Every finding on record at Northern Riverview Health Care, Inc

Based on record review and interviews conducted during the Abbreviated Survey, the facility did not ensure that one (Resident #1) of four residents reviewed for resident rights was treated with respect and dignity and cared for in a manner and in an environment that promoted maintenance or enhancement of the resident's quality of life, recognizing the resident's individuality. Specifically, on 06/30/2026, the Director of Nursing entered Resident #1's room, cleaned the room, and removed items while the resident was attending an activity despite the resident's repeated refusal of staff assistance with cleaning the room.The findings are: Resident #1 was admitted to the facility with diagnoses including, but not limited to, displaced [NAME] fracture of the right tibia, right fibula fracture, and hypothyroidism. The 05/06/2026 annual Minimum Data Set (MDS) assessment documented Resident #1 had intact cognition. The facility policy titled Resident Rights, last revised 05/28/2024, documented, Healthcare Personnel (HCP) shall treat all residents with kindness, respect, and dignity. Resident #1 was admitted to the facility with diagnoses including, but not limited to, displaced [NAME] fracture of the right tibia, right fibula fracture, and reduced mobility. The 05/06/2026 annual Minimum Data Set (MDS) assessment documented Resident #1 had intact cognition. The facility policy titled Resident Rights, last revised 05/28/2024, documented, Healthcare Personnel (HCP) shall treat all residents with kindness, respect, and dignity. The 05/11/2026 Grievance Form, received by Social Worker #1, documented Resident #1 requested that staff do not enter their room. The Grievance Form further documented staff entered the room due to safety concerns, located several expired food items, and discarded molded milk, rotten sandwiches, and other expired food items. The 05/12/2026 Investigation/Follow-Up to Grievance, completed by Social Worker #1 and signed by the Administrator, documented staff were in-serviced regarding removal of items, the resident was educated on food safety and expiration protocols, and moving forward, staff would remove items when the resident was present. The 05/13/2026 Grievance-Resident Notification Summary documented the grievance was addressed by the Nursing and Housekeeping departments. The Grievance-Resident Notification Summary further documented staff were in-serviced to remove items only when the resident was present, the resident was educated on the importance of proper food protocols, the importance of expiration dates and food safety, and moving forward, staff would remove items only when the resident was present. The resident refused to sign the grievance notification, and verbal authorization was obtained from the resident representative. The 07/01/2026 at 4:14 PM Social Services progress note by Social Worker #1 documented Resident #1 met with the social worker regarding a grievance and expressed concerns that personal belongings had been removed. The progress note further documented the previously completed grievance was reviewed, and the social worker planned to contact administration regarding replacement of some of the resident's belongings. The 07/17/2026 Missing Items/Misappropriation of Resident Property Form, initiated by Social Worker #1, documented Resident #1 reported missing items. The Administrator signature line was blank. On 07/22/2026 at 11:28 AM, the Assistant Administrator stated the Director of Nursing was on vacation; therefore, an interview with the Director of Nursing was not conducted. During an observation on 07/23/2026 at 11:15 AM, Resident #1 was observed preparing to be discharged home from the facility with multiple visible bags containing belongings and trash. Resident #1 was observed making multiple trips while independently transporting the bags to the resident's transportation and refusing staff assistance. During an interview on 07/23/2026 at 11:17 AM, Resident #1 stated that on 06/30/2026, between approximately 11:00 AM and 11:30 AM, while attending a singing/music activity with the Activities Director, the Director of Nursing entered the resident's room, cleaned the room, and removed items. Resident #1 stated that upon returning to the room, the resident observed belongings had been moved and the Director of Nursing informed the resident that the room had been cleaned. Resident #1 stated the resident had repeatedly refused staff requests to clean the room and wanted to be present if staff entered the room to remove items. Resident #1 further stated the resident immediately reported the incident to Social Worker #1 on 07/01/2026, the day after the room was cleaned. During an interview on 07/23/2026 at 11:30 AM, Registered Nurse Unit Manager #1 stated they were not involved in cleaning Resident #1's room on 06/30/2026 and were not in the building at the time. Registered Nurse Unit Manager #1 stated that upon returning to work, Resident #1 complained that items had been removed from the room. Registered Nurse Unit Manager #1 further stated they became aware of the incident through other staff. During an interview on 07/23/2026 at 11:36 AM, Social Worker #1 stated they had no involvement in the decision to clean Resident #1's room on 06/30/2026, were not present, and were not aware staff planned to enter the resident's room and clean it on that date. Social Worker #1 stated Resident #1 consistently refused staff requests to clean the room; however, staff had previously entered the room while the resident was present to remove moldy or expired food items due to safety concerns. Social Worker #1 further stated Resident #1 reported the incident to them on 07/01/2026. Social Worker #1 stated the resident should have been made aware and involved in the process prior to staff entering the room to clean and remove items and that Social Worker #1 should have also been made aware prior to the room being cleaned. During an interview on 07/23/2026 at 12:30 PM, the Assistant Director of Nursing stated they were not physically involved in cleaning Resident #1's room on 06/30/2026 but heard about the incident afterward.During an interview on 07/23/2026 at 03:18 PM, the Activities Director stated Resident #1 regularly attended the singing/music activity and consistently came out of the room to participate. The Activities Director further stated the singing/music activity was typically conducted before lunch, although activities could vary.10 New York Codes, Rules and Regulations (NYCRR) 415.3

Based on record review and interviews during survey, the facility failed to plan a safe and appropriate discharge for one (1) of two (2) residents (Resident #188) reviewed for discharge. Specifically, Resident #188 was admitted from a group home for individuals with intellectual disabilities and at the facility for short-term rehabilitation following hospitalization. The facility discharged the resident on 12/26/2025, without notice, for a non-emergent diagnostic test and the resident was left at the hospital outpatient department. The facility did not have a plan or date set with the group home for the residents' return. The resident was not cleared by a physician to be safely discharged , and the group home had not evaluated the resident's ability to safely return. The resident's representative was not notified in writing of the non-urgent discharge and was not given the option to appeal. It was determined that Resident #188's likelihood to experience actual psychosocial harm, using the reasonable person concept (referenced in the Centers for Medicare and Medicaid Services Psychosocial Outcome Severity Guide), occurred as a result of being left at the hospital.Findings include:The 04/28/2025 facility policy Discharge-Transfer/Discharge Notice documented the facility will coordinate a safe transfer or discharge for residents leaving the facility. When a resident is transferred or discharged from the facility, details of the transfer will be documented in the clinical record and appropriate information will be communicated to the receiving health care facility or provider. The facility's interdisciplinary team and the resident's healthcare provider will regularly review the resident's potential for discharge, change in discharge plan, and/or need for transfer to an alternate setting and develop an individualized post discharge plan. The resident's healthcare provider will determine if a transfer to the hospital is required for an urgent medical need or if the resident's behavior poses a threat to their or other's safety or well-being. The resident and/or their representative will receive written notice of the facility's intent for transfer or discharge and their appeal rights prior to the time of discharge from the facility. When a resident is transferred or discharged from the facility, pertinent information regarding the transfer/discharge will be documented in the clinical record, including the discharge/transfer destination, reason for discharge/transfer, and summary of the resident's current medical record. For transfers to the hospital, the nurse will document the details of the hospital transfer in the resident's clinical record. A hospital is not an appropriate discharge destination, and the resident has a right to return to the facility upon completion of hospital stay.Resident #188 was admitted to the facility from the hospital with diagnoses including a disease of spinal cord (bundle of nerves running under the backbone attaching the brain to the rest of body), autistic disorder (neurodevelopmental condition affecting communication, social interaction, and behavior, often involving intense interests and sensory sensitivities), and severe intellectual disabilities.The 12/10/2025 admission Minimum Data Set (a resident assessment tool) documented the resident was rarely/never understood or able to understand and had unclear speech, rarely/never understands, no behavior, impairment on both sides of lower extremity, used wheelchair, required assistance with daily care, did not walk, was frequently incontinent of urine and bowel, received insulin, antipsychotic, anticonvulsant, received Occupational Therapy, Physical Therapy and Respiratory Therapy, the family participated in assessment and goal setting.The 12/02/2025 care plan for impaired cognition related to intellectual disabilities and autism had a goal to maintain current level of functioning. Interventions included asking yes or no questions, engaging the resident in simple structured activities, keeping the resident's routine consistent, providing consistent caregiver as much as possible, simple choices, and simple directions.The 12/05/2025 Social Worker #10 progress note documented they met with the resident to complete assessment and were unable as resident was non-verbal. Social Work would contact the care manager. The resident's discharge goal was to be discharged back into the community to a group home. The resident was admitted for rehabilitation. Resident's Representative/Guardian would provide support for the community. Social Work would provide psychosocial support for the resident as needed and assist with the discharge planning process.An Interdisciplinary Team Meeting and Evaluation form documented a meeting was held on 12/18/2025 at the request of the group home to assess the progress of Resident #188. A magnetic resonance imaging (diagnostic test) of the back and head was requested, and the plan was to discharge the resident. Participants included the Registered Dietitian, Director of Nursing, Director of Rehabilitation, Recreation, the family member/guardian by phone, and the group home staff (case manager and nurse) participated virtually. The care plan summary documented goals would continue, and the social worker would follow up with the resident as needed. The section on the form for a discharge planning meeting had a box for appointment date/time and was left blank. The form was not signed or dated and the person completing it was not identified.The 12/26/2025 at 3:46 PM Licensed Practical Nurse #6 progress note documented the resident was alert and responsive, morning care rendered, ate breakfast and lunch. All care was provided. By 2:30 PM, the resident was discharged to the group home via ambulette in stable condition. No distress noted. Review of Resident #188's electronic medical record revealed no documented evidence of a plan for discharge. There was no discharge summary by a medical provider. There were no social work notes regarding the discharge. The physical therapy and occupational therapy notes documented Resident #188 received services from 12/03/2025 to 12/24/2025 and were signed off on 12/29/2025 documenting the resident was discharged to the hospital.The Skilled Nursing Facility (SNF) to Hospital Transfer Form (form that is given to the transporter to take to the hospital) dated 12/26/2025 at 1:00 PM, completed and reviewed by Director of Nursing #1 documented the reasons for transfer was behavioral symptoms (e.g. agitation, psychosis). The form documented the primary reason was not for diagnostic testing. Risk alerts included agitation with risk to harm self or others and high fall risk. Resident #188 was transferred to the hospital at 1:00 PM. The resident's guardian (family member) was notified of transfer and of the clinical situation, and report was called to the hospital Emergency Room.The Transfer/Discharge Notice (form for a facility-initiated transfer or discharge) dated 12/26/2025 documented the Designated Representative was Nurse followed by the first name of Group Home Registered Nurse #1 to inform them that the interdisciplinary team determined the resident would be discharged on 12/26/2025 to the hospital. The form documented the transfer/discharge notice was issued as: 1) the resident's needs could not be met after reasonable attempts at accommodation in the facility as evidenced by: (line left blank for reason); and 2) The safety of individuals in the facility would be endangered, as evidenced by: resident's behavior. The resident's signature section on the form documented unable to sign. The Resident Representative signature documented verbal call over the phone with a phone number and no name of the representative. The Facility Representative signature was Director of Nursing #1. The form documented the Designated Representative was informed on 12/26/2025. The dates for mailing the form to the Designated Representative, the New York State Ombudsman and the Family Member were all left blank.During an interview on 03/11/2026 at 4:16 PM, Resident's Guardian #1stated they were told Resident #188 was sent to the hospital for magnetic resonance imaging. The resident got there and did not have an appointment and was in the Emergency Room. The nursing home had packed the resident's belongings and sent them to the hospital with the resident. Resident's Guardian #1 stated they went to the hospital and took the resident home since the nursing home was not taking them back, and the group home could not accommodate since the resident was in a wheelchair and could not walk.During interviews on 03/12/2026 at 9:04 AM and 10:50 AM, Director of Nursing #1 stated Resident #188 was transferred on 12/26/2025 to the hospital for magnetic resonance imaging. Director of Nursing #1 stated Resident #188 lived in a group home prior to their hospitalization and admission to the facility. The group home Medical Director recommended magnetic resonance imaging prior to the resident returning to the group home. Director of Nursing #1 stated the hospital was informed and resident's representative was also notified that the resident was transferred to the hospital for magnetic resonance imaging. Director of Nursing #1 stated that the plan was for Resident #188 to go to the hospital for magnetic resonance imaging and when it was completed, the group home would be responsible for the resident. The plan was for Resident #188 to go back to the group home and not return to the nursing home.During an interview on 03/12/2026 at 11:25 AM, the Corporate Regional Director of Nursing #1 stated that Resident #188 should not have been discharged that way and it was not a safe discharge. They stated there was no plan for Resident #188 to return to the nursing home after the magnetic resonance imaging.During an interview on 03/12/2026 at 12:54 PM, Licensed Practical Nurse #6 reviewed their nursing note dated 12/26/2025 at 3:46 PM and stated they were misinformed that Resident #188 was discharged to group home. They found out later that the resident was transferred to the hospital and not the group home.During a phone interview on 03/13/2026 at 9:33 AM, Group Home Registered Nurse #1 stated that they knew the facility was sending the resident to the hospital for magnetic resonance imaging but did not know that the resident was not going back to the facility. Group Home Registered Nurse #1 stated that the Direct Support Professional #1 (group home aide providing 1:1 supervision) called them from the hospital and stated they arrived at the outpatient desk and were told the outpatient department had not received report that the resident was coming and did not have orders for any testing for Resident #188. Group Home Registered Nurse #1 stated they then spoke with the outpatient hospital desk staff member and was told they did not have an order for Resident #188 to get the magnetic resonance imaging and directed them to go to the Emergency Room. The resident's family member picked up Resident #188 from the emergency room and took the resident home with them. Group Home Registered Nurse #1 stated they were not expecting Resident #188 to come back to the group home directly after having magnetic resonance imaging because Resident #188 would have needed to be evaluated as medically stable and be able to climb stairs. They further stated that Resident #188 was not ambulatory and needed to be evaluated to be admitted to a different group home without stairs. Group Home Registered Nurse #1 stated there was no discharge meeting held, or any conversation had, or any arrangements made for Resident #188 to be transferred back to the group home after the magnetic resonance imaging at the hospital. Group Home Registered Nurse #1 stated their expectation was that Resident #188 would go back to the facility after the magnetic resonance imaging appointment. They stated they also found out Resident #188 was sent to the outpatient department with all their belongings.During an interview on 03/13/2026 at 2:49 PM, the Director of Social Services stated they started in their position on 12/21/2025. They did know much about Resident #188 and had no interaction with the resident. They stated the process for discharging a resident would be to have an interdisciplinary discharge planning meeting between the facility and staff from the group home. The discharge plan meeting would include discussions on medical clearance by the physician, medications, transportation arrangements and escort. The Director of Social Services stated they were not aware that the resident was going to the hospital on [DATE] and that their belongings were sent with them.During an interview on 03/13/2026 at 3:09 PM, Social Worker #10 stated they were not working on 12/26/2025 when Resident #188 was sent to the hospital. They stated they were not involved in discharge planning. They reviewed the Interdisciplinary Team Meetings and Evaluation form and confirmed a meeting did take place on 12/18/2025 and the form was completed by former Director of Nursing #2.During a follow-up interview on 03/13/2026 at 3:27 PM, Director of Nursing #1 stated Resident #188 was not appropriate for nursing home placement. Resident #188 had 1:1 supervision provided by the group home 24 hours/day, was cognitively impaired, unpredictable, aggressive and was hard to manage. Director of Nursing #1 stated they reached out to Group Home Registered Nurse #1 and was told Resident #188 needed magnetic resonance imaging prior to admission back to the group home. Director of Nursing #1 stated they told the clerk to schedule the magnetic resonance imaging and arrange for transportation. Director of Nursing #1 stated they called Physician #1 for magnetic resonance imaging order but did not enter the order on the computer.During a phone interview on 03/13/2026 at 4:20 PM, Nurse Practitioner #1 stated Resident #188 was from a group home and they saw the resident on 12/04/2025 as a new admission and one (1) or two (2) other times. Nurse Practitioner #1 stated they had not attended a meeting for a discharge planning for Resident #188. They stated they were aware the resident needed magnetic resonance imaging, but were not aware that the resident was going on 12/26/2025.During a phone interview on 03/13/2026 at 4:35 PM, Physician #1 stated Resident #188 was at the facility for rehabilitation and had difficulty ambulating due to a spine issue. They stated Resident #188 did not follow instruction, was not a candidate for rehabilitation, and could not participate in rehabilitation as they could not follow directions. They stated they were not aware the resident needed magnetic resonance imaging, did not give an order for it, and they were not involved with Resident #188's discharge planning. They stated they were not asked to provide medical clearance for Resident #188 to go back to the group home. They stated Resident #188 should not have been sent to the hospital; it was inappropriate for the resident to be sent to the hospital for magnetic resonance imaging without an order and in consideration of the resident's behavior and inability to cooperate.10 New York Codes, Rules and Regulations 415.3(i)(1)

