Every finding on record at New Paltz Center For Rehabilitation And Nursing

Based on interview and record review during an abbreviated survey #2616039, the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, and the comprehensive person-centered care plan for two (2) of three (3) residents (Resident #1 and Resident #3) reviewed for pain medication. Specifically, for Resident #1 and Resident #3 there was lack of consistent documentation of pain assessments each shift prior to and after administration of physician ordered as needed oxycodone 5 mg tablets.The findings include:The policy and procedure titled Pain Management revised 4/28/2025 documented prior to administering as-needed pain medication the nurse will evaluate and document in the clinical record the location of pain, pain level prior to medication administration, and the pain scale used. 1. Resident #1 had diagnoses including but not limited to bipolar disorder (psychiatric disorder), fracture of the right femur (long bone in the upper leg), and facture of the left tibia fibula (two long bones located in the lower leg). The comprehensive care plan titled Alteration in Comfort dated 12/13/2024 documented evaluate effectiveness of pain interventions in alleviating symptoms, dosing schedules, identify and record previous pain history and its management. The Minimum Data Set (a resident assessment tool) dated 01/08/2025 documented Resident #1 had intact cognition, no pain, and received pain medication.The physician's order, dated 12/12/2024, documented oxycodone HCl 5 milligrams, one (1) tablet every four (4) hours as needed for a pain scale of 4-6, and oxycodone HCl 5 milligrams, two (2) tablets every four (4) hours as needed for a pain scale of 7-10.The December 2024 narcotic control sheets revealed oxycodone HCL 5 mg tablets were signed out 26 times.There was no documented evidence in the December 2024 Medication Administration Record that oxycodone HCl 5 mg was administered, and that pain was assessed prior to and after administration of oxycodone 13 out of 26 times.The January 2025 narcotic control sheets revealed oxycodone HCL 5 mg tablets were signed out 83 times.There was no documented evidence in the January 2025 Medication Administration Record that oxycodone HCl 5 mg was administered, and that pain was assessed prior to and after administration of oxycodone 47 out of 83 times.The February 2025 narcotic control sheets revealed oxycodone HCL 5 mg tablets were signed out 82 times. There was no documented evidence in the February 2025 Medication Administration Record that oxycodone HCl 5 mg was administered, and that pain was assessed prior to and after administration of oxycodone 50 out of 82 times.During a telephone interview on 10/28/2025 at 10:59 AM, Resident #1 stated they were not getting their pain medication as ordered and as needed, especially on the overnight shift. They stated they did report, but their concerns were discounted. 2. Resident #3 was admitted with diagnoses that included, but not limited to right femur fracture, pain, and right hip wound. The admission Minimum Data Set, dated [DATE] documented Resident #3 had intact cognition pain of 7/10 and received pain medications. The care plan titled Alteration in Comfort dated 10/17/2025 documented medication as ordered and evaluation of the effectiveness of pain interventions. The physician's order dated 10/17/2025 documented oxycodone 5 MG 1 (one) tablet every six (6) hours as needed for pain of 6-10.The narcotic control sheets revealed oxycodone 5 mg tablets were signed out 22 times from 10/19/2025 to 10/28/2025. There was no documented evidence in the medication administration record that oxycodone 5 mg was administered from 10/19/2025 to 10/28/2025 and that pain was assessed prior to and after the administration of oxycodone11 out of 22 times During an interview on 10/28/2025 at 12:00 PM Licensed Practical Nurse #2 stated documentation on Resident #1's medication administration record was not complete therefore pain assessment was not always done prior to and after the administration of the oxycodone. During an interview on 10/29/2025 at 1:11 PM Licensed Practical Nurse #3 stated Resident #1 was alert, oriented, and demanded as-needed medications. They stated the narcotic book was usually reviewed to determine the last administration time instead of checking the medication administration record. They stated pain medication that was administered to Resident #1 as requested was not always documented as given on the medication administration record therefore, pain evaluation was not done prior to and after the administration of the oxycodone. During a telephone interview on 10/30/2025 at 11:16 AM Licensed Practical Nurse #5 stated when they signed in the Medication Administration Record that they administered as needed pain medication, the pain evaluation tool automatically populated on the medication administration record for evaluation prior to and after administration. During an interview on October 29, 2025, at 2:00 PM the Director of Nursing stated pain assessment would be documented in the Medication Administration Record when the medication was signed as administered. They stated pain assessment would not be triggered if as needed pain medications were not documented as having been administered. They further stated there was not documented evidence of consistent pain assessment done before and after Resident #1 and Resident #3 received pain medication.During a follow-up interview on 11/05/2025 at 9:30 AM, Licensed Practical Nurse #3 stated Resident #1 consistently reported a pain level of ten. They stated Resident #1's pain regimen was reviewed frequently with the physician, and the physician conducted in-person evaluations of Resident #1. They stated there was no documentation that Resident #1's pain was consistently monitored or assessed before and after the administration of pain medication. 10 NYCRR 415.12

Based on interview and record review during an abbreviated survey #2616039 the facility did not provide pharmaceutical services including procedures that assure the accurate dispensing, and administering of all drugs and biologicals to meet the needs of each resident for two (2) out of three (3) residents reviewed for pain medication administration. Specifically, for Resident #1 and Resident #3 oxycodone 5mg tablets (narcotic) were signed out on the narcotic control sheets but were not accounted for and documented in the resident's Medication Administration Record as administered to the residents. Additionally, there was no evidence that a pharmacist conducted periodic audits or oversight to ensure accurate record keeping and accounting of the controlled substances.The findings include: The policy and procedure titled Medication Administration, revised 2/2019, documented the individual administering the medication must initial the resident's Medication Administration Record on the appropriate line after giving each medication and before administering the next dose.1. Resident #1 had diagnoses including but not limited to bipolar disorder (psychiatric disorder), fracture of the right femur (long bone in the upper leg), and facture of the left tibia fibula (two long bones located in the lower leg). The Minimum Data Set (a resident assessment tool) dated 01/08/2025 documented Resident #1 had intact cognition, no pain, and received pain medication.The physician's order, dated 12/12/2024, documented oxycodone HCl 5 milligrams, one (1) tablet every four hours as needed for a pain scale of 4-6, and oxycodone HCl 5 milligrams, two (2) tablets every four hours as needed for a pain scale of 7-10.The narcotic control sheets revealed oxycodone HCL 5 mg tablets were signed out 26 times in December 2024, 83 times in January 2025, and 82 times in February 2025.There was no documented evidence in the Medication Administration Record that oxycodone HCl 5 mg was administered 13 out of 26 times in December 2024, 47 out of 83 times in January 2025, and 50 out of 82 times in February 2025. During a telephone interview on 10/28/2025 at 10:59 AM, Resident #1 stated they thought there was a drug diversion problem while they were at the facility. They stated they were not getting their pain medication as ordered and as needed, especially on the overnight shift. They stated they did report their suspicions, but their concerns were discounted. During an interview on 10/29/2025 at 2:51 PM, Licensed Practical Nurse Unit Manager #4 stated Resident #1 never reported concerns to them regarding administration of their pain medication. They stated if they received complaints or concerns from Resident #1, they would have investigated and reported it to the Director of Nursing. 2. Resident #3 was admitted with diagnoses that included, but not limited to, right femur fracture, pain, and wound right hip. The admission Minimum Data Set, dated [DATE] documented Resident #3 had intact cognition, pain of 7/10, and received pain medications. The care plan titled Alteration in Comfort dated 10/17/2025, documented medication as ordered and evaluation of the effectiveness of pain interventions. The physician's order dated 10/17/2025 documented oxycodone 5 MG, 1 (one) tablet every six (6) hours as needed for pain of 6-10.The narcotic control sheets revealed oxycodone 5 mg tablets were signed out 22 times from 10/19/2025 to 10/28/2025.There was no documented evidence in the Medication Administration Record that oxycodone 5 mg was administered 11 of the 22 times from 10/19/2025 to 10/28/2025.During an interview on 10/28/2025 at 3:11PM, Resident #3 stated that they received their pain medication consistently every six hours and denied any problems related to the administration of the medication.During an observation on 10/28/2025 at 3:00 PM, Licensed Practical Nurse Manager #5 and Licensed Practical Nurse #1 conducted a narcotic count. All narcotics were accounted for, and both individuals signed the sign-off sheet. No discrepancies were noted. The narcotic box was double locked, the medication room was locked, and the nurse kept the keys securely on their person.During an interview on 10/28/2025 at 12:00 PM, Licensed Practical Nurse #2 stated documentation on Resident #1's Medication Administration Record was not complete. They stated they knew they should sign the Medication Administration Record when giving an as needed pain medication but did not always do that as they were busy. During an interview on 10/29/2025 at 1:11 PM, Licensed Practical Nurse #3 stated Resident #1 was alert, oriented, and demanded as-needed medications. They stated pain medication that was administered to Resident #1 as requested was not always documented as given on the Medication Administration Record. They stated the narcotic control sheets were usually reviewed to determine the last administration time instead of checking the Medication Administration Record.During a telephone interview on 10/30/2025 at 11:16 AM Licensed Practical Nurse #5 stated when they administered a controlled medication, they usually signed it out in the narcotic book and then the Medication Administration Record. During an interview on 10/29/2025, at 2:00 PM, the Pharmacy Consultant stated that they did offsite regimen reviews only as that was how the contract with the facility was set up. They stated their review of medications including controlled substances was based solely on the documentation in the Medication Administration Record. They stated they did not review the narcotic control sheets. They stated the nurses assigned would be responsible for checking to ensure the controlled medications were logged accurately in the Medication Administration Record. They stated they did not review pain assessments but if they reviewed the Medication Administration Record and identified pain medications were administered often, they may have a concern. They stated if medication administration frequency was not accurate, they would not know to check into it unless it conflicted with the order. During an interview on 10/29/2025, at 2:00 PM, the Director of Nursing stated when nurses administered narcotics, they should sign both the narcotics log and the Medication Administration Record. They stated nurses had been educated to sign both. During an interview on 10/30/2025 at 3:15 PM the Director of Nursing stated there was no formal process to check the narcotic control sheets against the Medication Administration Record. They stated the pharmacist worked remotely and did not come to the facility. 10 NYCRR 415.18

