Every finding on record at Pine Forest Car Center for Rehab & Healthcare

Based on observation, record review, and interviews during an abbreviated survey (2633011) the facility failed to ensure that each resident received adequate supervision to prevent accidents. This was identified for ten (10) of 12 residents: Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, reviewed for Accidents. 1) Specifically, Resident #1 and Resident #2 went out on a pass together into the community, signed out by Resident #2 as the responsible party on six (6) different dates in August 2025, and then again on September 30, 2025. On 09/30/2025, Resident #1 and Resident #2 did not return to the facility at the designated time of 3:00 PM. They were found on 10/01/2025 at approximately 10 AM. Resident #5, with a diagnosis of psychoactive substance abuse with psychoactive substance induced anxiety disorder (the co-occurrence of a problematic pattern of substance uses and an anxiety disorder that is a direct physiological consequence of that substance use or withdrawal), was documented to have gone out on pass multiple times in August 2025 and September 2025, signed out as their own responsible party. There was no documented evidence the residents were assessed for physical and mental capabilities to go out into the community safely; and there was no documented evidence of a physician's order for going out on pass. In addition, there was no documented evidence that a safety assessment of physical and mental capabilities was completed for any of the 10 residents that went out on pass. This resulted in Immediate Jeopardy.The finding is:The facility's policy titled, Behavioral Health Policy, reviewed in July 2025 defined Mental disorder as usually associated with significant distress or disability in social, occupational, or other important activities. The facility would ensure that the necessary behavioral health care services are person-centered. Behavioral health encompasses a resident's whole emotional and mental well-being, which included, but is not limited to, the prevention and treatment of mental and substance abuse disorders, psychosocial adjustment difficultly, and trauma or post-traumatic stress disorders.The facility's policy titled, Suicide Prevention Policy reviewed in June 2025 documented the facility's policy was to act quickly and appropriately if a resident expressed thoughts of suicide. Compliance guidelines included, but were not limited to, to objectively and thoroughly document the resident's mood and behavior, as well as actions taken in the medical records and to immediately notify the resident's physicians if the resident presented with suicidal ideation.Resident #1 had diagnoses that included dementia, strange and inexplicable behavior, and homelessness. Resident #1's Minimum Data Set (resident assessment tool) dated 07/23/2025 documented Resident #1 had moderate cognitive impairment and required supervision, touch assistance for ambulation, and was at risk for wandering behavior.Resident #1's hospital Discharge summary dated [DATE] documented on 07/07/2025, Resident #1 was brought to the hospital after they were found walking along the highway looking for their boyfriend (Resident #2). The hospital discharge summary documented Resident #1 was alert and confused, weepy at times about wanting to see their boyfriend.Resident #2 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder (a mental health condition characterized by significant mood swings that include emotional highs and lows), type 2 diabetes, chronic multifocal osteomyelitis (an inflammatory bone disease that causes pain and inflammation) of the right foot and ankle, Resident #2 was identified by the facility as the boyfriend of Resident #1. There was facility documentation that Resident #1 and Resident #2 knew each other prior to admission. An Electronic Medical Record census report dated 07/31/2025 documented Resident #1 was moved into Resident #2's room the day Resident #2 was admitted to the facility.Resident #1's Comprehensive Care Plan for Wandering/Exit Seeking initiated on 07/17/2025, documented Resident #1 wandered related to cognitive impairment and was at risk for injury related to adjustment issues, mild dementia, and mental illness. Interventions included, but were not limited to, to attempt to determine any pattern or cause of wandering, administer medications as ordered and to monitor and document for effectiveness and potential adverse side effects.Resident #1's Comprehensive Care Plan for Psychosocial Wellbeing initiated on 10/02/2025, documented Resident #1 had a psychosocial wellbeing problem, little interest or pleasure in doing things. The intervention was to provide