Based on observations and interviews conducted during the recertification survey from 03/09/2026 to 03/13/2026, the facility did not store, prepare and serve food in accordance with professional standards for food service safety. Specifically, 1) unlabeled and undated food were stored in the kitchen and unit pantry refrigerators, and 2) expired foods were stored in the kitchen and unit pantry refrigerators.The findings are: The facility policy titled Food Service and revised 05/10/2024 documented all foods should be covered, labeled and dated. Date marking to indicate the date or day by which to consume will be visible on all food.The facility policy titled Food - From Outside revised 07/12/2023 documented food brought by family/visitors that is left with the resident to consume later will be labeled, (label will identify resident name, room number, item, date received and discard date). All refrigerated foods will be discarded within 48 hours.During the initial tour of the kitchen on 03/09/2026 at 6:24 AM with morning cook #5 an observation was conducted of the kitchen refrigerators of 16 sandwiches and full pan of cooked peas unlabeled and undated. The following food items were found expired: 30 cups of jello dated 02/03/2026, 20 cups of jello dated 02/26/2026, 15 cups of jello dated 03/05/2026, pan of peaches dated 02/28/2026, and the following foods all with expired date of 03/05/2026: pan of quiche, pan of chopped lettuce, pan of prepared tuna salad, and pan of prepared egg salad.During the initial tour the Food Service Director arrived and was interviewed at 6:44 AM. They stated they were not sure why the expired food had not been discarded, that all staff were responsible for removing expired food, and that all staff had been educated on labeling and dating food. During an observation on 03/09/2026 at 7:11 AM of the unit 3 resident refrigerator the following unlabeled and undated food items were observed: pizza box, soup, cinnamon roll in a baggie, a peanut butter and jelly sandwich, pasta, a Styrofoam container of vegetables from the facility kitchen, a grocery bag of Chinese food, and an expired salad dated 03/05/2026. The freezer contained a medical ice pack in a plastic bag. At that time the Food Service Director stated the nursing staff were responsible for labeling and dating the food when it is stored in the refrigerator and that they also discard expired food. The housekeeping staff were responsible for cleaning the refrigerator. 10 NY CRR 415.14(h)

Based on observations, interviews, and record review conducted during the recertification survey from 03/09/2026 to 03/13/2026, the facility did not ensure residents received care consistent with professional standards of practice to prevent and promote healing of pressure ulcers for one (1) of six (6) residents (Resident # 14) reviewed for pressure ulcers. Specifically, Registered Nurse #2 did not adhere to the physician orders for the treatment of Resident #14's pressure ulcer by omitting a topical medication and applying a dressing that was not ordered.Findings Include:The facility policy Pressure Ulcer Treatment revised 11/2024, documents to apply dressing/treatment according to the manufacturers direction, care plan and the physician order.Resident #14 had diagnoses of paraplegia, anemia and type 2 diabetes. The quarterly Minimum Data Set (an assessment tool) dated 11/24/2025 documented Resident #14 was at risk for pressure injuries and had three stage 4 pressure ulcers.The physician's order dated 01/26/2026 documented to apply Santyl External Ointment (Collagenase) to their left distal lateral foot every day shift for pressure wound.During a dressing change observation on 03/11/2026 at 10:54 AM, Registered Nurse #2 was observed cleansing Resident #14's left foot wound with normal saline solution, then applied a Xeroform dressing, and wrapped the dressing with gauze and kling.During an interview on 03/11/2026 at 11:20 AM, Registered Nurse #2 stated they did not check the physician order before going into Resident #14's room. They stated that the floor nurses usually changed the dressing. They stated that they normally took the computer with them, but they did not because they did not want to hold the surveyor up.During an interview on 03/11/2026 at 11:45 AM, the Director of Nursing stated that there was no excuse for Registered Nurse #2 to not follow the physician order and they did not know why this happened. Additionally, they stated that all nurses received a competency on wound care upon hire during their orientation. 415.12(c)(1)

Based on observations and interviews conducted during the recertification survey from 03/09/2026 to 03/13/2026, the facility did not ensure daily nurse staffing was posted in an area accessible to all residents and visitors. Specifically, the posting of daily nurse staffing for all nursing staff working in the facility on each shift was not displayed for the date of 03/08/2026.Findings include:During an observation on 03/09/2026 at 6:10 AM, the nurse staffing posted in the lobby of the facility was dated 03/07/2026. There was no observed nurse staffing posted for 03/08/2026.During an interview on 03/13/2026 at 10:20 AM, the Director of Nursing stated that the overnight nurse supervisor was responsible for posting the nurse staffing for the day. They stated they did not know why the nurse staffing was not posted on the bulletin board in the lobby for 03/08/2026.During an interview on 03/13/2026 at 11:28 AM, Registered Nurse Supervisor #8 stated it was their responsibility to post the nurse staffing on the bulletin board in the lobby. They stated they completed the form on the morning of 03/08/2026 but left the form in the nursing supervisor's office.

Based on record review and interview conducted during the recertification and abbreviated surveys (485232, 2704152) from 3/09/2026-3/13/2026, the facility did not ensure that the resident's legal representative upon written request, was provided with a copy of the resident's health care record within two (2) working days for one (1) of (2) residents (Resident #188) reviewed for discharge and one (1) of four (4) residents (Resident #74) reviewed for notification of change. Specifically, 1) Resident #74's Health Care Proxy requested health care records on 3/18/2025 and the records were not provided until 6/03/2025; and 2) Resident #188's legal guardian requested health care records on 12/29/2025 and there was no documented evidence the records were provided.Findings include:The facility's policy and procedure titled Medical Records Request last revised 11/2025 documented authorized requests of medical records will be made in accordance with current applicable laws. The Administrator will be notified of all requests for the release of medical records. The Administrator will ensure that written authorization for the release of medical records is received. The Medical Record staff person will make two (2) copies of the medical record. One copy of the record will be sent via FedEx/Registered mail or secure mail to the authorized person making the request when records are ready.1) Resident # 74 was admitted to the facility with diagnoses including cerebral infarction, dementia, and diabetes.The 12/15/2025 Minimum Data Set (an assessment tool) documented the resident had moderate cognitive impairment.The 3/18/2025 Authorization for Release of Health Information form documented Resident #74's resident representative requested the health care records of Resident #74 from 1/1/2024 to 3/18/2025. The health care records were provided to Resident #74's representative on 6/3/2025, more than 2 months after the representative's request.2) Resident #188 was admitted with diagnoses including disease of spinal cord, autistic disorder and severe intellectual disabilities.The 12/10/2025 Minimum Data Set documented Resident #188 was not interviewed for Brief Interview for Mental Status (cognitive test); the resident was rarely/never understood and had unclear speech.The 12/29/2025 Authorization for Release of Health Information form documented Resident #188's legal guardian requested Resident #188's health care records for the time period of 12/02/2025 - 12/26/2025.During an interview on 03/13/2026 at 12:02 PM, the Director of Medical Records stated when they received requests for medical records, they informed the Administrator, prepared the medical records requested, and sent them to the resident's representative. They acknowledged they received request from Resident #74's representative dated 3/18/2025. They stated they made copies and sent them via email on 6/03/2025 as per representative's request. The Director of Medical Records provided a copy of an email sent to Resident #74's representative that confirmed medical records were sent on 6/03/2025. The Director of Medical Records stated that on 01/07/2026, the facility informed Resident #188's legal guardian that Resident #188's medical records were ready with a cost of $289.50 for electronic and photocopying. The Director of Medical Records stated Resident #188's legal guardian changed their mind after learning of the cost and decided to only request the 12/26/2025 records. The Director of Medical Records was unable to provide documented evidence that the health care record for 12/26/2025 was provided to Resident #188's legal guardian. The Director of Medical Records further stated they were not aware there was a specific time period to respond to requests for medical records.During an interview on 3/13/2016 at 2:57PM, the Administrator stated they received mail from resident representatives requesting medical records. They stated the medical records were prepared by the Director of Medical Records and provided to the resident representative as soon as the records were ready. The Administrator was unable to provide a specific timeline as to when records had to be provided to resident representatives.10 NYCRR 415.3(d)(1)(iv)