Based on observations, interviews, and record reviews during the recertification and abbreviated surveys (Intake #2569939), the facility did not ensure sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, the Daily Nurse Staffing Rosters reviewed from 08/10/2025 through 09/12/2025 documented on four (4) of 34 days, there was one (1) certified nurse aide documented for the A unit night shift (1:35 or 1:36 ratio ) and on one (1) of 34 nights, there was one (1) certified nurse aide assigned to B unit (1:36 ratio). On 29 of 34 days reviewed, assigned staff did not complete their assigned shift (came in late or left early). A nurse supervisor was not assigned on 4 of 34 dates reviewed for day shift, 15 of 34 dates for evening shift and 26 of 34 dates for the night shift. Additionally, during the 11:00PM to 7:00 AM shift on 09/11/2025, Resident #32 sustained a fall and there was only one staff member, a licensed practical nurse, working on the A unit. Resident #56 dislodged their urinary catheter and nursing staff did not address in a timely manner. Residents, family members, and staff expressed concerns about low staffing, long wait times in response to call bells, and delays in receiving care.The findings included:The Facility assessment dated [DATE] documented the maximum capacity as 77 residents and an average daily census range of 70-77 residents. The Staffing Plan documented one registered nurse/licensed practical nurse per unit, per shift; two certified nurse aides per unit, day and evening shift (1:19 ratio); and one certified nurse aide per unit, night shift (1:38 ratio). Unit Acuity levels provided by the Director of Nursing documented six (6) residents were scheduled to get up prior to 7:00 AM on the A unit and one (1) resident on the B Unit. Seven (7) residents were on wander guard list on the A unit and two (2) on the B unit. Two (2) residents on A unit required supervision checks. Twenty residents on the A unit required incontinence cares and 11 required assistance with toileting. Thirteen residents on the B unit required incontinence cares and 11 required assistance with toileting. Eleven residents on the A unit and 11 residents on the B unit required a mechanical lift for transfers requiring two staff members. Five (5) residents on the A unit and one (1) resident on the B unit required total care assistance.On 4 of 34 days reviewed from 08/10/25 through 09/12/2025, a nurse supervisor was not assigned on the day shift.On 15 on 34 days reviewed from 08/10/2025 through 09/12/2025, a nurse supervisor was not assigned on the evening shift.On 26 of 34 days reviewed from 08/10/2025 through 9/12/2025, a nurse supervisor was not assigned for the night shift.On 08/23/2025, 08/30/2025, and 09/10/2025 there was one certified nurse aide documented for A unit night shift on the Daily Staffing Report.There were staffing inconsistencies noted between review of the Daily Certified Nurse Aide Assignment Sheets and the Daily Staffing Reports reviewed. For example, the Daily Certified Nurse Aide Assignment Sheets documented one certified nurse aide on the A unit on 08/17/25 for the 11:00 PM to 7:00 AM shift which was inconsistent with the Daily Staffing Report staffing of two (2) certified nurse aides assigned to A unit. On the 09/11/2025 11:00 PM to 7:00 AM shift, the Daily Staffing Report documented one (1) certified nurse aide was assigned to the A unit. The Certified Nurse Aide Schedule Form documented the name of an aide who called out. During interviews with staff, there was no aide assigned to Unit A unit until after Resident #32 sustained a fall at 2:00 AM.During a Resident Council meeting on 09/10/2025 at 11:06 AM, Resident #15's representative stated staff were not responsive to call bells. They stated Resident #15 was not taken out of bed at times due to low staffing and frequently had to return to bed early because there would not be enough staff to get them back into bed. Resident #67 stated turning and repositioning was not completed according to facility policy because of low staffing. All residents in attendance stated that the overnight shift was the worst for low staffing. During an observation on 09/10/2025 at 11:34 AM, a strong smell of urine was present in Resident #12's room.During interviews on 09/11/2025 at 4:20 PM and 09/12/2025 at 11:36 AM, the Director of Human Resources/Staffing Coordinator stated the night shift frequently did not have a supervisor in the building. They stated they had been instructed by Administrator to staff up to four (4) certified nurse aides on Unit A and Unit B for the day and evening shift and a minimum of two (2) certified nurse aides on Unit A and Unit B for the night shift and this was accomplished most of the time. They stated they had not been instructed to add more certified nurse aides during any shift based on acuity needs/changes and had been instructed to reduce staffing of certified nurse aides if the facility census dropped. They stated recruitment of nursing staff was on-going and licensed practical nurse recruitment was particularly difficult with main deterrent being salary. During interviews on 09/09/2025 at 9:03 AM and 09/12/2025 at 2:28 PM, the Administrator stated the Facility Assessment Staffing Plan was lowered after last survey in November 2024. They stated the staffing numbers listed on the Facility Assessment were based on the minimum number of staff needed to ensure safety of residents. They stated the facility expectation was that the unit registered nurse or licensed practical nurse staff assisted certified nurse aides with resident cares as needed, and that unit staff assisted the other unit staff as needed. The Administrator stated the night shift was the most difficult to staff due to frequent callouts and not being able to cover at last minute. They stated they provided the Staffing Coordinator with the number of staff for each shift and the goal was four (4) certified nurse aides each unit day shift, three (3) to four (4) certified nurse aides evening shift and two (2) certified nurse aides for night shift per unit. The Administrator stated the facility needed an additional registered nurse supervisor and a licensed practical nurse night shift supervisor and recruitment had been ongoing for the position. They stated that nursing staff were required to work complete shifts and there were times when adjustments had been made allowing staff to come in late/leave early due to covering callouts. The Administrator stated they were aware of one (1) star rating and believed it had recently improved, and that staffing was a work in progress with recruitment always ongoing. During interviews on 09/12/2025 at 9:05 AM and 09/13/2025 at 12:32 PM, Registered Nurse Unit Manager #21 stated Resident #32 sustained a fall about 2:00 AM on 09/12/2025. They stated staffing on Unit A was only one licensed practical nurse at the time of fall due to a callout which was not replaced and there was no night supervisor scheduled for the night shift. Registered Nurse Unit Manager #21 stated they were contacted at the time of fall by the licensed practical nurse and a telehealth assessment was completed. After the fall, Unit A received a certified nurse aide from the B unit. They stated Unit A frequently had only one (1) certified nurse aide assigned to night shift resulting in cares not always being completed. They stated staffing was reduced by administration due to budget concerns. They stated the Certified Nurse Aide Schedule Form for the night shift on 09/11/2025 contained the name of the certified nurse aide who called out and a replacement aide was not assigned to unit.During an interview on 09/12/2025 at 9:38 AM, Licensed Practical Nurse #19 stated staffing was low most of the time with both nursing and in particular, certified nurse aide staff during evenings and nights. They stated when there was only one certified nurse aide on each unit during the night shift, resident cares were not completed. When the day shift arrived, when only one certified nurse aide worked night shift, residents were soaking wet and complained that call bells were not answered during night. Residents requiring two (2) person assistance for cares were particularly affected. They stated that the licensed practical nurse/registered nurse on unit assisted with cares, but with only one nurse passing medications and providing treatments, it was not always feasible to assist certified nurse aides. They stated another staffing concern was that staff reported to shifts up to two hours late or left early. They stated this affected resident cares, medication administration and blood glucose testing/finger sticks which ended up being completed late. They stated when they present for 7:00 AM shift, they had often been forced to care for 40 residents due to another nurse being late.On 09/12/2025 at 11:56 AM, Resident #4 was interviewed and stated they were passing by Resident #56's room at approximately 5AM on the night shift in the end of May 2025 and observed Resident #56 trying to get out of their bed unassisted. Resident #4 stated they knew Resident #56 was confused and had fallen previously so they (Resident #4) attempted to find a staff member to attend to Resident #56. Resident #4 stated they were unable to find any staff member on the entire unit to assist Resident #56. Resident #4 decided to stay with Resident #56 until a staff member appeared, so the resident was safe. Resident #4 stated they noticed Resident #56's foley catheter had become dislodged. Resident #4 saw Licensed Practical Nurse #6 pass by in the hall giving out medication. Resident #4 stated they informed Licensed Practical Nurse #6 of Resident #56's condition and was told by the nurse that they were not allowed to go into Resident #56's room. Licensed Practical Nurse #6 did not get another nurse to address Resident #56. Resident #4 stated they stayed with Resident #56 for 2 hours until the morning shift nurse arrived at 7 AM and addressed Resident #56's fall risk and reinserted the foley catheter. During an interview on 09/12/2025 at 4:47 PM, Licensed Practical Nurse #6 stated they were scheduled to work a double shift, covering the evening and night shifts. Licensed Practical Nurse #6 stated they expressed frustration to the Administrator and the Director of Nursing regarding discrepancies between the posted nursing staff schedule and the actual hours worked by nursing staff. For example, a certified nurse aide on the night shift had an agreement with administration that they were able to leave at 5:00 AM, the most hectic time of the shift, on many nights. Licensed Practical Nurse #6 stated the Director of Nursing and Human Resources Director knew this aide would leave early, but did not communicate this to the nursing staff, creating confusion and more work for the rest of the staff. Licensed Practical Nurse #6 stated a nurse supervisor was not scheduled to be present in the facility most nights and aides walked out without informing the nurses. In addition, the nurse supervisors had the access key to the kitchen and stock room and if they were not present in the building, staff were unable to access these rooms. They stated earlier this morning, at approximately 2:00 AM, the licensed practical nurse from Unit A requested their assistance because a resident fell. After visiting the A Unit, they realized Unit A did not have a Certified Nurse Aide working on the 11:00 PM to 7: 00 AM shift. The Unit A license practical nurse asked Licensed Practical Nurse #6 to reassign one of their aides to the A Unit. Licensed Practical Nurse #6 stated this left the B Unit with only one Certified Nurse Aide for approximately 34 residents for the rest of the night shift. When asked about the incident in May 2025 with Resident #56, they stated they were not allowed to provide care for Resident #56 and had to get a nurse from the other unit to administer the resident's medications. No one was available to coordinate staff coverage or completion of assignments at night. Licensed Practical Nurse #6 stated there was one aide on the night Resident #56's catheter was dislodged and the aide left early. They were addressing call bells and trying to pass medications to residents timely.During an interview on 09/13/2025 at 6:48 AM, Certified Nurse Aide #11 stated scheduling one certified nurse aide per resident unit on the night shift was unmanageable. They stated workload was heavy due to callouts and staff not working their entire shift, either leaving early or coming in late. They stated when staff left early or came in late, it was not communicated to other staff members and workload became increased at busiest times. Certified Nurse Aide #11 stated unreliable nursing staff were routinely scheduled without a plan to prevent the unit from working short-staffed. Certified Nurse Aide #11 stated prior to the interview, they had four call bells ringing on three separate wings of Unit B and they had to rush to address resident needs because there were residents at risk for falls who tried to get out of bed, residents who requested ice and water in the morning, and some residents who wanted to start getting dressed or out of bed. Certified Nurse Aide #11 stated caring for all 34 residents on Unit B while the Licensed Practical Nurse passed medication was too much for them to handle and they were overwhelmed. Certified Nurse Aide #11 stated Unit A consisted of long-term residents with higher acuities who required more staff assistance and supervision. They stated it was impossible to manage Unit A with one certified nurse aide on the night shift. Certified Nurse Aide #11 stated they worked the 11PM to 7AM shift last night and started out on Unit B with one other aide. Certified Nurse Aide #11 stated their assignment was manageable until a resident fell at approximately 2:00 AM on Unit A. Licensed Practical Nurse #6 went to Unit A to help the other licensed nurse and became aware that no certified nurse aide showed up to work that night on Unit A and the licensed nurse was on the unit alone. Certified Nurse Aide #11 stated they were reassigned to Unit A for the rest of their shift and the resident needs were too much for them to address. Certified Nurse Aide #11 stated they were often unable to end their shift on time, including today, due to their relief not showing up on time for their shift. Certified Nurse Aide #11 stated they did not get paid for the time they had to stay past the end of their shift and were unable to take a break most nights because of the workload. During an interview on 09/13/2025 at 11:08 AM Certified Nurse Aide #14 stated they worked a variety of different shifts including working mostly double shifts and frequently seven (7) days a week. They stated callouts were not replaced had a big impact on resident cares not being completed. They stated when the units are short-staffed, they frequently must skip breaks. They stated the A unit has more early morning get ups and sometimes not all of them are completed and are left to the day shift to complete. Certified Nurse Aide #14 stated that many staff do not work their entire shift (leave early, come in late) causing workload to be divided between the remaining staff present. During an interview on 09/13/2025 at 11:28 AM, Certified Nurse Aide #20 stated the facility was always short staffed and callouts occurred daily each shift. They stated units mostly had three (3) certified nurse aides for day shift and evening and nights could have two (2) certified nurse aides. Due to low staffing, the units were extremely busy, and cares were always rushed. They stated they were frequently not able to take breaks properly because of the workload. Certified Nurse Aide #20 stated they work double shifts at least five (5) times a week and worked seven (7) days a week most of the time. They stated there were usually two nurses per unit each shift and a supervisor only sometimes during night shift. They stated that on night shift when only one certified nurse aide assigned to a unit, the residents complained that they were not changed but it was impossible for one (1) aide to provide cares for about 40 residents, especially on the A unit where residents required more incontinence cares and had dementia. During an interview on 09/13/2025 at 2:18 PM, the Director of Nursing stated staffing had room for improvement, was a work in progress, and recruitment was on going. The Director of Nursing stated daily callouts were the biggest concern /hindrance to meeting desired staffing ratios and sometimes extra staff were added to the shifts to cover potential callouts. They stated they believed residents were receiving quality care when there was only (one) 1 licensed practical nurse and one (1) aide on a unit during night shift. They stated it might not be ideal, but cares were completed, and safety was maintained. They stated they were aware that there was not always a nurse supervisor in the building during evening and night shifts and recruitment for an additional Registered Nurse Supervisor was ongoing. The Director of Nursing stated they were aware of Resident Council concerns regarding low staffing and staff had been disciplined and re-educated regarding call bell response and activities of daily living preferences as a result. The Director of Nursing stated that on the 09/11/2025, 11:00 PM to 7:00 AM shift, when Resident #32 sustained a fall, Certified Nurse #11 was assigned to Unit A along with one licensed practical nurse for the shift. 10NYCRR 415.13(a)(1)(i-iii)

Based on observations, interviews, and record review during the Abbreviated Survey (NY00376400) the facility did not ensure that 1 of 3 residents (Resident #1) investigated for abuse remained free from abuse. Specifically, on 3/27/2025, Resident #1, who was severely cognitively impaired with a history of wandering and entering other residents' rooms, was found in Resident #2's bed. Resident #2, who was cognitively intact, stated that they did touch Resident #1 on their breasts per their request. Resident #1 lacked the capacity to make sound decisions at the time of the incident. The facility investigative conclusion found that no abuse had occurred.The findings include:The Facility Policy titled Abuse revised 6/1/2024 documented that the facility has designed and implemented processes which strive to ensure the prevention, and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment and /or misappropriation of property. The Facility incident report dated 3/27/2025 documented that Resident #1 was found in Resident #2's bed. Resident #2 admitted to touching Resident #1's breasts when Resident #1 asked. Resident # 1 had diagnoses that included unspecified dementia, cerebral infarction, and unspecified psychosis. The Quarterly Minimum Data Set, dated [DATE], documented that the resident had severely impaired cognition, no behaviors, self-propels wheelchair independently, and a wander guard in use daily. The Annual Minimum Data Set, dated [DATE], documented that the resident had severely impaired cognition, no behaviors, self-propels wheelchair after set up assistance, and a wander guard in use daily. Resident #1's care plan initiated 4/4/2022, Resident at risk for misappropriation, neglect, abuse, and/or exploitation related to impaired cognition, documented a goal that resident will not experience any form of abuse, neglect, misappropriation, or exploitation. Interventions initiated 4/4/2022 included assessment of resident for any signs of abuse and investigate all allegations of abuse promptly Resident #1's care plan initiated 3/3/2022, Resident exhibits risk for elopement, cognitive impairment/decline, and wandering, documented a goal that resident safety will be maintained. Interventions initiated 3/3/2022 documented distract resident from wandering, identify patterns and triggers for wandering, and use of wander guard management device. Resident #1's care plan initiated 2/6/2023, Resident exhibits behavior symptoms including trying to feed and care for other residents and wanders into other residents' rooms, documented a goal that resident will exhibit less behaviors, safety will be maintained, and resident will not harm self. Interventions initiated 2/6/2023 included distracting resident with activities of interest, resident to sit at nurses' station as tolerated, and distract resident with activities. During an observation and interview on 7/9/25 at 2:06PM, Resident #1 was observed sitting in a wheelchair in the Unit A hallway. They were pleasant, denied any complaints, did not appear fearful or distressed, and were dressed appropriately. Resident #1 was interactive and engaging but had limited comprehension and unable to carry on effective conversation. Resident #2 had diagnoses that included, but not limited to, cerebral infarction, hemiplegia affecting the left side, and depression.The Quarterly Minimum Data Set, dated [DATE] documented intact cognition, no behaviors, antidepressant use, no antipsychotic medication use.The admission Minimum Data Set, dated [DATE] documented moderately impaired cognition, no behaviors, no antidepressant or antipsychotic medication use. There was no documented evidence, including a care plan, of Resident #2 exhibiting any type of behavior, including sexually inappropriate behavior prior to 3/27/2025. During an observation and interview on 7/9/2025 at 10:55AM, Resident #2 was observed in their bed, dressed, awake, and engaging. They denied any complaints. Resident did not exhibit any inappropriate comments or actions.During an interview on 7/10/25 at 3:10PM, Resident #2 stated that they remember the incident involving Resident #1 on 3/27/2025. They stated that they were both at an activity, after which Resident #1 asked them to keep them company. Resident #1 asked to use their bathroom which they allowed. Then Resident #1 asked them to touch and have oral contact with their breasts, which they stated they did. Resident #2 stated that Resident #1 then asked to lay down and invited them in the bed with them, but they stated there was not enough room, so they stayed in their wheelchair while Resident #1 rested. An aide arrived shortly after that, and many more people came including the police. They stated they thought Resident #1 was just hard of hearing, not cognitively impaired. During an interview on 7/9/2025 at 3:05PM, Certified Nurse Aide #1 stated that Resident #1 does wander. On 3/27/2025 they were looking for Resident #1 at dinner time and located them in Resident #2's room in their bed. They stated they monitor Resident #1 very closely now, hourly rounding was implemented after the incident. During an interview on 7/9/2025 at 3:36PM, Registered Nurse Supervisor #2 stated that they were the Supervisor on duty at the time of the incident. They stated that Resident #1 was observed in Resident #2's bed, and Resident #2 was in their wheelchair. Resident#1 was fully dressed, but they could see their brief and pants were down a little bit. They stated that Resident #2 stated that they did touch Resident #1's breasts but denied further sexual activity. Resident #1 was removed from the room, could not recall the incident, and did not appear distressed. They performed a physical assessment which revealed no findings. Resident #1 has a history of wandering and does go in other residents' rooms at times.During an interview on 7/10/25 at 10:40AM, Licensed Practical Nurse Unit Manager #4 stated Resident #1 has always had a history of wandering, but they haven't seen them wandering onto Unit B in some time, the staff usually redirect them back to Unit A. During an interview on 7/10/25 at 11:00AM, the Director of Social Work stated they monitor Resident #1 closely because they have a history of wandering. During an interview on 7/10/25 at 11:20AM, Registered Nurse Unit Manager #5 stated they were not at the facility the day of the incident. Resident #1 has severely impaired cognition. They do not have any behaviors except the wandering, and a wander guard is in place. Sometimes Resident #1 would wander through the facility in the hallways and they have tried to help other residents but is not exit seeking. They have always tried to monitor the resident closely, but the documented enhanced supervision was implemented after the incident. During an interview on 7/10/25 at 11:46AM, Certified Nurse Aide #6 stated that they were working the day of the incident and did observe Resident #1 in Resident #2's bed. They stated Resident #2 may have said something about feeling Resident #1 up. During an interview on 7/10/25 at 12:02PM, Certified Nurse Aide #7 stated Resident #1 is confused, and wanders in the hallways. They have wandered into other residents' rooms and transferred into their beds. Since the incident they are monitoring them closely every hour. During an interview on 7/10/25 at 12:20PM, Licensed Practical Nurse #8 stated Resident #1 is pleasantly confused, oriented to self, no behaviors except wandering, does try to help other residents and they have wandered into other residents' rooms. During an interview on 7/10/25 at 12:36PM the Activities Director stated Resident #1 can self-propel to activities, but since the incident activities staff transports them to and from the activities and notifies nursing. Frequent monitoring is in place since the incident. They don't seat any cognitively impaired residents with Resident #2 now. During an interview on 7/10/25 at 1:00PM, the Administrator stated they were informed immediately of the incident on 3/27/2025. The residents were already separated when they arrived on the unit. Resident #2 stated they did touch Resident #1's breasts because Resident #1 asked them to but denied anything more. Resident #2 stated they did not know that Resident #1 had limited capacity. The Administrator stated that the police were contacted and arrived and spoke with Resident #2. Resident #1 was not able to recall the event. They stated no other incidents with Resident #1 or Resident #2 have occurred since the incident on 3/27/2025. During an interview on 7/10/25 at 1:20PM, the Director of Nursing stated the enhanced monitoring was implemented for Resident #1 after the incident because of their wandering history and both residents were placed on behavioral monitoring. During a follow up interview on 7/10/25 at 4:00PM, the Administrator stated that they did not conclude that abuse occurred because there was no ill intent, and it was not malicious. 10NYCRR 415.4(b)(1)(i)