assistance, encouragement and support to identify problems that cannot be controlled.Resident #1's physician order dated 07/16/2025 documented to administer quetiapine fumarate (Seroquel, an antipsychotic medication used to treat mental health conditions) oral tablet 25 milligrams three (3) times a day for mild dementia.Resident #1's Medication Administration Record dated July 2025 documented of 42 opportunities for the administration of the quetiapine fumarate 25 milligrams, Resident #1 refused 12 doses.Resident #1's Medication Administration Record dated August 2025 documented of 93 opportunities for the administration of the quetiapine fumarate 25 milligrams, Resident #1 refused 40 doses.Resident #1's Medication Administration Record dated September 2025 documented of 90 opportunities for the administration of the quetiapine fumarate 25 milligrams, Resident #1 refused 65 doses.Resident #1's Medication Administration Record dated 10/01/2025 to 10/17/2025 documented of 70 opportunities for the administration of the quetiapine fumarate 25 milligrams, Resident #1 refused 23 doses.There was no documented evidence that the frequency of missed doses of quetiapine fumarate 25 milligrams was brought to the attention of the medical practitioners. A facility document titled, Resident Release Form: Out on Pass documented that on 09/30/2025 at 10:13 AM, Resident #1 left the facility to go to neighboring town and their expected return was 09/30/2025 at 3:00 PM. Resident #2 was listed as their responsible party.A nursing progress note written by the Director of Nursing dated 10/01/2025 documented the Medical Doctor was informed that Resident #1 returned from an unauthorized out on pass. The Medical Doctor gave an order for Resident #1 to be seen by psychiatry for capacity. The progress notes further documented Resident #1 was sitting in their room quietly and expressed concerns about their significant other. Emotional support was provided.A Social Services progress note written by the Director of Social Work with an effective date of 10/01/2025 and a created date of 10/03/2025 documented Resident #1 returned to the facility today from unauthorized out on pass with their boyfriend.A documented titled, 24 Hour Nursing Report, (a document used to inform staff of concerns with the residents for 24-hour period) dated 10/01/2025 documented Resident #1 returned from an unauthorized out on pass. Resident #1 walked around the unit concerned about their significant other. Resident #1 refused all their meals.A nursing progress note dated 10/05/2025, documented Resident #1 was alert and verbal with confusion. Resident #1 was seen outside of their room, walking around the unit, going into other residents' rooms. Resident #1 was redirected. At around 7:00 PM, Resident entered the elevator and wanted to go down to look for Resident #2 and became aggressive when they were redirected. The Nurse Supervisor was made aware. Resident #1 is to be monitored constantly.A Nursing Progress Note dated 10/09/2025 documented Resident #1 was seen by the Psychiatric Nurse Practitioner on 10/06/2025 and the following recommendations and plan were noted: to continue current medication regimen, a gradual dose reduction is not recommended because it could lead to behavior disturbances, continue to provide a safe and therapeutic environment, and continue to provide non-pharmacological interventions and monitor for changes in mood and behavior.There is no documented evidence that a psychosocial assessment was done on Resident #1 after a significant emotional change related to Resident #2's discharge from the facility on 10/01/2025. A facility document titled, Accident/Incident Report, dated 10/17/2025 documented Resident #1 was found on the ground at the back of the building. The causative factor was documented as Resident removed the air conditioner in the window and the nature of the incident was documented as a Fall, sitting on the stairs/ground. The action taken to prevent reoccurrence was documented as Resident was sent to the hospital. On 10/23/2025, Resident #1 was readmitted to the facility with new diagnoses that included suicide attempt, fracture of the left ilium (largest pelvic bone), fracture of the right humerus (upper arm bone), and a fracture of the lumbar transverse process (a bony structure located on the back side of each lumbar vertebra in the lower back).There is no documented evidence Resident #1 was assessed by a physician for depression or suicide from 10/23/2025 to 10/29/2025. During an interview on 10/17/2025 at 3:27 PM, Registered Nurse #1 stated Resident #1 and Resident #2 shared a room and after Resident #2 left the facility, Resident #1 frequently came out of their room at about 2:00 AM