Based on observations, record reviews and interviews during the recertification and abbreviated surveys (2625787) from 03/09/2026 through 03/13/2026, the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary care and services for 1 of 6 residents (Resident #138) reviewed for Activities of Daily Living. Specifically, Resident #138 was observed eating lunch lying in bed with head in a low position. The findings included: A facility policy titled Meal Service Process: Delivery, Set-up, Assistance, and Documentation last revised 12/15/2025 documented: The facility provides a safe and person-centered meal service to residents. The resident should be positioned/seated in an upright position so their -head and upper body are as upright as possible. Assist the resident with meal/tray set up as needed and requested. Resident #138's diagnoses included diabetes mellitus, bilateral above knee amputation, and dyspnea. A quarterly Minimum Data Set (a resident assessment tool) dated 01/08/2026 documented Resident #138 had moderate cognitive impairment, required moderate assistance from lying to sitting position, independent for feeding self, and dependent for transfer by mechanical lift. The resident care plan focus documented: Assistance with self-care and mobility related to fatigue, limited mobility related to bilateral above knee amputation and limited range of motion dated 04/15/2025 documented interventions included set up/clean-up for eating. The 02/27/2026 email from Resident #138's wife stated a need for a bed that could allow Resident #138 to sit upright when eating. During an observation and interview on 03/09/2026 at 11:49 AM Resident #138 was in bed lying flat. They stated the back of their bed did not tilt up so that they could sit up straight, when in bed they were mostly positioned lying flat. Resident #138 stated they had reported this to the nursing staff about a month ago and they were waiting for maintenance to repair the bed. During an observation on 03/09/2026 at 12:45 PM Resident #138 was in bed eating lunch lying with head in a low position spilling food over their chest while moving the utensil horizontally across their body to their mouth. During an interview on 03/13/2026 at 8:30 AM Certified Nurse Aide #7 described procedure for setting residents up for meals when eating in the dining room or in their room, including sitting residents upright when eating or when being fed. During an interview on 03/13/2026 at 8:35 AM the Director of Nursing stated the procedure for residents eating in bed is to set the residents up at 90 degrees for safe eating. 10 NYCRR 415.12 (a)(3)

Based on observation, record review and interviews during the recertification and abbreviated surveys (2702513) from 3/9/2026 to 3/13/2026, the facility did not ensure that each resident received the proper respiratory treatment and care consistent with professional standards of practice for two (2) (Residents #187 and #102) of four (4) residents reviewed for respiratory care. Specifically, 1) the facility did not ensure that a physician's order for continuous positive airway pressure settings and administration parameters was in place for Resident #187 who was reportedly using a continuous positive airway pressure (CPAP) machine; and 2) Resident #102 did not receive the correct flow rate of oxygen therapy based on the physician's order and care plan.The findings include: The Policy and Procedure titled Airway Pressure Support dated 12/2/2024, documented the facility follows current standards of practice in the care of residents requiring airway pressure support devices, to improve respiratory function in residents with respiratory conditions and/or obstructive sleep apnea. Device use will be performed in accordance with the state Nurse Practice Act scope of practice for Registered Nurses and Licensed Practical Nurses. A Physician's order is required. The order should include all settings and delivery route. 1.Resident #187 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease, respiratory failure and obstructive sleep apnea. The Minimum Data Set (resident assessment) dated 9/27/2025 documented the resident had intact cognition and received oxygen therapy. The Hospital Discharge summary dated [DATE], documented Resident #187's discharge plan, which included diagnoses of chronic obstructive pulmonary disease and obstructive sleep apnea. The discharge summary documented the use of a continuous positive airway pressure machine. The Physician's Orders dated 9/24/2025 documented that Resident #187 required the use of a continuous positive airway pressure machine at night related to a history of obstructive sleep apnea. The order did not have specific scheduling details and did not include continuous positive airway pressure machine settings or administration parameters. The Treatment Administration Records and Medication Administration Records dated October 2025 through January 2026 revealed no documented evidence of an order for or administration of a continuous positive airway pressure machine. The Physician Progress Notes dated October 2025 through January 2026 documented in the Assessment and Plan included acute hypoxemic respiratory failure and continuous positive airway pressure use at night related to a history of obstructive sleep apnea. During a phone interview on 3/12/2026 at 4:08 PM, Nurse Practitioner #1 stated that initiation of continuous positive airway pressure treatment required a physician order. Nurse Practitioner #1 stated that the order should include the machine settings and delivery route, and nursing staff were responsible for documenting the procedure in the resident's clinical record. Nurse Practitioner #1 stated that they had observed Resident #187 using continuous positive airway pressure machine in their room and could not recall specific details regarding continuous positive airway pressure treatment for this resident. During an interview on 3/13/2026 at 9:03 AM, Licensed Practical Nurse #3 stated that continuous positive airway pressure machines were provided with specific settings, and the order for the machine, including the settings, should be placed in the Treatment Administration Record so nurses could verify the machine settings with the physician order and document the procedure. Licensed Practical Nurse #3 stated that they could not recall whether Resident #187 had a continuous positive airway pressure machine. During an interview on 3/13/2026 at 3:36 PM, the Director of Nursing stated that the nurse practitioner's order was entered as a general order, did not include scheduling details, and was not triggered in the system to populate in the Treatment Administration Record for nursing staff to sign off on treatment administration. The Director of Nursing stated that nurses did not ensure that physician orders for respiratory treatment were complete, accurately entered into the electronic system, and properly transferred to the Treatment Administration Record for nursing documentation, which created the potential for treatment to be provided without verification of physician-prescribed parameters and without documentation of administration. 2.Resident # 102 was admitted with diagnoses of Chronic Obstructive Pulmonary Disease, Vascular Dementia and Chronic Kidney Disease. The 6/04/2025 Annual Minimum Data Set documented Resident # 102 had severe impaired cognition and was on oxygen therapy The 01/27/2026 physician order documented supplemental oxygen via nasal cannula at 2 Liters per minute every shift for hypoxia, check oxygen saturation every shift. The care plan updated on 2/2026 documented at risk for/has alteration in respiratory system related to Chronic Obstructive Pulmonary Disease with goal that resident will receive adequate oxygenation as evidenced by acceptable pulse oximetry level. Interventions included but not limited to provide oxygen per physician's orders. Maintain/change tubing per protocol. care plan updated10/25, 11/25,2/26 During observational rounds on 3/9/3026 at 8:41AM and 12:40PM, 3/10/2026 at 11:57AM, Resident was observed with oxygen via nasal cannula at 3.5 liters via concentrator. During observational round with the Unit Manager on 3/11/2026 at 11:47AM, resident was observed in room with oxygen via nasal cannula at 3.5 liters via bedside concentrator. On 3/11/2026 at 11:51AM, Licensed Practical Nurse Unit Manager #4 and surveyor checked the physician's order for Resident #102. Licensed Practical Nurse Unit Manager #4 confirmed the physician's order documented supplemental oxygen via nasal cannula at 2 liters per minute every shift for hypoxia. Licensed Practical Nurse Unit Manager #4 also checked Resident # 102's Treatment Administration Record dated 3/01/2026 – 3/10/2026 and confirmed that oxygen via nasal cannula at 2 liters per minute every shift was documented. Licensed Practical Nurse Unit Manager #4 stated they were ultimately responsible for checking residents on oxygen therapy to make sure they got the correct rate of oxygen as per physician's order. Licensed Practical Nurse Unit Manager #4 further stated Resident # 102 did not receive the correct rate of oxygen and the physician's order was not followed. On 03/11/2026 12:06 PM Director of Nursing stated that the Unit Manager or Charge Nurse were responsible for unit day-to-day operations. The unit manager was responsible in making sure residents got the correct oxygen as per physician's order. 415.12(k)(6)

Based on observation, record review and interview during the recertification survey conducted 03/09/2026 through 03/13/2026, the facility did not ensure proper disposal of garbage and refuse. Specifically, 1) the recycle dumpster had been left open and there were cardboard boxes spilling over the top onto the surrounding ground, and 2) the compactor door had been left open.The findings are:The facility policy titled Garbage - Food and Refuse Disposal revised 12/2020 documented, outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter.During an observation of the garbage area on 03/11/2026 at 12:11 PM with the Food Service Director, the recycle dumpster was open with cardboard boxes spilling over the top. There were observed boxes, a plastic bag of cans, and other litter on the ground surrounding the dumpster and trapped under it. During an observation of the compactor at the same time, the door was held in an open position with the door holding chain. During an interview at that time, the Food Service Director stated the entire facility used both the compactor and the recycle dumpster. They stated the kitchen staff had been educated to close the door to the compactor after use and to break down the boxes to fit into the recycle dumpster. All departments in the facility were responsible for keeping the area clean, and garbage picked up. They believed garbage pickup service was completed a few times a week. 10 NYCRR 415.14(h)

Based on observations and interviews conducted during the recertification and abbreviated surveys (2625787) from 03/09/2026 to 03/13/2026, the facility did not ensure that essential equipment was maintained in a safe and operating condition for one (1) (Resident #138) of four (4) residents reviewed for the environment. Specifically, Resident #138's bed was broken and could not be inclined beyond 30 degrees.The findings include:The facility policy titled Maintenance Services reviewed 05/2025 documented the facility provides maintenance services to the equipment in accordance with current standards of practice and State and Federal Regulations; and is responsible for maintaining equipment in a safe and operable manner.During an observation and interview on 03/09/2026 at 12:45 PM, Resident #138 was attempting to feed themself lunch while lying in bed. Resident #138 was positioned lying back at about a 30-degree incline and spilling food over their chest while moving the utensil horizontally across their body to their mouth. Resident #138 stated their bed had been broken in this position for about a month, they stated they told the nurse, but maintenance had not repaired it yet. At that time the Director of Nursing was on the unit and they were notified of the broken bed. The Director of Nursing arrived to Resident #138's room and stated the bed was not broken and the back needed to be raised to a more upright position. They attempted to increase the incline with the bed control but it did not work. The Director of Nursing stated they would get some pillows to prop Resident #138 up to eat in a safe manor but then decided to use the mechanical lift to move Resident #138 out of bed and into their wheelchair to eat lunch. During a follow up observation at 12:53 PM, Resident #138 was seated in their wheelchair eating lunch without difficulty. The Director of Maintenance arrived to the Resident's room to evaluate the bed.During an interview on 03/09/2026 at 3:46 PM the Director of Maintenance stated Resident #138's bed had to be replaced because it was not inclining to 90 degrees. During an interview on 03/13/2026 at 8:35 AM the Director of Nursing provided an email from Resident #138's wife dated 02/27/2026 that stated a need for a bed that could allow Resident #138 to sit upright.During an interview on 03/13/2026 at 10:58 AM the Director of Maintenance stated staff in the facility would notify them verbally of a work order request either by walkie talkie or the work log request book. The Director of Maintenance stated they checked the log book daily in the morning and afternoon. They were not notified of Resident #138 broken bed until 03/09/2026 when the Department of Health surveyor made the facility aware. The Director of Maintenance stated they tried to address equipment or other concerns immediately. 10 NYCRR 415.29

