Every finding on record at Northern Manhattan Rehabilitation and Nursing Cent

Based on observation, record review, and interviews, the facility failed to ensure sufficient nursing staff were available to provide nursing and related services. Specifically, the facility reported short staffing on weekends confirmed by a review of the Daily Staffing and the Payroll Based Journal Staffing Data Report. The findings include:The facility's Payroll Based Journal Staffing Data Report for the 3rd quarter of Fiscal Year 2025 (04/01-06/30/3025) triggered low weekend staffing.The Facility assessment dated [DATE] stated the facility had an average of 310 occupied beds on 8 units with 40 beds on each floor. Par levels were listed as follows:Day shift, Units 2, 3, 5, 6 and 9 - 1 to 2 Registered Nurses / Licensed Practical Nurses and 3 to 5 Certified Nursing AssistantsDay shift, Units 4, 7 and 8 - 1 to 2 Registered Nurses / Licensed Practical Nurses and 4 to 6 Certified Nursing AssistantsEvening shift, Units 2, 3, 5, 6 and 9 -- 1 Registered Nurse / Licensed Practical Nurse and 2-4 Certified Nursing Assistants Evening shift, Units 4, 7 and 8 -- 1 Registered Nurse / Licensed Practical Nurse and 3-5 Certified Nursing Assistants Night shift, 1 Registered Nurse / Licensed Practical Nurse and 2 to 3 Certified Nursing Assistants on all units.The weekend staffing sheets were reviewed from 04/01/2025 to 06/30/3025 and showed the following: 1. On Saturday, 05/24/2025, the night shift nurse on Unit 4 called out and was not replaced. 2. On Saturday, 06/14/2025, Unit 3 had no nurse on the evening shift, and the evening supervisor filled in. 3. On Sunday, 06/15/2025, the night shift nurse on Unit 6 was off and was not replaced. 4. On Saturday, 06/21/2025, the night shift on Units 6 and 9 had one (1) Certified Nursing Assistant each. The Physician Order Activity Detail Reports for the quarter (04/01/2025 to 06/30/3025) revealed that 13 residents on Unit 6 required 2-person physical assist for toilet transfers, and 6 needed 2 assists for bed mobility; On unit 9, 12 residents needed 2 person assist for toilet transfers and 6 residents needed 2 assists for bed mobility.Staffing sheets for the week of 09/01/2025 to 09/07/2025 were also reviewed and revealed that on Monday, 09/01/2025, the night shift nurse on unit 3 called out and was not replaced. On Wednesday, 09/03/2025, there was only 1 Certified Nursing Assistant on the night shift in Unit 9. On Friday, 09/05/2025, the evening nurse on Unit 6 called out and was not replaced. On Sunday, 09/07/2025, Unit 6 had no assigned nurse on the day shift; the assigned nurse was off, and the 2nd nurse was floated to perform wound treatment on another floor. On 09/16/2025, during Resident Council meeting, Resident #182 stated they require 2 staff to get out of bed and sometimes staff get them out of bed by 2:00 PM. On 09/19/2025 at 1:50 PM, Certified Nursing Assistant #6 stated that sometimes it is a struggle especially when there are only 3 Certified Nursing Assistants. On 09/19/2025 at 9:08 AM, the Staffing Coordinator was interviewed and stated that they were not aware that there were shifts when the facility had not met its par levels. The Staffing Coordinator stated that when a unit is short of staff, they have a call list of nursing staff for replacement. They also stated that they come to work before 7:00 AM to address any last-minute callouts or no-shows, and that they are on call on weekends as well to help with staffing.On 09/19/2025 at 2:15 PM, the Director of Nursing was interviewed and stated that there are three (3) Certified Nursing Assistants in high acuity floors. If there are fewer than 3 aides, the night shift supervisor will float an aide from another floor. The Director of Nursing stated there was never just one (1) aide to give care on any floor on any shift. 10NYCRR414.13(a)(1) (i-iii)

Based on observation, record review, and interviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards of food service safety. This was evident during Dining and Kitchen Observation Task. Specifically, 1.) Certified Nursing Assistant #8 failed to perform hand hygiene while assisting residents with their meals. 2.) Kitchen staff were observed with visible facial hair while in the kitchen area. 3.) Expired food items were observed in the kitchen refrigerator. The findings include: 1.) The facility's Handwashing/Hand Hygiene policy with a last reviewed date of 02/2023 documented that the purpose of the procedure is to provide guidelines for effective handwashing and hygiene techniques to aide in the prevention of the transmission of infections. The policy stated that in most situations, the preferred method of hand hygiene is an alcohol-based hand rub, for instance, after contact with resident's skin and after removing gloves. During dining observation in Unit 9 on 09/17/2025 between 12:49 PM to 1:05 PM, Certified Nursing Assistant #8 was observed bringing Resident #183's lunch tray to the resident's room. The Certified Nursing Assistant then moved the remote control on the resident's bedside table, placed the resident's call bell with their reach, picked up the remote control after it dropped on the floor; and without performing hand hygiene, Certified Nursing Assistant #8 proceeded to opening the resident's soda can with bare hands and poured the soda into a cup. The Certified Nursing Assistant then opened the resident's sandwich with bare hands and placed the sandwich on the lunch tray. Without performing hand hygiene, Certified Nursing Assistant #8 then proceeded to assist Resident #122 with their electronic device and then took and placed Resident #173's lunch tray on the table. During an interview on 09/17/2025 at 1:07 PM, Certified Nursing Assistant #8 stated they were moving fast and only realized they did not perform hand hygiene when asked by the State Surveyor. During an interview on 09/18/2025 at 11:43 AM, the Director of Nursing stated they provided infection control training to the staff and that they conduct random unit observations, including dining observation, to track infection control practices. 2.) The facility's policy titled Facial Hair Restraint for Food Service Staff with an effective date of 09/2025 stated any employee who has visible facial hair must wear an approved beard guard while in food service/kitchen/preparation areas whenever they are handling food or coming in contact with surfaces or equipment that contact food. The restraint must cover the facial hair completely and be maintained in place during all food preparation, plating, and service tasks. During an observation on 09/14/2025 at 9:59 AM, the Food Service Manager was observed without facial restraint and with visible mustache, beard, and sideburns while in the kitchen area.During an interview on 09/14/2025 at 10:18 AM, the Food Service Director stated that they were rushing and did not grab a beard net. They stated they must wear beard net in the kitchen to prevent facial hair from falling on the food. During an observation on 09/16/2025 at 11:12AM, [NAME] #1 was observed in the tray line area with their mustache not properly covered. On 09/16/2025 at 11:29 AM, [NAME] #1 was interviewed and stated that their facial hair must be covered. 3.) The facility's policy titled Inventory and Rotation Policy with a reviewed date of 09/2025 documented that all food inventory must be rotated on a First In, First Out basis ensuring that food with an earlier expiration date is used first and eliminating waste due to spoilage. During an observation on 09/14/2025 between 9:59 AM to 10:27 AM, a container of potato salad with a best if used by date of 08/31/2025 and a box of skinless boneless turkey breast with a use or freeze by date of 06/13/2025 was observed in the refrigerator. During an interview on 09/14/2025 at 10:18 AM, the Director of Food Service stated they inspect the refrigerators on an ongoing basis and did not notice these expired items. 10 NYCRR 415.14 (h)

Based on observation, record review, and interviews , the facility did not ensure that drugs were stored in accordance with professional standards. This was evident in two (2) (Unit 3 and Unit 5) of nine (9) units observed for medication administration and medication storage. Specifically, Unit three (3) and Unit five (5) medication carts were left unlocked and unattended on 2 occasions. The findings include: The facility's policy and procedure titled Medication Administration, with a revision date of 10/2024, documented that it is preferable for the nurse to prepare medications from the Medication Administration Record at a medication cart, which is to be kept in close view of the nurse at all times and locked unless in use.On 09/16/2025 at 11:10 AM, Licensed Practical Nurse #3 left the medication cart unlocked in the hallway when they went to Resident #314's room to administer insulin. On 09/16/2025 at 11:55 AM, an interview was conducted with Licensed Practical Nurse #3 who stated that they forgot to lock the medication cart when they went to administer Resident #314's insulin. On 09/17/2025 at 1:00 PM, Licensed Practical Nurse #4 left the medication cart unlocked when they went to administer Resident #288's medication. A medication drawer that contained multiple blister packs of pills was observed left open in the corridor of room [ROOM NUMBER] which is located out of the view of the nurses' station.On 09/17/2025 at 1:10 PM, an interview was conducted with Licensed Practical Nurse #4 who stated that they always lock the medication cart and was not sure why they did not lock the cart when they went to administer the resident's medication. Licensed Practical Nurse #4 further stated that it is unsafe to leave the medication cart unlocked with the drawers open as someone could take the medications from the cart without their knowledge.On 09/16/2025 at 12:40 PM, an interview was conducted with the Director of Nursing who was observed on the floor with Licensed Practical Nurse #3. The Director of Nursing stated that nurses should lock the medication carts when they leave them in the hallway to go to a resident's room to administer medication. The Director of Nursing also stated that leaving medication carts open, unlocked, and unattended is a safety issue. A resident, especially those who wander, can take medications from unlocked medication art. 10 NYCRR 415.18(e)(1-4)

Based on observation, record review, and interviews the facility failed to ensure that residents are free of any significant medication errors. This was evident for one (1) (Resident #324) of 8 residents reviewed during the Medication Administration Task. Specifically, Resident #324 was not administered the 10:00 AM dose of Dorzolamide-Timolol eye drops as ordered by the physician and a 2:00 PM dose of Hydralazine 50 milligrams was held without physician notification.The findings include:The facility's policy and procedure titled Medication Administration, with a last revision date of 10/2024, documented medications are to be administered in a two-hour timeframe, one (1) hour before or after the medication order time. The nurse will review the Medication Administration Record for accuracy when all medication for a specific resident has been prepared. The nurse reviews each resident's medication as needed and notifies the physician if changes are needed.Resident #324 was admitted to the facility with active diagnoses that included Glaucoma and Hypertension.The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #324 had intact cognition. 1.) On 09/16/2025 at 12:03 PM, during medication administration observation with Licensed Practical Nurse #3 in Unit Five (5). Resident #324 reported to the surveyor that they had not been consistently receiving eye drops for glaucoma that are for scheduled for 10:00 AM. A physician's order dated 09/11/2025 documented to instill Dorzolamide 22.3 milligrams-Timolol 6.8 milligrams per milliliter one (1) drop in each eye two (2) times per day at 10:00 AM and 6:00 PM for ocular hypertension. A Care Plan Activity Report dated effective 02/07/2024, documented that Resident #324 had a sensory/visual deficit and received Dorzolamide and Latanoprost eye drops as ordered. A quarterly review note dated 07/24/2025 documented that Resident #324 continues Dorzolamide and Latanoprost eye drops as ordered.The Electronic Medication Administration Record for Resident #324 dated 09/16/2025, was reviewed with Licensed Practical Nurse #3. The 10:00 AM dose of Dorzolamide-Timolol eye drops was not signed off as given.On 09/16/2025 at 12:07 PM, an interview was conducted with Licensed Practical Nurse #3 who stated that when they administer medications, they review the electronic medication administration record for the resident's scheduled medications. Licensed Practical Nurse #3 stated they were confused by Resident #324 when they had questions about the eye drops so they did not administer the medication. Licensed Practical Nurse #3 further stated that they should have rechecked the medication administration record for accuracy and explained the medication dose and frequency to Resident #324, but they delayed instilling the eye drops and then forgot to go back and administer them. 2.) A physician's order dated 09/11/2025, documented Hydralazine 50 milligrams, give one (1) tablet three (3) times a day for Essential (Primary) Hypertension, scheduled at 10:00 AM, 2:00 PM, and 6:00 PM.A Care Plan Activity Report with an effective date of 02/07/2024, documented that Resident #324 had hypertension and was to be administered Hydralazine as ordered by the physician to maintain the blood pressure within normal limits. Abnormal findings should be promptly reported to the physician. On 09/17/2025 at 2:44 PM, a medication administration observation was performed with Licensed Practical Nurse #5 in Unit Nine (9) where Resident #324 had been transferred. Licensed Practical Nurse #5 reported that they will put on hold Resident #324's 50 milligram dose of Hydralazine that was scheduled for 2:00 PM because the resident's blood pressure was 119/53. Resident #324 was heard denying any complaints or signs/ symptoms of hypotension. Registered Nurse #2, the charge nurse was notified by Licensed Practical Nurse #5.On 09/18/2025 at 10AM, The Electronic Medication Administration Record dated 09/17/2025 was reviewed. The 09/17/2025 2:00 PM dose of Hydralazine 50 milligrams was not signed off as given. There was no documented evidence that the physician was notified. On 09/18/2025 at 3:13 PM, an interview was conducted with Registered Nurse #2, who was the charge nurse in Unit Nine (9), who stated that they were present on 09/17/2025 when Licensed Practical Nurse #5 held the 2:00 PM dose of Hydralazine for Resident #324. The Electronic Medical record was reviewed with Registered Nurse #2. They stated that the Medication Administration Record for the 2:00 PM dose of Hydralazine was not signed off. Registered Nurse #2 also stated that Licensed Practical Nurse #3 should not have decided to omit a medication without calling the doctor and that they should have documented the details of the call. Registered Nurse #2 further stated that they should have followed up with Licensed Practical Nurse #5 to ensure the physician was notified and if not done, they should have called the physician. On 09/18/2025 at 3:50 PM, an interview was conducted with the Director of Nursing who stated that the physician must be called as soon as possible if a medication is held or omitted and that it is unacceptable that medications are omitted because the nurse forgot to give the medication. The Director of Nursing also stated that the documentation on the details of why the medication was omitted should be entered in the electronic medical record by the end of the shift.10 NYCRR 415.12 (m) (2)