with their backpack and asked where Resident #2 was. Registered Nurse #1 stated Resident #1 frequently refused their medication and when they did not take the Seroquel, they appeared to become more hyper-concerned about Resident #2 and would ask for Resident #2 more often.During an interview on 10/28/2025 at 1:18 PM, the Director of Social Work stated Resident #1 and Resident #2 had a relationship before they were admitted in July 2025. The Director of Social Work stated Resident #2 leaving the facility would have been a significant emotional change for Resident #1 and they did not assess Resident #1's mood after Resident #2 was discharged from the facility on 10/01/2025. The Director of Social Work stated Resident #1 was not assessed for depression or suicide when they were readmitted on [DATE] with a new diagnosis of suicide attempt. The Director of Social Work stated Resident #1's mood should have been assessed on 10/01/2025 and 10/23/2025 to determine if Resident #1 was at risk for harm.During an interview on 10/29/2025 at 11:29 AM with Resident #1, they stated when Resident #2 left they were very sad. Resident #1 started to cry and was visibly upset and stated they were worried, I will always go looking for Resident #2. During an interview on 10/29/2025 at 12:03 PM, the Director of Nursing stated Resident #1's mood improved when Resident #2 was admitted . The Director of Nursing Services stated when Resident #2 left the facility it would have been a significant emotional change. During an interview on 10/30/2025 at 11:57 AM, the Medical Director stated when Resident #2 was discharged from the facility that it would have been a significant emotional change for Resident #1 and Resident #1's mood should have been assessed at that time.The Medical Director stated Resident #1's emotional state should have been assessed when they were readmitted to the facility with a new diagnosis of suicide attempt on 10/23/2025. The Medical Director stated they felt Resident #1 was probably looking for their boyfriend and they did not try to commit suicide; however, their mood should have been assessed when they were readmitted to ensure no further harm came to Resident #1.During an interview on 10/31/2025 at 11:57 AM, the Psychiatric Nurse Practitioner stated Resident #2 leaving the facility would have been a significant emotional change for Resident #1 and Resident #1's mood should have been assessed when Resident #2 left the facility. The Psychiatric Nurse Practitioner stated they did not think Resident #1 was suicidal, but they were confused when they went out the window. The Psychiatric Nurse Practitioner stated the facility should have made the Medical Director aware on 10/23/2025 that Resident #1 was readmitted with a new diagnosis of suicide attempt and an assessment should have been completed upon readmission by the nursing or social work staff. During an additional interview on 11/14/2025 at 10:49 AM, the Director of Nursing stated Resident #1 was seen by the psychiatric nurse practitioner on 10/26/2025 but was not assessed by the social worker for their mood until 10/29/2025. The Director of Nursing stated Resident #1's mood should have been assessed when they were readmitted to the facility on [DATE] with a new diagnosis of suicide attempt. 10 NYCRR 415.12(f)(1)

Based on record review and interviews during the abbreviated survey (Intake ID 2645865) initiated on 10/17/2025 and completed on 11/06/2025, the facility failed to ensure that a resident who displayed or was diagnosed with a mental disorder or psychosocial adjustment difficulty, or who had a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or attain the highest practicable mental and psychosocial well-being. This was identified for one (1) (Resident #1) of twelve (12) sampled residents. Specifically, Resident #1 was assessed as having wandering and exit seeking behavior. Resident #1 had a significant emotional experience after which there was an increase in wandering behavior. There was no documented evidence that a psychosocial assessment was completed for Resident #1 following their significant emotional experience. On 10/17/2025, Resident #1 was observed on the ground below their third story room window. This resulted in Resident #1 sustaining multiple fractures that required hospitalization that is Immediate Jeopardy.The finding is:The facility's policy titled, Behavioral Health Policy, reviewed in July 2025 defined Mental disorder as usually associated with significant distress or disability in social, occupational, or other important activities. The facility would ensure that the necessary behavioral health care services are person-centered. Behavioral health encompasses a resident's whole