobility. Interventions included the resident had upper dentures and staff were to brush the resident's teeth, rinse their dentures, clean gums with a toothette, and rinse the resident's mouth with wash. Changes were to be reported to the nurse.The 6/14/24 personal inventory record documented the resident was admitted to the facility with top dentures.The 5/16/2025 missing item report documented on 5/15/2025 Resident #138 reported their dentures were missing. The certified nurse aides were told to be on the lookout for the dentures. The Registered Nurse Unit Manager put the resident on the dentist list to be seen as soon as possible, and they would check back at the end of August 2025 after the resident was seen.During an interview on 8/11/2025 at 12:15 PM, Resident #138 stated the facility lost her dentures. Resident #138 spoke to the social worker but had not gotten anywhere and did not know the status of finding or replacing their dentures. They were upset as they had paid for their dentures.The 8/15/2025 missing item report for the missing dentures documented Resident #138 did not want to go to an outside dentist and had no issues eating. The dentures were found in their room on 8/15/2025 (3 months after the initial missing item was reported). During an interview on 8/15/2025 at 8:41 AM the Administrator provided a grievance log that included five entries for both 2024 and 2025. The Administrator stated they implemented the log when they started and reinstated the grievance process as the facility had not been using it. Missing items were on a separate report which was also re-implemented.During an interview on 8/15/2025 at 10:07 AM, Certified Nurse Aide #34 stated someone found the residents dentures in their nightstand that morning. The dentures were reported missing for over a month, and they previously thoroughly searched the resident's room looking for them. Certified Nurse Aide #34 stated they initially reported them missing to Licensed Practical Nurse #10.During an interview on 8/15/2025 at 10:29 AM, Social Service Director #35 stated they were responsible for grievances and missing items. If a resident was interested in filing a grievance they would have to report it directly to them. Residents who wanted to file an anonymous grievance would have to reach out to the Ombudsman. Grievances and missing items should be resolved within 24 hours; however, that was not always feasible. Resident #138's dentures had been searched for by multiple staff and were unable to be located. The Unit Manager was to put the resident on the dentist list. They stated they did not update the resident on being put on the dentist list as they thought the Unit Manager did.During an interview on 8/15/2025 12:00 PM, Licensed Practical Nurse #10 stated the resident's dentures were found in their drawer that morning. The resident and staff had been unable to find them after searching for them after the resident moved rooms and then moved back. They stated the dentures had been missing for more than a month.10NYCRR 415.3(C)(1)(ii)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00357525) surveys conducted 8/11/2025-8/15/2025, the facility did not provide on-going assessment and monitoring of bed rails (side rails) for three (3) of three (3) residents (Residents #4, #30, and #126) reviewed. Specifically, Resident #4 had bilateral bed rails and did not have an order or a comprehensive care plan that included the use of bed rails, regular assessments to ensure the bed rails remained appropriate or documented evidence that risks and benefits were reviewed with the resident or resident representative or consents were obtained prior to bed rail use; Residents #30 and #126 had bilateral bed rails and did not have regular assessments to ensure the bed rails remained appropriate or documented evidence that risks and benefits were reviewed with the resident or resident representative or consents were obtained prior to bed rail use; and the facility did not have documented evidence of inspections of bed frames, mattress, and bed rails as part of a regular maintenance program. Findings include:The facility policy Siderail and Enabler, revised 10/16/2024, documented side rails were used as enablers to promote independent movement in bed; the side rail assessment would be completed by the rehabilitation department upon admission, readmission, quarterly, significant change, and as needed; maintenance would ensure if enabler bars were recommended they were secured in the upright enabler position to prevent them from being moved out of the enabler position; and the resident or designated representative would be educated on the benefits and risks of side rail use.1) Resident #4 had diagnoses including arthropathies (joint diseases). The 6/9/2025 Minimum Data Set assessment documented the resident had severely impaired cognition, required supervision for bed mobility, and did not use bed rails.The following observations of Resident #4 were made:-on 8/11/2025 at 11:45 AM bed rails were zip tied in an upright position on the resident's bed.-on 8/14/2025 at 2:41 PM the bed rails were double looped p-shaped bed rails engaged in the enabler bar position.The Comprehensive Care Plan initiated 9/14/2023, and revised 9/13/2024, documented an activities of daily living self-care performance deficit. Interventions included extensive assistance of one for bed mobility and use of a concave mattress. There was no documented evidence of the use of bed rails/enabler bars.The physician orders did not document the use of enabler bars.There was no documented evidence of risk/benefits, an assessment, or a consent for the use of the rails.The 7/25/2025 Physical Therapist #43 discharge summary documented the resident required minimal assistance to perform bed mobility tasks without the use of side rails. There was no documented evidence of a recommendation for the use of side rails.During an interview on 8/14/2025 at 2:58 PM Resident #4 stated they needed the enabler bars and used them to get in and out of bed.During an interview on 8/15/2025 at 11:43 AM Certified Nurse Aide #44 stated if a resident was supposed to have mobility bars on their bed it would be listed on their care card. They stated Resident #4's mobility bars were taken off and the resident was really upset about it. They believed they were taken off on 8/14/2025 when there was a realization they were not in their care plan. The resident had since been reassessed and a bar was going to be put back on the bed. During an interview on 8/15/2025 at 12:00 PM Licensed Practical Nurse #10 stated if a resident had mobility bars on their bed, they should be care planned for it. Resident #4 told them their bars were removed, and they were upset about it. Physical therapy went in and talked to the resident and one small bar was put back on the bed. Zip ties were used so the residents could not pull down the bar and create a risk for entrapment. They did not think that prior to that day the resident was care planned for the bars but should have been.During an interview on 8/15/2025 at 12:14 PM Registered Nurse Unit Manager #36 stated if a resident had mobility bars on their bed, they should have a care plan. They were not aware that resident #4 had mobility bars. They should have had a related care plan prior to 8/15/2025 as well as a consent.2) Resident #30 had diagnoses of kidney disease. The 7/11/2025 Minimum Data Set assessment documented the resident had severely impaired cognition, required supervision with most activities of daily living, and did not used bed rails. The 12/23/2022 Comprehensive Care Plan documented an activities of daily living self-care performance deficit. Interventions included concave mattress and 2 enabler bars.The 4/14/2025 physician order documented bilateral enabler bars to enhance mobility.There was no documented evidence of a bed rail assessment or a consent for use of the rails.During observations on 8/11/2025 at 10:15 AM and 8/14/2025 at 11:31 AM the resident had two mismatched bilateral bed rails, both zip tied in an up position at the head of the bed.During an observation on 8/14/2025 at 11:31 AM the resident sat on the edge of the bed and reclined to a lying position without using the bed rails.During an interview on 8/14/2025 at 1:33 AM Certified Nuse Aide #21 stated enabler bars were zip tied if the resident was not care planned to have them. Resident #30's rails were positioned such that they were not in use. If they were in use, they would not be zip tied and would be positioned lower on the bed. They stated the resident did not use the bed rails and after checking the care card, stated the resident was care planned for 2 enablers.3) Resident #126 had diagnoses including stroke with left sided weakness. The 5/11/2025 Minimum Data Set assessment documented the resident had moderately impaired cognition, a functional range of motion impairment on one side, required moderate assistance for bed mobility, and did not use bed rails.The Comprehensive Care Plan initiated 9/12/2019 and revised 2/25/2020 documented an activity of daily living deficit. Interventions included extensive assistance of one for turning and repositioning, a specialized air mattress, and 2 bed enablers.The 10/16/2024 physician order documented enabler bars to enhance mobility.The 4/23/2025 Physical Therapist # 43 discharge summary documented the resident required minimal assistance to perform bed mobility tasks without the use of side rails. There was no documentation for the recommendation for bed rail use.There was no documented evidence of a bed rail assessment or a consent for use of the rails.During an interview on 8/14/2025 at 11:54 AM Certified Nurse Aide #4 stated Resident #126 could move themselves in bed and did not use the bed rails. Their rails were supposed to be strapped but they were not, so the mattress moved all over.During an interview on 8/15/2025 11:42 AM Maintenance Technician #2 stated they installed bed rails if physical therapy told them to. They checked beds for rusty bolts, made sure nothing was broken, and checked the condition of the bed rails. They did not know about entrapment zones, what entrapment meant, and had not had any related training.During an interview on 8/14/2025 at 2:26 PM Licensed Practical Nurse #20 stated bed rails should be listed in the care plan and be zip tied. They thought if there was not a zip tie then the resident could use the bar as an enabler. They were unsure why a bed with two bars only had one with a zip tie.During an interview on 8/15/2025 at 11:34 AM the Rehabilitation Director stated if a resident needed bed rails, they completed the device form and updated the care plan. They would also update the care plan with any changes. There should not be a rail on a bed if there was no recommendation for it or if it had not been cared planned for. Zip ties were put in place so the bars could not be put down. If they were down, then they were considered siderails. Zip ties prevented them from becoming a siderail. Any rail that was on a bed should be zip tied.10NYCRR 415.12(h)(1)(2)

Based on observations and interviews during the recertification survey conducted 8/11/2025-8/15/2025, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for one (3) of four (4) medication carts (Units A2, B2 and C1) and two (2) of two (2) medication rooms (Units A and C) reviewed. Specifically, the Unit A2 medication cart had opened and undated eye drops and multiple prefilled medication cups; the Unit C1 medication cart had opened and undated eye drops and an inhaler; the Unit B2 medication cart was left unattended and unlocked; and the medication refrigerator temperatures on Units A and C were not consistently monitored.Findings include:The facility policy Storage and Maintenance of Medications, revised 10/2017, documented medications were stored safely, securely, and properly following the manufacturer's recommendation or those of the supplier under proper temperature. The refrigerator must maintain a proper temperature of 36-46 degrees Fahrenheit. Medications were checked regularly for expiration dates and deterioration. Expired medications were removed from use. The August 2025 medication refrigerator temperature logs had the following missing temperatures: -Unit A2 day shift on 8/2/2025, 8/3/2025, 8/7/2025, and 8/9/2025.-Unit C1 night shift on 8/6/2025 and 8/7/22025.During an observation of the Unit A2 medication room and medication cart on 8/11/2025 at 4:27 PM, the medication refrigerator had ice built up in the freezer, registered a temperature of 50 degrees Fahrenheit, and the August 2025 medication refrigerator log was missing documentation of temperature readings for the day shift on 8/2/2025, 8/3/22025, 8/7/2025, and 8/9/2025. There were multiple medication cups in the top drawer of the medication cart containing both whole and crushed medications. One cup contained a small piece of white paper with a resident name and time on it. Latanoprost eye drops for Resident #11 were dated as opened 6/1/2025 and expired 7/1/2025. During an interview on 8/11/2025 at 4:27 PM, Registered Nurse #9 stated they were trained on the medication cart but was not sure what the refrigerator temperature was supposed to be. The refrigerator temperature was reviewed and documented on the day and night shift to ensure medications were stored at the proper temperatures. If medications were not stored at the proper temperatures, they were discarded. They were not sure why temperatures were not reviewed or recorded but they should have been. They stated they were slow with their medication pass and used the time from 2:30 to 4:00 to put all the resident's medications in a cup in the medication cart. They put their name on a piece of paper and what time the medications were scheduled to be administered. They were not trained to do this, however, did not feel it was a safety concern because the cart was locked. Once they got a little faster, they were going to stop this process. Resident #11 eye drops should have been discarded on 7/1/2025. They were not sure why they remained in the cart or when they were last administered. During an observation of the Unit C1 medication room and medication cart on 8/12/2025 at 7:51 AM, the August 2025 medication refrigerator log was missing documentation of temperature readings for the night shift on 8/6/2025 and 8/7/22025. The medication cart contained Lumigan 0.01% eye drops for Resident #85 that were not labeled when opened and an Arnuity inhaler for Resident #103 opened on 7/1/2025 and did not have a documented expiration date. During an interview on 8/12/2025 at 7:51 AM, Licensed Practical Nurse #10 stated all eye drops and inhalers were dated when opened and with an expiration date. Eye drops and inhalers were good for 30-60 days depending on the medication. Resident #85 received eye drops in the evening and those drops should be labeled when opened to ensure efficacy of the medication. They were not sure why the medication was not labeled because they had not worked for several days. They were not sure the last time the medication was administered but it should have been labeled when it was opened. The Arnuity inhaler for Resident #103 had an open date of 7/1/2025 and per the manufacturer it was good for 6 weeks after opening so it expired on 8/12/2025. The medication refrigerator temperature was reviewed and documented twice a day to ensure medications did not get too cold or too warm for proper efficacy when administered. They were not sure why the night shift did not take or document the temperatures, but they should have. During an observation on 8/14/2025 at 10:41 AM, the Unit B2 medication care was across from the nurse's station and unlocked. A resident was sitting nearby in their wheelchair, a second resident wheeled past the cart, and a third resident exited their room and wheeled toward the unlocked medication cart. At 10:46 AM Registered Nurse #11 exited a resident room and walked toward the unlocked medication cart. During an interview on 8/14/2025 at 2:21 PM, Registered Nurse #11 stated the medication carts should be locked at all times when unattended for the safety of all residents. They left the medication cart unlocked and unattended earlier in the day because a resident's family member asked for assistance, and they forgot to lock the cart. Several residents wheeled themselves independently around the unit and the cart should be locked for resident safety. During an interview on 8/15/2025 at 12:11 PM, The Director of Nursing stated medication carts should be locked at all times when not in use for resident safety. Eye drops and inhalers were dated when opened and expired in 30 days. Medications should be discarded after 30 days to ensure they were effective. They completed new employee training on the process for administering medications and medications were never prepared in a cup ahead of time for safety reasons. The medication refrigerator temperatures should be monitored twice daily by the day and night shift nurse to ensure the medications inside were safe to administer. If the temperatures were missed by the day or night shift nurse the evening nurse should document the temperatures. 10NYCRR 415.18(d)