Based on observation, record review, and interview, the facility failed to provide a summary of the baseline care plan for two (2) (Residents #5 and #98) of 40 sampled residents. Specifically, Resident #98 and Resident #5's representative were not provided with a written summary of the residents' baseline care plan. The findings include:The facility policy titled Baseline Care Plan with a last revised date of March 2025 documented that it is the policy of the facility to develop baseline care plan within 48 hours of admission. Along with the baseline care plan is a summary of care plan that is provided to the resident and or representative in a language that can be understood.1. Resident #98 was admitted with diagnoses that included Heart Failure and Peripheral Vascular Disease.The admission Minimum Data Set assessment dated [DATE] documented Resident #98's cognition as intact and that the resident participated in the assessment.On 09/15/2025 at 9:51 AM, Resident #98 was interviewed and stated they received a copy of their medication list but did not receive a written summary of their baseline care plan.Resident #98's baseline care plan was initiated on 05/19/2025 and was completed on 05/21/2025. There was no documented evidence that the summary was given to the resident or their representative. 2. Resident #5 was admitted to the facility with diagnoses that included Cerebrovascular Accident and Heart Failure.The admission Minimum Data Set assessment dated [DATE] documented Resident #5's cognition as moderately impaired and that Resident #5's family representative participated in the assessment. Resident #5's baseline care plan was initiated on 08/08/2025 and was completed on 08/10/2025. There was no documented evidence that the summary was given to the resident's representative.On 09/15/2025 at 11:00 AM, Resident #5's representative was interviewed and stated they have not received a written summary of Resident #5's baseline care plan.On 09/18/2025 at 11:20 AM, Social Worker #2 was interviewed and stated that the resident's baseline care plan is completed 48 hours from admission. They stated they do not provide a written summary of the baseline care plan to the resident, and that it is the Minimum Data Set nurse who is responsible for giving the resident or their representative a written copy of the baseline care plan. On 09/18/2025 at 11:30 AM, the Minimum Data Set Assessor was interviewed and stated that the baseline care plan is completed within 48 hours of admission and is given to the resident along with the medication list. The Assessor stated they do not remember giving the residents or their representative a copy of their baseline care plan. On 09/19/2025 at 10:29 AM, the Minimum Data Set Coordinator was interviewed and stated that the Minimum Data Set nurse is responsible for issuing the baseline care plan to the residents and must document when it was issued. They stated they are responsible for ensuring that the Baseline Care Plan is issued and documented. On 09/19/2025 at 9:30 AM, the Director of Nursing was interviewed and stated that the baseline care plan is supposed to be completed within 48 hours. They stated it is discussed with the resident , a copy given to the resident, and that the resident must sign indicating they received the summary of the baseline care plan. If the resident is not alert, a summary is given to the family, and the family must also sign that they received the copy. The Director stated that if the resident's family cannot come to the facility, then a copy of the baseline care plan is mailed and must be documented in the resident's progress notes. They stated the Minimum Data Set Nurse is responsible for providing the resident and / or their representative of the summary of the baseline care plan. 10 NYCRR 415.11(c)

Based on observation, record review, and interviews, during the Recertification and Complaint (Intake 622067) Survey, the facility failed to notify a resident's representative of a significant change in the resident's status. This was evident for one (1) (Resident #43) of 40 sampled residents. Specifically, Resident #43's representative was not notified of the resident's change in condition that resulted to a hospital transfer on 10/17/2024. The findings include: The facility's policy and procedure titled Notification of Change with a last revised date of March 2024 documented that it was the policy of the facility to document any changes in the resident's condition and inform the medical doctor and designated representative. The facility must inform the resident representative when there is significant change in the resident's physical, mental or psychological status and a decision to transfer a resident. Resident #43 was admitted to the facility with diagnoses that included Hypertension, Depression, and Dementia.The Minimum Data Set assessment dated [DATE] documented Resident #43's cognition as moderately impaired.On 09/15/2025 at 9:07 AM, Resident #43's Health Care Proxy was interviewed and stated that Resident #43 was hospitalized last year but the facility staff did not notify them. The Resident Transfer Form dated 10/10/2024 documented that Resident #43 remained difficult to arouse for 20 minutes. Emergency Medical Service was called. At the time of transfer, the resident was more responsive but sluggish. A review of Resident #43's progress notes from 10/10/2024 to 10/16/2024 had no documentation of Resident #43's change in condition and that Resident #43's family representative was notified of the hospital transfer. The Hospital Discharge summary dated [DATE] documented that Resident #43 was admitted on [DATE] and was discharged on 10/17/2024.On 09/18/2025 at 11:48 AM, Registered Nurse #1, who was the nursing supervisor, was interviewed and stated that Resident #43 had a change in condition and was sent to the hospital and was readmitted to the facility on [DATE]. Registered Nurse #1 stated they called the resident's family to let them know that Resident #43 had returned to the facility. According to Registered Nurse #1, the family was upset because they were not informed that the resident was sent to the hospital. On 09/18/2025 at 12:00 PM, the Assistant Director of Nursing was interviewed and stated that the physician and the family must be notified of a change in a resident's condition. The Assistant Director of Nursing stated that on 10/10/2024, they assessed Resident #43 after they were informed by the unit nurse of the resident's change in condition. They stated that Resident #43 was not responding so they called the physician and the emergency medical service. The Assistant Director stated Resident #43 was transferred to the hospital and that they asked the unit nurse to contact the family. On 09/19/2025 at 9:17 AM, the Director of Nursing was interviewed and stated that the family members must be immediately notified when there is a change in resident's condition. They stated that Registered Nurse #1 called Resident #43's family to inform them that the resident returned to the facility from the hospital and that the family was upset because they were unaware that the resident was hospitalized . 10 NYCRR 415.3(f)(2)(ii)(d)