emotional and mental well-being, which included, but is not limited to, the prevention and treatment of mental and substance abuse disorders, psychosocial adjustment difficultly, and trauma or post-traumatic stress disorders.The facility's policy titled, Suicide Prevention Policy reviewed in June 2025 documented the facility's policy was to act quickly and appropriately if a resident expressed thoughts of suicide. Compliance guidelines included, but were not limited to, to objectively and thoroughly document the resident's mood and behavior, as well as actions taken in the medical records and to immediately notify the resident's physicians if the resident presented with suicidal ideation.Resident #1 had diagnoses that included dementia, strange and inexplicable behavior, and homelessness. Resident #1's Minimum Data Set (resident assessment tool) dated 07/23/2025 documented Resident #1 had moderate cognitive impairment and required supervision, touch assistance for ambulation, and was at risk for wandering behavior.Resident #1's hospital Discharge summary dated [DATE] documented on 07/07/2025, Resident #1 was brought to the hospital after they were found walking along the highway looking for their boyfriend (Resident #2). The hospital discharge summary documented Resident #1 was alert and confused, weepy at times about wanting to see their boyfriend.Resident #2 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder (a mental health condition characterized by significant mood swings that include emotional highs and lows), type 2 diabetes, chronic multifocal osteomyelitis (an inflammatory bone disease that causes pain and inflammation) of the right foot and ankle, Resident #2 was identified by the facility as the boyfriend of Resident #1. There was facility documentation that Resident #1 and Resident #2 knew each other prior to admission. An Electronic Medical Record census report dated 07/31/2025 documented Resident #1 was moved into Resident #2's room the day Resident #2 was admitted to the facility.Resident #1's Comprehensive Care Plan for Wandering/Exit Seeking initiated on 07/17/2025, documented Resident #1 wandered related to cognitive impairment and was at risk for injury related to adjustment issues, mild dementia, and mental illness. Interventions included, but were not limited to, to attempt to determine any pattern or cause of wandering, administer medications as ordered and to monitor and document for effectiveness and potential adverse side effects.Resident #1's Comprehensive Care Plan for Psychosocial Wellbeing initiated on 10/02/2025, documented Resident #1 had a psychosocial wellbeing problem, little interest or pleasure in doing things. The intervention was to provide assistance, encouragement and support to identify problems that cannot be controlled. Resident #1's physician order dated 07/16/2025 documented to administer quetiapine fumarate (Seroquel, an antipsychotic medication used to treat mental health conditions) oral tablet 25 milligrams three (3) times a day for mild dementia.Resident #1's Medication Administration Record dated July 2025 documented of 42 opportunities for the administration of the quetiapine fumarate 25 milligrams, Resident #1 refused 12 doses.Resident #1's Medication Administration Record dated August 2025 documented of 93 opportunities for the administration of the quetiapine fumarate 25 milligrams, Resident #1 refused 40 doses.Resident #1's Medication Administration Record dated September 2025 documented of 90 opportunities for the administration of the quetiapine fumarate 25 milligrams, Resident #1 refused 65 doses.Resident #1's Medication Administration Record dated 10/01/2025 to 10/17/2025 documented of 70 opportunities for the administration of the quetiapine fumarate 25 milligrams, Resident #1 refused 23 doses.There was no documented evidence that the frequency of missed doses of quetiapine fumarate 25 milligrams was brought to the attention of the medical practitioners. A facility document titled, Resident Release Form: Out on Pass documented that on 09/30/2025 at 10:13 AM, Resident #1 left the facility to go to neighboring town and their expected return was 09/30/2025 at 3:00 PM. Resident #2 was listed as their responsible party.A nursing progress note written by the Director of Nursing dated 10/01/2025 documented the Medical Doctor was informed that Resident #1 returned from an unauthorized out on pass. The Medical Doctor gave an order for Resident #1 to be seen by psychiatry for capacity. The progress notes further documented Resident #1 was sitting in their room quietly and expressed concerns about their significant other. Emotional support was provided.A Social Services progress note written by the Director