Based on observations, record review, and interviews during the recertification survey conducted 8/11/2025-8/15/2025 the facility did not ensure each resident received and the facility provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for two (2) of two (2) residents (Residents #18 and #6) reviewed. Specifically, Resident #18 had an emergency department visit due to suicidal ideations, did not receive follow up from social services or psychology services upon return, did not receive psychotherapy services timely as requested and did not have a person-centered care plan and interventions in place to address their mental health; and Resident #6 did not have person-centered care plan interventions in place to address their mental health. Findings include: The facility policy Comprehensive Care Planning, revised 12/15/2024 documented comprehensive care plans would include measurable objectives and timetables to meet the resident's medical, nursing, and psychosocial needs identified by the admission assessments, comprehensive assessments, Resident Assessment Protocols, and additional problems, strengths, or needs identified by the interdisciplinary team. All residents had the right to participate in the development and implementation of their person-centered plan of care. The facility policy Behavioral Health Services, revised 12/2024 documented the facility would provide residents with behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Behavioral health services were provided to residents as needed as part of the interdisciplinary, person-centered approach to care. Residents who exhibited signs of emotional/psychosocial distress were to receive services and support that addressed their individual needs and goals for care. Staff were trained regarding behavioral health services to recognize changes in behavior, implementing and monitoring care plan interventions, reporting changes in condition, and protocols and guidelines related to the treatment of mental disorders. Behavioral health services were provided by staff who were qualified and competent in behavioral health and trauma-informed care.1) Resident #18 had diagnoses including recurrent severe major depressive disorder, stroke, and congestive heart failure. The 6/4/2025 Minimum Data Set documented the resident has moderately impaired cognition, had no symptoms of depression, and had no behavioral symptoms.The 9/28/2023 Comprehensive Care Plan, revised 7/14/2025, documented the resident used psychotropic medications related to depression, insomnia, and migraines. Interventions included administer psychotropic medications as ordered by the physician, monitor for side effects and effectiveness, discuss with the physician and family the ongoing need for use of medication, review behaviors, interventions, and alternate therapies attempted and their effectiveness, consult with the pharmacy with the physician to consider dosage reduction when clinically appropriate, and monitor, document, and report any adverse reactions of psychotropic medications.There was no documented evidence the care plan addressed the resident's mental health diagnoses, history and any nonpharmacological interventions.The 12/26/24 Psychiatric Nurse Practitioner #55 progress note documented the resident was hospitalized for multiple medical problems. The resident's only concern was still wanting to see their former therapist and resume mental health counseling. Nurse Practitioner #55 planned to inquire about the status of the referral for the psychotherapist and request staff update the resident on the status and timeline of the referral.The 1/22/2025 Psychiatric Nurse Practitioner #55 progress note documented the resident wanted an update on the status of their referral to resume psychotherapy as they felt it would be helpful to talk to someone. They informed the resident they would request another update on the referral from the facility staff. Nurse Practitioner #55 recommended the facility staff should seek an update on the status of the resident's psychotherapy referral and provide an update to the resident and to them.The 4/9/2025 Psychiatric Nurse Practitioner #55 progress note documented the resident wanted to know the status of their referral for psychotherapy. They stated they needed it as they had broken down crying the day before and their mood was low. They denied suicidal ideations, but they did not want to get to that point again. They were getting very depressed and wanted to stay ahead of the depression. They did not feel it would be helpful to adjust their medications; they just wanted to speak with a counselor. Nurse Practitioner #55 documented they would check with the staff on the status of the referral and advised the resident to alert the staff if they felt unsafe or developed suicidal ideations. Nurse Practitioner #55 had inquired with the facility regarding the counseling referral and requested they update the resident.There was no documented evidence of follow-up regarding Resident #18 request to resume therapy with their previous counselor. The 6/24/2025 Emergency Department after visit summary documented the resident had experienced situational problems due to being unhappy about the nursing home they were at as they felt they were not getting the mental health support they needed and was feeling depressed and suicidal but no longer had suicidal ideation. The resident previously had suicidal ideations.The 6/30/2025 unsigned Social Service Initial Evaluation documented the resident had a suicide risk assessment. The resident had a weak suicide plan with past threats, had a controlled but depressed mood, had a barely adequate idea with means (e.g. method used), and had suicidal thoughts and self-harm. The plan was to continue with the current plan of care.There were no physician orders for psychotherapy consultation, and no documented psychiatric nurse practitioner, psychotherapy, or social work follow up following the resident's emergency department visit for suicidal ideations. There was no documented care plan addressing the resident's suicidal ideation. During an interview on 8/11/2025 at 10:47 AM, Resident #18 stated their depression was bad and it had reached the point where they did not want to live. The facility just watched them, and someone had talked to them about it, but they did not know who it was. The facility was supposed to be working on counseling services for them.During a follow up interview on 8/13/20245 at 11:19 AM, Resident #18 stated they were on a waitlist for the previous place they went for psychotherapy. The facility had not asked if the resident wanted to go to a different counselor or offered to send a referral somewhere else. They stated they just wanted to get into psychotherapy as soon as possible as the practitioner at the facility did not sit down and talk to the resident.During an interview on 8/14/2025 at 2:16 PM, Certified Nurse Aide #57 stated interventions and strategies on how to prevent resident behaviors were on the resident's care plan. Resident #18 expressed wanting counseling services several times and they continued to report the information to the nurse. Resident #18 had not had an appointment with psychotherapy they were aware of. Resident #18 was sent out for a psychiatric evaluation as the resident told them they wanted to harm themself, and they told the Unit Manager. Nurse Practitioner #37 wanted the resident to be sent to hospital as the resident was still waiting on counseling services.During an interview on 8/15/2025 at 12:00 PM, Licensed Practical Nurse #10 stated some of the care plans had interventions for resident behaviors such as how to calm a resident down. Resident #118 had expressed to them they wanted counseling and was supposed to be going. They stated it had taken a while for the resident to get into counseling as the resident did not want to talk to anyone in the facility. They were unaware of who was covering the psychology services in the facility while Psychiatric Nurse Practitioner #55 was out.During an interview on 8/15/2025 at 10:29 AM, the Social Services Director stated they were responsible for the social and emotional wellness of the residents and advocating for residents and their family. The Social Services Assistant was responsible for doing a lot of paperwork and forms but did not have a caseload in the facility. They stated they sometimes set up behavior plans or if there were issues with a resident's behavior, they would look to see what needed to be added to the care plan. Prior to the current Administrator, they were not involved in care plans, it was mainly the nurses who did the care plans. Care plans were reviewed every quarter. They were unaware of how the staff addressed a resident's behavior with non-pharmacological interventions if they were not on the care plan. They would get the non-pharmacological interventions from the psychiatric practitioner and from the Pre-admission Screening and Resident Review Level II Assessment. They did review the psychiatric nurse practitioner's notes and if there were recommendations, the nurses implemented them, even if they were not medication related. Resident #18 stated they wanted to go to psychotherapy but did not want to go in-house which the psychiatric nurse practitioner provided but it had taken a while to set up an outside consult. The Unit Managers sent all referrals and set up all appointments, including mental health appointments. It likely took a while as the unit has had at least four different Unit Managers since December of 2024, and staff thought the resident was getting therapy through the psychiatric nurse practitioner. They would talk to the resident to support their emotional wellbeing but would not document it if it was too personal in nature. Resident #18 did not have a care plan for their mental health. The resident should have a care plan in place with their history of mental health issues. There was no documented follow up from social services after the resident returned from the emergency department visit for suicidal ideations and there should have been. Psychiatric Nurse Practitioner #55 had been out on leave from June to the end of August, and they were unaware if anyone was covering for them at this time.During a phone interview on 8/15/2025 at 12:39 PM, Nurse Practitioner #37 stated they had been managing the building's psychiatric services while Nurse Practitioner #55 was out. They had sent Resident #18 out to the emergency department due to suicidal ideations where they could have a psychiatric evaluation. When the resident came back from the emergency department they started an antidepressant for the resident. They were unaware of why there was a delay in getting the resident into psychotherapy. They did not believe getting the resident into psychotherapy would have stopped the resident from going to the emergency department because the resident had variable moods. Resident #18 had been on a regimented schedule with Nurse Practitioner #55 prior to going out to the hospital. They expected social services to have followed up with the resident after their emergency department visit related to their mental health to follow up on what the resident's needs and wants were after their return.2) Resident #6 had diagnosis including schizophrenia, bipolar, and recurrent severe major depressive disorder without psychotic features. The 6/10/2025 Minimum Data Set documented the resident had moderately impaired cognition, had no behavioral symptoms, and had little interest or pleasure in doing things and feeling down, depressed, or hopeless two to six of seven days.The 9/19/2022 Comprehensive Care Plan, revised 8/4/2025, documented the resident utilized psychotropic medication related to behavior management, insomnia, depression, and anxiety. Interventions included administer the psychotropic medications as ordered by the physician and monitor for side effects and effectiveness every shift, consult with the pharmacy and medical provider to consider dosage reductions when clinically appropriate, and monitor, document, and report any adverse reactions of the psychotropic medications.There was no documented care plan to address the resident's mental health diagnoses, history and nonpharmacological interventions.The resident had a Level I Screen dated 9/19/2022 that documented the resident had a Level II Pre-admission Screening and Resident Review Level II assessment completed.There was no documented Pre-admission Screening and Resident Review Level II assessment (evaluation for serious mental illness) in the resident's record and no documented care plan to reflect their Level II resident review for mental illness.During an interview on 8/15/2025 at 11:43 AM, Certified Nurse Aide #44 stated a resident's care plan should have interventions for a resident who had behaviors. Resident #6 did not have behaviors except for some episodes of making false allegations. They did not see anything in the resident's care plan related to behaviors.During an interview on 8/15/2025 at 10:29 AM, the Social Services Director stated they only followed up with the resident about what was in the psychiatric nurse practitioner notes if the resident brought it up to them when they inquired how the resident was. They had never put in a care plan for the resident's mental health, but they had some mentions of their anxiety and depression and psychotropic medications. The only non-pharmacological intervention was to reduce psychotropic medications. Resident #6 was not seeing anyone while Nurse Practitioner #55 was on leave, but Nurse Practitioner #37 was managing their medications. During a follow up interview at 11:40 AM, the Social Services Director stated they were unaware Resident #6 had a Pre-admission Screening and Resident Review Level II when they were admitted in 2022. They did not have one on file for the resident and would have to reach out to obtain a copy.During an interview on 8/15/2025 at 12:14 PM, Registered Nurse Unit Manager #36 stated they had never been made aware nursing was responsible for putting in mood and behavior care plans for the facility. Resident #6 should have mental health care plans related to their mental diagnosis and histories.During a phone interview on 8/15/2025 at 12:39 PM, Nurse Practitioner #37 stated Resident #6 should have a care plan addressing their mental health history and/or their behaviors. 10 NYCRR 415.12

Based on observations, record review, and interviews during the recertification and abbreviated (IQIES 525144 and 2582064) surveys conducted 8/11/2025-8/15/2025, the facility did not ensure residents had the right to a dignified existence in a manner and an environment that promoted the maintenance or enhancement of quality of life for six (6) of six (6) staff (Licensed Practical Nurse #12, and Certified Nurse Aides #22, #51, #52, #53, and #54) observed. Specifically, during meal service on Unit A2 residents were observed being fed by Licensed Practical Nurse #12, and Certified Nurse Aides #22 and #51 while standing; and Licensed Practical Nurse #12, and Certified Nurse Aides #52, #53, and #54 addressed residents as honey and feeders. Findings include: The facility policy Maintaining Resident Respect and Dignity, revised 5/27/2025, documented the facility provided loving care to all residents in a timely manner that best bespeaks dignity, respect, compassion, sensitivity, and concern. The care embraced the physical, emotional, and spiritual needs of all residents. They respected social status and created a dignified homelike environment respecting the resident’s room and personal space. Clothing was clean, fit properly, and matched. Residents would be addressed by his/her given name in an adult manner. When feeding staff should be seated at eye level to promote socialization. The dining experience was pleasant, relaxing, and like that in a fine restaurant. The following observations were made in the Unit A2 dining room: -on 8/11/2025 at 12:20 PM, Licensed Practical Nurse #12 was feeding a resident while standing. At 12:24 PM, Licensed Practical Nurse #12 moved and stood while feeding Resident #35. -on 8/11/2025 at 12:36 PM, Certified Nurse Aide #22 fed residents while standing. -on 8/12/2025 at 12:45 PM, Licensed Practical Nurse #12 was standing while feeding Resident #35. -on 8/12/2025 at 12:47 PM, Certified Nurse Aide #51 was standing while feeding Resident #48. -on 8/13/2025 at 9:34 AM, Licensed Practical Nurse #12 addressed multiple residents by the name “honey” and not their preferred names. -on 8/13/2025 at 11:12 AM, Certified Nurse Aide #52 asked staff in the area Is this where the feeders are going? -on 8/13/2025 at 11:13 AM, Certified Nurse Aides #54 and #53 were at the nurse’s station where multiple residents were sitting and asked where “the feeders were going.” During an interview on 8/13/2025 at 12:07 PM, Certified Nurse Aide #53 stated they had many trainings on different topics including dignity and abuse training. They were not trained to refer to residents as “feeders”. It was not professional to call residents “feeders,” and they should not do it. They were trained not to address residents as “honey” but did it all the time because they felt it was welcoming. During an interview on 8/13/2025 at 12:18 PM, Licensed Practical Nurse #12 stated they tried to use the residents’ last names but that they did use pet names. Residents should not be called honey or sweetie or labeled as a lift or a Hoyer because it was a dignity issue. Residents should be addressed in the way their parents named them. They stated they knew they should be sitting down when feeding a resident, but the chairs were locked up and they did not have access to them. They should not be standing when feeding because it intimidated residents into eating. During an interview on 8/13/2025 at 12:40 PM, Certified Nurse Aide #51 stated when feeding residents, staff should sit next to them and not stand over them. They stood when feeding Resident #48 because they did not know they were allowed to pull up a chair and there was not a lot of room for the chair. 10 NYCRR 415.5(d)(1)(i)