Based on record reviews and interviews conducted during a Abbreviated Survey, the facility did not ensure that all alleged violations including injuries of unknown origin were reported to the Department of Health immediately, but not later than 2 hours after the allegation if the events that caused the allegation result in serious bodily injury, or not later than 24 hours if the event that cause the allegation do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey agency) in accordance with the State law through established procedures, and report the results of all investigations to other officials (including to the State Survey Agency), within 5 working days of the incident for one (Resident #4) of three Residents reviewed for injury of unknown origin. Specifically, 0n 1/21/2026, Resident #4 reported right knee pain during cares and was found with swelling to the right knee. A STAT Xray was completed. The radiology report dated 01/21/2026 documented an acute non-displaced fracture of the right tibial plateau. The injury (fracture) constituted a serious bodily injury, requiring immediate reporting within 2 hours. The incident was not reported to the New York State Department of Health until 01/22/2026, exceeding the 2-hour requirement. The 5-day investigative report was not submitted until 02/09/2026, exceeding the required 5-working-day timeframe. The findings are:Resident #4 was admitted to the facility with diagnoses including, but not limited to, anemia, dementia, and hypothyroidism The 10/24/2025 Annual Minimum Data Set documented that Resident #4 had severely impaired cognition, required supervision with bed mobility, and required substantial to maximal assistance with transfers, toileting, and showers. On 01/21/2026 at 12:46 PM, the physician's order documented that a right knee x-ray was to be completed related to muscle weakness, swelling, and pain for Resident #4.The Nursing Home Investigation Form dated 01/22/2026 and submitted to the Department of Health documented the date of incident as 01/22/2026 and documented that Resident #4 was identified with an injury.On 01/21/2026 at 01:26 PM, the nursing progress note by Registered Nurse Supervisor #2 documented that on 01/21/2026 at 11:00 AM, while being turned and positioned Resident #4 was observed guarding their right knee and complaining of pain. Swelling to the right knee was observed. The charge nurse was called to the room, and a stat x-ray of the right knee was ordered and completed.On 01/21/2026 at 07:55 PM, the radiology report documented that the right knee x-ray identified an acute nondisplaced fracture of the right tibial plateau for Resident #4.On 01/21/2026 at 08:37 PM, the nursing Situation, Background, Assessment, Recommendation (SBAR) note documented the x-ray result identified an acute nondisplaced fracture of the right tibial plateau and included a provider recommendation to transfer Resident #4 to the hospital for further evaluation.On 01/21/2026 at 10:03 PM, the nursing progress note by Registered Nurse Supervisor #1 documented that at 10:00 PM, the physician was notified that the x-ray revealed an acute nondisplaced fracture of the right knee. Resident #4 was assessed with right knee swelling and pain. The Director of Nursing was made aware, and Resident #4 was transferred via EMS to the hospital for further evaluation.The facility's hospital transfer form documented that on 01/21/2026 at 10:11 PM Resident #4 was transferred to the hospital for further evaluation.On 01/22/2026 at 02:18 AM, the hospital after-visit summary document received by the facility upon the resident's return to the facility documented that four views of the right knee x-ray were completed and documented a questionable fracture of the lateral tibial plateau for Resident #4.On 01/22/2026 at 09:40 AM, the nursing progress note documented that Resident #4 returned from the hospital emergency department at approximately 09:20 AM. The A review of the facility submission report, the facility did not report the injury which was of unknown origin to the New York State Department of Health until 01/22/2026 at 1:20 PM more than two (2) hours after injury was identified.The facility was required to submit their investigative report to the New York State Department of Health on 01/28/2026 five working days after the injury was identified. Review of the New York State Department of Health Nursing Home Investigative Report Submission #22298 revealed the facility did not submit their investigative report of the unknown injury to the Department until 02/09/2026, thirteen (13) days after they identified the injury of unknown incident. During an interview on 02/12/2026 at 3:49 PM, the Director of Nursing stated that on 01/21/2026 Resident #4 complained of pain to the right knee, a stat x-ray was ordered and completed at the facility, and the radiology results identified an acute non-displaced fracture of the right tibial plateau. The Director of Nursing stated that the physician was notified of the x-ray results on 01/21/2026 and gave an order for Resident #4 to be transferred to the emergency room for further evaluation. Resident #4 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. The Director of Nursing stated that the facility documented the date of incident as 01/22/2026, although the fracture was identified on 01/21/2026. The Director of Nursing stated that the facility initiated the incident report and investigative documentation upon Resident #4's return to the facility on [DATE]. The Director of Nursing stated that they were waiting for the New York State Department of Health to send confirmation of receipt of the facility's reporting of the injury. They didn't receive confirmation and sent the report of their investigation on 02/09/2026. 10 NYCRR 415.4(b)(1)(i) and (ii), 415.4(b)(5)

Based on observations, interviews, and record reviews during an Abbreviated Survey, the facility failed to thoroughly investigate injuries of unknown origin for two(2) of four(4) sampled residents (Residents #1 and #4). Specifically: 1) Resident #1: Following the discovery of a forehead hematoma, the facility failed to provide a completed investigative report. Documentation lacked staff statements from those providing care prior to the injury and failed to include a detailed description of that care. Facility staff could not provide an explanation of how the injury occurred. 2) Resident #4: After an X-ray on 01/21/2026 revealed an acute right tibial plateau fracture, the facility's investigation was incomplete. Missing elements included staff descriptions of care at the time of the incident, details on how the resident was transferred, and a formal investigative conclusion or root cause. The findings are:The facility's policy titled Accident - Incidents, documented a review date of 06/01/2024, and that The Incident/Accident Statement Form must include a list of nursing staff caring for the resident at the time of the incident and one shift prior, and any witnesses must be listed by name and a statement completed. The policy further documented that the Incident/Accident Report Form must be completed and include the required information, including identification of staff involved, statements, and a complete investigation with conclusion. 1. Resident #1 was admitted with diagnoses included but not limited to anemia, dementia, and hypothyroidism. The Annual Minimum Data Set, dated [DATE] ( an assessment tool used to assess residents) documented that Resident #1 had severely impaired cognition and required supervision with transfers and ambulation.The 12/10/2025 Nursing Home Facility Incident Report submitted to the Department of Health documented the following: Injury appears to be of unknown origin, as no staff witnessed an incident. On 12/10/2025, Resident #1 was transferred to the hospital emergency department for evaluation. During an interview on 01/29/2026 at 01:11 PM, Resident #3, roommate of Resident #1, stated that no staff member interviewed them regarding the incident in which Resident #1 was found with a hematoma to the forehead. Resident #3 stated that they were not asked to provide a written or verbal statement and were not questioned about what may have occurred. Review of the facility-provided investigation documentation did not include a statement from Resident #3, despite Resident #3 being present in the room during the timeframe in which Resident #1 was last observed prior to being found with hematoma. Additionally, the documentation did not include determination as to whether abuse, neglect, or mistreatment was considered or ruled out as part of the investigation.During an interview on 01/29/2026 at 03:49 PM, the Administrator stated that he was not the individual who initiated or completed the investigation and reported that the prior Director of Nursing was responsible for completing the investigation. The Administrator further stated that he did not review the investigation and was unable to state whether the investigation provided to the surveyor was complete. During an interview on 01/30/2026 at 02:10 PM, Director of Nursing #2 stated that the facility determined the hematoma to Resident #1's forehead identified on 12/10/2025 was an injury of unknown origin. The Director of Nursing stated that the facility's investigation consisted of statements obtained from staff working the shift during which the hematoma was identified. The Director of Nursing stated that statements were obtained from staff working that shift and that statements were not obtained from staff working prior shifts. The Director of Nursing stated that they trusted that staff would have reported if an incident had occurred prior to the injury being identified. The Director of Nursing further stated that although they held the Director of Nursing position at the time, they had recently started in the role and were still receiving orientation with the previous Director of Nursing (Director of Nursing #1) and was not responsible for initiating the investigation or submitting the final report to the New York State Department of Health. When asked to provide the completed investigation, Director of Nursing #2 stated that there was no additional documentation related to the investigation on file at the facility. The only documentation was what was submitted to the Department of Health. t 2. Resident #4 was admitted with diagnoses including, but not limited to, anemia, dementia, and peripheral vascular disease. The Annual Minimum Data Set, dated [DATE] documented that Resident #4 had moderately impaired cognition, required supervision with bed mobility, was dependent on staff for toileting and showering, and required substantial to maximal assistance with transfers. The facility's investigation report dated 01/22/2026 documented on 01/21/2026 during AM care, Resident #4 was noted to guard body during turning and positioning and complained of pain. The charge nurse was called to the room and swelling of the right knee was identified. A STAT right knee x-ray was ordered and completed, which revealed an acute non-displaced fracture of the right tibial plateau. Per physician's order, Resident #4 was transferred to the hospital for further evaluation. Physician's order dated 1/21/26 documented that a right knee x-ray was to be completed one time on 01/21/2026 at 12:46 p.m. related to muscle weakness, swelling, and pain. The radiology report dated 01/21/2026 for the right knee x-ray performed at the facility documented an acute non-displaced fracture of the right tibial plateau for Resident #4. The Hospital After Visit Summary dated 01/21/2026 documented that the reason for visit was leg injury and the diagnoses included knee pain and tibial plateau fracture. Review of the Accident/Incident Statement Forms completed by Certified Nurse Aide #5 documented that care was provided to Resident #4 and that Certified Nurse Aide #5 was assigned to Resident #4. The statements further documented that no incident was witnessed and identified one witness by name.The statements did not document the type of care provided to Resident #4, including how Resident #4 was transferred or assisted with activities of daily living at the time of the occurrence. Further review of the Accident/Incident Statement Forms showed that two statements completed by Certified Nurse Aide #5 were missing required identifying information and detail. One statement lacked the name, title, and date of the individual completing the form, and an additional statement lacked a date. Both statements did not include the shift and/or time Certified Nurse Aide #5 was assigned to Resident #4, despite indicating assignment to Resident #4. In addition, while the statements indicated that care was provided, they did not include sufficient detail to identify the specific care provided or the circumstances surrounding the injury. Review of the Accident/Incident Statement Form completed by Certified Nurse Aide #6 showed that within the section of the form that asks whether the aide was assigned to the resident and whether care was provided, Certified Nurse Aide #6 indicated no to being assigned to Resident #4 and no to providing care. However, in another section of the same form, Certified Nurse Aide #6 documented assigned aide for appointment on 01/20/2026 - yes During an interview, Certified Nurse Aide #6 stated that assistance was provided with completion of dressing and transfer of Resident #4 to the wheelchair using stand and pivot method in preparation for the outside medical appointment. Review of the Accident/Incident Statement Form completed by Certified Nurse Aide #6 showed the form did not include a description of the care or assistance provided to Resident #4, did not identify the role of Certified Nurse Aide #6 during the outside medical appointment, and did not include a description of how Resident #4 was prepared or transferred at the time of the occurrence During an interview on 02/12/2026 at 01:41 PM, Certified Nurse Aide #5 stated that on 01/20/2026, morning care was provided to Resident #4 to prepare Resident #4 to go out to an outside medical appointment with Certified Nurse Aide #6. Certified Nurse Aide #5 stated that Certified Nurse Aide #6 assisted with completion of care and transfer of Resident #4 into the wheelchair via Hoyer lift. Certified Nurse Aide #5 stated that during care there were no issues or concerns, and Resident #4 reported no pain. Certified Nurse Aide #5 stated that when Resident #4 returned from the outside medical appointment, Certified Nurse Aide #5 and Certified Nurse Aide #7 transferred Resident #4 back into bed using a Hoyer lift without incident and Resident #4 did not voice any complaints. Certified Nurse Aide #5 stated that on the following day, 01/21/2026, when assigned to Resident #4 and providing morning care, Resident #4 was guarding the right knee and complained of pain, and the complaint was immediately reported to the nurse. The Facility's Accident/Incident investigation did not include review of Resident #4's care plan related to transfer requirements, did not include an evaluation of the Hoyer lift transfer performed, and did not include interviews with staff from all shifts involved in Resident #4's care and transfer. The investigation record did not identify the transfer requirements for Resident #4 at the time of the occurrence, did not identify the staff involved in the transfer across shifts, and did not identify the circumstances surrounding the transfer to determine how the injury occurred. During an interview on 02/12/2026 at 04:47 PM, Certified Nurse Aide #6 stated assignment included escorting Resident #4 to an outside medical appointment. Certified Nurse Aide #6 stated upon entering the room, Certified Nurse Aide #5 assisted Resident 4 with dressing and Resident #4 was partially dressed. Certified Nurse Aide #6 stated assistance was provided to complete dressing and to transfer Resident #4 into a wheelchair. Certified Nurse Aide #6 demonstrated the transfer was completed using a stand and pivot method and stated a Hoyer lift was not used. Certified Nurse Aide #6 stated Resident #4 did not complain of pain at that time and Resident #4 was transported to and from the appointment in a wheelchair. Certified Nurse Aide #6 stated that during the medical appointment Resident #4 remained in the wheelchair and was not transferred in or out of the wheelchair and stated that during transport in the ambulette there were no incidents.During a follow up interview on 02/12/2026 at 05:13 PM, Certified Nurse Aide #5 stated that a mistake was made and that during the original interview there was confusion regarding when the Hoyer lift was used. Certified Nurse Aide #5 stated that Resident #4 was not transferred into the wheelchair via Hoyer lift prior to leaving for the outside medical appointment and that the transfer to the wheelchair was completed without the use of a Hoyer lift. Certified Nurse Aide #5 stated that the Hoyer lift was used upon return from the outside medical appointment to transfer Resident #4 back into bed because Resident #4 reported being tired. Certified Nurse Aide #5 stated that Resident #4 is not a Hoyer lift resident and stated being aware that at the time of the transfer Resident #4 was not identified as requiring a Hoyer lift.During an interview on 02/12/2026, the Director of Nursing stated that Resident #4 reported right knee pain on 01/21/2026 and an X-ray revealed an acute non-displaced fracture of the right tibial plateau. The Director of Nursing stated that no staff reported any incident during care or transfer and that Resident #4 returned from the outside medical appointment on 01/20/2026 without reported issues. The Director of Nursing stated that Certified Nurse Aide #5 and Certified Nurse Aide #7 reported Resident #4 was transferred with two staff using a Hoyer lift; however, the reason the Hoyer lift was used was not known. The Director of Nursing stated follow-up with staff was needed and that the Accident/Incident Statement Forms did not include the specific care provided to Resident #4. 10 NYCRR 415.12 (c)