of Social Work with an effective date of 10/01/2025 and a created date of 10/03/2025 documented Resident #1 returned to the facility today from unauthorized out on pass with their boyfriend. A documented titled, 24 Hour Nursing Report, (a document used to inform staff of concerns with the residents for 24-hour period) dated 10/01/2025 documented Resident #1 returned from an unauthorized out on pass. Resident #1 walked around the unit concerned about their significant other. Resident #1 refused all their meals.A nursing progress note dated 10/05/2025, documented Resident #1 was alert and verbal with confusion. Resident #1 was seen outside of their room, walking around the unit, going into other residents' rooms. Resident #1 was redirected. At around 7:00 PM, Resident entered the elevator and wanted to go down to look for Resident #2 and became aggressive when they were redirected. The Nurse Supervisor was made aware. Resident #1 is to be monitored constantly.A Nursing Progress Note dated 10/09/2025 documented Resident #1 was seen by the Psychiatric Nurse Practitioner on 10/06/2025 and the following recommendations and plan were noted: to continue current medication regimen, a gradual dose reduction is notrecommended because it could lead to behavior disturbances, continue to provide a safe and therapeutic environment, and continue to provide non-pharmacological interventions and monitor for changes in mood and behavior.There is no documented evidence that a psychosocial assessment was done on Resident #1 after a significant emotional change related to Resident #2's discharge from the facility on 10/01/2025. A facility document titled, Accident/Incident Report, dated 10/17/2025 documented Resident #1 was found on the ground at the back of the building. The causative factor was documented as Resident removed the air conditioner in the window and the nature of the incident was documented as a Fall, sitting on the stairs/ground. The action taken to prevent reoccurrence was documented as Resident was sent to the hospital. On 10/23/2025, Resident #1 was readmitted to the facility with new diagnoses that included suicide attempt, fracture of the left ilium (largest pelvic bone), fracture of the right humerus (upper arm bone), and a fracture of the lumbar transverse process (a bony structure located on the back side of each lumbar vertebra in the lower back).There is no documented evidence Resident #1 was assessed by a physician for depression or suicide from 10/23/2025 to 10/29/2025. During an interview on 10/17/2025 at 3:27 PM, Registered Nurse #1 stated Resident #1 and Resident #2 shared a room and after Resident #2 left the facility, Resident #1 frequently came out of their room at about 2:00 AM with their backpack and asked where Resident #2 was. Registered Nurse #1 stated Resident #1 frequently refused their medication and when they did not take the Seroquel, they appeared to become more hyper-concerned about Resident #2 and would ask for Resident #2 more often.During an interview on 10/28/2025 at 1:18 PM, the Director of Social Work stated Resident #1 and Resident #2 had a relationship before they were admitted in July 2025. The Director of Social Work stated Resident #2 leaving the facility would have been a significant emotional change for Resident #1 and they did not assess Resident #1's mood after Resident #2 was discharged from the facility on 10/01/2025. The Director of Social Work stated Resident #1 was not assessed for depression or suicide when they were readmitted on [DATE] with a new diagnosis of suicide attempt. The Director of Social Work stated Resident #1's mood should have been assessed on 10/01/2025 and 10/23/2025 to determine if Resident #1 was at risk for harm.During an interview on 10/29/2025 at 11:29 AM with Resident #1, they stated when Resident #2 left they were very sad. Resident #1 started to cry and was visibly upset and stated they were worried, I will always go looking for Resident #2. During an interview on 10/29/2025 at 12:03 PM, the Director of Nursing stated Resident #1's mood improved when Resident #2 was admitted . The Director of Nursing Services stated when Resident #2 left the facility it would have been a significant emotional change. During an interview on 10/30/2025 at 11:57 AM, the Medical Director stated when Resident #2 was discharged from the facility that it would have been a significant emotional change for Resident #1 and Resident #1's mood should have been assessed at that time.The Medical Director stated Resident #1's emotional state should have been assessed when they were readmitted to the facility with a new diagnosis of suicide attempt on 10/23/2025. The Medical Director stated they felt Resident #1 was probably