Based on observations, record review, and interviews during the recertification survey conducted 8/112/2025-8/15/2025, the facility did not ensure planned menus were followed for three (4) of thirteen (13) residents (Residents #8, #69, #98, and #148) reviewed. Specifically, Residents #69, #98, #148 did not receive Mighty Shakes (nutritional supplement) as planned; Resident #148 was missing multiple items listed on their meal ticket; and Resident #8 received bread at meals when care planned for no bread. Findings include: The facility policy Food and Nutritional Services, effective 5/2019, documented each resident was provided with a nourishing, palatable, well-balanced diet that met their daily nutritional and special dietary needs, taking in the preferences of each resident. 1) During a lunch meal observation on 8/11/2025 at 12:14 PM, Resident #98's lunch meal ticket documented the resident was to receive a Mighty Shake. The meal tray did not include a Mighty Shake. During a lunch meal observation and interview on 8/13/2025 at 12:51 PM, Resident #98's lunch meal ticket documented the resident was to receive a Mighty Shake. Resident #98's tray was missing the Mighty Shake. Resident #98 stated they trays were always wrong and they never received Mighty Shakes. They would have drunk the Mighty Shake if they received it. During a lunch meal observation on 8/13/2025 at 12:57 PM, Resident #69's lunch meal ticket documented the resident was to receive a Mighty Shake. Resident #69's tray was missing their mighty shake. During an observation and interview on 8/13/2025 at 1:10 PM, Resident #148 did not have their Mighty Shake, egg salad in a bowl, boiled egg, cheeseburger on a bun, or tomato soup. They stated if they had the egg salad, boiled egg, and soup they would have eaten it. During an observation and interview on 8/14/2025 at 12:57 PM, Resident #148 did not have a boiled egg, vegetable soup, or sweet potato fries on their meal tray and had regular French fries. The resident stated they did not eat white foods like French fries, however, would have liked the sweet potato fries and the soup. They did not have much of an appetite and had soup earlier in the week and it tasted good. During an interview on 8/14/2025 at 2:21 PM Registered Nurse #11 stated it was the kitchen's responsibility to make sure all items on the meal ticket were on the resident's tray and they had seen items missing from trays. Mighty shakes were ordered for residents who were nutritionally deprived or had wounds. Resident #98 had a wound. During an interview on 8/15/2025 at 8:05 AM Registered Nurse Unit Manager #6 stated the kitchen staff was initially responsible for making sure all items on the meal ticket were on the tray. Staff passing the trays double checked the trays to make sure there were no missing items. Mighty shakes were offered for weight loss, poor intake or extra supplements. Resident #148 had a poor intake and would benefit from Mighty Shakes. If the dietitian recommended Mighty Shakes, it was documented on the care plan and residents should get them. After looking at the care plan for Residents #69, #98, and #148, all were recommended to have Mighty Shakes for lunch and dinner. During an interview on 8/15/2025 at 10:42 AM, Registered Dietitian #8 stated they recommended Mighty Shakes when estimated protein needs were not being met or they had higher protein requirements for wounds or poor intake. Resident #148 had an assessment with their preferences and was expected to get their preferences as listed on their meal ticket. Resident #148 had Mighty Shakes added to their lunch and dinner trays because of poor intakes. Resident #69 had Mighty Shakes on their lunch and dinner tray because they were under weight and had a decline in their weight. Resident #98 had Mighty Shakes on their lunch and dinner trays because they had a wound. They expected Mighty Shakes to be on the resident trays if recommended and were not sure why the kitchen did not put them on the trays. During an interview on 8/15/2025 at 11:55 AM, Dietary Aide #42 stated food was prepared and set up in the kitchen by dietary aides. The dietary aides were responsible for making sure trays were accurate. Mighty shakes were used for residents that required additional calories. There were times when mighty shakes were not available because they did not arrive on the delivery truck, and they had been out of mighty shakes for approximately one week. If a resident asked for soup, they should have received it and were not sure why the resident did not get the soup. They had sweet potato fries on the meal ticket, however had never seen sweet potato fries in the building and did not feel they should have been on the meal ticket since they were not available. During an interview on 8/15/2025 at 12:04 PM, the Food Service Director stated kitchen staff working the tray line made sure all items on the meal ticket were on the tray. Mighty shakes were ordered for residents to gain weight. Mighty shakes were not on resident trays this week because staff did not know where to locate them. They should have been on the tray. Sweet potato fries were listed on the meal tickets but not available from the vendor and they were working with the dietitian to get them removed. The cook called in sick on 8/14/2025 and they had stepped in to cook. They did not have time to make soup, therefore Resident #148 did not get their soup as requested. 2) Resident #8 had diagnoses including dysphagia (difficulty swallowing) and a gastrostomy (a feeding tube). The 7/2/2025 Minimum Data Set assessment documented the resident was cognitively intact, required setup or clean-up assistance for eating, did not have a swallowing disorder, received a mechanically altered diet, and previously received nutrition via gastrostomy tube.The Comprehensive Care Plan initiated 6/30/2025, and revised 8/11/2025, documented the resident had a nutritional problem related to mechanically altered diet of mechanical soft with thin liquids and relied on a tube feeding to meet estimated nutrient needs. Interventions included provide and serve mechanical soft diet with ground meats and no bread, thin liquids diet as ordered. During a lunch meal observation on 8/13/2025 at 12:50 PM, Resident #8's lunch meal ticket documented the resident was to receive cheeseburger on a bun-ground, baked beans, oatmeal cookie, tossed salad, water, whole milk, and coffee. Serve nothing on bread or biscuits. Meats must be ground. The ground meat was observed on a bun. Resident #8 told Licensed Practical Nurse #20 they were not allowed to have bread acknowledged the resident and left the room leaving the bun on the tray. During a lunch meal observation on 8/14/2025 at 12:46 PM, Resident #8's lunch meal ticket documented the resident was to receive glazed chicken fritters, sweet potato fries, coleslaw, chocolate peanut butter cake, coffee, whole milk, and water. Serve nothing on bread or biscuits. Meats must be ground. The ground meat was observed on a bun. During an observation and interview on 8/14/2025 at 12:48 PM Resident #8 told Certified Nurse Aide #39 they were not allowed to have the bun that was on their tray. Certified Nurse Aide #39 removed the bun from the tray. During an interview on 8/14/2025 at 2:21 PM, Registered Nurse #11 stated most residents that were at risk for choking were on an altered consistency diet. Resident #8 was at risk for choking on a thickened liquid only diet and on 8/11/2025 was changed to a mechanical soft diet with no bread. The kitchen was responsible for making sure all trays were accurate, so resident got the protein and calories required and did not choke. Resident #8 could not have buns and had one on their tray earlier today. They notified the Director of Nursing. During an interview on 8/14/2025 at 2:53 PM, Licensed Practical Nurse #20 stated Resident #8 was at risk for choking because they had swallowing difficulties. They had an appointment on 8/11/2025 with speech and language pathology for a swallowing evaluation and was upgraded to mechanical soft foods, ground meet, and no bread. They had a bun on their tray on 8/13/2025 and they did not remove it because the resident was oriented enough not to eat it. They should have removed the bun. During an interview on 8/15/2025 at 10:30 AM, Speech Language Pathologist #7 stated Resident #8 had Parkinson's disease with difficulty swallowing and received feeding through a gastrostomy tube. They were evaluated on 8/11/2025 and upgraded mechanical soft and thin liquids, no straws, no bread with ground meats. The recommendations were sent to the facility the same day. There was no bread because it was fluffy and got stuck in the back of the resident's throat. A bun was considered bread and Resident #8 should not have it. During an interview on 8/15/2025 at 11:55 AM, Dietary Aide #42 stated trays were prepared in the kitchen by staff on the tray line. The tray line staff was responsible for making sure the trays were accurate. If a meal ticket said no bread or biscuits, they should not get a bun. They were not sure why Resident #8 had buns on their lunch tray two days. During an interview on 8/15/2025 at 12:04 PM, the Food Service Director stated the tray line staff was responsible for preparing trays and making sure the items on the tray matched the meal ticket. They did not have any formal process for ensuring trays were accurate. If a ticket said no bread, they should not have the bun. They believed staff was not reading the meal ticket which was the reason for the bun on the tray. 10NYCRR 415.14(c)(1-3)

Based on observations, record review, and interviews during the recertification survey conducted 8/11/2025-8/15/2025, the facility did not ensure all residents were fully informed of and participated in their treatment, including the right to be fully informed in a language that they can understand of their total health status, including but not limited to, their medical condition, and the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternatives or the option they prefer for one (1) of two (2) residents (Residents #53) reviewed. Specifically, Resident #53 was not informed of a medical order for a chest x-ray nor of the results of the x-ray. Findings include:The facility policy Resident Rights, revised 3/2025, documented residents had a right to be informed and make their own decisions. Residents had the right to be fully informed about their total health status, medical condition, and participate in decisions that affected their care. Resident #53 had diagnoses including atrial fibrillation (irregular heartbeat), high blood pressure, and heart failure. The 5/26/2025 Minimum Data Set assessment documented the resident was cognitively intact, was able to make themself understood and understood others. The 6/25/2021 Health Care Proxy form documented the resident appointed their child as their health care agent to make health care decisions for them effective only when and if they became unable to make their own health care decisions. The 5/20/2025 Capacity Evaluation documented the resident had decisional capacity regarding medical decisions. The 8/10/2025 at 12:14 PM Registered Nurse #19 progress note documented they were called to the unit due to Resident #53 sustaining a fall. Resident had sutures to their right eyebrow that had re-opened and there was a new order to apply steri-strips to reinforce the sutures. The resident's oxygen saturation (amount of oxygen in blood) was 88 percent, and the resident was not wearing oxygen. Nurse Practitioner #37 was made aware and a new order for a chest x-ray for desaturation was given. The resident's child was unavailable for a call. The 8/10/2025 physician order documented chest x-ray one time only. The 8/11/2025 at 7:03 AM, Registered Nurse Unit Manager #26 progress note documented the resident was seen by the provider. The designated representative was updated on the fall and the order for the chest x-ray and agreed with the current plan of care. The 8/11/2025 Nurse Practitioner #37 progress note documented the resident was seen after a fall on 8/10/2025. The resident was noted to have stable vital signs except for the oxygen saturation of 88 percent without wearing oxygen. The resident had a recent fall with a head laceration requiring suture repair and they hit that site during the fall and the area was reinforced with steri-strips. The oxygen saturation had been waxing and waning, and there were no other respiratory symptoms. An order was given to obtain a chest x-ray today and they were awaiting results. During an observation on 8/11/2025 at 10:23 AM, a portable x-ray machine was taken into the resident's room. The resident asked the technician why they were doing a chest x-ray. The resident stated they did not know they were getting a chest x-ray. The 8/11/2025 radiology report for the chest x-ray documented the exam was at 10:20 AM, signed by the radiologist, and results were provided to the facility at 11:11 AM. The report was initialed and dated 8/11/2025 by Nurse Practitioner #37 and Registered Nurse Unit Manager #26. During an observation on 8/13/2025 at 3:33 PM (2 days after the x-ray was ordered and after results were available), Registered Nurse Unit Manager #26 was in Resident #53's room to complete a new Medical Orders for Life-Sustaining Treatment form. The resident asked about the chest x-ray and why it was done. Registered Nurse Unit Manger #26 stated it was to make sure they did not have pneumonia because they were short of breath and needed oxygen a couple of days ago. The resident asked if the results were ok and was told they were. There was no documented evidence the resident was made aware of the chest x-ray order or the results of the testing prior to 8/13/2025. During an interview on 8/15/2025 at 10:43 AM, Registered Nurse Unit Manager #26 stated x-rays were ordered by Nurse Practitioner #37. Registered Nurse Unit Manager #26 entered them in the computer and called the imaging company. The resident's family was notified before the testing was completed and then again with the results. If the resident had a health care proxy they called them, or if the resident was their own health care proxy they told the resident directly. Resident #53 had a health care proxy, so they always notified them. The resident was asking about it when they went over the Medical Orders for Life-Sustaining Treatment form. They often deferred decisions to the resident's health care proxy, but the resident could make their own decisions and had capacity and should have been told about the reasons for the x-ray, and the results. 10NYCRR 415.3(e)(1)(i)