Based on observation, record review, and interviews conducted during the Abbreviated Survey (2695368), the facility did not ensure adequate supervision and implementation of an identified intervention for one (Resident #1) of three residents reviewed for injury of unknown origin. Specifically, Resident #1, who resided on a secure unit, required supervision with ambulation and had a history of wandering and falls, was found on 12/10/2025 with a hematoma to the forehead of unknown origin. Following the incident, enhanced monitoring for safety was initiated on 12/10/2025, however, the facility was unable to demonstrate consistent implementation of the enhanced monitoring intervention. The facility provided incomplete enhanced monitoring documentation from 12/15/2025 through 01/10/2026 which contained missing staff signatures and lacked supervisory review.The findings are:The facility policy titled Safety and Supervision of Residents, revised on 02/01/2024, documented that facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors. The policy further documented that the Interdisciplinary Team (IDT) will develop targeted interventions to reduce individual resident risk factors related to identified hazards in the environment, including adequate supervision and assistive devices.Resident #1 was admitted with diagnoses including, but not limited to, anemia, dementia, and hypothyroidism.The 10/24/2025 Annual Minimum Data Set documented that Resident #1 had severely impaired cognition and required supervision with transfers and ambulation.The risk for falls care plan documented that Resident #1 was at risk for falls related to confusion, gait and balance problems, incontinence, and vertigo. Interventions included enhanced monitoring for safety initiated on 12/10/2025. The Enhanced Monitoring Rounding Tool required staff to document monitoring of the resident each shift (day, evening, and night) including the date, the identified concern, and the initials of the staff that verify that monitoring was completed.The Accident/Incident Statement Form (Involved Party) dated 12/10/2025 documented that Certified Nurse Aide #4 last provided care to Resident #1 at approximately 5:30 PM and last observed the resident in bed at approximately 6:30 PM; however, Resident #1 was later observed with a hematoma to the forehead at approximately 7:30 PM, and staff were unable to identify when or how the injury occurred.The 12/10/2025 Nursing Home Facility Incident Report submitted to the Department of Health documented the following: Injury appears to be of unknown origin, as no staff witnessed an incident. On 12/10/2025, Resident #1 was transferred to the hospital emergency department for evaluation.On 12/11/2025 at 5:43 AM, a nurse's progress note by a Registered Nurse documented that Resident #1 returned to the facility at approximately 5:35 AM following evaluation at the hospital emergency department. The progress note documented that imaging studies completed in the emergency department included a computed tomography scan of the cervical spine without contrast, a computed tomography scan of the head without contrast, X-rays of the left knee (front and side views), X-rays of the right knee (front and side views), and an X-ray of the pelvis, with no abnormalities identified. The note further documented that no new orders were received and that the resident continued on neurological checks.During an interview on 01/30/2026 at 01:03 PM, Certified Nurse Aide #1 stated that Resident #1 frequently walks around the unit and enters other residents' rooms. Certified Nurse Aide #1 stated that staff attempt to keep an eye on Resident #1, however, Resident #1 moves around the unit independently and is not continuously monitored. Certified Nurse Aide #1 stated that when staff attempt to redirect Resident #1, the resident becomes upset and resists redirection. Certified Nurse Aide #1 stated remembering that Resident #1 had a knot on the head and was unsure how the injury occurred.During an interview on 01/29/2026 at 01:08 PM, Certified Nurse Aide #2 stated that Resident #1 walks around frequently and goes into other residents' rooms. Certified Nurse Aide #2 stated that Resident #1 does not like to stay in bed and is frequently out of their room.During an interview on 01/29/2026 at 01:11 PM, Resident #3, roommate of Resident #1, stated that Resident #1 wanders in and out of the room. Resident #3 stated that they are a light sleeper and prefer the door to their room is always closed. Staff always close the door to their room after Resident #1 is placed back in bed. Resident #3 stated that as quickly as Resident #1 is placed in bed, Resident #1 gets back out of bed. Resident #3 stated that on the evening of 12/10/2025, no loud noise, thump, or sound was heard inside of the room that would indicate a fall or impact involving Resident #1.During an interview on 01/29/2026 at 01:18 PM, Licensed Practical Nurse #1 stated that Resident #1 is a wanderer and goes from room to room, and stated that Resident #1 is not on enhanced monitoring checks for safety, and is only on a wandering checklist that is signed once per shift.During an interview on 01/30/2026 at 01:46 PM, Certified Nurse Aide #4 stated that on 12/10/2025, Resident #1 was observed sleeping in the dining room and was asked if the resident wanted to go to bed. Certified Nurse Aide #4 stated the nurse placed Resident #1 back into bed; however, Resident #1 got back up shortly after being placed in bed. Certified Nurse Aide #4 stated that Resident #1 sleeps during the day because Resident #1 is up during the night and frequently walks around the unit and enters other residents' rooms. Certified Nurse Aide #4 stated that it is difficult to redirect Resident #1 when the resident goes into other residents' rooms because Resident #1 becomes upset and resists redirection.During an interview on 01/30/2026 at 02:10 PM, the Director of Nursing stated that Resident #1 ambulates independently on the unit and that no staff witnessed the incident on 12/10/2025 in which Resident #1 was found with a hematoma to the forehead of unknown origin while residing on a secured unit. The Director of Nursing stated that Resident #1 walks around the unit independently and is not accompanied by staff. During the interview, the surveyor discussed an observation in which Resident #1 was seated in the dining room with the resident's head down and forehead resting against the edge of the table while appearing to be asleep. The Director of Nursing stated that staff do not place Resident #1 in bed when the resident falls asleep in the dining room because Resident #1 does not remain in bed. The Director of Nursing reviewed the care plan with the surveyor and stated that enhanced monitoring for safety was initiated on 12/10/2025 following the incident. The Director of Nursing further stated that the investigation related to the injury of unknown origin was conducted under the previous Director of Nursing. Resident #1's record was reviewed with the Director of Nursing during the interview. Review of the care plan documented that Resident #1 required supervision with ambulation and that enhanced monitoring for safety was initiated on 12/10/2025 following the incident in which Resident #1 was found with a hematoma to the forehead.The Director of Nursing provided enhanced monitoring intervention documentation for Resident #1 from 12/15/2025 through 01/10/2026. Review of the Enhanced Monitoring Rounding Tool identified multiple instances where required staff initials were missing and the Unit Manager/Supervisor signature line located at the bottom of the monitoring tool was blank, which demonstrated that the facility was inconsistent in utilizing and verifying the completion of the enhanced monitoring intervention for Resident #1. 10 NYCRR 415.12(h)

Based on record review and interviews conducted during the Abbreviated Survey (2622688), the facility did not ensure that the resident's family representative was notified of a change in condition for one (Resident #1) of three residents reviewed for notification of changes. Specifically, on 08/29/2025, Resident #1's family representative observed redness to Resident #1's right eye. The Family representative reported the observation to facility staff and was informed that the redness was due to an allergic reaction to medication the issue had already been addressed by the physician. There was no documented evidence that nursing staff identified or assessed the redness prior to the family representative' observation. There was no documented evidence that the resident's representatives were notified of the change in condition prior to the report from the family representative.The findings include: The facility policy titled Notification of Change, revised 07/07/2025, stated that the nurse will notify the resident, resident representative, and the resident's physician promptly of significant changes in condition, including the development of new symptoms or changes requiring treatment. Resident #1 was admitted with diagnoses including but not limited to dementia, anemia, and systemic lupus erythematosus. The 07/26/2025 Quarterly Minimum Data Set documented that Resident #1 had severe impaired cognition and the resident required extensive assist of one person with toileting, showering, and personal hygiene. Record review showed that on 08/29/2025, ciprofloxacin ophthalmic drops were ordered for Resident #1's right eye. There was no documented assessment to support the reason for the order, and no nursing documentation indicating when the redness was first observed or reported to the physician. During an interview on 10/29/2025 at 01:27 PM, the Assistant Director of Nursing stated that they were not aware of any documentation showing that the resident's family was notified of the red eye, and that staff should have observed and reported any changes in condition. During an interview on 10/29/2025 at 03:07 PM, the Regional Director of Nursing stated that if a resident with dementia is being assisted with daily care, staff should have observed and reported a change such as a red eye. The Regional Director of Nursing stated that the family should not have been the first to identify the change in condition that led to the initiation of ciprofloxacin ophthalmic drops (antibiotic eye drops). During an interview on 10/29/2025 at 03:28 PM, Registered Nurse Supervisor #1 stated that they were informed by a nurse that the family representative was upset regarding the appearance of Resident #1's right eye. Registered Nurse Supervisor #1 stated that when they spoke with the family representative, they were asking about an antibiotic for the eye that another nurse had told them was prescribed for the resident. Registered Nurse Supervisor #1 stated they were not aware of any redness or concerns with Resident #1's right eye prior to been contacted by the nurse. Registered Nurse Supervisor #1 stated they initiated the antibiotic order because the family representative was agitated, and they were attempting to address the concern. Registered Nurse Supervisor #1 stated they did not complete or document a nursing assessment of the resident prior to entering the order.During an interview on 10/29/2025 at 05:16 PM, the family representative stated that when they visited on 08/29/2025, they observed that Resident #1's right eye was red and reported this to the nurse. The family representative stated that the nurse informed them that the redness was already addressed, that the resident had an infection related to an allergic reaction to medication, and that the issue had been handled. The family representative stated that they had not been contacted by staff prior to their visit about any redness or change in the resident's condition. 10NYCRR 415.3

Based on record review and interviews conducted during the Abbreviated Survey (2622688), the facility did not ensure that all alleged violations involving abuse and neglect are reported not immediately but not later than 2 hours after the allegation is made if the events that caused the allegation involve abuse or results in serious bodily injury, or not later than 24hours if the events that cause the allegation do not result in serious bodily injury to the administrator of the facility and to other officials including the State Survey Agency for one (1) resident (Resident #1) of three (3) reviewed for abuse. Specifically, on 09/12/2025, Resident #1's family representative informed the facility that Resident #1 had been punched in the face by another resident. The facility's investigation form and progress notes revealed that a report was received on 09/12/2025 from the family representative and an investigation was initiated on 09/13/2025. There was no documented evidence that the allegation was reported to the New York State Department of Health or local law enforcement. The Facility did not report the results of the investigation within 5 working days of the incident.The findings include: The Facility's Abuse Policy revised on 07/18/2025 documented that the Administrator or Director of Nursing is required to notify the appropriate State Agency and local law enforcement immediately, no later than two hours after an allegation of abuse is identified. The policy also required that the legal guardian or responsible family member and the physician be notified without delay, and that an investigation be initiated, including completion of the facility's investigation form, interviews with the reporter and witnesses, review of the resident's record, and documentation of findings. The policy stated that the Administrator or Director of Nursing is responsible for ensuring that all alleged violations are fully investigated and that the results are reported to the proper authorities as required by State law. Resident #1 was admitted with diagnoses including but not limited to dementia, anemia, and systemic lupus erythematosus. The 07/26/2025 Quarterly Minimum Data Set (MDS) documented that Resident #1 had severe impaired cognition. Review of Resident #1's medical record, including progress notes and the facility's investigative form dated 09/13/2025, revealed that the facility first became aware of an allegation of resident-to-resident physical abuse involving Resident #1 on 09/12/2025 when the complainant reported that Resident #1 had been punched in the face by another resident. There was no documentation that the allegation was reported to the New York State Department of Health within 24 hours or at any time thereafter. The facility's Investigative Form dated 09/13/2025 documented that the incident was categorized as an allegation of resident-to-resident physical abuse. The form stated that the family representative reported that another resident had punched Resident #1 in the face, and that the allegation had been referred to the Assistant Director of Nursing. There was documentation on the form indicating the incident was reported to the State Survey Agency. No documentation was provided during the survey to show that any report was submitted to the New York State Health Department. During an interview on 10/29/2025 at 01:27 PM, the Assistant Director of Nursing stated that they were aware of the allegation of abuse made on 09/12/2025. The Assistant Director of Nursing stated that they were responsible for initiating the internal investigation and acknowledged that the incident should have been reported to the New York State Health Department. During an interview on 10/29/2025 at 05:01 PM, the Director of Nursing stated that all allegations of abuse are required to be reported to the Department of Health, and that the Administrator is responsible for submitting the report. The Director of Nursing stated that there was no documentation showing that the allegation involving Resident #1 was ever reported. During an interview on 10/29/2025 at 05:16 PM, the complainant stated that they notified the facility on 09/12/2025 that two residents had reported that Resident #1 was punched in the face by another resident. The complainant stated that they contacted law enforcement because they believed that Resident #1 was not safe, and that the facility did not report the allegation to the Department of Health. 10 NYCRR 415.4(b)(1)(ii)