Based on observation, record review, and interviews conducted during an abbreviated survey (622104 & 662084), the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. This was evident for two (2) of seven (7) residents (Residents #4 and #5) sampled. Specifically: 1. Resident #4 complained of pain to their left arm on 03/27/2025 and 03/28/2025. There was no documented evidence medical interventions were completed. On 03/31/2025, Resident #4 was transferred to the hospital with altered mental status and to rule out deep vein thrombosis (a blood clot forming in the deep vein). At the hospital, Resident #4 was diagnosed with a fracture of the left proximal humerus. This resulted in actual harm to Resident #4 that was not Immediate Jeopardy. 2. Resident #5 complained of pain to their right hip on 09/17/2024 and a STAT x-ray was ordered by Physician #3 on 09/18/2025. Resident #5 was transferred to the hospital on [DATE] at 9:11 AM and was diagnosed with a fracture to their left hip. There was no documented evidence a physical assessment was done to ascertain the source of the pain, or that a physician was notified on 09/17/2024. A STAT x-ray was not ordered and was not done in the facility. The findings include:The policy titled 'Pain Assessment', last reviewed 10/2005, states every resident will be assessed on admission for pain management and thereafter as medically indicated. Respectively, pain control measures should be used before pain becomes severe. It also states to notify the physician if measures are unsuccessful or if current complaint is a significant change from the resident's experience. The policy titled 'Change in Resident's Condition', last reviewed 03/2022, documented it is the policy of Northern Manhattan Nursing Home to document any change in a resident's condition and to inform the Medical Doctor and designated representative in a timely fashion. The policy also documented that the resident is placed on the 24-hour report and care is rendered according to need and Medical Doctor order. The facility policy and procedure titled 'Diagnostic Services and Guidelines', dated 11/2023, documented upon a physician's order for diagnostic tests, the nursing department will arrange for the specimen to be obtained or tests to be done as per nursing policies and procedures, on a schedule basis or immediately, if the order is for stat (immediately or without delay) tests. Resident #4 was last admitted to the facility 08/14/2024 with diagnoses including cerebrovascular accident (stroke) with hemiplegia (paralysis to one side of the body) and dementia. The Minimum Data Set (a resident assessment tool) dated 01/02/2025 documented Resident #4 had mentally impaired cognition. Primary language Creole.A Nursing Note by Registered Nurse #4, dated 03/31/2025 at 1:47 PM indicated that it was a late entry for 03/28/2025 at 3:20 PM. It documented that Resident #4 had a swollen left arm that was larger than the right and complained of pain. Temperature 98.2, pulse 82, respiration 18, and blood pressure 132/78. Physician #1 was notified via telephone and ordered an x-ray of the left arm and Acetaminophen 1000 milligrams times one (1) received. The note documented a verbal report was given to Licensed Practical Nurse #3 (day shift) of Resident #4's clinical condition and the physician's order for x-ray and Acetaminophen times one (1) dose. There was no documented evidence that Registered Nurse #4 conducted a pain assessment or verified that pain medication was administered to the resident. There was no documented evidence that Registered Nurse #4 informed Licensed Practcial Nurse #3 of the order for an x-ray. A Nursing Note by the Assistant Director of Nursing dated 03/31/2025 at 7:04 PM, documented that they were called by Registered Nurse Supervisor #1 to evaluate Resident #4. Resident #4's left upper extremity was swollen especially around the left shoulder extending to the resident's neck and left face. There was no bruising noted, and no falls were reported by staff. A Transfer Summary Note by Registered Nurse #1 dated 03/31/2025 at 1:28 PM, documented Resident #4 was being transferred to the hospital to rule out deep vein thrombosis (a blood clot forming in the deep vein) to their left upper extremity and altered mental status. Resident #4's blood pressure was 184/110 and pulse 110.A Nursing Note by Licensed Practical Nurse #6 dated 03/31/2025 documented Resident #4 left for the hospital at 1:55 PM.There was no documented evidence Resident #4 was placed on the 24-hour report from 03/27/2025 - 03/29/2024. A Physician Order Activity Detail Report from 03/27/2025 through 03/31/2025 revealed no documented evidence of an order for Tylenol 1000 milligrams or of a STAT x-ray of the left arm. The Medication Administration Record from 03/27/2025 through 03/31/2025 revealed no documented evidence of Tylenol 1000 milligrams being administered to Resident #4. The Facility Investigative Summary dated 03/31/2025 documented Resident #4 reported that they had pain in their left arm. The nurse in charge assessed the area and administered Tylenol, which provided temporary relief. On 03/28/2025, staff observed slight swelling of the left upper arm with continued reports of mild pain. The physician was notified, an x-ray was ordered, and pain management was adjusted. On 03/31/2025, Resident #4's swelling had increased, and the affected area was noted to be warm to the touch. The resident also began to exhibit altered mental status. Physician #2 evaluated the resident and ordered hospital transfer to rule out deep vein thrombosis and assess mental status change. On 04/01/2025, during a follow up with the hospital, they reported Resident #4 had a left proximal humerus fracture. The report did not indicate if the fracture was acute or chronic. The investigation concluded there was no evidence to suggest abuse, neglect, or staff misconduct in relation to the resident's left proximal humerus fracture. In a Nursing Note by the Director of Nursing dated 04/01/2025 at 12:14 PM, they documented on 03/27/2025 Resident #4 complained of left arm pain on 03/27/2025. Registered Nurse #1 assessed the resident and Tylenol given with temporary relief. Follow-up with the hospital on [DATE], revealed Resident #4 was admitted with left humeral fracture. A late entry note dated 04/14/2025 (for 03/28/2025) by Physician #1, documented they were contacted by nursing on 03/28/2025 at 3:50 PM regarding Resident #4's pain and swelling to the left upper arm with activity. No trauma was reported. A STAT upper arm x-ray and Tylenol 1000 milligrams times one (1) dose was ordered. Physician to be called with the results and change in condition. The primary floor attending would be informed. During an interview on 07/08/2025 at 3:32 PM, Certified Nursing Assistant #3 (who was assigned to Resident #4 during the month of March 2025), stated Resident #4 complained of pain to their left arm on 03/27/2025 just before lunch. Certified Nursing Assistant #3 stated that they reported this information to Registered Nurse #4 who looked at the resident and said they will administer medication. Certified Nursing Assistant #3 stated that they do not know if the resident received pain medication. Certified Nursing Assistant #3 stated that on the morning of 03/28/2025, Resident #4 complained of more pain and the resident's left arm was more swollen. Certified Nursing Assistant #3 stated Registered Nurse #4 looked at Resident #4's left arm and verbalized they would notify the doctor. Certified Nursing Assistant #3 stated when they returned to work on the morning of 03/31/2025 (7:00 AM - 3:00 PM), they observed Resident #4's left arm was more swollen, and the resident was complaining of worsening pain in the left arm, and they notified Registered Nurse Supervisor #1. Certified Nursing Assistant #3 stated Registered Nurse Supervisor #1 looked at Resident #4's left arm and said the resident needed to be transferred to the hospital. Certified Nursing Assistant #3 stated Resident #4 did not return to the facility. During a telephone interview on 07/10/2025 at 11:52 AM, Registered Nurse #4 (former employee/Complainant) stated that on 03/28/2025 at about 3:40 PM, Certified Nursing Assistant #3 informed them Resident #4 was complaining of pain, and they both went to the resident's bedside. They stated they assessed the resident and observed that their left arm was slightly swollen (larger than the right arm), and they notified Physician #1 (on 03/28/2025), who gave a telephone order for x-ray of the left arm and Tylenol 1000 milligrams times one (1) dose. Registered Nurse #4 stated they did not have any training on the electronic medical record (Sigma), so they notified the oncoming (evening shift) Licensed Practical Nurse #3 to have the evening shift supervisor put the order in Sigma. During a follow-up telephone interview with Registered Nurse #4 on 09/11/2025 at 2:14 PM, they stated they informed Licensed Practical Nurse #3 (day shift), who was administering medications (on 03/28/2025), that Physician #1 ordered Tylenol for the resident's pain. They stated they assessed the resident on 03/27/2025 (unsure of time) and the left arm was not swollen. During an interview on 07/08/2025 at 1:58 PM, Registered Nurse Supervisor #1 stated that they first learned of Resident #4's swollen left arm and complaints of pain on 03/31/2025 (unsure of time). Registered Nurse Supervisor #1 stated that they administered Tylenol 650 milligrams, and they transferred the resident to the hospital as per the attending Physician #2. Registered Nurse Supervisor #1 stated that an x-ray was not done in the facility. During a telephone interview 07/11/2025 at 2:31 PM, Licensed Practical Nurse #2 stated they were the evening shift nurse on 03/28/2025 and Certified Nursing Assistant #3 informed them that Resident #4 had pain during the morning shift, and they informed Registered Nurse #1 who worked on the day shift. Licensed Practical Nurse #2 stated Registered Nurse #1 told them Physician #1 ordered Tylenol and a STAT x-ray. Licensed Practical Nurse #2 stated that no one came to do the x-ray on 03/28/2025 and they did not notify Registered Nurse Supervisor #1 who worked on the day shift nor Registered Nurse Supervisor #2 who worked on the evening shift. During a telephone interview with Registered Nurse Supervisor #2, who worked on the evening shift (3:00 PM to 11:00 PM) on 03/28/2025, they stated that no one reported an order to them, and they were not aware of any orders not being picked up. Registered Nurse Supervisor #2 stated Licensed Practical Nurse #2 never reported anything regarding Resident #4 to them on 03/28/2025. During a follow up interview with Registered Nurse Supervisor #2 on 09/11/2025 at 10:32 AM, they stated they conducted rounds on the units and asked nurses if there were any issues and they did not report any issues on 03/28/2025. They stated the nurse who takes the orders, or the physician themself can enter the order in the Electronic Medical Record. During an interview with the Director of Nursing on 07/18/2025 at 1:09 PM, they stated when a STAT order (x-ray) is received, the order is put in the electronic medical record which then sends the order to the diagnostic company, insurance is verified, and the facility receives a confirmation number. The Director of Nursing stated a STAT order is expected to be completed within six (6) to seven (7) hours. If there has been no response from the x-ray company on the day shift as to what time a technician is available, it is expected that the next shift will follow-up with a call to the x-ray company. The night shift is expected to inform the day shift whether the x-ray is still not done.During a follow up telephone interview on 09/29/2025 at 1:53 PM, the Director of Nursing stated on 03/31/2025 (unsure of time) Registered Nurse Supervisor #1 reported to them that Resident #4 was being transferred to the hospital for swelling and that Physician #2 suspected a deep vein thrombosis. They stated on 03/31/2025, an x-ray was ordered, but it was not done because Resident #4 was transferred to the hospital. They stated on 04/01/2025, they were inquiring as to the result of Resident #4's transfer and discovered that Resident #4 was diagnosed with a shoulder fracture. They also stated that the hospital physician reported that Resident #4's admitted diagnosis was osteoporosis and osteopenia. They stated that Resident #4 did not return to the facility after being transferred on 03/31/2025. They stated that their investigation started on 04/01/2025 after becoming aware that Resident #4 was diagnosed with a fracture. They stated on 04/01/2025 (unsure of time) they conducted a telephone interview with Certified Nursing Assistant #3 who reported to them that on Thursday, 03/27/2025, Resident #4 was sitting in the dining room complaining of pain, and they informed Registered Nurse #4. In the presence of Certified Nursing Assistant #3, Registered Nurse #4 administered Tylenol to Resident #4, which relieved their pain. They stated Certified Nursing Assistant #3 continued to report that on Friday, 03/28/2025, they observed swelling to Resident #4's shoulder and reported it to Registered Nurse #4. They stated Certified Nursing Assistant #3 informed them that Registered Nurse #4 assessed Resident #4 in their presence and told them that they would call the doctor. They stated that on 03/29/2025 and 03/30/2025, Certified Nursing Assistant #3 did not work and on Monday 03/31/2025, Certified Nursing Assistant #3 reported to Registered Nurse Supervisor #1 that the swelling to Resident #4's arm had worsened. They stated on 04/01/2025, they reviewed Resident #4's electronic chart and noticed that there was no documentation about Resident #4 complaining of pain or swelling from 03/27/2025 and they interviewed Registered Nurse #4 via the telephone on 04/01/2025. They stated that Registered Nurse #4 admitted that they were aware and that they called Physician #1 and Physician #1 gave them a verbal order for Tylenol and x-ray, however they did not transcribe the order in the electronic medical record and did not relay information to the supervisor. They stated Registered Nurse #4 did not provide them with any reasonable justification for not entering the order in the system. They stated that Registered Nurse #4 was terminated as a result. They stated Registered Nurse #4 later documented a late entry note. They stated they do not know how Registered Nurse #4 was able to have remote access to the system and document a late entry note. During a telephone interview on 09/11/2025 at 10:16 AM, Physician #2 stated they received a call from Registered Nurse Supervisor #1 on 03/31/2025 (unsure of time) stating Resident #4 had swelling to their left arm. They stated Resident #4 cannot move independently so they asked Registered Nurse Supervisor #1 if there were any trauma or falls. Physician #2 stated since there was no trauma, they determined it could be deep vein thrombosis, so they immediately ordered the resident transferred to the hospital. Physician #2 stated they were not aware the resident complained of pain on 03/27/2025. They were not aware there was an order for STAT x-rays and Tylenol on 03/28/2025 and that the order was not carried out. During a telephone interview with Physician #1 on 09/11/2025 at 3:44 PM, they stated usually, when a verbal or telephone order is given to a nurse, the nurse puts the order in the computer. They stated they did not visit any residents in the facility during the weekend of 03/28/2025 through 03/30/2025 and there were no calls regarding a resident's change in condition that warranted a visit. During a follow up interview with Physician #1 on 09/29/2025 at 1:41 PM, they stated they spoke to a nurse (unsure of name) and gave them a verbal order for Tylenol and an x-ray to the left upper arm. They stated they do not check the resident's chart to see if the order was put in place after giving a verbal order. They stated the nursing protocol is to sign out with the nurse supervisor and the supervisor is supposed to ensure that the treatment is carried out. They stated that since they were the on-call physician, the supervisor was supposed to report to them if there were any changes as a result of the treatment and the supervisor was also supposed to inform the attending physician. They stated they were not aware the Tylenol and x-ray orders were not entered in the electronic system. 2. Resident #5 was admitted to the facility with diagnoses including hypertension, diabetes mellitus, and non-Alzheimer's dementia. The Minimum Data Set, dated [DATE] documented Resident #5 had severely impaired cognition. A nursing note by Licensed Practical Nurse #1 dated 09/17/2024 at 11:01 PM, documented Resident #5 complained of pain to their left leg. Resident #5 was seen by Registered Nurse Supervisor #2 and Tylenol (650 milligrams) was administered (9:53 PM). There was no documented evidence a comprehensive assessment was done. A nursing note by Licensed Practical Nurse #5 dated 09/18/2024 at 6:24 AM, documented following up on upper left leg pain monitoring for further complaints of pain, and monitoring the affected area for swelling. Some swelling noted to the left leg. Tylenol 650 milligrams administered for upper left leg pain. A nursing note by Registered Nurse Supervisor #1 dated 09/18/2024 at 8:37 AM, documented Resident #5 complained of pain to their left hip and femur. Resident #5 was assessed and limited range of motion was observed at the affected area with pain on palpation. Tylenol (650 milligrams) was administered as needed with good results. Physician #3 was notified and recommended an x-ray to the left hip and femur. Order carried out as ordered.There was no documented evidence an x-ray was ordered on 09/18/2024.A medical note by Physician #3 dated 09/18/2024 at 5:59 PM documented Resident #5 was evaluated for left hip pain. There were no reports of a fall. Resident #5 was observed with mild shortening of their left leg compared to their right with eversion (sole turns outward) of foot. Mild tenderness in hip joint area with no swelling. A STAT x-ray was ordered. Instructed not to move resident until x-ray was done and to administer pain medication as needed.Review of a Physician Order Activity Detail Report dated 09/01/2024 - 09/30/2024 revealed that a STAT x-ray was ordered on 09/19/2024 at 5:13 PM. The facility's investigation dated 09/19/2024, documented Licensed Practical Nurse #6 was interviewed and stated on 09/17/2024 at approximately 10:00 AM, Resident #5 complained of left leg pain and Tylenol was administered, and the resident remained in bed. The resident continued to complain of left leg pain at approximately 11:01 PM on 09/17/2024. An assessment revealed there was no swelling and Tylenol was administered. The investigation documented Registered Nurse Supervisor #2 was interviewed and stated they were notified that Resident #5 complained of pain to their left leg and Tylenol was administered. Registered Nurse Supervisor #2 stated they went to see Resident #5 and the resident was sleeping and did not seem to be in any distress or discomfort. Physician #3 evaluated Resident #5 on Wednesday 09/18/2024. An assessment revealed mild shortening of the left leg compared to the right with eversion of the foot with mild tenderness in hip joint area. Left hip and lower extremity x-ray ordered. Resident #5 was transferred to the hospital on [DATE] for an x-ray. The facility received a call from the hospital at 12:00 PM informing them the resident had a fracture to their left hip. The facility has determined there was insufficient evidence for a prudent person to believe that physical abuse, mistreatment, or neglect had occurred. A Hospital Radiology report dated 09/19/2024 at 1:17 PM, documented displaced comminuted intertrochanteric fracture of the left proximal femur (a complex hip fracture where the thigh bone's top section breaks into many pieces, moves significantly out of alignment, and occurs between the bony prominences on the upper leg). Extensive Pagetoid changes throughout the right hemipelvis (a cellular appearance where atypical cells, particularly tumor cells, migrate upwards in a spreading pattern with the affected bones showing different phases of the disease at the same time) appeared demineralized (lost essential minerals, making them weaker, thinner, and more porous, which increases the risk of fractures). During a telephone interview on 07/14/2025 at 11:37 AM, Certified Nursing Assistant #2, (who worked on the day shift from 7:00 AM to 3:00 PM) stated on 09/17/2024 (unsure of time), they observed Resident #5, who was ambulatory, unable to stand and complained of pain, and they reported the pain to Licensed Practical Nurse #3. During a telephone interview on 07/11/2025 at 1:45 PM, Certified Nursing Assistant #1, who worked on 09/17/2024 from 3:00 PM - 11:00 PM shift, stated they observed Resident #5 between 5:00 PM and 6:00 PM sitting on a chair asking for assistance to the bathroom. Certified Nursing Assistant #1 stated they noticed that Resident #5 was unable to stand and was complaining of pain (unsure of pain location). Certified Nursing Assistant #1 stated after they informed Licensed Practical Nurse #1 of the pain, they asked another certified nursing assistant to assist them with taking the resident to the bathroom then they put the resident in bed. Certified Nursing Assistant #1 stated Licensed Practical Nurse #1 informed Registered Nurse Supervisor #2 of Resident #5's complaint of pain but was unsure when Registered Nurse Supervisor #2 arrived on the unit to assess Resident #5During a telephone interview on 07/14/2025 at 10:01 AM, Licensed Practical Nurse #1 stated that on 09/17/2024 between 4:00 PM and midnight (unsure of time) Certified Nursing Assistant #1 informed them Resident #5 complained of pain to their left leg. Licensed Practical Nurse #1 stated that when they went to the resident's room (unsure of time), the resident was already in bed. Licensed Practical Nurse #1 stated that they reported the pain to Registered Nurse Supervisor #2 who instructed them to administered Tylenol (650 milligrams) to the resident. Licensed Practical Nurse #1 stated that the resident went to sleep after receiving the pain medication. Licensed Practical Nurse #1 stated they do not recall when Registered Nurse Supervisor #2 arrived on the unit. During an interview on 07/08/2025 at 2:14 PM, Registered Nurse Supervisor #1 stated on 09/18/2024, they could not recall the time, they were informed by Licensed Practical Nurse #6 that Resident #5 was complaining of left hip pain. They stated they conducted an assessment and on palpation the resident complained of pain to their left hip. There was no swelling or bruising, only limitation. They stated Physician #3 was notified and a STAT x-ray was ordered at approximately 8:37 AM on 09/18/2024. They stated since the STAT x-ray was not completed as of 09/19/2024, they notified Physician #3 who ordered to transfer the resident to the hospital. Registered Nurse Supervisor #1 stated that STAT orders should be done within four (4) to eight (8) hours. Registered Nurse Supervisor #1 stated that Physician #1 ordered a STAT x-ray on 09/18/2024, but when they returned to work on 09/19/2024, the x-ray was not done, and they informed Physician #3 who ordered for the resident to be transferred to the hospital. During a telephone interview on 07/14/2025 at 10:13 AM, the Director of Nursing stated that they investigated the injury and concluded that abuse and neglect did not occur. The Director of Nursing stated Resident #5 complained of pain on 09/17/2024, and on 09/18/2024 a STAT x-ray was ordered. The Director of Nursing stated the STAT x-ray should have been done within six (6) hours but there could have been a delay due to insurance verification needed. The Director of Nursing stated that when the technician did not arrive on 09/19/2024, Resident #5 was sent to the hospital. The Director of Nursing stated Registered Nurse Supervisor #2 assessed Resident #5 but did not document their assessment in the resident's chart.During a telephone interview on 07/14/2025 at 11:44 AM, Physician #3 stated they are unsure of when they were notified of Resident #5's complaints of pain to their left leg. Physician #3 stated they examined Resident #5 (unsure of date), and the resident did not display any signs of distress or pain. Physician #3 stated based on their examination they felt an x-ray should have been done STAT. Physician #3 stated they were informed by a facility staff (unsure of name) that the technician did not perform the STAT x-ray, so they ordered Resident #5 to be transferred to the hospital. They stated the x-ray done at the hospital revealed the resident had a fracture. During a follow up interview on 09/15/2025 at 10:00 AM, Physician #3 stated on 09/18/2024 they suspected Resident #5 had a fracture after their examination revealed shortening to the left leg, therefore, they gave a verbal order to the nurse on duty (unsure of name) to order a STAT x-ray. Physician #3 stated they were not aware that the x-ray had been entered into the electronic order system on 09/19/2024, after Resident #5 was transferred to the hospital on [DATE]. 10 NYCRR 415.12