Based on record review and interview conducted during the recertification survey from 11/14/24 to 11/22/24, the facility did ensure that a Registered Nurse worked eight cosecutive hours a day, seven days a week. Specifically, the facility was unable to provide documented evidence that a Registered Nurse worked 10/20/24, 11/2/24, 11/3/24, 11/16/24, 11/17/24. Findings include: The Facility Wide assessment dated [DATE] documented the staffing plan as follows: Day shift unit A and B: 2 nurses each unit. Evening shift units A and B: two nurses each unit. Night shift Units A and B: 1 nurse each unit. The Facility Wide Assessment does not include Registered Nurse for at least eight consecutive hours per day, seven days per week as per the regulations. The 10/10/24-11/21/24 Daily Nurse Staffing Roster documented the facility did not have a Registered Nurse at least 8 consecutive hours a day for 7 days a week on 10/20/24, 11/2/24, 11/3/24, 11/16/24, 11/17/24. During an interview on 11/20/24 at 10:17 AM the Staffing Coordinator stated there have been occasions on weekends when the facility has not had a Registered Nurse in the building. They stated the facility have a Registered Nurse on staff who works every other weekend from 7:00AM-3:00PM and the remaining weekends are covered by Licensed Practical Nurse staff. They stated the Director of Nursing and/or Unit Managers are on-call when a Registered Nurse in not in the building. They stated the facility is actively recruiting for Registered Nurse staff. During an interview on 11/21/24 at 10:32 AM the Director of Nursing stated there have been weekends when there has not been a Registered Nurse in the facility. During days when there is no Registered Nurse in the facility there is a telehealth line at the nurse station which provides mid-level coverage by a Physician Assistant/Nurse Practitioner. They stated they are also on-call and live locally so they can present to the facility if a Registered Nurse is needed. They stated there are other Registered Nurses in the facility who also participate in the on-call rotation. They stated staffing has been challenging and efforts are in place to hire additional Registered Nurses. During an interview on 11/22/24 at 10:45 AM Licensed Practical Nurse #3 stated the facility does not have a Registered Nurse at night or every other weekend days. They stated they work every other weekend and at times there is no Registered Nurse in the building. If a situation occurs where a Registered Nurse is needed, they call the Director of Nursing who is on-call. They stated the Director of Nursing or on-call Registered Nurse will present to the facility. During an interview on 1/22/24 at 02:22 PM the Administrator stated the facility has had a lot of difficulty hiring locally and that staffing could be challenging. 10NYCRR 415.13(b)(1)

Based on record review and interview conducted during the recertification survey from 11/16/2024 to 11/22/2024, the facility did not ensure Annual Performance Reviews were completed at least once every 12 months. Specifically, the facility was unable to provide Annual Performance Reviews for 3 of 5 Staff Members (#9, #10, #12) reviewed. The findings are: The facility policy titled Employee Evaluations, dated 9/29/2019, documented: A performance evaluation will be completed on each employee at least annually. During an interview and record review with the Assistant Director of Nursing/Nurse Educator on 11/20/24 at 11:07 AM, they stated they were not able to provide documentation of an Annual Performance Review for Staff Members (#9, #10, #12). They stated they are new to the facility and have not completed annual performance reviews as of yet. During an interview and record review with the Director of Nursing on 11/20/24 at 11:07 AM, they stated they were aware the Assistant Director of Nursing/Nurse Educator was not able to provide documentation of an Annual Performance Review for Staff #9, #10, and #12. 10NYCRR 415.26 (c)(2)(iii)

Based on observation and interview during the Recertification survey from 11/14/24 to 11/22/24, the facility did not ensure residents were provided food and drink that is palatable, attractive, and at a safe and appetizing temperature. Specifically, food was not served at palatable and safe temperatures for 2 of 3 residents (Resident #17 and Resident #23) reviewed for Food. The findings are: The Policy titled Food Temperatures last reviewed 3/2023 documented temperatures of cold and hot food items will be recorded on all menu items and substitutions for meal service to maintain a high level of quality and to monitor potentially hazardous food temperatures as per state and federal regulations thus ensuring that food is provided in a safe, palatable manner. All employees are responsible to notify their supervisor of any food item that does not meet the regulated safe acceptable service ranges (at or below 41 degrees Fahrenheit or above 135 degrees Fahrenheit). During an interview on 11/15/24 at 11:27 AM Resident #17 stated they do not like the food, the food is always cold. During an interview on 11/14/24 at 12:55 PM and on 11/15/24 at 11:24 AM Resident #23 stated they do not like the food, the food is served cold. On 11/21/24 at 1:01 PM temperatures were checked on a test tray by the Dietary Technician and registered as follows: pork gravy 103.3 degrees Fahrenheit, mashed potatoes 123.4 degrees Fahrenheit, cooked carrots 102.6 degrees Fahrenheit, cranberry juice 62 degrees Fahrenheit. The Dietary Technician stated they could not explain the reason food had a low temperature. During an interview on 11/21/24 at 1:03 PM the Dietary Technician stated the food and cold beverages were at acceptable temperatures when they left the kitchen. 10NYCRR 415.14 (d)(1)(2).

Based on observation, record review and interview conducted during a recertification survey from 11/14/24-11/22/24, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infections. Specifically,1) the Water Management Plan had not been updated annually and the Environmental Risk Assessment had not been performed annually to identify areas where Legionella could spread, 2) Resident #13's urine collection bag was not maintained or emptied in a manner to prevent infection, 3) Resident #51 consented to receive the Respiratory Syncytial Virus vaccine but did not receive it until almost two months later. 4) 4 of 10 Staff, Certified Nurse Aide #4, Minimum Data Set Coordinator, Dietary Aide #1, and Cook, reviewed for vaccinations were not screened, offered, or given the opportunity to accept or decline pneumococcal vaccination. 5) Staff did not apply proper Personal Protective Equipment while assisting Resident #23 and #26, who were on Enhanced Barrier Precautions. The findings are: The facility policy titled Enhanced Barrier Precautions last revised on 5/30/24 documented Enhanced Barrier Precaution is applicable for residents with any of the following: wounds (e.g., any type of wound requiring a dressing) and/or indwelling medical devices (e.g., urinary catheter, tracheostomy/ventilator, etc.) regardless of Multiple Drug Resistant Organisms colonization status. Enhanced Barrier Precaution is primarily intended to apply to care that occurs within a resident's room where high-contact resident care activities are commonly bundled together - e.g., AM/PM care, transfers, toileting, etc. Enhanced Barrier Precaution requires wearing disposable gloves and an isolation gown prior to high contact activity. High contact resident care activities include dressing, transferring, device care or use: urinary catheter. 1)The Environmental Risk Assessment was reviewed and dated 5/18/2021. The facility's Water Management Plan did not have the last review date on the document. During an interview on 11/20/24 at 1:30 PM the Director of Maintenance stated they were responsible for Water Management Program but was not aware the Water Management Plan needed to be reviewed and revised, if necessary, annually. They further stated they did not know the Environmental Risk Assessment should be performed annually but stated it made sense since the team members do change. 2)Resident #13 was admitted with diagnoses including Spinal Stenosis, Type II Diabetes Mellitus, and Urinary Retention. The Minimum Data Set (an assessment tool) dated 9/25/24 documented Resident #13 was cognitively intact and had an indwelling urinary catheter. During an observation on 11/20/24 at 9:05 AM Resident #13 was in bed and the urine collection bag and drainage port were in contact with the floor. During observation on 11/20/24 at 10:41 AM and 11/20/24 at 5:08 PM Resident #13's leg bag (used to collect urine) was observed hanging over the toilet handrail without a cap cover on the end that would be connected to the catheter tubing. During an observation on 11/20/24 at 10:39 AM the Certified Nurse Aide #1 applied a gown and gloves, removed the Resident #13's used urinal from the toilet area, rinsed it with water and attended to the resident's urine collection bag to drain the urine. The urinal was placed on the floor, the collection bag drainage port was put inside the urinal and touched the sides of the urinal. During an interview on 11/20/24 at 10:39 AM Certified Nurse Aide #1 stated sometimes there are no caps for the urine collection bags and that is just the way it is. Certified Nurse Aide #1 stated if they don't wedge the collection bag drainage port end inside the urinal, the urine can get all over the floor and was not aware the technique could be spreading infections. During an interview on 11/20/24 at 3:38 PM the Infection Preventionist/Assistant Director of Nursing stated new bags should be used after disconnecting the old bags and not stored hanging over the toilet handrail. The Infection Preventionist stated leaving urine collection bags uncapped is not a clean practice. They stated Certified Nurse Aides need constant reminding and education to perform tasks correctly, making sure the collection bag tips don't touch the inside of the urinals which may lead to infections. 3) Resident #51 was admitted with diagnoses including Hypothyroidism, Bipolar Disease and Neurogenerative Lewy Body Neuropathy. The Minimum Data Set (an assessment tool) dated 10/10/24 documented Resident #51 had moderate cognitive impairment. During an interview on 11/15/24 at 10:33 AM Resident #51 stated they were offered the Respiratory Syncytial Virus vaccination when they were admitted to the facility and signed the consent form, but they have not received the shot yet. The Consent for Vaccine Form documented on 10/3/24, Resident #51 signed that they wanted to receive the vaccine. There was no documented evidence the vaccine was given. During an interview on 11/20/24 at 3:38 PM the Infection Preventionist/Assistant Director of Nursing stated there was a supply on hand for the vaccine and it was not given but should have been given by the Unit Manager. 4) The Vaccine Records for Certified Nurse Aide #4, Minimum Data Set Coordinator, Dietary Aide #1 and the [NAME] #1, determined there was evidence the staff were screened for eligibility, offered, was administered or declined the pneumococcal vaccination. During interview on 11/20/24 at 3:58 PM the Infection Preventionist/Assistant Director of Nursing stated they were not aware they needed to screen for the vaccine and had not been obtaining declinations or providing education to staff about the vaccine but will make sure it is done. 5) Resident #26 had diagnoses including but not limited to Parkinson's Disease, Seizure and Peripheral Vascular Disease. The 10/21/24 Care Plan titled Enhanced Barrier Precautions documented wear Personal Protective Equipment (gowns, gloves) when providing high contact activities including wound care. The 11/20/24 Physician Order documented cleanse right elbow opening with normal saline, cover with dressing, wrap with Kerlix every day shift. During wound observation on 11/22/24 at 3:46 PM Licensed Practical Nurse #10 did not apply a gown when removing the wound dressing, cleaning the wound and applying a new dressing. During an interview on 11/22/24 at 3:46 PM Licensed Practical Nurse stated they were aware the Resident was on Enhanced Barrier Precautions which meant staff needed to wear a gown and gloves during dressing changes but could not provide a reason why they did not follow precautions. 49255 Resident #23 was admitted to the facility with diagnoses including Heart Failure, Obstructive Uropathy, Diabetes Mellitus. The 10/30/24 Admission Minimum Data Set documented Resident #23 was cognitively intact. had an indwelling catheter, was frequently incontinent for bowel, had 2 stage 3 Pressure Ulcers and 1 unstageable- deep tissue injury that were present upon admission. During observation on 11/18/24 at 1:51 PM Enhanced Barrier Precaution signage was outside Resident #23's room and documented apply gown and gloves before room entry and remove them prior to room exit. During observation on 11/18/24 at 1:56 PM Certified Nurse Assistant #2 applied gloves and emptied the resident's drainage bag. Certified Nurse Assistant #2 was not wearing a gown at the time they performed the drainage bag care. Certified Nurse Assistant #7 assisted Certified Nurse Assistant #2 with Resident #23 transfer. Certified Nurse Assistant #7 applied gloves and was not wearing a gown at the time they transferred the resident. During an interview on 11/18/24 at 1:59 PM Certified Nurse Assistant #2 and #7 stated they were aware Resident #23 was on Enhanced Barrier Precaution and they were supposed to wear the gown, but at the time they forgot to put the gown on. 10 NYCRR 415.19(b)(4)

Based on record review and interview conducted during a recertification survey from 11/14/24 to 11/22/24, the facility did not ensure Certified Nurse Aides were provided the required 12 hours of training and/or annual in-services to ensure safe delivery of care. Specifically, the facility was unable to provide documentation that 3 of 6 Certified Nurse Aides (#10, #14, and #15), reviewed for Certified Nurse Aide training, were provided 12 hours of mandatory training. The findings are: The facility policy titled: Staff Development and In-service Programming, revised 1/18/23, documented: Personnel shall participate in in-service training to remain current in knowledge which affects the delivery of services within the facility and meets Federal and State Requirements. Policy Implementation: Certified Nurse Aides shall complete any additional in-services / education as required by topic and numbers of hours in accordance with state and federal regulations (e.g., 12 hour minimum). Certified Nurse Aide #10: 6.5 hours of annual in-service training documentation was provided. Certified Nurse Aide #14: 3.5 hours of annual in-service training documentation was provided. Certified Nurse Aide #15: 3.0 hours of annual in-service training documentation was provided. During an interview on 11/20/24 at 12:04 PM the Assistant Director Nursing, stated they were not able to provide 12 hours of annual in-service training for Certified Nurse Aides #10, #14, and #15. They stated they have been employed by the facility since September, 2024, but had contacted the previous Assistant Director of Nursing and they were not able to provide additional hours of in-service training for Certified Nurse Aide #10, #14, and #15. During an interview on 11/20/24 at 12:04 PM, the Director of Nursing stated the Assistant Director of Nursing was not able to provide 12 hours of annual in-service training for Certified Nurse Aide #10, #14, and #15. 10 NYCRR 415.26 (c)(1)(iv)

2) The facility Clinical Competency Assessment Skill: Transfers revised 7/24 documented Position wheelchair or chair at the bedside, lock brakes if transferring to a wheelchair. Resident #23 was admitted to the facility with diagnoses including heart failure, obstructive uropathy, diabetes mellitus. The admission Minimum Data Set (resident assessment tool) dated 10/30/24 documented Resident #23 was cognitively intact, received substantial assistance for sit to stand, chair to bed transfer, and toilet transfer. During interview on 11/18/24 at 1:47 PM Resident #23 stated the left brake on their wheelchair has been broken for the past three weeks. During observation on 11/18/24 at 1:54 PM Certified Nurse Assistant #2 and Certified Nurse Assistant #7 transferred Resident # 23 from bed to the wheelchair. Certified Nurse Assistant #2 did not lock the wheelchair's left brake. During an interview on 11/18/24 at 1:56 PM Certified Nurse Assistant #2/Certified Nurse Assistant #7 stated the left brake on Resident #23's wheelchair had been broken for at least a week. They stated that despite the broken brake they transferred Resident #23 from bed to the wheelchair. They stated Maintenance and Rehabilitation were notified about a week ago. During an interview on 11/18/24 at 02:13 PM the Occupational Therapist stated they had worked with Resident #23 for transfers. They stated they were aware of the broken wheelchair brake and had notified the Therapy Director. During an interview on 11/18/24 at 02:16 PM the Therapy Director stated they were not aware that the brake on Resident #23's wheelchair was broken. During an interview on 11/19/24 at 10:34 AM the Director of Maintenance stated they were notified about the broken brake on the resident's wheelchair yesterday. 10 NYCRR 415.5 (h)(2) Based on observation and interview conducted during a recertification survey (11/14/24-11/22/24), the facility did not ensure a safe, clean, comfortable, and homelike environment was provided on 3 of 4 units (West, East and North). Specifically, North Unit had noticeable dirt and food throughout the hallway, a resident over bed table was dirty with food stains and caked on food in room [NAME] 7, and Resident #5 had no privacy curtain dividing the toilet area from the resident's room, allowing anyone entering the room to see the resident on the toilet and 2) Resident #23 was transferred into a wheelchair with a broken left wheel brake. The findings are: During observation on the North Unit on 11/14/24 at 11:16 AM, the floor area in the hallway near double doors had dirt, dust, and food crumbs and dirt was on the floor outside room B-15-N. During an interview on 11/15/24 at 12:03 PM Resident #5 stated they were able to use the toilet but, would like a curtain because it was embarrassing because anyone could see them while they are on the toilet. During observation on 11/15/24 at 12:07 PM, 11/18/24 at 9:38 AM and 11/19/24 at 12:29 PM there was no privacy curtain that could be pulled closed while the resident was on the toilet in Resident #5's room. During observation on 11/15/24 at 12:12 PM, 11/18/24 at 9:39 AM and 11/19/24 12:37 PM, the over bed table in room [NAME] 7 had dried coffee stains and caked food on the top/sides of the table. During an interview on 11/19/24 at 12:26 PM Certified Nurse Aide #16 stated it has been awhile since there was a privacy curtain in the room. They stated they did not know why it was not there. During an interview on 11/19/24 at 12:29 PM Certified Nurse Aide #16 stated they often wipe down the over bed table, but the table looks dirty. They stated housekeeping comes around and should do a better job. During an interview on 11/19/24 1:04 PM Registered Nurse #1 stated housekeeping was supposed to come around and clean inside the rooms including the over the bed table after meals. They stated anyone could clean the over bed table/s. Registered Nurse #1 stated residents need their privacy when using the bathroom and they had not noticed the curtain was missing. They stated the Director of Maintenance should be doing rounds and checking on this. During an interview on 11/19/24 at 1:33 PM the Director of Maintenance stated they were not aware of the missing privacy curtain but, should have noticed that during rounds. During observation on 11/20/24 at 10:33 AM there was dirt, dust balls and food crumbs along hallway walls. During observation on 11/20/24 at 10:54 AM there was dust, dirt, food particles,rubber bands behind the closed doors. During an interview on 11/20/24 at 10:56 AM the Director of Housekeeping (Corporate) stated they use a machine but it's not cleaning the floors good enough.