Based on record review and interviews conducted during an abbreviated survey (2622688), the facility did not report to the State Agency an alleged violation of abuse against a resident who is receiving care from the facility no later than 24hours if the events that cause the suspicion did not result in serious bodily injury for one(1) Resident #1 of three (3) residents reviewed for abuse. Specifically, on 09/12/2025, Resident #1's family representative informed the facility that Resident #1 was punched in the face by a peer. The facility's investigation form and progress notes revealed the report from the family representative was received on 09/12/2025 receiving the information from the family representative. The Facility provided documentation of an investigation initiated on 9/17/2025. There was no documented evidence that the allegation was reported to the New York State Department of Health or local law enforcement. The Facility did not report the results of the investigation within 5 working days of the incident.The findings include: The Facility's Abuse Policy revised on 07/18/2025 documented that the Administrator or Director of Nursing is required to notify the appropriate State Agency and local law enforcement immediately, no later than two hours after an allegation of abuse is identified. The policy also required that the legal guardian or responsible family member and the physician be notified without delay, and that an investigation be initiated, including completion of the facility's investigation form, interviews with the reporter and witnesses, review of the resident's record, and documentation of findings. The policy stated that the Administrator or Director of Nursing is responsible for ensuring that all alleged violations are fully investigated and that the results are reported to the proper authorities as required by State law. Resident #1 was admitted with diagnoses including but not limited to dementia, anemia, and systemic lupus erythematosus. The 07/26/2025 Quarterly Minimum Data Set (MDS) documented that Resident #1 had severe impaired cognition. Review of Resident #1's medical record, including progress notes and the facility's investigative form dated 09/13/2025, revealed that the facility first became aware of an allegation of resident-to-resident physical abuse involving Resident #1 on 09/12/2025 when the complainant reported that Resident #1 had been punched in the face by another resident. There was no documentation that the allegation was reported to the New York State Department of Health within 24 hours or at any time thereafter. The facility's Investigative Form dated 09/13/2025 documented that the incident was categorized as an allegation of resident-to-resident physical abuse. The form stated that the family representative reported that another resident had punched Resident #1 in the face, and that the allegation had been referred to the Assistant Director of Nursing. There was documentation of the form indicating the incident was reported to the State Survey Agency. No documentation was provided during the survey to show that any report was submitted to the New York State Health Department. During an interview on 10/29/2025 at 01:27 PM, the Assistant Director of Nursing stated that they were aware of the allegation of abuse made on 09/12/2025. The Assistant Director of Nursing stated that they were responsible for initiating the internal investigation and acknowledged that the incident should have been reported to the New York State Health Department. During an interview on 10/29/2025 at 05:01 PM, the Director of Nursing stated that all allegations of abuse are required to be reported to the Department of Health, and that the Administrator is responsible for submitting the report. The Director of Nursing stated that there was no documentation showing that the allegation involving Resident #1 was ever reported. During an interview on 10/29/2025 at 05:16 PM, the complainant stated that they notified the facility on 09/12/2025 that two residents had reported that Resident #1 was punched in the face by another resident. The complainant stated that they contacted law enforcement because they believed that Resident #1 was not safe, and that the facility did not report the allegation to the Department of Health. 10 NYCRR 415.4(b)(1)(ii)

Based on record review and staff interviews conducted during the Abbreviated Survey (2622688), the facility did not ensure that Resident #1's Comprehensive Care Plan was revised to include measurable, resident-specific interventions specifically reflecting a change in condition involving right-eye redness that resulted in the initiation of antibiotic eye drops. Specifically, Ciprofloxacin(antibiotic) ophthalmic drops were ordered on 08/29/2025 and initiated on 08/30/2025 for the resident's right-eye redness. The Comprehensive Care Plan was not revised to include interventions related to the new treatment and the change in condition. Resident #1's comprehensive care plan interventions was last update 01/23/2025 which addressed a prior influenza related infection. There was no documented evidence of the current condition reported on 08/29/2025. The findings are: The facility's policy titled Care Plans - Comprehensive (revised 10/2019 and reviewed 08/02/2024) documented, Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. Resident #1 was admitted with diagnoses including but not limited to dementia, anemia, and systemic lupus erythematosus. The Quarterly Minimum Data Set, dated [DATE] documented that Resident #1 had severe impaired cognition. The Physician's order dated 08/29/2025 documented that Resident #1 was to receive Ciprofloxacin ophthalmic drops for right-eye redness, to begin on 08/30/2025. There were no nursing progress notes, no nursing assessments, no physician's assessment indicating the necessity for these eye drops until 09/04/2025. The Comprehensive Care Plan documented a focus entry dated 08/29/2025 indicating, Resident has an actual infection (redness of the right eye), start on eye drop Cipro x 5 days, The care plan was not revised to include measurable goals or individualized interventions specific to the resident's right-eye redness and did not identify the nursing actions required to address the condition. All goals and interventions on the comprehensive care plan remained those established on 01/23/2025, which addressed influenza-related concerns. The resident's current condition and treatment needs/goals/interventions were not reflected in the Comprehensive Care Plan. During an interview on 10/29/2025 at 1:27 PM, the Assistant Director of Nursing stated that charge nurses complete the care plans. The Assistant Director of Nursing stated that care plans should be updated and reviewed quarterly and as needed. The Assistant Director of Nursing stated that there was no charge nurse on the first floor at the time the incident with Resident #1's right-eye redness was observed. The unit did not have a charge nurse for a long time. When the surveyor asked whose responsibility, it was to update residents' care plans in the absence of a charge nurse, the Assistant Director of Nursing stated that they did not want to answer and directed the surveyor to ask administration. During an interview on 10/29/2025 at 2:19 PM, the Director of Nursing stated that it is the responsibility of the charge nurse to update and revise care plans. The Director of Nursing stated that on 08/29/2025 when Ciprofloxacin(antibiotic) ophthalmic drops were ordered for Resident #1's right eye redness, the facility did not have a charge nurse and had not had one for several months. The Director of Nursing stated that as of 10/29/2025, the facility has hired a charge nurse for the unit. The Director of Nursing stated that care plans should always be updated and revised with any change in condition or any change in the plan of care. During an interview on 10/29/2025 at 3:07 PM, the Regional Director of Nursing stated that care plans are reviewed and revised at least quarterly and as needed. The Regional Director of Nursing stated that the resident's change in condition related to right-eye redness, and the initiation of eye drops, should have resulted in updated interventions being added to the care plan. During an interview on 10/29/2025 at 3:28 PM, Registered Nurse Supervisor #1 stated that they initiated the order for ciprofloxacin ophthalmic antibiotic eye drops on 08/29/2025 for Resident #1's right-eye redness without completing a nursing assessment or documenting any evaluation or assessment of the resident's condition. Registered Nurse Supervisor #1 stated that there were no clinical indications documented to support why the resident would need antibiotic eye drops. When asked where the care plan interventions were for the Resident #1's right-eye redness, Registered Nurse Supervisor #1 stated that they were probably rushing to complete an admission and that interventions should have been added on the care plan. Registered Nurse Supervisor #1 stated that every time there is a change in condition, the care plan should be updated to reflect new interventions and appropriate goals. 10 NYCRR 415.11(c)(1)

Based on observations, record review, and interviews conducted during the Abbreviated Survey (# 2622688), the facility did not ensure that necessary care and services were provided to maintain the resident's highest practicable physical well-being for one (Resident #1) of three (3) residents reviewed for abuse. Specifically, on 08/29/2025, Resident #1's family representative reported redness to Resident #1's right eye to nursing staff. The family representative stated that nursing staff told them the condition was already addressed. Record review revealed was no documented nursing assessment, a change-in-condition evaluation or a physician notification. There was no documentation that staff identified the redness prior to the family representative report. Ciprofloxacin ophthalmic (antibiotic) eye drop was ordered on 08/29/2025 and initiated on 08/30/2025 with no documented clinical rationale for the treatment. There was no registered nurse assessment or a physician evaluation at the time the order was placed. Resident #1 was not evaluated by a medical provider until 09/04/2025(six days after redness was discovered) and was diagnosed with subconjunctival hemorrhageThe findings include: Resident #1 was admitted with diagnoses including but not limited to dementia, anemia, and systemic lupus erythematosus. The Quarterly Minimum Data Set, dated [DATE] documented that Resident #1 had severe impaired cognition. Review of Resident #1's medical record showed no documented Registered Nurse assessment, and no nursing progress note on or after 08/29/2025(after notification from family representative of redness in the right eye) that the facility identified a change in condition, evaluated the eye, or notified the physician. Review of the physician's orders dated 08/29/2025 revealed ciprofloxacin ophthalmic (antibiotic) eye drops were ordered on 08/29/2025 to begin on 08/30/2025 for right eye redness. The order was created by Registered Nurse Supervisor #1 and there was no corresponding nursing assessment or documentation supporting the need for treatment. There was no documentation that a physician was contacted at the time the order was entered. Review of the Medication Administration Record revealed that the first dose of ciprofloxacin ophthalmic drops was administered on 08/30/2025. The medical progress note dated 09/05/2025 by Nurse Practitioner #1 documented that Resident #1 was evaluated on 09/04/2025 and diagnosed with a right subconjunctival hemorrhage. This was the first documented medical provider assessment following the reported change in condition on 08/29/2025. During an interview on 10/29/2025 at 03:28 PM, Registered Nurse Supervisor #1 stated they were notified on 08/29/2025 by a nurse that the family representative for Resident #1 reported redness to resident's right eye. Registered Nurse Supervisor #1 stated they sent a text message to the provider to obtain an order for eye drops but did not document an assessment of the resident's eye and did not document the physician notification. Registered Nurse Supervisor #1 stated they could not recall the appearance of the Resident#1's right eye at the time they received the report and notified the physician. During an interview on 10/29/2025 at 01:27 PM, the Assistant Director of Nursing stated they were not notified of any redness to Resident #1's right eye on 08/29/2025 and were not aware of any documentation reflecting that staff assessed the resident on that date. During an interview on 10/29/2025 at 02:56 PM, the Medical Director stated that when a resident has a change in condition, a provider should be notified, an assessment should be completed, and documentation should reflect these actions. The Medical Director stated that the nurse likely contacted a provider and may have forgotten to document because staff can become busy. The Medical Director stated they could not explain why there was no nursing assessment or documentation of provider notification related to the 08/29/2025 report of right-eye redness. The Medical Director stated they were driving during the interview and did not have access to the resident's medical record to clarify what occurred. During an interview on 10/29/2025 at 05:01 PM, the Director of Nursing stated they were not employed at the facility when the redness to Resident #1's right eye was first reported on 08/29/2025. The Director of Nursing was unable to provide documented evidence of any nursing assessment, provider notification, or clinical rationale supporting the initiation of ciprofloxacin ophthalmic eye drops for the reported right-eye redness of Resident #1. During an interview on 10/29/2025 at 04:40 PM, Physician #1 stated they were aware that ciprofloxacin ophthalmic drops were ordered for Resident #1 on 08/30/2025 but did not assess the resident at that time. Physician #1 stated they first evaluated the resident on 09/13/2025 and relied on the diagnosis of subconjunctival hemorrhage previously documented by the nurse practitioner on 09/04/2025. Physician #1 stated they did not know why no assessment or clinical documentation was not completed when the redness was first reported on 08/29/2025. During an interview on 10/29/2025 at 05:16 PM, the family representative stated they observed redness to the resident's right eye on 08/29/2025 and reported it to the nurse on duty. The family representative stated they were told the condition had already been addressed. The Family representative stated they did not receive any notification before their visit on 08/29/2025. 10 NYCRR 415.12(c)

Based on record review and interviews conducted during an Abbreviated Survey (2622688), the facility did not ensure physician supervision oversight of medical care for one (Resident #1) of (3) three residents reviewed for physician services. Specifically, an order for ciprofloxacin(antibiotic) eye drops was ordered for Resident #1's right eye on 08/29/2025 after redness was reported by family representative. There was no documented physician assessment or nursing assessment at the time the order was entered. The treatment began 08/30/2025, and Resident #1 was not evaluated by a medical provider until 09/04/2025 six days after the change in condition was identified and after treatment had already been initiated.The findings include:The facility policy titled Physician Services, revised 05/2019 documented that a physician shall review and document orders for the care and treatment of residents and shall evaluate residents as clinically indicated. The policy also stated that all verbal orders must be authenticated by the physician. Resident #1 was admitted with diagnoses including dementia, anemia, and cardiac arrhythmias. The Minimum Data Set, dated [DATE] documented that the resident had severe impaired cognition and required extensive assistance of one staff for toileting, personal hygiene, and bathing. Record review of the physician's orders dated 08/29/2025 documented that ciprofloxacin 0.3% ophthalmic drops, one drop to the right eye three times daily was created by Registered Nurse Supervisor #1 with a start date of 08/30/2025. The order did not contain documentation of physician notification or assessment of the resident's change in condition. The medication administration record showed the eye drops was first administered on 08/30/2025. An initial Optum visit progress note dated 09/04/2025 at 11:06 AM documented that the resident was evaluated by a nurse practitioner and diagnosed with a subconjunctival hemorrhage to the right eye. The note did not reference the prior order for antibiotic eye drops. The note did not document response to treatment, and did not include an assessment of the resident at the time the antibiotic eye drops was initiated. During an interview on 10/29/2025 at 03:28 PM, Registered Nurse Supervisor #1 stated that ciprofloxacin(antibiotic) eye drops were ordered after a nurse notified them that the family representative for Resident #1 reported that the resident's eye appeared red. Registered Nurse Supervisor #1 stated they contacted the physician by text message to obtain the order but did not complete or document a nursing assessment of the resident and did not document physician notification in the medical record. Registered Nurse Supervisor #1 stated they could not recall the appearance of the resident's eye at the time the order was entered. During an interview on 10/29/2025 at 02:56 PM, the Medical Director stated that physicians may not evaluate a resident immediately if they are unavailable or on vacation and that the covering provider may also be busy. When asked whether a resident receiving antibiotic eye drops should be assessed by a medical provider, the Medical Director stated they were unaware that six days had passed between when the order was first initiated and the first provider evaluation. During an interview on 10/29/2025 at 04:40 PM, Physician #1 stated that nurse practitioners are in the facility every day and that they generally expect residents with a change in condition to be seen within two days. Physician #1 confirmed there was no documented evaluation of Resident #1 between 08/29/2025 and 09/04/2025 and stated that they had instructed staff to refer the resident to an ophthalmologist, but did not know whether the resident was ever seen. No documentation of an ophthalmology referral or visit was found in the medical record. 10 NYCRR 415.15(b)(1)(i)-(ii)