looking for their boyfriend and they did not try to commit suicide; however, their mood should have been assessed when they were readmitted to ensure no further harm came to Resident #1.During an interview on 10/31/2025 at 11:57 AM, the Psychiatric Nurse Practitioner stated Resident #2 leaving the facility would have been a significant emotional change for Resident #1 and Resident #1's mood should have been assessed when Resident #2 left the facility. The Psychiatric Nurse Practitioner stated they did not think Resident #1 was suicidal, but they were confused when they went out the window. The Psychiatric Nurse Practitioner stated the facility should have made the Medical Director aware on 10/23/2025 that Resident #1 was readmitted with a new diagnosis of suicide attempt and an assessment should have been completed upon readmission by the nursing or social work staff. During an additional interview on 11/14/2025 at 10:49 AM, the Director of Nursing stated Resident #1 was seen by the psychiatric nurse practitioner on 10/26/2025 but was not assessed by the social worker for their mood until 10/29/2025. The Director of Nursing stated Resident #1's mood should have been assessed when they were readmitted to the facility on [DATE] with a new diagnosis of suicide attempt.10 NYCRR 415.12(f)(1)

Based on observations, record review, and interviews during the Abbreviated Survey (Intake ID 2633011 and 2645865) the facility did not ensure all drugs and biologicals were stored in a locked compartment and accurately labeled. This was identified for one (1) of two (2) facility treatment carts. Specifically, the treatment cart on the first floor was noted to be unlocked with the second drawer open in the hallway without any staff members present. The finding is: The facility policy titled Medication Storage reviewed in June 2024 documented all drugs and biologicals will be stored in locked compartments under proper temperature controls. Only authorized personnel will have access to the keys to locked compartments. During a medication pass, medications must be under the direct observation of the person administering medication or locked in the medication storage area/cart.During an observation on 11/04/2025 at 2:00PM a treatment cart was observed outside Resident #12's room. The treatment cart was unlocked, and the second drawer was open about three inches and treatment medications were visible to the surveyors. Registered Nurse #2 exited Resident #12's room and stated they were using the treatment cart.During an interview on 11/04/2025 at 2:06 PM, Registered Nurse #2 stated that the treatment cart was unlocked, and the lock was broken. Registered Nurse #2 stated they accepted the treatment cart with the broken lock at the beginning of their shift and that the lock had been broken for a while. Registered Nurse #2 stated they should not have accepted a treatment cart without a functioning lock because residents could get into the treatment cart and take a medication.During an interview on 11/04/2025 at 4:08PM, with Director of Nursing Services they stated that all treatment carts should be locked and if they are unlocked the nurse should be present at the cart. The Director of Nursing Services stated that if the lock was not working, the cart should not have been in use because a resident could potentially obtain and ingest a treatment medication from the cart. 10 NYCRR 415.18(e)(1-4)

Based on observation, record review, and interviews during an abbreviated survey (2633011) initiated on 10/27/2025 and completed on 11/06/2025, the facility did not ensure that a comprehensive person-centered care plan was developed and implemented for each resident that included measurable objectives and timeframes to meet each resident's medical and nursing needs. This was identified for eleven (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, and Resident #11) of eleven residents reviewed for accidents. Specifically, 1) the facility's out-of-pass form documented that Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, and Resident #11 went out on pass multiple times and dates. There was no documented evidence that a comprehensive person-centered care plan was developed and implemented for each resident that included measurable objectives and timeframes to meet each resident's medical and nursing needs. 2) Resident #1, Resident #2, and Resident #5 had room changes, and no documented comprehensive person-centered care plan was developed and implemented for each resident that included measurable objectives and timeframes to meet each resident's medical and nursing needs. 