Every finding on record at Montgomery Nursing And Rehabilitation Center

Based on observations, interviews, and record review, the facility failed to ensure residents remained free from abuse for one of two residents (Resident #57) reviewed for abuse. Specifically, Resident #49's comprehensive care plan was not reviewed or revised after increased agitation, paranoia, hallucinations and verbal aggression on 04/15/2026. Subsequently, on 04/17/2026, Resident #49 physically assaulted Resident #57 while in the dining room, by grabbing their neck and placing Resident #57 in a choke hold. This resulted in actual physical and psychosocial harm to Resident #57 that was not Immediate Jeopardy. The findings include:The Policy for abuse and neglect last revised 12/07/2021 documented that all residents will be free of abuse.1.Resident #57 (victim) had diagnoses that included dementia (disease of the brain characterized by progressive persistent loss of intellectual function), osteoarthritis (disease characterized by breakdown of cartilage and bone and joint pain), and chronic pain (persistent pain lasting longer than three months).The quarterly Minimum Data Set (a resident assessment tool) dated 03/29/2026 documented moderately impaired cognition, mood score (severity of depressive symptoms) was zero, no behaviors, and moderate assistance required with most activities of daily living. Resident #57's Care Plan for abuse prevention and prohibition last reviewed on 04/07/2026 documented the facility will establish systems for identifying potential abuse.2.Resident #49 (aggressor) had diagnoses that included Parkinson's Disease (progressive nervous system disorder characterized by tremors, stiffness, and slow movement), anxiety (emotion characterized by fear, tension, and worry), and depression (mood disorder that causes persistent sadness, low energy, and loss of interest in activities). Resident #49's quarterly Minimum Data Set, dated [DATE] documented Resident #49 had intact cognition, no behaviors, and required moderate assistance for transfers and standing. Resident 49's Care Plan for abuse prevention and prohibition last reviewed 01/26/2026 documented residents with needs and behaviors which might lead to conflict should have appropriate assessment, care planning and monitoring.Resident #49's Care Plan for potential victim/victimizer last reviewed 01/26/2026 documented maintain resident in supervised area as necessary when out of bed, observe for emotional distress around other residents and immediately remove from confrontational situation involving other residents. The Medical Director Order renewal dated 03/12/2026 documented psychology consults and follow up as needed.The Neurology Consultation note for Resident #49 dated 03/26/2026 documented that Resident #49 had increased tremors and reported hallucinations involving gunfights in their room, the Nazi's coming for them, or other things that were not real. They stated they recognized they were not real. The recommendation was not to increase current medications, but to consider additional medication if the hallucinations became intrusive.Licensed Practical Nurse #10 progress note for Resident #49 dated 04/09/2026 at 11:00 PM, documented that Resident #49 was unusually confused, paranoid, and agitated that evening. They refused all medications including insulin in fear of being poisoned. There was no documented evidence that a Medical Provider was made aware of Resident #49's medication refusal.The Psychologist #1 note dated 04/10/2026 documented no changes in mental status noted. Worked with the resident for treatment of depression and anxiety. Reduce symptoms of depression and anxiety and provide supportive psychotherapy. There was no documented evidence in the Psychology note to address Resident #49's documented increase in paranoia, agitation, and medication refusal. Licensed Practical Nurse #7 progress note for Resident #49 dated 04/15/2026 at 2:31 PM, documented that Resident #49 exhibited increased confusion when talking to other residents and the nurse. They were unable to explain their thought process when asked.Licensed Practical Nurse #2 progress note for Resident #49 dated 04/15/2026 at 6:13 PM, documented that the increased confusion was discussed with the Medical Director and a new order for lab work was received for 04/17/2026.Registered Nurse #6 progress note for Resident #49 dated 04/15/2026 at 10:53 PM documented that Resident #49 exhibited some agitation and paranoia during bedtime. They became argumentative with Resident #37. Resident #49 had to be removed to have personal space. Resident # 49 refused care, was paranoid and asked if the other resident had a gun. Two-person assistance was required to return Resident #49 to bed. Redirected during cares with positive effect. There was no documented evidence that Resident #49's care plan was reviewed and revised to address the documented escalation in behaviors.The Accident and Incident Report dated 04/17/2026 at 12:49 PM, documented a resident-to-resident altercation. While eating lunch, Resident #49 stood up and went behind Resident #57 putting their arms around them. Resident #57 sustained an injury to their right cheek with an area of swelling measuring 3 centimeters by 3 centimeters and a superficial abrasion (superficial skin injury or scrape that wears away the outer layer of skin) to the left cheek measuring 1 centimeter by 0.2 centimeters. They also had bruising to their left lateral wrist. Resident #57's family members refused emergency room evaluation. The Accident and Incident Statement dated 04/17/2026 written by Unit Clerk #3, documented that after lunch, they observed Resident #49 telling Resident #57 to shut up and go paint their nails. Resident #57 did not answer them. Resident #49 got up and put a choke hold around Resident #57's neck. Resident #57 was yelling for Resident #49 to stop, and staff had to remove Resident #49 from Resident #57. The Accident and Incident Statement dated 04/17/2026 written by the Activity Director, documented that they were in the South Day Room dropping a cup off for an upcoming activity. They observed Unit Clerk #3 in the room at a table with residents. After being in the room for two minutes, they heard Unit Clerk #3 gasp. They looked and saw Resident #49 with their arms grasped around Resident #57's neck from behind them. They immediately ran to separate the two residents with the help of certified nurse aides who came into the room to help. Certified Nurse Aide #5 who helped separate Resident #49 and Resident #57 then took Resident #49 out of the room and stayed with them. Licensed Practical Nurse #7 came to ask Resident #49 what happened and assessed their cognition. Registered Nurse Unit Manager #1 progress note for Resident #49 dated 04/17/2026 at 3:39 PM, documented that Resident #49 exhibited behavior outside of their normal baseline, order received to transfer Resident #49 to the emergency room for evaluation. Licensed Practical Nurse Infection Preventionist progress notes for Resident #57 dated 04/17/2026 at 3:22 PM, documented circular reddened, slightly swollen area to the right cheek measuring 3 centimeters by 3 centimeters, superficial abrasion to the left cheek measuring 1 centimeter by 0.2 centimeters under their left eye. Resident #57 reported mild pain to their right cheek as they held the area.The Psychotherapy note for Resident #57 dated 04/17/2026, documented that Resident #57 was seen after they were involved in a resident-to-resident incident where the other resident was aggressive. Resident #57 verbalized being scared, safety was reinforced, and support was provided.The Medical Director progress note for Resident #57 dated 04/19/2026 at 11:39 AM, documented a visit on 04/17/2026 for increased anxiety after a resident-to-resident altercation. Anxiety was likely episodic as no previous history of anxiety, supportive therapy for now and monitor symptoms. The Care Plan note for Resident #57 dated 04/21/2026 documented that a high-level care plan meeting was conducted. Discussion regarding medical and psychological management, neck pain, one-to-one support.During an observation on 07/21/2026 at 10:37 AM, Resident #57 was in their room in bed, engaging and pleasant. There were no observed concerns related to fear or mistreatment. During observations on 07/21/2026 at 10:17 AM and 12:56 PM, and 07/22/2026 at 12:56 PM, Resident #49 was in their room with one-to-one supervision. During an interview on 07/22/2026 at 10:13 AM, Resident #57's Representative stated that when the incident occurred on 04/17/2026, they were worried about the response Resident #57 had to the incident. They stated Resident #57 exhibited fear for a period after the incident, but it had since improved and the perpetrator now remained supervised. During an interview on 07/27/2026 at 8:21 AM, the Activity Director stated they witnessed the resident-to-resident altercation involving Resident #49 and Resident #57 on 04/17/2026. They stated Resident #49 grabbed Resident #57 by the neck. They stated they assisted with separating the two residents and other staff responded and helped separate the residents. They stated Resident #49 did not offer a reason for their actions. They stated they were not informed of any changes in Resident #49's behavior before the incident occurred. They stated the whole incident was very traumatic for Resident #57. They stated Resident #57 had bruising and an abrasion to their face after the incident. During an interview on 07/27/2026 at 8:39 AM, Unit Clerk #3 stated that just before the 04/17/2026 incident occurred, they remember Resident #49 telling Resident #57 to shut up. They stated that staff could hear Resident #49, but the behavior was not out of character for Resident #49. They stated Resident #49 lunged at Resident #57 and grabbed their neck. They stated once the physical interaction started, staff began to respond. They stated the staff that responded, removed Resident #49's hands from Resident #57's neck and separated them. They stated Resident #57 was very upset. They stated they could see Resident #57 shaking. They stated they were not aware of any concerns about Resident #49's behaviors prior to the incident. During an interview on 07/27/2026 at 11:15 AM Certified Nurse Aide #4 stated that they responded to the incident on 04/17/2026. They stated when they entered the South Day room, they saw Resident #49 with their hands around Resident #57's neck. They stated they assisted the Activities Director with removing Resident #49 from Resident #57. They stated Resident #57 was in shock. They stated Resident #49 said I got this one and tried to get the other one but could not reach. They stated no one reported to them that Resident #49 had an increase in behavior, or any concerns regarding Resident #49, prior to the incident that day. They stated Resident #57 stayed in their room a little more for maybe a day or two after the incident and then returned to their baseline. During an interview on 07/27/2026 at 11:57 AM, Registered Nurse #5 stated that they observed Resident #49 exhibit behaviors on 04/15/2026 during the evening. They stated Resident #49 was having a verbal altercation with another resident in the hallway. They stated there was no physical interaction, but they had to intervene, separate them, and de-escalate the situation. They stated they did not notify the supervisor or report the incident because they were able to manage the situation, and they wrote a note. They stated that Resident #49 had been aggressive with staff, not residents, in the past. They stated they believed that those behaviors were a result of the disease process. During an interview on 07/27/2026 at 12:42 PM, Licensed Practical Nurse #6 stated that they responded after the incident occurred on 04/17/2026 but did not witness it. They stated that Resident #49 told them others were threatening to kill them. They stated on 04/15/2026, Resident #49 did have an increase in confusion and hallucinations. They stated they wrote a note and reported it to Licensed Practical Nurse Unit Manager #2, who stated they and the physician were aware. They stated that they were off on 04/16/2026 and on 04/17/2026, they had not received anything further in report about additional concerns or Resident #49 having increased behaviors. During an interview on 07/28/2026 at 8:39 AM, Licensed Practical Nurse Unit Manager #2 stated they did not recall being informed of Resident #49's medication refusal and paranoia on 04/09/2026. They stated they were off after 04/15/2026, therefore, they would not have known about the incident on the evening of 04/15/2026. They stated the supervisor and physician should have been notified, however they were unable to find documentation of that notification. They stated they could update care plans; however, the Director of Nursing oversees any entries for new care plans and must add the new care plans. During an interview on 07/28/2026 at 10:27 AM, the Medical Director stated Resident #49 was seen the week prior to the incident for increased confusion, paranoia, and hallucinations. They stated that the symptoms that were being exhibited could develop because of the disease process, but it was hard to predict how and when the disease would progress. They stated they had ordered lab work to rule out anything acute like an infection that week because of the increased tremors, confusion, and paranoia. They stated that Resident #57 sustained a bruise and abrasion to the face because of the incident. They stated that because of Resident #57's limited cognition and poor recall, they did not believe they suffered long term effects from the incident. They stated that the event was traumatic and was likely the cause of Resident #57's anxiety that day. During an interview on 07/28/2026 at 1:28 PM, the Director of Nursing stated that Resident #49 did exhibit some changes the week prior to the incident on 04/17/2026 and labs were ordered and pending that day. They stated Resident #49 had not exhibited aggressive behavior with other residents before 04/17/2026. They stated nursing interventions were not implemented because Resident #49 had experienced paranoia and hallucinations for the last year and could often identify them as hallucinations and knew they were not real. They stated they could not show any documentation dated prior to 04/17/2026 that included interventions to handle those episodes. 10 New York Code Rules Regulations 415.4(b)(1)(i)