Based on observation, record review and interview conducted during the Recertification and Abbreviated Surveys (NY00336704) from 11/14/24-11/22/24, the facility did not ensure for 1 of 3 residents reviewed for Abuse (Residents #176) that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately, but not later than two hours after the allegation is made, to the State Agency. Specifically, 1) Resident #176's family reported Resident #176 was found with bruises on their forehead when transferred to the hospital for altered mental status. A 2/19/24 Investigation/Accident Report statement written by Licensed Practical Nurse documented on 2/17/24 they overheard Resident #174 yelling and screaming at their family ouch you're hurting me and they beat me up last night, and the facility did not report the allegations to the State Agency. The findings are: The Policy titled Abuse last reviewed on 6/1/24 documented the facility is to notify the local law enforcement and appropriate State Agency(s) immediately (no later than 2 hours after) by the agency's designated process after identification of alleged/suspected incident. Resident #176 was admitted with diagnosis including but not limited to anxiety, cerebral infarction, right hemiplegia, and unspecified psychosis. The 2/1/24 Admission Minimum Data Set Assessment documented Resident #176 had severely impaired cognition. The Accident and Incident Reports documented Resident #176's last fall was 2/5/24, and there were no injuries noted. The 2/18/24 Employee Statement Form written by Certified Nurse Aide #11 documented Resident #176 stated they are being beat up by everyone all day. The 2/19/24 Accident and Incident Report documented Alleged Physical Abuse was reported by Resident #176's family. Bruises were noted to the left and right side of the forehead upon return from the hospital. The allegation was made by the residents sister while the resident was at the hospital and the facility immediately began an investigation. The 2/19/24 Accident and Incident Investigative Report Statement by Licensed Practical Nurse #9 documented on Sunday 2/17/24, while they were working at their medication cart, Resident #176 was yelling and screaming at their family, and yelled ouch you're hurting me. The resident then yelled they beat me up last night. The 2/19/24 Investigation Form findings documented bruising noted has been identified from previous falls. The 2/20/24 Abuse Care Plan documented Resident #176 is at risk for misappropriation, neglect, abuse and/or exploitation related to cognitive status/cognitive impairment after a cerebrovascular accident and is dependence on others for care. Interventions included monitor the resident for signs/symptoms of abuse, neglect, misappropriation, and/or exploitation and report to the facility's abuse officer and medical provider. The 2/20/24 Notice of Discipline form documented Certified Nurse Aide #11 received verbal warning for not alerting administration of alleged abuse. The 2/20/24 Notice of Discipline form documented Licensed Practical Nurse #9 received a verbal warning for not alerting administration of alleged abuse right away. During an interview on 11/20/24 at 3:13 PM, Registered Nurse Unit Manager #1 stated they initiated an investigation for alleged abuse because Resident #176 came back from the hospital with bruises on their forehead and they were not consistent with previous falls. Registered Nurse Unit Manager #1 stated they gave Notice of Discipline to Licensed Practical Nurse #11 and Certified Nurse Aide #9 because they did not report statements of alleged abuse. The Director of Nursing stated they were instructed by the Regional Director of Nursing to initiate an investigation and the Administrator would report the abuse allegation to the State Agency. During an interview on 11/21/24 at 1:56 PM, the Medical Director stated they saw Resident #176 on 2/20/24 for a brief visit upon their readmission from the hospital. They stated they were not aware of the alleged abuse incident. The Medical Director stated if there is alleged abuse, they expect staff to notify them immediately. During an interview on 11/21/24 at 5:41 PM, Resident #176's Health Care Proxy stated on numerous occasions, they reported to the facility that Resident #176 verbalized to them that staff were beating them up, and that they had meetings with Registered Nurse Unit Manager #1 and the Administrator to address their concerns and nothing was done. During an interview on 11/22/24 at 10:27 AM, Licensed Practical Nurse #11 stated they received a verbal counseling for not reporting to the facility that while Resident #176 was being visited by family, they heard Resident #176 yelling and screaming that someone was hurting them. They stated they did not tend to the resident because the resident was always fighting with the boyfriend, and they did not think much of it. Licensed Practical Nurse #11 stated the reason they did not get written up is because the union representative informed the facility they could not write them up if they did not report the alleged abuse to the State Agency. Licensed Practical Nurse #11 stated on a few occasions, they would hear Resident #176's boyfriend being verbally abusive to them. They stated Resident #176 made statements they were raped by two men and were being abused, and the facility was aware, but they did not remember if an investigation was done. During an interview on 11/22/24 at 1:42 PM, the Administrator stated the initial accusation of alleged abuse was from Resident #176's family and they explained to the family that the bruises were from falls and confirmed that Resident #176's last fall with no injury was on 2/5/24. The Administrator stated the Accident and Incident form should not have been titled Alleged Abuse, but they wanted to appease the family due to their constant abuse allegations, and that they were afraid the family would report the incident to the Department of Health. The Administrator stated the investigation was a precautionary measure because the family was not educated on the resident falling and obtaining bruises from falls and wanted to make them happy. The Administrator stated their understanding is that if the facility had an alleged abuse, they have 2 days to report to the State Agency and if the facility rules out abuse and neglect they did not have to report it. The Administrator stated despite having two statements from Licensed Practical Nurse #11 and Certified Nurse Aide #9 documenting they witnessed Resident #176 stating they were being abused they ruled out abuse and neglect because they obtained statements from staff, interviewed residents and no one ever witnessed or saw anything. During an interview on 11/22/24 at 2:39 PM, the Director of Nursing stated staff should not delay reporting alleged abuse to them. The Director of Nursing stated all reports of alleged abuse must be reported to the State Agency despite the facility's investigation. They stated they can report abuse but in a nursing home, the Administrator normally reports. 10 NYCRR 415.4(b)

Based on observation, record review and interview conducted during the Recertification and Abbreviated Surveys (NY00336704) from 11/14/24-11/22/24, the facility did not ensure for 1 (Resident #176)) of 3 resident reviewed for Abuse that all alleged violations involving abuse, mistreatment, or neglect, were thoroughly investigated. Specifically, there was no documented evidence the facility conducted a complete thorough investigation after Resident #176's family member reported Resident #176 had multiple bruises on their forehead when they were transferred to the hospital on 2/19/24. The findings are: The facility policy titled Abuse last reviewed on 6/1/24 documented that Allegations / reports of suspected abuse, neglect, mistreatment, distortion, injury of unknown etiology or misappropriation shall be promptly and thoroughly investigated by facility management. Resident #176 was admitted with diagnosis including but not limited to anxiety, cerebral infarction, right hemiplegia, and unspecified psychosis. The 2/1/24 Admission Minimum Data Set documented Resident #176 had severely impaired cognition. The 2/18/24 Employee Statement Form written by Certified Nurse Aide #11 documented Resident #176 stated they are being beat up by everyone all day. The 2/19/24 Investigation Form documented staff statements demonstrated no abuse took place and that the bruising was documented due to falls in the facility. The 2/19/24 Accident and Incident Report documented that Alleged Physical Abuse was reported by Resident #176's family. Bruises were noted to the left and right sides of their forehead. The allegation was made by the sister while the resident was out of the facility at the hospital and the facility immediately began an investigation. The 2/19/24 Accident and Incident Report Investigative Statement by Licensed Practical Nurse #9 documented on Sunday 2/17/24, while they were working at their medication cart, Resident #176 was yelling and screaming at their family, and they yelled ouch you're hurting me. The resident then yelled they beat me up last night. The 2/19/24 Investigation Form documented bruising noted have been identified from previous falls. The 2/20/24 Abuse Care Plan documented Resident #176 is at risk for misappropriation, neglect, abuse and/or exploitation related to cognitive status/cognitive impairment after a cerebrovascular accident and is dependence on others for care. Interventions included monitor the resident for signs/symptoms of abuse, neglect, misappropriation, and/or exploitation and report to the facility's abuse officer and medical provider. During an interview on 11/20/24 at 03:13 PM, Registered Nurse Unit Manager #1 stated Resident #176 came back from the hospital with bruises on their forehead that were not consistent with falls they had. They stated the investigation was not done thoroughly because there were reports from staff that the resident's family and the resident were verbally abusive to one another. Registered Nurse Unit Manager #1 stated based on the Licensed Practical Nurse #11 and Certified Nurse Aide #9, abuse and/or neglect should not have been ruled out. During an interview on 11/21/24 at 01:56 PM, the Medical Director stated they were never made aware of an abuse allegation. They stated an investigation would not be complete until they are notified that they need to assess the resident. During an interview on 11/21/24 at 05:41 PM, the Complainant stated that on numerous occasions, they reported to the facility that Resident #176 verbalized to them that staff were beating them up, and that they had meetings with Registered Nurse Unit Manager #1 and the Administrator to address their concerns and nothing was done. The Complainant stated that Resident #176 had bruises in places not consistent with the falls and that when they would visit and they saw a new bruise, they would ask if the resident fell , and they would get told no. During an interview on 11/22/24 at 10:27 AM, Licensed Practical Nurse #11 stated a few days prior to the facility investigating alleged abuse, they heard Resident #176 yelling and screaming that someone was hurting them, and that they did not go tend to the resident because the resident was always fighting with the boyfriend, and they did not think much of it. Licensed Practical Nurse #11 stated on a few occasions, they would hear Resident #176's boyfriend being verbally abusive to them. They stated the resident made statements that they were raped by two men and were being abused and the facility was aware but they did not remember if an investigation was done. During an interview on 11/22/24 at 01:42 PM, the Administrator stated the previous Director of Nursing did the investigation for alleged abuse and documented the bruises were from prior falls and confirmed that Resident #176's last fall was on 2/5/24 in which they had no injuries noted. The Administrator stated they ruled out abuse and neglect because they received statements from staff, interviewed residents and no one ever witnessed or saw anything. When asked why they did not take Licensed Practical Nurse #11 and Certified Nurse Aide #9 statements into consideration, the Administrator had no response. During an interview on 11/22/24 at 02:39 PM, the Director of Nursing stated if a resident's family reports they observed bruises on a resident's skin, they would look at prior Accident and Incident Reports and see if the bruises are consistent with falls. The Director of Nursing stated based on the investigation, it was not done thoroughly and the statements from Certified Nurse Aide #9 and Licensed Practical Nurse #11 should have been taken seriously, especially since they wrote statements that they heard Resident #176 yelling someone was hitting them prior to the family reporting the bruises. 10 NYCRR 415.4(b)(3)

Based on record review and interview conducted during the recertification survey from 11/14/24 to 11/22/24, the facility did not ensure that the resident and/or resident representative were notified in writing of the reason for the transfer/discharge to the hospital in a language that they understood and that a copy of the notice was sent to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 3 resident (Resident #63) reviewed for hospitalization . The findings are: Resident #63's diagnoses included Acute Kidney Failure, Neuromuscular Dysfunction of Bladder and Encephalopathy. The 5/7/24 Situation Background, Assessment and Recommendation documented send to the hospital for further evaluation Blood in stool, Gastrointestinal bleed. Family notified. The 5/7/24 Nursing Progress note documented called family representative to notify them the resident was being transferred to the hospital for possible Gastrointestinal Bleed. The 5/8/24 Nursing Progress Note documented Resident #63 was sent to the emergency room for evaluation due to an abnormal hemoglobin 6.9 or hematocrit 20.5 (low). The 5./8/24 Transfer Report documented the reason for transfer and that the family representative was notified by telephone of transfer. During an interview on 11/19/24 at 12:46 PM with Resident #63's family representative, they stated they were informed by telephone of the plan to send Resident #63 to the hospital in May 2024 and were in agreement with the plan. They stated they did not receive notification of transfer in writing. During an interview on 11/20/24 at 4:36 PM the Director of Nursing stated they were not able to locate/provide a copy of written transfer notification. They stated when a resident is transferred to the hospital, the nurse who is in charge of transfer is responsible for filling out the form. They stated the form is a triplicate and one copy goes to hospital with resident, one goes to medical record paper at the facility, and one is sent to the resident contact/family. They stated the Ombudsman is notified monthly via email or sometimes at the time of transfer. They stated the Social Worker would be responsible for notifying the Ombudsman and resident family. They stated the facility Social Worker terminated employment on September 25, 2024, and has not yet been replaced. They stated they were unable to locate Ombudsman notification from May 2024 for Resident #63. 10 NYCRR 415.3(h)(1)(iii) (a-c)