3) Resident #5, who had a diagnosis of psychoactive substance abuse with psychoactive substance induced anxiety disorder (the co-occurrence of a problematic pattern of substance use and an anxiety disorder that is a direct physiological consequence of that substance use or withdrawal), had no comprehensive person-centered care plan developed and implemented for each resident that included measurable objectives and timeframes to meet each resident's medical and nursing needs.The findings are, but not limited to:The facility policy titled Comprehensive Care Planning, last reviewed 08/20/2025, documents that the facility will develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs. The Interdisciplinary Team will update the care plan as needed with changes in treatment, needs, and conditions.The facility policy titled Out on Pass/Therapeutic Leave of Absence, dated 06/2023, documented that a physician's order was required. There was no documentation that the comprehensive person-centered care plan would be developed and implemented for residents going out on pass that included measurable objectives and timeframes to meet each resident's medical and nursing needs.Resident #1 had diagnoses that included Dementia, Strange and Inexplicable Behavior, and Homelessness. Resident #1's Minimum Data Set assessment dated [DATE] documented that Resident #1 had moderate cognitive impairment, required supervision/ touch assistance for ambulation, and was at risk for wandering behavior.A review of the Electronic Medical Record for Resident #1 had no documented evidence that Resident #1 had a physician's order to go out on pass.No comprehensive person-centered care plan was developed and implemented for Resident #1 going out on pass that included measurable objectives and timeframes to meet each resident's medical and nursing needs.The facility out on pass form documented that Resident #1 went out on pass 6 times from August to September 2025.Multiple progress notes for August and September 2025 documented that Resident #1 went out on pass.Resident #2 had diagnoses that included bipolar disorder (a mental health condition characterized by significant mood swings that include emotional highs and lows), Type 2 Diabetes, Chronic Multifocal Osteomyelitis (an inflammatory bone disease that causes pain and inflammation) of the Right Foot and Ankle, and Difficulty Walking. Resident #2 was admitted to the facility for post-operative care after a right great toe (the big toe) amputation. Resident #1's Minimum Data Set assessment dated [DATE] documented that Resident #2 had intact cognition, used a walker for ambulation, and an assessment for walking was not attempted due to medical condition or safety concerns.A review of the Electronic Medical Record for Resident #2 had no documented evidence that Resident #2 had a physician's order to go out on pass.No comprehensive person-centered care plan was developed and implemented for Resident #2 going out on pass that included measurable objectives and timeframes to meet each resident's medical and nursing needs.The facility out on pass form documented that Resident #2 went out on pass 7 times from August to September 2025.Multiple progress notes for August and September 2025 documented that Resident #2 went out on pass.Resident #5 had diagnoses that included Cellulitis (infection of the skin) of the left Lower Limb, Psychoactive Substance Abuse with Psychoactive Substance-Induced Anxiety Disorder (the co-occurrence of a problematic pattern of substance uses and an anxiety disorder that is a direct physiological consequence of that substance use or withdrawal), and Difficulty in Walking. Resident #5's Minimum Data Set assessment dated [DATE] documented that Resident #5 had intact cognition, used a walker and wheelchair for ambulation, and was able to ambulate independently.A review of the Electronic Medical Record for Resident #5 had no documented evidence that Resident #2 had a physician's order to go out on pass.No comprehensive person-centered care plan was developed and implemented for Resident #5 going out on pass that included measurable objectives and timeframes to meet each resident's medical and nursing needs.The facility out on out-of-pass form documented that Resident #5 went out on pass alone, 8 times from August to October 2025.A nursing progress note dated 10/12/2025 documented that Resident #5 went out on pass.During an interview on 10/27/2025 at 12:44 PM, Registered Nurse Supervisor #1 stated that when a resident wants to go out on pass, they need a physician's order, and we have a paper to be filled out at the front desk. The nurses on the unit write a note when a resident goes out on pass, and they should verify that the resident has an out on pass order. If the resident does not have an order, the nurse will call the doctor to obtain