Every finding on record at Morris Park Rehabilitation and Nursing Center

Based on observation, record review, and interviews during survey, the facility failed to ensure residents received adequate supervision to prevent elopement. This was evident in one out of six residents (Resident #1) sampled for elopement. Specifically, Resident #1, who was severely cognitively impaired, with a history of wandering behavior and identified as an elopement risk exited the facility grounds unsupervised on 05/08/2026 at 12:30:40 AM per video surveillance footage and has not been found. Resident #1 exited through the New Wing Hall lobby (1st floor); the alarm on the exit door did not activate due to alarm system malfunction. Resident #1 was last seen on 05/08/2026 at 12:15 AM by Certified Nursing Assistant #1 in a hallway on the first-floor unit. Resident #1 was not identified as missing until 8:20 AM. This resulted in Immediate Jeopardy Past Noncompliance.The findings include:The facility's policy and procedure titled Care of Residents with Wandering Behavior dated 12/05/2025 states that policy is to ensure that each resident receives adequate supervision and assistance devices to prevent accidents. The purpose is to minimize the potential for accidents resulting from a resident's wandering behavior.The facility's policy and procedure titled Wandering and Elopement dated 12/07/2025 states that it is the policy to ensure that residents will be maintained in a safe and secure manner and protected from any harm. The facility will make every effort to identify residents with potential for elopement. In the event that a resident is discovered to be missing, a search and rescue operation will commence immediately. Resident #1 was admitted to the facility with diagnoses including dementia (decline cognitive function), bipolar disorder (mental health condition that causes extreme mood swings) and chronic heart failure (heart muscle do not pump enough blood). The Minimum Data Set (a resident assessment tool) dated 04/10/2026 identified Resident #1 to have severely impaired cognition. An Elopement/Wandering Risk assessment dated [DATE] documented Resident #1 was identified as at risk for elopement. The interventions included daily monitoring and every 30-minute monitoring.A review of Physician Orders from 03/31/2026 through 05/08/2026 revealed an order for 30-minute monitoring for elopement risk and behavior. There was no documented evidence of a monitoring log sheet for 05/07/2026 during the 11:00 PM to 7:00 AM shift.A Potential for Elopement Care Plan dated 01/15/2026 was last updated on 04/13/2026 with interventions for Resident #1 to be monitored every 30-minutes, to continue to monitor behavior and moods and provide redirection during active wandering behavior. The facility's video surveillance was reviewed with the Administrator on 05/12/2026. The video surveillance dated 05/08/2026 revealed Resident #1 talking to Security Guard #1 in the lobby at 12:28:20 AM. Security Guard #1 was seen pointing to the right side of the lobby then Resident #1 proceeded toward the elevator located to the right of the lobby. At 12:29:35 AM, Resident #1 walked past the elevator. From 12:30:06 to 12:30:30 AM, Resident #1 was walking in the New Wing Hall lobby on the first floor and at 12:30:40 AM, Resident #1 exited through an exit door (equipped with an alarm). The facility's Accident Report dated 05/08/2026 documented that Registered Nursing Supervisor #1 was performing rounds at 8:15 AM (on 05/08/2026) when they observed that Resident #1 was not in their room. A unit searched was conducted and Code E (elopement) activated. Resident #1 was confirmed to be missing from the facility at 8:45 AM. At 8:50 AM, staff members searched the surrounding neighborhood and nearby areas. Local police were notified and responded at 9:00 AM. The facility reviewed their video surveillance footage and confirmed Resident #1 exited the facility on 05/08/2026 at 12:30 AM. The facility concluded Resident #1 eloped from the facility at 12:30 AM. A Nursing Progress Note, signed by Registered Nurse Supervisor #1 on 05/09/2026 at 9:01 AM, documented that Resident #1 was on 30-mimute monitoring for elopement. During morning rounds at approximately 8:15 AM, Resident #1 observed not to be in their room, bathroom or dining room. A search and head count initiated, but Resident #1 was nowhere to be found. Code E activated, staff searched, and police was notified. During an interview on 05/12/2026 at 2:21 PM, Certified Nursing Assistant #1 stated they worked on 05/07/2026 during the 11:00 PM to 7:00 AM shift. Certified Nursing Assistant #1 stated that Resident #1 was regularly assigned to them. Certified Nursing Assistant #1 stated during their initial rounds at approximately 11:00 PM, Resident #1 was sitting in their bed. Certified Nursing Assistant #1 stated Resident #1 was ambulatory and at approximately 12:15 AM they came out of their room, and they (Certified Nursing Assistant #1) gave Resident #1 a sandwich and juice which they sat in a chair in the hallway and ate then walked towards their room. Certified Nursing Assistant #1 stated that between 4:00 AM and 5:00 AM, they entered Resident #1's room and provided care to their roommate but did not visually check Resident #1 but because the curtain was pulled as they thought Resident #1 was in their bed. Certified Nursing Assistant #1 stated that they were aware Resident #1 was supposed to be checked every 30 minutes, but they only checked on them at 11:00PM at the start of the shift. During an interview on 05/12/2026 at 1:15 PM, Licensed Practical Nurse #1 stated they worked on 05/07/2026 on the 11:30 PM to 7:30 AM shift, but did not do an initial rounding because they assumed the certified nursing assistants performed their rounds. Licensed Practical Nurse #1 stated they should have done their unit rounds and checked on Resident #1. Licensed Practical Nurse #1 stated they did not go to Resident #1's room because they did not want to disrupt the resident. Licensed Practical Nurse #1 stated they knew Resident #1 had a noncompliant behavior of refusing medications and does not want to be disturbed when they are sleeping. Licensed Practical Nurse #1 stated that they did not give Resident #1 their medications at 7:00 AM, but they signed in the Medication Administration Record that medications were given. Licensed Practical Nurses #1 stated they should not have signed that the medications were given.During an interview on 05/12/2026 at 12:05 PM, Registered Nurse Supervisor #1 stated Resident #1 was not wearing a wander guard because they had refused to wear one and that they were placed on 30-minute monitoring due to wandering and at risk for elopement behavior. Registered Nurse Supervisor #1 stated while conducting unit rounds on 05/08/2026 at 8:15 AM, they observed that Resident #1 was not physically in their room. Registered Nurse Supervisor #1 stated that the staff searched the unit, but Resident #1 was not found. Registered Nurse Supervisor #1 stated they immediately called security and activated Code E. Registered Nurse Supervisor #1 stated Resident #1 was confirmed missing at 8:45 AM. Registered Nurse Supervisor #1 stated the Director of Nursing and Administrator were notified (unsure of time). Registered Nurse Supervisor #1 stated local police were notified and arrived at the facility on 05/08/2026 (unsure of time) and were provided with Resident #1's information and picture. Registered Nurse Supervisor #1 stated Licensed Practical Nurse #1 reported they did not perform rounding, but they saw Resident #1 and administered medications to them at 6:00 AM. Registered Nurse Supervisor #1 stated they questioned Licensed Practical Nurse #1 as to how they administered medications to Resident #1 at 6:00 AM when the resident exited the building at 12:30 AM. Registered Nurse Supervisor #1 stated Licensed Practical Nurse #1 reported being sorry. During an interview on 05/12/2026 at 2:45 PM, the Director of Nursing stated they confirmed that Resident #1 was missing at 8:45 AM (on 05/08/2026) and they notified the Administrator and police at 8:50 AM. The Director of Nursing stated the Medical Director and family were notified at 9:00 AM. The Director of Nursing stated that the Maintenance Director and other maintenance staff reviewed the video surveillance footage at 8:45 AM and at 9:15 AM, and confirmed Resident #1 exited the facility through the New Wing Hall lobby exit alarm door (garage door going toward the parking lot) on 05/08/2026 at 12:30 AM. The Director of Nursing stated during the investigation, they found that the alarm on the exit door did not activate and was found to have malfunctioned. The Director of Nursing stated they contacted the alarm company, and they arrived at the facility on 05/08/2026 at 10:30 AM and repaired the alarm system. The Director of Nursing stated they immediately conducted a Quality Assurance Performance Improvement meeting at 10:30 AM to identify the root cause and established a plan for correction. The Director of Nursing stated that Certified Nursing Assistant #1 was suspended for not completing 30-minute monitoring documentation for Resident #1. The Director of Nursing stated that Licensed Practical Nurse #1 was interviewed and stated they did not perform their nursing rounds to check Resident #1. The Director of Nursing stated further investigation revealed Licensed Practical Nurse #1 documented that they administered medications at 7:00 AM and that they saw Resident #1 at 6:00 AM. The Director of Nursing stated the findings revealed failures in required Resident #1's supervision and monitoring, inaccurate nursing documentation and malfunctioned exit alarm door that failed to alert staff when Resident #1 exited the facility unnoticed. During an interview on 05/12/2026 at 5:51 PM, the Administrator stated they were notified by the Director of Nursing on 05/08/2026 (unsure of time) that Resident #1 was missing. The Administrator stated they reviewed the video surveillance footage as well and Resident #1 exited the facility on 05/08/2026 at 12:30 AM without supervision. The Administrator stated they and other staff called multiple hospitals, shelters, drove to Time Square and [NAME] Station where Resident #1 used to live and stay around. The Administrator stated they are in communication with the police and that as of today 05/12/2026, Resident #1 could not be located. The Administrator stated they were made aware Resident #1's monitoring log from 11:00 PM to 7:00 AM revealed Resident #1 was not monitored, and the Licensed Practical Nurse #1 did not perform their unit rounds during their shift. During an interview on 05/12/2026 at 5:42 PM, the Medical Director stated they were notified by the team (unsure who notified them) that Resident #1 eloped from the facility on 05/08/2026 (unsure of time). The Medical Director stated that Resident #1 missing one dosage of their blood pressure and bipolar medications would not cause the resident harm, but missing the medications chronically could cause harm.Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement prior to surveyors' s onsite visit on 05/12/2026. A Plan of Correction is not required for this citation. 10 New York Codes, Rules, and Regulations 415.12(h)(2) The facility took immediate corrective actions and was found to be in substantial compliance on 05/11/2026.Immediate Corrective Actions:On 05/08/2026 at 8:45 AM, phone calls were made throughout New York City to determine whether Resident #1 had been presented to any emergency room or hospital. On 05/08/2026 at 8:45 AM, exit door alarms and wander guard systems were reviewed. A door watcher stayed at the door. At 11:00 AM, the exit alarm door leading to the parking lot (Magnetic lock door) was repaired. A documentation form from Tikva Fire Security dated 05/08/2026 reviewed.On 05/08/2026 at 9:00 AM, local law enforcement was called and responded on 05/08/2026 at 9:15 AM. Resident #1's information and picture were given to the local police.On 05/08/2026 at 9:00 AM, internal staff interviews were initiated regarding Resident #1 supervision and last known Resident #1 location. On 05/08/2026 - Policy and Procedure titled Wandering and Elopement dated 05/07/2025 reviewed with no revisions. On 05/08/2026 - Policy and Procedure titled Fire Door Inspection dated 02/26/2026 reviewed with revision that all fire doors shall be inspected every shift. On 05/08/2026 at 10:00 AM, staff assignments, supervision practices and overnight accountability process were reviewed. Resident #1 records, care plans, elopement risk assessments and documentation were reviewed. On 05/08/2026 at 10:30 AM, a Quality Assurance meeting was held to review the incident, identify immediate corrective actions and implement facility wide interventions. On 05/08/2026 Licensed Practical Nurse #1 was taken off the schedule. On 05/08/2026 a Discipline Notice documented Certified Nursing Assistant #1 was taken off the schedule pending investigation outcome.On 05/08/2026 an audit tool for exit door/alarms and ongoing. They were being checked every shift. On 05/08/2026, initiated an audit tool to assess residents who may be at risk for elopement. Audit is ongoing. On 05/08/2026 to 05/11/2026 - a lesson plan and facility wide reeducation on elopement prevention, Code E (Elopement), Wandering/Missing Resident, Abuse/Neglect, Accurate Documentation by Certified Nursing Assistant and Nurse, signing in the Medication Administration Record after the medication given and Medical Doctor order for 30-minute monitoring in kiosk (for Certified Nursing Assistant Instructions) and Treatment Administration Record. Attendance reviewed.On 05/10/2026 - an email dated 05/10/2026 revealed Licensed Practical Nurse #1 was reported to their agency. On 05/11/2026 - a Professional Discipline Complaint form dated 05/11/2026, revealed Licensed Practical Nurse #1 was reported to Office of Professional Discipline.On 05/11/2026 a follow-up Quality Assurance meeting was held. Attendance sheet reviewed. The facility wide reeducation: Total of staff = 202 = 100 percentDepartmentCompleted % CompleteAdministrator1100% Recreation8100%Certified Nursing Assistants71100%Dietary/Kitchen21100%Dietician2100%Maintenance3100%Home Health Aide/Escort3100%Housekeeping18100%Licensed Practical Nurses20100% Admissions1100%Administration Staff3100%Reception/Security3100%Rehabilitation21100%Registered Nurses25100%Social Services2100%

Based on interviews and record reviews, the facility failed to ensure that the direct care staffing information based on payroll data was submitted based on the schedule specified by the Centers for Medicare and Medicaid Services. Specifically, the facility failed to submit the direct care staffing data for fiscal year Quarter 1/2026 (10/01/2025 - 12/31/2025) timely.The findings include:The Centers for Medicare & Medicaid Services Electronic Staffing Data Submission Payroll-Based Journal, Long Term Care Facility Policy Manual version 2.7 dated 06/2025 documented Section 6106 of the Affordable Care Act requires facilities to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other auditable data. Direct care staffing and census data will be collected quarterly and is required to be timely and accurate. Staffing and census data will be collected for each fiscal quarter. The deadline for submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Time) after the last day in each fiscal quarter in order to be considered timely.The facility policy titled Staffing and Payroll-Based Journal with a last revised date of 04/2024 stated the facility was responsible for ensuring payroll-based journal submissions in compliance with Centers for Medicare & Medicaid Services regulations. The policy also documented staffing information is reported through the Payroll-Based Journal system for each fiscal quarter no later than forty-fine days after the end of the reporting quarter.The Centers for Medicare and Medicaid Services Payroll Based Journal Staffing Data Report documented that there was no data submitted by the facility for fiscal year Quarter 1 2026 (October 01 - December 31). During an interview on 05/14/2026 at 2:26PM, the Director of Payroll stated that they were responsible for submitting payroll-based journal information for the facility to Centers for Medicare and Medicaid Services after double checking all data from Human Resource department. Director of Payroll stated that after double checking data from the Human Resource department, they download a file from SBV (software report). Director of Payroll stated they used Simple Payroll-Based Journal software to analyze the report, to check any issues, then they click submit button to Centers for Medicare and Medicaid Services from Simple Payroll-Based Journal website. The Director of Payroll stated when they tried to submit the report, the software had given an error message. The Director of Payroll stated they called customer service at Simple Payroll-Based Journal, and they assured them that everything will be going through and everything is fine. The Director of Payroll stated unfortunately, nothing was submitted and nothing was issued. The Director of Payroll stated that they made it aware a couple of days ago when they tried to upload Quarter Two of 2026 data, Quarter One was not submitted. The Director of Payroll stated they reached Simple Payroll-Based Journal and Centers for Medicare and Medicaid Services with different numbers to see if the facility can rectify this error, but the answers were no. During an interview on 05/14/2026 at 2:43 PM, the Administrator stated Director of Payroll is responsible for submitting the staffing data as of January 2026. The Administrator stated that they were not aware that Payroll Base Journal for the first quarter was not submitted and became aware yesterday, 05/13/2026. 10 New York Codes, Rules and Regulations 400.2