Based on observation and interview the facility failed to ensure that kitchen equipment and floors were maintained in a sanitary condition to prevent food contamination and safety hazards. Specifically, pooling water was present on the kitchen floor and in a closed floor drain and loose flaking residue was noted on the food slicer meat grip.The findings include:The undated Policy for maintenance work order reporting documented that all facility maintenance concerns shall be reported using the electronic work order system. All employees are responsible for promptly reporting maintenance deficiencies that may affect resident safety, employee safety, infection prevention, security, regulatory compliance, or facility operations.During an observation and interview on 7/21/2026 at 1:54 PM standing water was noted on the kitchen floor and in a closed floor drain between the steam table and ovens. The Food Service Director stated the standing water in the kitchen and closed floor drain was from the food steamer which overflowed into the closed floor drain. They stated the water was removed by using a vacuum every two weeks or it dried up on its own. During an interview on 07/23/2026 at 3:35 PM, the Maintenance Director stated the closed floor drain in the kitchen previously had water from a separate leaky pipe emptying into it. They stated the leaky pipe was repaired several months ago, and the floor drain was filled with concrete. They stated the work was done because the floor drain did not empty to the outside of the building. They stated any water from equipment now emptied into a bucket that required to be disposed of daily. They stated the kitchen equipment was repaired by an outside company, and the maintenance department was not responsible for it. During an observation and interview on 07/27/2026 at 10:40 AM, the meat grip on the food slicer had a flakey coating. The Food Service Director stated they were not aware of the metal coating flacking off the meat grip. They stated the food steamer water outflow emptied into a bucket that was supposed to be emptied daily. They stated occasionally the bucket was not emptied when full and would overflow into the closed floor drain, about 1-2 times a month. They stated they would use the wet/dry vacuum to remove the water. They stated the water was then disposed of in an outside drain near the refuse area. They stated emptying the bucket was not on the cleaning checklist that that was to be completed each day by the kitchen staff. The Food Service Director stated they and the Dietary Supervisor were responsible for ensuring the closing checklists were completed.There was no documented evidence on the Food Service Closing Checklist to address emptying of the food steamer water overflow bucket and keeping the closed floor drain dry.10 New York Code Rules Regulations 415.14(h)

Based on record review and interviews, the facility failed to ensure that the resident environment remained as free from accident hazards as possible for two of seven residents (Resident #103 and Resident #104) reviewed for accidents. Specifically, there was no documented evidence that routine maintenance and filter replacement and/or cleaning was performed prior to a 04/14/2025 oxygen concentrator fire in the room of Resident #103 with a physician's order for continuous oxygen via nasal cannula. Following the incident, Resident #103 and roommate Resident #104 were sent to the hospital for evaluation of possible smoke inhalation and later returned to the facility. Additionally, the facility did not have documented evidence that a timely thorough investigation was completed after the 04/14/2025 incident. The findings include:Resident #103 had diagnoses including but not limited to Chronic Obstructive Pulmonary Disease, Cancer, and Hip Fracture.The Physician Order for Resident #103 dated 03/19/2025 documented oxygen via nasal cannula at 1.5 liter/minute, continuous, no humidification and change oxygen tubing every week on Sunday during the 11 PM-7 AM shift.The Care Plan for oxygen therapy dated 03/20/2025 documented maintain oxygen/nebulizer/ puffer equipment per facility policy.The admission Minimum Data Set assessment for Resident #103 dated 03/26/2025 documented Resident #103 had intact cognition and received continuous oxygen therapy.The Physician Order for Resident #103 dated 04/03/2025 documented taper oxygen and monitor oxygen saturation during weaning period. Maintain oxygen at 92%.The Incident Report dated 04/14/2025 documented at around 3:50 PM, staff in the facility responded to a smoke alarm. Smoke was noted coming from a resident's room and the fire extinguisher was used. Residents were safely evacuated away from the smoke. No residents were injured. The fire departement responded. The investigation is ongoing. However, the issue may have been the oxygen concentrator. Staff were educated on the fire policy; the fire inspector checked the area and deemed the impacted unit safe for residents to return. The impacted room will receive a deep cleaning. All oxygen concentrators will be inspected for safety.There was no documented evidence included with the Investigation Report to indicate incident location/room location, affected resident names/identifiers, whether or not oxygen was being administered via nasal cannula at the time of the incident, statements obtained and/or interviews conducted with involved staff and/or residents and there was no documented evidence of maintenance history for the affected oxygen concentrator prior to the 04/14/2025.There was no documented evidence of maintenance logs for oxygen concentrators related to maintenance checks and filter cleaning and or filter changes prior to the fire on 04/14/2025.The Fire Department Investigation Report dated 04/14/2025 documented incident type, accident. The fire department was dispatched to an automatic alarm at the facility. Upon arrival they found a light smoke condition and requested a response from the County fire investigation unit. The oxygen concentrator model number AKLC-1 malfunctioned and burned the circuit board and caused smoke to fill the room. At this time the conclusion if this fire was caused by oxygen machine circuit board malfunction and this fire is ruled accidental.The 04/14/2025 Nurse Progress note documented the Registered Nurse Supervisor completed assessment on Resident #103 status post possible smoke inhalation. Resident alert and oriented, baseline. Blood Pressure 111/67, Pulse 77, Respiration 20, Temperature 97.9, Oxygen 93% on RA and then O2 at 2 liter/minute via nasal cannula continuously applied. No signs/symptoms of respiratory distress, shortness of breath, dizziness, headache or pain/discomfort on assessment. Medical Doctor notified and gave orders to send to the emergency room for further evaluation. Son contacted and in agreement to transfer. 911 called to transport.The 04/14/2025 Nurse Progress note at 8:15 PM documented Resident #103 was evaluated and discharged from the emergency room. Returned accompanied by family. No new order. No change in level of consciousness observed or reported. No complaints were voiced by the resident.The 04/14/2025 Nurse Progress note at 4:37 PM documented Registered Nurse Supervisor completed assessment on Resident #104 status post possible smoke inhalation from active fire in resident's bedroom. Blood pressure 123/82, 82, 16, oxygen saturation 96% on room air. Resident's baseline. Medical Doctor notified and gave orders to send to the emergency room for further evaluation. Son contacted and in agreement to transfer.The 04/15/2025 Nurse Progress note documented 3:10 AM Resident #104 returned from the emergency room to room [ROOM NUMBER]D. Alert no respiratory distress. Family made aware of resident return.During an interview on 07/23/2026 at 11:41 AM, Physical Therapist #8 stated they heard the speaker announce the location of the fire and thought it was a fire drill on the north side. Physical Therapist #8 stated they grabbed the fire extinguisher and went to the resident room. They stated the oxygen concentrator had a small flame, approximately 6 inches, coming out of it. They stated they extinguished the fire. They stated the resident was sleeping at the time of the fire, and Licensed Practical Nurse #9 woke the resident and removed them from the room. They stated the residents on the unit were evacuated by staff, approximately 15-20 residents and taken outside the building through the emergency fire door. They stated the fire was contained in the oxygen concentrator. They stated the fire department was called in.During an interview on 07/23/2026 at 12:02 PM, Licensed Practical Nurse #9 stated Resident #103 was in bed by the window and roommate Resident #104 was by the door. They stated they observed smoke coming from room [ROOM NUMBER]. They stated the smoke activated the fire alarm. They stated Resident #104 was out of the room, moving away from the smoke. They stated Resident #103 was sleeping, and their oxygen tube was off their face. They stated the oxygen concentrator had a small fire on top. They stated they took Resident #103 out of bed and all residents were taken outside through the front and exit doors. They stated everyone remained outside until the fire department cleared them. They stated that if there was a problem, alarms on the oxygen concentrator would normally sound, and maintenance would check the unit. They stated that day the oxygen concentrator did not alarm.During an interview on 07/23/2026 at 3:16 PM, the Director of Maintenance stated that before the 04/14/2025 fire incident, they did not keep preventative maintenance logs and filter cleaning schedule logs for oxygen concentrators. They stated that after the incident on 04/14/2025, they created a schedule to clean the oxygen concentrator filters weekly.During an interview on 07/24/2026 at 9:47 AM, the former Administrator stated not adding involved resident names and the room # to the investigation was an oversight. They stated they could not recall all the details of the incident at this time.During an interview on 07/28/2026 at 9:55 AM, the current Administrator stated they were unable to locate staff/resident statements and/or interviews related to the 04/14/2025 incident.10 New York Code Rules Regulations 415.12(H)(1)(i)