The findings include:The facility's policy titled 'Pain Assessment' with a review date of 10/2005, directed that every resident will be assessed on admission for pain management and thereafter as medically indicated. Respectively, pain control measures should be used before pain becomes severe. It also directed that the physician was to be notified if measures are unsuccessful or if current complaint is a significant change from the resident's experience. The facility's policy titled 'Change in Resident's Condition', with a review date of 03/2022, directed staff to document any change in a resident's condition and to inform the Medical Doctor and designated representative in a timely fashion. The policy also documented that the resident is placed on the 24-hour report and care is rendered according to need and Medical Doctor's order. The Facility Investigative Summary dated 03/31/2025, documented Resident #4 reported that they had pain in their left arm. The nurse in charge (Registered Nurse #4) assessed the area and administered Acetaminophen, which provided temporary relief. On 03/28/2025, staff observed slight swelling of the left upper arm with continued reports of mild pain. Physician #1 was notified, and an x-ray was ordered, and pain management was adjusted. On 03/31/2025 Resident #4 swelling had increased, and the affected area was noted to be warm to the touch. The resident also began to exhibit altered mental status. Physician #2 evaluated the resident and ordered hospital transfer to rule out Deep Vein Thrombosis and assess mental status change. On 04/01/2025 during a follow up with the hospital, they reported Resident #4 had a left proximal humerus fracture. The report did not indicate if the fracture was acute or chronic. The investigation concluded there was no evidence to suggest abuse, neglect, or staff misconduct in relations to the resident's left proximal humerus fracture. The Director of Nursing documented on 04/01/2025 that Resident #4 complained of left arm pain on 03/27/2025. Registered Nurse #1 assessed the resident and Acetaminophen given with temporary relief. Follow-up with the hospital revealed Resident #4 was admitted with left humeral fracture. The report included a written statement from Registered Nurse #4. In the statement Registered Nurse #4 stated that they assessed the resident for pain on 03/28/2025 and observed the swelling of the left arm. They stated that they notified Physician #1 who ordered stat X-Ray and Acetaminophen 1000 milligrams to be administered to the resident. They did not administer the medication, but informed Licensed Practical Nurse #2 of the order. They did not indicate that they assessed the resident on 03/27/2025. Resident #4 was last admitted to the facility 08/14/2024 with diagnoses including cerebrovascular accident (stroke) with hemiplegia (paralysis to one side of the body) and dementia. The Minimum Data Set (a resident assessment tool) dated 01/02/2025, documented Resident #4 had mentally impaired cognition. Primary language Creole. Resident #4 does not have a pain management regimen; however, a pain assessment interview should be conducted. A Pain Management Care Plan was created on 10/09/2024 and last updated on 01/04/2025. Documentation revealed a quarterly evaluation, and that the resident was stable and verbalized no complaints of pain. Also states that pain medication will be administered as needed per order. Also documented that monitoring will continue for 90 days. There was no documented evidence the Pain Management Care Plan was revised after 01/04/2025.A Nursing Note by Registered Nurse #4, dated 03/31/2025 at 1:47 PM indicated that it was a late entry for 03/28/2025 at 3:20 PM. It documented that Resident #4 had a swollen left arm that was larger than the right and complained of pain. Temperature 98.2, pulse 82, respiration 18, and blood pressure 132/78. Physician #1 was notified via telephone and ordered an x-ray of the left arm and Acetaminophen 1000 milligrams times one (1) received. The note documented a verbal report was given to Licensed Practical Nurse #3 (day shift) of Resident #4 clinical condition and the physician's order for left arm x-ray and Acetaminophen times one dose. There was no documented evidence that Registered Nurse #4 conducted a pain assessment or verified that pain medication was administered to the resident. There was no documented evidence that Registered Nurse #4 informed Licensed Practcial Nurse #3 of the order for an x-ray. The Medication Administration Record from 03/27/2025 through 03/31/2025 revealed no documented evidence of Acetaminophen 1000 milligrams being administered to Resident #4. A Transfer Summary Note by Registered Nurse #1 dated 03/31/2025 at 1:28 PM, documented Resident #4 was being transferred to the hospital to rule out deep vein thrombosis (a blood clot forming in the deep vein) to their left upper extremity and altered mental status. Resident #4 blood pressure was 184/110 and pulse 110.A Nursing Note by the Assistant Director of Nursing dated 03/31/2025 at 7:04 PM, documented that they were called by Registered Nurse Supervisor #1 to evaluate Resident #4. Resident #4 left upper extremity was swollen especially around the left shoulder extending to the resident's neck and left face. There was no bruising noted, and no falls were reported by staff. A Nursing Note by Licensed Practical Nurse #6 dated 03/31/2025 at 5:12 PM, documented Resident #4 left for the hospital at 1:55 PM.There was no documented evidence Resident #4 was placed on the 24-hour report from 03/27/2025 - 03/29/2024. A Physician Order Activity Detail Report from 03/27/2025-03/31/2025, revealed no documented evidence of an order for Acetaminophen 1000 milligrams and a STAT x-ray of the left arm. A late entry note dated 04/14/2025 (for 03/28/2025) by Physician #1 documented they were contacted by nursing on 03/28/2025 at 3:50 PM regarding Resident #4 pain and swelling to the left upper arm with activity. No trauma was reported. A STAT upper arm x-ray and Acetaminophen 1000 milligrams times one (1) dose was ordered. Physician to be called with the results and change in condition. The primary floor attending would be informed. During an interview on 07/08/2025 at 3:32 PM, Certified Nursing Assistant #3 (who was assigned to Resident #4 during the month of March 2025), stated Resident #4 complained of pain to their left arm on 03/27/2025 just before lunch. Certified Nursing Assistant #3 stated that they reported Resident #4's complaint to Registered Nurse #4 who looked at the resident and said they will administer medication. Certified Nursing Assistant #3 stated that they do not know if the resident received pain medication. Certified Nursing Assistant #3 stated that on the morning of 03/28/2025 Resident #4 complained of more pain and the resident's left arm was more swollen. Certified Nursing Assistant #3 stated Registered Nurse #4 looked at Resident #4 left arm and verbalized they would notify the doctor. Certified Nursing Assistant #3 stated when they returned to work on the morning of 03/31/2025 (7:00 AM - 3:00 PM), they observed Resident #4 left arm was more swollen, the resident was complaining of worsening pain in the left arm, and they notified Registered Nurse Supervisor #1. Certified Nursing Assistant #3 stated Registered Nurse Supervisor #1 looked at Resident #4 left arm and said the resident needed to be transferred to the hospital. Certified Nursing Assistant #3 stated Resident #4 did not return to the facility. During a telephone interview on 07/10/2025 at 11:52 AM, Registered Nurse #4 (former employee/Complainant) stated that on 03/28/2025 at about 3:40 PM Certified Nursing Assistant #3 informed them Resident #4 was complaining of pain, and they both went to the resident's bedside. They stated they assessed the resident and observed that their left arm was slightly swollen and was larger than the right arm, and they notified Physician #1 (on 03/28/2025), who gave a telephone order for x-ray of the left arm and Acetaminophen 1000 milligrams times one (1) dose. Registered Nurse #4 stated they did not have any training on the electronic medical record (Sigma), so they notified the oncoming (evening shift - Licensed Practical Nurse #2) to have the evening shift supervisor put the order (03/28/2025 for x-ray and Acetaminophen) in Sigma. During a follow-up telephone interview with Registered Nurse #4 on 09/11/2025 at 2:14 PM, they stated they informed Licensed Practical Nurse #3 (day shift), who was administering medications, that Physician #1 ordered Acetaminophen for the resident's pain. They stated they assessed the resident on 03/27/2025 (unsure of time), and the left arm was not swollen. They stated they do not know if Licensed Practical Nurse #3 documented anything. During an interview on 07/08/2025 at 1:58 PM, Registered Nurse Supervisor #1 stated that they first learned of Resident #4 swollen left arm and complaints of pain on 03/31/2025 (unsure of time) from Certified Nursing Assistant #3. Registered Nurse Supervisor #1 stated that they administered Acetaminophen 650 milligrams, and they transferred the resident to the hospital as per the attending Physician #2. Registered Nurse Supervisor #1 stated that an x-ray was not done in the facility. During a telephone interview 07/11/2025 at 2:31 PM, Licensed Practical Nurse #2 stated they were the evening shift nurse on 03/28/2025 and Certified Nursing Assistant #3 informed them that Resident #4 had pain during the morning shift, and they informed Registered Nurse #1 who worked on the day shift. Licensed Practical Nurse #2 stated Registered Nurse #1 told them Physician #1 ordered Acetaminophen and a STAT x-ray. Licensed Practical Nurse #2 stated that no one came to do the x-ray on 03/28/2025 and they did not notify Registered Nurse Supervisor #1 who worked on the day shift nor Registered Nurse Supervisor #2 who worked on the evening shift. During a telephone interview with Registered Nurse Supervisor #2, who worked on the 03/28/2025 evening shift (3:00 PM to 11:00 PM), stated that no one reported an order to them, and they were not aware of any orders not being picked up. Register Nurse Supervisor #2 stated Licensed Practical Nurse #2 never reported anything regarding Resident #4 to them on 03/28/2025. During a follow up interview with Registered Nurse Supervisor #2 on 09/11/2025 at 10:32 AM, they stated they conducted rounds on the units and asked nurses if there were any issues and they did not report any issues on 03/28/2025. They stated the nurse who takes the orders, or the physician themself can enter the order in the electronic medical record. During an interview with the Director of Nursing on 07/18/2025 at 1:09 PM, they stated when a STAT order (x-ray) is received, the order is put in the electronic medical record which then sends the order to the diagnostic company, insurance is verified, and the facility receives a confirmation number. The Director of Nursing stated a STAT order is expected to be completed within six (6) to seven (7) hours. If there has been no response from the x-ray company on the day shift as to what time a technician is available, it is expected that the next shift will follow-up with a call to the x-ray company. The night shift is expected to inform the day shift whether the x-ray is still not done During a follow up telephone interview on 09/29/2025 at 1:53 PM, the Director of Nursing stated on 03/31/2025 (unsure of time) Registered Nurse Supervisor #1 reported to them that Resident #4 was being transferred to the hospital for swelling and that Physician #2 suspects a deep vein thrombosis. They stated on 04/01/2025, they inquired about Resident #4's disposition and was informed that Resident #4 was diagnosed with a shoulder fracture. They stated on 04/01/202,5 an internal investigation was initiated to determine how Resident #4 obtained the fracture. They stated on 04/01/2025 (unsure of time) they conducted telephone interviews with Certified Nursing Assistant #3 and Registered Nurse #4. They stated Certified Nursing Assistant #3 reported that on 03/27/2025 and 03/28/2025, they reported to Registered Nurse #4 that Resident #4 complained of pain on 03/27/2025 and that Resident #4 was observed with swelling to their shoulder on 03/28/2025. Director of Nursing stated on 03/31/2025, Certified Nursing Assistant #3 reported to Registered Nurse Supervisor #1 that the swelling to Resident #4's arm had worsened. Director of Nursing stated there was no documentation in Resident #4's chart about them complaining of pain or swelling from 03/27/2025. They stated during their interview with Registered Nurse #4 via the telephone on 04/01/2025, Registered Nurse #4 admitted that they were aware of Resident #4's complaint and that Physician #1 was called, and they received a verbal order to administer Acetaminophen and x-ray, however, they did not enter the order in the electronic medical record and did not relay information to the supervisor. During a telephone interview on 09/11/2025 at 10:16 AM, Physician #2 stated they received a call from Registered Nurse Supervisor #1 on 03/31/2025 (unsure of time) stating Resident #4 had swelling to their left arm. They stated Resident #4 cannot move independently so they asked Registered Nurse Supervisor #1 if there were any trauma or falls. Physician #2 stated since there was no trauma, they determined it could be deep vein thrombosis, so they immediately ordered the resident transferred to the hospital. Physician #2 stated they were not aware the resident complained of pain on 03/27/2025. They were not aware there was an order for STAT x-rays and Acetaminophen on 03/28/2025 and that the order was not carried out. During a telephone interview with on-call Physician #1 on 09/11/2025 at 3:44 PM, they stated usually, when a verbal or telephone order is given to the nurse, the nurse puts the order in the computer. They stated they did not visit any residents in the facility during the weekend of 03/28/2025 - 03/30/2025 and there were no calls regarding a resident's change in condition that warranted a visit. 10 NYCRR 415.12