Based on record review and interviews during survey the facility failed to ensure that services provided or arranged by the facility met professional standards of quality. This was evident in one (1) out of six (6) residents (Resident #1) sampled. Specifically, on 05/08/2026, Licensed Practical Nurse #1 documented in the Medication Administration Record that they administrated medications to Resident #1 and took the resident's vital signs at 7:00 AM. Additionally, Licensed Practical Nurse #1 documented in the Treatment Record that they monitored Resident #1 at 7:30 AM. According to the facility video surveillance footage, Resident #1, who was severely cognitively impaired, with a history of wandering behavior and identified as an elopement risk exited the facility grounds unsupervised on 05/08/2026 at 12:30:40 AM and has not been found. Resident #1 was last seen on 05/08/2026 at 12:15 AM by Certified Nursing Assistant #1 in a hallway on the first-floor unit. Resident #1 was not identified as missing until 8:20 AM Cross Reference: F842 - Resident- Identifiable InformationThe findings include: The facility policy and procedure titled Medication Management dated 10/18/2024 documented the purpose to establish a safe standard for ordering, dispensing, administration and documentation of medications. The nurses obtain specific vital signs and follow specific instructions before administering medication. The nurse administers the right drug to the right resident at the right time in the right dose via right route and the right documentation. Immediately after administering mediations, the nurse documents on the Medication Administration Record. The Nurse will also document in their nurses notes the reason for medication not given.The facility policy and procedure titled Treatment Administration dated 10/18/2024 states it is the policy that all treatments are administered safely, accurately, and in accordance with physician/practitioner orders, accepted standards of nursing practice, applicable federal and state regulations, and facility protocols. Treatments shall be provided in a manner that promotes resident safety, comfort, dignity, infection prevention and continuity of care. Resident #1 was admitted to the facility with diagnoses including dementia (decline cognitive function), bipolar disorder (mental health condition that causes extreme mood swings) and chronic heart failure (heart muscle do not pump enough blood). The Minimum Data Set (a resident assessment tool) dated 04/10/2026 identified Resident #1 to have severely impaired cognition. Resident #1 was assessed to be on diuretic (water pill) medication and anticonvulsant (treat and prevent seizure) medication.The Physician's Orders dated 03/31/2026 through 05/08/2026 revealed orders for Furosemide (diuretic) 20 milligram one (1) tablet once daily, Metoprolol Succinate Extended Release 25 milligram daily for essential hypertension, Valproic Acid 250 milligram per five (5) milliliter two (2) times a day for bipolar disorder, Thiamine Hydrochloride (vitamin B1) 100 milligram daily for Thiamine deficiency, and monitor blood pressure and pulse daily before administering metoprolol. The Medication Administration Record revealed that on 05/08/2026 Licensed Practical Nurse #1 administered the above medications and took Resident #1's blood pressure at 7:00 AM. Resident #1's blood pressure recorded as 130/80. The Physician's Order initiated 03/31/2026 documented monitor every shift and as needed for ID and Neon arm band (an elopement band) placement. The Treatment Administration Record dated 05/07/2026 from 11:30 PM to 7:30 AM, revealed Licensed Practical Nurse #1 documented that they monitored Resident #1 on 05/08/2026 at 7:30 AM. The facility's video surveillance was reviewed with the Administrator on 05/12/2026. The video surveillance footage dated 05/08/2026 showed Resident #1 talking to the Security Guard #1 in the lobby at 12:28:20 AM. Security Guard #1 was seen pointing to the right side of the lobby then Resident #1 proceeded towards the elevator located to the right of the lobby. At 12:29:35 AM, Resident #1 walked past the elevator. From 12:30:06 to 12:30:30 AM, Resident #1 was walking in the New Wing Hall lobby on the first floor and at 12:30:40 AM, Resident #1 exited through an exit door (equipped with an alarm). The facility's Accident Report dated 05/08/2026 documented that Registered Nursing Supervisor #1 was performing rounds at 8:15 AM (on 05/08/2026) when they observed that Resident #1 was not in their room. A unit searched was conducted and Code E (elopement) activated. Resident #1 was confirmed to be missing from the facility at 8:45 AM. At 8:50 AM, staff members searched the surrounding neighborhood and nearby areas. Local police were notified and responded at 9:00 AM. The facility reviewed their video surveillance footage and confirmed Resident #1 exited the facility on 05/08/2026 at 12:30 AM. The facility concluded Resident #1 eloped from the facility at 12:30 AM. A Nursing Progress Note, signed by Registered Nurse Supervisor #1 on 05/09/2026 at 9:01 AM, documented that Resident #1 was on 30-mimute monitoring for elopement. During morning rounds at approximately 8:15 AM, Resident #1 observed not to be in their room, bathroom or dining room. A search and head count initiated, but Resident #1 was nowhere to be found. Code E activated, staff searched, and police was notified. During an interview on 05/12/2026 at 1:15 PM, Licensed Practical Nurse #1 stated they worked on 05/07/2026 on the 11:30 PM to 7:30 AM shift, but did not do an initial rounding because they assumed the certified nursing assistants performed their rounds. Licensed Practical Nurse #1 stated they should have done their unit rounds and checked on Resident #1. Licensed Practical Nurse #1 stated they did not go to Resident #1's room because they don't want to disrupt the resident. Licensed Practical Nurse #1 stated they knew Resident #1 had a noncompliant behavior of refusing medications and does not want to be disturbed when they are sleeping. Licensed Practical Nurse #1 stated that they did not give Resident #1 their medications at 7:00 AM but they signed in the Medication Administration Record that medications were given. Licensed Practical Nurses #1 stated they should not have signed that the medications were given.During an interview on 05/12/2026 at 12:05 PM, Registered Nurse Supervisor #1 stated Resident #1 was not wearing a wander guard because they had refused to wear one and that they were placed on 30-minute monitoring due to wandering and at risk for elopement behavior. Registered Nurse Supervisor #1 stated while conducting unit rounds on 05/08/2026 at 8:15 AM, they observed that Resident #1 was not physically in their room. Registered Nurse Supervisor #1 stated that the staff searched the unit, but Resident #1 was not found. Registered Nurse Supervisor #1 stated they immediately called security and activated Code E. Registered Nurse Supervisor #1 stated Resident #1 was confirmed missing at 8:45 AM. Registered Nurse Supervisor #1 stated the Director of Nursing and Administrator were notified (unsure of time). Registered Nurse Supervisor #1 stated local police were notified and arrived at the facility on 05/08/2026 (unsure of time) and were provided with Resident #1's information and picture. Registered Nurse Supervisor #1 stated Licensed Practical Nurse #1 reported they did not perform rounding, but they saw Resident #1 and administered medications to them at 6:00 AM. Registered Nurse Supervisor #1 stated they questioned Licensed Practical Nurse #1 as to how they administered medications to Resident #1 at 6:00 AM when the resident exited the building at 12:30 AM. Registered Nurse Supervisor #1 stated Licensed Practical Nurse #1 reported being sorry. During an interview on 05/12/2026 at 2:45 PM, the Director of Nursing stated they confirmed that Resident #1 was missing at 8:45 AM (on 05/08/2026) and they notified the Administrator and police at 8:50 AM. The Director of Nursing stated the Medical Director and family were notified at 9:00 AM. The Director of Nursing stated the Maintenance Director and other maintenance staff reviewed the video surveillance footage at 8:45 AM and at 9:15 AM, and confirmed Resident #1 exited the facility through the New Wing Hall lobby exit alarm door (garage door going towards the parking lot) on 05/08/2026 at 12:30 AM. The Director of Nursing stated during the investigation, they found that the alarm on the exit door did not activate and was found to have malfunctioned. The Director of Nursing stated they contacted the alarm company, and they arrived at the facility on 05/08/2026 at 10:30 AM and repaired the alarm system. The Director of Nursing stated they immediately conducted a Quality Assurance Performance Improvement meeting at 10:30 AM to identify the root cause and established a plan for correction. The Director of Nursing stated that Certified Nursing Assistant #1 was suspended for not completing a 30-minute monitoring documentation for Resident #1. The Director of Nursing stated that Licensed Practical Nurse #1 was interviewed and stated they did not perform their nursing rounds to check Resident #1. The Director of Nursing stated further investigation revealed Licensed Practical Nurse #1 documented that they administered medications at 7:00 AM and that they saw Resident #1 at 6:00 AM. The Director of Nursing stated the findings revealed failures in required Resident #1's supervision and monitoring, inaccurate nursing documentation and malfunctioned exit alarm door that failed to alert staff when Resident #1 exited the facility unnoticed. During an interview on 05/12/2026 at 5:51 PM, the Administrator stated they reviewed the video surveillance footage as well and Resident #1 exited the facility on 05/08/2026 at 12:30 AM without supervision. The Administrator stated they and other staff called multiple hospitals, shelters, drove to Time Square and [NAME] Station where Resident #1 used to live and stay around. The Administrator stated they are in communication with the police and that as of today 05/12/2026, Resident #1 could not be located. The Administrator stated they were made aware Resident #1's monitoring log from 11:00 PM to 7:00 AM revealed Resident #1 was not monitored, and the Licensed Practical Nurse #1 did not perform their unit rounds during their shift. Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement prior to surveyors' s onsite visit on 05/12/2026. A Plan of Correction is not required for this citation. 10 New York Codes, Rules, and Regulations 415.11(c)(3)(i) The facility took immediate corrective actions and was found to be in substantial compliance on 05/11/2026 prior to surveyors onsite 05/12/2026.Immediate Corrective Actions: On 05/08/2026 - Policy and Procedure titled Medication Management dated 10/18/2024 reviewed with no revisions. On 05/08/2026 - Policy and Procedure titled Treatment Administration Record dated 10/18/2024 reviewed with no revisions. On 05/08/2026 the facility discussed in their Quality Assurance meeting the issues related to Licensed Practical Nurse #1 signing for medications administration and monitoring of Resident #1. On 05/08/2026 at 9:00 AM, internal staff interviews were initiated regarding Resident #1 supervision and last known Resident #1 location. On 05/08/2026 at 10:00 AM, staff assignments, supervision practices and overnight accountability process were reviewed. Resident #1 records, care plans, elopement risk assessments and documentation were reviewed. On 05/08/2026 at 10:30 AM, a Quality Assurance meeting was held to review the incident, identify immediate corrective actions and implement facility wide interventions. On 05/08/2026 Licensed Practical Nurse #1 was taken off schedule. On 05/08/2026 a Discipline Notice documented Certified Nursing Assistant #1 was taken off the schedule pending investigation outcome.On 05/08/2026 to 05/11/2026 - In-service provided to nursing staff. Lesson plan titled Abuse/Neglect, Accurate Documentation, Signing Medication Administration Record after Medication is given, Treatment Record, and Doctor's Orders for 30-minute monitoring in Kiosk (Certified Nursing Assistants Instructions). Attendance sheet with signatures reviewed.On 05/10/2026 - an email dated 05/10/2026 revealed Licensed Practical Nurse #1 was reported to their agency. On 05/11/2026 - a Professional Discipline Complaint form dated 05/11/2026, revealed Licensed Practical Nurse #1 was reported to Office of Professional Discipline.On 05/11/2026 a follow-up Quality Assurance meeting was held. Attendance sheet reviewed. Reeducation: Total of nursing staff = 116 = 100 percent DepartmentCompleted % CompleteCertified Nursing Assistants71100%Licensed Practical Nurses20100% Registered Nurses25100%

Based on observation, record review, and interviews, the facility failed to ensure the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the Administrator and the Director of Nursing failed to identify hazards and risks to ensure residents were adequately supervised to avoid elopement. Immediate Jeopardy was determined on 05/13/2026 when direct care and nursing staff failed to ensure Resident #1 received adequate supervision with safety monitoring to prevent an elopement. Resident #1 was able to exit the facility unsupervised on 05/08/2026 at 12:30:40 AM due to alarm system malfunction. Resident #1 who was severely cognitively impaired, with a history of wandering behavior and identified at risk for elopement has not been found. These circumstances subjected to likelihood of serious adverse outcome that was immediate jeopardy for Resident #1. Cross Reference: F689 Past Noncompliance - Free of Accident Hazards/Supervision/DevicesThe findings include:The facility's policy and procedure titled Administrator documented it is responsible for day-to-day functions of the facility with ensuring compliance maintains compliance with federal, state, and local regulations, promotes resident-centered care, and supports quality improvement initiatives. The facility Administrator shall oversee the daily operations of the facility and ensure that all departments function in accordance with applicable laws, regulations, facility policies, and standards of care.Immediate Jeopardy was determined 05/13/2026. The facility failed to ensure resident received adequate supervision to prevent an elopement to account for and monitor Resident #1, a resident with severely cognitively impaired, with a history of wandering behavior and identified as an elopement risk exited the facility grounds on 05/08/2026 at 12:30:40 AM unsupervised and has not been found. The facility failed to ensure implementation of required 30-minute monitoring for elopement risk behavior, accuracy in documentation in medication administration and treatment record. Resident #1 exited through the New Wing Hall lobby (1st floor); the alarm on the exit door did not activate due to alarm system malfunction. Resident #1 was last seen on 05/08/2026 at 12:15 AM by Certified Nursing Assistant #1 in a hallway on the first-floor unit. Resident #1 was not identified as missing until 8:20 AM. There was no documented monitoring log sheet for 05/07/2026 during the 11:00 PM to 7:00 AM shift.The facility's video surveillance was reviewed with the Administrator on 05/12/2026. The video surveillance dated 05/08/2026 revealed Resident #1 talking to Security Guard #1 in the lobby at 12:28:20 AM. Security Guard #1 was seen pointing to the right side of the lobby then Resident #1 proceeded toward the elevator located to the right of the lobby. At 12:29:35 AM, Resident #1 walked past the elevator. From 12:30:06 to 12:30:30 AM, Resident #1 was walking in the New Wing Hall lobby on the first floor and at 12:30:40 AM, Resident #1 exited through an exit door (equipped with an alarm). During an interview on 05/12/2026 at 2:45 PM, the Director of Nursing stated they confirmed that Resident #1 was missing at 8:45 AM (on 05/08/2026) and they notified the Administrator and police at 8:50 AM. The Director of Nursing stated the Medical Director and family were notified at 9:00 AM. The Director of Nursing stated that the Maintenance Director and other maintenance staff reviewed the video surveillance footage at 8:45 AM and at 9:15 AM, and confirmed Resident #1 exited the facility through the New Wing Hall lobby exit alarm door (garage door going toward the parking lot) on 05/08/2026 at 12:30 AM. The Director of Nursing stated during the investigation, they found that the alarm on the exit door did not activate and was found to have malfunctioned. The Director of Nursing stated they contacted the alarm company, and they arrived at the facility on 05/08/2026 at 10:30 AM and repaired the alarm system. The Director of Nursing stated they immediately conducted a Quality Assurance Performance Improvement meeting at 10:30 AM to identify the root cause and established a plan for correction. The Director of Nursing stated that Certified Nursing Assistant #1 was suspended for not completing 30-minute monitoring documentation for Resident #1. The Director of Nursing stated that Licensed Practical Nurse #1 was interviewed and stated they did not perform their nursing rounds to check Resident #1. The Director of Nursing stated further investigation revealed Licensed Practical Nurse #1 documented that they administered medications at 7:00 AM and that they saw Resident #1 at 6:00 AM. The Director of Nursing stated the findings revealed failures in required Resident #1's supervision and monitoring, inaccurate nursing documentation and malfunctioned exit alarm door that failed to alert staff when Resident #1 exited the facility unnoticed. During an interview on 05/12/2026 at 5:51 PM, the Administrator stated they were notified by the Director of Nursing on 05/08/2026 (unsure of time) that Resident #1 was missing. The Administrator stated they reviewed the video surveillance footage as well and Resident #1 exited the facility on 05/08/2026 at 12:30 AM without supervision. The Administrator stated they and other staff called multiple hospitals, shelters, drove to Time Square and [NAME] Station where Resident #1 used to live and stay around. The Administrator stated they are in communication with the police and that as of today 05/12/2026, Resident #1 could not be located. The Administrator stated they were made aware Resident #1's monitoring log from 11:00 PM to 7:00 AM revealed Resident #1 was not monitored, and the Licensed Practical Nurse #1 did not perform their unit rounds during their shift. The Administrator also stated they were made aware of exit door alarm malfunctioned on 05/08/2026 and company arrived on 05/08/2026 at 10:30 AM and was repaired at 11AM. The Administrator stated the maintenance department responsible for checking them monthly. The Administrator stated they revised the policy of fire alarm door to be checked every shift daily on 05/08/2026.10 New York Codes, Rules, and Regulations 415.26 Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement prior to surveyors' s onsite visit on 05/12/2026. A Plan of Correction is not required for this citation.The facility took immediate corrective actions and was found to be in substantial compliance on 05/11/2026.Immediate Corrective Actions:On 05/08/2026 at 8:45 AM, phone calls were made throughout New York City to determine whether Resident #1 had been presented to any emergency room or hospital. On 05/08/2026 at 8:45 AM, exit door alarms and wander guard systems were reviewed. A door watcher stayed at the door. At 11:00 AM the exit alarm door leading to the parking lot (Magnetic lock door) was repaired. A documentation form from Tikva Fire Security dated 05/08/2026 reviewed.On 05/08/2026 at 9:00 AM, local law enforcement was called and responded on 05/08/2026 at 9:15 AM. Resident #1's information and picture were given to the local police.On 05/08/2026 at 9:00 AM, internal staff interviews were initiated regarding Resident #1 supervision and last known Resident #1 location. On 05/08/2026 - Policy and Procedure titled Wandering and Elopement dated 05/07/2025 reviewed with no revisions. On 05/08/2026 - Policy and Procedure titled Fire Door Inspection dated 02/26/2026 reviewed with revision that all fire doors shall be inspected every shift. On 05/08/2026 at 10:00 AM, staff assignments, supervision practices and overnight accountability process were reviewed. Resident #1 records, care plans, elopement risk assessments and documentation were reviewed. On 05/08/2026 at 10:30 AM, a Quality Assurance meeting was held to review the incident, identify immediate corrective actions and implement facility wide interventions. On 05/08/2026 Licensed Practical Nurse #1 was taken off from the schedule. On 05/08/2026 a Discipline Notice documented Certified Nursing Assistant #1 was taken off from schedule pending investigation outcome.On 05/08/2026 initiated an Audit tool for exit door/alarms and ongoing. They were being checked every shift. On 05/08/2026 initiated an Audit Tool initiated to assess Residents who may be at risk for elopement. Audit is ongoing. On 05/08/2026 to 05/11/2026 - a lesson plan and facility wide reeducation on elopement prevention, Code E (Elopement), Wandering/Missing Resident, Abuse/Neglect, Accurate Documentation by Certified Nursing Assistant and Nurse, signing in the Medication Administration Record after the medication given and Medical Doctor order for 30-minute monitoring in kiosk (for Certified Nursing Assistant Instructions) and Treatment Administration Record. Attendance reviewed.On 05/10/2026 - an email dated 05/10/2026 revealed Licensed Practical Nurse #1 was reported to their agency. On 05/11/2026 - A Professional Discipline Complaint form dated 05/11/2026, revealed Licensed Practical Nurse #1 was reported to Office of Professional Discipline.On 05/11/2026 a follow-up Quality Assurance meeting was held. Attendance sheet reviewed. The facility wide reeducation: 1 Administrator -1 = 100 percent8 Recreation - 8= 100 percent71 Certified Nursing Assistants- 71= 100 percent21 Dietary/Kitchen= 21= 100 percent2 Dietician- 2= 100 percent 3 Maintenance- 3= 100 percent3 Home Health Aide /Escort- 3 = 100 percent18 Housekeeping - 18= 100 percent20 Licensed Practical Nurse- 20= 100 percent1 Admission-1 = 100 percent3 Administration Staff = 3= 100 percent3 Reception/Security - 3= 100 percent21 Rehabilitation staff -21= 100 percent25 Registered Nurses- 25= 100 percent2 Social Services- 2= 100 percent Total of staff = 202 = 100 percent