Based on observation, record review, and interview, the facility failed to maintain essential electrical equipment in a safe and functional operating condition. Specifically, the plastic covering on an electrical outlet near the kitchen oven was broken and contained visible live electrical wires and components. The findings include:The undated Policy for maintenance work order reporting documented that all facility maintenance concerns shall be reported using the electronic work order system. All employees are responsible for promptly reporting maintenance deficiencies that may affect resident safety, employee safety, infection prevention, security, regulatory compliance, or facility operations.During an observation and interview on 7/21/2026 at 1:54 PM the cover of an electrical outlet near the kitchen oven was broken and had live electrical wires and components visible. They stated the electrical outlet was broken for a week or two and was reported to maintenance. During an interview on 07/23/2026 at 3:35 PM, the Maintenance Director stated the facility used a maintenance program which was available to all staff on the computers. They stated no work order for a broken electrical outlet was documented. They stated the maintenance department was verbally told of the electrical outlet on Tuesday, 07/21/2026, and the electrical outlet was repaired. During an observation and interview on 07/27/2026 at 10:40 AM, the Food Service Director stated they did not report the broken electrical outlet in the facility maintenance program and believed they verbally reported it to someone in the maintenance department. 10 New York Codes Regulations and Rules 415.29

Based on observation, record review, and interview during the recertification and abbreviated surveys (NY00359070 ) from 1/7/2025 to 1/14/2024, the facility did not ensure that an effective pest control program was maintained so that the facility was free of rodents on 1 of 2 units (South) and the physical therapy department. Specifically, there was no documented evidence of facility follow up/monitoring to assess ongoing need and/or effectiveness of interventions put in place by the pest control company to eradicate and/or contain mice. The findings are: The policy and procedure effective 3/2019 last reviewed 3/2024 titled Pest Control documented this facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. The Pest Control Logbook dated 2/7/24 to 1/8/25 documented mice were observed in room [ROOM NUMBER] and #106 on 4/16/24, a mole was observed in room [ROOM NUMBER], and maintenance shop on 10/15/24, a mouse was in room [ROOM NUMBER] on 10/15/24, and a mouse was in the therapy room on 11/3/24. The 4/17/24 Service Inspection Report documented mice were in room [ROOM NUMBER] and room [ROOM NUMBER]. Ready to use glue boards were placed in each room. No other reports. Inspected and treated all nursing stations, common areas and kitchen. The 10/16/24 Service Inspection Report documented treated all nursing stations in common areas and kitchen for general pest prevention. Check all ready to use monitors and tincats. One mouse caught on the glueboard near the exit door under ventilation. Replenished all monitors. The 11/13/24 Service Inspection Report documented light activity in the therapy department. Inspected and treated the entire interior and exterior for all pest and rodent activity including all common areas, nursing stations and kitchen. Replenished all bait stations throughout the facility interior and exterior. During observation on 1/07/25 at 11:17 AM, room # 131/Resident #54 was observed to have a mouse trap behind the dresser and located under the radiator. It was also observed that Resident #54 had an open box of donuts on the dresser and extra food items in the room. During interview on 1/13/25 at 3:53 PM, the Director of Rehabilitation stated they did not actually see mice, but they saw mice droppings in the physical therapy department. They stated they alerted the head of maintenance and they called the pest control company who sprayed all along the baseboards and put a mouse trap in the room.They stated the mouse trap was no longer in place. During interview on 1/14/25 at 9:13 AM, Licensed Practical Nurse #14 stated they did not recall seeing or hearing about mice in April of 2024. Licensed Practical Nurse #14 stated if a Certified Nurse Aide saw a mouse they would verbally report it to maintenance. Licensed Practical Nurse #14 stated they did not have maintenance repair/housekeeping logs on the units where they would report concerns for maintenance/housekeeping such as mice. During interview on 1/14/25 at 9:47 AM, the Director of Maintenance/Housekeeping stated when there were reports of mice, they had pest control company place mouse traps. The Director of Maintenance/Housekeeping stated they knew traps were placed but, a review of reports to determine if the traps were working/rounds to check for mice was not done. The Director of Maintenance/Housekeeping stated they had no documentation of their follow regarding the issue. The Director of Maintenance/Housekeeping stated they felt it was being taken care of by having the mouse traps. The Director of Maintenance/Housekeeping stated the pest control company checked the traps to see if there were mice in them. The Director of Maintenance/Housekeeping stated they were not informed of any mice being found in the mouse traps. 10 NYCRR 415.29(j)(5)

Based on observation and interview during the recertification survey conducted from 1/7/25 to 1/14/25, the facility did not ensure a clean and home like environment was maintained for 1 of 2 nursing units (South unit). Specifically, (1) the floor and radiators in room [ROOM NUMBER], #129 and #130 were dirty, the walls and closet trim in room [ROOM NUMBER] had chipped and scuffed paint, room [ROOM NUMBER] had feces on the toilet and room [ROOM NUMBER] had a brown liquid spill on the floor and (2) a meal tray was provided to Resident #24 and contained a hot beverage cup and utensils with a build up of lime deposit stains. The findings include: The policy and procedure titled Cleaning and Disinfection of Environmental Surfaces effective 9/30/2020 last reviewed 3/2024 documented environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standard. Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. Disinfection (or detergent) solutions will be prepared as needed and replaced with fresh solution frequently (e.g. floor mopping solution will be replaced every three resident rooms, or changed no less than at 60-minute intervals). 1) On 1/7/25 between 10:59 AM and 11:17 AM and 1/10/25 between 12:33 PM and 12:41 PM rooms #128, #129 and #130 on the South unit were observed and had floors that were unclean and radiators that were dirty: room [ROOM NUMBER] walls/ closet trim had chipped and scuffed paint, room [ROOM NUMBER] had feces on the toilet and room [ROOM NUMBER] had a brown liquid spill on the floor. On 01/13/25 at 11:30 AM, during a tour with survey staff, the Director of Housekeeping and Maintenance observed scuffed and chipped paint on the walls and dirty baseboards, floors and radiators in room [ROOM NUMBER], feces on the toilet in room [ROOM NUMBER], and a brown liquid spill mark on the floor in room [ROOM NUMBER]. The Director of Maintenance and Housekeeping stated if the rooms were not cleaned then the housekeeper must not have cleaned them On 01/13/25 at 12:07 PM during an interview, the Director of Housekeeping and Maintenance stated they did not have maintenance and repair logs. They stated the rooms on the South unit were not renovated. The Director of Housekeeping/Maintenance stated they never had a chance to do the repairs in the rooms as they reopened the unit following COVID and they wanted to fill the beds. The Director of Housekeeping and Maintenance stated they did not have a regular schedule for work orders but did rounds every week on Tuesdays and Thursdays. The Director of Housekeeping and Maintenance stated they did not have a log of repairs they made throughout the facility. 50766 2) During an observation on 01/07/25 at 12:25 PM Resident #24's meal with was served on a tray containing a hot beverage cup and utensils with a build up of lime deposit stains. During an interview and observation on 01/13/25 at 03:54 PM the Kitchen Manager stated they observed hot beverage cups and utensils with a build up of lime deposit stains. They stated lime stains built up and left a film on beverage cups and utensils because the facility had hard water. They stated the beverage cups and utensils were supposed to be sprayed, rinsed and scrubbed prior to entering the dishwasher. During an observation and interview on 01/14/25 at 10:29 AM the Director of Food Services stated hot beverage cups and utensils were observed with lime build-up stains. They stated a de-[NAME] product was used for equipment. They stated they tried using de-[NAME] on silver but that caused the silver to tarnish and removed the finish. The Director of Food Services stated a water softener would be of assistance in removing lime scale from beverage cups and utensils. They stated in the past they had discussed the addition of a water softener with Administration and stated the dishwasher repair company also recommended a water softener. During an interview on 01/14/25 at 11:00 AM the facility Administrator stated they believed a water softener addition to prevent lime build up was brought up in the past but was not aware if there had been follow up. They stated the appearance of lime deposit stains on cups, and utensils was not home-like. The Administrator stated the facility recently purchased new cups and utensils, however the lime build-up eventually returned after repeated washing. 10 NYCRR 415.5(h-i)(1-3)