Based on observation, record review, and interviews conducted during an Abbreviated survey (6220995), the facility did not ensure a resident was free from abuse. This was evident for one (1) of four (4) residents (Resident #7) sampled. Specifically, on 03/05/2025 at 6:30 PM, Resident #7 reported to Licensed Practical Nurse #1 that they were hit with a bottle on their upper lip by Certified Nursing Assistant #9. Resident #7 was assessed by the Director of Nursing on 03/05/2025 and was observed with slight swelling to their upper lip. The findings are:The policy and procedure on Abuse dated 02/2025 stated each resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion. It is the responsibility of the employees, facility consultants, attending physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management. Resident #7 was admitted to the facility with diagnoses including Hypertension and Anxiety Disorder.The Minimum Data Set (an assessment tool) dated 06/18/2024 documented Resident #7 had moderately impaired cognition. A potential for abuse/neglect/misappropriation/exploitation care plan dated 01/29/2025 documented interventions which included to provide 1:1 visit and encourage the resident to socialize and participate in recreational activities.A Nursing Note by the Director of Nursing dated 03/05/2025 at 9:09 PM, documented at approximately 6:30 PM Resident #7 alleged Certified Nursing Assistant #9 threw an Ensure (a liquid supplement) bottle at their lips. Physical assessment revealed slight swelling. There was no bruising or bleeding observed. An ice pack was applied to the lips. Certified Nursing Assistant #9 denied the allegation. Emergency personnel arrived on the unit, but did not provide a report. Resident #7 was placed on 15 minutes monitoring for three (3) days and was referred for psychiatric and psychological evaluation. The facility's investigation dated 03/05/2025 documented Resident #7 reported Certified Nursing Assistant #9 made physical contact with their upper lip using an Ensure bottle. Upon examination, the resident had slight swelling to their right upper lip. Certified Nursing Assistant #9 denied the allegation. The resident could not recall the location of the Ensure bottle and a bottle was not found in the resident's area, therefore the facility concluded there were no evidence of abuse, neglect, or mistreatment. A Medical Note by Medical Doctor #1 dated 03/07/2025 at 3:36 PM documented Resident #7 was evaluated and reiterated they asked Certified Nursing Assistant #9 to help them with something and Certified Nursing Assistant #9 grew angry at them and threw a bottle of Ensure at them. An assessment revealed a bruise to the upper midsection of the lip, and inside the lip was black and blue. A new black and blue area was noted this morning (03/07/2025) inside the edge of the left lower lip area with bruising extending underneath. During an interview on 07/08/2025 at 11:51 AM, Resident #7 stated Certified Nursing Assistant #9 hit them with a soft bottle on their lip. Resident #7 was unsure of date and time.Several unsuccessful attempts were made to contact Certified Nursing Assistant #9. A certified letter was mailed on 07/28/2025 with no response as of today. Certified Nursing Assistant #9 provided a statement to the facility dated 03/05/2025. The statement documented they went into Resident #7's room at around 6:15 PM on 03/05/2025 to turn on their heater and then left. The resident did not verbalize any complaints and was stable. The resident's family was visiting and approached them in an aggressive and threatening manner at 6:30 PM and accused them of abuse. The statement further documented they did not abuse the resident.During a telephone interview on 07/28/2025 at 12:46 PM, Certified Nursing Assistant #10 stated at approximately 5:58 PM they responded to Resident #7's call bell and observed Resident #7 tapping and pointing at their mouth. Certified Nursing Assistant #10 stated Resident #7 reported they were hit on their lip. Certified Nursing Assistant #10 stated Certified Nursing Assistant #9 was standing in the doorway at Resident #7's room and reported Resident #7 hit them with a bottle, and they threw the bottle at Resident #7. Certified Nursing Assistant #10 stated they did not see an Ensure bottle, but a juice bottle was next to Resident #7's bed. Certified Nursing Assistant #10 stated Resident #7's lip was swollen at the top, but they did not see any redness. Certified Nursing Assistant #10 stated Registered Nurse Supervisor #2 had all staff members in Resident #7's room and the resident identified Certified Nursing Assistant #9 as the staff who hit them with the bottle. During a telephone interview on 07/28/2025 at 2:27 PM, Licensed Practical Nurse #1 stated Registered Nurse Supervisor #2 arrived on the unit at 6:30 PM and went to Resident #7's room. Licensed Practical Nurse #1 also stated Resident #7 reported Certified Nursing Assistant #9 hit them with an Ensure bottle. Licensed Practical Nurse #1 further stated they looked in the room and did not see any Ensure bottles but saw other bottles in Resident #7's closet. During a telephone interview on 07/29/2025 at 1:44 PM, the Director of Nursing stated they responded to Resident #7's unit on 03/05/2025 at approximately 6:30 PM after they were told by Registered Nurse Supervisor #2 Resident #7 alleged they were hit with a bottle on their lip by Certified Nursing Assistant #9. The Director of Nursing also stated they assessed Resident #7 and observed a slight swelling to the resident's lip. There was no bruising or marks. The Director of Nursing further stated they asked Resident #7 to present the Ensure bottle and the resident was unable to provide the bottle. The Director of Nursing stated Resident #7 identified Certified Nursing Assistant #9 as the alleged perpetrator and the police and family was notified. Certified Nursing Assistant #9 was interviewed and denied the allegation. The Director of Nursing also stated Resident #7 was reassessed the following day (03/05/2025) by Medical Doctor #1 and was observed with increased swelling to their upper lip. The Director of Nursing further stated Resident #7 was consistent with their statement, but there was no evidence to support something happened and Resident #7 was unable to provide the ensure bottle, so they concluded abuse did not occur. During a telephone interview on 07/31/2025 at 9:31 AM, Registered Nurse Supervisor #2 stated Licensed Practical Nurse #1 alerted them that Resident #7 alleged they were hit on their lip. Registered Nurse Supervisor #2 also stated they assessed Resident #7 and observed slight redness to the lip (unsure of area). Registered Nurse Supervisor #2 further stated they interviewed Resident #7, and they reported Certified Nursing Assistant #9 came into their room, grabbed an Ensure bottle and threw it at their lip. Registered Nurse Supervisor #2 stated Certified Nursing Assistant #9 was in Resident #7's room while the resident was being interviewed and resident identified Certified Nursing Assistant #9 as the perpetrator, so they informed the Director of Nursing and Certified Nursing Assistant #9 was sent home. During a telephone interview on 07/31/2025 at 12:35 PM, the Administrator stated they were informed by the Director of Nursing on 03/05/2025 (unsure of time) of the alleged incident. The Administrator also stated Registered Nurse Supervisor #2, and the Director of Nursing assessed Resident #7, and the resident had a small swelling to the upper lip resembling a bite. The Administrator further stated Certified Nursing Assistant #9 was removed from the schedule pending investigation and they did not return to the facility. The Administrator stated the investigation concluded abuse did not occur. 10 NYCRR 415.4(b)(1)(i)

Based on observation, record review, and interviews conducted during an abbreviated survey (622104), the facility did not ensure licensed nurses have the specific competencies, and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. This was evident for one (1) of seven (7) residents (Resident #4) reviewed. Specifically, Resident #4 complained of pain to their left arm on 03/27/2025 and 03/28/2025. Physician #1 was notified on 03/28/2025 and ordered Tylenol 1000 milligrams and a STAT x-ray of the left arm. Registered Nurse #4 stated they did not enter the orders because they did not receive training on the electronic medical record (Sigma). This resulted in a delay in treatment for Resident #4 who was transferred to the hospital on [DATE] at 1:55 PM and was admitted with diagnosis of left arm fracture. Findings include:The policy titled 'Nursing Orientation Program', last reviewed 01/2025 documented it is the policy of this facility to provide all newly hired and agency nursing staff with a structured orientation program prior to assuming independent resident care assignments. This program ensures that all nursing personnel demonstrate the knowledge, skills, and competencies necessary to provide safe, effective, person-centered care in accordance with federal and state regulations, Centers for Medicare & Medicaid Services requirements of participation and facility policies. The policy titled 'Physician's Orders', last reviewed 03/2022 documented physician's orders shall be maintained for each resident in the electronic medical record. The physician/nurse will enter all medication/treatment orders in the physician order section in the Electronic Medical Record. The order will be reviewed by three nurses on consecutive shifts. The policy titled 'Change in Resident's Condition', last reviewed 03/2022 documented it is the policy of Northern Manhattan Nursing Home to document any change in a resident's condition and to inform Medical Doctor and designated representative in a timely fashion. The policy also documented that the resident is placed on the 24-hour report and care is rendered according to need and Medical Doctor order. The facility Policy and Procedure titled Diagnostic Services and Guidelines dated 11/2023 documented upon a physician's order for diagnostic tests, the nursing department will arrange for the specimen to be obtained or tests to be done as per nursing policies and procedures, on a schedule basis or immediately, if the order is for stat tests. Resident #4 was last admitted to the facility 08/14/2024 with diagnoses including Cerebrovascular Accident (Stroke) with hemiplegia and Dementia. The Minimum Data Set (a resident assessment tool) dated 01/02/2025 documented Resident #4 had mentally impaired cognition. Primary language Creole.A Staff Development checklist, for Registered Nurse #4, dated 01/07/2025 revealed no documented evidence of training on the Electronic Medical Record. A Nursing Note by Registered Nurse #4 dated 03/31/2025 (late entry for 03/28/2025) documented Resident #4 had a swollen left arm that was larger than the right and complained of pain. Temperature 98.2, Pulse 82, Respiration 18, and Blood Pressure 132/78. Physician #1 was notified via telephone and ordered an x-ray of the left arm and Tylenol 1000 milligrams times one received. Also documented, a verbal report was given to oncoming Licensed Practical Nurse #3 of the physician's order for x-ray and Tylenol. There was no documented evidence Tylenol was administered, and a STAT x-ray was ordered 03/28/2025.A Physician Order Activity Detail Report from 03/27/2025-03/31/2025, revealed no documented evidence of an order for Tylenol 1000 milligrams and a STAT x-ray of the left arm. The Medication Administration Record from 03/27/2025-03/31/2025, revealed no documented evidence of Tylenol 1000 milligrams was administered to Resident #4. A Nursing Note by the Assistant Director of Nursing dated 03/31/2025 documented that they were called by Registered Nurse Supervisor #1 to evaluate Resident #4. Resident #4's left upper extremity was swollen especially around the left shoulder extending to the resident's neck and left face. There was no bruising noted, and no falls were reported by staff. A Transfer Summary Note by Registered Nurse #1 dated 03/31/2025 documented Resident #4 was being transferred to hospital to rule out Deep Vein Thrombosis to their left upper extremity and Altered Mental Status. Resident #4's blood pressure was 184/110 and pulse 110.A Nursing Note by Licensed Practical Nurse #6 dated 03/31/2025 documented Resident #4 left for the hospital at 1:55 PM.During a telephone interview on 07/10/2025 at 11:52 AM Registered Nurse #4 (former employee/Complainant) stated that on 03/28/2025 at about 3:40 PM Certified Nursing Assistant #3 informed them Resident #4 was complaining of pain, and they both went to the resident's bedside. They stated they assessed the resident and observed that their left arm was slightly swollen (larger than the right arm), and they notified the Physician #1, who gave a telephone order for x-ray of the left arm and Tylenol 1000 milligrams times one dose. Registered Nurse #4 stated they did not have any training on the Electronic Medical Record (Sigma), so they notified the oncoming (evening shift) Licensed Practical Nurse #3 to have the evening shift supervisor put the order in Sigma.During a follow-up telephone interview with Registered Nurse #4 on 09/11/2025 at 2:14 PM, they stated they had an Electronic Medical Record class with two (2) other Registered Nurses in the educator's office during orientation (unsure of date). They stated they were told by the educator there was no money for training Registered Nurses on the Electronic Medical Record. They stated they were taught how to sign on to the Electronic Medical Record and that they informed the educator of the deficiency in training. They stated that they have never signed any checklist for Sigma training and whatever they learnt was on their own on the resident floor. They stated they were never made aware of the 24-hour Report and has never documented on it. During an interview on 09/12/2025 at 10:58 AM, the facility educator stated that Registered Nurse #4 never reported that they were not comfortable with the Electronic Medical Record. The facility educator stated that they asked the orientees individually about their computer experience and if they had no experience, they would verbally go over the basics for entering orders, progress notes templates, and the medication administration record. The facility educator stated that each orientee is assigned a preceptor on the unit. The educator stated that they used the checklist as a guide go over with orientee. The educator stated if an orientee is not comfortable with the electronic medical record, the orientee would remain on orientation. The educator stated they sign off on the computer checklist after interviewing the orientee. During a telephone interview on 10/10/2025 at 3:09 PM, Director of Nursing stated on the first day of orientation, the new staff would be oriented on the policies and given mandatory in services, such as abuse, elopement, etc. in a classroom. They stated on the second day, the orientee will shadow another staff based on their credentials. They stated the experienced nurse will orient the orientee on rounding, 24-hour report, treatments, Physician's orders, and entering orders into the electronic medical record. They stated the nurse educator will check on the orientee daily to ensure that they understood what was being taught and would discuss with the orientee if they need further orientation. They stated that the nurse educator does an evaluation/competency on medication pass, transcribing and picking up orders and then sign off that the orientee is competent. They stated Registered Nurse #4 received in service on transcribing and picking up Physician's orders. They stated they became aware that Registered Nurse #4 did not transcribe the orders received by Physician #1 during their investigation and cannot provide information as to why Registered Nurse #4 did not transcribe the order into the electronic medical record. They stated they were aware that there were no documented evidence that the medication was given since the order was not transcribed. 10NYCRR 415.13