Based on record review, and interviews during survey conducted the facility failed to ensure medical records were complete and accurately documented in accordance with accepted professional standards and practices. Licensed Practical Nurse #1 failed to accurately document in Resident #1's medical record. This was evident for one (1) of six (6) residents (Resident #1) sampled. Specifically, on 05/08/2026, Licensed Practical Nurse #1 documented in the Medication Administration Record that they administrated medications to Resident #1 and took the resident's vital signs at 7:00 AM. Additionally, Licensed Practical Nurse #1 also documented that they monitored Resident #1 at 11:30 AM and 7:30 AM in the Treatment Record that they monitored Resident #1 at 7:30 AM. According to the facility video surveillance footage, Resident #1, who was severely cognitively impaired, with a history of wandering behavior and identified as an elopement risk exited the facility grounds unsupervised on 05/08/2026 at 12:30:40 AM and has not been found. Resident #1 was last seen on 05/08/2026 at 12:15 AM by Certified Nursing Assistant #1 in a hallway on the first-floor unit. Resident #1 was not identified as missing until 8:20 AM. Cross Reference: F658 - Services Provided Meet Professional StandardsThe findings include: The facility policy and procedure titled Medication Management dated 10/18/2024 states the purpose is to establish a safe standard for ordering, dispensing, administration and documentation of medications. The nurses obtain specific vital signs, follow specific instructions before administering medication. The nurse administers the right drug to the right resident at the right time in the right dose via right route and the right documentation. Immediately after administering mediations, the nurse documents on the Medication Administration Record. The Nurse will also document in their nurses notes the reason for medication not given.The facility policy and procedure titled Treatment Administration dated 10/18/2024 states it is the policy that all treatments are administered safely, accurately, and in accordance with physician/practitioner orders, accepted standards of nursing practice, applicable federal and state regulations, and facility protocols. Treatments shall be provided in a manner that promotes resident safety, comfort, dignity, infection prevention and continuity of care. Resident #1 was admitted to the facility with diagnoses including dementia (decline cognitive function), bipolar disorder (mental health condition that causes extreme mood swings) and chronic heart failure (heart muscle do not pump enough blood). The Minimum Data Set (a resident assessment tool) dated 04/10/2026 documented that Resident #1 had severely impaired cognition. Resident #1 was assessed to be on diuretic (Furosemide - water pill) medication and anticonvulsant (treat and prevent seizure) medication.The Physician's Orders dated 03/31/2026 through 05/08/2026 revealed orders for Furosemide (diuretic) 20 milligram one (1) tablet once daily, Metoprolol Succinate Extended Release 25 milligram daily for essential hypertension, Valproic Acid 250 milligram per five (5) milliliter two (2) times a day for bipolar disorder, Thiamine Hydrochloride (vitamin B1) 100 milligram daily for Thiamine deficiency, and monitor blood pressure and pulse daily before administering metoprolol. The Medication Administration Record dated 05/08/2026 revealed Licensed Practical Nurse #1 signed that they administered the above medications and took Resident #1's blood pressure at 7:00 AM. Resident #1's blood pressure recorded in the medication administration record as 130/80.A Physician's Order dated 03/31/2026 documented monitor every shift and as needed for ID and Neon arm band (elopement ID band) placement every day at 11:30 PM-7:30 AM, 3:30 PM-11:30 PM and as needed.The Treatment Administration Record dated 05/07/2026 from 11:30 PM-7:30 AM, revealed Licensed Practical Nurse #1 documented that Resident #1 was monitored at 7:30 AM on 05/08/2026. The facility's video surveillance was reviewed with the Administrator on 05/12/2026. The video surveillance dated 05/08/2026 at 12:28:20- 58 AM showed Resident #1 talking to the Security Guard #1 in the lobby. Security Guard #1 was seen pointing to the right side of the lobby then Resident #1 proceeded towards the elevator located to the right of the lobby. At 12:29:35 AM, Resident #1 walked past the elevator. From 12:30:06-30 AM, Resident #1 was walking in the New Wing Hall lobby on the first floor and at 12:30:40 AM, Resident #1 exited through an exit door (equipped with an alarm). The facility's Accident Report dated 05/08/2026 documented that Registered Nursing Supervisor #1 was performing rounds at 8:15 AM (on 05/08/2026) when they observed that Resident #1 was not in their room. A unit searched was conducted and Code E (Elopement) activated. Resident #1 was confirmed to be missing from the facility at 8:45 AM. At 8:50 AM, staff members searched the surrounding neighborhood and nearby areas. Local police were notified and responded at 9:00 AM. The facility reviewed their video surveillance footage and confirmed Resident #1 exited the facility on 05/08/2026 at 12:30 AM. The facility concluded Resident #1 eloped from the facility at 12:30 AM. During an interview on 05/12/2026 at 1:15 PM, Licensed Practical Nurses #1 stated they worked on 05/07/2026 on the 11:30 PM to 7:30 AM shift, but did not do an initial rounding because they assumed the Certified Nursing Assistants performed their rounds. Licensed Practical Nurses #1 stated they should have done their unit rounds and checked on Resident #1. Licensed Practical Nurse #1 stated they did not go to Resident #1's room because the resident does not want to be disrupted. Licensed Practical Nurse #1 stated they knew Resident #1 had a noncompliant behavior of refusing medications and does not want to be disturbed when they are sleeping. Licensed Practical Nurse #1 stated that they did not give Resident #1 their medications at 7:00 AM but they signed in the Medication Administration Record the medications were given. Licensed Practical Nurses #1 stated they should not have signed that the medications were given.During an interview on 05/12/2026 at 12:05 PM, Registered Nurse Supervisor #1 stated Resident #1 was not wearing a wander guard because they had refused to wear one and that they were placed on 30-minute monitoring due to wandering and at risk for elopement behavior. Registered Nurse Supervisor #1 stated while conducting unit rounds on 05/08/2026 at 8:15 AM, they observed that Resident #1 was not physically in their room. Registered Nurse Supervisor #1 stated that the staff searched the unit, but Resident #1 was not found. Registered Nurse Supervisor #1 stated they immediately called security and activated code E (code elopement). Registered Nurse Supervisor #1 stated Resident #1 was confirmed missing at 8:45 AM and the Director of Nursing and Administrator were notified (unsure of time). Registered Nurse Supervisor #1 stated local police were notified and arrived at the facility on 05/08/2026 (unsure of time) and was provided with Resident #1 information and picture. Registered Nurse Supervisor #1 stated Licensed Practical Nurse #1 reported they did not perform rounding, but they saw Resident #1 and administered medications to them at 6:00 AM. Registered Nurse Supervisor #1 stated they questioned Licensed Practical Nurse #1 as to how they administered medications to Resident #1 at 6:00 AM when the resident exited the building at 12:30 AM. Registered Nurse Supervisor #1 stated Licensed Practical Nurse #1 reported being sorry. During an interview on 05/12/2026 at 2:45 PM, the Director of Nursing stated they confirmed that Resident #1 was missing at 8:45 AM (on 05/08/2026) and they notified the Administrator and police at 8:50 AM. The Director of Nursing stated the Medical Director and family were notified at 9:00 AM. The Director of Nursing stated the Maintenance Director and other maintenance staff reviewed the video surveillance footage at 8:45 AM and at 9:15 AM, and confirmed Resident #1 exited the facility through the New Wing Hall lobby exit alarm door (garage door going towards the parking lot) on 05/08/2026 at 12:30 AM. The Director of Nursing stated during the investigation they found that the alarm on the exit door did not activate and was found to have malfunctioned. The Director of Nursing stated they contacted the alarm company, and they arrived at the facility on 05/08/2026 at 10:30 AM and repaired the alarm system. The Director of Nursing stated they immediately conducted a Quality Assurance Performance Improvement meeting at 10:30 AM to identify the root cause and established a plan for correction. The Director of Nursing stated that Certified Nursing Assistant #1 was suspended for not acquiring a 30-minute monitoring documentation for Resident #1. The Director of Nursing stated that Licensed Practical Nurse #1 was interviewed and stated they did not perform their nursing rounds to check Resident #1. The Director of Nursing stated further investigation revealed Licensed Practical Nurse #1 documented that they administered medications at 7:00 AM and that they saw Resident #1 at 6:00 AM. The Director of Nursing stated the findings revealed failures in required Resident #1's supervision and monitoring, inaccurate nursing documentation and malfunctioned exit alarm door that failed to alert staff when Resident #1 exited the facility unnoticed. Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement prior to surveyors' s onsite visit on 05/12/2026. A Plan of Correction is not required for this citation.10 New York Codes, Rules, and Regulations 415.22(a) (1-4)The facility implemented corrective actions and was found to be in substantial compliance on 05/11/2026, prior to start of the abbreviated survey on 05/12/2026.Immediate Corrective Actions:On 05/08/2026 - Policy and Procedure titled Medication Management dated 10/18/2024 reviewed with no revisions. On 05/08/2026 - Policy and Procedure titled Treatment Administration Record dated 10/18/2024 reviewed with no revisions. On 05/08/2026 the facility discussed in their Quality Assurance meeting the issues related to Licensed Practical Nurse #1 signing for medications administration and monitoring of Resident #1. On 05/08/2026 at 9:00 AM, internal staff interviews were initiated regarding Resident #1 supervision and last known Resident #1 location. On 05/08/2026 at 10:00 AM, staff assignments, supervision practices and overnight accountability process were reviewed. Resident #1 records, care plans, elopement risk assessments and documentation were reviewed. On 05/08/2026 at 10:30 AM, a Quality Assurance meeting was held to review the incident, identify immediate corrective actions and implement facility wide interventions. On 05/08/2026 Licensed Practical Nurse #1 was taken off schedule. On 05/08/2026 a Discipline Notice documented Certified Nursing Assistant #1 was taken off the schedule pending investigation outcome.On 05/08/2026 to 05/11/2026 - In-service provided to nursing staff. Lesson plan titled Abuse/Neglect, Accurate Documentation, Signing Medication Administration Record after Medication is given, Treatment Record, and Doctor's Orders for 30-minute monitoring in Kiosk (Certified Nursing Assistants Instructions). Attendance sheet with signatures reviewed.On 05/10/2026 - an email dated 05/10/2026 revealed Licensed Practical Nurse #1 was reported to their agency. On 05/11/2026 - a Professional Discipline Complaint form dated 05/11/2026, revealed Licensed Practical Nurse #1 was reported to Office of Professional Discipline.On 05/11/2026 a follow-up Quality Assurance meeting was held. Attendance sheet reviewed. Reeducation: Total of nursing staff = 116 = 100 percentDepartmentCompleted % CompleteCertified Nursing Assistants71100%Licensed Practical Nurses20100% Registered Nurses25100%