Based on observation, interview and record review conducted during a recertification survey, the facility did not ensure the comprehensive care plan was revised for 1 of 5 resident ( Resident #53) reviewed for Accidents. Specifically, for Resident #53, who sustained falls on 8/20/24, 9/27/24 and 10/9/24 there was no documented evidence that care plan interventions were reviewed and/or revised to address the falls. Findings include: The Policy and Procedure titled Falls Management and Prevention last revised on 1/2023 documented if the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will reevaluate the continued relevance of current interventions. Resident #53 was admitted with diagnoses including but not limited to encounter for hip fracture, muscle weakness, benign prostatic hyperplasia. The 5/23/24 Care Plan titled Risk for Falls/Actual Falls documented anticipate and meet the resident needs/occupational and Physical Therapies to evaluate and treat as ordered. The 5/28/24 Quarterly Minimum Data Set (assessment tool) documented Resident #53 was cognitively intact, cognition was intact frequently incontinent of bowel and bladder, required partial assistance with sit to stand, chair to bed, and toilet transfers, and was independent with wheeling 50 feet in wheelchair. The 8/20/24 at 2:15 am Accident and Incident Report documented Resident #53 had an unwitnessed fall to the floor while transferring to their wheelchair from the bed. Investigation conclusion documented the resident able to self-report attempting to transfer from wheelchair to bed without required level of assistance resulting in fall to the floor. Gait analysis documented Resident was unable to independently come to standing. Uses an assistive device. The 8/20/24 Fall Risk Assessment documented Resident #53 was at moderate risk for falls. There was no documented evidence to indicate the Fall Care Plan was reviewed and or revised after the 8/20/24 fall. The 8/28/24 Quarterly Minimum Data Set (assessment tool) documented supervision with toilet transfers, chair to bed transfers, and was independent with ambulation 150 feet and locomotion in wheelchair. The 9/27/24 at 8:45 am Accident and Incident Report documented Resident #53 had an unwitnessed fall and was found in supine position on the floor adjacent to bed. Investigation conclusion documented the resident stated they were seated on the edge of the bed and fell as they turned and shifted their positioning. The resident was assessed with no injuries, musculoskeletal deviations, or acute pain. Screened by rehab and continued rehab services for strengthening and safety. No abuse/neglect indicated at this time. There was no documented evidence to indicate the Fall Care Plan was reviewed and or revised after the 9/27/24 fall. The 10/9/24 at 4:34 pm Accident and Incident Report documented Resident #53 had witnessed fall by staff. The resident was standing, losing their balance, and falling on window side of room. Investigation conclusion documented skin tear to right hand and forming hematoma to posterior aspect of head. The order from medical doctor was to transfer to emergency room for further evaluation and rule out injurious head trauma, no acute findings. Fall self-directed with no indication of abuse/neglect currently. There was no documented evidence to indicate the Fall Care Plan was reviewed and or revised after the 10/9/24 fall. During observations on 11/14/24 at 9:38 AM and on 11/18/24 at 10:03 AM Resident #53 was propelling themselves in the wheelchair in their room without assistance. During an interview on 11/19/24 at 1:39 PM Certified Nurse Aide #2 stated they assisted the resident with dressing, breakfast set, toilet transfer, most of the activities the resident did by themselves. Certified Nurse Aide #2 stated the resident was able to raise the height of their bed too high with a remote control, reached for things on the floor, tries to be independent and keeps their room door closed. Certified Nurse Aide #2 stated they always remind the resident to use a call bell for assistance and leave the room door cracked open so the staff could observe the resident. They stated in general the staff check on the resident every 2 hours. During an interview on 11/19/24 at 1:49 PM Licensed Practical Nurse #5 stated they provide care for the resident. The resident always tries to be independent as much as they can with their daily activities, They stated the resident ignores staff members reminder about calling for assistance. They stated that was the main reason why the resident fell has fallen in the past. They stated they always remind the resident to use a call bell for assistance. Licensed Practical Nurse #5 stated before the last hospitalization the resident was transferred closer to the nurse station for frequent observations. Licensed Practical Nurse #5 could not find care plan interventions following the falls on 8/20/24 and falls on 9/27/24 and 10/9/24. During an interview on 11/19/24 at 2:16 PM the Director of Nursing stated care plans are initiated and updated by the Registered Nurses. In case of fall, the interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls or injuries. The staff would document risk factors for falling in the resident's record, discuss the resident's fall risk and implement interventions in the care plan based on the resident's needs. If the resident continues to fall, the staff will re-evaluate the situation and consider other possible reasons for the resident's falling and will re-evaluate the continued consequence of current interventions. Director of Nursing stated that specifically for Resident #53, risk factors were the resident's preference to be in their room and keeping their room door closed, refusing to participate in recreational activities, and the desire to do many things on their own despite on the staff's reminder to use a call bell for assistance. The Director of Nursing could not provide documented evidence that the facility revised the care plan with new interventions following falls on 8/20/24, 9/27/24 and 10/9/24. 10 NYCRR 415.11

Based on observation, record review and interview conducted during the Recertification and Abbreviated Surveys (NY00336697 and NY00324141) from 11/14/24 to 11/22/24, the facility did not ensure 2 (Residents #174 and #177) of 2 residents reviewed for Quality of Care received treatment and care in accordance with the professional standards of practice, the comprehensive person-centered care plan, and the residents' choice. Specifically, 1.) for Resident #174 who was admitted with a wearable defibrillator (Life Vest) related to a history of Sudden Cardiac Arrest, became unresponsive on 3/16/24 the nurse tending to the resident documented they pushed the response button. Additionally, there were multiple omissions on the March Medication Record that the nurses were not addressing and signing for the Life Vest as per physician order and 2.) for Resident #177 with diagnosis of Type 1 Diabetes Mellitus and history of Diabetic Ketoacidosis there were multiple omissions in the Medication Administration Record for insulin administration/ blood sugar monitoring from 5/2024-7/2024. The findings are: The facility policy title Life Vest last revised on 2/2020 documented only the resident is responsible for pressing response buttons. If you're with the patient when the life vest alarms and sends out a voice alert, don't press the response button. 1. Resident #174 was admitted with diagnosis including but not limited to atherosclerotic heart disease, cardiomyopathy, heart failure, and ventricular tachycardia. The 3/15/24 Defibrillator Care Plan documented Resident #174 has a wearable defibrillator (Life Vest) related to a history of Sudden Cardiac Arrest. Interventions included determine responsiveness, and only the resident is responsible for pressing the response button. The 3/13/24 Physician Order documented monitor every shift for correct placement and functioning of the Life Vest. Resident is to always wear the life vest except when showering/vigorous cardiac rehabilitation. The Physician Order to monitor the Life Vest every shift for correct placement and functioning, and resident to always wear the Life Vest except when showering/vigorous cardiac rehabilitation was not documented in the March Medication Administration Record on 3/13/24 (3pm), 3/12/24 and 3/15/24 (7 am/11pm). The 3/13/24 Physician Order documented to change the battery on the Life Vest daily, every shift to maintain battery charge and replace the used battery on the charger. The Physician Order every day shift for maintenance, change Life Vest battery was not documented in the March Medication Administration Record on 3/15/24 at 7am. The Physician Order March 2024 Medication and Treatment Administration ensure Life Vest every shift ensure backup battery was not documented in the March 2024 Medication and Treatment Administration on 3/12/24 and 3/13/24 (3pm), 3/12/24 and 3/15/24 (7am/11pm). The 3/12/24 Medical Order Form from the heart center documented Life Vest to be started on 3/13/24. The 3/13/24 Physicians Order documented care/maintenance and monitor placement of life vest always worn except for hygiene (do not get wet), battery is to be removed before removing Life Vest by the Licensed Staff. Monitor circulation and skin integrity. The Physician Order care/maintenance and monitor placement of life vest always worn except for hygiene (do not get wet), battery is to be removed before removing Life Vest by the Licensed Staff. Monitor circulation and skin integrity was not documented in the March 2024 Medication and Treatment Administration on 3/13/24 (3pm), 3/12/24 and 3/15/24 (7 am/11pm). The 3/16/24 Life Vest Inservice Attendance Record documented only the resident is responsible for pressing the response button/do not touch the patient when there are loud two-time sirens broadcasting from the Life Vest. The patient may be in the progress of receiving a shock and you can be shocked if you are touching them at this time. The 3/16/24 at 7:57 am Nursing Progress Note by Licensed #2 documented approximately 1:55 am Unit B Licensed Practical Nurse heard a beeping sound coming from Resident #174's room and noticed Resident #174 was unresponsive and the Life Vest was alarming. As the resident was unable to hit the shock button, the Licensed Practical Nurse delivered shock. During an interview on 11/18/24 at 10:07 am, Complainant #1 stated when Resident #174 became unresponsive, there were no Registered Nurses in the building. Complainant #1 stated the Director of Nursing knew on Friday 3/15/24, that Resident #174 was declining and did not put care instructions in place for the weekend or call the facility to check on Resident #174. Complainant #1 stated they had no staff to care for the highly medically complex resident. Complainant #1 stated Resident #174 had a Life Vest that is supposed to send a shock to the heart if they have an abnormal rhythm, and Resident #174 was unable to shock themselves. They stated when the alarm on the Life Vest went off, the Nurse caring for Resident #174 pushed the response button, although they were in serviced that only the resident can push the response button. During an interview on 11/18/24 at 3:44 pm, Licensed Practical Nurse #2 stated while doing rounds on 3/15/24 during the night shift, they found Resident #174 unresponsive, and the Life Vest was beeping. Licensed Practical Nurse #2 stated they pushed the response button because the resident was unable. Licensed Practical Nurse #2 stated they received Life Vest training and knew how to operate it, but they were unsure if they should have pushed the button but, were thinking quickly and wanted to help the resident. Licensed Practical Nurse #2 stated there were no Registered Nurses in the building at the time, They stated a Licensed Practical Nurse and Certified Nurse Aide helped with the full code. During an interview on a 11/19/24 at 9:24 am Registered Nurse Unit Manager #1 stated Licensed Practical Nurse #2 called them after initiation of the emergency response system and informed them they pushed the Life Vest response button when Resident #174 became unresponsive. Registered Nurse Unit Manager #1 stated nurses were trained to not push the response button even if the resident becomes unresponsive/ if doing cardiopulmonary resuscitation. During an interview on 11/21/24 at 1:34 pm the Medical Director stated when a resident is wearing a Life Vest, only the resident is supposed to deliver the shock. They stated the Life Vest detects rhythm automatically. The Medical Director stated they expect nurses to document and sign off on all physician orders. During an interview on 11/22/24 at 3:16 pm, the Director of Nursing stated all staff should follow the Life Vest policy and procedure and should not push the response button if a resident becomes unresponsive. They stated staff has been trained and receive refresher courses on the Life Vest. The Director of Nursing stated the unit manager should review the dashboard to see if medications were given. and review with the team and if anything is noted, it should be investigated and addressed, and if meds are not given for anything, they should be documenting, and if the resident refuses, the physician must be notified to receive orders and interventions to be implemented. 2. The Policy titled Insulin Administration last reviewed on 1/2020 documented resident blood sugar and insulin administration should be documented. Resident #177 was admitted with diagnosis including but not limited to diabetes mellitus Type 1, colostomy status, and protein calorie malnutrition. The 4/22/24 Admission Minimum Data Set documented Resident #177 had intact cognition and was receiving insulin. The 4/21/24 Diabetes Care Plan documented diabetes mellitus type 1, administer medication as ordered and monitor blood glucose finger stick as per physicians' orders. The 6/27/24 Physician Order documented 30 units of Insulin Glargine in the morning for diabetes mellitus The 6/27/24 Physician Order documented 8 units of Humalog two times a day with breakfast and dinner for diabetes mellitus. There was no documented evidence in the May 2024 Medication Administration Record for blood sugar monitoring on 5/4/24 at 7:30am and 11:30am-BS 300 on 5/6/24 at 7:30am and 11:30 am-BS 315 at 5 pm, 5/18/24 at 5pm. The May 2024 Medication Administration Record documented blood sugar monitoring on 5/11/24 was 228 at 7:30 and 228 at 11:30 am There was no documented evidence in the May 2024 Medication Administration Record for administration of Humalog Kwikpen (5 units) on 5/4/24 at 9am/1pm and 5/18/24 at 6:30pm and Humalog Kwikpen (8 units) on 5/4/24 at 8am, 5/6/24 at 8am, and 5/8/24 at 5pm, The May 2024 Medication Administration Record for blood sugar monitoring on 5/26/24 at 7:30 was 400 and 8 units were given, and 5/27/24 at 7:30 am was 489. There was no documented evidence in the June 2024 Medication Administration Record for administration of Humalog Kwikpen(8 units) on 6/5/24 at 5pm and blood sugar monitoring on 6/4524 at 9pm. During an interview on 11/21/24 at 1:43 pm, the Medical Director stated they should be notified if a resident's blood sugar is over 400 or below 70, and residents should receive physician ordered insulin. They stated if insulin is not administered, staff should document the reason in the progress notes/medication administration record and notify the physician. The Medical Director stated they review blood sugar monitoring/administration of insulin in the electronic record and if not accurately documented they would not know if the diabetes is being managed properly. The Medical Director stated if the resident is on a sliding scale, they cannot receive coverage if the blood sugar is not done. They stated if something is not documented in the Medication Administration Record, then it was not done. During an interview on 11/22/24 at 12:27pm, Registered Nurse Unit Manager #1 stated nurses are responsible for ensuring they sign off on medications, and the facility started coming down on the nurses for not signing for medications. Registered Nurse Unit Manager #1 stated if nurses did not sign for administration of insulin and sliding scale, then it was not given, and stated they would not know if a resident received the insulin. Registered Nurse Unit Manager #1 stated it was important for Resident #177 to receive the physician ordered insulin because they always had high blood sugars. During an interview on 11/22/24 3:35 pm, the Director of Nursing stated nurses are responsible to check the medications on dashboards, and nurses are responsible for ensuring residents get their medications according to physician orders. The Director Nursing stated if medications are not documented in the Medication Administration Record, they were not given, and that if the resident had a sliding scale, the findings of the blood sugar should be documented in order to be able to administer the insulin. 10NYCRR415.12