Based on record reviews and interviews during an abbreviated survey (NY00355946, NY00334577, NY00336626), the facility did not ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. The facility also did not report the results of all investigations to the New York State Department of Health in accordance with State law, within 5 working days of the incident for 3 out of 3 residents (Resident #1, Resident #3, Resident #5) reviewed for abuse. Specifically, (1) on 9/27/2024 Resident #1 reported to their representative that staff had beat them up while in the dining room the day before. The Administrator was not made aware of the allegation until 9/30/2024 and there was no documented evidence of the investigative conclusion being submitted to the New York State Department of Health; (2) On 2/26/2024 Resident #4 went to their neighbor Resident #3's room and unzipped their pants and exposed themself to Resident #3. Resident #3 was upset and crying due to Resident #4's behavior. There was no documented evidence of the investigative conclusion being submitted to the New York State Department of Health; (3) On 3/19/2024 Resident #5 complained that Certified Nurse Aide #5 on the 7 AM to 3 PM shift, showed no empathy when they told them their spouse had passed away years ago. Resident #5 also informed other staff that the Certified Nurse Aide #5 was kind of rough with them and described them as a goliath to other employees. There was no documented evidence of the investigative conclusion being submitted to the New York State Department of Health. The findings are: The facility Abuse policy last reviewed 6/1/2024 documented the facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. The Administrator and Director of Nursing are responsible for investigation and reporting. Report results of investigation to the proper authorities as required by State law. Failure to report to required Regulatory Agencies in the capacity of a facility administrator could result in termination. 1) Resident #1 had diagnoses including Chronic Obstructive Pulmonary Disease, Schizophrenia and Major Depressive Disorder. A Quarterly Minimum Data Set, dated dated dated [DATE] documented Resident #1 had moderate cognitive impairment. The resident required a wheelchair for locomotion, maximal assistance with eating, dependent for toileting, bed mobility and transfers. Review of the undated facility investigation form documented Resident #1's representative stated they reported the incident to the Department of Health because they were frustrated and felt the two Registered Nurses were dismissive and unprofessional. The investigative conclusion dated 10/5/2024 documented there is no evidence to substantiate the allegation, investigation revealed no cause to believe that the resident had been abused as alleged. Review of the complaint submission report revealed the incident occurred on 9/26/2025, staff were first made aware on 9/27/2024 at 6:00 AM, and the Administrator was made aware on 9/30/2024 at 10:30 AM. There was no documented evidence of an investigative conclusion being submitted to the New York State Department of Health. 2) Resident #3 had diagnoses including but not limited to Dementia, Major Depressive Disorder and Personal History of COVID-19. Review of an admission Minimum Data Set, dated dated dated [DATE] documented Resident #3 had moderate cognitive impairment. Resident #3 used a wheelchair for mobility, required set up assistance with eating, moderate assistance with toileting, bed mobility and transferring. 3) Resident #4 had diagnoses including but not limited to Dementia, Schizoaffective Disorder and Epilepsy. A Quarterly Minimum Data Set, dated dated dated [DATE] documented Resident #4 was cognitively intact with no behaviors noted. The resident required a wheelchair or a walker for locomotion, independent with eating, bed mobility and transfers, required supervision for toileting. Review of the investigative summary dated 2/26/2024 documented on 2/26/2024 it was reported to the Director of Nursing that Resident #4 had exposed themself to Resident #3 and while holding their penis asked what they thought of their penis. It was reported that Resident #3 was upset and crying about Resident #4's behavior. Resident #3 did not report this to the nurses or the certified nurse aides. Resident #3 and Resident #4 both confirmed that no touching had occurred. The investigative conclusion dated 3/3/2024 documented there is no evidence to support that any alleged resident Abuse may have occurred. There was no documented evidence of the investigative conclusion being submitted to the New York State Department of Health. 4) Resident #5 had diagnoses including but not limited to Muscle Weakness, Major Depressive Disorder and Anxiety. A Quarterly Minimum Data Set, dated dated dated [DATE] documented the resident was cognitively intact with no behaviors noted. The resident required a wheelchair for locomotion, set up assistance with eating, moderate assistance with toileting and transfers and supervision with bed mobility. Review of a facility full Quality Assurance report dated 3/20/2024 documented on 3/19/2024 Resident #5 complained that Certified Nurse Aide #5 on the 7 AM to 3 PM shift showed no empathy when they told them their spouse had passed away years ago. Resident #5 also informed other staff that the Certified Nurse Aide #5 was kind of rough with them and described them as a goliath to other employees. Review of the investigation form dated 3/25/2024 documented Resident #5's complaint was investigated and concluded as no evidence of abuse, neglect or mistreatment, resident wishes to not have Certified Nurse Aide #6 and this will be honored. No trauma or any other negative effect observed at this time. Resident #5's representatives informed of the outcome of the investigation. There was no documented evidence of the investigative conclusion being submitted to the New York State Department of Health. During an interview on 4/14/2025 at 6:00 PM, the Director of Nursing stated they are responsible for reporting incidents to the Department of Health. The Director of Nursing stated they also submit the 5-day investigative conclusion but was unaware that the 5-day conclusion was not submitted. The Director of Nursing stated they believe when the incident occurred it was shabbat, but the Administrator is informed of any incident that happens before sundown, as soon as shabbat ends. The Director of Nursing stated Resident #1 reported to their representative that the day before they had gotten beat up by a staff in the dining room. The Director of Nursing stated they reported this case because, Resident #1's representative had called it in so they did not want some to tell them they should have reported the incident to the Department of Health. During an interview on 5/9/2025 at 12:22 PM, the Administrator stated all reportable incidents are completed and submitted by them or the Director of Nursing and most senior person if they are unavailable. The Administrator stated they are informed of all reportable incidents and if an incident occurs on the [NAME], the Director of Nursing does the reporting to the Department of Health. The Administrator stated during [NAME] they are still informed timely via text message, and they are aware as soon as they turn their cellphone back on. The Administrator stated the 5-day investigative conclusions are submitted by them or the Director of Nursing. The Administrator stated the Director of Nursing keeps a record of all the reportable information. The Administrator stated they do not remember when they were informed about the incident reported on 9/26/2024 with Resident #1 and they do not recall the investigative conclusion not being submitted to the New York State Department of Health. The Administrator stated they do not remember Resident #5's case either and they do not recall the investigative conclusion not being submitted to the New York State Department of Health. 10NYCRR 415.4(b)(1)(ii)

Based on record review and staff interviews, the facility failed to provide a meaningful Quality Assessment and Assurance Program that functions to develop and implement appropriate plans of actions to correct identified quality deficiencies, including monitoring the effect of implemented changes and making needed provisions to the action plans to correct quality deficiencies. Specifically, The Administrator, Director of Nursing (DON) and Director of Social Work, who are members of the facility Quality Assessment and Assurance Committee were aware of significant injuries occurring at the facility as a result of falls, the facility's failure to investigate falls, the facility's failure to follow outlined interventions to prevent injury related to falls, the facility's failure to review and revise plans of care for residents who experienced falls and the facility's failure to report accidents/incidents to the NYSDOH as required. This resulted in actual harm that is IMMEDIATE JEOPARDY. Please refer to F323 Findings are: Review of the facility's Administrative Policy and Procedure documents the Quality Assessment and Assurance Committee is responsible to "develop and implement appropriate plans of actions to correct identified quality deficiencies, including monitoring the effect of implemented changes and making needed provisions to the action plans to correct quality deficiencies." Interview with the Administrator on 5/2/11 at 11:00AM revealed that the facility Quality Assurance and Assessment Committee had not identified falls as an area requiring review and guidance by the committee. When interviewed, on 5/6/11 at 6:00PM, the Administrator stated that he relied on the DON to manage these issues. When interviewed on 5/2/11, The Director of Social work stated that she failed to thoroughly read incident reports prior to signing them. During an interview with the DON on 5/6/11, he stated that the facility would have to look more carefully into incidents in the future. 415.27(a)-(c)