Based on observations, record review, and interviews during the recertification survey conducted 8/11/2025-8/15/2025, the facility did not ensure residents had the right to have reasonable access to the use of a telephone and a place in the facility where calls can be made without being overheard for two (2) of four (4) residents (Residents #69 and #126) reviewed. Specifically, Resident #69 did not have access to a telephone and Resident #126 had to make phone calls at the nurse's station where others could overhear their conversations. Findings include: The facility policy Resident Right to Forms of Communication/Privacy, effective 4/7/2023, documented the facility protected and facilitated the resident's right to communicate with individuals and entities within and external to the facility. Resident's had easy access to telephones and a place in the facility where calls could be made without being overheard. 1) Resident #69 had diagnoses including fractured left arm and anxiety. The 8/2/2025 Minimum Data Set assessment documented the resident had intact cognition; felt it was very important to have their family involved in their care; required partial/moderate assistance with most activities of daily living; had functional limitation of one arm; and used a manual wheelchair for mobility with partial/moderate assistance.The Comprehensive Care Plan initiated 7/31/2025, documented the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs. Interventions included support for socialization and stimulation and to respect the residents right to refuse. The resident had an activity of daily living self-care performance deficit related to limited mobility. Interventions included limited assistance of one for locomotion using the wheelchair. During an interview and observation on 8/11/2025 at 12:38 PM there was a phone in the resident's room without a dial tone. The resident stated they were upset they were unable to reach their family. They stated they were told to go to a different room to use a telephone, but they were unable to use their wheelchair to get to another room as their arm was in a cast. On 8/12/2025 at 11:09 AM the resident stated calling their family made them feel better and when they could not call their family, they felt depressed. During an interview on 8/12/2025 at 11:14 AM, Maintenance Technician #2 stated the wall jack for the telephone in the resident's room was dead and they requested a splitter from the Director of Maintenance a week or so ago.During an observation and interview on 8/14/2025 at 12:17 PM the resident was wheeled by the Director of Nursing to room [ROOM NUMBER] to use the phone. The Director of nursing offered the resident to move to that room as it had a working phone. The Director of Nursing stated they called the resident's #69 family to notify them of an x ray. During the phone call the family stated they were more concerned they were not able to reach the resident by phone. The Director of Nursing offered the resident a new room and they accepted. During an interview on 8/14/2025 at 12:19 PM, Certified Nurse Aide #24 stated everyone had a phone in their room, but it was not working. They believed maintenance was notified and they did not know why it was not fixed.2) Resident #126 had diagnoses including anxiety and major depressive disorder. The 5/11/2025 Minimum Data Set assessment documented the resident had moderate cognitive impairment; was able to make themself understood; understand others; and felt down, depressed, or helpless 2-6 of 7 days. During an observation and interview on 8/11/2025 at 11:35 AM, the resident was in their room and stated they did not have a phone and could not have private telephone conversations with their family. They had to use the telephone at the nurse's station and talk in front of staff. There was no telephone observed in their room.During an interview on 8/13/2025 at 9:39 AM, Certified Nurse Aide #33 stated all residents should have a phone in their room. Resident #126 did not have a phone in their room and used the desk phone at the nurse's station to call their family. Staff could walk away but there were always other residents outside the nurse's station who could hear the conversations. The resident had the right to have private telephone conversations. During an interview on 8/13/2025 at 9:55 AM, Licensed Practical Nurse #27 stated Resident #126 did not have a phone in their room and came out to the nurse's station to call their family. The resident could not have a private conversation because there were always people around the nurse's station. The resident should be able to have a private conversation. During an interview on 8/15/2025 at 11:14 AM, Registered Nurse Unit Manager #26 stated all resident had a land line phone or some had cellular phones. Residents had the right to have private conversations. They could not have private conversations at the nurse's station because it was a very busy, high traffic area and people were nosey. During an interview on 8/15/2025 at 11:42 AM, Maintenance Technician #2 stated every resident room was supposed to have a phone, but they were not sure if every room did. They were not aware Resident #126 did not have a phone and was unaware of a broken jack in that room. 10NYCRR 415.3(d)(3)

Based on observations, record review, and interviews during the recertification survey conducted 8/11/2025-8/15/2025, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents for two (3) of seven (7) residents (Residents #22, and #83) reviewed. Specifically, Resident #22 did not have an enabler bar on their bed as care planned; and Resident #83 was transferred with assistance of one and not two as care planned.Findings include: The facility policy Comprehensive Care Planning, revised 12/15/2025, documented the Comprehensive Care Plan included measurable objectives to meet the resident's medical, nursing and psychosocial needs identified from admission assessments, the comprehensive assessment, and application of the Resident Assessment Protocols. Other problems, strengths or needs identified by the Interdisciplinary Team were included in the Comprehensive Care Plan as appropriate. Types of problems which should be included were, risk for falls and activities of daily living. The facility policy Sit to Stand Mechanical Lift, revised 3/2025, documented a minimum of one caregiver was to be present and assisting at all times during a sit to stand mechanical lift transfer of residents. The caregiver was to refer to the resident's transfer status prior to transfer to determine the exact number of staff required to perform the sit to stand mechanical lift transfer for the specific resident. The facility policy Hoyer Lift, prepared 3/2019, documented residents were transferred safely to/from bed to chair and/or toilet via Hoyer lift when ordered by either the physician and/or therapy department. The procedure was carried out by two nursing assistants/nurses, or physical therapy/occupational therapy always; there were no exceptions. The facility policy Siderail and Enabler, revised 10/16/2024, documented enablers (bar attached to the bed to assist with bed mobility) promoted independent movement in bed and provided a handhold for getting into or out of bed. The use of side rails was to only be utilized for the purposes intended and when they assisted the resident to maintain their highest practicable level of physical or psychosocial well-being. A side rail assessment was completed by the Rehabilitation Department and decisions to use or discontinue were made in the context of an individualized resident assessment using an interdisciplinary team approach. Recommendations for side rails were discussed with the resident's physician and orders were placed. Updates to the resident's activities of daily living were added to the care plan to outline the medical factors necessitating the side rail. The facility policy Falls and Fall Risk, Managing, prepared 12/10/2024, documented staff identified interventions related to the resident's specific risks and causes to prevent the resident from falls and to minimize complications from falls. Staff implemented a resident-centered fall prevention plan to reduce specific risk factors of falls for each resident at risk or with a history of falls. 1) Resident #22 had diagnoses including right below the knee amputation and diabetes. The 8/4/2025 Minimum Data Set assessment documented the resident had intact cognition, had limitation in functional mobility of one leg, and was dependent for transfers. Incident Reports for Resident #22 included: -on 8/1/2025 the resident was found sitting on the floor with their legs in front of them. The resident stated they were trying to get into the chair and was educated on using the call bell when they required assistance. -on 8/4/2025 the resident was found sitting on the floor with their buttocks against the bed. The resident stated they were repositioning themselves in bed and an enabler bar for the left side of the bed was issued. -on 8/7/2025 the resident was attempting to self-transfer when they fell landing on their back in front of their dresser. -on 8/9/2025 the resident was found on the floor in front of the bathroom door. The Comprehensive Care Plan initiated 7/31/2025, and revised 8/7/2025, documented the resident was at risk to falls related to deconditioning, right below the knee amputation and medication use. Interventions included fall protocol, call bell in reach and an enabler bar for positioning. The device rail assessment completed on 8/7/2025 by the Director of Nursing, Rehabilitation Director #3, and Social Worker #13 documented Resident #22 had a right below the knee amputation and required extensive assistance of 1 for transfers. A left enabler bar was implemented for enhanced bed mobility. The undated care instructions documented Resident #22 required assistance of 1 for bed mobility and had a left sided enabler bar. During observations on 8/11/2025 at 11:34 AM, and 8/12/2025 at 10:40 AM and 1:50 PM, there was no enabler bar on Resident #22's bed. During an observation and interview on 8/12/2025 at 2:36 PM, Resident #22 was in bed and stated they fell several times because staff did not come timely when they rang their call bell. There was no enabler bar on the bed. The resident stated they were told on 8/8/2025 by the Director of Nursing an enabler bar was going to be placed on their bed, but it never was. During an interview on 8/13/2025 at 2:41 PM, Certified Nurse Aide #23 stated enabler bars were not used in the facility because they were considered a restraint. During an interview on 8/14/2025 at 12:19 PM, Certified Nurse Aide #24 stated Resident #22 fell several times. Interventions implemented for falls were documented on the care plan and should be followed. The facility did not use enabler bars because they were considered a restraint. During an interview on 8/14/2025 at 2:21 PM, Registered Nurse #11 stated if a resident frequently fell, interventions would be documented on the care plan. Care planned interventions should be followed. They were not sure if Resident #22 had a care plan for enabler bars and if they did, the enabler bar should be on the bed. They stated Resident #22 did not have enabler bars on the bed, and they were not sure why. During an interview on 8/15/2025 at 8:05 AM, Registered Nurse Unit Manager #6 stated they were responsible for updating the nursing section of the care plan. The care plan directed staff on the individual care required for each resident. Resident #22 was care planned for enabler bars. They were not sure why the enabler bar was not on the bed as recommended but should have been. During an interview on 8/15/2025 at 8:33 AM, Rehabilitation Director #3 stated their department was notified after every fall and they completed an evaluation. Interventions recommended included cushion devices, physical therapy for strengthening, and enabler bars. When enabler bars were recommended, they completed a device form and updated the care plan. The Director of Maintenance was emailed and put the bars on the bed. They recommended a left sided enabler bar for Resident #22 on 8/7/2025 and emailed the Director of Maintenance the same day. The Director of Maintenance quit without notice on 8/8/2025 and they were not aware until 8/11/2025. They expected the enabler bars to be on the bed for Resident #22 because they had balance issues from their amputated leg. 2) Resident #83 had diagnoses including morbid obesity, difficulty walking, and right sided paralysis after a stroke. The 7/20/2025 Minimum Data Set assessment documented the resident had severe cognitive impairment, had limitations in functional mobility on one side of both upper and lower extremities, and was dependent for transfers. The Comprehensive Care Plan initiated 7/27/2021, and revised 2/25/2025, documented the resident had an activity of daily living self-care performance deficit and decreased mobility related to activity intolerance, dementia, fatigue, and hemiplegia (paralysis on one side of the body). Interventions included extensive assistance of 2 with standing Hoyer (mechanical lift) for toileting and transfers. The resident care instructions documented the resident required extensive assistance of 2 staff and standing Hoyer for toileting and transfers. During an observation on 8/11/2025 at 11:07 AM, Resident #83 was seated in their wheelchair outside the nurse's station and verbalized the word bathroom. Certified Nurse Aide #32 addressed the resident and stated they needed to get the mechanical lift. At 11:11 AM Certified Nurse Aide #32 entered the room with the resident and closed the door. At 11:13 AM, the resident said ow which was heard in the hallway outside the room. At 11:16 AM, Certified Nurse Aide #32 opened the door to the resident's room and told the resident to put the call light on when they were done and exited the room with a trash bag. There were no additional staff present in the resident's room. At 11:17 AM the resident's wheelchair in their room was empty and the bathroom door was closed. At 11:23 AM, Certified Nurse Aide #32 stated she was going to lunch and told Certified Nurse #33 Resident #83 was in the bathroom. Certified Nurse Aide #49 said they worked on a different unit but came down to cover for a break. At 11:27 AM, Certified Nurse Aide #33 and Certified Nurse Aide #49 entered the room. During an observation on 8/12/2025 at 11:05 AM, the resident was in their room in their wheelchair. They verbalized the word bathroom repeatedly and was heard from the hallway. Certified Nurse Aide #50 entered the room with the mechanical lift and closed the door. There were no additional staff present in the resident's room. At 11:18 AM, Certified Nurse Aide #50 wheeled the resident out of their room to just outside the nurse's station, went back into the resident's room and exited the room with the mechanical lift. During an interview on 8/12/2025 at 11:44 AM, Certified Nurse Aide #50 stated they put the resident on and off the toilet. They used the stand Hoyer to transfer them. They did both transfers by themself. During an interview on 8/13/2025 at 8:51 AM, Certified Nurse Aide #32 stated Resident #83 used the standup Hoyer for transfers. They transferred the resident by themself on 8/11/2025 and they knew they were not supposed to, but they were short staffed that day. There were only 2 certified nurse aides on the floor because the third was out with a resident on an appointment. The resident was heavy to lift to hook up the pad because one side of their body was paralyzed. The resident should be assisted by two for all transfers. During an interview on 8/13/2025 at 9:55 AM, Licensed Practical Nurse #27 stated the stand Hoyer required assistance of two if they were care planned that way. Resident #83 required assistance of two because they could not use one side of their body. The resident could only hang on with one arm and probably should be a full Hoyer with transfers. They had seen certified nurse aides transfer the resident with just one and not two. During an interview 8/15/2025 at 11:18 AM, Registered Nurse Unit Manger #26 stated all residents who required a mechanical lift were an assist of 2. This was for safety of the residents and the staff. Resident #83 used the stand Hoyer and required assistance of 2. Appointment days were Monday and Tuesday, and they tried to have extra staff scheduled on those days but there were call ins this week. They were not aware of staff transferring with only one, but it probably depended on the staffing ratios. 10 NYCRR 415.12(h)(1)(2)