Based on record review, observation and interview conducted during the recertification and complaint (NY00336704) surveys from 11/14/24 to 11/22/24, the facility did not ensure adequate supervision to prevent accidents for 1 (Residents #176) of 5 residents reviewed for Accidents. Specifically, fall risk assessments were not completed to identify Resident #176's risk for accident and need for supervision after falls on 1/26/24, 1/28/24, and 2/1/24. There was no documented evidence of enhanced monitoring and one to one supervision as per the 2/27/24 Accident and Incident Report after Resident #176 verbalized suicidal ideation. Additionally, Resident #176 had one unwitnessed fall on 1/28/24, two on 2/1/24, two on 2/22/24, 2/27/24, 2/29/24, 3/11/24, and one on 3/19/24 and there was no documented evidence neurological checks were done to assess for neurological status or underlying conditions. Findings include: The facility policy titled Falls Management and prevention last revised 1/2023 documented obtain neurological checks per policy for any unwitnessed fall or any fall with evidence of injury to the head. Fall risk assessments will be completed for all residents; initially on admission / readmission, quarterly, significant change and after an identified fall. Resident #176 was admitted with diagnosis including but not limited to anxiety, cerebral infarction, right hemiplegia, and unspecified psychosis. The 1/26/24 Accident and Incident Report documented at 3:30 pm, Resident #176 had a witnessed fall in the common area and slid from their wheelchair at 3:30 pm. No injuries were noted. There was no documented evidence of a fall risk assessment after the 1/26/24 fall. The 1/28/24 Accident and Incident Report documented Resident #176 had an unwitnessed fall and was found on the floor next to their bed in their room at 1:45 am. There was bruise on the left knee, they guarded their hip. Sent to the emergency department for evaluation. There was no documented evidence of a fall risk assessment/neurological checks after the 1/28/24 fall. The 1/30/24 Accident and Incident Report documented Resident #176 had an unwitnessed fall in their room at 5:00 pm, and neurological checks were initiated. There was no documented evidence of neurological checks being initiated after the 1/30/24 fall, as per the Accident and Incident Report. The 2/1/24 Admission Minimum Data Set Assessment documented Resident #176 had severely impaired cognition, and required extensive assist with toileting and bed mobility. The 2/1/24 Accident and Incident Report documented Resident #176 had an unwitnessed fall and was found lying on the floor in their room at 4 pm. There bruises noted to the right and left hips. There was no documented evidence of neurological checks being initiated after the he 2/1/24 at 4 pm fall. The 2/1/24 Accident and Incident report documented at 11:15 am, Resident #176 had an unwitnessed fall in the dining room and was found sitting on the foot/leg rests of their wheelchair. There was no documented evidence of a fall risk assessment/neurological checks after the 2/1/24 at 11:15 am fall. The 2/22/24 Accident and Incident Report documented Resident #176 had an unwitnessed fall and was observed lying on their side on the floor next to the door in their room at 10:35 pm. There was no documented evidence of neurological checks after the 2/22/24 at 10:35 pm fall. The 2/22/24 Accident and Incident Report documented Resident #176 had an unwitnessed fall in their room and was found lying on the floor with their head against the wall at 1:45 pm. Neurological checks initiated. There was no documented evidence of neurological checks being initiated after the 2/22/24 at 1:45 pm fall, as per the Accident and Incident Report. There was no documented evidence of the Fall Care Plan being reviewed and revised until 2/27/24. The 2/27/24 Accident and Incident Report documented at 3:00 pm, Resident #176 verbalized suicidal ideation. No injuries were noted. Care plan was updated. Resident was placed on enhanced monitoring and one on one supervision implemented. There was no documented evidence of enhanced monitoring/one to one supervision was initiated after the 2/27/24 at 3:00 pm incident, as per the Accident and Incident Report. There Suicide Care Plan was last revised on 2/5/24.There was no documented evidence of a care Plan update to to reflect the 2/27/24 suicidal ideation. The 2/27/24 Accident and Incident Report documented Resident #176 had an unwitnessed fall in their room and was found on the floor lying on their left side next to the radiator at 3:00 pm. Resident #176 complained of back pain, had a laceration to right their eyebrow, and an abrasion to their right lower leg. Resident transferred to the emergency room due to complaints of back pain. The 2/29/24 Accident and Incident Report documented Resident #176 had an unwitnessed fall in their room and was found sitting on the floor at 10am. No injuries were noted. There was no documented evidence of neurological checks after the 2/29/24 fall. The 3/11/24 Accident and Incident Report documented Resident #176 had an unwitnessed fall in their room and was found lying on the floor next to their bed at 9:11 am. There was no documented evidence of neurological checks after the 3/11/24 fall. The 3/19/24 Accident and Incident Report documented Resident #176 had an unwitnessed fall in their room and was found lying next to their bed at 2:30 pm. No injuries noted. Sent to emergency department for evaluation. Staff noticed the resident had another bruise on their forehead. Resident does maintain another bruise 1-cmx13cm light purple in color, skin is intact. Certified Nurse Aide was walking in the room and noted the resident on the floor off the mattress. The 3/19/24 change in skin condition evaluation due to falls documented there was discoloration to the forehead and no other changes noted. Resident #176 was sent to the emergency department for further work up. The 3/20/24 emergency room discharge summary documented Resident #176 was admitted on [DATE] with ecchymosis to their periorbital/forehead, and a skin avulsion was noted to their right shin. During an interview on 11/20/24 at 3:13 pm, Registered Nurse Unit Manager #1 stated when a resident is on one to one supervision, the staff document on paper and there is no solid method to keep track/papers get lost, and that neurological checks should have been uploaded into the computer. Registered Nurse Unit Manager #1 stated if a resident has an unwitnessed fall, neurological checks must be done. Registered Nurse Unit Manager #1 stated Resident #176 should have been placed on permanent one to one supervision because the resident had multiple falls, and had no impulse control. They stated the facility does not like placing resident/s on one to one supervision due to staffing. Registered Nurse Unit Manager #1 stated if a resident has suicidal ideation , they are immediately placed on one to one supervisor and the care plan must be updated. On 11/21/24 at 12:15 pm, the Administrator stated they were unable to locate neurological checks for Resident # 176. During an interview on 11/21/24 at 1:56 pm,the Medical Director stated they will place a resident on one to one supervision when the resident is suicidal, and they must be cleared by the Psychiatrist before removing the one to one supervision. The Medical Director stated if a resident has an unwitnessed fall or hit their head. During an interview on 11/21/24 at 5:41 pm, the Complainant stated every time they visited, Resident #176 was always lying on the floor, and stated that on one visit, the resident had their head against the wall. They stated they requested on multiple occasions to move the radiator that was in the residents room up against the wall due to the corners and it being unsafe for the resident because the resident goes on the floor. During an interview on 11/22/24 at 11:20 am, Certified Nurse Aide #5 stated when a resident is having falls, the nurse will verbally tell them the resident is on one to one supervision, but the instructions will not go to the Certified Nurse Aide Kardex. Certified Nurse Aide #5 stated they have been employed in the facility since 2013 and never documented one to one supervision or 15 min checks, and has never seen such instructions in the Kardex. Certified Nurse Aide #5 stated even when a resident is on one to one supervision, they do not have the staff and the resident will go without one to one supervision. During an in interview on 11/22/24 02:39 pm, the Director of Nursing stated prior to 9/2024, neurological checks were not being done consistently and they were supposed to be uploaded.They stated they were unable to locate any of Resident #176's neurological checks. The Director of Nursing stated, starting 9/2024, they implemented a new system to keep track of neurological checks. They stated neurological checks are now kept in a binder on the unit and the nurses should be communicating to each other. The Director of Nursing stated all care plans should be reviewed and noted, everything should be documented even if there are no new revisions. 10NYCRR415.12(h)(2)

Based on record review and interview conducted during the recertification from 11/14/24 to 11/22/24, the facility did not ensure there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the staffing schedule from 10/10/24 through 11/21/24 revealed the facility did not consistently provide adequate staffing on all units/shifts to meet the needs of the resident/s 35/43 days reviewed. The findings are: The Facility Wide assessment dated [DATE] documented Day shift, Units A and B: 2 nurses/5 certified nurse aides per unit. Evening shift: 2 nurses/4 certified nurse aides per unit. Night shift: 1 nurse/2 certified nurse aides per unit. The facility staffing from October 10, 2024 through November 21, 2024 and the staffing plan based on Facility Wide Assessment, documented the facility was understaffed 35/43 days for Certified Nurse Aides. During a Resident Council meeting on 11/15/24 ad 1:32 PM, Resident #23 stated call bells are not being answered timely. Residents can wait almost 30 minutes for a response, especially on B unit. Resident #23 stated at night staffing is short and needs are not being met. During an interview on 11/14/24 at 10:41 AM, Resident #57 and Representative stated staff ignore residents at night and can be rude. They stated staffing appears short all shifts, but the night shift is particularly bad. The representative stated staff sleep, are on phones, or watching television at night. Resident and representative stated call bells are not answered at night. During an interview and observation on 11/14/24 at 12:01 PM, Resident #25 stated staff treat them well, however, the facility is short-staffed often. The short-staffing varies by shift. Resident #25 stated they have to wait extended times for requested pain medications. During an interview on 11/19/24 at 01:09 PM, family representative of Resident #61 stated the facility is short staffed daily. They stated staff are not friendly and often have attitudes. They stated there can be long wait time for services such as medication administration and feeding of residents. During an interview on 11/20/24 at 10:17 AM the Staffing Coordinator stated daily staffing is determined by census and the minimum staffing requirements for each unit. Five certified nurse assistants for 7:00AM-3:00PM shift on both units and 2 nurse staff for each unit. The 3:00PM - 11:00PM shift: 4 certified nurse assistants per unit and 2 nurse staff. The 11:00PM to 7:00AM shift: 2 certified nurse assistants and 1 nurse per unit. They stated there have been shifts when units are understaffed. They stated call-outs are handled by calling staff that is off. Staff on duty are offered to stay and given a shift off for covering. Overtime is offered. Bonuses not frequently offered and require approval. They stated some certified nurse staff have discussed workload concerns with them in the past. They stated when this has occurred, certified nurse aides will be offered time off and attempts made to improve staffing on units.They stated contract travel agencies are used for certified nurse aide recruitment and local agencies rarely used for licensed practical nurses only. They stated the facility is always recruiting for local staff. During an interview on 11/21/24 at 10:32 AM the Director of Nursing stated staffing difficulties are present and universal in the industry. They stated since July 2024 when they started employment at the facility, there have been staffing challenges, but tremendous progress has been made. The facility continues recruiting for certified nurse assistants, licensed practical nurses and registered nurses. They stated the facility recently hired a registered nurse unit manager, a registered nurse Assistant Director of Nursing, and a registered nurse Supervisor. They stated certified nurse aides are primarily hired through a travel agency. Local recruitment is difficult due to competition in the area. During an interview on 11/22/24 at 10:45 AM Licensed Practical Nurse #3 stated staffing has been horrible at times, especially at weekends. They stated the shortage of certified nurse aides affects residents because cares are hurried. They stated they have to perform certified nurse aide duties frequently because of short staffing. They stated there have been occasions at night when there is only one or no certified nurse aide was on duty. When this occurs, they perform medication administration and certified nurse aide duties. They stated the facility has a high turnover due to the use of traveling certified nurse aides. They stated training for traveling aides could be improved, such as training on New York State regulations (allowable certified nurse aide tasks vary from state to state. They stated residents are not happy with constant turnover of staff. During an interview on 1/22/24 at 02:22 PM the Administrator stated the facility has had a lot of difficulty hiring locally and staffing could be challenging. The Administrator stated the use of travel certified nurse aides has assisted the facility meet their staffing numbers. NY CRR 415.13(a)(1)(i-iii)

Based on interview and record review conducted during the recertification survey from 11/14/2024 to 11/22/2024, the facility did not ensure the attending physician documented in the resident's medical record that the identified drug regimen review recommendations were reviewed, and any action taken to address recommendations were completed. This was evident for 1 (Resident #42) of 5 residents reviewed for unnecessary medications, psychotropic medications and medication regimen review. Specifically, there was no documented evidence the Medical Director reviewed and responded to Resident #42's Drug Regimen Reviews dated June 2024. The findings are: The facility policy title Medication Regimen Reviews (revised 11/2021) documented the Consultant Pharmacist reviews the medication regimen of each resident at least monthly. The Consultant Pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication. The attending physician documents in the medical record that the irregularity has been reviewed and (if any) action was taken to address it within 30 days of receiving the report. Resident #42 was admitted with diagnoses including but not limited to Diabetes Mellitus II with Hyperglycemia, Cardiac Arrythmia and Depression. The Drug Regimen Review for Resident #42 dated June 2024 documented Discrepancy between psychiatry recommendation and actual prescription Psychiatry consult 6/18/24 recommendations: Increase Sertraline to 100 mg. PO daily for depression. Current order Sertraline HCL tablet. Give 75 milligrams by mouth one time day for depression. The Drug Regimen Review was not signed or dated by Medical Director, disagreement or recommendation was not documented in electronic medical record, and an order for an increase in sertraline hcl to 100 milligrams was not documented in electronic medical record. The physician order dated 6/4/24 documented Sertraline HCl Tablet Give 75 milligrams by mouth one time a day for Depression. The physician order dated 8/29/24 documented Sertraline HCl Tablet 50 Milligrams. Give 1.5 tablet by mouth one time a day for Depression. The physician order dated 10/7/24 documented Sertraline HCl Tablet 50 milligrams. Give 1.5 tablet by mouth in the evening for Depression. The Drug Regimen Review dated June 2024 documented consider a lipid profile to monitor Atorvastatin Calcium tablet 20 milligram. Statin monitoring lipid panel 4-12 weeks after statin initiation then every 3 to 12 months. Consider dose reduction if two consecutive LDL measurements are less than 40 mg. dl (1.03 mmol/L). Check ALT at baseline. Repeat if symptoms of hepatotoxicity occur. The Drug Regimen Review was not signed or dated by Medical Director, disagreement or recommendation was not documented in electronic medical record. A lipid profile was completed on 7/5/24 and 10/16/24. The Physician Order dated 10/3/24 documented: Lipid Panel (thyroid profile I). One time only related to presence of cardiac pacemaker. During an interview on 11/21/24 at 10:26 AM the Director of Nursing stated Drug Regimen Reviews from the pharmacy are printed monthly or as needed if a change/recommendation is indicated and provided to attending physician for review. They stated they email Pharmacy Drug Regimen reviews to Unit Managers to print and place in the Medical Director review folder located at the nurse stations. They stated the June 2024 Drug Regimen Reviews for Resident #42 were not signed and dated by the physician and there was no documented reply to the recommendation. During an interview on 11/21/24 at 2:20 PM the Medical Director, stated Pharmacy sends the Drug Regimen Reviews to the facility, facility prints them out and places in Medical Director folders on each unit. They stated they are present in facility about four days a week and they review Medical Director folders on units daily when present. They stated upon review of Drug Regimen Reviews, they agree, disagree, or provide alternative recommendation, if applicable. They sign and return reviewed Drug Regiment Reviews to the folder for unit managers to review and upload to electronic medical record or provide to Director of Nursing. During the interview, the two Drug Regimen Reviews from June 2024 were observed. The Medical Director stated since there was no signature or date on the form, they did not receive the form for review. They stated if they provide a new order after reviewing a Drug Regimen Review, the Unit Manager or Director of Nursing would enter the order into electronic medical record for Medical Director to approve. 10 NYCRR 415.18(c)(2)

Based on observation, record review and interview conducted during a recertification survey 11/14/22-11/22/24, the facility did not ensure necessary dental services were provided in a timely manner for 1 of 1 resident (Resident #25) reviewed for Dental Services. Specifically, Resident #25 was not provided routine dental services since their 2/29/24 admission to facility. The findings are: The facility policy titled Dental Services, last revised 9/2019, documented routine and emergency dental services are available to meet the resident's oral health care needs based upon resident assessment and plan of care. Resident #25 was admitted with diagnoses including but not limited to Peripheral Vascular Disease, Major Depressive Disorder, and Acquired Absence of Left Leg above Knee. The Quarterly Minimum Data Set (resident assessment tool) dated 11/3/24 documented Resident #25 had intact cognition. There was no documented evidence of a Dental Consult for Resident #25. During an interview and observation on 11/19/24 at 9:31 AM, Resident #25 stated they have not received a routine dental consultation since their 2/29/24 admission. Resident #25 was observed edentulous during interview. Resident #25 stated they have had dentures (upper) in the past, prior to admission, which required adjustment and never fit right. Resident #25 stated they did not have dentures in place upon admission to facility. Resident #25 stated they would like to have dentures in place to assist with eating. During an interview on 11/22/24 at 05:31 PM the Director of Nursing stated the facility has a dental consultant who visits the monthly and as needed. They stated residents are followed routinely and have follow-up visits for episodic issues. Long-term residents seen routinely. They were not sure of exact visit cycle. Community dental appointments are assisted through the facility and transportation provided. They stated that any member of the nursing team can report observed resident concerns to the unit manager or Assistant Director of Nursing. The Director of Nursing stated they will discuss Resident #25's concern with the physician and if in agreement, an order can be placed for a dental consult. 10 NY CRR 415.17(a-d)