Based on record review and interview conducted during the recertification survey from 1/7/25 to 1/14/25, the facility did not ensure sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility did not meet minimum staffing requirements for Certified Nurse Aides as documented on the Facility Assessment on 10 of 28 days reviewed. The findings are: The Facility Assessment Staffing Plan Minimum Staffing documented Day shift: 3 Licensed Nurses on both units and 3 Nurse Aides on both units. Evening shift: 2 Licensed Nurses on both units and 3 Nurse Aides on both units. Night shift: 1 Licensed Nurse on both units and 2 Nurse Aides on both units. Actual staffing from December 9 2024 to January 6 2025 documented: 12/14/24 South Unit 11:00 PM-7:00 AM one Certified Nurse Aide, and North Unit 11:00 PM-3:00 AM one Certified Nurse Aide. 12/22/24 North Unit 7:00 PM-9:30 PM two Certified Nurse Aides. 12/25/24 South Unit 7:00 AM-12:00 PM two Certified Nurse Aides. 12/28/24 North Unit 10:00 AM-1:00 PM two Certified Nurse Aides. 12/30/24 North Unit 11:00 PM-4:00 AM one Certified Nurse Aide and South Unit 4:00 AM-7:00 AM one Certified Nurse Aide. 12/31/24 North Unit 11:00 PM-5:30 PM one Certified Nurse Aide and South Unit 11:00 PM-4:15 AM one Certified Nurse Aide. 1/1/25 North Unit 11:00 PM-4:15 AM one Certified Nurse Aide 1/3/25 South Unit 3:00 PM-4:00 PM two Certified Nurse Aides and 10:00 PM-11:00 PM two Certified Nurse Aides. 1/4/25 South Unit 2:30 PM-3:00 PM two Certified Nurse Aides. 1/6/25 South Unit 10:00 PM-11:00 PM two Certified Nurse Aides. During an interview on 1/08/25 at 1:53 PM Certified Nurse Aide #5 stated they came in at 3:00 AM (night shift) on 12/14/24 to assist on the North Unit. They stated they provided care to residents, since there had been only one Certified Nurse Aide working from 11:00 PM until they got there at 3:00 AM. During an interview on 1/08/25 at 2:00 PM Certified Nurse Aide #6 stated they worked with only one other Certified Nurse Aide on the South Unit on 12/25/24 from 7:00 AM to 12:00 PM. They stated each of the Certified Nurse Aides had to stay on one wing to answer call bells and assist residents as best they could. They further stated on 12/28/24 from 10:00 AM until 1:00 PM, they worked with only one other Certified Nurse Aide on the North Unit. They stated it was difficult to keep the residents safe and assist them with cares as needed with only one other Certified Nurse Aide. During an interview on 1/10/25 at 9:05 AM Certified Nurse Aide #10, stated on 1/3/25 they worked with only one other Certified Nurse Aide from 3:00 PM to 4:00 PM and from 10:00 PM to 11:00 PM. They stated on 1/6/25 they worked with only one other Certified Nurse Aide on the South Unit from 10:00 PM to 11:00 PM. They stated it was challenging to meet resident needs, keep residents safe, and assist with toileting when they were short staffed. During an interview on 1/10/25 at 9:09 AM Certified Nurse Aide #8 stated on 12/30/24 they came in at 4:15 AM and were the only Certified Nurse Aide on the unit. They stated they completed as many cares as possible to try to meet all the resident's needs. Certified Nurse Aide #8 stated in order to meet all resident needs, it was much better to work with two Certified Nurse Aides. During an interview on 1/10/25 at 9:16 AM Certified Nurse Aide #7 stated on 12/22/24 they worked with only one other Certified Nurse Aide from 7:00 PM to 9:30 PM. They stated it was difficult getting residents ready for bed. They stated on 1/4/25 they worked with only one other Certified Nurse Aide from 2:30 PM to 3:00 PM. They stated it was always hard when working with only one other Certified Nurse Aide. During an interview on 1/13/25 at 8:49 AM Certified Nurse Aide #4 stated on 12/14/24 they were the only Certified Nurse Aide on the unit from 11:00 PM to 3:00 AM, on 12/31/24 they were the only Certified Nurse Aide on the unit from 11:00 PM to 5:30 AM, and on 1/1/25 they were the only Certified Nurse Aide on the unit from 11:00 PM to 4:15 AM. They stated they tried to do the best they could, but it was impossible to take care of approximately 40 residents and answer the call bells timely. They stated they completed what they could, but it was hard. During an interview on 1/13/25 at 9:16 AM Certified Nurse Aide #18 stated on 12/31/24 they were the only Certified Nurse Aide on the unit from 11:00PM to 4:15 AM. They stated it was not easy to provide care to so many residents by themselves. They stated they changed as many residents and answered as many call bells as they could. During an interview on 1/13/25 at 9:40 AM the Staffing Coordinator reviewed the Staffing Plan Minimum Staffing documented in the Facility Assessment and reviewed the actual staffing from December 9 2024 to January 6 2025 and stated they were aware the facility did not meet the minimum staffing numbers for Certified Nurse Aides on 10 of 28 days reviewed. They stated last minute callouts had been a problem. On 01/13/25 at 10:53 AM during an interview with the facility Administrator, they stated they are aware that the facility did not meet the minimum staffing numbers of Certified Nurse Aides on multiple days reviewed. They stated they were meeting with the union regarding issues with callouts, they already implemented a gift package for the Employee of the Month, they wanted to implement a bonus for attendance and needed to speak with Corporate about it. 10 NYCRR 415.13(a)(1) (i-iii)

Based on record review and interview during the recertification survey from 1/7/25 to 1/14/25, the facility did not ensure Certified Nurse Aide performance appraisals were completed at least once every 12 months for 5 of 5 Certified Nurse Aides reviewed. Specifically, performance appraisals were not documented every 12 months for Certified Nurse Aides #1, #2, #3, #4, and #5. The findings are: There was no documented evidence that performance appraisals were completed every 12 months for Certified Nurse Aide #1, #2, #3, #4 and #5. During an interview on 1/08/25 at 9:25 AM the Director of Nursing stated they were aware that performance appraisals should be completed for the Certified Nurse Aides and stated they were responsible for writing the performance appraisals. 10 NYCRR 415.12(h)(1)

Based on observation and interview conducted during the recertification survey from [DATE] to [DATE], the facility did not ensure food was stored in accordance with professional standards for food service safety. Specifically, 1. the refrigerators contained food and/or packages that were unlabeled, had no received on date, and did not contain an expiration date, 2. the walk-in freezer contained food and/or packages that were unlabeled and not properly sealed to prevent freezer burn, and 3. the dry storage pantry contained food products that did not contain expiration dates. The findings are: During an initial tour of the kitchen on [DATE] at 09:52 AM accompanied by the Director of Food Services, the following was observed in the food service refrigerators/walk in freezer and dry storage area: The Refrigerator contained: -Six 80 individual slice packs of American Cheese with no expiration date -One unlabeled container of beef meatballs -Three and one-half trays of eggs with no received date and no expiration date -One unlabeled/undated container of thawed chicken thighs -One four-pound jar of grape jelly with no expiration date The Walk in Freezer contained: -One open box of sausage patties was not covered to protect from freezer burn. -One five-pound bag of French fries with no expiration date. -One unlabeled opened bag of tater tots -One opened bag of meatballs with no open on date and no expiration date. The Dry Storage Area, contained: - One four pound can of tuna with no expiration date. - One can of spaghetti sauce with no expiration date. - One gallon bottle of Sweet and Sour Sauce with no expiration date. - Four boxes of individual size oat meal pies with no expiration date. -One box of approximately 30 individual packs of graham crackers with no expiration date. -One 16-ounce bottle of Curry Powder with no expiration date. -One 16-ounce jar of Chicken Paste with no expiration date. -One 13-ounce Classic [NAME] Gravy packet with no expiration date. -One 10-pound bag of dry pasta with no expiration date. During an interview on [DATE] at 9:52 AM the Director of Food Services stated kitchen staff was trying not to have as many boxes in the refrigerator, freezer, and dry storage area and that the discarded boxes may have contained expiration dates for the products. They stated they would discuss why canned and packaged goods did not have individual expiration dates with the food supplier. The Director of Food Services stated kitchen staff were expected to label and date all products in the kitchen and the facility received weekly deliveries of food products, therefore no products should be expired. 10NYCRR 415.14(h)