Based on observation, record review, and interview during the abbreviated survey (NY00304851 and NY00315847), the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 2 of 4 residents (Residents #3 and 6) reviewed. Specifically, Resident #3 developed pressure ulcers and treatments were not ordered, transcribed, or administered and pressure relief interventions were not provided. This resulted in harm that was not immediate jeopardy to Resident #3 when their pressure ulcers subsequently worsened to Stage 3 (full thickness tissue loss) and Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle), requiring hospitalization and (IV) antibiotics for osteomyelitis (bone infection). Additionally, Resident #6's pressure ulcer treatments were not completed as ordered. Findings include: The facility policy Pressure Injury Prevention & Management/Wound Rounds revised 12/2022 documented when a pressure ulcer was identified, the nurse was responsible to notify the physician and obtain the appropriate treatment order, initiate the Skin Tracking Assessment Sheet, notify the dietitian, and document in a nurse's note. The registered nurse (RN) Manager/designee was responsible to monitor and assess healing/deterioration minimally on a weekly basis and communicate changes to the physician so that appropriate revision to the plan of care could be implemented. The dietitian was responsible for conducting a nutrition assessment and reassessing the resident when an actual pressure injury was identified. The medical provider was responsible to complete an assessment and document findings in the medical record, conduct periodic evaluation of the pressure injury on an ongoing basis until healed, modify treatment plans and make referrals. 1) Resident #3 was admitted to the facility with diagnoses including dementia, venous insufficiency (poor blood flow) and functional quadriplegia (paralysis of both arms and legs). The 11/2/2022 Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired, they required extensive assistance of 2 with bed mobility and transfers, was at risk of developing pressure ulcers, and had no current pressure ulcers. The 8/23/2022 comprehensive care plan (CCP) documented the resident had potential for skin impairment related to incontinence. Interventions included avoid scratching, good nutrition and hydration, keep skin clean and dry, and a pressure relieving cushion in the wheelchair. The 12/1/2022 wound rounds tracking sheet by licensed practical nurse (LPN) Manager #13 documented the resident had an open coccyx (tailbone) pressure ulcer that had 90% granulation tissue (new healthy tissue) and 10% slough (tan/yellow dead tissue) and the current treatment was wound gel (water-based treatment, hydrates wounds) and a dressing daily. There was no documentation of the wound stage and no evidence the medical provider (attending physician #17, nurse practitioner (NP) #1 were contacted for a treatment for the wound. The 12/2022 Treatment Administration Record (TAR) did not include documentation of a treatment to the coccyx wound from 12/1/2022 through 12/9/2022. The 12/9/2022 at 1:13 PM LPN Manager #13's progress note documented a certified nurse aide (CNA) reported the resident had scar tissue on their coccyx that had re-opened. Nurse practitioner (NP) #1 was notified and ordered a treatment. The 12/9/2022 medical order, entered into the electronic medical record (EMR) by LPN Manager #13 documented to the open area on the coccyx, cleanse with normal saline (NS), apply wound gel and cover with a foam dressing daily. The 12/2022 TAR contained no documentation that the coccyx wound treatment order entered by LPN Manager #13 on 12/9/2022 carried over as an order onto the resident's 12/2022 TAR. The 12/2022 TAR contained no documentation a treatment was applied to the coccyx wound from 12/10/2022 through 1/4/2023. The 12/15/2022, 12/22/2022 and 12/29/2022 wound rounds tracking sheet, completed by NP #1 documented the resident's coccyx pressure ulcer was 5 centimeters (cm) x 2.7 cm with 90% granulation and 10% slough. NP #1 noted the current treatment was wound gel and a dressing. There was no documentation on the 12/2022 TAR that the treatment to the resident's coccyx wound was ordered or administered from 12/9/2022 through 1/3/2023. The 1/4/2023 and 1/5/2023 physician's order documented a treatment to a Stage 2 (partial thickness loss of skin layer) pressure ulcer on the resident's coccyx including wound gel and cover with foam dressing daily and to deep tissue injuries (DTI, purple/maroon intact skin, or blood-filled blister due to damage from pressure) on both heels, both ankles, and the right outer foot, apply skin prep (a liquid protective film) every shift. The 1/17/23 at 4:16 PM LPN Manager #13's progress note documented the resident's right heel had a DTI and the left ankle had an open area that measured 0.1 cm and appeared to be lifting. The note documented to start wound gel and collagen (a protein, stimulates new tissue growth), cover with abdominal pad (ABD) and secure with gauze wrap (dressing) daily. The 1/18/23 medical order documented to the right heel and left ankle, cleanse right heel and left ankle, apply skin prep (treatment), mix wound gel and collagen to open area and cover with an ABD pad, and secure with gauze wrap daily. The 1/2023 TAR documented treatments were not administered: - on 1/5/2023 through 1/11/2023 to the coccyx pressure ulcer; and - on 1/18/2023 through 1/23/2023 to the right heel and left ankle DTIs. There was no documented rationale why the treatments were not administered as ordered. The 1/24/2023 physician's order documented the coccyx pressure ulcer treatment was changed from once daily to every shift. Wound tracking sheets documented: - on 2/7/2023 by registered nurse (RN) #19 the resident's coccyx pressure ulcer had minimal drainage and wound gel continued as the treatment. - on 2/14/23 by RN #19, the coccyx, right ankle had minimal drainage, left outer ankle, left outer foot and right ankle had 100% eschar, and the left heel had 25% eschar (black necrotic tissue). - on 2/21/23 (unsigned), the coccyx continued with wound gel and dressing, the left outer ankle was red and warm with moderate drainage and all other areas were unchanged. - on 2/28/2023 (unsigned) documented the resident's foot and ankle wounds were DTI's and the coccyx wound was a Stage 2. The 2/28/23 at 8:24 AM, LPN Manager #13's progress note documented the resident had multiple wounds including the right heel wound had bloody drainage; the right ankle wound continued with a black scab; the left ankle wound had bloody drainage; the left foot outer aspect wound continued with a black scab, and the resident continued with a Stage 2 on the coccyx. LPN Manager #13 noted there was no dressing on the resident's coccyx wound at the time of wound rounds and all treatments continued as previously ordered and were rendered at that time by LPN Manager #13. The updated 3/11/2023 CCP documented the resident had a Stage 2 pressure ulcer on the coccyx and unstageable pressure ulcers on both heels and ankles. Interventions included an air mattress, monitor/document/report any changes in skin status; appearance, color and wound healing, signs and symptoms of infection, wound size, and stage. The 3/13/2023 at 5:41 PM, RN #6's progress note documented a CNA asked them to assess the resident's right heel, left outer foot, and left outer ankle area. The resident's right heel DTI was necrotic (dead tissue) and had a thick area that was lifting at the distal (furthest) end. The area appeared to have some depth and a foul odor. The left outer ankle had shiny moist skin and yellow slough. The lateral (outer side) foot was necrotic and not open. The note documented they would notify the interdisciplinary team. There was no documentation the medical provider was notified of RN #6's concerns. The 3/15/2023 at 3:32 PM LPN Manager #13's progress note documented NP #1 was on the unit and assessed the resident's foot wounds and ordered Bactrim DS (antibiotic) twice daily for 7 days. The treatment was changed to cleanse the ulcers on the left and right heels and ankles, cover with a petroleum dressing and silver alginate (a highly absorbent antimicrobial dressing) and wrap with gauze dressing daily. There was no documented evidence the petroleum dressing was ordered as noted in LPN Manager #13's progress note on 3/15/2023. The 3/2023 TAR and Medication Administration Record (MAR) documented: - wound gel and collagen treatment to the right heel and left ankle was discontinued on 3/15/2023. - Skin prep was to be applied to all pressure areas every shift from 3/16/2023 to 3/21/2023. - Bactrim DS 800-160 milligrams (mg) every 12 hours for infected wounds on both feet for 7 days. There was no documentation that petroleum and silver alginate dressings were ordered and/or added to the resident's TAR. The 3/16/2023 at 10:53 AM LPN Manager #13's progress note documented all the resident's foot wounds had a foul odor. The coccyx dressing was noted to be off. The surrounding tissue was uneven, had broken edges and was macerated (softening/breaking down of tissue from prolonged moisture). The 3/21/2023 physician's order documented to wounds on left and right heels and ankles apply petroleum dressing then silver alginate and wrap with gauze dressing daily. The order was written 6 days after LPN Manager #13 noted the planned order change. The 3/24/2023 at 1:42 PM LPN Manager #13's progress note documented the resident's right heel wound had brownish green drainage; the left ankle wound had greenish yellow drainage, a foul odor, and 60% slough; the left outer foot wound had brownish green drainage and a foul odor; and the coccyx wound had 75% slough. There was no evidence the medical provider was notified the resident's wounds continued with foul odor 2 days after the course of Bactrim was completed. The 3/28/2023 at 5:54 PM, LPN Manager #13's progress note documented the resident's right heel wound had brown/green drainage and foul odor; right ankle wound had brown/green drainage; left ankle wound now had depth, red/pink wound bed, broken edges, green-brown drainage, and no odor; left outer foot wound now had depth, 60% slough, green-brown drainage, and no odor, and coccyx wound had depth increased from 0.2 cm to 0.5 cm. There was no documentation the medical provider was notified for consideration of a treatment change when the wounds worsened and continued with foul odor. The 3/30/2023 at 4:53 PM LPN Manager #13's progress note documented they discussed the resident's right heel odor and drainage with NP #1. A new order was received for doxycycline (antibiotic) 100 mg twice daily for 10 days for an infected ulcer. The 3/30/2023 NP #1's progress note documented a urinary catheter (drains urine form the bladder) would be placed to promote better healing to the resident's coccyx ulcer. The resident had been given rounds of oral antibiotics for the left and right heel and ankle DTIs. Wound tracking sheets from 3/14/23 to 4/4/23 were incomplete or blank and did not document assessment of the resident's wounds. The 4/4/2023 NP #1's progress note documented the resident presented with an infection to the left heel and left ankle DTIs. The resident was currently on doxycycline and prior to that had completed a regimen of Bactrim DS twice daily for 10 days. The left heel and ankle had ongoing DTIs that progressed over the last month. Both wounds had foul thick brown drainage, and the surrounding tissue was very red, warm, and tender. The wound beds were necrotic, boggy (spongy), and had slough. The right heel DTI and coccyx appeared to be doing poorly, were not progressing, and did not appear infected. The 4/4/23 at 1:45 PM LPN #13 Manager note documented NP #1 was on the unit and assessed the following wounds: coccyx had depth to the tailbone, right heel was boggy, pink and necrotic with foul odor, left outer heel and left ankle had very foul odor. They had given report to the hospital nurse and informed them of impending transfer. The resident was transferred to the hospital emergency department on 4/4/23 for evaluation of worsening pressure ulcers. The 4/10/2023 hospital discharge summary documented the resident was admitted on [DATE] with acute osteomyelitis of the right and left feet and wound cultures showed Proteus Mirabilis (bacteria). The resident was treated with intravenous (IV) antibiotics during their stay. They were to continue daily wound care, continue oral doxycycline and Augmentin (antibiotic) and were stable for discharge. On 5/24/2023 at 10:20 AM, the resident was observed during a dressing change with Wound RN #14 and LPN #12. The resident was positioned on their left side and their adult brief was removed. There was no dressing on the resident's coccyx. LPN #12 and RN #14 both stated the dressing frequently fell off and the staff did not always report when that happened. The resident's coccyx wound was approximately 2.4 cm x 2.8 cm x 0.2 cm with 100% slough. Wound gel, a highly absorbent dressing and a bordered gauze dressing was applied. During a telephone interview on 6/1/2023 at 9:53 AM, the Assistant Director of Nursing (ADON) stated the order for wound gel was not entered correctly in the EMR by LPN Manager #13, so it did not show up as an order on the 12/2022 TAR. During a telephone interview on 6/9/2023 at 8:30 AM, CNA #23 stated the resident required assistance with bed mobility and transfers. They had an air mattress, a pillow between their knees, was on a turning and positioning program, and had booties on their feet while in bed for pressure relief. The resident had an open area on their buttocks and if the dressing fell off when they did care, they would notify the nurse to apply a new one. During a telephone interview on 6/9/2023 at 10:21 AM, LPN #12 stated there was a period when the facility did not have a wound team and LPN #12 and LPN Manager #13 completed wound rounds together. They rounded weekly and documented their findings. They never had an RN or NP accompany them during wound rounds. They believed LPN Manager #13 had NP #1 or the DON sign off on the wound round tracking sheets. They stated when a treatment was not available, they should notify the medical provider for an alternate treatment. They were not sure why they had missing documentation on the TAR in 1/2023 on multiple dates and stated it could have been because the order dropped off the TAR. They stated if they were not able to complete their treatment during their shift, they stayed late to complete the treatments. During a telephone interview on 6/9/2023 at 3:13 PM, LPN Manager #13 stated they completed wound rounds at the facility for several months. NP #1 accompanied them on wound rounds for several weeks but otherwise, they completed them with LPN #12. They documented on the wounds and gave the wound sheets to the DON or NP #1 to review weekly. LPN Manager #13 stated they and LPN #12 determined the best treatment when they saw residents and they did not call the medical provider to discuss the treatment plan. The medical provider signed any new orders the next time they were in the facility. If a medical provider was in the building at the time a skin concern was identified, they would have them assess the resident. LPN Manager #13 stated they were responsible to enter treatment orders in the EMR and the order transferred to the TAR. When the resident developed DTIs on their feet and a Stage 2 pressure ulcer to their coccyx in 12/2022, they entered the orders and was not aware the orders did not transfer to the TAR to alert the nurses to the orders. LPN Manager #13 stated there was an issue in the past with orders falling off the TAR and they did not report the issue to anyone. On 12/28/2022, they noted the area to the resident's right heel was opening and they thought they got an order for wound gel and was not aware there was no order entered. If a treatment product was not available, the DON should be notified to determine next steps. LPN Manager #13 stated they were not aware treatments were not signed as completed on multiple occasions in 1/2023 and not doing treatments increased the resident's risk of infection. On 2/28/2023 and 3/16/2023, the resident's dressing probably fell off during incontinence care and they believed they spoke with the CNA at the time but could not be sure. LPN Manager #13 stated they were responsible for implementing and updating CCPs. When a resident developed pressure ulcers, interventions should be added immediately to the CCP. On 3/11/2023, they implemented an alternating air mattress for the resident for pressure relief, it had never been discussed prior to that date, and it was not added to the plan of care timely. On 3/15/2023, they were not aware the orders for petroleum and silver alginate were not implemented and it was not timely when they were added 6 days later. On 3/24/2023 and 3/28/2023, they did not ask a RN to assess the resident when their wounds had a change in condition and was not sure if NP #1 assessed them. They stated the ADON read progress notes daily and should have been aware to do an assessment. When orders were obtained 2 days later on 3/30/2023, it was not done timely. During an interview on 6/20/2023 at 8:30 AM, NP #1 stated, they were a part of the wound team for a short time along with LPNs. During wound rounds, they got called away frequently for resident emergencies and when they would return to complete the rounds, the LPNs were already done. They were supposed to review the LPN's documentation on wounds but sometimes the sheets were not available for up to a month. They reported the issue to the DON and the DON was aware LPNs were doing wound rounds on their own. The protocol was a RN was to be present during wound rounds. They expected a RN to assess new wounds or deteriorating wounds and wanted to be contacted so they could intervene and determine a treatment. If treatments were not available for any reason, they should be contacted for an alternate treatment. If no treatment was available and they were not contacted, the resident could be at risk of infection or worsening wound condition. From 12/1/2022 to 1/5/2023, 6 weeks was not timely to obtain a treatment order for the resident. They were not made aware that staff did not administer treatments from 1/5/2023 through 1/11/2023 and 1/18/2023 through 1/23/2023 and they should have been notified. The resident should have had an alternating air mattress added to their CCP after they developed pressure ulcers and it was not timely when it was added in 3/2023. On 3/13/2023, they expected the RN to call them for orders and the resident's heel wound was probably infected at that time. They were not aware on 3/15/2023 that the order for petroleum dressing and silver alginate was not carried through and skin prep was not an appropriate treatment for foul odor and drainage. On 3/24/2023, they should have been notified to assess the resident to determine if they needed another antibiotic. On 3/28/2023, when the wound depth increased, the wound was deteriorating, and they expected to be notified. On 3/30/2023, it was not timely when the antibiotic was ordered. That day they ordered a urinary drainage catheter to assist with healing and to prevent worsening of the resident's Stage 3 coccyx pressure ulcer. The cumulative effect of untimely care could have led to the resident developing osteomyelitis. During a telephone interview on 6/28/2023 at 11:39 AM, the DON stated, pressure ulcers were to be monitored weekly by the RN during wound rounds and daily during dressing changes by LPNs. LPNs should report any wound changes to a RN/NP so the wound could be assessed to determine if a treatment change was needed. If wound rounds did not occur routinely or a RN/NP was not available during wound rounds, they expected to be notified to intervene. Assessments needed to completed with a RN/NP because LPNs could not assess. Back in 11/2022 through 3/2023, the LPN Managers completed wound rounds along with NP #1. They were not aware that wound rounds were not completed routinely with NP #1. The air mattress was not added timely and should have been added when the resident initially developed pressure ulcers. They were not aware the resident had foul odor from their wounds on multiple occasions and the medical provider should have been notified. 