Based on observation, record review, and interviews during the Recertification and Abbreviated Survey (NY00365258) conducted from 01/26/2025 to 01/31/2025, the facility did not ensure that sufficient nursing staff was consistently provided to meet residents' needs in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being, as determined by resident assessments and individual plans of care. Specifically, 1.) Several residents reported the facility was short staffed of Certified Nursing Assistants which resulted in lack of timely staff response to residents who needed assistance, 2.) Multiple nursing staff members reported lack of sufficient staffing, 3.) Facility's staffing levels were repeatedly below facility assessed levels, and 4.) Excessively low weekend staffing was triggered in the Payroll Based Journal Staffing Data Report. The findings include but are not limited to: 1.) The facility's policy titled Staffing Coverage with a last reviewed date of 12/01/2024 documented each unit will be staffed according to the facility's 24-hour nurse staffing guidelines. The use of agency/contractual staff and mandatory overtime may be used as an alternative to meet staffing needs. The total daily number of Certified Nursing Assistants needed during the weekdays on the day shift are 22 and 21 are needed on the evening shift for 5 resident units. The Daily Staffing Schedule for 12/16/2024 documented that Resident #89's unit (3rd Floor) had a census of 37, and 3 Certified Nursing Assistants on schedule for both day and evening shifts. Resident #89 had diagnoses of Morbid Obesity, Contracture of Right Hand, and Peripheral Vascular Disease. The Quarterly Minimum Data Set, dated dated dated [DATE] documented that Resident #89 had intact cognition and was dependent on staff for toileting and hygiene. On 01/29/2025 at 10:18 AM, Resident #89 was interviewed and stated that on the day they made the complaint, no one responded to their call bell on both the day and evening shifts. The night shift aide responded to their call bell at the start of their shift. Resident #89 stated this happens often and the situation improved when they notified Registered Nurse #2 of the incident. On 01/30/2025 at 2:23 PM, the Staffing Coordinator was interviewed and stated they were short of Certified Nursing Assistants on 12/16/2024 on the 3rd floor for both the day and evening shifts. The Staffing Coordinator stated 3rd floor should have 4 Certified Nursing Assistants scheduled for both the day and evening shifts. On 01/30/2025 at 3:36 PM, Certified Nursing Assistant #2, who worked the evening shift on 12/16/2024, was interviewed and stated there should be 4 Certified Nursing Assistants scheduled for the day and evening shifts. They stated some days there are only 3 Certified Nursing Assistants working which makes it challenging to complete all their work and showers especially with residents requiring 2 staff for personal care. Certified Nursing Assistant #2 stated Resident #89 requires 2 aides, and the Resident recently made a complaint about not receiving incontinent care from the previous shift because they were working short. On 1/30/2025 at 3:44 PM, Certified Nursing Assistant #4, who worked the day shift on 12/16/2024, was interviewed and stated that residents receive delayed incontinent care when there are only 3 Certified Nursing Assistants on the unit. Certified Nursing Assistant #4 stated they try their best to get all the showers done when they are short but sometimes showers have to be rescheduled for the following day. 43350 2.) The Payroll Based Journal Staffing Data Report for 4th Quarter of 2024 (07/01/2024 - 09/30/2024) documented that excessively low weekend staffing was triggered. The Facility assessment dated [DATE] documented the facility's average daily census ranged from 175 - 180. The facility assessment documented the following facility resources to provide competent resident support and daily and during emergencies are as follows: Day shift - 5 Unit Managers, 5 Licensed Practical Nurses, and 22 Certified Nursing Assistants Evening shift - 2 Registered Nurse Supervisors, 5 Licensed Practical Nurses, and 20 Certified Nursing Assistants Night shift - 1 Registered Nurse Supervisor, 5 Licensed Practical Nurses, and 11 Certified Nursing Assistants The facility's policy titled Staffing Coverage (Nursing Department Par Levels) dated 11/01/2020 with reviewed dates of 10/01/2023 and 12/01/2024 documented the total daily number of nursing staff needed for each shift on weekends are as follows: Day and Evening shifts - 2 Registered Nurses, 5 Licensed Practical Nurses, and 20 Certified Nursing Assistants Night shift - 1 Registered Nurse, 5 Licensed Practical Nurses, and 10 Certified Nursing Assistants On 01/27/2025 at 9:27 AM, Resident #2 was interviewed and stated some days the facility is really short of staff, and they had to wait a long time for help. On 01/27/2025 at 9:36 AM, Resident #144 was interviewed and stated the residents are not getting the care they need due to not having enough staff. On 01/27/2025 at 9:51 AM, Resident #37 was interviewed and stated there was no point ringing the call bell because staff ignore it especially on weekends. The actual staffing schedule documented the following: On 07/06/2024, Saturday, documented 17 Certified Nursing Assistants worked on the evening shift (par level of 20) On 07/07/2024, Sunday, documented 17 Certified Nursing Assistants worked on the evening shift (par level of 20) On 07/13/2024, Saturday, documented 18 Certified Nursing Assistants worked on the day shift (par level of 20), and 16 Certified Nursing Assistants worked on the evening shift (par level of 20) On 07/14/2024, Sunday, documented 17 Certified Nursing Assistants worked on the day shift (par level of 20), and 16 Certified Nursing Assistants worked on the evening shift (par level of 20) On 07/20/2024, Saturday, documented 17 Certified Nursing Assistants worked on the evening shift (par level of 20) On 07/21/2024, Sunday, documented 8 Certified Nursing Assistants worked on the night shift (par level of 10) On 07/27/2024, Saturday, documented 14 Certified Nursing Assistants worked on the day shift (par level of 20), and 15 Certified Nursing Assistants worked on the evening shift (par level of 20) On 08/11/2024, Sunday, documented 15 Certified Nursing Assistants worked on the day shift (par level of 20), and 16 Certified Nursing Assistants worked on the evening shift (par level of 20) On 08/17/2024, Saturday, documented 16 Certified Nursing Assistants worked on the day shift (par level of 20) On 08/31/2024, Saturday, documented 15 Certified Nursing Assistants worked on the evening shift (par level of 20) On 09/08/2024, Sunday, documented 17 Certified Nursing Assistants worked on the day shift (par level of 20), and 14 Certified Nursing Assistants worked on the evening shift (par level of 20) On 09/21/2024, Saturday, documented 15 Certified Nursing Assistants worked on the day shift (par level of 20), and 14 Certified Nursing Assistants worked on the evening shift (par level of 20) On 01/30/2025 at 9:53 AM, Certified Nursing Assistant #8 was interviewed and stated there are usually 2-3 aides in the unit on the weekends. They stated that male aides are only allowed to care for male residents, so if there are 2 male aides in the unit, most of the residents which are female are left for the single female aide to take care of. Certified Nursing Assistant #8 stated it is very hard and stressful, and they cannot do a good job when they are short of staff. On 01/30/2025 at 11:17 AM, Certified Nursing Assistant #7 was interviewed and stated when they work on weekends, the unit is usually working short. The aide stated when they start to fall behind, they sometimes take it into their own hands to phone colleagues who have the day off and beg them to come in to assist. On 01/30/2025 at 3:36 PM, Certified Nursing Assistant #2 was interviewed and stated there were as few as 3 aides on the evening shift in their unit despite some of the residents requiring 2 assists for care. The aide stated it can be challenging. On 01/30/2025 at 3:43 PM, Certified Nursing Assistant #4 was interviewed and stated there will be times when there are a lot of last-minute call outs and the nursing supervisor who is sometimes working alone would be assisting with care as well. Certified Nursing Assistant #4 stated that incontinent care may be delayed until the end of the shift and showers may have to be postponed until the following day when more staff are scheduled. On 01/31/2025 at 9:18 AM, Registered Nurse #2 was interviewed and stated it is very stressful on the weekend because they had to assist the aides with resident care because of short staffing and at the same time had to do their supervisory tasks. On 01/30/2024 at 2:24 PM, the Staffing Coordinator was interviewed and stated that because of short staffing, they schedule home health aides to assist in the units, and while home health aides are not permitted to provide direct patient care, they can make beds, serve meals, and answer call bells to lighten the load for other staff. The Coordinator stated the facility offers cash bonuses to any nursing personnel who are working so hard that they miss their lunch or their break. On 01/30/2025 at 11:52 AM, the Director of Nursing was interviewed and stated that the facility is hiring continuously and currently uses several agencies as well, but the agency workers can pick and choose which facilities they go to by comparing hourly rates and accepting only the highest. This leaves the permanent staff doing constant overtime or taking just one day off a week instead of two. The Director of Nursing stated they tried to retain agency staff by giving them a permanent floor assignment so they can feel some sense of ownership of the workload on that unit as well as providing continuity of care for the residents, but that the nursing staff typically like the flexibility of agency work and seldom stay at the facility for very long. On 01/31/2025 at 9:33 AM, the Administrator was interviewed and stated that the facility uses several strategies to attract nursing staff. The facility advertises available nursing positions on its website and posts a large sign outside the building that says they are hiring. Four new agency contracts have been added, sign-in bonuses are offered, and 5 televisions were awarded to staff members who had no call-outs. The Administrator stated 90 certified nursing assistants were hired in the past nine months, but currently only thirty of them remain on staff. As for the rest, many were let go because they were consistently no-call-no-show, particularly on the weekends. 10 NYCRR 415.13(a)(1)(i-iii)

Based on observation, record review, and interviews during the Recertification Survey conducted from 01/26/2025 to 01/31/2025, the facility did not ensure drugs and biologicals were stored in accordance with professional standards of practice. This was evident in 2 of 5 units observed. Specifically, 1.) Unit 4 emergency drug box contained expired medications, and 2.) Unit 5 medication cart was observed with insulin pens that were not properly and sanitarily stored and were not marked with the dates they were opened. The findings are: The facility's policy titled Storage of Medications with a revised date of 10/20/2023 documented that the facility shall store all drugs and biologicals in a safe, secure and orderly manner. All medications will be stored, distributed, and administered, in compliance with all applicable laws and regulations. The nursing staff shall be responsible for maintaining medication storage. The facility shall not use discontinued, outdated or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy for destruction. The facility's policy titled Emergency Medications with a revised date of 09/15/2024 documented that the facility shall maintain a supply of medications typically used in emergencies. The emergency medication box will include medications and biologicals that are essential in providing emergency treatment. Each nurses' station will store an emergency medication kit in the medication room. The contents of each emergency medication kit will be clearly listed. The Consultant Pharmacist shall inspect the emergency medication kits monthly and record the findings on the record maintained with each kit. The facility's policy titled Role of the Consultant Pharmacist with a reviewed date of 10/01/2024 documented that the consultant pharmacist shall provide consultation on all aspects of pharmacy services in the facility, including regular review of the emergency medication supply, review of medication storage areas at least monthly, and medication carts at least quarterly, for proper storage and labeling of medications, cleanliness, and expired medications; and providing the facility with written or electronic reports and recommendations related to all aspects of medication and pharmaceutical services review. 1.) On 01/30/2025 at 10:28 AM, an observation of the 4th floor unit medication storage room was conducted with the Assistant Director of Nursing. Emergency Box #1794 was labeled with a medication list with a delivery date of 05/2024. The emergency box contained the following expired medications: 1.) Diphenhydramine vial 50 milligram/milliliter with expiration date of 11/2024, 2.) Two 1 milliliter ampules of Epinephrine 1:1000 with expiration date of 12/2024. The 24-hour Report form documented that the emergency box in 4th floor were checked by each nurses on all shifts on 01/30/2025. On 01/30/2025 at 10:40 AM, The Assistant Director of Nursing was interviewed and stated that the nurses in each shift are responsible to check the emergency drug box for expired medications. They stated they do not document when the nurses complete the checks. 01/30/2025 at 2:28 PM, Licensed Practical Nurse #1 was interviewed and stated that the charge nurse is responsible for checking if there are expired medications in the box. On 01/30/2025 at 11:08 AM, the Director of Nursing was interviewed and stated that emergency drug boxes are provided by a contracted pharmacy and nurses in each shift and the Assistant Director of Nursing are responsible for ensuring that the medications are not expired. They stated that the Pharmacy Consultant audits the emergency drug box 2-3 times in a year. 44842 2). On 01/29/2025 at 12:37 PM, an observation of the 5th Floor medication cart was conducted with Licensed Practical Nurse #2. The following were observed: Two insulin pens for 2 different residents were stored in the same plastic bag, 6 opened insulin pens were not marked with the dates they were opened, 1 insulin pen with an open date of 12/16/2024 with no resident name, and 2 unopened insulin pens stored in resealable bags labeled Refrigerate. On 01/29/2025 at 12:39 PM, Licensed Practical Nurse #2 was interviewed and stated insulin pens are supposed to be labeled, dated when opened, and each resident's insulin pen should be kept in a separate bag to prevent contamination. They stated unopened insulin pens are supposed to be in the refrigerator and not stored in the medication cart until opened. Licensed Practical Nurse #2 further stated they were busy administering medications and did not inspect the cart and could not explain the findings. On 01/29/2025 at 3:19 PM, Registered Nurse #1 was interviewed and stated the insulin pens that are delivered from the pharmacy are supposed to be kept in the refrigerator until opened. The pharmacy sends the insulin pens in separate bags for the individual residents. Registered Nurse #1 also stated they frequently remind the unit nurses to check their carts every shift for undated, unlabeled, expired medications, and to date medications when opened. On 01/30/2025 at 4:16 PM, the Director of Nursing was interviewed and stated that medication nurses are responsible for the upkeep of the medication cart, such as dating medications when opened, keeping cart locked when not in use, keeping cart clean, and disposing of expired medications. The Director of Nursing further stated insulin pens delivered from the pharmacy should be placed in the refrigerator until opened and then once opened they must be dated and kept in the medication cart. 10 NYCRR 415.18 (e)(1-4)

Based on observation, record review, and interviews during the Recertification Survey conducted from [DATE] to [DATE], the facility did not ensure food were stored in accordance with professional standards for food service safety. This was evident during kitchen and dining observation. Specifically, 1.) The kitchen walk-in refrigerator and freezer contained opened and undated food items. 2.) The 5th floor unit refrigerator contained unlabeled and undated food items. The findings are: 1.) The facility's policy titled Stock Rotation/Dated Items and Safe Defrosting of Nutritional Items with a revised date of [DATE] documented that items received from the meat and chicken company will be placed in a plastic bin with a cover. The bins will be labeled with date arrived, date pulled for defrosting, and the date to be used. On [DATE] at 11:33 AM, kitchen observation revealed the following: the freezer was observed with 6 plastic bins containing frozen meats that were not labeled/dated. The walk-in refrigerator was observed with 4 plastic bins containing thawed meat and an opened container of tartar sauce that were not labeled and had no date indicating the use by date. On [DATE] at 12:39 PM, the Food Service Director was interviewed and stated when food products are delivered on Thursdays, the staff unpacks the meat from the original box, put them inside the plastic bin, and label the items to include product delivery date, date taken out of the box, use by date. The Food Service Director stated the meat found in the freezer were just delivered over the weekend and must have been put in the freezer by staff without labeling. 44842 2.) The facility's policy titled Food Safety Requirements-Outside Food dated [DATE] documented that resident and or person bringing in the food will be notified that perishable food will only be kept for 48 hours. All non-perishable food will be kept for 72 hours once package is opened. Food that requires refrigeration must be placed in pantry refrigerator, labeled with resident name and date received. Nursing staff will monitor resident's room, unit pantry, and refrigeration units for food and beverage disposal. On [DATE] at 11:03 AM, the 5th Floor pantry refrigerator was observed with an unlabeled and undated package of smoked salmon, unlabeled and undated container with fruit salad, and an unlabeled and undated container of unknown food in a Chipotle paper bag. On [DATE] at 11:05 AM, Licensed Practical Nurse #2 was interviewed and stated staff are supposed to label any food with resident's name and the date it was brought in and remind residents when it has to be discarded. On [DATE] at 11:34 AM, Registered Nurse #1 was interviewed and stated the unit nurses on every shift are supposed to make sure food is labeled and dated in the pantry refrigerator and that expired food are thrown after 72 hours. On [DATE] at 4:13 PM, the Director of Nursing was interviewed and stated that food must be labeled and dated before storing in the pantry refrigerators and are only kept for ,d+[DATE] hours. The Director of Nursing further stated that nursing staff are responsible to check the pantry refrigerators on the units to make sure staff are following this policy. 10 NYCRR 415.14(h)