Based on observation, record review, and interviews conducted during an abbreviated survey (622104), the facility did not ensure that a resident care plan was reviewed and revised by the interdisciplinary team. This was evident for one (1) out of seven (8) residents sampled (Resident #4). Specifically, Resident #4 reported to Certified Nursing Assistant #3 that they had pain in their left arm on 03/27/2025, just before lunch, and Registered Nurse #4 was notified. Resident #4 complained of pain their left arm again on 03/28/2025 and the left arm was observed to be swollen and larger than the right. Registered Nurse #4 notified Physician #1 who ordered Tylenol (1000 milligrams) and a STAT x-ray. Resident #4 was transferred to the hospital on [DATE] with Altered Mental Status, a blood pressure of 184/110, pulse 110, and to rule out Deep Vein Thrombosis (a blood clot forming in the deep vein). Resident #4 was diagnosed with a fracture of the left proximal humerus in the hospital. There was no documented evidence the care plans were updated to reflect on Resident #4's pain and changes in condition. Findings are:The Policy titled Comprehensive Assessment and Comprehensive Care Planning Process last reviewed 10/2023 documented the interdisciplinary comprehensive care planning team will function to ensure that each resident has a care plan that identifies the physical, social, nutritional, environmental, recreational, spiritual and rehabilitative aspects of care with immediate and long-term care goals as well as a discharge plan. Each individualized comprehensive care plan will identify resident's needs as well as approaches to care and methods for provision of care. Resident #4 was last admitted to the facility 08/14/2024 with diagnoses including Cerebrovascular Accident (Stroke) with hemiplegia and Dementia. The Minimum Data Set (a resident assessment tool) dated 01/02/2025 documented Resident #4 had mentally impaired cognition. Primary language Creole.A Pain Management Care Plan was created 10/9/2024 and last updated 01/04/2025. Documentation reveals a quarterly evaluation, and that the resident was stable and verbalized no complaints of pain. Also states that pain medication will be administered as needed per order. Also documented is that monitoring will continue x 90 days. A Nursing Note by Registered Nurse #4 dated 03/31/2025 (late entry for 03/28/2025) documented Resident #4 had a swollen left arm that was larger than the right and complained of pain. Temperature 98.2, Pulse 82, Respiration 18, and Blood Pressure 132/78. Physician #1 was notified via telephone and ordered an x-ray of the left arm and Tylenol 1000 milligrams times one received. Also documented, a verbal report was given to oncoming Licensed Practical Nurse #3 (day shift) of the physician's order for x-ray and Tylenol. The Facility Investigative Summary dated 03/31/2025 documented Resident #4 reported that they had pain in their left arm. The nurse in charge assessed the area and administered Tylenol, which provided temporary relief. On 03/28/2025 staff observed slight swelling of the left upper arm with continued reports of mild pain. The physician was notified, and an x-ray was ordered, and pain management was adjusted. On 03/31/2025 Resident #4's swelling had increased, and the affected area was noted to be warm to the touch. The resident also began to exhibit altered mental status. Physician #2 evaluated the resident and ordered hospital transfer to rule out Deep Vein Thrombosis and assess mental status change. On 04/01/2025 during a follow up with the hospital, they reported Resident #4 had a left proximal humerus fracture. The report did not indicate if the fracture was acute or chronic. The investigation concluded there was no evidence to suggest abuse, neglect, or staff misconduct in relations to the resident's left proximal humerus fracture. A late entry note dated 04/14/2025 (for 03/28/2025) by Physician #1 documented they were contacted by nursing on 03/28/2025 at 3:50 PM regarding Resident #4's pain and swelling to the left upper arm with activity. No trauma was reported. A STAT upper arm x-ray and Tylenol 1000 milligrams times one dose was ordered and physician to be called with the results and change in condition. The primary floor attending to be informed. There was no documented evidence the relevant care plans were reviewed and revised to reflect on Resident #4's changes in condition. During a telephone interview on 08/08/2025 at 3:28 PM, the Assistant Director of Nursing stated the care plans are updated when there's a change in condition. They stated that the Registered Nurses are responsible for updating the care plans. The Assistant Director of Nursing stated that if a resident is complaining of pain, the physician should be informed, pain medication should be ordered, and the relevant care plans should be updated with monitoring. During a telephone interview on 08/08/2025 at 3:11 PM, Registered Nurse Supervisor #2 stated that the Registered Nurses and Registered Nurse Supervisors are responsible for updating the care plans if there is a change in condition. They stated they were not aware of Resident #4's complaint of pain. 10 NYCRR 415.12

Based on observation, record review, and interviews conducted during an abbreviated survey (NY00339715), the facility failed to protect a resident from physical abuse by nursing home staff. This was evident in one out of ten residents sampled for abuse (Resident #1). Specifically, on 04/19/2024 at 8:30 pm, Certified Nursing Assistant #1 and Certified Nursing Assistant #2 were providing Incontinence care to Resident #1. Certified Nursing Assistant #2 witnessed Certified Nursing Assistant #1 slap Resident #1 several times in the head. On 04/19/2024 at 9:30 pm, Registered Nurse #1 did a physical assessment on Resident #1 and there were no bruises. Subsequently, on 04/20/2024 at 7:00 am, the Director of Nursing did a physical assessment of Resident #1 and saw a red bruise measuring 2 centimeters by 1.5 centimeter under Resident #1's left eye. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy. The findings are: The Facility's Policy and Procedure on Abuse and Neglect, revised date of 12/2023, documented the facility's commitment to protect residents from abuse by anyone including, but not necessarily limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. The Facility's Occurrence Report documented on 04/19/2024 at 8:30 pm, Certified Nursing Assistant #2 witnessed physical abuse and reported it to Licensed Practical Nurse #1. Resident #1 was assessed by Registered Nurse Supervisor #1 at 9:30 pm and there were no bruises noted. The facility's investigation documented that Certified Nursing Assistant #1 and #2 admitted that Resident #1 did not have any head/facial discoloration prior to them rendering care. Physical examination of Resident #1 on 04/20/2024 at 7:00 am revealed a red bruise under Resident #1's left eye which is consistent with the allegation that during care Certified Nursing Assistant #1 slapped Resident #1. The facility concluded that abuse occurred. Certified Nursing Assistant #1 was suspended on 04/20/2024 and terminated on 04/23/2024. Resident #1 was admitted to the facility on [DATE] with diagnoses including Non-Alzheimer's Dementia (memory loss), and Paranoid Schizophrenia (distrustful and suspicious of others). The Minimum Data Set (assessment tool), dated 02/15/2024, documented that Resident #1 had a Brief Interview of Mental Status and scored 3 out of 15, indicating severely impaired cognition. A Comprehensive Care Plan for Potential for Abuse dated 12/22/2021 documented interventions to promptly investigate all allegations of abuse, provide a safe person for Resident #1 to report to, and assistance with activity of daily living. The care plan was updated on11/28/2023 to continue with plan of care. A nursing progress note written by Registered Nurse Supervisor #1, dated 04/20/2024 at 1:47 am, documented Licensed Practical Nurse #1 reported to them Certified Nursing Assistant #2 told Licensed Practical Nurse #1 that while providing care to Resident #1 along with Certified Nursing Assistant #1 on 04/19/2024 at 8:30 pm, Certified Nursing Assistant #1 slapped Resident #1 repeatedly on the head and threatened to beat them because they became restless, uncontrollable, and bit Certified Nursing Assistant #1's arm. Resident #1 was alert but confused and unable to state what happened. Resident #1 was assessed, and there were no visible injuries. On 04/24/2024 at 9:16 am, Resident #1 was not interviewable due to severely impaired cognition. During a telephone interview on 04/24/2024 at 10:43 am, Certified Nursing Assistant #1 stated on 04/19/2024, during the 3:00 pm to 11:00 pm shift, they were not assigned to Resident #1 and were assisting Certified Nursing Assistant #2 to provide Incontinence care for Resident #1. Certified Nursing Assistant #1 stated Resident #1 was restless during care, and they observed Resident #1 with a mark on Resident #1's left arm and a bump on the left side of Resident #1's eye after Incontinence care was provided. Certified Nursing Assistant #1 stated they did not notice the marks before they started care and that they did not slap or hit Resident #1. Certified Nursing Assistant #1 stated Resident #1 did not bite them, and Resident #1 was not hit by anyone. During an interview on 04/24/2024 at 1:00 pm, the Director of Nursing stated on 04/19/2023 at 11:45 pm, Registered Nurse #1 informed them Certified Nursing Assistant #2 witnessed Certified Nursing Assistant #1 slap Resident #1 several times in the head during Incontinence care at 8:30 pm. During an interview on 04/24/2024 at 2:27 pm, the Facility's Administrator stated on 04/19/2024 at 11:59 pm they received a text message from the Director of Nursing that that alerted them of the allegation of abuse. The Administrator also stated that the police were informed and that they advised the facility to call them when the staff are in the facility. During an interview on 04/25/2024 at 9:33 am, Certified Nursing Assistant #2 stated they were assigned to Resident #1 and while they were providing incontinence care to them, Resident #1 bit Certified Nursing Assistant #1's arm. Certified Nursing Assistant #1 then slapped Resident #1 several times. During an interview on 04/25/2024 at 10:29 am, Medical Doctor stated that the bruise to Resident #1's eye can be related to trauma or the blood thinner medication that was currently administered to Resident #1. 10 NYCRR 415.4(b)(1)(i)