2) Resident #6 was admitted to the facility with diagnoses including end stage renal disease (kidney disease), diabetes, and cellulitis (infection) of the right leg. The 9/19/2022 Minimum Data Set (MDS) assessment documented the resident had intact cognition, required extensive assistance of 2 for bed mobility and transfers, and had 2 unhealed unstageable (depth unknown) pressure ulcers that were present on admission. Physician orders documented treatments were ordered to wounds on the resident's right heel and coccyx including: - on 9/13/2022, to the right heel, cleanse and apply calcium alginate (absorbent dressing for wound healing), and wrap with gauze, one time daily. - On 9/15/2022, to the coccyx: cleanse wound with NS (normal saline), apply calcium alginate, cover with DSD (dry sterile dressing), and wrap with gauze daily. The 9/2022 Treatment Administration Record (TAR) did not document the right heel treatment was not completed on 9/14/2022 and 9/19/2022 and the coccyx treatment was not signed as completed on 9/20/2022. Physician orders documented treatment changes were ordered to the wounds on the resident's right heel and coccyx including: - on 9/21/22, to the right heel, apply skin prep (protective barrier/film), float heels, every shift. - On 9/21/22, to the coccyx, cleanse with NS, apply Santyl (collagenase, an enzymatic debriding treatment) and calcium alginate to the wound bed followed by superabsorbent dressing. The 9/2022 TAR documented the heel wound treatments were not signed as completed on 9/23/2022 and 9/25/2022 during the day shift and on 9/29/22 during the evening shift. The coccyx wound treatment was not signed as completed from 9/23/2022 through 9/27/2022 and on 9/29/2022. There were no documented progress notes related to the multiple heel and coccyx treatments that were not signed/completed in 9/2022. There was no documented evidence the medical provider was notified of the missed treatments in 9/2022. The 10/3/2022 registered nurse (RN) #6's progress note documented nurse practitioner (NP) #1 ordered a new treatment for wounds to bilateral feet: calcium alginate (highly absorbent treatment) and cover with transparent film until healed. The 10/4/2022 NP #1's progress note documented the resident was noted with 2 half dollar sized deep tissue injuries (DTIs, dark/purple areas, depth unknown) to the bottom of their bilateral feet. The coccyx pressure ulcer continued to worsen, and daily dressings remained in place. Physician orders documented: - on 10/4/22, to the bilateral feet, calcium alginate dressing with a transparent film cover to bilateral foot wounds daily. - On 10/3/2022, to the sacrum, cleanse with NS, fill with hydrogel (adds moisture to a wound and encourages removal of dead tissue), and cover with a foam dressing, every day. - On 10/6/2022, to the coccyx, cleanse with NS, apply calcium alginate to wound bed followed by superabsorbent dressing, every day shift. The 10/2022 TAR documented multiple treatments were not signed as completed including: - the bilateral heel treatments on 10/4/2022 and from 10/22/2022 through 10/24/2022. - The right heel treatment for 17 shifts. - The coccyx treatment from 10/1/2022 through 10/4/2022 and 10/22/2022 through 10/26/2022. - The sacral treatment on 10/4/2022 and from 10/22/2022 through 10/26/2022. The 10/6/2022 Weekly Wound Assessment documented a treatment change for the coccyx wound, to discontinue hydrogel. There were no documented progress notes related to the multiple heel/feet and coccyx treatments that were not signed/completed in 10/2022. There was no documented evidence attending physician #17 or NP #1 were notified of the missed treatments in 10/2022 and no documentation treatment orders were clarified when multiple treatments were ordered to the same wounds. During an interview on 6/12/2023 at 1:59 PM, the Director of Nursing (DON) stated when treatments were completed, the TAR would be signed. If the TAR was not signed, a nursing progress note should be documented related to the reason the treatment was not completed and what the plan was, such as medical provider notification. When the resident had a new order for bilateral foot treatments, the DON was unaware of the location of the areas to be treated. They stated the order did not clarify the location of the foot wounds and was not aware if the treatment for the right heel should have been discontinued. The orders should have been clarified to show the location of each treatment for each foot. The resident's coccyx wound, and sacral wound were likely the same area. The DON was not able to clarify which treatment was to be completed for the areas and stated there were 2 different active treatment orders. The treatments were different, and the DON stated both treatments could not have been completed at the same time. There was no documentation of clarification, and the orders should have been clarified by the medical provider. The treatments that were not signed should have a progress note documenting the reason why the treatments were not completed. During a telephone interview on 6/20/2023 at 8:30 AM NP #1 stated when they entered the new order on 10/4/2022 for Resident #6's feet, it was for DTIs on both heels. The NP ordered calcium alginate because both heels were on the verge of opening. The order for skin prep should have been discontinued at that time and the NP was not sure why it was not. NP #1 was not able to enter or discontinue their own orders into the electronic medical record (EMR). NP #1 was not notified of the missing treatments and should have been notified. Hydrogel should have been discontinued when calcium alginate started. There was only one wound on the sacral area. The NP was not aware there were missing treatments and expected to be notified. 10 NYCRR 415.12(c)(2)

Based on observation, interview, and record review during the abbreviated survey (NY00315847), the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 4 residents reviewed (Resident #7). Specifically, for Resident #7 who developed a diabetic ulcer, treatments ordered were not transcribed; ordered treatments were not implemented; attending physician #17 or nurse practitioner #1 were not notified of worsening wounds; a wound culture was not ordered as recommended, and wound culture results were not reported to the medical provider. Subsequently, the wound worsened, the resident developed osteomyelitis (bone infection) and required treatment with intravenous (IV) antibiotics and a wound V.A.C (vacuum assisted closure). This resulted in harm to Resident #7 that was not Immediate Jeopardy. Findings include: The undated facility policy Managing Skin Integrity documented any deterioration in or development of an alteration in skin integrity would be promptly addressed and individualized approaches would be implemented. Upon admission and readmission, the registered nurse (RN) would thoroughly inspect all residents' skin and document findings in the medical record. The attending physician would be notified of any alteration(s) to skin integrity and interventions/treatments would be ordered as indicated. A licensed nurse skin observation should be completed weekly, and any abnormal looking skin should be reported to the Nurse Manager/Supervisor immediately. The area of concern should be reported to the attending physician and resident's representative. If an alteration in skin was deemed to be significant, the resident would be referred to the wound team for weekly follow-up. The facility policy Consults-Outside Facility dated 5/2019 documented the medical provider would order medical appointments/clinic visits. The Nurse Manager/designee would make the appointment, notify medical records staff of the appointment, complete the consult packet, and notify the resident/resident representative of the appointment. The facility policy Laboratory, Radiology and Other Diagnostic Services revised 4/2023 documented a licensed nurse would obtain an order for the lab from the provider and the licensed nurse would complete the lab request before cosigning the order had been picked up. When a lab was received, the nurse completed the lab tracking form noting the lab result was received. When the lab result was obtained, the form would be cosigned by the provider indicating they had reviewed the results. Lab tests that had critical results would be reported to the provider immediately. Resident #7 was admitted to the facility with diagnoses including diabetes, a left below knee amputation, and peripheral vascular disease (PVD, impaired blood flow). The 9/27/2022 Minimum Data Set (MDS) assessment documented the resident's cognition was intact. The resident required extensive assistance with bed mobility and transfers, and had no pressure ulcers or venous or arterial ulcers (ulcers resulting from impaired blood flow). The 10/12/2022 weekly skin check completed by licensed practical nurse (LPN) #21 documented the resident's right heel had an open area with a large amount of clear light yellow drainage. There was no documentation in the resident's orders or Treatment Administration Record (TAR) of an ordered treatment for the resident's right heel from 10/12/2022 to 10/17/2022. The 10/18/2022 at 1:13 PM, LPN Manager #13's progress note documented a new treatment order for a deep tissue injury (DTI, full thickness depth unknown) on the resident's right heel to cleanse with normal saline, apply skin prep (protective liquid film barrier) to the peri wound (the skin around the wound), apply silver antimicrobial wound gel (hydrates wounds, protects against infection) to the open areas around the dark area in center of wound, and cover with a foam dressing daily. There was no documentation as to who gave the order to LPN Manager #13 or if the resident's wound was assessed. The 10/2022 Treatment Administration Record (TAR) documented on 10/18/2022, a new order for silver antimicrobial wound gel to open areas around the dark area in center of wound, and cover with a foam dressing daily. The 10/28/2023 nurse practitioner (NP) #1's progress note contained no documentation that NP #1 was aware the resident had a DTI on the right heel. The 11/2/2022 at 11:50 AM, LPN Manager #13's progress note documented LPN Manager #13 observed the resident's right heel wound had a foul odor and the old dressing had bloody drainage. There was no documentation LPN Manager #13 reported the foul odor or bloody drainage to a registered nurse (RN), attending physician #17, or NP #1. The 11/2/2022 attending physician #17's progress note did not document the physician was aware of the resident's right heel wound. On 11/6/2022 at 8:52 AM, RN #20's progress note documented the resident reported severe pain to their right leg and heel and received pain medication (Tylenol). On 11/6/2022 at 1:58 PM, RN #20's progress note documented RN #20 completed the treatment to the resident's right heel wound and noted some redness on their right heel and leg and no warmth was noted to the right leg. The 11/7/2022 NP #1's progress note documented the resident's right heel wound had increased foul drainage over the weekend. The plan was to start doxycycline (antibiotic) for 10 days, obtain a wound culture, and STAT (immediate) referral to wound care for an evaluation. The resident was to start calcium alginate (a topical absorbent dressing) and an absorbent dressing (secondary dressing) to the right heel. The 11/2022 Medication Administration Record (MAR) documented on 11/7/2022, the antibiotic was ordered and administered for 10 days. There was no documentation an order was written for the wound culture, the treatment change to calcium alginate, or for the STAT wound care referral. The 11/2022 TAR documented from 11/7/2022 through 11/16/2022, the treatment to the resident's right heel DTI remained as skin prep, silver antimicrobial wound gel, and a foam dressing daily. On 11/16/2022 at 3:54 PM, LPN #22's progress note documented the resident had bloody drainage on the right heel dressing and the surrounding DTI appeared slightly red and warm to touch. The resident complained of pain during the dressing change and refused to take anything for pain. There was no documentation the resident's skin condition or pain was reported to an RN, attending physician #17, or NP #1. On 11/17/2022 at 5:57 PM, RN #11's progress note documented the resident complained of severe pain to the right heel and requested to be sent to the hospital. The 11/17/2022 hospital emergency room (ER) report documented the resident was seen for a right heel diabetic ulcer. Recommendations included a follow up with podiatry (health care provider specializing in disorders of the foot) and Bactrim DS (antibiotic) 800-160 mg for 10 days for a wound infection. The 11/18/2022 at 4:09 AM, LPN #22's progress note documented the resident returned to the facility from the ER. The 11/18/2022 at 10:18 AM, LPN Manager #13's progress note documented the podiatrist's office called with an appointment for the resident on 12/15/2022 at 2:00 PM. The 11/2022 TAR documented from 11/16/2022 through 11/21/2022, the treatment to the resident's right heel DTI remained as skin prep, silver antimicrobial wound gel, and a foam dressing daily. The 11/22/2022 weekly wound assessment completed by an unidentified RN documented the resident's right heel diabetic ulcer had declined and measured 4 cm x 7 cm with heavy serosanguinous (thin, bloody fluid) drainage. The RN recommended to change the treatment to collagenase (an enzyme that breaks down dead tissue) and a foam dressing. LPN Manager #13's progress note documented on 12/1/2022, the resident's right heel wound was necrotic (dead tissue) with slough (soft, yellow dead tissue) and had heavy purulent (pus) drainage with a foul odor. Collagenase and foam dressing continued. There was no documentation an RN, attending physician #17, or NP #1 were notified of the resident's skin condition. LPN Manager #13's progress note on 12/6/2022 at 7:33 PM documented they discussed the resident's heel wound with NP #1 and a new order was obtained for Bactrim DS twice daily for 10 days. The 12/2022 MAR documented the antibiotic was ordered and administered from 12/7/2022 through 12/16/2022. LPN Manager #13's progress note on 12/15/2022 PM documented the resident returned from podiatry and the treatment was changed to Providine iodine (antiseptic), covered with a gauze pad and gauze wrap daily. LPN Manager #13's progress note documented on 1/4/2023 at 10:47 AM, the resident's heel had a foul odor, and the NP ordered a wound culture. LPN Manager #13's progress note documented on 1/7/2023 at 10:47 AM and 1/8/2023 at 7:35 AM, the