Based on observation, record review, and interview during the recertification survey from 1/7/25 to 1/14/25, the facility did not ensure infection prevention and control program designed to prevent the development and transmission of communicable diseases and infection was maintained for 2 of 8 residents ( #49, and #66) reviewed for Infection Control. Specifically, 1) the facility did not properly implement transmission-based precautions for Resident #49 and 2) the facility did not ensure an infection surveillance plan was implemented for identifying, tracking, and monitoring infections, communicable diseases, and outbreaks for Resident #49 and # 66, The findings are: The Policy titled Transmission-Based Precaution last updated 7/8/20/24 documented transmission- based precautions shall be used when caring for residents who are documented or suspected to have communicable diseases of infections that can be transmitted to others. Droplet precautions are to be implemented for residents known to be infected with microorganisms that can be transmitted by droplets which includes Coronavirus. Contact precautions should be implemented for residents infected with microorganisms that can be transmitted by direct contact which includes diarrhea associated with colostrum difficile, and the resident should be placed in a private room if it is not feasible to contain drainage excretions and blood or body fluids. Enhanced barrier precautions should be implemented for residents with wounds. The Policy titled Infection Control last updated 11/12/24 documented that to prevent, detect, and control infections within the nursing home the facility will develop and maintain a surveillance program to prevent and control infections within the facility with its purpose to detect and record nosocomial infections to institute effective control measures, including to record data of infections on resident's surveillance reports and infection line listing reports. Resident #49 was positive for Colostrum Difficile (inflammation of the colon caused by bacteria) on 10/18/24. During observation on 1/7/25 at 3:09 PM, there was no Contact Precaution sign on the door and 1/08/25 at 9:35 AM, there was no personal protective equipment or Contact Precaution sign outside Resident #49's room. During an interview on 1/13/25 at 1:16 PM, Housekeeper #34 was observed in Resident #49's room wearing gloves and without a gown. Housekeeper # 34 was squatting down while cleaning the molding and the floor. Housekeeper #34 removed their gloves, and left the room without performing hand hygiene. During an interview at that time, Housekeeper #34 stated they did not wash their hands with soap and water and did not know they should have worn a gown. Duirng an interview on 1/13/25 at 2:04 PM the Director of Nursing stated the Physician Order for Resident #49's Contact Precautions was renewed on 1/5/25. The Director of Nursing stated a sign for Contact Precautions should have been posted on Resident #49's door. The Director of Nursing stated for a resident with Colostrum Difficile, staff and visitors should be alerted to wear a gown and gloves 2. During an interview on 1/13/25 at 2:04 PM the Director of Nursing stated they could not provide tracking and prevention purposes regarding the number of residents who currently had urinary tract infections because the information was not documented in one centralized document tool. The Director of Nursing stated they did not keep an updated record in real time to identify clusters of infections and to prevent the spread of infections for residents on precautions, residents who had infection, residents who had signs and symptoms of infection, and residents on antibiotics. During an interview on 1/13/25 at 2:35 PM the Director of Nursing Resident #49 who had a diagnosis of Colostrum Difficile was not included on the November 2024 or the December 2024 tool for infections. They stated on November 5th, Resident #49 went to the Infectious disease physician for recurrent infection, and a recommendation to taper off antibiotics was made, but when the antibiotic Vancomycin was re-started on 11/20/24, they did not enter Resident #49 onto the tool to document infections but stated they should have done so. During an interview on 1/14/25 at 10:25 AM the Director of Nursing stated Resident #66 who had a diagnosis of a chronic urinary tract infection, was not included on the December 2024 or January 2025 tool for infections. They stated Resident #66 was on standing antibiotic Macrodantin since 4/24/2023 and should be listed on the tool to document infections. 10NYCRR 415.19(a)(2) 41666 50766

Based on record review and interview during the recertification and abbreviated surveys (NY00360214) conducted from 1/7/25 to 1/14/25, the facility did not ensure residents were free from significant medication errors for one of one resident (Resident #70) reviewed for Neglect. Specifically, staff administered medications to Resident #70 including Doxycycline 100 mg (antibiotic), Metformin 500 mg (diabetes pill), [NAME] 95-100 mg ( heart pill), Torsemide 20 mg (water pill), Metoprolol ER 75 mg (blood pressure pill), and Farxiga 10 mg (kidney pill), which were not physician prescribed for Resident #70 resulting in Resident #70 developing chest pain and being transferred to an acute care hospital for evaluation. The findings include: The facility policy Medication Incident Errors dated 12/28/2020 and revised on 11/12/2024, documented medication incidents to include wrong resident, wrong dose, wrong medication, wrong time, wrong day, wrong route. To determine if the incident is significant include, resident condition and medical history, drug category, frequency, and dosing. Resident #70 had diagnoses including Cerebral Vascular Accident, Type 2 Diabetes, and Peripheral Vascular Disease. The Quarterly Minimum Data Set ( assessment tool) dated 11/21/24 documented Resident #70 had severe cognitive impairment. The Investigation Report dated 11/20/24 documented occurrence date 11/10/24 at 8:40 AM, the Licensed Practical Nurse self-reported they gave the wrong medication to the resident. The resident received Doxycycline 100 mg, Metformin 500 mg, Entresto 95-100 mg, Torsemide 250mg, Metoprolol 75 mg, and Farxigia 10 mg. The Medical Provider was notified immediately and ordered monitoring of vital signs and blood sugar. The Investigation Report documented Licensed Practical Nurse #16 was suspended pending investigation, interviewing other alert residents on Licensed Practical Nurse #16's assignment for any other potential issues. The facility policy and procedure for medication error and medication administration was reviewed and revised. Statements were obtained from all parties. Education and in-service was conducted with nurses, completed on 12/2/24, and random medication pass observations were conducted. The nurse involved resigned on 11/14/24. The Progress Note dated 11/11/24 documented vital signs 173/67, 59, 16 96% blood glucose 148. Monitoring and Vital Signs 10 AM, 164/56, 60, 21 96% blood glucose 168, 11 AM 181/76, 60, 16 96% blood glucose 186, 12:15 PM 135/68, 62, 20 98%. At 12:45 PM resident complained of chest pain and was sent to the Emergency Room. The emergency room records documented the resident was brought in by Emergency Medical Services following the resident receiving another resident's medication in the Skilled Nursing Facility. The resident had an episode of feeling faint and complained of chest pain at the facility. During an interview on 1/10/25 at 1:01 PM the Administrator stated they were made aware right away of the error, the family was at the bedside at the time. The physician was notified at the time and felt they could manage the resident's monitoring in the facility. When the resident complained of chest pain they sent the resident to the Emergency Room. During an interview on 1/13/25 at 12:14 PM the Physician stated they were called when the medication error occurred. The resident later complained of chest pain and was sent to the emergency room and was subsequently admitted for an unrelated issue. Since the resident received medication not prescribed including a diuretic (torsemide-water pill), they felt it should be considered a significant medication error. During an interview on 1/13/25 at 12:25 PM the Director of Nursing stated they did the investigation right away; they were grateful the nurse self-reported. Because the resident received another resident's medication, they considered it a significant medication error. They started an investigation, the nurse was suspended, and the event was reported to the State Agency. During an interview on 1/13/25 at 1:09 PM Licensed Practical Nurse Supervisor #21 stated they were the supervisor when the medication nurse let them know they had given Resident #70 someone else's medication. They stated they had a Registered Nurse assess the resident and called the Medical Doctor. They continued to monitor the resident until Resident #70 complained of chest pain. They notified the Medical Doctor and sent the resident to the Emergency Room. The Director of Nursing was notified of the medication error. 10 NYCRR 415.12 (m)(2)

Based on record review and interview during the recertification survey from 1/7/25 to 1/14/25, the facility did not ensure that a Level 1 Screen was thoroughly completed prior to admission to the nursing home for 2 of 23 residents (Resident #1 and #30) reviewed for Pre-Admission Screening. Specifically, questions #23 through #27 were left blank on the Level 1 Screen for Resident #1,and questions #27 through #35 were left blank on the Level 1 Screen for Resident #30. The findings include: The facility Policy and Procedure titled PASRR Screening effective 3/2019 last reviewed 3/2024 documented, it is the policy of the facility that all residents must have a PASRR Screen upon admission to this facility and, thereafter, when there is a significant change that has a bearing on the resident's specialized service needs. The screen assesses residents for mental illness, dementia and mental retardation. Resident #1 was admitted to the facility with diagnoses of Cerebral Palsy Seizure Disorder and Dysphagia. The Quarterly Minimum Data Set ( assessment tool) dated 10/14/2024, documented Resident #1 was cognitively intact and had unclear speech. There was no documented evidence that questions #23 through #27 were answered on the 6/19/2019 Level I Pre Admission Screen for Resident #1. Resident #30 was admitted with diagnoses of Chronic Obstructive Pulmonary Disease, Insomnia, and Depression. The Prospective Payment System Minimum Data Set, dated dated dated [DATE] documented Resident #30 was cognitively intact, had clear speech and understands/was understood. There was no documented evidence that questions #27 through #35 were answered on the 12/21/2020 Level I Pre Admission Screen for Resident #30. On 1/14/25 at 9:57 AM, the Covering Social Worker stated the Level I Pre Admission Screen for Resident #1 should have been completed thoroughly and acknowledged questions #23 through #27 were blank and acknowledged that Resident #30 had blanks for questions 23 through 35 on the Level I Pre Admission Screen as well. The covering Social Worker stated if audits had been done, they would have identified the incomplete screens. The covering Social Worker stated the Social Worker/s that worked when Resident #1 and #30 were admitted , no longer work at facility. 10 NYCRR415.11(e)