Based on observation, record review, and interviews conducted during an Abbreviated Survey (NY00340915), the facility failed to ensure that a resident received adequate supervision to prevent an elopement. This was evident in one out of six residents sampled (Resident #1). Specifically, Resident #1 exited the facility on 05/01/24 at 4:22 pm undetected by staff. Facility staff became aware at 7:10 pm that Resident #1 was missing. According to staff, dinner was served between 5:00 pm and 6:00 pm and they were unaware that Resident #1 was missing. Resident #1 was found by a facility staff member on 05/05/24 at around 4:55 pm at a bus stop and was brought back to the facility. Resident #1 had no visible injuries but was sent to the hospital for a wellness check. The findings are: The facility's Policy titled Wandering and Elopement, last reviewed date 11/20/23, documented that the policy of this facility is to ensure that residents will be maintained in a safe and secure manner and protected from any harm. The facility will make every effort to identify residents with potential for elopement. If a resident is discovered to be missing, a search and rescue operation will commence immediately. The facility's Policy titled Security Risk Management Plan, last reviewed on 10/20/20, documented that it is the policy of the facility to protect all residents from accidents and incidents related to unsupervised exit. The facility will always maintain and provide a safe and secure environment. Resident #1 was admitted to a facility with diagnoses that include Bipolar Disorder, Psychotic Disorder, and Depression. The Minimum Data Set Assessment (a resident assessment tool) dated 12/04/23 documented that Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) score of 9 out of 15 associated with moderately impaired cognition. An Elopement /Wandering Risk assessment dated [DATE] documented that Resident #1 was not at risk for elopement. A Nursing Progress Note, written by Registered Nurse Supervisor #1, dated 05/01/24 at 08:11 pm, documented that Registered Nurse Supervisor #1 was notified at 7:10 pm that Resident #1 was not on the unit and Code E (code for missing resident) was activated. Staff searched all units. Resident #1 was last observed at around 4:00 pm wearing a green shirt and dark pants. Staff was deployed to search outside and neighboring streets. The Director of Nursing and police were notified. The police came and collected the necessary information. A facility surveillance camera recording showed that on 05/01/24 at 4:22:08 pm, Resident #1 approached the lobby area and sat (for 17 seconds) in a chair across from the security desk. Resident #1's back was to the exit door in the lobby. Security Guard #1 was on a telephone (Security Guard #1 said they answered a facility phone call) while looking towards the lobby exit door, but away from Resident #1's direction. A pharmacy delivery person (identified by the Administrator) walked past the Security' desk and exited the facility (Security Guard #1 buzzed the door open). Resident #1 got up from the chair, walked towards the exit door, and walked out behind the pharmacy delivery person before the door automatically closed. Resident #1 was wearing a long dark coat (well dressed). A Facility Investigation Summary dated 05/01/24 documented at 7:10 pm the nurse reported that Resident #1 was not observed on the unit. Code E was activated. Resident #1 was last seen on the unit at the nursing station at around 4:00 pm wearing a green shirt with a collar and dark pants. Facility investigation concluded that abuse, neglect, or mistreatment did not occur. A Nursing Note dated 05/05/24 at 8:06 pm documented that Resident #1 arrived in the facility at approximately 6:10 pm with staff. Resident #1 ambulated freely, was alert, and verbally responsive. Resident #1 was assessed with no visible injury and vital signs within normal limits. Resident #1 was transferred to the hospital for a wellness check. During an interview on 05/07/24 at 12:30 pm, Resident #1 stated that they had just decided to visit their friends in [NAME] and was not aware they needed permission to leave the facility. During an interview on 05/07/24 at 1:00 pm, the Recreation Leader stated that they assisted with collecting the dinner trays on 05/01/24 between 5:00 pm and 6:00 pm. The Recreation Leader stated there was a dinner tray on the table that was half-covered and that there was no ticket on the tray. The Recreation Leader stated that they did not verify whose tray it was and did not check to see if the food was untouched. During an interview on 05/07/24 at 1:16 pm, Resident #1's assigned Certified Nurse Assistant #1 stated they last saw Resident #1 between 3:40 pm and 4:00 pm in the day room watching Television. Certified Nurse Assistant #1 stated that Resident #1 was not at risk for elopement and was not on any monitoring. Certified Nurse Assistant #1 stated that they fed residents in their rooms and did not know if Resident #1 ate in the dining room. Certified Nurse Assistant #1 stated when into the dining room, all trays were collected from the tables, and no one told them that Resident #1 did not eat. During an interview on 05/07/24 at 2:10 pm, Security Guard #1 stated that they knew Resident #1 and that Resident #1 often sits in the lobby with no attempts to leave the facility. Security Guard #1 stated that on 05/07/24 they did not see Resident #1 sitting in the lobby. Security Guard #1 stated they remembered buzzing out the pharmacy delivery person but did not see Resident #1 exiting the facility. Security Guard #1 went on to say that they were on the phone answering a call to the facility. Security Guard #1 stated that their responsibility is to sign visitors in but not out. Security Guard #1 stated that the residents need a pass to leave the facility. During an interview on 05/07/24 at 2:40 pm, Certified Nurse Assistant #2 stated that they handed out trays to the tables in the dining room between 5:00 pm and 6:00 pm. Certified Nursing Assistant #2 stated that they called Resident #1 to come to the dining room but did not verify if Resident #1 was in the dining room. Certified Nurse Assistant #2 stated they went to feed residents in their room and did not know Resident #1 was not in the dining room. Certified Nurse Assistant #2 stated that when they came to the dining room, Resident #1's tray was already picked up from the table. Certified Nurse Assistant #2 stated sometime after 6:00 pm (not sure about the time) they were conducting rounds and observed that Resident #1 was not in their room. Certified Nursing Assistant #2 stated that they searched the unit and Resident #1 was not found and they immediately notified Licensed Practical Nurse #1. During an interview on 05/07/24 at 3:43 pm, Licensed Practical Nurse #1 stated that Resident #1 was not at risk for elopement, was not on visual monitoring, and did not voice a desire to leave the facility. Licensed Practical Nurse #1 stated that they saw Resident #1 sometime after 4:00 pm (not sure of the time) at the nursing station, sitting in a chair and wearing something black. Licensed Practical Nurse #1 stated at approximately 7:00 pm, the staff was asking for Resident #1, and Resident #1 was not in the unit. Licensed Practical Nurse #1 stated they called Registered Nurse Supervisor #1. Licensed Practical Nurse #1 stated that Code E was called immediately, and the staff searched inside and outside of the facility, and Resident #1 was not found. During an interview on 05/07/24 at 4:23 pm, Registered Nurse Supervisor #1 stated that they were called at 7:10 pm by Licensed Practical Nurse #1, who stated that Resident #1 was not observed on the unit. Registered Nurse Supervisor #1 stated that they were told that Resident #1 was last seen in the hallway after 4:00 pm. Registered Nurse Supervisor #1 stated the staff should have known that Resident #1 did not eat their meal during dinner and that Resident #1 was not on the unit. Registered Nurse Supervisor #1 stated that they activated Code E, a head count was done on all units, and the staff searched outside, and neighboring streets, but Resident #1 was not found. Registered Nurse Supervisor #1 stated it was noted during the investigation that Certified Nurse Assistant #2 served Resident #1's tray, and the Recreation Leader picked up the tray. Registered Nurse Supervisor #1 stated that staff should have verified that Resident #1 did not eat and report it to the nurse. During an interview on 05/08/24 at 4:45 pm, the Director of Nursing stated that they were notified about the incident at around 7:10 pm and came to the facility. The Director of Nursing stated they investigated the incident and reviewed the facility surveillance camera recording, and it showed that Resident #1 left the faciity on [DATE] at 4:22 pm behind a pharmacy delivery person, and the Security Guard did not stop them. The Director of Nursing stated that the staff should have looked for Resident #1 during dinner time, which was between 5:00 pm and 6:00 pm. The Director of Nursing went on to say the staff did not notice that Resident #1 did not eat their dinner, and the Recreation Leader collected Resident #1's tray and did not notify anyone that the tray was untouched. The Director of Nursing stated a staff drove by the bus station on 05/05/24 and saw Resident #1, who stated they were returning to the facility. The Director of Nursing went on to say that Resident #1 was returned to the facility and was assessed without injuries. Resident #1 was transferred to the hospital for a wellness check. The Director of Nursing stated that the investigation concluded that abuse, neglect, or mistreatment did not occur. During an interview on 5/8/24 at 3:00 pm, the Administrator stated that they were notified immediately by the Director of Nursing, and they drove to the facility and observed the search was already in progress. The Administrator stated that they reviewed the camera and saw that Security Guard #1 buzzed out a pharmacy delivery person, and Resident #1 went out behind them. The Administrator stated that Security Guard #1 was supposed to stop the resident for identity. The Administrator stated that they sent a copy of the camera to the security company, and they questioned Security Guard #1, who had no idea that Resident #1 left the faciity on [DATE] at 4:22 pm. Immediate Jeopardy was not identified. Facility Past Noncompliance was identified on 05/07/24. Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the Past Noncompliance and was in substantial compliance with this specific regulatory requirement prior to the surveyor's onsite visit on 05/07/24. The facility was back in compliance on 05/05/24. The facility implemented the following corrective action prior to surveyor's entrance on 05/07/24: The facility investigated the elopement and concluded that abuse, neglect, or mistreatment did not occur. The facility developed an action plan which includes the following: The police were notified and responded to the facility on [DATE]. On 05/01/24, an elopement care plan was implemented for Resident #1 with interventions to prevent elopement. The facility started re-in-servicing all staff members on 05/01/24 (ongoing). Lesson Plan: new/revised policies, policy on elopement, whereabouts log, monitoring/supervision, door openings. Visitors check/in/out electronically. On 05/01/24, the facility reviewed/revised its Elopement policy to include a whereabouts log and visitors check-in/out electronically. On 05/02/24, the facility created a new Policy and Procedure titled Were About Log. On 05/02/24, the facility created a new Policy and Procedure titled Wandering Elopement Risk Log Criteria. On 05/03/24, Security Guard #1 was terminated. On 05/02/24, a Quality Assurance Meeting was held. The title of the meeting was Elopement Incident. The Director of Nursing, Human Resources, Supervisors, and other department heads. An audit tool titled Accident/Supervision was developed and implemented on 05/05/24. The audit will be done weekly on all new admissions after any attempted elopement and elopement. Audits will be done by nursing supervisors. The audit tool also has a form with a questionnaire for staff members. Resident #1 was located by facility staff and brought back to the facility on [DATE], transferred to the hospital, and was found to be without injuries. On 05/05/24, the Interdisciplinary Team met with Resident #1. Education provided on leaving the facility without permission. On 05/05/24, Resident #1 was reassessed and was placed on 30 minutes monitoring. It is documented that Resident #1 agreed to wear a wander-guard and that the wander-guard will alarm when Resident #1 is close to exit door to alert both Resident #1 and staff. On 05/05/24 the elopement care plan was updated upon Resident #1's return to the facility. The facility has 179 staff, of which 92.2% were in-serviced by the Director of Nursing, Assistant Director of Nursing, and supervisors. 4 out of 4 Security Guards in-serviced 62 out of 65 Certified Nursing Assistants in-serviced 4 out of 4 Home Health Aides 20 out of 21 Licensed Practical Nurses in-serviced 15 out of 17 Registered Nurse Supervisors in-serviced 7 out of 8 Recreations staff in-serviced 20 out of 23 Housekeeping and maintenance staff in-serviced 17 out of 20 Dietary staff in-serviced 2 out of 2 Social Services in-serviced 6 out of 7 Administration staff in-serviced 8 out of 8 Physical Therapist/Occupational Therapist in-serviced. The Director of Nursing/designee will contact the remaining 7.8% of staff for in-servicing prior to their return to work or returning to units. 10NYCRR 415.12(h)(1)(2)

Based on observation, record review, and interview conducted during a Recertification and Abbreviated (NY00312961) survey, the facility failed to ensure a resident received adequate supervision to prevent accidents. This was evident for 1 (Resident #284) of 4 residents reviewed for Accidents of 38 total sample residents. Specifically, on 3/19/2023 Resident #284 fell in their room when left unsupervised by a Certified Home Health Aide (HHA) #1 assigned to provide the resident one-to-one (1:1) observation. Subsequently, Resident #284 sustained a left scalp hematoma (bruising and swelling) and left hip fracture. This resulted in actual harm to Resident #284 that was not immediate jeopardy. The findings are: The facility policy titled Constant Observation for Safety of Resident dated reviewed 3/20/2023 documented constant observation is for a resident who is always kept within visual contact (eyesight), with no visual barriers between staff and resident, enabling rapid intervention to transfer the resident to the hospital when needed to ensure safety. The facility may assign a Certified Nursing Assistant (CNA) or HHA to do 1:1 constant observation when a resident is at risk for potential self-harm. The Registered Nurse Supervisor (RNS) informs the Medical Doctor (MD) and obtains an order for 1:1 constant observation. Resident #284 was admitted with diagnoses of Alzheimer's dementia and epilepsy (a neurological disease that causes seizures). The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #284 was severely cognitively impaired, required extensive assistance of 1 person for transfers and walking, and had no falls since the last assessment. The Comprehensive Care Plan (CCP) initiated 11/2/2022 and last revised 03/19/2023 documented interventions including 1:1 monitoring due to risk for falls. The Resident Nursing Instructions (RNI), the resident care needs communicated to the assigned Certified Nursing Assistant (CNA), dated 11/2/2022 documented Resident #284 was at risk for falls and staff should not leave Resident #284 in their room unattended as the resident may get up without assistance and fall. On 12/27/2022, the RNI documented Resident #284 was placed on enhanced 1:1 monitoring due to their high risk for falls The Resident Fall Risk assessment dated [DATE] documented Resident #284 was at high risk for falls. Nursing Note (NN) dated 2/3/2023 documented Resident #284 was observed on the floor at the foot of their bed. On 3/8/2023, the NN documented Resident #284 was on 1:1 observation. NN dated 3/10/2023 documented Resident #284 fell in their room. On 3/16/23, the NN documented Resident #284 was on 1:1 observation. There is no documented evidence of ongoing 1:1 observation of Resident #284. NN dated 3/19/2023 documented Resident #284 was found lying on the floor in their room with left temporal hematoma (bruising and swelling) and tender left hip. Resident #284 was transferred to the hospital and was admitted post fall with left hip fracture. The Accident/Incident Report (A/I) dated 03/19/2023 documented Resident #284 was observed lying on the floor with tender left hip. Registered Nurse Supervisor (RNS) #1 assessed Resident #284, contacted the Physician Assistant (PA) #1 and Resident #284 was transferred to the hospital. HHA #1's statement documented HHA #1 went to the bathroom at 3:30 AM and by the time they came back, Resident #284 was on the floor by their bed. The A/I documented a statement from CNA #1 that HHA #1 was in the room with the Resident #284 and CNA #1 did not witness the resident's fall and did not know what happened. The statement from HHA #1 documented, at 3:30 AM, Resident #284 was asleep in bed. HHA #1 went to the bathroom and, upon return, saw Resident #284 on the floor. HHA #1 then called Licensed Practical Nurse (LPN) #1. LPN #1 documented HHA #1 called their attention to Resident #284's room and LPN #1 observed Resident #284 on the floor in front of their bed. During a telephone interview on 06/29/23 at 10:54 AM, HHA #1 stated they were accustomed to providing Resident #284 with 1:1 observation. On 3/19/2023, HHA #1 was assigned to monitor Resident #284. Resident #284 was sleeping in bed, and HHA #1 quickly left to use the bathroom. HHA #1 stated they did not alert staff they were leaving Resident #284 because they were going for less than 2 minutes. When HHA #1 returned from the bathroom, Resident #284 was on the floor and the nurse was called. HHA #1 stated, on multiple previous occasions, they left Resident #284 asleep to go to the bathroom and nothing happened. HHA #1 received an in-service related to 1:1 observation when they were first hired and after Resident #284's incident. They understood that 1:1 observation means they must be with the resident at all times. During a telephone interview on 06/30/2023 at 02:16 PM, Certified Nursing Assistant (CNA) #1 stated they were assigned to Resident #284's unit on 3/19/2023. CNA #1 stated they did not witness the fall. HHA #1 was assigned to provide 1:1 observation to Resident #284. HHA #1 can call an LPN or CNA if they need a break. HHA #1 did not call anyone to relieve them, and Resident #284 fell . During an interview on 06/30/2023 at 01:29 PM, LPN #1 stated Resident #284 fell often, and staff could not turn their back because the resident would get up and fall. On 3/19/2023, LPN #1 assigned HHA #1 to Resident #284's room. LPN #1 stated they explained the assignment and 1:1 observation of Resident #284 to HHA #1. LPN #1 told HHA #1 if they need to go to the bathroom or take a break, HHA #1 should ring the call bell, and the LPN will respond to see what HHA #1 needs. LPN #1 stated HHA #1 was not accustomed to ringing the bell because LPN #1 always made rounds and relieved HHA #1 as needed. On the night Resident #284 fell , LPN #1 was walking towards the resident's room when HHA #1 exited and informed LPN #1 that Resident #284 was on the floor. LPN #1 immediately took vital signs and called RNS #1. HHA #1 did not use the call bell to call for assistance before leaving Resident #284. During an interview on 06/29/2023 at 02:12 PM, the RNS #1 stated Resident #284 had a history of not sleeping and constantly getting up. Resident #284 was placed on 1:1 observation for safety in 12/2022. HHAs are usually assigned to 1:1 observation. HHA #1 was reliable with no prior issues with performing their job. The HHA received an in-service on 1:1 observation, and RNS #1 instructed HHA #1 to call staff for assistance. During interviews on 06/30/2023 at 01:48 PM and 07/03/2023 at 11:39 AM, the Assistant Director of Nursing (ADON) stated they are responsible for orienting HHAs to facility policies and procedures and the HHA job description. HHAs are not placed on the nursing assignment sheets because they are just additional help on the unit. The HHA assigned to Resident #284 was in-serviced to always stay with the resident when assigned to 1:1 observation. The HHA is aware if they need a take a break or step away for any reason, the HHA must inform the charge nurse, the nurse on the unit and/or the CNA, whoever is available, before leaving the resident. The HHA was suspended during the investigation, and they were given an in-service to reinforce 1:1 observation policy and procedure. During an interview on 06/30/2023 at 11:22 AM, the Director of Nursing Services (DNS) stated Resident #284 had several falls since their admission to the facility. Resident #284 was placed on 1:1 observation in 12/2022. On 3/19/2023, Resident #284 fell and sustained a left hip fracture. HHAs are hired and provided with inservices by the ADON which included 1:1 observation assignment. The nurse on the unit informs the HHA of the reason for the 1:1 observation. The HHA is instructed that they cannot leave the resident without someone relieving them. The nurse on the unit is responsible for monitoring the HHAs and the ADON follows-up with the HHAs as needed. 10 NYCRR 415.12(h)(1)

Based on observation, record review, and staff interview conducted during the recertification survey from 6/26/23 to 7/3/23, the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. This was observed during review of the Kitchen. Specifically, cold sandwiches and milk were not maintained at the proper temperature of 41 degrees Fahrenheit (F) or below. The findings are: The facility's policy titled Refrigerators and Freezers dated 11/1/21 documented that the facility will ensure safe refrigerator/freezer maintenance, temperatures, sanitation and will observe food expiration guidelines. During an observation of the kitchen on 6/28/23 at 11:30 AM, the Food Service Director (FSD) and the Dietary Cook (DC) #2 were observed calibrating a thermometer in the kitchen to test food items on the tray line. DC #2 removed two turkey sandwiches and FSD removed 4-ounce milk from the walk-in fridge. Temperature checks of the cold food items revealed that 1) turkey sandwich measured 52 degrees F, 2) second turkey sandwich measured 52 degrees F, and 3) 4-ounce milk measured 53.1 degrees F. On 6/28/23 at 12:07 PM, DC #2 stated the walk-in refrigerator contained sandwiches and the milk that measured above the proper temperature because the walk-in refrigerator is frequently opened and used during the mealtimes. DC #2 further stated the walk-in refrigerator has also been malfunctioning recently and that the technician came to repair it few times. On 7/3/23 at 10:40 AM, Food Service Director (FSD) stated the cold foods should be kept below 40 degrees F. However, the temperatures of cold items were observed not within acceptable range because the walk-in refrigerator was out of order on 6/28/23. FSD stated that the walk-in refrigerator was checked earlier that day to ensure that it was working properly, and temperature was noted below 40 degrees F. FSD stated that the equipment has been repaired and now cooling properly. 415.14(h)