resident's heel continued with a foul odor. The faxed wound culture report, received by the facility on 1/9/2023 documented the bacteria present in the resident's right heel wound and which antibiotics the bacteria was sensitive too. There was no documentation attending physician #17 or NP #1 were made aware of the wound culture results. The 1/9/2023 at 12:42 PM, Director of Nursing (DON) progress note documented the resident had an appointment on 1/13/2023 for a magnetic resonance imaging (MRI)/ultrasound. LPN Manager #13's progress note documented the resident's right heel had foul to extremely foul odor on 1/10/2023, 1/11/2023, 1/12/2023, 1/16/2023 and 1/17/2023. There was no documentation in the progress notes that LPN Manager #13 reported the foul odor to an RN, attending physician #17, or NP #1 for evaluation. LPN Manager #13's progress note on 1/17/2023, documented the podiatrist called and said the resident's test results were received and reviewed by podiatry and the resident had osteomyelitis (bone infection) of the right foot. LPN Manager #13's progress note on 1/18/2023 at 10:07 AM, documented the resident was lethargic, cool, and clammy to touch and had delayed speech. NP #1 was notified and advised to send the resident to the emergency room (ER). The 1/18/2023 ER report documented the resident had fever, pallor (pale appearance) and malaise (general feeling of discomfort), and osteomyelitis of the right foot. The resident was scheduled to go to a different hospital for an amputation that week. The 1/31/2023 hospital report documented the resident was sent to the hospital for an amputation of their foot and the resident wanted their foot saved if possible. They had a large heel ulcer that was down to the bone and 40% of the wound had green, malodorous (foul odor), wet necrotic tissue. The resident went to the operating room and had a partial resection of the calcaneus (heel bone) and received IV antibiotics. The resident was discharged back to the facility with a wound V.A.C and IV antibiotics. The medical record from 1/31/2023 through 5/25/2023 (the date of the on-site investigation) contained documentation that orders were in place for wound care and orders were implemented. On 5/23/2023 at 10:30 AM, the resident was observed for a dressing change with LPN #12 and Wound RN #14. The resident's dressing was removed from the right foot and an approximately 6 cm x 2 cm x 0.2 cm wound was observed on the right heel with red granulation tissue (new tissue) and a small amount of yellow slough on the outer perimeter of the wound. The wound was cleansed, and the treatment was applied by LPN #12 and Wound RN #14. During a telephone interview on 6/9/2023 at 3:13 PM, LPN Manager #13 stated they became the LPN Manager in 8/2022 and completed weekly wound rounds at the facility. For several weeks, NP #1 accompanied them on wound rounds but when NP #1 was not present, they completed rounds with LPN #12. LPNs #13 and 12 collected data and completed wound sheets that were given to the Director of Nursing (DON) or NP #1 to review. When they gave the wound sheets to the DON for review, they never got them back so they started making a copy for the DON and keeping their notes on the unit. LPN #13 stated they determined the best treatments for residents along with LPN #12. They did not call attending physician #17 or NP #1 to discuss the treatments, LPN #13 entered the new orders into the medical record and attending physician #17 or NP #1 signed the orders the next time they were in the facility. If NP #1 was in the building at the time a skin concern was identified, they would have NP #1 evaluate the resident but because that often took a while to get NP #1 to the unit, LPN #13 stated they preferred to look at the wound themselves. LPN Manager #13 looked at wounds weekly. When a resident had a change in condition, the RN or medical provider should be notified. On 10/12/2022, LPN #21 should have had an RN assess the resident's wound. On 10/18/2022, it was not timely when it took 6 days to obtain a treatment order for the resident's heel. LPN Manager #13 stated they determined what treatment to use that day along with LPN #12 who was present. On 11/2/2022, they did not notify anyone the resident had foul drainage from the wound. They stated it was not timely when it took 5 days for NP #1 to evaluate the resident and order an antibiotic. Sometimes it took weeks to receive NP #1's notes and because of this, NP #1 wrote what orders they wanted in the communication book. During the interview, LPN Manager #13 reviewed the communication book and stated there was nothing documented by NP #1 about the treatment order being changed, the wound culture, or the STAT wound care referral and that was why they were not ordered. LPN Manager #13 stated the communication book was used by NP #1 and the nurses documented concerns in there for NP #1 to be aware of and NP #1 documented any new orders for the nurses to enter into the electronic medical record. LPN Manager #13 stated on 12/1/2022, they did not believe they notified the medical provider. On 1/9/2023, they were not sure if they saw the wound culture results. They stated the medical provider should have been notified of the wound culture results. During a telephone interview on 6/20/2023 at 8:30 AM, NP #1 stated, when they wanted a treatment, medication or consult ordered, they wrote the order in the communication book and a nurse entered the orders in the electronic medical record (EMR). NP #1 stated they were not able to enter their own orders. Nursing or a medical records staff person were in charge of scheduling appointments for outside consults. On 10/12/2022, an RN should have assessed the resident's heel and called a medical provider for a treatment order. NP #1 stated it was not timely when it took 6 days to obtain a treatment order. On 10/22/2022, they were not sure if they were aware the resident had a right heel ulcer when they wrote their note and if they had known, they would have documented it. On 11/2/2022, they did not recall being notified the resident's right heel had foul drainage. On 11/7/2022, when they ordered a STAT referral for a wound consult, they expected the referral would have occurred within the day and if the appointment could not be made that quickly, they wanted to be notified and would have sent the resident to the ER for evaluation. They ordered the wound culture because they wanted to see what bacteria the resident's wound had so they could order the appropriate antibiotic. They expected the wound culture to be obtained immediately and was not aware it was not. Calcium alginate was ordered because the resident had a lot of drainage. They were not aware it was not ordered and the silver treatment that was ordered was not an appropriate treatment for that drainage. On 12/1/2022, they should have been notified the resident had foul odor and drainage from the wound and it was not timely when Bactrim was ordered on 12/6/2022. On 1/9/2023, they would have wanted to know about the wound culture results and would have ordered an antibiotic the bacteria was sensitive to. When the resident had extremely foul drainage that continued from 1/8/2023 to 1/17/2023, they would have sent the resident to the hospital had they been aware. All the delays in assessments, treatments and laboratory testing could have led to the resident developing osteomyelitis. During a telephone interview on 6/28/2023 at 11:39 AM, the DON stated wounds should be monitored weekly by the RN during wound rounds and daily during dressing changes by LPNs. LPNs should report any wound changes to an RN/NP so the wound could be assessed to determine if a treatment change was needed. If wound rounds were not occurring routinely or an RN/NP was not available during wound rounds, they expected to be notified to intervene. Assessments should be completed by a RN/NP because LPNs were not allowed to assess. If the NP wanted a culture ordered, the NP was responsible to notify the nurse so orders could be implemented. They stated from 11/2022 through 3/2023, the LPN Managers completed wound rounds along with NP #1. They were not aware that wound rounds were not completed routinely with NP #1. They were not aware a wound culture was not ordered timely and when the results were available, nursing should have communicated the results to the provider. They were not aware the resident's wound had a foul odor and expected that would have been communicated timely to the provider. 10 NYCRR 415.12

Based on record review and interview conducted during the abbreviated survey (NY 939), it was determined for 1 of 4 residents reviewed for accidents (Resident #3), the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents. Specifically, when Resident #3 who was independent with ambulation, began experiencing dizziness, the level of supervision provided was not increased in an attempt to prevent falls. The resident sustained [REDACTED]. The resident sustained [REDACTED]. This resulted in actual harm to Resident #3 who sustained a skull fracture with two hematomas. Findings include: Resident #3 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident's cognition was moderately impaired per the [DATE] Minimum Data Set (MDS) assessment, he ambulated with supervision and a walker, and he had no falls during the assessment period. The Task List (care instructions) updated on [DATE] documented the resident required distant supervision for ambulation with his walker. The [DATE] fall risk assessment documented the resident was at high risk for falls and a comprehensive care plan (CCP) should be initiated. The CCP, updated on [DATE] documented the resident was at risk for falls related to unsteady gait, balance problems, medication use, cognitive loss, and a history of falls in the past 6 months. The approaches included following the facility's Standard of Care, Prevention of Falls. No other approaches were listed for the resident. The facility's Standard of Care #14, Prevention of Falls, dated [DATE], documented residents were to be educated on call bell use; were to wear proper footwear; were to be monitored for medication side-effects; were to be encouraged to use assistance devices; were to be monitored by staff; were to have therapy recommendations followed, and the standard of care also documented proper post-fall procedures. The [DATE] registered nurse (RN) #10's progress note documented at 1:13 PM, the resident complained of being very dizzy. His pulse was 55 and blood pressure was ,[DATE]. She instructed him to get up slowly and call for help if it happened again. On [DATE], the attending physician's progress note documented the resident was seen, vital signs were reviewed and no new orders were written. The [DATE] RN #10's progress note documented at 4:29 PM, the resident's blood pressure was ,[DATE], pulse was 54 and he had a dizzy spell. The resident was instructed to get up slowly. The physician was aware. The [DATE] RN #12's progress note documented at 1:15 AM, the certified nurse aide (CNA) heard a loud noise and the resident was found on the floor in his room lying on his back. He had been ambulating with his walker, lost his balance, and bumped his head sustaining a scratch on the right ear. Neurological checks were initiated. The [DATE] accident and incident report documented the resident fell at 1:15 AM, bumped his head, and sustained a scratch on the ear. There was no documented evidence the physician was notified of the fall and RN #12 documented on the incident report that no changes were to be made to the plan of care. An attached statement written by CNA #13 documented the resident had been having dizzy spells for the past few days and the nurses were aware. The [DATE] RN #7's progress note documented at 8:45 AM, the resident was found lying on his right side in the doorway of the bathroom. The resident reported he hit his forehead and denied head pain. Neurological checks were initiated. At 9:30 AM, RN #7 was notified the resident complained of hip pain that the and ice and as needed medications were not effective. He was sent to the emergency room . An attached statement from CNA #15 documented the resident was confused after the fall and stated he was dizzy. The [DATE] hospital records documented the resident was sent to the hospital following a fall in the bathroom with a head injury. The results from the head CT documented the resident had a right acute skull fracture with hematoma and a more prominent hematoma to the left aspect of the skull. The [DATE] nursing progress note documented the resident was going to return to the facility on comfort care as the resident's family declined treatment. The resident expired on [DATE]. On [DATE] at 11:05 AM, RN # 10 stated in an interview, she was the Unit Manager when he was at the facility. She stated he normally ambulated on his own with a walker but his gait was unsteady at times. She stated prior to his falls in ,[DATE], he was having some dizziness and they were monitoring him for that. She stated the physician was aware of his dizziness that came and went. Because of that, she stated staff adjusted how they cared for him based on the day. She stated at times you would see him teetering when walking and staff would go to him and help him safely sit down. She stated you could tell when he was dizzy because his walking was different than his usual. She stated because his condition changed daily, she did not make any changes to his plan of care related to his ambulation status or fall prevention and did not request that therapy evaluate him. She stated after the resident's first fall, the RN on duty should have reviewed his CCP and determined whether changes needed to be made. On [DATE] at 1:20 PM, CNA #15 stated in an interview, after the resident's second fall, the RN had her ask the resident if he had any pain. The resident said he hit his forehead but did not complain of head pain, he complained of hip pain. She stated before the resident's two falls he was having dizziness. She stated other staff told her this although he did not complain to her directly. She stated even though he was dizzy, he ambulated on his own with a walker. On [DATE] at 9:10 AM, the Assistant Director of Nursing (ADON) stated in an interview, when a fall occurred, the RN who did the assessment should look at the resident's CCP and determine whether changes were warranted immediately following the fall. On [DATE] at 9:50 AM, the Director of Rehabilitation stated in an interview, the resident was screened by therapy in ,[DATE] and was safe for distant supervision with a walker for ambulation. She stated distant supervision meant that he would be safe 60% of the time to ambulate on his own with a walker. She stated if staff needed to physically intervene with his ambulation when he was having dizziness, then he would not be distant supervision at that time and they should have asked therapy to look at him again. On [DATE] at 10:10 AM, RN #12 stated in an interview, she assessed the resident following the fall on [DATE]. She stated he was a bigger guy and went down hard. He hit his head either on the door or the floor she could not remember. She stated she did not notify the physician that night because it was the middle of the night. She stated when there was not a major injury, they notified the physician of a fall the following morning. She stated she usually did not make changes to CCPs following falls as the day shift did that. She stated she did not recall having a discussion with staff on [DATE] about the resident's care plan or about making change to the plan of care. On [DATE] at 10:25 AM, the Director of Nursing (DON) stated in an interview, after the resident's first fall, the night Supervisor should have looked at the CCP to see if changes needed to be made. She stated she reviewed both of the resident's falls after he expired but she did not speak to RN #12 to determine whether she reviewed the CCP or whether she considered changing the resident's plan of care. She stated she noticed the resident had dizziness prior to the falls but did not look into that further to determine whether appropriate action was taken by the staff. On [DATE] at 1:44 PM, LPN #18 stated in an interview, she was working the day the resident had his second fall. She knew he had a fall a day or so prior and also knew he was having some dizziness. She thought the RN on ,[DATE] was RN #10 and knew they were addressing his dizziness. She could not recall if she saw the resident earlier in the shift on [DATE] before he fell but did go into the room when he fell and helped get him up. She stated at that time he had his jeans on backwards so she knew he was not himself. She stated prior to the falls, he knew how to put jeans on and putting them on backwards was not usual for him. In an interview with the attending physician on [DATE] at 2:35 PM, he stated he recalled the resident but not the falls and did not have access to the medical record at the time of the interview. The physician stated if a resident fell with a significant injury he would expect to be notified right away. He stated if a resident hit their head and the injury was not significant, he would expect the nurse to start neurological checks and notify him if there was an issue with the neurological checks. The physician stated he also did not recall the resident's dizziness but stated when someone had dizziness he would look for a medical cause for it and address that if there was one. He stated if a medical cause could not be determined, the staff should monitor the resident and notify him if there were changes. 10NYCRR 415.12(h)