Based on observation, record review and interview conducted during the Recertification Surveys from 11/14/24 to 11/22/24, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, there was undated ice cream in the meat freezer and vegetable freezer, a dietary aide was observed in the kitchen without a beard covering, there was 8 boxes of deluxe original cheddar macaroni noodles with an expiration date of 11/1/24 in the emergency food supply room, and the ceiling in the emergency food room was peeling and had black/brown stains. The findings are: The facility policy titled Food service last revised on 5/10/24 documented dry storage rooms must be well ventilated. All storage areas should have adequate illumination with temperature and humidity controls to prevent condensation of moisture and growth of mold. All refrigerated foods should be covered, labeled, and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. All frozen foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. All frozen leftovers must be used within 30 days. The facility policy titled Sanitation Policy last revised on 1/2023 documented the food service area shall be maintained in a clean and sanitary manner. The facility policy titled Maintenance Services last revised 8/2019 the Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. During an initial tour of the kitchen on 11/14/24 at 10:08 AM, there were three buckets of chocolate, vanilla, and strawberry ice cream undated in the meat freezer, there were unlabeled and undated individual packs of three 4 ounce burgers, there was a 10 lb box of opened and undated 2.5 ounce steak sandwiches, there was an opened and undated box of cheese pizza with 6 of 54 slices remaining, there was an opened and undated bag of frozen boneless skinless chicken breast, there was an opened and undated pack of hot dogs, there was one box of undated and opened precooked flat lasagna sheets, there was an opened and undated 10 lb box of whole strawberries with freezer burn, there was a bag of opened and undated French toast(5 left) and full bag of French toast with ice accumulation inside, there was 3 bags of garlic toast with 6 loose toast unlabeled and undated, there was an open and undated 20 pound box of diced carrots in the vegetable freezer, there was a loose bag of peas opened and undated with no box on the bottom of the vegetable freezer, a dietary aide was observed in the kitchen without a beard covering, there was 8 boxes of deluxe original cheddar macaroni noodles with expiration date of 11/1/24 in the emergency food supply room, and the ceiling in the emergency food room was peeling and had black/brown stains. On 11/14/24 at 10:31 AM, Dietary Aide #3 was observed in the kitchen near food, with a beard and was not wearing a beard covering On 11/15/24 at 1:13 PM, there were 8 boxes of deluxe original cheddar macaroni noodles with an expiration date of 11/1/24 in the emergency food supply room, and the ceiling in the emergency food supply room was peeling and had a black/brown substance. During an interview on 11/15/24 at 01:13 PM, the Food Service Director stated hey became employed at the facility in March and the ceiling in the emergency food supply room has been damaged since that have been there On 11/18/24 at 9:57 AM, the corner and middle of the ceiling in the emergency room supply was peeling/stained. During an interview on 11/18/24 at 10:00 AM, the Food Service Director stated all dietary workers/staff entering the kitchen must wear a hair net and anyone with a beard must wear a beard covering while in the kitchen. The Director of Food Service stated all food items that are opened must be labeled and dated, and that there should not be freezer burn on the items. The Food Service Director stated they have been speaking to staff about labeling and dating foods in the kitchen. During an interview on 11/19/24 at 10:18 AM, the Director of Maintenance stated they were unaware the ceiling in the emergency food supply room had mold since they do not go in there and do not have anything to do with the room unless staff report to maintenance tat something is wrong. The Director of Maintenance stated it is probably a water leak. The Director of Maintenance stated the facility does not do work orders, and that maintenance is told verbally by staff what needs to be repaired. During an interview on 11/19/24 at 11:14 AM, the Director of Maintenance stated they scraped the ceiling in the emergency food supply room of flaking dead paint and that it was a water leak but they were unable to tell if it was mold. They stated they were not aware of the damaged ceiling and that it must have happened years ago. During an interview on 11/22/24 at 10:50 AM, Dietary Aide #3 stated they are aware they need to wear a beard covering when in the kitchen especially while preparing food, and that they forgot to wear one. 10NYCRR 415.14(h)

Based on observations, record reviews and interviews conducted during an abbreviated and extended survey (NY00318363) the facility failed to maintain an environment free of accident hazard for 1 of 12 residents (Resident # 1) reviewed for accidents. The facility did not ensure that a resident was adequately supervised to prevent an elopement. This resulted in actual harm for Resident #1 which was Immediate Jeopardy and Substandard Quality of care with the likelihood of risk for harm to the health and safety of 11 other residents identified as at risk for elopement. Specifically, on 5/31/2023 facility staff failed to provide adequate supervision and did not follow the facility protocol when the front door alarm sounded, which requires that all residents are accounted for. Resident # 1 who was cognitively impaired, assessed as a high risk for elopement and wore an alert device exited the facility through the front entrance undetected between 8:00 PM and 8: 59 PM on 5/31/2023. Facility staff did not discover the resident was missing until an Emergency Medical Technician (EMS # 1) approached the facility and met Certified Nurse Aide (CNA #1) at the facility entrance sometime before 9:00 PM. EMS#1 showed them the picture of the resident. CNA#1 identified Resident #1 as a facility resident. EMS#1 informed the facility that Resident#1 was found lying on the roadside about 250 feet from the facility. Subsequently, Resident #1 was transported to the emergency room (ER) and was diagnosed with injures that included rib fractures, right thumb dislocation, partial dislocation of left and a broken right temporal mandibular joint (jaw). The findings include: Review of the facility Elopement-Missing Resident policy dated 7/2014 and revised 1/2020 documented residents identified at risk for elopement would be frequently monitored for the resident's whereabouts to ensure they remain in the facility. All staff should report to the Charge Nurse or Director of Nursing (DON) any resident attempting to leave the facility. Should staff discover a resident missing from the facility, staff should announce Code Grey over the intercom to alert the other staff and notify the Charge Nurse and/or DON. Resident #1 was admitted to the facility with diagnoses that included dementia, hypertension, and aphasia (inability to express speech). The Quarterly Minimum Data Set (MDS, an assessment tool) dated 4/8/2023 documented Resident #1 had severe cognitive impairment with unclear speech and wore an electronic alert device. The resident had wandering behaviors, was independent with bed mobility and transfer and required supervision/set up for ambulating in room, and locomotion on and off the unit. The Physician's Order for Resident #1 dated 9/16/2022 documented the resident had an electronic alarm system to the left ankle, staff were to check placement of the electronic alarm every shift for safety. The Facility Potential Risk for Elopement Nursing Care Plan dated 6/29/2021 and updated 2/9/2023, documented the goal was that Resident#1 would not leave the facility unattended. Interventions included to check the electronic alarm system functionality daily, check the electronic alarm system ankle placement every shift, distract the resident from wandering by offering pleasant diversions, identify patterns to target interventions, initiate psychology and psychiatric evaluation, and a room change to be closer to the nurse's station for closer monitoring. The Facility Elopement Evaluation dated 3/9/2023 documented Resident #1 was scored a high risk for elopement. The facility Accident/Incident Report dated 5/31/2023 documented Resident #1 eloped on 5/31/2023 from the facility when there was no staff posted at the front door. Staff were occupied with the care for other residents and did not respond to the electronic alarm system when it sounded. Resident #1 was found and returned to the facility by local EMS, assessed by staff before the resident was transferred to the hospital for evaluation and treatment of injuries sustained. Review of the Trauma Surgeon Hospital History and Physical dated 6/1/2023 documented Resident #1 was diagnosed with right and left rib fractures, right thumb dislocation, partial dislocation of their left and right temporal mandibular joint (jaw), and left arm and left knee abrasions. Resident #1 was admitted to the intensive care unit (ICU) to monitor for respiratory deterioration. During observations at the facility from 6/15/2023 to 6/17/2023 during onsite visit revealed the facility's electronic alarm system was functional and audible on both units. An electronic alert device was checked by exit doors and it revealed the alert devices were functional. During an interview on 6/15/2023 at 2:42 PM, LPN #1 stated they were the nurse assigned to Unit A (Resident #1's unit) on the evening of 5/31/2023 and last saw Resident #1 at 8:00 PM. LPN #1 stated they went on their break shortly after they saw the resident. LPN #1 stated that they informed the Registered Nurse (RN) #1 (who was assigned to Unit B) that they were leaving the facility for their dinner break. RN #1 was to provide coverage for Unit A while LPN #1 was out on break. LPN #1 stated they were returning to the facility when they saw Resident #1 and CNA #1 on the side of the road with EMS. LPN #1 stated that they notified the Registered Nurse Supervisor (RNS) #1 and the Director of Nursing (DON) by phone of the elopement. After Resident #1 arrived at the facility, RNS #1 did a head-to-toe assessment then notified Resident #1's Attending Physician (AP) #1 and the resident's family then Resident #1 was transferred to the hospital. LPN #1 stated they did not recall if the elopement door alarm was sounding when they returned to the facility. During an interview on 6/15/2023 at 6:39 PM, CNA #1 stated they heard the electronic alarm sounding faintly at the facility entrance door, but the electronic alarm did not sound on Unit A nurses' station. CNA #1 stated they noticed that Resident #1 was not in their room at approximately 8:30 PM. CNA #1 stated they were looking for Resident #1 by the facility entrance door when EMS #1 arrived and showed them the picture. CNA #1 stated they identified the picture as Resident #1 and went with EMS #1 to the scene (by the roadside about 250 feet from the facility) where Resident #1 was sitting upright on the ground with EMS. CNA #1 stated they notified RNS #1 of the elopement by phone at 8:30 PM. During a subsequent interview on 6/16/2023 at 2:35 PM, CNA #1 stated they heard the entrance door alarm sounding on the evening of 5/31/2023 at about 8:30 PM but because the alarm often goes off due to staff entering and leaving the facility, they did not check the front door or conduct a resident head count. CNA #1 stated they were the only staff on the Unit A at that time. They could not locate LPN #1 or CNA #2. They were unaware that LPN #1 and CNA #2 went out on break without informing her. CNA #1 stated they took a smoke break outside the building but did not inform the RNS#1 they were talking a break. CNA#1 stated they were approached by EMS #1 who showed them a picture of Resident #1. CNA#1 stated It was at that time they became aware that Resident #1 had exited the facility. CNA #1 stated they did not perform a head count when they heard the front door alarm sound, did not announce a Code Grey on the intercom, and did not notify RNS #1. During an interview on 6/15/2023 at 4:45 PM, RN #1 stated on the evening of 5/31/2023 LPN #1 informed them they were leaving the facility on break and RN#1 needed to cover Unit A. RN #1 stated they were managing resident issues with RNS #1 on Unit B down the corridor from Unit A. RN#1 stated they overheard RNS #1 on the phone with CNA #1 informing them of Resident #1's elopement. RN #1 stated they did not hear the electronic alarm sounding at the facility entrance door while on Unit B. RN #1 stated they went to Unit A to check on the residents and found CNA #5(floats between Unit A and Unit B) exiting a resident's room, so they directed them to do a head count of the residents on Unit A. RN #1 stated they could hear the electronic alarm sounding at the facility entrance door when on Unit A. RN#1 stated they did not announce Code Grey as required by the facility policy. RN #1 stated Resident #1 had exit-seeking behaviors. Nurses documented placement of the electronic alarm on the treatment administration record (TAR) every shift. RN #1 stated there was no required time to check the electronic alarm and staff had no set intervals for monitoring the residents. During an interview on 6/15/2023 at 8:00 PM Receptionist #2 stated Resident #1 was often exit seeking, the receptionist called the nursing staff to escort Resident #1 back to the unit. Receptionist #2 stated Resident #1 was not easily redirected from their attempts at leaving the facility. During an interview on 6/16/2023 at 9:59 AM the Director of Social Work (DSW) stated Resident #1 became exit seeking on 2/3/2023 and was relocated to a room that was closer to the nurses' station. Registered Nurse Unit Manager (RNUM) #1 and the DSW had a care planning meeting with Resident #1's family on 5/4/2023. RNUM#1 and DSWcanvassed for locked Dementia units at other facilities which would be more appropriate for the resident due to increased exit seeking behaviors. The DSW stated that when Resident # 1 was less able to be redirected, the facility Administrator provided a 1:1 sitter which was done at times after Resident #1's family visited. Residents like Resident #1 needed more monitoring since the facility did not have a locked unit. During an interview on 6/16/2023 at 11:56 AM emergency medical services (EMS) #1 stated they responded to a call involving an unidentified person found lying on the side of the road. EMS #1 stated they observed Resident #1 lying on the side of the road, unable to speak, and appeared to have fallen. EMS #1 stated since Resident #1 was unable to state their name and was wearing an electronic alarm device, they took a picture of Resident #1 and sent one of the members of EMS to the nearby facility. EMS #1 stated CNA #1 identified the resident from the picture and stated they were unaware Resident #1 had eloped. EMS #1 stated they then took CNA #1 back to the scene to identify and provide medical information regarding Resident #1. During an interview on 6/16/2023 at 10:16AM EMS #2 stated CNA #1 and identified the resident. CNA #1 called RNS #1 to report the incident. RNS #1 then called CNA #1 and directed them to return Resident #1 to the facility. EMS #2 returned Resident #1 to the facility by ambulance. EMS #2 stated they heard the entrance door alarm sounding as they approached the building. EMS #2 stated they were met by RNS #1 who stated they were unaware that Resident #1 had eloped. EMS #2 stated that RNS #1 took Resident #1 back to their room and performed a head-to-toe assessment, then notified Attending Physician (AP) who ordered Resident #1 be transferred to the hospital for further evaluation. During an interview on 6/16/2023 at 12:08 PM with RNS #1 stated they received a call from CNA #1 who stated Resident #1 had eloped and they were at the scene of the incident where Resident #1 was found by a member of the community and was unsure how to proceed. RNS #1 stated this was the first time they were alerted that Resident #1 had eloped and was unsure how to proceed, so they called the Director of Nursing (DON). RNS #1 stated the DON told them that they were heading to the facility. However, RNS #1 stated that the DON provided no guidance on how to proceed. RNS #1 then notified the facility's Administrator, who instructed them to inform CNA #1 to have EMS return Resident #1 to the facility instead of transporting the resident to the hospital for evaluation. During an interview on 6/15/2023 at 5:45 PM with the Administrator stated Resident #1 had exit seeking behaviors and eloped from the facility on 5/31/2023 after 8:00 PM when there was no staff posted at the front door. The Administrator stated there was no staff assigned to monitor the front door from 8:00 PM to 8:00 AM and the facility had no security cameras. The Administrator stated they were notified by RNS #1 of Resident #1's elopement and into the facility to investigate and in-service staff about elopement prevention and missing resident response. The Administrator stated the previous electronic alarm only sounded in the Unit A nurses' station and at the front door, the alarm could not be heard in other parts of the facility which meant that all staff did not respond to residents seeking to exit the facility. The new active functioning electronic alarm system in place that sounded an alarm throughout the facility when triggered. The facility has provided evidence that 100% of their staff, including all agency and per diem staff have received re-education on elopement prevention and response between 6/16/2023 and 6/19/2023. During a telephone interview on 6/20/2023 at 11:00 AM the Medical Director/Attending Physician(AP#1), they stated Resident #1 was identified as an elopement risk on admission and was ambulatory. AP #1 stated because Resident #1 was an elopement risk, they were provided an electronic alarm device. AP #1 stated they were called by facility staff the evening of 5/31/2023 regarding Resident #1's elopement and informed the staff that Resident #1 needed to be transferred to the hospital for further evaluation following the incident. AP #1 provided order for transfer. AP #1 stated there is a physician on call 24/7, shared between themselves and another geriatrician. AP #1 stated resident's receive monthly physician visits and are seen as needed for clinical issues between visits. The Immediacy was removed on 6/19/2023 prior to exit based on corrective measures taken by the facility: Facility provided training sign in sheets for 100% of staff, including agency and per diem staff Lessons provided between 6/16/2023 and 6/19/2023 included re-education on elopement prevention and response. A check of the electronic alarm system at the facility on 6/15/2023 from 11:05 AM to 12:15 PM revealed the facility's electronic alarm system was functional and audible on all units. The Treatment Administration Record documented the alert device was checked every shift by the nurses. Observations were conducted on 6/17/2023 between 10:20 AM-1:00 PM and 9:00 PM-10:00 PM on 6/20/2023. There was a staff member at the front desk during these hours. Staff confirmed that there was a staff member at the front desk of the facility at all times of the day. Facility provided proof of employment that the facility hired a full-time staff to work the front desk at night as of 6/16/2023. Facility document titled Front Desk Sign-In was reviewed on 6/17/2023 listed staff names, signatures, and the time of coverage. Document revealed staff were present at the front desk from 8 PM on 6/16/2023. Interviews were conducted on 6/17/2023 and 6/20/2023 with 8 staff LPN's, 2 agency/per diem LPN's, 8 staff CNA's, 2 agency/per diem CNA's, 1 per diem/agency dietician, 2 housekeepers, 1 receptionist revealed the staff were knowledgeable of the facility policy/procedure/response protocol including alarm identification and steps to take following when the facility alarm going off. Facility provided a reassessment list for all residents. Residents identified were logged in the elopement logbook and orders and care plans were updated. 10 NYCRR415.12 (h) (2)