Based on observation, interviews, and record review conducted during the recertification survey from 6/26/23 to 7/3/23, the facility did not implement an effective pest control program so the facility is free of pests. This was evident during environmental observations. Specifically, fruit flies were observed during the initial tour of the kitchen, in food service director's (FSD) office and in the conference room of the facility. The findings are: The facility policy titled Pest Control dated 11/2/21 documented the facility shall establish and maintain an integrated pest control program to ensure a healthy, clean, and safe environment for our residents, families, and staff and to comply with infection control practices. On 6/26/23 at 9:31 AM, an initial tour of the Kitchen was conducted with the Dietary Cook (DC). Multiple fruit flies were observed flying around the ice machine and a puddle of water dripping from the ice machine. Behind the ice maker was observed with open drainage exposed and standing water. On 6/26/23 at 11:40 AM, fruit flies were observed in the FSD office. On 6/26/23 at 1:40 PM and 6/27/23 at 10:15 AM, fruit flies were observed in the conference room. The Pest Control Management documented the exterminator visited the facility on 6/6/23, 6/13/23 and 6/20/23. There was no documented evidence the exterminator identified fruit flies as a concern in the conference room, FSD's office, and Kitchen. On 6/28/23 at 11:59 AM, the Dietary Cook (DC) was interviewed and stated they have seen more fruit flies in the kitchen recently because of the warm weather. DC stated they didn't notice that there were that many in the kitchen until they saw multiple fruit flies flying near the ice maker when the surveyor came to visit on 6/28/23. There is a drain behind the ice machine that may be why there were many fruit flies noted near that area. On 7/3/23 at 10:40 AM, the FSD was interviewed and stated they initially observed fruit flies in their office little over a month ago and notified the exterminator. FSD stated they did not observe any fruit flies in the kitchen and staff didn't report any issues of seeing fruit flies; therefore, FSD was not aware that there were fruit flies in the kitchen. On 7/3/23 at 8:20 AM, the Pest Company Supervisor (PCS) was interviewed and stated the exterminator visited the facility for routine pest control service on 6/6/23, 6/13/23, 6/20/23 and 6/28/23. They did not know that fruit flies were seen in the kitchen area and was only made aware on 6/28/23. On 7/3/23 at 9:37 AM, the Director of Maintenance (DM) was interviewed and stated they were not aware there were fruit flies in the kitchen because kitchen is inspected by the Food Service Director (FSD). If there was any pest noted, DM/FSD will notify the exterminator immediately or bring up the issue during the exterminator's weekly visit depending on the severity of the pest problem. The exterminator will use appropriate chemicals to treat the pests and document it in the pest control logbook. Upon reviewing the logs, DM stated that there was no documentation of sighting or treating the fruit flies in the logbook. 415.29(j)(5)

Based on interviews and record review conducted during the recertification survey conducted from 6/26/23 to 7/3/23, the facility did not ensure residents received a Minimum Data Set 3.0 (MDS) assessment not less frequently than once every 3 months. This is evident for 16 (Resident #s 4, 20, 28, 41, 47, 61, 72, 103, 117, 131, 139, 144, 151, 156, 165 and 170) of 17 residents reviewed for Resident Assessment. Specifically, MDS assessments for Resident #4, Resident #20, Resident #28, et al. were not completed within 14 days of the Assessment Reference Date (ARD). The findings are but not limited to: The facility's policy titled MDS Completion and Submission dated 9/15/21 documented the facility shall ensure that MDS assessments are completed and submitted within federal and state guidelines. 1) Resident #4's MDS with ARD of 5/31/23 documented a completion date of 6/26/23, more than 14 days after the ARD. had a quarterly assessment with assessment reference date of 5/31/23 and completion date of 6/26/23. The assessment was submitted late on 6/26/23. 2) Resident #20's MDS with ARD of 5/19/23 documented a completion date of 6/26/23, more than 14 days after the ARD. 3) Resident #28's MDS with ARD of 5/12/23 documented a completion date of 6/26/23, more than 14 days after the ARD. On 6/30/23 at 9:29 AM, the MDS Coordinator was interviewed and stated there are currently two MDS assessors completing the assessments as per schedule. The MDS Coordinator was not able to explain why the assessments were completed late, but they acknowledged that they are aware of these issues. 415.11(a)(4)

Based on observation, record review, and interviews conducted during a Recertification Survey from 06/26/23 to 07/03/23, the facility did not ensure handrails remain firmly affixed to the wall. Specifically, loose hands were observed on 2 (Unit 1 and 4) of 5 units. Specifically, there were observations of handrails in the hallways on Unit 1 and Unit 4 that were not firmly affixed to the wall. The findings are: On 06/26/23 between 10:50 AM and 11:50 AM, Unit 1 was observed with handrails near the elevators and near the staff bathroom that were not firmly affixed to the wall and Unit 4 was observed with handrails near the corridor and elevators that were not firmly affixed to the wall. On 07/03/23 at 09:30 AM, The Maintenance Director was interviewed and stated they make rounds and check the Maintenance logbook on each of the units. The Maintenance Director checks for loose handrails when they walk through the units and check with the nurses to ask if there is anything that needs to be addressed. 415.29

Based on observation, record review, and interviews conducted during the Recertification survey from 6/26/23 to 7/3/23, the facility did not ensure a resident was treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of their quality of life. This was evident for 1 (Resident #123) of 2 residents reviewed for Dignity out of 38 total sampled residents. Specifically, Resident #123 was observed wearing the same blood-stained shirt on 3 consecutive days. The findings are: The facility policy titled Activities of Daily Living (ADL) dated 3/3/21 documented residents are provided the necessary support in dressing and personal hygiene. The facility policy titled Resident Rights and Responsibilities dated 12/20/22 documented the facility would ensure that all residents are afforded the right to a dignified existence and courtesy in treatment and care for personal needs. Resident #123 had diagnoses of bipolar disorder and anxiety disorder. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #123 had moderately impaired cognition and required assistance from 1 person for dressing. On 6/26/23 at 12:05 PM, Resident #123 was observed sitting in a wheelchair in their room wearing a white shirt with dark colored blood stain on the lower right side of the body. Resident #123 stated the stain was from another day. On 6/27/23 at 10:34 AM, Resident #123 was observed asleep in their bed wearing the same blood-stained white shirt as the previous day. At 11:27 AM, Resident #123 was observed in their room, sitting in a wheelchair, wearing the same blood-stained shirt. On 6/28/23 at 10:24 AM, Resident #123 was observed being wheeled from the shower room in their wheelchair by Certified Nursing Assistant (CNA) #4. Resident #123 was wearing the same white blood-stained shirt as the previous day. The Comprehensive Care Plan (CCP) related to ADLs, effective 10/28/20 and last updated 5/13/23, had a goal of resident will be well groomed daily. Interventions included provide assist of supervision with dressing. The Resident CNA Documentation Record for June 2023 documented Resident #123 received CNA care and personal hygiene assistance every shift. No refusals of care were documented. On 6/29/23 at 11:14 AM CNA #4 was interviewed and stated residents receive assistance to change clothes every day, even if they don't get a shower. At night, residents change into a nightgown, and in the morning, they change into clothes. CNA #4 stated they change residents from their night clothes into their day clothes and if the clothing becomes soiled. If residents refuse to change clothes, they can stay for the day; but if it becomes a pattern, CNA #4 reports it to the nurse. CNA #4 does everything for Resident #123 and the resident does not refuse care. CNA #4 stated they must have missed the blood stain on Resident #123's shirt, and it should have been changed. On 6/30/23 at 11:29 AM, Registered Nurse Supervisor (RNS) #3 was interviewed and stated they observe the CNAs daily to check on what they are doing. CNAs get in-services on resident care regularly. RNS #3 stated residents' clothes need to be changed daily. Soiled clothes need to be changed. Some residents resist and don't want to change their clothes. RNS #3 stated they did not hear anything about Resident #123 resisting to change clothes this week. RNS #3 stated they were not aware Resident #123 had been wearing a stained shirt. On 7/03/23 at 10:27 AM, the Director of Nursing Services (DNS) was interviewed and stated that ADL care and personal hygiene are provided on the unit. Sometimes patients refuse to be changed or cleaned. As soon as the CNA sees a blood stain on a resident's clothing, the CNA should change it. Throughout the shifts, someone should have seen Resident #123's blood-stained shirt and changed it. The night shift should have seen the stained shirt when they put Resident #123 to bed. 415.5(a)

Based on observation, record review, and interviews conducted during the Recertification and Complaint (NY00317216) survey from 6/26/23 to 7/3/23, the facility did not ensure a person-centered Comprehensive Care Plan (CCP) was developed and implemented to meet the resident's goal, and address the resident's medical, physical, mental, and psychosocial needs. This was evident for 1 (Resident #108) out of 38 total sampled residents. Specifically, a CCP related to Resident #108's skin lesion was not developed. The findings are: The facility policy titled Care Planning Process dated 10/20/20 documented care plans shall be developed for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental and psycho-social needs that are identified, at a minimum in the resident assessment tool. Resident #108 had diagnoses of bipolar disorder and Alzheimer's disease. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #108 was severely cognitively impaired. On 6/27/23 at 3:18 PM Resident #108's family member was interviewed and stated they had noticed a growth on Resident #108's right thumb on 5/19/23. The family member stated they had been in communication with the facility regarding the lesion and had been told it was a fungal infection and had to be followed up by a specialist. On 6/30/23 at 10:20 AM Resident #108's right thumb was observed a hypertrophic, opaque nail over the distal half of the nail. A Medical Doctor (MD) Order dated 5/22/23 documented dermatology follow-up for Resident #108's right thumb. A MD Note dated 5/22/23 documented Resident #108's right thumb nail was hypertrophic and mycotic. A dermatology consult was ordered. A MD Note dated 5/24/23 documented Resident #108 was to start Terbinafine HCl 1 % topically to the right thumb and await dermatology consult. The Treatment Administration Record (TAR) for May and June 2023 documented Resident #108 received Terbinafine HCl 1 % topical cream twice a day for 14 days, from 5/24/23 until 6/6/23. A Dermatology Consult note dated 6/14/23 documented Resident #108 had a wart to the right thumb under the nail bed. Resident #108 was referred to a nail specialist for further treatment. There was no documented evidence a CCP related to Resident #108's right thumb skin concern. On 6/30/23 at 11:01 AM, Registered Nurse (RN) #3 was interviewed and stated Resident #108 has a wart under their fingernail and was seen by a dermatologist, who referred the resident to a nail specialist. The facility is waiting to get an appointment. RN #3 stated they noticed the wart a while ago when providing care. Treatment didn't work. RN #3 stated RNs are responsible for initiating and updating CCPs. A new CCP should have been developed for Resident #108's right thumb fungal infection but it was not. Any time the doctor sees a resident or starts a new treatment, it should be added to the care plan. RNS #3 stated this was an oversight. On 7/03/23 at 10:20 AM, the Director of Nursing Services (DNS) was interviewed and stated that RNs oversee CCPs. RNs add new resident issues to CCPs at the time they initiate the CCP. A CCP should be developed within 48 hours of identifying an issue. 415.11(c)(1)

Based on observation, interviews, and record review conducted during the Recertification survey from 6/26/23 to 7/3/23, the facility did not ensure that infection control practices were maintained. This was evident for 1 (Unit 1) of 5 Units observed for Dining. Specifically, a Certified Nursing Assistant (CNA) was observed with their fingers inside cups being served to residents during lunch. The finding is: The facility policy titled Handling Food, Cups & Feeding Utensils dated 05/20/22 documented cups must be picked up touching from the base/bottom. No fingers must touch the rim or inside of the cup. On 06/26/23 at 12:15 PM, CNA #3 was observed during lunch service on Unit 1 with their fingers inside plastic water cups being filled with water and served to residents. The CNA #3 was interviewed at 2:20PM on 06/26/23 and stated they did not realize their fingers were inside the water cups. CNA #3 thought they were grabbing the cups from the bottom to prevent contamination and promote infection control. On 06/29/23 at 09:42 AM, Registered Nurse (RN) #2 was interviewed and stated they saw CNA #3 grab the cups by the brim and instructed the CNA to hold the cup from the bottom. RN #2 stated they already spoke to CNA #3 on how to handle and pick up the cups to avoid contamination and infection control issues. 415.19(b)(1)