Based on observation, record review and interview conducted during the recertification survey from 1/7/25 to 1/14/25, the facility did not ensure that the comprehensive person-centered care plan was followed for 1 of 4 residents (Resident #11) reviewed for Accidents. Specifically, for Resident #11, the use of Bilateral Fall Mats were not implemented as per Care Plan after a 10/8/24 fall. The Findings Include: The undated Policy and Procedure titled Accident/Fall Prevention documented a plan of care to prevent falls/injury would be developed. The plan of care would include but not limited to floor mattress, low bed. Each resident would be provided a fall prevention device as needed and the staff would ensure that they were in working order. Resident #11 was admitted with diagnoses including but not limited to Encephalopathy, Dementia, and Chronic Obstructive Pulmonary Disease. The Care Plan titled Risk for Falls effective 10/5/24 last updated 1/5/25 documented an actual fall on 10/8/24, Bilateral Fall Mats. The 5 Day Perspective Payment Minimum Data Set, dated dated dated [DATE] documented Resident #11 had moderately impaired cognition, required substantial to maximum assist with all activities of daily living and had a fall in the last 2-6 months. During observation on 1/7/25 at 9:20 AM, 01/10/25 at 03:45 PM, 01/13/25 at 08:53 AM, and 01/13/25 at 10:02 AM Resident # 11 was resting in bed and did not have Bilateral Fall Mats in place. The 10/9/24-Current Certified Nurse Aide Care Guide documented nonskid socks, Fall Mats at bedside, and bed low. During an interview on 01 /10/25 at 09:16 AM Certified Nurse Aide #13 stated if a resident needed Fall Mats, they would be placed on either side of the bed. During an interview with 01 /10/25 at 01:22 PM Resident #11's daughter, stated they had never seen Fall Mats next to the bed. During an interview on 1/13/25 at 10:32 AM Certified Nurse Aide #13 stated they usually received report in the morning from the night supervisor, and they were not aware the resident should have Fall Mats. They stated they knew the resident so well, so they did not always check the Certified Nurse Aide care guide prior to providing care/s. After reviewing the care guide, Certified Nurse Aide # 13 stated Fall Mats should have been placed when the resident was in bed. They stated since there were no Fall Mats in the room, they were unaware they should have been placed. During an interview on 1/13/25 at 10:35 AM Unit Manager #19 stated the staff should check the care guide prior to giving care. They stated the care guide and the care plan included interventions for the use of fall mats. They stated they did not know why the fall mats were not in the room. 10 NYCRR 415.11 (c)(1)

Based on observation, record review, and interview during the recertification survey conducted 1/07/2025 from 1/14/2025, the facility did not ensure residents who required dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) received services consistent with professional standards of practice for 1 of 1 resident (Resident #68) reviewed for Dialysis. Specifically, there was no documented evidence of consistent assessment and oversight before, during and after dialysis treatment for Resident #68 who received Hemodialysis treatments at a community-based Dialysis Center. Additionally, communication and collaboration between the facility and the Dialysis Center was not consistently documented Findings include: Policy & Procedure titled Hemodialysis dated 3/2019 last reviewed 3/2/2024 documented there will be ongoing communication between the interdisciplinary team and the dialysis center. To ensure exchange of information required to care for the resident is provided through the use of communication book. Book will accompany resident to each dialysis treatment. The Dialysis Book is sent with the resident when the resident travels to dialysis. Important information may include but is not limited to change in vital signs, appetite, labs, wounds, consult, medications, test and behaviors. Resident # 68 with diagnosis of Type 2 Diabetes, End Stage Renal Disease, and History of Cerebral Vascular Accident. The Care Plan titled Renal Failure/Hemodialysis dated 7/25/24 documented exchange information required to care for the resident through use of the Communication Book. Maintain ongoing communication with the Interdisciplinary Team and Dialysis. The Quarterly Minimum Data Set, dated dated dated [DATE] documented Resident #68 had moderately impaired cognition and received dialysis. The January 2025 Physician Order documented: Dialysis on Monday/Wednesday/Friday with a chair time of 10:30 AM and pickup time of 8:30 AM, Assess site for bruising/bleeding/symptoms of infection. Monitor left arm thrill/bruit. Monitor for fluid volume overload. The Facility/Dialysis Center Communication Book revealed the Dialysis Center did not compete their section on 12/9/24, 12/16/24, 12/20/24, 1/6/24, and 1/8/24. The 1/10/25 Pre Dialysis Assessment Communication was not completed by the facility. There was no documented evidence that Post Dialysis Assessments were completed from 12/8/24-1/10/25. During an interview on 1/14/25 at 9:09 AM the Unit Manager #19 stated they communicated with Dialysis via a Communication Book. Unit Manager #19 stated the Medication Nurse was responsible for obtaining resident vital signs and completing the top portion of the form and the Dialysis Center was responsible for completing the middle section. Unit Manager #19 stated the Medication Nurse should have checked the communication book upon the residents return from dialysis and filled out the bottom section. They stated the Medication Nurse should have reported to them any concerns dialysis had. They stated they did not review the Communication Book and were unaware of any issues with the Dialysis Center not completing their section. During an interview on 1/14/25 at 10:00 AM the Director of Nursing stated communication with the Dialysis Center was completed via a form that went back and forth between the facility and the Dialysis Center. The Director of Nursing stated the Medication Nurse should check the Communication Book prior to the resident leaving the facility and should write the resident's vital signs and any changes in the resident's medication. They stated Dialysis Center Staff should complete their section and send the communication book back to the facility. They stated the Medication Nurse should check the book upon its return to the facility. During an interview on 1/14/25 at 11:00 AM Licensed Practical Nurse #20 stated they did not always fill out the post dialysis section in the Dialysis Communication Book. They stated they had to call the Dialysis Center in the past to inform them they did not complete their section in the Communication Book. They stated the forms that did not include a resident name and date were most likely that way due to staff being busy and forgetting to complete the section. During an interview on 1/14/25 at 12:20 PM the Assistant Administrator at Dialysis stated the facility sends a Communication Book back and forth to the Dialysis Center. They stated it would be the responsibility of the Dialysis Nurse to review the Communication Book and complete the Dialysis Center section of the form. They stated they were not aware there was a problem with the information not being communicated as needed. 10NYCRR 415.12(k)

Based on observation, record review, and interview conducted during the recertification survey from [DATE] to [DATE], the facility did not ensure a medication error rate of no more than 5%, 2 of 35 opportunities (5.71%) for 2 of 4 residents (Resident #34 and Resident #31) reviewed for Medication Administration. Specifically, 1) Resident #34 was administered one Tums 200 mg/ Calcium 500 mg chewable tablet instead of two as per physician order, and 2) Resident #31 did not receive Vitamin C as per physician order. The findings include: The Policy titled Medication Administration dated [DATE] documented medications would be administered to residents in a timely and accurate manner by a licensed nurse or physician. Resident #34 was admitted to the facility with diagnoses including but not limited to Atrial Fibrillation, Dysphagia and Hypertension. The [DATE] Physician Order documented Tums 200 mg/Calcium 500 mg chewable tablet, give 2 by oral route for heartburn. During the [DATE] at 9:40 AM medication administration observation Licensed Practical Nurse #21 removed one tablet of Tums 200 mg/Calcium 500 mg chewable tablet from the bottle and administered it to Resident #35. During an interview on [DATE] at 12;49 PM Licensed Practical Nurse #21 stated they did not realize they needed to administer two Tums 200 mg/Calcium 500 mg chewable tablets, and should have read the order more closely. Resident # 31 was admitted with diagnoses including but not limited to Atrial Fibrillation, Congestive Heart Failure and Pleural Effusion. The [DATE] Physician Order documented Vitamin C 500 mg tab, two tablets every day. During the [DATE] at 10:00 AM medication administration observation Vitamin C was not administered. The Medication Administration Record documented Vitamin C was signed off by the Licensed Practical Nurse #20 on [DATE] as administered at 9:00 AM. During an interview on [DATE] at 11:15 AM Licensed Practical Nurse #20 stated they gave the Vitamin C during the medication pass. Licensed Practical Nurse #20 then stated the Vitamin C bottle was expired, they needed to get a new bottle. When asked why they signed for the Vitamin C before they administered the Vitamin C, they stated they accidentally signed off. During an interview on [DATE] at 11:56 AM the Director of Nursing stated medications needed to be given as prescribed by the physician. They stated the nurses needed to do better. 10NYCRR 415.12(m)(1)