Based on observations, interviews and record review, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 5 residents who sustained multiple falls with serious injuries. The facility failed to implement care plans, thoroughly investigate accidents related to falls with injuries, and initiate and implement new interventions after falls to prevent recurrence for 5 sampled residents. Specifically, the facility failed to ensure that care plans to prevent recurrent falls were reviewed and revised to prevent injuries related to falls for Resident # 30, who had multiple falls and sustained multiple compression fractures. The facility failed to ensure that assistive devices that were provided to prevent falls with injuries for Resident #19 and 28. Resident #19 sustained a hematoma to the head and Resident #28 sustained head injury and blunt force chest trauma. The facility failed to ensure that care plan interventions were provided to prevent injury related to falls for Resident # 15 and #33. Resident#15 required 12 staples for a head injury and Resident #33 sustained a head injury and a fractured wrist. This was evidenced for 5 of 17 residents reviewed for accidents in a sample of 34. This resulted in actual harm for all 5 residents that resulted in IMMEDIATE JEOPARDY AND SUBSTANDARD QUALITY OF CARE. Findings are: The facility's "Accident/Incident Reporting and Investigation Policy and Procedure" documented specific guidance for facility staff with regard to resident incidents and accidents. Examples of staff guidance include, but are not limited to; guidance with regard to definitions, interviewing, collecting statements, investigating, root cause analysis, protecting residents, preventing recurrence, and reporting responsibilities. 1. Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per the MDS of [DATE] (a standard assessment) this resident is assessed as having moderately impaired decision making skills. This MDS indicates the resident requires minimal supervision and set-up for transfer. A Fall Risk assessment dated [DATE] documents this resident as being at moderate risk for falls. The resident self-propels in his wheelchair. Review of the resident's care plan of [DATE] titled, "Potential for fall and/or injury, " reveals the following interventions listed to prevent injury related to falls; assess risk factors related to falls, anticipate needs and answer calls promptly, well lit floors and hallways, bed in lowest position, non-skid floor mats, and keep call bell within reach. Review of A&I Reports (Accident and Incident Reports) from [DATE] through [DATE] revealed the following: On [DATE] at 10:50 PM, the resident was heard to be calling out for help and was found on the floor of his room. The Registered Nurse (RN) Shift Supervisor observed large amounts of baby powder on the floor. Care plan update to prevent recurrence was documented as, "Limit the use of powder to keep floor clean and dry." There was no thorough investigation of this incident. On [DATE] at 5:50 AM the resident was found on the floor in his room. According to the accident/incident report, the resident stated that he was attempting to transfer from the bed to his wheel chair and fell . There were no apparent injuries as a result of this incident. There were no new interventions added to the plan of care to prevent recurrence. On [DATE] at 10:30 AM, the resident was found on the floor in his room. According to the A&I Report, the charge nurse documents that the resident's call bell sounded at 10:30 AM. She went to his room and found him sitting on the floor. The report further documents that the resident felt dizzy and slid from the chair; and that vital signs were taken and the resident was put in bed for a nap. There were no injuries as a result of the fall. The care plan was not reviewed and revised to implement any new intervention to prevent recurrence. During an interview with the RN (Registered Nurse) Unit Manager and Director of Nursing (DON) on [DATE], at 2:45 PM, they stated that the facility had not implemented any new interventions to prevent recurrence of these 2 falls. On [DATE] at 9:45 PM, the resident was found sitting on the floor near the elevator on another unit. The resident was transferred to the hospital on [DATE] for evaluation which revealed compression fractures of T 1, L 1, L 2, L 4, and possibly L 5. The plan of care to prevent injuries related to falls was not reviewed or revised with any new interventions to prevent recurrence. When interviewed on [DATE] at 2:50 PM, the RN Unit Manager and DON stated that the plan of care for this resident was not reviewed or revised after the [DATE] fall with any new interventions to prevent recurrence. In addition, the A&I Report documented that no neglect occurred and the report was signed by the DON. The corrective action on the A/I report documented that the resident was told to ask for help. When questioned why this accident was not investigated thoroughly or reported to NYSDOH (New York State Department of Health), the DON stated that the facility would have to look more carefully into accidents and incidents in the future. On [DATE] at 2:10 PM, Resident #30 was found on the floor in front of his wheelchair. The A&I Report documents that the resident slid from the chair to the floor. There were no new interventions added to the care plan to prevent recurrence. When interviewed on [DATE] at 3:00 PM, the DON stated that the plan of care provided to prevent injuries related to falls for this resident had not been reviewed and revised to prevent reocurrence after the [DATE] fall. On [DATE] at 2:10PM, the resident was found on the floor near his bed. According to the A&I Report, the resident was apparently attempting to self transfer from the bed to the chair and fell . There was no injury per the A&I Report. There were no new interventions added to the plan of care to prevent recurrence. The RN Unit Manager stated on [DATE] at 2:55 PM that the resident's plan of care was not revised with interventions to prevent recurrence after the [DATE] fall. During an interview with the DON on [DATE] at 3:00PM, he stated that the resident's plan of care had not been reviewed and revised to prevent recurrence. On [DATE] at 12:00PM, the resident was found on the floor of his room. The incident report documented that he was apparently attempting to transfer from the chair to bed and sustained no injury. There was no thorough investigation conducted to determine the root cause of the fall nor subsequent interventions added to the care plan to prevent recurrence. During an interview with the RN Unit Manager and DON on [DATE] at 3:10 PM, they stated that the facility did not conduct an investigation nor provide a new intervention to prevent recurrence from the [DATE] fall. The DON stated that the resident is a behavior problem. 2. Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Falls Risk assessment dated [DATE] reveals that this resident was assessed as being a high risk for falls . The [DATE] care plan and the [DATE] CNA care guide interventions to reduce the risk for injuries related to falls include "Tab Alarm to wheelchair when out of bed" and " keep resident within eye contact when out of bed. " Nursing notes of [DATE] documented that he slid from his chair and was found on the floor at 5:30 PM. Review of the A&I Report completed on that date documented no monitoring device was used. The report documented that an aide heard something, turned and found the resident on the floor. The resident sustained [REDACTED]. There was no thorough investigation completed as a result of this fall on [DATE] nor any new interventions added to the care plan to prevent recurrence. When interviewed at 2:30 PM on [DATE], the Interim LPN (Licensed Practical Nurse), Assistant Director of Nursing (ADON), who is also the Unit Manager of the Dementia Unit, stated that the resident was not wearing the tab alarm on [DATE] which may have prevented the fall. During an interview with the DON on [DATE] at 3:10 PM, he stated that this [DATE] accident had not been investigated, nor was it reported to the NYSDOH. On [DATE], the resident was in the dining room prior to lunch when the resident was found on the floor by C.N.A.#1 (Certified Nurse Aide). The A&I Report documented that C.N.A.#1 who was sitting in the dining room at that time heard a " loud thud, " turned around, and saw the resident on the floor. The C.N.A.#2 assigned to this resident stated, "I did not witness the resident falling. I was in another room with another resident." The resident sustained [REDACTED]. Review of the [DATE] fall investigation completed by the (ADON) documents, "The C.N.A.#1 assigned to the Dining Room was handing out snacks to residents-she then heard an alarm and turned around and saw the resident on the floor." During an interview with the ADON on [DATE] at 2:30 PM the ADON stated that the above investigation was inaccurate, in fact, the resident did not have the tab alarm connected at the time. He was unable to explain why this accident had not been reported to NYSDOH as the facility 's failure to follow the resident 's plan of care resulted in resident injury. Interview with the DON on [DATE] at 3:00 PM revealed that the care plan for this resident was not implemented and that the incident of [DATE]should have been reported to NYSDOH. 3. Resident # 28 was a [AGE] year-old female admitted with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS, a resident assessment tool) dated [DATE], assessed the resident ' s cognition as being moderately impaired with both, short and long-term memory loss. The resident was further assessed as being a high risk for falls. She required extensive assist with ADLs (Activities of Daily Living). A review of the resident ' s closed record (Resident expired in the facility on [DATE]) revealed the resident was able to ambulate on admission and a Wanderguard was placed on her. Review of the resident ' s A&I Reports revealed the following: On [DATE] at 3:30 AM, the resident was found sitting on the floor in her room. She sustained a skin tear on the left upper arm. The care plan and the CNA care guide were revised to place a chair and bed alarm. On [DATE] at 6:35 am, CNA#4 found the resident lying on the floor in her room. No monitoring device is checked off and it is noted that no alarm was sounding. The resident had no injury. The CCP was revised with interventions that called for a medication review, pain assessment, and toileting every 2 hours. On [DATE] at 4:50 AM, C.N.A#5. heard the resident calling for help and found her on the floor. The A&I Report notes no monitoring device in place. The resident sustained [REDACTED]. On [DATE] at 1:25 PM, the resident was found on the floor in the dayroom with a 4 cm. laceration to the right side of the head. The A&I report noted there was no alarm present. The CCP was not revised. On [DATE] at 3:10 PM, the resident was found on the floor of the dining room with a "small lump" on the left back of the head. The A&I report does not note any alarm on the resident. There was no facility investigation to determine the root cause for this unwitnessed fall nor was it reported to the DOH. Additionally, the report noted that there was no supervision in the room at the time. The resident was sent to the E.R. for a CAT scan of the head and returned to the facility the same day with [DIAGNOSES REDACTED]. During an interview with the RN Unit Manager and the DON on [DATE] at 2:00 PM they stated that they had no explanation as to why the Tab alarm was not implemented as per the care plan. 4.. Resident #15 is a [AGE] year old female who was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated , [DATE], assessed the resident as being moderately impaired for decision making skills. The MDS also assessed the resident as having no sitting balance or standing balance. The Falls care plan dated [DATE] identified the resident as a moderate risk for falls due to her impaired cognition. The interventions that were to be put in place included that the resident be observed for safety during all activities ; such as toileting, Activities of Daily Living and transferring the resident between bed and chair or wheelchair. Review of the A/I report of [DATE] indicated that on [DATE], the resident was in the dayroom and brought to the bathroom located in the dayroom by CNA#6. CNA#6, who was supposed to be observing the resident closely, left the resident to assist another resident in the dayroom. Resident # 15 fell from the toilet and sustained a head injury requiring 12 staples as well as abrasions to her upper arm. In an interview with C.N.A#6. on [DATE] at 10:30 AM, assigned to the dayroom on [DATE], she stated that she took Resident # 15 to the bathroom and was watching the resident with the door open. She could see another resident trying to stand up in his wheelchair. She then left Resident # 15 unattended. CNA#6 stated that she knew she had to stay with Resident # 15 at all times. There is no documented evidence of a thorough investigation to determine root cause analysis after this incident on [DATE]. Additionally, there is no documentation of a disciplinary notice for CNA #6. During an interview with the DON on [DATE] at 9:30 AM, he described what had happened and that CNA#6 did not leave the resident alone intentionally and therefore no further investigation was necessary so the accident was not reported to NYSDOH. 5. Resident # 33 is an [AGE] year old female who was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DATE] MDS indicated the resident is assessed as being moderately impaired for decision making skills as well as having short term and long term memory problems. The MDS also documented that the resident required limited assistance of one person for ambulation and transfers. The CCP dated [DATE] documented the resident to be at risk for falls and that the resident ambulates on the unit without the use of a walker, cane or wheelchair. Care plan interventions for falls that were put in place at that time included; bed in lowest position, monitor risk factors that may cause falls, and bed alarm. Review of the A& I Reports from [DATE]-[DATE] revealed; On [DATE] at 8:35AM, Resident # 33 was in her bedroom. The CNA found the resident on the floor. As a result of the [DATE] fall, the resident sustained [REDACTED].N.A. Care Guide was updated to include; close supervision, monitoring for safety, bed alarm for safety, and to ambulate with constant supervision. The A/I report dated [DATE] documented that the bed alarm was not in place. A thorough investigation of this injury was not conducted nor was this reported to the NYSDOH. In an interview with the DON on [DATE] at 10:30 AM, he offered no further explanation as to why the facility did not further investigate the [DATE] occurrence or report the fall with the injury to the NYSDOH. On [DATE] at 5:30PM, Resident # 33 who was ambulating independently, was found on the floor in the hallway. The resident sustained [REDACTED]. The Falls CCP was updated on [DATE] to document the occurrence. The previous interventions listed above in the C.N.A. Care Guide were not followed by staff which was that the resident was only to ambulate with supervision and close monitoring. The resident was found by CNA#7 who documented on the A&I Report , that she did not witness the occurrence but assisted picking up the resident with the nurse. In the nursing notes on [DATE], the Medical Doctor was notified and ordered an x-ray. On [DATE], the resident was complaining of headaches and vomiting. The Medical Doctor was notified and the resident was sent to the hospital for further evaluation. The resident returned to the facility on [DATE] with a [DIAGNOSES REDACTED].# 33 for every shift for 24 hours. A review of the neurological assessment tool indicated it was done only between the hours of 4PM-10PM on [DATE]. In an interview with the DON on [DATE] at 3:15PM, he was unable to provide an explanation as to why the neuro checks were not done for the full 24 hours. During an interview with CNA#7 at 5:30PM on [DATE], she described what happened when Resident #33 fell on [DATE]. After she received her medications, the resident was walking to the dayroom unassisted to have dinner when she fell . There was no further investigation to rule out abuse or neglect and the DON did not report the occurrence to NYSDOH. Additionally, on [DATE] in the PM hours, the DON stated this resident should have been closely supervised when ambulating. 415.12(h)(1)-(2)

Based on record review and interview, the administrator failed to be administer in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well being of each resident. Specifically, the Administrator failed to ensure that policies and procedures were implemented for Accident/Incidents and Abuse Prohibition. This resulted in actual harm that is IMMEDIATE JEOPARDY. See F323 Findings are: Review of the Administrative Policy and Procedure manual indicates that the Administrator has the authority and responsibility for carrying out all day to day functions required in operating the facility successfully. Review of the facility's "Accident/Incident Reporting and Investigation Policy and Procedure" documents specific guidance for the facility administrator with regard to resident incidents and accidents. Examples of that guidance include, but are not limited to; guidance with regard to definitions, interviewing, collecting statements, investigating, root cause analysis, protecting residents, preventing recurrence, and reporting responsibilities. During an interview with the Administrator on 5/5/11 at 4:30PM, each case cited under F323 was reviewed. The above referenced policy and procedure was reviewed with the Administrator at that time. His response was that the facility had not followed its policy and procedures in that: thorough investigations should have been conducted for the 5 residents cited in F 323 with new interventions established to prevent recurrence for Resident # 19 and #28. He stated that staff failed to follow the plan of care for Residents #15 and #33. He stated that new interventions were not added to Resident #30's plan of care to reduce the risk of injury related to falls. During this interview, the Administrator stated that these incidents should have been reported to NYSDOH and that he was depending on the Director of Nursing to review, monitor and intervene accordingly. 415.26

Based on interview and record review, the Governing Body failed to ensure that policies regarding the management and operation of the facility are carried out effectively to enable it to use its resources to effectively and efficiently attain or maintain the highest practicable physical, mental, and psychosocial well being of each resident. Specifically, the governing body failed to ensure that the Administrator, Director of Nursing and Director of Social Work, who is the designated party responsible for operationalizing the Abuse Prohibition protocol carried out their functions as described in facility policies and procedures to ensure that residents remain free from injury as a result of accident hazards, care plan interventions to reduce the likelihood of injury are followed, new interventions are developed to prevent resident injury from falls, and that allegations of abuse and neglect are investigated and reported to NYSDOH, if indicated. This resulted in actual harm that is IMMEDIATE JEOPARDY. See F323 and F490 Findings are: Review of the Administrative Policy and Procedure manual indicates that the governing body grants the Administrator the authority and responsibility for carrying out all day to day functions required in operating the facility successfully. During an interview on 5/6/11 at 8:10PM with the Corporate Administrator, who was representing the Governing Body of the facility, he stated that he was surprised by the outcome of the survey and that the company, " assumed that they did not have to monitor this facility as carefully as they did based on the qualifications of the DON (Director of Nursing)." During an interview with the new Acting DON on 5/6/11 at 7:00PM, she stated that the facilty would be hiring a Social Work consultant to educate the Director of Social Work with regard to her responsibility as the facility designated Abuse Prohibition Coordinator as the Director of Social Work stated during an interview with a surveyor on 5/3/11 at 1:30PM that she does not always fully read A/I reports prior to signing them indicating that abuse/neglect has been ruled out. 415.26(b)(3)(1)