Based on observation, record review, and interviews during the abbreviated survey (Case # NY00312120), the facility did not ensure resident's right to be free from physical abuse. This was evident in 1 out of 4 residents reviewed (Resident #1). Specifically, on 03/06/2023 at 3:30 PM, Licensed Practical Nurse #1 (LPN #1) was seen by Recreation Staff #1 (RS #1) and on the Facility's Surveillance Camera forcefully and aggressively pushing Resident #1 in their wheelchair to their room. The wheelchair tilted and Resident #1 fell to the floor while in the wheelchair. The RS #1 immediately reported the incident to the Director of Nursing (DON). Resident #1 complain of pain in the left arm and was evaluated in the Hospital emergency room and returned to the facility. The findings are: The facility's Policy and Procedure entitled Abuse Prevention reviewed on 10/20/2020, documented that the resident of the facility will be protected from abuse, neglect, mistreatment, or misappropriation of property and exploitation in accordance with State and Federal Regulations. This included but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. The facility will protect its residents from and will not use verbal, mental sexual, or physical abuse, corporal punishment, or involuntary seclusion. Resident #1 was admitted to the facility with a diagnosis including Dementia and Mood Disorder. The Minimum Data Set (MDS, a resident assessment tool) dated 02/08/2023, documented that Resident #1 had a Brief Interview of Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 5, indicating that Resident #1 was severely cognitively impairment. Resident #1 used a wheelchair for mobility. The facility's undated, Surveillance Camera Footage (SCF) was reviewed on 03/15/2023 with the Director of Nursing (DON) and Administrator. The DON stated that the SCF was saved without the date or time. Footage #1: showed Resident #1 sitting in their wheelchair in the middle of multiple wheelchairs, with other residents on both sides of the hallway. The hallway was obstructed with multiple Residents in wheelchairs, they were not positioned appropriately. LPN #1 was observed standing behind Resident #1's wheelchair pushing the wheelchair but Resident #1 was resistive and continued to lock their wheelchair as LPN #1 pushed the wheelchair to clear the hallway. There was a struggle between Resident #1 and LPN #1 as the wheelchair was being pushed and Resident #1 attempted to prevent the wheelchair from rolling freely by placing their feet on the floor preventing the wheelchair from moving forward. Footage #2: showed LPN #1 still struggling to push Resident #1's wheelchair as Resident #1 held onto the handrail in the hallway and continues to lock the wheelchair. As LPN #1 arrived at Resident #1's room with the wheelchair, LPN #1 quickly turned the wheelchair around to pull the wheelchair backwards into the room and the wheelchair tilted on the left side with Resident #1's lower body resting on the floor. LPN #1 quickly lifted the left side of the wheelchair and placed LPN #1's foot between the floor and the left wheel of the wheelchair. CNA #2 arrived at the scene, LPN #1 had already partially lifted the left side of the wheelchair off the floor. LPN #1 and CNA #2 lifted the Resident and the wheelchair back to an upright position and the SCF ended. The facility's investigation dated 03/06/2023, completed by DON, documented that on 03/06/2023 at 03:30 PM, the DON received a report from RS #1 that there were a few residents in the hallway in front of the nurses' station. LPN #1 arrived on the unit and started moving the resident. LPN #1 wheeled Resident #1 roughly into the direction of their room forceful enough to cause the wheelchair to tilt on the left side. RS #1 stated they did not see if Resident #1 fall, because RS #1 was on the other end of the hall but what they witnessed was very concerning. Resident #1 was interviewed, and could not give a full account of the incident but stated that they fell while eating. Resident #1 was calm and complained of pain in the left elbow. Registered Nurse #1 (RNS#1) assessed Resident #1 and there were no signs of physical injury, no bruises, and no discolorations, but the left elbow was tender to touch. The Medical Doctor (MD) was notified and ordered an image of the bones of the body (X-ray) of the left shoulder and elbow. Resident #1 was transferred to the Hospital for immediate X-ray and evaluation. The camera was reviewed and the involved staff (LPN #1) was immediately pulled from the unit and suspended pending the investigation. The Administrator was made aware, and the family was notified. Law enforcement was notified on 03/06/2023 at 11:39 PM. Resident #1 returned from Hospital emergency room in a stable condition, no injuries or fractures were identified on the X-ray or on the other scans. The investigation concluded that there was evidence to suspect abuse, neglect, or mistreatment occurred. A Comprehensive Care Plan (CCP). potential for Victimization dated 02/06/2023, documented intervention to provide emotional support. The care plan was updated on 03/06/2023, with Resident #1 being wheeled to the room with force despite their resistance. An Abuse Potential/Risk Assessment Tool dated 03/06/2023, documented that Resident #1 was being wheeled roughly by a staff member forceful enough to cause the chair to tilt on the left side and Resident #1 landed on the floor with the wheelchair. The involved staff was immediately removed from the unit. Resident #1 was assessed with no signs of physical injury. Resident #1 was transferred to the Hospital. A Nurse's note dated 03/06/2023 at 09:04 PM, written by RNS #1 documented that RNS #1 was called on the floor for Resident #1, who complained of pain in their arms. Resident #1 was sitting on the bed. Resident #1's left arm had tenderness on the left elbows, rest was unremarkable. Resident #1 stated ' they were near a group while eating, and said that they fell , but would not elaborate. Reported that Staff was transporting Resident via wheelchair hurriedly, lost a balance and the wheelchair tilted to the left, resulting in Resident #1 landed on the floor, with part of the body still in the wheelchair, and another Staff helped to put Resident #1 and wheelchair back to the floor and to their room. MD was notified with an order for X-Ray STAT (immediately) to the multiple body parts. The Family was notified. The new order was to Transfer Resident #1 to the Hospital for an X-Ray and evaluation. An MD note dated 03/08/2023 04:01 PM, documented that the resident was evaluated due to falling on 3/6/2023. Resident #1 had a Head CT scan, x-rays, and Electrocardiogram (EKG) in the hospital. All tests were negative. Resident #1 complained of pain in the left elbow. Plan: continue pain management as needed, fall precautions, neuro watch, monitor for developing injuries from falls, and supportive care. A Resident Nursing Instructions dated from 03/01/2023 through 03/31/2023, documented that the resident was monitored for safety; falls and behavior; resisting care and aggressive behavior; may be physically aggressive, approach in a calm manner. LPN #1 written statement dated 03/06/2023, documented that Resident #1 was combative. LPN #1 tried to redirect Resident #1 to their room. Resident #1 kept on holding the guard rail and resisting while LPN #1 was moving their hands from the guard rail. Resident #1 continued to be combative. LPN #1 turned the wheelchair around and put Resident on the bed. During an interview on 03/16/2023 at 10:59 AM, the 3:30-11:30 shift, Licensed Practical Nurse (LPN #1) stated that when they came to the unit, they saw that area near the nursing station was obstructed by residents in wheelchairs. LPN #1 asked the residents to move the wheelchairs against the wall because the dinner truck would be coming. LPN #1 stated that Resident #1 was combative and refused to move. LPN #1 stated that they tried to redirect the residents to sit against the wall but Resident #1 was combative. LPN #1 stated that they decided to move Resident #1 to their room because it usually makes Resident #1 non-combative. LPN #1 stated that Resident #1 usually eats in their room. LPN #1 stated that when they tried to move Resident #1 to the room, Resident #1 started to grab the handlebars in the hallway. LPN #1 stated that they just pry the Resident's hands from the handlebar and the Resident put down their feet to stop the progress of the wheelchair. LPN #1 stated that when they tried to turn the wheelchair to get into the room, the wheelchair got on one wheel, but the resident did not touch the floor. LPN #1 stated that they called CNA #2 to come and assist them and they brought Resident #1 into their room and put the Resident on the bed and the resident calmed down. LPN #1 stated that there was no reason to call the supervisor or write a behavior note because nothing wrong happened. LPN #1 stated that they did not abuse Resident #1 even if it looks bad on the camera. During an interview on 03/15/2023 at 10:34 AM, RS#1 stated that they worked from 8:30 AM to 4:30 PM. RS #1 stated that they were decorating the walls on Resident #1's unit when the Physical Therapist (PT) brought Resident #1 to the unit from therapy and Resident #1 wheeled themself to the nursing station. There were other residents sitting. RS #1 stated that there was no commotion or arguments, and everything was quiet. RS #1 stated that they did not remember if Resident #1 was blocking the nursing station. Resident #1 had no behavior. RS #1 stated that they observed that LPN #1 came to the unit from the stairwell at the back of the hallway. LPN #1 took Resident's wheelchair by the handles and forcefully, and quickly moved Resident #1 toward their room. Resident #1 did not want to go but LPN #1 kept pushing the wheelchair. RS #1 stated that they did not see if the resident was resisting but when LPN #1 reached room [ROOM NUMBER], RS #1 observed that the Resident s wheelchair was tilted on the left side and the right side was up. RS #1 stated that they did not see if Resident #1 fell because they were far and on the opposite side of the hallway. RS # stated that they observed that CNA #2 approached LPN #1 and helped Resident #1. RS #1 stated that they went to the Resident's room to see if Resident #1 was okay. RS #1 stated that Resident #1 was sitting on the bed and said that they are okay. RS #1 stated that the way LPN #1 moved Resident #1 in the wheelchair was inappropriate and they immediately went down and reported to the DON. During an interview on 03/15/2023 at 3:12 PM, CNA #2 stated that they were working the 3-11 shift on 03/06/2023. CNA #2 stated that they were not assigned to but were familiar with Resident #1. CNA #2 was in room [ROOM NUMBER] assisting another CNA with a resident. CNA #2 stated that they heard a commotion from the hallway and came out of the room and saw LPN #1 struggling with a tilted wheelchair with Resident #1 in it. CNA #2 stated that the wheelchair was not touching the floor and the Resident #1 was not on the floor. CNA #2 stated that they approached the incident and helped to position the wheelchair and adjusted Resident #1 in the wheelchair. CNA #2 stated that Resident #1 looked angry (facial expression) with LPN #1, but neither LPN #1 nor Resident #1 did not say what happened. LPN #1 took Resident #1 into the room and CNA #2 assisted to put Resident #1 into bed in a sitting position and left. CNA #2 did not report this occurrence to anyone. CNA #2 stated that they did not see LPN #1 rough handle Resident #1 or other Residents. CNA #2 stated that they were suspended until today (3/15/23) because they did not report the fall. CNA #2 stated that Resident #1 does not like to be in the bed and when staff changes them, they go back to the chair. CNA 2 stated that they received in-service on abuse. During an interview on 03/15/2023 at 4:53 PM, the 3-11 shift, CNA #1 stated that they saw LPN #1 near the nursing station trying to pass by the residents who were sitting in their wheelchairs blocking the hallway. CNA #1 stated that Resident #1 was in the middle with of the hallway sitting in their wheelchair and refused to move. CNA #1 stated that they pushed Resident #1's roommate out of the way since Resident #1 did not want to be moved. CNA #1 stated that LPN #1 pushed Resident #1's wheelchair to their room. Resident #1 was locking the wheelchair while LPN #1 was pushing the wheelchair. Eventually, LPN #1 pushed Resident #1's wheelchair into the hallway and Resident #1 grabbed the handrail. CNA #1 stated that LPN #1 was removing Resident #1's hands off the handrail. CNA #1 stated that the way how LPN #1 was handling Resident #1 was wrong, but CNA #1 did not stop LPN #1 and did not report the occurrence to anyone because they went to continue care. CNA #1 stated that they did not see when Resident #1's wheelchair tilted. During an interview on 03/15/2023 at 4:07 PM, Nurse Manager #1 (NM#1) stated that they were the evening Supervisor on 03/06/2023. NM #1 stated that they were instructed by the DON to go and assess Resident #1 due to complaints of pain in the arms. NM #1 stated that they went to assess Resident #1 who was sitting on the bed and guarding their left elbow. A complete body assessment revealed no visible injury, only tenderness to the left elbow. NM #1 offered pain medication but Resident #1 refused. Later when NM #1 asked again Resident #1 said that there was no pain anymore. NM #1 stated that Resident #1 said that they were eating with friends and fell on the floor. NM #1 stated that at that time no staff reported any falls. NM #1 stated that the doctor ordered a STAT x-ray, and Resident #1 was transferred to the hospital. NM #1 stated that they reviewed a camera with the maintenance director and saw that LPN #1 actions were abusive towards Resident #1 and resulted in Resident #1's falling. NM #1 stated that LPN #1 pushed the wheelchair with force while Resident #1 was grabbing the handrail and stopping the wheelchair with their feet. NM #1 stated that they made a copy of the video and gave it to the DON. LPN #1 removed from the unit and was suspended. During an interview on 3/16/23 at 11:39 AM, the DON stated that they were responsible for investigating an incident. DON stated that RS#1 came to their office on 03/06/2023 at approximately 4:00 PM and stated that they saw something that bothered them. RS #1 said that LPN #1 forcefully wheeled Resident #1 strong enough that the wheelchair tilted. Resident#1 did not want to move, but LPN #1 was still more and there were marks on the floor from the wheels. DON stated that they interviewed LPN #1 and LPN #1 denied abusing or that Resident fell on the floor. DON stated that they showed LPN #1 the camera record, but LPN #1 still insisted that Resident #1 did not fall. DON stated that LPN #1 did not show any remorse. LPN #1 was suspended and terminated. CNA #2 was suspended because CNA #2 did not report a fall. DON stated that LPN #1 should call the supervisor to assess Resident #1 prior to moving them up off the floor. DON stated that LPN #1 action toward Resident #1 was considered unsafe and abusive. DON stated that they called the police. LPN #1 was reported to the office of the profession. 10 NYCRR: 415.11(c)(2)(i-iii)

Based on record review and interviews conducted during an abbreviated survey (Case # NY00297946), the facility did not report an alleged violation involving abuse immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to the New York State Department of Health (NYSDOH). This was evident in 1 out of 4 residents reviewed (Resident #1). Specifically, on 06/21/2022 at 9:30 AM, Resident #2 reported an allegation of abuse to Certified Nurse Assistant #2 (CNA #2). On 06/24/2022 at 01:22 AM, the facility reported the allegation to the NYSDOH. The findings are: The facility's Policy and Procedure entitled Abuse dated 10/20/2020, documented that each covered individual shall report to the State Agency, and to local law enforcement, any reasonable suspicion of a crime against any individual who is a resident of or is receiving care from the facility. Each covered individual shall report immediately but not later than 2 hours after the suspicion, if the event that causes the suspicion does not result in serious bodily injury. Resident #1 was admitted to the facility with a diagnosis of Severe Mental Retardation, Autism, and Epilepsy. The Minimum Data Set (MDS, a resident assessment tool) dated 05/28/2022, documented that Resident #1 had long-term and short-term memory problems. A review of the facility's investigation conducted by the Director of Nursing (DON) dated 06/21/2022, documented that on 06/21/2022, Resident #2 (Resident #1's roommate) alleged that a CNA hit Resident #1 with slippers on their hand, back, and legs. Resident #2 reported that this happened after lunch yesterday on 06/20/2022. The facility reviewed the camera, conducted an investigation, and concluded that abuse did not occur. Comprehensive Care Plan (CCP) at risk for victimization date initiated 02/24/2017, documented interventions to observe for signs of abuse, neglect, or maltreatment and report immediately. The care plan after the alleged incident was updated on 06/21/2022 at 9:20 AM, Resident #1's roommate reported that Resident #1 was hit by a caregiver. A Nurse's note dated 06/23/2022 at 3:37 AM, written by Registered Nurse Manager (RNM #2) documented a follow-up to the an alleged report from a roommate who stated that a CNA hit Resident #1 on 06/20/2022. The Skin was intact, some areas of discoloration were on the right arm and right legs, but does not appear to be of a traumatic origin. Resident #1 has bloodwork drawn the day before and had seizures a week ago. During an interview on 03/16/2023 at 2:45 PM, RNM #1 stated that CNA #2 told RNM #1 on 06/21/2022 in the morning that Resident #2 want to tell them something. When RNM #1 came to Resident #2's room, Resident#2 started that a aide came to their room after lunch one day ago and went to make Resident #1 get out of bed. Resident #2, stated that Resident #1 was slow, and the CNA start to hit them with a soft black shoe. RNM #1 stated that they checked Resident #1's body and there were no visible injury related to trauma. RNM #1 stated that they reported to DON immediately. During an interview on 03/16/2023 at 3:24 PM, the DON stated that they were notified of an abuse allegation and interviewed Resident #1. The DON stated that they were responsible for reporting to NYSDOH and know that they must report an allegation of abuse within two hours. DON stated that they reported late to NYSDOH because they were not sure if it was an abuse allegation because Resident #1 was saying at the beginning that something bothering them, and they were not sure if they need to tell. The DON stated that when they interviewed Resident #2 personally, Resident #2 told them about the abuse allegation toward Resident #1. The DON stated that they should report the incident within two hours to NYSDOH. 10 NYCRR 415.4(b)