Based on observation, interview, and record review conducted during a recertification survey from 01/07/25 to 01/14/25, the facility did not ensure residents had the right to a dignified experience for 2 of 2 residents (Residents # 65 and Resident # 341) reviewed for dignity. Specifically, 1) Licensed Practical Nurse # 31 was observed standing over Resident # 65 while feeding them their lunch meal and 2) Resident # 341's urine collection bag was observed uncovered and visible to other residents and visitors. The findings include: 1)The facility policy titled Assistance with Meals dated 3/2/24 documented residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity for example, not standing over residents while assisting them with meals. Resident # 65 was admitted to the facility with diagnoses including Cerebral Infarct, Diabetes, and Atrial Fibrillation. The 7/17/23 Comprehensive Care Plan titled Potential for Altered Nutritional Status documented provide necessary encouragement/assist during meals to optimize intake. The 12/4/24 Significant Change Minimum Data Set (an assessment tool) documented Resident # 65 had severely impaired cognition and required staff assistance with eating. During observation on 1/07/25 at 12:13 PM, Registered Nurse # 31 was standing while feeding Resident #65 their meal. During an interview on 1/07/25 at 3:13 PM, Licensed Practical Nurse # 31 stated there were a lot of residents in the room and a small area to feed the resident/s. They stated the resident's chair was large, and although not ideal they did the best they could to feed the resident/s. They stated they should sit down while feeding residents. During an interview on 1/14/25 at 10:14 AM the Director of Nursing stated they needed to emphasize in trainings that feeding residents while standing was not appropriate because residents would like to be fed by staff they could see. 50766 2) Resident # 341 was admitted [DATE] with diagnoses including Iron Deficiency Anemia, Cystitis, and Urinary Tract Infection. The Admission Minimum Data Set, dated dated dated [DATE] documented Resident #341 was cognitively intact and had an indwelling urinary catheter. The Physician Order dated 12/29/24 documented catheter care every shift and as needed. The Care Plan dated 12/29/24 titled Benign Prostatic Hyperplasia/Urinary Retention documented maintain resident dignity at all times. The Care Plan dated 1/5/25 titled Urinary Incontinence and Indwelling Catheter documented catheter care every shift and privacy bag in place whenever resident is out of bed. During an observation on 1/07/25 at 11:08 AM, 1/10/25 at 8:28 AM and 1/13/25 at 9:21 AM Resident #341 was observed lying in bed. The urinary catheter bag was observed without a privacy cover and was visible to other residents and visitors. During an interview on 1/10/25 at 2:04 PM Certified Nurse Assistant #17, stated they were aware the urinary catheter for Resident #341 was not covered with a privacy cover during the morning of 1/7/25 and 1/8/25. They stated the urinary catheter bag privacy cover was attached to the wheelchair. During an interview on 1/13/25 at 2:34 PM Registered Nurse Unit Manager #19, stated there were residents with catheters and Certified Nurse Assistants are educated to cover the catheter bags with privacy covers. They stated they round the unit at least 2-3 times a shift and had observed catheter bags without privacy bags and they re-educated the Certified Nurse Assistant. During an interview on 1/14/25 at 11:17 AM the Administrator stated the facility had a supply of urinary catheter bag privacy covers. They stated the expectation is that urinary catheter bags should be covered for privacy. During an interview on 1/14/25 at 12:20 PM the Director of Nursing, stated urinary catheter privacy covers should always be used for Residents with urinary catheters. They stated nurses and unit managers supervise staff on units and should monitor to ensure that Certified Nurse Assistants were using privacy covers. 10 NYCRR 415.5

Based on observation, record review and interview conducted during an abbreviated survey (NY00358461) on 10/28/24, the facility did not ensure each resident received treatment and care in accordance with professional standards of practice for 1(Resident #1) of 3 residents reviewed for accidents. Specifically, a left hip x-ray was not performed as per the 10/20/24 physician order after Resident #1 who was admitted status post (previous) left hip open reduction and internal fixation (hip fracture repair) sustained a fall 3 days after admission. The findings include: The Policy titled Medication and Treatment Orders with a revision date of 4/8/24 documented orders treatments will be consistent with principles of safe and effective orders. Verbal orders must be recorded immediately in the resident chart by the person receiving the order. Resident #1 had diagnosed including but not limited to dementia, open reduction internal fixation of the left hip (repair of a hip fracture) and metabolic encephalopathy (a brain disorder caused by a chemical imbalance in the blood that affects brain function). The 10/20/24 Incident and Accident Report completed by Registered Nurse Supervisor #2 documented the resident attempted to transfer and put the bed up and was found on the floor. Educated resident to call for assist. Physician updated and ordered a left hip x-ray. The Comprehensive Care Plan titled Risk for Falls updated 10/20/24 documented x-ray left hip. The 10/20/24 Physician Order documented x-ray left hip unilateral and pelvis/four views. There was no documented evidence in the electronic medical record to indicate the left hip x-ray was done as per physician order. The 10/22/24 Discharge Minimum Data set documented Resident #1 had severely impaired cognition and was totally dependent on two staff for transfer with a mechanical lift. During an interview on 10/28/24 at 2:00 PM Registered Nurse Supervisor #2 stated the resident fell at 11:00 PM on 10/20/24, the staff called them, and they assessed the resident. They stated the resident was not sent to the hospital. Registered Nurse Supervisor #2 stated the resident denied hitting their head, no ecchymosis noted, no external rotation or shortening of either lower extremity. The Physician ordered a left hip x-ray and they endorsed it to the oncoming shift They stated they did not know why it was not done During an interview on 10/28/24 at 2:15 PM Registered Nurse Unit Manager #1 stated they were unable to find the left hip x-ray result on the Diagnostic Imaging Company wbsite. They also stated that the physician order for the left hip x-ray was not sent to the x-ray company. During an interview on 10/28/24 at 2:30PM the Director of Nursing stated they checked the Diagnostic Imaging Company requisitions and found that the company was not notified of the physician order for a left hip x-ray. The Director of Nursing stated Registered Nurse Supervisor #2 who took the order for the left hip x-ray from the physician should have ordered the x-ray on the Diagnostic Imaging website after entering the order into the facilities electronic medical system. The Director of Nursing stated the Registered Nurse Unit Manager, should have followed up the next morning to ensure the physician ordered left hip x-ray was entered in the electronic medical record and that the Diagnostic Imaging Company was notified. 10 NYCRR 415.

Based on observation, record review and interviews conducted during an abbreviated survey (NY00358461) the facility did not ensure each resident received adequate supervision consistent with resident's needs goals and care plan to prevent accidents. This was evident for 1 (Resident #1) of 3 residents reviewed for accidents. Specifically, Resident #1 who was assessed as having suicidal ideation and a high risk for falls on admission had a physician's order for 15-minute safety checks. There was no documented evidence that 15-minute safety checks were consistently done as per the 10/18/24 physician's order. The certified nursing aide care instructions did not include the order for 15-minute safety check. Resident #1 was found on the floor in their room on 10/20/24. The findings include: The Policy titled Accidents/Incident Report with a 3/2/24 revision date documented the facility is responsible to investigate accidents to determine possible causative factors and implement interventions that may prevent a reoccurrence. Administer treatment to resident per physician orders. Resident #1 was admitted with diagnoses which included dementia, open reduction internal fixation of the left hip (repair of a hip fracture), and metabolic encephalopathy (a brain disorder caused by a chemical imbalance in the blood that affects brain function). The Fall Risk assessment dated [DATE] documented a score of 10 indicating the resident was at a high risk for falls. The 10/18/24 Comprehensive Care Plan titled Suicidal Ideations care plan note documented to start 15-minute safety checks. The 10/18/24 Physician's Order documented 15-minute safety checks x 72 hours. The 10/20/24 Incident and Accident Report documented the resident attempted to transfer out of bed and put the bed up. Resident was found on the floor at 11:00 PM. The resident denied hitting their head. The resident was last seen by staff at 9:30 PM. The resident was educated to call for assistance. The physician was updated, and an order was obtained for an x'ray of the left hip. The 5-day Minimum Data Set assessment dated [DATE] documented the resident had moderately impaired cognition and a Patient Health Questionnaire -9 score of 21 indicating severe depression. The 10/22/24 discharge Minimum Data Set documented the resident is totally dependent on two staff members for transfer with a mechanical lift. Review of the October 2024 Medication Administration Record revealed that 15-minute safety checks were not documented on 10/19/24 and 10/20/24 on the night shift (11PM-7AM). There was no documented evidence in the October 2024 Certified Nurse Aide Care instructions for15-minute safety checks. During an interview on 10/30/24 at 11:30 AM, Certified Nurse Aide #1 stated that they did not know that resident was on 15-minute safety checks. They stated that they would usually be told in report when coming on shift if a resident is on 15-minute safety checks. When asked how they know what other interventions are in place for residents, Certified Nurse Aide #1 stated that care instructions are also provided during report or instructions can also be found in the computer where they document cares. Certified Nurse Aide #1 stated they remember the resident trying to get out of the bed on the evening of 10/20/24 so they were frequently checking on the residnt. During an interview on 10/30/24 at 11:36 AM, Licensed Practical Nurse # 1 stated they worked the evening shift on 10/20/24 however they don't remember if the resident was on 15-minute safety checks. They stated they would normally get that information from report from the previous shift. They stated the resident was attempting to get out of bed, and they believe they performed frequent checks. Licensed Practical Nurse # 1 stated they signed the 15-minute safety checks in the Medication Administration Record. During an interview on 10/30/24 11:18AM, Registered Nurse #2 stated they worked the overnight shift(11pm-7am) on 10/19/24 and 10/20/24 and they received report about Resident #1 falling on 10/20/24, however they could not recollect specifically about the 15-minute safety checks. Registered Nurse #2 stated the 15-minute safety checks were probably an intervention for the fall, however they could not remember all the details. When made aware of the omissions on the Medication Administration Record for the 15-minute safety checks, Registered Nurse #2 stated that the omissions does not necessarily mean it was not done. When asked how Certified Nurse Aides are made aware of 15-minute safety checks, they stated the Certified Nurse Aides would get that information in report. When asked why the resident was last seen at 9:30 PM and was on 15-minute check they stated I was doing frequent checks on the resident. During an interview on 10/28/24 at 2:00 PM, Registered Nurse Supervisor #2 stated the resident fell at 11:00 PM and the staff called them, and they assessed the resident. The resident denied hitting their head, there was no ecchymosis noted, no lower extremity external rotation or shortening of both legs. They stated the resident was not sent to the hospital. Registered Nurse Supervisor #2 stated they did not know why the 15-minute safety checks were not documented as being done during the night shift on 10/19/24 and 10/20/24. Registered Nurse Supervisor #2 stated when staff was interviewed, they stated the last time the resident was seen was at 9:30 PM. During interview on 10/28/24 at 2:33 PM, the Director of Nursing stated the nurse should have signed the 15-minute safety checks in the Medication Administration Record on 10/19/24 and 10/20/24 during the night shift and the unit manager should have checked that the Medication Administration Record documented 15-minute safety checks were done. 10 NYCRR 415.12 (h) (2)