Based on record review and interview conducted during the partial extended survey (NY 572), for 2 of 5 residents (Residents #1 and 4) reviewed for anticoagulation medications (blood thinners), the facility failed to have a system in place to consistently monitor the therapeutic laboratory values of all residents on anticoagulant therapy. Specifically, for Resident #1, on 5/11/17 the physician ordered her to receive [MEDICATION NAME] (an anticoagulation medication), with [MEDICATION NAME] time/international normalized ratio (PT/INR) laboratory tests to be measured the following week, and then weekly. A requisition for the PT/INR testing was not completed, and she subsequently experienced extensive bleeding which required hospitalization on [DATE] for [MEDICATION NAME] toxicity, the result of a critically high PT/INR level. This resulted in actual harm to Resident #1. For Resident #4, on 2/24/2017 the physician ordered an adjusted dose of [MEDICATION NAME] with a PT/INR to be measured in one week. There was no PT/INR testing performed at the facility through the time of the resident's transfer to the hospital on [DATE]. The facility failure to have an effective system in place to consistently ensure implementation of physician orders [REDACTED]. This resulted in Immediate Jeopardy to resident health and safety and Substandard Quality of Care for the facility's 10 residents receiving anticoagulant therapy. The facility implemented corrective measures to remove the Immediate Jeopardy prior to survey exit on 6/5/2017. Actions taken by the facility included: - Revision on 6/2/2017 of the facility's [MEDICATION NAME] ([MEDICATION NAME]) policy, with continuation of utilizing the anticoagulation flowsheet to facilitate accurate and concise communication with the physician. Changes included that two nurses will be present to verify and confirm the order obtained or changed by the physician, including PT/INR frequency, at the time of obtaining the order. The two nurses will sign off both the order and the lab slip communication to ensure compliance. - Revision on 6/5/2017 of the facility's Lab policy, with changes including all residents receiving anticoagulation therapy will have their [MEDICATION NAME] order and lab testing frequency noted on the 24-hour report sheet. The date of their next scheduled PT/INR lab draw will be highlighted on the Medication Administration Record [REDACTED]. - All licensed nursing staff were educated on the updated [MEDICATION NAME] and Lab policies, including documentation expectations. A plan was developed to educate those nurses not currently on duty prior to them providing resident care. Findings include: The facility policy Transcription of Physician Orders, effective 8/1989 and revised 1/16/2006, documented a physician's orders [REDACTED]. All orders will be checked by another nurse on the same shift to assure proper documentation and to avoid medication or treatment errors. The facility policy Lab, revised 8/30/2005, documented routine lab tests will be performed on residents receiving certain medications, are diabetic, or receive tube feedings based on pharmacy recommendations. Nursing will communicate pharmacy recommendations based on residents' laboratory results to physicians. Nursing will document the physician's response to the recommendations in a nursing note. Labs will be scheduled on routine lab days, unless otherwise specifically ordered by the physician. The policy did not address the procedures involved to take off lab orders and ensure implementation of the orders. 1) Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was moderately impaired. She required extensive assistance for most activities of daily living (ADLs) and received anticoagulation medication. The comprehensive care plan (CCP) dated 5/31/2017 identified the resident was on [MEDICATION NAME] and documented to follow the facility's Standard of Care (S(NAME)) for [MEDICATION NAME] therapy. The S(NAME) documented an anticoagulated resident was to be monitored for any abnormal bleeding and bruising, and to utilize the anticoagulation flowsheet to keep an accurate history. A physician progress notes [REDACTED]. A physician order [REDACTED]. The physician order [REDACTED]. A nursing progress note dated 5/11/2017 documented to discontinue the Xarelto and start [MEDICATION NAME] 5 milligrams (mg) daily and check the PT/INR next week and then weekly. The 24-hour shift-to-shift report dated 5/11/2017 did not identify Resident #1 had a new order for [MEDICATION NAME] or a PT/INR. An undated anticoagulation flowsheet labeled with Resident #1's name was blank. The Medication Administration Record [REDACTED]. There was no documented evidence in the medical record the ordered PT/INR blood testing was completed for the resident from 5/11 - 5/28/2017. A nursing progress note dated 5/28/2017 at 3:46 PM documented the resident's right upper lip was swollen, not bleeding at this time, and the resident thought she may have bumped it with her toothbrush. The MAR indicated [REDACTED]. A nursing progress note dated 5/28/2017 at 6:17 PM documented the resident's right side of her face was swollen and her upper lip was purple. The resident was sent to the emergency department for evaluation. A hospital history and physical dated 5/28/2017 documented the resident was sent to the hospital from a nursing home after she had bumped her lip while brushing her teeth and the bleeding could not be stopped. The resident was found to have an elevated PT level greater than 165 seconds (normal 9.6 - 13.2 seconds, therapeutic range 14.4 - 30 seconds on anticoagulants). She was treated with Vitamin K ([MEDICATION NAME] reversal agent) and admitted to the hospital for [MEDICATION NAME] toxicity. A hospital discharge summary dated 6/1/2017 documented the resident was treated in the hospital for [MEDICATION NAME] toxicity after she presented to the emergency department with bleeding from her ear and mouth. She was given Vitamin K, which initially did not decrease the elevated PT level. She was given more Vitamin K and fresh frozen plasma (FFP) to normalize the PT level. During an interview with registered nurse (RN) #2 on 6/1/2017 at 1:00 PM, she stated the process for transcribing a physician laboratory order was to fill out the laboratory slip, put the slip in a white basket located at the nursing station, and document the new order in a progress note. The second check to ensure physician orders [REDACTED]. RN #2 did not identify to include the new order on the 24-hour hour report. During an interview with licensed practical nurse (LPN) #3 on 6/1/2017 at 1:10 PM, she stated the process for transcribing physician laboratory orders was to write the new order on the 24-hour report. She stated the second check was the night nurse would look at the 24-report for any new orders and then make sure the orders were carried out. LPN #3 did not describe filling out the laboratory slip or documenting the new order in the nursing progress notes. During an interview with LPN #4 on 6/1/2017 at 1:20 PM, she stated a new laboratory order was documented on the 24-hour report and the night nurse would check the 24-hour report to ensure the order was carried out. She stated she did not transcribe orders, as that was the responsibility of the RNs. During an interview with RN #5 on 6/1/2017 at 1:35 PM, she stated the process for transcribing physician laboratory orders was to sign and initial the order, document the new order in the computer, fill out a lab communication slip and take it to the scheduler's office, and document the new order on the 24-hour report. The night nurse would do a second check and make sure the laboratory slip was filled out. During an interview with LPN #1 on 6/1/2017 at 1:40 PM, she stated the process for transcribing physician laboratory orders was to fill out the laboratory sheet and bring it to the scheduler's office, or place it in a white basket at the nursing station, which was picked up every morning by the scheduler. She stated the new order would be documented on the 24-hour sheet and the night nurse would refer to that and then check the basket to ensure the lab slip was filled out. LPN #1 did not identify to document the new order in the nursing progress notes. During an interview with RN #6 on 6/1/2017 at 2:40 PM, she stated the process for transcribing physician laboratory orders was to fill out the laboratory slip, email the scheduler about the new lab order, place the slip in the white basket on the unit, and document the new order in the nursing progress notes. She stated the second check was the DON and ADON would check all the progress notes for the past 24 hours, and if they saw a new order documented they would follow up on it and ensure it was completed. She did not identify to document the new order on the 24-hour report. She stated when she had taken off the resident's order on 5/11/2017 that included the order for the PT/INR, she did not fill out a lab slip, as she had put the new order on the top of the chart and handed it to the other nurse to fill out the lab slip. During an interview with the DON on 6/1/2017 at 3:45 PM, she stated the physician order [REDACTED]. She stated the process for transcribing laboratory orders was the nurse who notes the new order fills out the laboratory slip and brings it to the scheduler or places it in the white basket at the nursing station, documents the new order in a progress note, and also documents the new order on the 24-hour report. She stated the second check to ensure orders were carried out was performed by the ADON and herself. The ADON was responsible for picking up the contents of the white basket daily and reviewing the lab communication slips. When the ADON saw the lab communication slip, she would contact the laboratory scheduler and make sure the lab was ordered. The DON stated she printed out all the progress notes for the past 24 hours daily, or 48 hours if over the weekend, and reviewed all the nursing progress notes. If she saw a new order for a lab, she would go to the unit and ensure the order had been carried out and the lab was scheduled. She stated the night nurse would also check the 24-hour report for any new orders, and she would not know of any new orders unless it was documented on there. She stated if the nurse who noted the order did not fill out the laboratory slip, and document it on the 24-hour report and in the progress notes, there would be no way of knowing the order existed. The DON stated RN #6 did not fill out Resident #1's PT/INR laboratory slip, which needed to be put in the white box or brought down to the scheduler's office. During an interview with the facility's Medical Director on 6/1/2017 at 4:20 PM, he stated he had heard about the incident with Resident #1 that morning. He was not aware of the facility's policy or process regarding transcribing laboratory orders or a safeguard system to ensure orders were carried out if a nurse who notes the order makes an error in the process. He stated ultimately the checks and balances would be the responsibility of the physician ordering the PT/INR, and they would be the one who would follow up on the results. During an interview with the resident's attending physician on 6/1/2017 at 5:00 PM, he stated after the resident was treated at the hospital for [MEDICATION NAME] toxicity, he was notified that her PT/INR had not been drawn at the facility. He stated the resident had an exaggerated response to the [MEDICATION NAME] and that could have been identified earlier if the PT/INR test had been done. He stated he did not have a way to track every laboratory test he ordered to ensure it was done. During an interview with LPN #7 on 6/1/2017 at 5:35 PM, she stated she would not routinely check a resident's PT/INR level before administering [MEDICATION NAME]. If the resident was on the same dose of [MEDICATION NAME] for an extended period of time, she would question that as [MEDICATION NAME] doses change frequently and labs for PT/INR are generally checked every 2 weeks. She stated she had not questioned or reviewed the PT/INR results for Resident #1 in the past. During an interview with LPN #8 on 6/1/2017 at 5:40 PM, she stated she did not review PT/INR levels before administering [MEDICATION NAME] and was not sure she even had access to residents' laboratory reports. 2) Resident #4 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was intact. He required extensive assistance for most activities of daily living (ADLs) and he received anticoagulation medication daily. The comprehensive care plan (CCP) dated 5/9/2017 identified the resident was on [MEDICATION NAME] and documented to follow the facility's Standard of Care (S(NAME)) for [MEDICATION NAME] therapy. The S(NAME) documented an anticoagulated resident was to be monitored for any abnormal bleeding and bruising, and to utilize the anticoagulation flowsheet to keep an accurate history. A laboratory report dated 2/24/2017 documented the resident's PT/INR level had been drawn with results of PT 19.0 (normal 9.6 - 13.2 seconds, therapeutic range 14.4 - 30 seconds on anticoagulants) and INR 1.70 (normal 0.8 - 1.2, therapeutic range 2.0 - 3.0). Handwritten at the bottom of the report documented the resident was on 5 mg (milligrams) of [MEDICATION NAME] and change to 6 mg daily with a repeat INR in one week. The report was noted by a nurse on 2/24/2017. A nursing progress note dated 2/24/2017 documented the resident had a new order for [MEDICATION NAME] 6 mg daily and repeat PT/INR in one week. A physician order [REDACTED]. The order was signed by a nurse that she received the order. The anticoagulation flowsheet documented the resident had a PT/INR drawn on 2/23/2017, the resident was on [MEDICATION NAME] 5 mg, and the results of the PT/INR were 19.0/1.70. The action taken was increasing the [MEDICATION NAME] to 6 mg daily with the next PT/INR to be drawn on 3/3/2017. The next PT/INR level documented on the flowsheet was on 4/21/2017. A physician progress notes [REDACTED]. (Per the anticoagulation flowsheet, the resident's PT/INR level was 2.44 on 2/17/2017.) There was no documented evidence in the medical record the physician requested the PT/INR results that were due to be drawn on 3/3/2017. A nursing progress note dated 3/11/2017 documented the resident was evaluated by the physician and the current physician orders [REDACTED]. There was no documentation regarding the PT/INR that was due on 3/3/2017. A physician order [REDACTED]. There was no documented evidence in the medical record the ordered PT/INR blood testing was completed for the resident from 2/24/2017 - 4/21/2017. An untitled sheet found in the laboratory section of the resident's chart on 6/2/2017 documented the resident had laboratory testing drawn at the facility on 2/24/2017 and the next laboratory testing drawn documented on the sheet was on 4/21/2017. The Medication Administration Record [REDACTED]. A nursing progress note dated 4/4/2017 documented the resident was sent to the emergency room for nausea, weakness and coughing. A nursing progress note dated 4/5/2017 documented the resident was admitted to the hospital for [MEDICAL CONDITION] (high blood potassium). Readmission orders [REDACTED]. Per the anticoagulation flowsheet, the resident's PT/INR testing resumed on 4/21/2017. During an interview with the resident's attending physician on 6/1/2017 at 5:00 PM, he stated he did not have a way to track every laboratory test he ordered to ensure it was done. During an interview with LPN #8 on 6/1/2017 at 5:40 PM, she stated she did not review PT/INR levels before administering [MEDICATION NAME] and was not sure she even had access to residents' laboratory reports. During an interview with Unit Manager licensed practical nurse (LPN) #1 on 6/2/2017 at 11:15 AM, she stated the resident's PT/INRs were managed by the facility. She stated the nurse who noted the order was to fill out a laboratory slip and the night nurse was responsible for ensuring the lab slip was filled out. LPN #1 reviewed the resident's physician orders [REDACTED]. She did not know why it had not been drawn on 3/3/2017 as planned and thought maybe the lab slip did not get filled out. 10NYCRR 415.12