Based on observations, record review and interviews conducted during an abbreviated survey (Complaint #NY 830) completed on 11/4/2021, the facility failed to have an effective system in place for the resident's environment to remain as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents during meals for residents who are at risk for choking, Specifically, Resident #1 had diagnoses, which include Dysphagia, and Dementia. The Speech-language pathologist's (SLP) reports dated 5/4/21 and 8/23/21 documented dysphagia, oropharyngeal phase. The SLP recommended mechanical soft diet, pureed fruit and vegetables, and no bread allowances. The physician's order indicated the same. The resident was assessed as requiring extensive assistance for eating. On 8/21/2021 the facility reported that Resident #1 was served bread by staff and experienced a coughing episode. On 11/3/2021 at 11:40 AM a Surveyor observed the resident feeding herself with a weighted spoon. The surveyor observed a fresh banana on the resident's tray. The surveyor then observed a Licensed Practical Nurse (LPN) peel the banana and leave it on the resident's food tray. The LPN was not aware that the resident was to only receive pureed fruit until the surveyor intervened and verified the physician's order as documented on the meal ticket. This resulted in the likely hood for serious injury or death that was Immediate Jeopardy for Resident #1 and 22 other residents who had physician orders for mechanically altered diets. Findings include: The facility Tray Identification Policy with a revision date of 4/2021, documented that appropriate identification/ coding shall be used to identify various diets. To assist in setting up and serving the correct food trays/diets to residents, the Food Services Department will use appropriate identification - color coded or computer-generated diet cards to identify the various diets. The food service staff will check the trays for correct diets before the food carts are transported to their designated areas. Nursing staff will check each food tray for the correct diet before serving the residents. If there is an error, the nurse supervisor will notify the Dietary Department immediately by phone so that the appropriate food tray can be served. The facility's Innovation Services Diet Manual of 2021 described Mechanical Soft diet consists of foods that are in an easy to chew form. Food from the regular diet menu is mechanically altered and ground, so it can be consumed by a resident with chewing difficulty. This diet is indicated for residents with chewing difficulty, teeth loss, poor fitting dentures, mouth pain, or residents that require extensive time to complete a meal. The Pureed Diet is designed using the regular diet and mechanically altering the texture of the food items into a pureed consistency. The goal of this type of diet is to improve or maintain the resident's nutritional status and provide foods that are safe to swallow, minimizing the chance of aspiration. Resident #1 had diagnoses which include Alzheimer's disease, Dementia. The Face Sheet record documented a secondary diagnosis of Food in Respiratory Tract, Part Unspecified Causing Asphyxiation on 3/12/21. The Quarterly Minimum Data Set (MDS; a resident assessment tool) dated 8/1/21, documented that the resident has severe cognitive impairment and required extensive assistance of one person with eating. The facility incident documented that on 8/21/21 at 11:59 AM, the assigned CNA #1 was seating Resident #1 for lunch. CNA #1 placed the lunch tray in front of the resident and noticed that the bread should not have been there, and s/he went to get some tea for the resident. By the time CNA #1 came back, the resident had one bite of the bread, and started coughing. CNA #1 was given 1:1 education at the time of the incident, the dietary staff were educated on meal try accuracy, and all staff members were educated on the policy and procedure on dining room service, meal tray set-up and assistance. This investigation was conducted by the former Director of Nursing (DON #1). A nursing progress noted written by DON#1 on 8/21/21 at 12:05 PM, documented that the resident experienced a coughing episode. Staff reported that (lunch) tray had bread. CNA#1 went to get tea and was going to remove the bread upon return. It was then that Resident #1 ate one bite of bread and began coughing. The resident continued to cough and was suctioned to remove the food out of the resident's mouth. Resident #1 brought up a quarter size piece of bread that was in their mouth. The physician was immediately notified and gave orders for a chest x-ray. The lunch meal ticket dated 8/21/21 documented, the resident was to receive a regular, mechanical soft diet with puree fruits, puree vegetables. The CCP documented that it was updated on 8/21/2021 with a note written by the Dietary Technician (DT). The note documented the coughing episode related to patient receiving food item that was not appropriate. Interventions included to provide diet and consistency per MD (physician) order: Heart Healthy, Puree with Mechanical Soft Meats, No Bread OOB (Out of Bed) for all meals. The SLP Evaluation and Plan of Treatment report dated 8/23/21, documented the resident has dysphagia, oropharyngeal phase and recommended to continue mechanical soft diet with puree fruits and vegetables and no bread allowances. The 10/1/21 Quarterly MDS documented that the resident continued to require extensive assistance of person with eating. The resident's comprehensive care plan (CCP) identified potential nutrition and hydration as a problem updated on 8/23/2021 initiated documented chewing problems related to dysphagia (difficulty swallowing), dependence on staff to provide food and fluids, and need for mechanical altered meals and therapeutic supplements. Interventions included to observe for chewing or swallowing problems, provide diet and consistency per Medical Doctor (MD) order: Heart Healthy, Puree with Mechanical Soft Meats, No Bread OOB (Out on Bed) for all meals and use of adaptive feeding device: built-up utensils at all meals to increase independence with self-feeding. The Physician Orders for August, September, October and November 2021 documented mechanical soft diet with pureed vegetables and fruits. During an interview on 11/3/21 at 10:40 AM, the Registered Dietitian (RD) #1 stated that the resident has a mixed consistency diet consisting of pureed and mechanical soft diet, and no bread was allowed. The RD stated that bread can form a bolus in the mouth, and if the resident has a swallowing problem it can cause some problems including aspiration or choking. RD #1 stated that CNA #1 should have removed the bread immediately since CAN #1 already knew it wasn't supposed to be on Resident #1's tray. During an interview on 11/5/21 at 11:00 AM, CNA #1 stated they were assigned to Resident #1 at the time of the incident. CNA #1 stated that they had been providing care to the resident for a year and was aware that the resident should not have bread. CNA #1 stated that on the date of the incident they took the bread from the resident's plate and placed it on the other side of the resident's table. The CNA stated that they turned around to call the kitchen for another tray without the bread and that in less than a minute the resident had taken a bite of the bread and began coughing. CNA #1 stated they immediately called for assistance. The nursing supervisor responded and successfully suctioned the bread out of the resident's mouth. CNA#1 denied giving the resident the bread. CNA #1 stated the resident was fine after the incident. 2.) During an observation of the meal tray line conducted in the facility's main kitchen on 11/3/21 at 11:25 AM, the Dietary Aide (DA) #1 was observed calling out to the cook the type of food consistencies needed for Resident #1. At that time, DA #2 stated that the tray for Resident #1 was being prepared. DA #2 was observed to read Resident #1's meal ticket, placed food items into the resident's tray including mechanical soft turkey, 4 oz. of pureed broccoli, ½ cup pureed fruit, and a whole fresh banana in its peel. DA #2 placed a cover on the resident's plate and informed the transporter that the food cart was ready for delivery to the resident's unit. After the arrival of the food cart on the Resident #1's unit at 11:40 AM, LPN #1 opened the meal cart, read Resident #1's name on the meal ticket on the tray, and placed it in front of the resident. LPN #1 removed the plate cover, then peeled the fresh banana, and placed the banana back on the resident's plate. DT #1 was standing next to Resident #1 and LPN #1 when the LPN placed the peeled the banana back on the resident's plate. During an immediate interview, DT #1 was questioned if Resident #1 was allowed to have a non-altered banana. DT#1 checked the meal ticket and removed the banana from the tray. The DT stated, I do not know why the banana was placed on the resident's tray. During an interview on 11/3/21 at 12:00 PM, DA #2 stated that they placed the banana Resident #1's meal tray error. During an interview on 11/3/21 at 12:30 PM, DT #1 stated that after Resident #1's first incident on 8/21/21, they conducted observational audits to ensure that residents received the correct meal consistency as ordered by their physician. DT #1 stated that they would again in-service the kitchen staff to prevent this incident from further occurrence. During an interview on 11/3/21 at approximately 12:40 PM, the interim Director of Nursing (DON#2) stated that the banana should not have been placed on Resident #1's tray. During an interview on 11/3/21 at 3:00 PM, LPN #1 stated that they were not an employee of the facility. They accompanied the nursing consultant to help out for the day. LPN #1 stated that they did not receive any prior information regarding Resident #1. LPN#1 stated that they only read the residents name on the ticket and did not review the ticket for food items or diet consistency. During an interview on 11/3/21 at 3:30 PM, the facility administrator stated they understood the possible problem that may have occurred if Resident #1 ate the banana. During an interview on 11/4/21 at 10:25 AM, CNA #2 stated that Resident #1 can feed themself, using a special spoon and fork. CNA #2 stated that the resident's meal should be pureed and there should be no bread on the tray. During an interview on 11/4/21 at 2:40 PM, the attending physician stated that the resident is very frail and has oropharyngeal dysphagia. The attending physician stated that the resident's diet must be pureed because the resident's muscles of mastication (act of chewing) may be weak to chew the food well and may cause aspiration or choking. During an interview on 11/4/21 at 10:35 AM, LPN #2 stated that the resident required extensive assistance in most of her activities of daily except for eating. LPN #2 stated the resident can feed herself using built-up utensils. LPN #2 stated that the resident's meal should be pureed and mechanical soft with no bread allowed. Immediate Jeopardy was identified, and the facility Administrator was notified on 11/3/21 at 6:41 PM. The facility Administrator stated that they would start an immediate in-service of all staff. Immediate Jeopardy was removed on 11/4/21 at 4:30 PM. based on the following corrective actions taken by the facility: - LPN #1 was immediately in-serviced on diets and accuracy of meal tickets. - A facility-wide in-service education was conducted on 11/3/21 starting at 12:00 PM. - Monitoring and supervision was instituted with the dietary and kitchen staff for meal tray accuracy. - Nursing staff and other departments assisting with meals were in-serviced on meal tray tickets and diet accuracy. The nurse will check the tray for the proper food consistency, signs the meal ticket that meal was correct, hands the tray to the CNA who then checks the tray again before serving the residents. - On 11/4/21, the facility conducted review of all 22 residents with mechanically altered diets to make sure that the diet prescription is consistent with the physician's order and care plan. - The facility in-serviced 95.4% of its staff members who are directly involved with meal service. 415.12(h)(1)(2)

Based on record review and staff interviews, the facility failed to provide adequate monitoring for a resident on anti-coagulant therapy. Specifically, the staff continued to administer [MEDICATION NAME], a blood thinning medication, to a resident with abnormal laboratory values causing a large hematoma (a collection of blood outside a blood vessel) that required hospitalization and subsequent evacuation of the hematoma. This was evident for 1 of 1 resident reviewed during an abbreviated survey. (Resident #1). This resulted in actual harm that is not immediate jeopardy. The facility policy regarding oral anticoagulant therapy dated 4/1/2010 documents the nurse will obtain the PT/INR results prior to administering [MEDICATION NAME]. The nurse will advise the Physician of the results and obtain orders regarding the [MEDICATION NAME] dose and the next PT/INR to be drawn. Findings are: Complaint ID NY 790 Resident #1 is an [AGE] year old female with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0- a resident assessment tool- dated 7/20/12 documents the resident is cognitively intact. Review of the "Clinical Monitoring Detail Report", a summation of the events by the Medical Director dated 8/1/12, documents the PT/INR ([MEDICATION NAME] time/International Normalized Ratio- blood tests to determine the clotting tendency of blood) was performed on 6/27/12 per physician's orders [REDACTED]. The medical record documents the therapeutic goal for this resident was to have the INR between 2 and 3. Review of the facility investigation dated 7/6/12 reveals the LPN (Licensed Practical Nurse) Medication Nurse obtained the INR by fingerstick on 6/27/12 and it was 4.7. She informed the physician who stated "that is not therapeutic. Hold the [MEDICATION NAME]." No physicians' order was written to hold the [MEDICATION NAME] or to re-check the PT/INR. Review of the MAR (Medication Administration Record) for June 2012 reveals [MEDICATION NAME] 3 mg. was administered daily at 9:00pm from June 16, 2012 through July 4, 2012. Review of the nursing progress notes dated 7/4/12 at 8:38pm reveal the resident presented with an ecchymosis (escape of blood into the tissues from ruptured blood vessels) to her right upper arm. Review of the nursing progress notes dated 7/5/12 at 8:22pm reveal the resident presented with a large hematoma to the right arm. She complained of pain and difficulty raising her arm. The physician was notified and a verbal order was received to check the PT/INR and to hold the [MEDICATION NAME]. The PT/INR result was 5.2 (high). Review of the nursing progress notes dated 7/6/12 at 7:10am reveal the resident continued to complain of pain to the right arm and a Doppler ultrasound (test to examine blood flow in the arteries) was ordered by the physician. The test results revealed a large bruise with extensive swelling, but no evidence of a clot. The INR on this date was 5.04. Review of the nursing progress notes dated 7/7/12 at 10:18am reveal the resident was noted with increased confusion and lethargy. The right arm was noted to be warm and swollen with a large ecchymosis to the upper, inner area of the arm. She was unable to move the right arm without extreme pain. The physician was notified and the resident was ordered to be sent to the emergency room . She was subsequently admitted to the hospital for surgical evacuation of the hematoma. The resident returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. Observation of the resident on 11/15/12 at 12:00pm revealed a healed suture line to the right upper arm approximately 4 inches long. The inner aspect of the upper arm was slightly swollen. The resident was alert and responsive and stated "I had about 20 stitches." The physician was interviewed on 11/19/12 at 4:40pm and she stated when she was told that the INR was 4.7 on 6/27/12 she told the LPN Charge Nurse to hold the [MEDICATION NAME] as this level was not therapeutic. However, the medication was never held and the resident kept receiving it until 7/4/12. Review of the "Medical Director Case Review regarding High INR- hematoma right arm" dated 8/1/12 and signed by the physician (who is also the Medical Director) documents on 6/27/12 the INR was 4.7 per verbal report from the LPN. The physician told her to hold the [MEDICATION NAME] as the INR was sub-therapeutic. There was no physician signed documentation of the INR results and no documentation detailing an assessment of the resident. On 7/4/12, nursing noted a bruise to the resident's right arm which turned into an ecchymosis. The [MEDICATION NAME] sheet with the high INR was missing. Nursing continued to administer [MEDICATION NAME] for 7 days after that date and the repeat INR on 7/5/12 was 5.2. The physician revealed her standard of practice is to hold the [MEDICATION NAME] for an INR of 3 or higher. An interview with the LPN Medication Nurse took place on 11/20/12 at 1:00pm. She stated she checked the resident's INR by fingerstick on 6/27/12 and it was 4.7. She handed the report to the Physician and the LPN Charge Nurse as they were doing rounds and told them the results. The LPN Medication Nurse stated she heard the Physician state that 4.7 was not therapeutic and to hold the [MEDICATION NAME]. The LPN Medication Nurse never wrote an order to hold the [MEDICATION NAME]. The LPN Charge Nurse was interviewed on 11/15/12 at 2:00pm and stated she did recall the LPN Medication Nurse informing her and the Physician of the INR results on 6/27/12. The LPN Charge Nurse then took the report and placed it in the chart room and did not see it again. She added that she did not associate the swelling and ecchymosis of the resident's arm with [MEDICATION NAME] therapy. The Director of Nursing was interviewed on 11/15/12 at 10:30am and stated the facility policy was to perform the INR prior to administering [MEDICATION NAME]. Staff is then to inform the physician of the results and obtain orders regarding the [MEDICATION NAME] dose and the next INR to be drawn. The facility continued to administer [MEDICATION NAME] to a resident without performing necessary monitoring of the INR to ensure that the resident was receiving a therapeutic dose and did not suffer any adverse effects. 415.12(l)(1)