Based on record review and interviews conducted during the abbreviated survey (NY00358461), the facility did not ensure that a resident received appropriate behavioral care intervention to address suicidal ideation for 1 (Resident #1) of 3 residents reviewed for behavioral health care. Specifically, Resident #1, was admitted with a diagnosis of depression and verbalized having suicidal ideation with no plan of self-harm on 10/18/2024. A physician's order dated 10/18/2024 for 15-minute safety checks documented no indication for the order. 2)The 15-minute safety check was not listed as an intervention on the suicidal ideation history care plan or included on the certified nurse aide instruction. The 15-minute safety checks were not consistently documented by staff per the physician's order. Resident #1 was found on the floor on 10/20/2024 when they attempted to transfer self without assistance. Findings include: The Facility Policy titled Suicidal Precaution revised 10/2024 documented resident suicide threats should be taken seriously and addressed appropriately. All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the residents' behavior immediately, staff shall document details of the situation objectively in the resident's medical record. The facility policy titled comprehensive care plan dated July 2024 documented the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment and identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident are the end point of the interdisciplinary process. The resident was admitted with diagnoses which included hip fracture, Alzheimer's dementia, and depression. The 5-day Minimum Data Set assessment dated [DATE] documented the resident had moderately impaired cognition and a Patient Health Questionnaire -9 score of 21 indicating severe depression. It documented the resident reported symptom frequency which included; little interest or pleasure in doing things, felt down depressed or hopeless, had trouble falling asleep or staying asleep or sleeping too much, felt tired or had a little energy, had a poor appetite or overate, felt bad about themselves, and thought they would be better off dead or of hurting themselves in someway 12 to 14 days over the last two weeks. A Facility progress note dated 10/18/2024 documented resident told social services they Sometimes have thoughts of wanting to die and finding a way out. Denied plan for self-harm. Physician informed and an order received to commence a 15-minute safety checks. Wander guard applied to left wrist. Son updated and agreeable to all plan of care. Family confirmed resident had left assisted living twice and often states why they am I still here when others have passed. No attempts of self-harm. The Physician's Order dated 10/18/2024 at 3:56 PM documented 15-minute safety checks daily x 72 hours, every day 7 AM am-3 PM, 3 PM pm-11 PM, 11 PM pm-7 AM for 3 days. The Physician's Order dated 10/21/2024 at 1:38 PM documented 15-minute checks every day. The Suicidal Ideation History Care Plan dated 10/18/2024 documented the resident presented with history of suicidal ideation. The interventions did not include 15-minute safety checks. The Accident/Incident report dated 10/20/2024 at 11:00 PM documented the resident was found on the floor and was last seen by staff at 9:30 PM. Resident stated they were trying to get out of bed, and they raised the bed. The 10/21/2024 Social Services note documented they met with both the resident and the resident representatives regarding suicidal ideation statements made to staff, the representatives stated that this was resident's baseline and that the resident thinks a lot about death. Resident #1 had been diagnosed with depression by their primary care provider but had not taken any medications. Social work continues to monitor as needed. The 10/25/2024, 1:19 pm social services note documented Resident #1 stated that they often thought about dying given their medical status and age and if there was a way out, they would take it. Resident Representatives stated this is the resident's baseline. Resident has no history of substance abuse, alcohol use, or a mental health diagnosis. Resident has dementia diagnosis. Resident has no history of significant trauma. Resident referred to psychology. The October 2024 Medication Administration Record revealed 15-minute checks were only documented once every shift and not every 15 minutes as indicated on the physician's order, and there was no documentation on the medication administration record on 10/19/2024 and 10/20/2024 on during the night shift (11PM-7AM). On 10/28/2024 at 2:33 PM during an interview with the Director of Nursing, a review of the resident's Medication Administration Record was completed. There was no documentation for the 15-minute check on 10/19/2024 and 10/20/2024 on the night shift. The Director of Nursing stated the night nurse responsible for medication administration was also responsible to sign the 15-minute safety checks. The unit manager should have checked that the Medication Administration Record signage was not completed. In addition, the nurse documented on the incident & accident report dated 10/20/2024, that the resident was last seen at 9:30 pm, however the 15-min safety check on the medication administration record dated 10/20/2024 for the 3-11 shift was signed as completed for the shift. On 10/28/2024 at 6:34 PM and on 10/29/2024 at 11:34 AM during interviews and review of the resident's medical record with the Director of Nursing, they stated the Physician's Order for 15-minute safety checks did not include an indication as to the reason the order was placed, and there was no documentation in the resident's medical record as to the reason why the order was discontinued on 10/27/2024. Additionally, 15-minute safety checks were not documented in the Suicidal Ideation History Care Plan Interventions. The Director of Nursing stated the Social Worker or Unit Manager should have documented the 15-minute safety checks under interventions. The Director of Nursing further stated that the Physician's order for 15-minute safety checks should have had an indication or a reason for the order. The reason for discontinuing the order on 10/27/2024 should have been documented. On 10/29/2024 at 2:05 PM during an interview with Registered Nurse Supervisor #1, they stated after they spoke with the resident's primary physician and received an order to discontinue the 15-minute safety checks, they forgot to write a note documenting the reason for discontinuing the 15-minute safety checks. They stated they realize they should have documented in the resident's medical record. 10 NYCRR 415.12

Based on record review and interviews conducted during an abbreviated survey (NY00305611), the facility did not ensure that the resident and/or their representative was informed in advance of treatment risks and benefits, options, and alternatives when a medication was changed for 1 of 3 (Resident #1) residents reviewed. Specifically, Resident #1's representative was not informed of the risks, benefits, and treatment alternatives prior to increasing the Clonazepam 0.5mg from once daily to twice daily. Resident #1 was on palliative care, had 2 recent falls from bed, was confused and agitated. The findings are: The facility policy and procedure titled Notification to Resident/Resident Representative dated 1/15/2020 and received 10/19/23 documented our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: There is a significant change in the resident's physical, mental, or psychosocial status; Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatments. Resident #1 had diagnoses that included chronic atrial fibrillation, chronic obstructive pulmonary disease, congestive heart failure, and Alzheimer's disease. The Quarterly Minimum Data Set (MDS, an assessment tool) dated 9/30/2022 documented Resident #1 had moderately impaired cognitive function, had no mood or behavior problems, and was always incontinent of bowel and bladder. The Antipsychotic Medication Seroquel for anxiety disorder Care Plan dated 3/4/2021 documented a gradual dose reduction (GDR) 37.5mg on 5/12/2021. Interventions included administer medications as ordered, encourage participation in activities, followed by psych, offer support and expression of feelings as needed. The Psychiatric Consultation Report dated 10/18/2022 documented that Resident #1 gets easily agitated and occasionally lashes out at family and staff. Not usually redirectable but will calm once left alone. Restless, angry, resistive to cares. On Klonopin, Seroquel, and Zoloft. Episodic agitation during Activities of Daily Living (ADL) cares. Poor insight and judgement. Consider discontinuing Zoloft and adding Depakote 125mg q12hours x 3 days then increase to 125mg every morning and 250 at bedtime to manage mood lability, impulsivity, agitation, continue Klonopin and Seroquel. The Nursing Note dated 10/31/2022 documented that at 12:20 AM resident in bed with rapid decline. Continues to refuse food and now having much difficulty with fluids and medications. Agitated and combative with arousal and cares. Continue palliative cares, did not appear to be in pain or respiratory distress, VSS. The Medical Note dated 10/31/2022 documented resident fell and was found on floor by their roommate. On palliative care. On Clonazepam for agitation with minimal response. Continues to have poor oral intake. Plan to increase Clonazepam to 0.5mg 2xday, continue Depakote. Continue supportive care with palliative care. The Nursing Note dated 11/1/2023 documented writer received order from physician to increase Klonopin to 0.5mg 2xday. Attempted to call Health Care Proxy (HCP), to provide update on resident's status and interventions put in place. No answer, message left for HCP to call back-Note electronically entered on 1/26/2023 at 11:41AM. There was no documented evidence that the facility informed the resident representative. During an interview conducted with Registered Nurse Unit Manager (RNUM #1) on 9/11/2023 at 10:59AM, RNUM #1 stated they did not believe they spoke with the daughter regarding the change in the Klonopin from daily to twice daily, if they did they would have charted it. Resident #1 was very anxious, and the medication increase was to help with that. RNUM #1 stated they did not recall any concerns regarding the drug regimen review (DRR), all DRR were presented to RNUM #1 and they did not have concerns. During an interview conducted with the Director of Nursing (DON) on 9/11/2023 at 3:33PM, the DON stated that the floor nurse, RN Supervisor (RNS) or RNUM were supposed to notify the HCP of medication or treatment changes. The DON reviewed Resident #1's nurses note and saw documentation that RNUM attempted to contact the HCP about the medication change but was unsuccessful. The DON stated the RNUM #1 was supposed to contact Resident #1's HCP, they should have notified the HCP prior to starting the increased medication dose to have their approval. 415.3