Based on record review and interviews conducted during an abbreviated survey (NY00339715), the facility did not ensure that all allegations of abuse were reported in a timely manner to local law enforcement, facility administrator, and the New York State Department of Health in accordance with federal and state regulations. This was evident in one out of ten residents sampled (Resident #1). Specifically, on 04/19/2024 at 8:30 pm, Certified Nursing Assistant #2 reported to License Practical Nurse #1 that Certified Nursing Assistant #1 slapped Resident #1 several times in the head. On 04/19/2024 at 11:59 pm, The Director of Nursing notified the facility's Administrator by a text message about the incident. On 04/20/2024 at 12:44 am, the facility failed to report the allegation to law enforcement and the New York State Department of Health within two hours. The findings are: The Facility's Policy and Procedure on Abuse and Neglect, revised date of 12/2023, documented any staff member or person affiliated with the facility who has witnessed or who believes that a resident has been a victim of mistreatment, abuse or any other criminal offense shall immediately report or cause a report to be made. Immediately means as soon as possible but not to exceed two hours after the allegation/incident discovery is made if the event that caused the allegation involved abuse or resulted in serious body injury or no later than twenty-four hours if the event that caused the allegation did not involve abuse or did not involve serious bodily injury to the Administrator and other officials including State Survey Agency, Adult Protection Services, if applicable. The Facility's Occurrence Report documented on 04/19/2024 at 8:30 pm, Certified Nursing Assistant #2 witnessed physical abuse and reported it to Licensed Practical Nurse #1. Resident #1 was assessed by Registered Nurse Supervisor #1 at 9:30 pm and there were no bruises noted. Certified Nursing Assistants #1 and #2 admitted that Resident #1 did not have any head/facial discoloration or bruises prior to them rendering care. Physical examination of Resident #1 on 04/20/2024 at 7:00 am revealed a red bruise under Resident #1's left eye, which is consistent with the allegation that during care Certified Nursing Assistant #1 slapped Resident #1. The facility concluded that abuse occurred. Certified Nursing Assistant #1 was suspended on 04/20/2024 and terminated on 04/23/2024. Resident #1 was admitted to the facility on [DATE] with diagnoses including Non-Alzheimer's Dementia (memory loss), and Paranoid Schizophrenia (distrustful and suspicious of others). The Minimum Data Set (assessment tool), dated 02/15/2024, documented that Resident #1 had a Brief Interview of Mental Status and scored 3 out of 15, indicating severely impaired cognition. A Comprehensive Care Plan for Potential for Abuse dated 12/22/2021 documented interventions to promptly investigate all allegations of abuse, provide a safe person for Resident #1 to report to, and assistance with activity of daily living. The care plan was updated on11/28/2023 to continue with plan of care. A nursing progress note written by Registered Nurse Supervisor #1 dated 04/20/2024 at 1:47 am, documented they were notified by Licensed Practical Nurse #1 on 04/19/2024 at 8:30 pm, Certified Nursing Assistant #1 was assisting Certified Nursing Assistant #2 with Incontinence care for Resident #1. Resident #1 became restless and uncontrollable and bit Certified Nursing Assistant #1's arm. Certified Nursing Assistant #1 slapped Resident #1 repeatedly on the head and threatened to beat Resident #1. Resident #1 is alert but confused and unable to state what happened. Resident #1 was assessed and there were no visible injuries noted. During an interview on 04/24/2024 at 12:01 pm, Licensed Practical Nurse #1 stated Certified Nursing Assistant #2 approached them on 04/19/2024 at 8:45 pm and informed them Certified Nursing Assistant #1 slapped Resident #1 on the head during Incontinence care. Licensed Practical Nurse #1 stated they reported to Registered Nurse Supervisor #1 at 9:00 pm. During an interview on 04/24/2024 at 1:00 pm, the Director of Nursing stated that on 04/19/2024 at 11:45pm, Registered Nurse Supervisor #1 informed them that Licensed Practical Nurse #1 reported at 10:00 pm that Certified Nursing Assistant #2 witnessed Certified Nursing Assistant #1 slap Resident #1 several times on the head. Director of Nursing stated if they are not available, the Assistant Director of Nursing reports incidents to the Department of Health and that any staff can call the police. Director of Nursing stated they reported the incident on 04/20/2024 at 12:44 am to the Department of Health and Law Enforcement. During an interview on 04/24/2024 at 2:27 pm, Administrator stated they received a text message about the incident from the Director of Nursing at 11:59 pm on 04/19/2024. During a telephone interview on 04/25/2024 at 10:29 am, the Medical Doctor stated they were informed about the incident by Director of Nursing on 04/19/2024 but cannot recall the time. 10 NYCRR 415.4(b)(1)(i)

Based on observation, record review, and interviews conducted during the recertification survey from 11/27/2023 to 12/01/2023, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was evident for 6 of 8 resident floors (Floor 2, 4, 5, 6, 7, and 9) and the kitchen. Specifically, 1) ice machines in the pantry on Floors 2, 4, 5, 6, 7, and 9 were dirty and dusty, and 2) the kitchen had dusty air vents and walls. The findings are: The facility policy titled Exhaust Fans dated 12/2022 documented exhaust fans will be cleaned weekly and as needed. The facility policy titled Procedures for Cleaning Work Areas dated 12/2022 documented all walls are washed down with detergent and sanitizing agent once each week. The facility policy titled Ice Machines dated 04/2023 documented the ice machines must be kept in a sanitary condition to provide an uncontaminated product. The Ice Machine Inspection Log documented the ice machines were last checked on units 2, 3, 4, 5, 6, 7 and 9 on 11/26/2023. On 11/28/2023 at 09:16 AM and 11/29/2023 at 11:41 AM, the 6th Floor pantry ice machine was observed with a white substance built up on the spout where ice is dispensed. The grates and air filter were dusty and stained with a brown substance. On 11/28/2023 at 10:46 AM and 3:42 PM and 11/29/23 at 09:15 AM, the 5th Floor pantry ice machine was observed with a white substance built up around the spout that dispenses ice. The air filter of the ice machine was dusty. A food service tray and used cereal bowl were observed in the cupboards of the pantry. On 11/29/2023 at 09:37 AM, the kitchen was observed with a dusty fan, a dusty air vent, and black grime on the wall and floor tiles in the area where dishes are cleaned. dusty vent near dish room. The wall tile by the steamer oven was covered with dust. The room storing clean dishes had a dusty fan blowing air onto the dishes. One of the dish holders had dried food stuck to it. The clean plates were also stored under a dusty air vent on the ceiling. On 11/29/2023 at 10:04 AM and 11/30/23 at 12:10 PM, the 9th Floor pantry ice machine the following was observed with white build up near the spouts that dispense ice and on the grates below the spouts. On 11/29/2023 at 10:32 AM and 12/01/2023 at 11:02 AM, the 7th Floor pantry ice machine was observed with white build up on the spouts that dispense ice, and the air filter was covered in gray dust. On 11/29/2023 at 10:45AM and 12/01/2023 at 11:18 AM, the 4th Floor ice machine was observed with a dusty air filter and white build up on the spouts that dispense the ice. On 11/29/2023 at 11:55 AM and 12/01/2023 at 11:24 AM, the 2nd Floor pantry ice machine was observed with a dusty air filter, white and brown spots on the tray beneath the dispenser spouts, and white build up on the ice dispenser spouts. During an interview on 11/30/2023 at 10:14 AM, Dietary Aide (DA) #1 stated they cleaned the kitchen in sections and the last time they cleaned was last week. A special cleaning of the walls and floors was done at night weekly. The air vent was cleaned a month ago. DA #1 did not have supplies to clean the air vent and noticed that dust gets blown from the dusty air vent. An interview was conducted on 12/01/2023 at 11:05AM, with Maintenance Worker (MW) #2 who stated the housekeeper cleans the pantry daily and MW #2 does monthly cleaning of the ice machines by flushing the drain and cleaning the ice machine system. The Director of Maintenance and Housekeeping (DOM/HK) does rounds and looks at the ice machines. MW #2 last cleaned the ice machine in October 2023 on the 2nd and 5th Floors. During an interview on 11/30/2023 at 09:56 AM, the Food Service Supervisor (FSS) stated cleaning is done by the porter on the overnight shift and all kitchen staff were responsible for cleaning their station. The walls and floors were cleaned twice weekly with bleach. The air vent was cleaned 3 weeks ago. The fan in the dish washing room was broken and should have been discarded. During an interview on 11/30/2023 at 10:20 AM, the Food Service Director (FSD) stated that kitchen staff were responsible for cleaning their assigned station and any equipment they used. The FSD had a checklist that was completed before each dinner service to ensure staff completed their tasks. The FSD stated they checked the kitchen for dust and grime every 15 days and documented this weekly and monthly. The air vent was cleaned every 2 weeks. During an interview on 12/01/2023 at 11:33 AM and 11/30/2023 at 10:39 AM, the DOM/HK stated the ice machine dispenser spouts are cleaned annually. The air vents in the kitchen were last cleaned on 9/7/2023. 10 NYCRR 415.14

Based on observation, record review, and interviews conducted during the recertification survey from 11/27/2023 to 12/01/2023, the facility did not ensure a clean, comfortable, and homelike environment was maintained. This was evident for 6 of 8 resident floors (Floors 4, 5, 6, 7, 8, and 9) during review of the Environment. Specifically, 1) Air Conditioning/Heating (AC/H) units were observed with missing covers leaving the inside of the unit exposed, 2) cabinets were in disrepair with misaligned, cracked doors and shelves and missing doorknobs, and 3) a cracked bedside table and cracked tile in room [ROOM NUMBER]. The findings are: On 11/28/2023 at 10:13 AM, cracked bathroom tile and a wooden bedside table that was cracked, and split were observed in room [ROOM NUMBER]. An AC/H unit with cardboard covering the right side and bottom was observed in room [ROOM NUMBER]. On 11/29/2023 at 10:04 AM, the 9th Floor AC/H units throughout the floor were observed dusty. The pantry had cabinet doors with chipped paint and were detached from the wall on the left side of the room. On 11/29/2023 at 10:18 AM, the 8th Floor pantry was observed with cabinets with chipped paint, a hole in the wall, grime along the edge of the tile floor, and missing baseboards on the left side of the room. AC/H units throughout the floor were dusty and the AC/H by the bulletin board was missing part of its cover. exposing the inner metal grate. On 11/29/2023 at 10:31 AM, the 5th Floor AC/H unit was observed missing the left side of the outer covering exposing the metal grate on the inside of the unit. On 11/29/2023 at 10:32 AM, the 7th Floor pantry cabinets under the sink were observed with multiple cracks in the wooden doors. On 11/29/2023 at 10:45 AM, the 4th Floor pantry cabinets was observed without doorknobs. The AC/H units on both sides of the room were missing part of their covers on the left side of the unit exposing the inside metal grates. Dried food particles, cardboard pieces, and dust were observed inside the units. During an interview on 11/30/2023 at 10:39 AM and 12/01/2023 at 11:33 AM, the Director of Maintenance and Housekeeping (DOM/HK) stated they conduct daily rounds to ensure cleanliness is addressed. The cabinets in the pantries had normal wear and tear. lean. The AC/H units were last cleaned in September 2023. During an interview on 11/30/2023 at 10:33 AM, Maintenance Worker (MW) #1 stated AC/H units were last cleaned in September 2023. AC/H units are cleaned every 3 to 6 months. 10 NYCRR 415.12(h)(1)(2 )

Based on observation, record review, and interviews conducted during the Recertification survey from 11/27/2023 to 12/01/2023, the facility did not ensure medications and biologicals were stored in accordance with currently accepted professional principles. This was evident for 1 (5th Floor) of 8 resident units. Specifically, the 5th Floor medication room contained an expired bag of intravenous (IV) fluids. The findings are: The facility policy titled IV Therapy dated 03/2023 documented to check IV medication for expiration dates. On 12/01/2023 at 12:52 PM, the 5th Floor medication room was observed with Licensed Practical Nurse (LPN) #3 and contained a bag of IV fluid 5% dextrose 1000 ml (lot # Y381345) with an expiration date of May 2023. LPN #3 was interviewed at the time and stated the IV fluid bag was expired and needed to be returned to the pharmacy. The medication room was checked daily for anything that was expired and the IV fluid bag was missed because it was at the bottom of storage area. On 12/01/2023 at 12:57 PM, Registered Nurse (RN) #2 was interviewed and stated the expired IV fluid bag was ordered for a rsident that was no longer in the facility. RN #2 last checked the 5th Floor medication room in October and did not notice the expired IV fluids. On 12/01/2023 at 1:58 PM, the Director of Nursing (DON) was interviewed and stated they observe the medication rooms twice a week to look for expired medications. If anything was expired the DON would remove it from the medication rooms and alert staff. The Pharmacy Consultant (PC) came to the facility to check the medication rooms for expired medications monthly. On 12/01/2023 at 03:03 PM, the PC was interviewed and stated that their company sends staff to observe the medication rooms monthly for expired medications. The expired IV bag was buried in a box and it was an isolated incident that it was missed. 10 NYCRR 415.18(e)(1-4)