Based on record review and interviews during an abbreviated survey (NY00294773), the facility failed to ensure that the resident environment remains as free from accident hazards as is possible, and each resident receives adequate supervision and assistance devices to prevent accidents. This was evident in 1 out of 3 residents sampled (Resident #1). Specifically, on 4/14/2022 during the 3-11 shift, Resident #1 stated that while having a shower, he/she fell in the bathroom. The three Certified Nurse Assistants (CNA) who were present, did not report the fall to the Charge Nurse/ Licensed Practical Nurse #1 (LPN #1). On 4/14/2022, during the night shift, Resident #1 was complaining of pain and was seen kneeling on the floor. On 4/15/2022, Resident #1 was seen by the Physician Assistant (P.A.) for complaints of pain to the right hip, an x-ray of the hip was ordered. On 4/15/2022, the X-ray results, revealed that Resident #1 sustained an acute fracture of the Right femur (hip/thigh bone). On 4/15/2022, Resident #1 was transferred to the hospital for a right femoral partial hip arthroplasty (a hip joint replacement surgery). This resulted in actual harm to Resident #1 that was not Immediate Jeopardy. The findings are: The Facility's Policy and Procedure entitled, Accident Policy and Procedure dated 7/28/2021, documented that a fall refers to unintentionally coming to rest on the ground, floor, or other lower levels, but not a result of an overwhelming force. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. The policy further documented that when an accident occurred, the Charge Nurse of the unit or designee and the Nursing Supervisor must be informed. The Charge Nurse /designee will investigate and determine if there has, in fact, been an accident. The Charge Nurse/designee will inform the Nursing Supervisor. Resident #1 was initially admitted to the facility with diagnoses including Hypertension, Type 2 Diabetes Mellitus, and Schizophrenia. The Minimum Data Set (MDS) dated [DATE], documented that Resident #1 had Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognitive status. Resident #1 required supervision and limited assistance of one-person for transfer, locomotion off the unit, dressing, toileting, and extensive assistance of one-person for bathing. A fall risk assessment dated [DATE], identified Resident #1 with a total score of 9, indicated that Resident #1 was a high risk for falls. A Care Plan for Falls was initiated on 12/15/2020, and updated on 3/15/2022, documented interventions that included, orienting Resident #1 to the environment, place the call bell within easy reach, keeping the bed in the lowest position and monitoring for changes in activities of daily living, cognition, behavior, and mood. The Facility's Investigation Summary dated 4/15/2022, documented that on 4/14/2022 at approximately at 9:00 PM, Resident #1 was given a shower during the 3-11 PM shift. Resident #1 walked in the shower room with the assigned CNA #1. CNA #1 called CNA # 2 and CNA # 3 for assistance because Resident #1 was cursing at CNA #1. The statements obtained from CNA #2 and CNA #3 revealed that Resident #1 fell in the shower room, during the shower. CNA #1 and CNA #3 picked up Resident #1 from the floor and put him/her in a shower chair. Then CNA #3 wheeled Resident #1 in the shower chair to his/her bedroom. Later that day, 0n 4/14/2022 at 10:45 PM, CNA #1 observed Resident #1 kneeling on the floor in the bedroom. LPN # 1 was called immediately. LPN #1 and CNA #1 placed Resident #1 back in bed. On 4/15/2022, Resident #1 was assessed by the P. A. for complaints of pain to the right hip. Resident #1 was observed with a bruise to the Right hip, there were no swelling, but there was pain when the hip was touched. Resident #1 was unable to move the Right leg. An X-ray of the bilateral hips and pelvis showed an acute fracture of the Right femur (hip). Resident #1 was transferred to the hospital and had a right femoral partial hip arthroplasty (hip repair surgery). The facility investigation concluded that there was no reason to suspect that abuse related to Resident's #1 care or violation of Resident 's #1 plan of care has occurred. However, CNA #1, CNA #2, CNA #3, and LPN #1 failed to follow the Facility's Policy and Protocol on accidents/incidents reporting. A Nursing Progress Note, written by the RNS #1, dated 4/15/2022 at 8:15 PM, documented that Resident #1 was assessed by the P.A. for complaints of pain and swelling to the right hip, which was warm and painful to touch. There were two areas of red discoloration on the Right hip. Resident #1 reported that on 4/14/2022, he/she fell in the main bathroom during shower. Resident #1 was later observed on 4/14/2022 about 10:55 PM, kneeling on the floor to the left side of his/her bed. Resident #1 was assisted back to bed by the staff. Resident #1 complained of pain and was given Tylenol 650mg as ordered. The X-ray report revealed that Resident #1 had an acute fracture of the right femur. Resident #1 was transferred to the hospital. A Review of P.A.'s note dated 4/20/2022 at 4:32 PM, documented that Resident #1 was seen on 4/15/2022, for complaint of pain to the right hip. Resident #1 stated that he/she fell the night of 4/14/2022 in the bathroom. Resident #1 denied head injury. On exam by the P.A., Resident #1 was observed with bruise to right hip, no swelling, pain to touch, and was unable to move the right leg. An immediate X-ray of both hips and pelvis was ordered. A Diagnostic Result dated 4/15/2022, documented that Resident #1 had an X-ray of right hip that showed an acute fracture of the right femur. A Physician's Order dated 04/15/2022, revealed an order to transfer Resident #1 to the hospital for further evaluation and treatment after a fall. The Patient Review Instrument dated 4/22/2022, revealed that Resident #1 was brought to the hospital after a fall in the shower. Resident #1 complained of severe pain and inability to ambulate. Diagnoses: Impacted fracture of the right femoral neck. On 4/16/2022 Resident #1 had Right femoral partial hip repair. The Nurse's Progress Note dated 4/22/2022, written by RNS #1 documented that Resident #1 returned to the facility at 7:20 PM, with diagnoses of Right hip fracture. Resident #1 was alert and oriented. The Resident Certified Nurse's Assistant (CNA) Documentation Record dated April 2022 revealed that on 4/23/2022, the bathing activity was changed from extensive assistance of one person to extensive assistance of two-persons physical assistance. During an interview on 06/16/2022 at 1:05 PM, Resident #1 stated that on 4/14/2022, he/she walked into the shower room with CNA # 1, during the shower he/she stood up so he/she could be washed better. Resident #1 stated that he/she slipped on the wet floor. Resident #1 stated that CNA #1 was assisting him/her but then called the other CNAs for help. Resident #1 stated that three CNAs picked him/her up from the floor and put them in the shower chair. Resident #1 stated that CNA #1 cursed them out. Resident #1 stated that the same night on 4/14/2022, he/she was in pain, so he/she lowered themselves from the bed to the floor to be comfortable. Resident #1 stated that they received Tylenol for pain. Resident #1 stated that the following day on 4/15/2022, he/she was sent to the hospital. Resident #1 stated that they had an x-ray done both in the facility and in the hospital. During an interview on 6/16/22 at 12:28 PM, the Assistant Director of Nursing (ADON), stated that on 4/15/2022, the Director of Physical Therapy (DPT), reported that Resident #1 had pain to Right hip and could not move. The ADON assessed Resident #1's Right hip and it was swollen, red, and painful to touch. Resident #1 was not able to move his/her Right hip. Resident #1 was interviewed and stated that on 4/14/2022, during the 3-11 PM shift, he/she fell in the bathroom. The Medical Doctor (MD) was informed and ordered an emergency x-ray. The x-ray showed fracture of the Right femur. The MD then order Resident #1 to be transferred to the hospital. The ADON stated that he/she viewed the video camera and the camera showed that three staff members were in the bathroom during the shower on 4/14/2022. The ADON stated that CNA #1 took Resident #1 into the shower room. CNA # 1 called CNA #2 to assist with Resident #1's shower. CNA # 2 stated that Resident #1 fell in the shower room when Resident #1 was trying to run away. CNA # 3 came to the shower room to help to pick up Resident #1 from the floor. The ADON stated that the CNAs failed to report Resident #1's agitated behavior and a fall in the shower room to the nurse in charge. The CNAs were suspended and terminated subsequently. The ADON stated that the CNAs and LPN #1 received prior in-service on Accident and Immediate Reporting. During an interview on 6/16/2022 at 2:00 PM, CNA # 4 stated that he/she worked the 7- 3 PM shift and was assigned to Resident #1 on 4/15/2022. CNA # 4 stated that he/she served Resident #1 breakfast in bed, and he/she did not eat. CNA #4 stated that he/she fed Resident #1 breakfast which was unusual. CNA # 4 stated that when he/she provided morning care to Resident #1, he/she tried to move Resident #1 to their side and Resident #1 made a noise and said that they had pain to the right side. CNA # 4 stated that he/she immediately reported to the nurse in charge/ LPN #1. During an interview on 6/16/2022 at 2:10 PM, LPN #1 stated that he/she worked the 3:30- 11:30 PM shift on 4/15/2022. LPN #1 stated that around 10:50 PM, CNA #1 called him/her stating that Resident #1 was on the floor. LPN #1 stated that when he/she entered the room Resident #1 was on their knees with their back turned to the window. Resident #1's hand was holding the side rail. The bed was very low. LPN #1 stated that they placed Resident #1 back in the bed. LPN #1 stated that Resident #1 stated that they did not fall. LPN #1 stated that it was not an actual fall, so she/he did not document the accident in the Electronical Medical Record. During an interview on 6/16/2022 at 2 :37 PM, CNA # 2 stated that he/she worked on 4/14/2022, the 3 - 11 PM shift and was not assigned to Resident #1. CNA # 2 stated that he/she went into the bathroom to help CNA # 1 with Resident #1's shower. CNA # 2 stated that Resident #1 ran away and slipped on the wet floor. CNA # 2 stated that Resident #1 fell on their stomach and did not hit their head. Resident #1 did not scream and did not complain of pain. CNA # 2 stated that he/she told CNA #1 to call the nurse and CNA #1 said no. CNA # 2 stated that CNA # 1 called CNA # 3 and the three of them picked up Resident #1 off the floor and put Resident #1 in the chair. CNA # 2 stated that he/she was aware that he/she must call the nurse before picking Resident #1 up from the floor. During an interview on 6/16/2022 at 3:00 PM, the Director of Physical Therapy, (DPT) stated that on 4/15/2022, in the morning, he/she saw Resident # 1 who was not able to move. The DPT stated Resident #1 was independent with walking. The DPT stated that he/she immediately reported the observation to ADON. During an interview on 6/17/22 at 11:03 AM, LPN # 2 stated that on 4/15/2022 around 10:00 AM, CNA # 4 reported to her/him that Resident #1 was in bed and not moving. Resident #1 told LPN # 2 that he/she fell in the shower room. LPN # 2 stated that they assumed that Resident #1 was referring to a previous fall that occurred few days ago. LPN # 2 stated CNA # 4 came to him/her a second time and stated that Resident #1 told CNA # 4 that they fell in the shower room on 4/14/2022, last night. LPN # 2 stated that he/she spoke to Resident #1 again and the Resident #1 said that they had pain to the right side and could not get up. LPN # 2 stated that while he/she and CNA # 4 were in Resident #1's room, the physical therapist came and said that it looked like a fracture. LPN # 2 stated that he/she immediately informed RNS # 1, the Supervisor. During a telephone interview on 7/1/2022 at 1:30 PM, CNA #3 stated that he/she worked the 3-11 PM shift and was not assigned to Resident #1's unit. CNA #3 stated that she/he was on another floor when CNA #1 called him/her to come down and help with Resident #1's shower. CNA #3 stated that when he/she entered the shower room Resident #1 was already on the floor. CNA #3 stated that he/she helped CNA #1 to place Resident #1 back in the chair, so he/she could be properly washed. CNA #3 stated that after the shower, she/he wheeled Resident #1 in the shower chair to their room. CNA #3 stated that she/he received in-service on falls and accident reporting. CNA #3 stated that she/he should have reported to the charge nurse that Resident #1 was on the floor, and she/he did not do it. During a telephone interview on 7/1/2022 at 3:00 PM, CNA #1 stated that he/she worked on 4/14/2022 the 3-11 PM shift and was assigned to Resident #1. CNA #1 stated that Resident #1 was a bit hesitant but agreed to have a shower. CNA #1 stated that during the shower Resident #1 stood up from the shower chair. CNA #1 stated that she/he asked CNA # 2 to bring a pair of non-skid socks. CNA #1 stated that Resident #1 was acting up during the shower and put themselves on the floor with their legs stretched out. CNA #1 stated that he/she called CNA # 3 because she/he had better relationship with Resident #1. CNA #1 stated that all three CNAs helped Resident #1 to get up from the floor. CNA #1 stated that Resident #1 was able to stand up and walk themselves to the shower chair. CNA #1 stated that when he/she entered Resident #1's room, near the end of the shift, Resident #1 was kneeling on the floor with their legs bent underneath. CNA #1 stated that he/she and LPN #1 placed the resident back in bed. CNA #1 stated that she/he received in service on accident, abuse, neglect, and reporting. CNA #1 stated that she/he was aware of the protocol, and she/he should have reported the incident. CNA #1 stated that she/he did not know what went wrong and why she/he did not do it. During a telephone interview on 8/1/2022 at 10:26 AM, LPN #1 stated that staff was periodically provided with in-services on falls/reporting. LPN #1 stated that she/he did not ask Resident#1 why they were on the floor on 4/14/2022. LPN #1 stated that Resident #1 did not complain of pain. LPN #1 stated that Resident #1 asked them to get him/her back in bed. LPN #1 stated that she/he did not recall if she/he saw Resident #1 with facial expression showing pain. LPN #1 stated that they gave Resident #1 Tylenol as Resident #1 asked for it to help them to sleep. During a telephone interview on 8/1/2022 at 11:24 AM, CNA #1 stated that Resident #1 was trying to run away from the shower room on 4/14/2022. CNA #1 stated that she/he did not recall where exactly Resident #1 fell . CNA #2 stated that they received in-service on accident, abuse, neglect, and reporting. During a telephone interview on 8/1/2022 at 12:00 PM, the Director of Nursing (DON) stated that procedure for falls was that when an accident occurs, the LPN / Charge Nurse and the Nurse Supervisor /RNS must be informed immediately. The RNS should complete a full body assessment. The LPN would initiate and complete the accident report. Statements from involved staff would be obtained. The charge nurse or nurse supervisor would notify the attending physician of the accident and document any immediate change and orders. The DON stated that the CNAs did not report Resident #1's agitated behavior during shower to the nurse. CNAs did not report that Resident #1 fell in the shower room. CNAs transferred Resident #1 off the floor without the nurse supervisor's assessment. LPN #1 did not document an incident report in the Electronic Medical Record or a shift report. Despite Resident #1 denying a fall, an incident report should have been done. All three CNAs were suspended and terminated subsequently. LPN #1 received a 5-day suspension and was re-educated upon return to work. The house wide Inservice education was given to all CNAs and Nurses regarding policy and procedure on Accident prevention and reporting. During a telephone interview on 9/22/2022 at 2:00 PM, the Medical Doctor acknowledged that Resident #1 fell and was transferred to the hospital with a diagnosis of a hip fracture on 4/15/2022. The M.D stated that he/she was not informed of the incident on 4/14/2022. NYCRR: 415.12(h)(2)

Based on staff interviews and record review during an abbreviated survey, the facility did not ensure that a resident received adequate supervision to prevent accidents. This was evident for one (1) of four (4) sampled residents (Resident #1). Resident #1, with a known history of wandering, stealing food and on aspiration precaution, choked and expired after eating unsupervised in his room. This resulted in actual harm that is not Immediate Jeopardy. Complaint ID # NY 722 The finding is: Resident #1 was a [AGE] year old male, admitted at the facility on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set Assessment 2.0 ((MDS) dated [DATE] documented the resident has short and long term memory problems and moderately impaired cognitive skills for daily decision making. According to the MDS the resident had chewing and swallowing problems and requires limited assistance of one person during eating. The Eating/Feeding Comprehensive Care Plan (CCP) initiated on [DATE] documented that the resident required intermittent supervision with set up related to impaired cognition, vascular Dementia, CVA, Dysphagia and high risk for aspiration. On [DATE] after readmission to the facility the feeding requirement changed to limited assistance during eating. Interventions included verbal cues, providing limited assistance in feeding, assessing feeding status quarterly or as needed, referring to speech therapist for swallowing evaluation, providing with ordered diet and liquids, and observing for aspiration precautions. The Behavior CCP initiated on [DATE] and re-evaluated on [DATE], documented that the resident was physically abusive towards staff, aggressive towards other residents and wandered into other rooms taking food. Additionally, the resident refuses medication, resists care and takes food from food trucks. Interventions included, providing psychiatry consult, monitor behavior and re-directing resident away from exit doors, other resident's rooms and food pantries. The Alternate Choice CCP dated [DATE] documented that the resident refused to eat in the unit dining room. Interventions included, providing Spanish speaking staff to translate as needed, and re-approach/reinforce for resident to eat meals in the unit dining room consistently. The Resident's swallowing evaluation dated [DATE] documented that the resident had moderate oral-pharyngeal Dysphagia characterized by difficulty with bolus formation, bolus movement, labial loss of bolus and intermittent coughing with some nectar liquids. The resident is extremely self-directed and does not follow commands. The recommendation is to continue pureed diet with nectar thickened liquids. Also offer extra nectar thickened liquids with meals and in between meals to prevent self-directed taking of thin liquids and risk of aspiration. The facility's daily menu dated [DATE] through [DATE] documented that sliced peaches were served during dinner on [DATE]. Resident #1's [DATE] dinner menu documented that he received a pureed meal with nectar thickened liquids. Nurse's notes dated [DATE] from 5:10 PM to 7:30 PM documented that the resident was served dinner in his room. At 5:33 PM Code blue was called. The resident was noted with no vital signs obtainable. Mouth check was done and no foreign objects were noted. According to the CNA (Certified Nursing Assistant) the resident was walking in the hallway and collapsed. CPR (Cardiopulmonary resuscitation) was initiated at 5:34 PM and 911 was called. EMS arrived on the unit and took over. As EMS was intubating the resident, ",[DATE] processed peach was removed from resident's throat". The resident was pronounced dead by EMS at 6:14 PM. The Facility Accident/Incident Report dated [DATE] documented that the CNA saw the resident walking and talking in the hallway on the unit. The CNA approached resident to help him when he realized that the resident had slurred speech. The CNA called the nurse immediately. No signs or symptoms of distress were noted at that time. The resident and the CNA continued to walk in the hallway towards the nursing station, while the resident continued talking with slurred speech that was unusual for him. After reaching the nurse station he suddenly collapsed. The CNA carried him to the nearest chair and resident was sitting on the chair with 2 CNAs supporting him. The LPN checked the resident and there were no vital signs noted and no obstructions in the mouth. The supervisor called 911, put resident on the nearest bed and initiated CPR. EMS arrived 5:45PM and took over. The Facility's summary of investigation dated [DATE] documented that the resident was pronounced dead at 6:14 PM by EMS personnel and the family was notified. The supervisor was asked to obtain statements from all staff. "The patient plan of care and staff interviewed (statements) was reviewed, it was concluded that the staff followed the plan of care". The ,[DATE] PM Registered Nurse Supervisor (RNS) was interviewed on [DATE] at 9:50 AM. The RNS stated that the residents are monitored in the main and unit dining rooms during meals. She stated that "no one particularly monitors the residents eating in their rooms". The RNS stated that the resident is known to take food from the pantry and is redirected by staff. However the resident speaks Spanish and they need more Spanish speaking staff to communicate with him. The Dietician was interviewed on [DATE] at 6:30 PM. She stated that she has seen the resident stealing ice cream and sandwiches from the refrigerator on multiple occasions. The Dietician reported the incidents to nursing staff. She stated that the staff knows about the resident's behavior and "that's why we have to watch him". The ,[DATE] PM regular Registered Nurse (RN) was interviewed on [DATE] at 6:59 PM. The RN stated that she saw two CNAs holding the resident and before she reached to the resident he already fainted in front of the nurse's station. She instructed one CNA to get oxygen and another CNA called Code Blue. The RN initiated CPR until the RNS arrived to help. The ,[DATE] PM RNS was interviewed on [DATE] 5:35 PM. The RNS stated that she responded to the Code and the CPR was in progress. The RNS called the MD and then took over the CPR. The EMS personnel arrived and continued with CPR. The RNS stated that EMS suctioned and intubated the resident. She saw the EMS personnel pull a processed peach measuring 3 cm (centimeter) by 1cm out of the resident's mouth. The resident expired at 6:15 PM. The EMS personnel then told the RNS that they found a peach in his throat during intubation. The assigned 3PM-11PM CNA was interviewed on [DATE] 7:00 PM. The CNA stated that the resident is known to take food from the floor, food carts and other resident's trays. He stated that the resident is encouraged to eat in the dining room but he prefers to stay in his room. The staff "knows the way he is". On [DATE], between 5:15 PM and 5:20 PM, the CNA served the resident dinner in his room. He had a pureed meal with thickened liquid and soft fruit juice. The CNA stated that the resident's roommate, who is on a chopped consistency diet, was also eating in the room. The CNA set-up Resident #1's food and then left the room to watch other residents in the dining room. At approximately 5:25 PM the CNA saw the resident walking from his room towards the nurse's station. The resident's face looked dark red and he had slurred speech. The CNA walked down the hall with the resident towards the nurse's station and then he collapsed. The CNA called the nurses for help and they sat the resident on a chair. The RN checked the resident's vitals and then called a code. The resident was then put to bed and CPR was started. The CNA stated that the resident's "color was changing so fast as soon as we put him to bed and his eyes were closed". 415.12 (h)(2)