Based on observation, interviews, and record review conducted during the recertification and complaint (NY00323859) survey from 11/27/2023 to 12/01/2023, the facility did not ensure a resident received treatment and care in accordance with professional standards of practice. This was evident for 1 (Resident #241) of 37 total sampled residents. Specifically, the Registered Nurse (RN) and the Medical Doctor (MD) were not made aware in a timely manner when Resident #241 had a change in condition and required hospitalization . The findings are: The facility policy titled Notification of Change dated 03/2023 documented that any change in the resident's condition was to be documented and the medical doctor (MD) and designated representative (DR) were to be informed. A facility must immediately consult with the MD when there is a significant change in the resident's condition. Resident #241 had diagnoses of stroke and dementia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #241 was severely cognitively impaired. On 11/30/2023 at 04:54 PM, Resident #241's DR was interviewed and stated they visited Resident #241 on 9/13/2023 and observed the resident was sleepy and in a wheelchair in the dayroom. Resident #241 normally ambulated using a cane. The DR reported to Registered Nurse (RN) #2 that they saw a change in the Resident #241's condition that concerned them the resident may have had a stroke and wanted the resident evaluated by the MD and transferred to the hospital for evaluation. The RN took Resident #241's vital signs, informed the MD, and transferred the resident to the hospital. The DR was informed by the hospital that Resident #241 had a mini stroke and ischemic attack. MD Orders dated 10/02/2023 documented monitor Resident #241's Blood Pressure (BP) daily. The Comprehensive Care Plan (CCP) related to cardiac diseases dated 2/18/2023 documented interventions to monitor Resident #241's BP as ordered by the MD and report abnormal findings to the MD. Nursing Note dated 9/7/2023 at 4:30 PM documented Resident #241's DR reported the resident did not look like the normally do. RN #2 assessed Resident #241 had a delay in speech, muscle spasms and stiffness, and was unable to stand or walk. Resident #241's BP was 160/85. The MD was informed, and Resident #241 was transferred to the hospital at 5:00 PM. The Nursing Resident Transfer Summary dated 9/7/2023 at 6:19 PM documented Resident #241 was transferred to the hospital to rule out a stroke. The Hospital Patient Review Instrument (PRI) dated 9/12/2023 documented Resident #241 had a primary diagnosis of altered mental status secondary to hypertensive Encephalopathy. The Hospital After Visit Summary dated 9/13/2023 documented Resident #241 was admitted to the hospital on 9/7/2023 for altered mental status and high BP. The facility Employee Warning Notice dated 9/14/2023 documented Licensed Practical Nurse (LPN) #2 was assigned to Resident #241's unit on 9/7/2023 and was informed by Occupational Therapist (OT) #1 at 8:40 AM that Resident #241 had muscle spasms. LPN #2 reported they checked Resident #241 and did not see any muscle spasms. Resident #241's DR came at 3:00 PM to report the change in Resident's #241's. LPN #2 did not report Resident #241's change in condition to the supervisor, RN #2, and was warned any repetition of this unsatisfactory performance may lead to further disciplinary action, including termination. There was no documented evidence LPN #2 informed the RN Supervisor of Resident #241's change in condition that required assessment and hospitalization . On 11/20/2023 at 12:00 PM and 3:11 PM, OT #1 was interviewed and stated they provided Resident #241 with treatment on 9/7/2023 at 8:30 AM and observed the resident sitting at the edge of their bed with closed eyes and clenched hands. Resident #241 attempted to eat their breakfast but dropped their utensil and was not able to maintain their posture. OT #1 spoke with LPN #2, inquired whether Resident #241 had received their morning medications yet or had been started on new medication, and reported the change in the resident's condition. OT #1 continued working with Resident #241 and observed the resident was unable to stand which was unusual and informed LPN #2 at 08:45AM. At 9:00 AM, OT #1 spoke with LPN #2 again and asked LPN #2 to check on Resident #241 and ensure they receive their medications. OT #1 informed the Director of Rehab that Resident #241's was unable to ambulate, and OT #1 provided Resident #241 with a wheelchair at 9:30 AM. OT #1 did not see LPN #2 go to Resident #241's room to check on the resident. On 11/30/2023 at 12:46PM, LPN #2 was interviewed and stated they called and paged the RN Supervisor, RN #2, after being informed by OT #1 that Resident #241 had a change in condition. LPN #2 stated they did not receive a response from RN #2. When RN #2 arrived on the unit to assess another resident, LPN #2 informed RN #2 of the change in Resident #241's condition. LPN #2 returned to the unit at 3:00 PM after taking their break and was informed by RN #2 that the resident's DR had to go to the nursing office to inform RN #2 that Resident #241 needed to be evaluated. LPN #2 stated that RN #2 reported that LPN #2 never informed them of Resident #241's change in condition. On 11/30/23 at 11:28 PM and 3:23 PM, RN #2 was interviewed and stated Resident #241's DR came to the nursing office between 2:00 PM and 3:00 PM to inform RN #2 that the resident was lethargic and needed to be assessed. OT #1 informed RN #2 Resident #241 had been in this condition since morning. RN #2 took Resident #241's vital signs, saw they had high BP and slurred speech, informed the MD, and transferred the resident to the hospital. RN #2 was on the Resident #241's unit at approximately 10:00 AM to see another resident and did not speak with LPN #2 at the time. LPN #2 should have paged RN #2 when LPN #2 was aware Resident #241 was not feeling good. RN #2 immediately responds to concerns when they are paged or informs the Assistant Director of Nursing (ADON) and Director of Nursing (DON) if they are busy and cannot respond to a page by the LPN on the unit. On 12/01/2023 at 02:02 PM, the DON was interviewed and stated Resident #241's DR came to the nursing office and informed RN #2 the resident was not feeling well. RN #2 assessed the resident and informed the DON that LPN #2 knew Resident #241 was not feeling well and did not inform RN #2 earlier. The DON stated they would have responded if RN #2 was paged but did not hear LPN #2 page RN #2 throughout the day. LPN #2 was written up and suspended after providing the DON with their statement regarding the incident. 10 NYCRR 415.12

Based on observations, record review, and interviews conducted during the Recertification survey from 11/27/2023 to 12/01/2023, the facility did not ensure that infection control practices were maintained. This was evident for 1 (Resident #216) of 37 total sampled residents. Specifically, Registered Nurse (RN) #2 was observed during wound care did not perform hand hygiene before wound care or during wound care at required intervals when doing wound care on a resident. The findings are: The facility policy titled Handwashing/Hand Hygiene dated 02/2023 documented hand washing with antimicrobial or nonantimicrobial soap and water must be performed before and after direct contact with residents, after contact with blood, body fluids, secretions, mucous membranes, or non-intact skin, after removing gloves, and after handling items potentially contaminated with blood, body fluids or secretions. The use of gloves does not replace handwashing. Resident #216 had diagnoses of Peripheral Vascular Disease and Anemia. During a wound care observation for Resident #216 on 11/29/2023 at 02:51 PM, RN #2 gathered wound care supplies from the treatment cart in the hallway and brought them into Resident #216's room. RN #2 donned gloves, removed a food tray from the residents bedside table, retrieved disinfecting wipes from the treatment cart in the hallway, wiped down the bedside table and removed their gloves. RN #2 did not perform hand hygiene after removing their gloves. RN #2 then setup the wound care supplies on Resident #216's bedside table with their bare hands, and adjusted Resident #216's position in the bed using the bed remote. RN #2 did not perform hand hygiene and donned gloves, poured saline solution onto gauze on the table and opened the calcium alginate dressing. Resident #216's right leg was placed on a drape cloth and RN #2 removed the dressing to the right heel by cutting the tape with a scissor. RN #2 removed their gloves and donned new gloves without performing hand hygiene. RN #2 then cleaned Resident #216's right heel and applied the dressing. On 11/29/2023 at 03:12 PM, RN #2 was interviewed and stated they did not perform wound care often and this was the first time they performed wound care on Resident #216. RN #2 stated they forgot to perform hand hygiene prior to wound care. Hand hygiene should be performed after the soiled dressing was removed, and before cleaning the resident's wound. RN #2 also did not wash their hands after picking up the resident's food tray and after handling the bed remote. On 11/29/2023 at 1:58 PM, the Director of Nursing/ Infection Preventionist (IP) was interviewed and stated they perform rounds twice daily to ensure nursing staff were performing proper hand hygiene and wound care protocols. 10 NYCRR 415.19(a)(1)(b)(4)

Based on interviews and record review during an abbreviated survey (NY00291550), the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegations of abuse were made to the New York State Department of Health (NYSDOH). This was evident in 2 of 13 residents reviewed (Resident #6 and Resident #7) for abuse. Specifically, On 02/20/22 at 1:55 AM, Resident #6 and Resident #7 were involved in an alleged resident to resident physical abuse, the facility reported the incident to the NYSDOH on 02/20/2022 at 2:41 PM. The findings are: The facility's policy and procedure titled Abuse Neglect, Mistreatment, Exploitation, Injury of Unknown Sources which was last reviewed on 2/23 documented it is the responsibility of facility's employees, facility consultants, attending physicians, family members, visitors, etc. to promptly report any incident or suspected incident of neglect or resident abuse including injuries of unknown source, and theft or misappropriation of resident property to facility management. Alleged violations must be reported to the NYSDOH immediately, but no later than 2 hours if the events that caused the allegation involves abuse or result in serious bodily harm. Resident #6 was admitted to the facility with diagnoses of Non-Alzheimer's Dementia, Diabetes Mellitus, and Depression. The Minimum Data Set (MDS, a resident assessment tool) dated 4/29/22 documented that Resident #6 had severely impaired cognition. Resident #7 was admitted to the facility with diagnoses of Non-Alzheimer's Dementia, Diabetes Mellitus. and Hypertension. The MDS dated [DATE] documented Resident #7 had moderately impaired cognition. The facility's Resident Occurrence Report documented that on 02/20/22 at 1:55 AM, staff observed a laceration to Resident #7's nose bridge. The facility's occurrence report documented Resident #6 stated Resident #7 hit their face near the bathroom sink. Resident #7 stated that Resident #6 hit them with the garbage bin in the bathroom. No injury was noted for Resident 6. Resident #7 was observed with swollen nose and laceration to nose bridge measuring 1.0x1.5x0.3cm, with small amount of bleeding. Resident #7 was transferred to the hospital for evaluation and treatment. Resident #7 was transferred to another room upon returning from the hospital to prevent reoccurrence. The investigation was completed on 2/21/22 to conclude that there was no reasonable cause to believe that any alleged abuse occurred. The Aspen Complaint Tracking System documented the facility reported this allegation of resident-to-resident physical abuse to NYSDOH on 2/20/22 at 2:41 PM, more than 2 hours after the incident occurred. On 11/20/23 at 2:20 PM, the Assistant Director of Nursing (ADON) was interviewed and stated the incident involving Resident #6 and Resident #7 occurred on 2/20/22 at 1:55AM. The investigation was initiated immediately and was completed the following day. However, ADON acknowledged that alleged incident was not reported to NYSDOH within 2 hours and was submitted on 2/20/22 at 2:41PM. On 11/20/23 at 2:05 PM, an interview was conducted with the Director of Nursing (DON). DON stated that an alleged incident of abuse should be reported to the NYSDOH within 2 hours. On 11/20/23 at 1:55 PM, the Administrator was interviewed and stated that immediate reporting of abuse allegations to NYSDOH is within 2 hours. The Director of Nursing (DON) and the ADON (Assistant Director of Nursing) are responsible for the submitting allegations of abuse to NYSDOH. 10 NYCRR 415.4(b)

Based on observation, record review and staff interviews conducted during an Abbreviated survey (NY 668), the facility did not ensure that all alleged violation involving abuse are reported to the New York State Department of Health (NYSDOH), immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury. This was evident for 1 out of 3 residents reviewed for Abuse (Resident #1). Specifically, Resident #1 called the emergency number (911) on 2/3/2022 at approximately 12:00 PM and alleged that on 2/2/2022, Certified Nurse Assistant #1 (CNA #1) hit Resident #1 on the right shoulder while providing personal care to Resident #1. The facility reported the allegation to the NYDOH on 2/3/2022 at 06:56 PM. The facility failed to report the alleged staff abuse within two hours after being notified of the abuse allegation. The findings are: The facility Policy and Procedure entitled Abuse, Neglect, and Mistreatment dated 3/2018, documented that the decision of potential abuse and notification to NYDOH is made by the Administrator/Designee within 24 hours of complaint followed by a written notification and results of the facility's investigation as soon as possible. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 2/3/2022 documented that Resident #1 had a Brief Interview of Mental Status (BIMS used to determine attention, orientation, and ability to recall information) and a score of 14/15 (00-07 severe impairment, 08-12 moderate impairment and 13-15 cognitively intact). Resident #1 requires two persons to a assist with personal care and activity of daily living. A review of the facility's investigation dated 2/3/2022, documented that on 2/3/2022, Resident #1 called 911 and alleged that on 2/2/2022 at around 11:30 AM, staff #1 hit him/her on his/her shoulder while providing personal care. Resident #1 who was alert and oriented to person, place and time was admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Staff administered the pain medication as ordered. Based on the investigation, two staff members were providing care to the resident #1 on 2/2/2022 during the 7-3 shift. While providing personal care, resident #1 did not complain of pain or any discomfort. Resident #1 did not report anything to staff on 2/2/2022. The facility concluded that there was no evidence of abuse, neglect, or mistreatment. The case was reported to NYDOH on 2/3/2022 at 06:56 PM A review of the Nurse's note dated 2/3/2022 at 05:23 documented that at approximately 12:00 PM, two police officers and 911 emergency personnel arrived on the unit and stated that Resident #1 called and reported that staff assaulted Resident #1. Resident #1 was interviewed along with the Director of Nursing (DON), social service, resident' family, and the 911 personnel. Resident #1 stated that on 2/2/2022, around 11.30 am, the staff that was providing care hit him/her on the right shoulder. A physical assessment was done, and no visible injury were observed. A Medical Doctor (MD) was notified, and an order was received to transfer Resident #1 to the hospital as per family request. At 12:37 PM, Resident #1 left the facility accompanied by 911 personnel and a family member for the hospital. During an interview on 3/16/2022 at 3:00 PM, the Assistant Director of Nursing (ADNS), staff # 3, stated that he/she was responsible for reporting to NYDOH and local law enforcement. Abuse allegations should be reported within 2 hours to NYDOH. The facility usually call the police immediately if an abuse is suspected. Resident #1 called the police first, and the facility only became knowledgeable of the allegation when the police arrived at the facility. The ADNS stated that they did not report within 2 hours because they were still investigating the incident. During an interview on 3/16/2022 at 4:00 PM, The DNS, staff #3 stated that any alleged abuse should be reported within 2 hours. The DNS stated that the staff had no knowledge about the allegation until the police came to the facility on [DATE]. The DNS stated the incident was investigated and there was no evidence of abuse. Resident #1 was admitted to the facility with a fracture to the right shoulder and was on pain management. Investigation showed that resident #1was receiving pain medication on a scheduled and as-needed basis. The accused CNA staff #1 was providing care with another CNA staff #2, because Resident #1 required two persons to provide personal care. Both CNAs were interviewed and denied the allegation. 415.4(b)(1)(i)