an order and update the care plans.During an interview on 10/28/2025 at 10:37 AM, Licensed Practical Nurse #1 stated that residents must have a physician's order to go out of the facility on pass. If a physician's order is obtained, they are permitted to leave. Additionally, the charge nurse conducts an assessment before the resident goes out for the initial pass and updates the care plans accordingly.During an interview on 10/28/2025 at 01:18 PM, the Director of Social Work/ Director of Admissions stated that the physician would put in the order for out on pass. They stated they do not complete a psychosocial assessment for residents to go out on pass, nor do they update the care plans.During an interview on 11/06/2025 at 11:07 AM, the Director of Nursing Services stated the interdisciplinary team, or registered nurses should develop a care plan when an order for out-of-pass is obtained prior to the resident going out on pass. A care plan should have been developed and updated.2) The facility policy, titled Room Change Policy, last reviewed on 10/06/2025, documented before making a room change or roommate assignment, all persons involved in the change, residents and their representatives, will be given advance notice of such change as is possible. The notice of change in room or roommate will be provided to the resident and or representative. There was no documented evidence in the policy to update and revise the comprehensive care plan.Resident #1 had diagnoses that included Dementia, Strange and Inexplicable Behavior, and Homelessness. Resident #1's Minimum Data Set assessment dated [DATE] documented that Resident #1 had moderate cognitive impairment, required supervision/ touch assistance for ambulation, and was at risk for wandering behavior.No comprehensive person-centered care plan was developed and implemented for Resident #1 for a room change that included measurable objectives and timeframes to meet each resident's medical and nursing needs.The census documented Resident #1 had a room change on 07/31/2025.No progress notes documented that Resident #1 was adjusting to the room and new roommate.Resident #2 had diagnoses that included bipolar disorder (a mental health condition characterized by significant mood swings that include emotional highs and lows), Type 2 Diabetes, Chronic Multifocal Osteomyelitis (an inflammatory bone disease that causes pain and inflammation) of the Right Foot and Ankle, and Difficulty Walking. Resident #2 was admitted to the facility for post-operative care after a right great toe (the big toe) amputation. Resident #1's Minimum Data Set assessment dated [DATE] documented that Resident #2 had intact cognition, used a walker for ambulation, and an assessment for walking was not attempted due to medical condition or safety concerns.No comprehensive person-centered care plan was developed and implemented for Resident #2 when they received a new roommate on 07/31/2025, which included measurable objectives and timeframes to meet each resident's medical and nursing needs.No progress notes documented that Resident #2 was adjusting to the new roommate.Resident #5 had diagnoses that included Cellulitis (infection of the skin) of the left Lower Limb, Psychoactive Substance Abuse with Psychoactive Substance-Induced Anxiety Disorder (the co-occurrence of a problematic pattern of substance uses and an anxiety disorder that is a direct physiological consequence of that substance use or withdrawal), and Difficulty in Walking. Resident #5's Minimum Data Set assessment dated [DATE] documented that Resident #5 had intact cognition, used a walker and wheelchair for ambulation, and was able to ambulate independently.No comprehensive person-centered care plan was developed and implemented for Resident #5 for a room change that included measurable objectives and timeframes to meet each resident's medical and nursing needs.The census documented Resident #5 had a room change on 07/19/2025, 08/05/2025, 08/09/2025, and 10/29/2025.Nursing progress notes dated 07/19/2025, 08/05/2025, and 08/09/2025 document that Resident #5 is adjusting to the room change.During an interview on 10/27/2025 at 12:44 PM, Registered Nurse Supervisor #1 stated It depends on the needs of the facility if we change a resident's room. The Administrator and the Admissions Director would change a resident's room. The care plan should be updated by the Interdisciplinary Team.During an interview on 11/04/2025 at 1:20 PM, the Director of Social Work/Director of Admissions stated that when a resident's room is changed or they receive a new roommate, Nursing should put a note in the medical record of the move.During a reinterview on 11/05/2025 at 9:43 AM, the Director of Social Work/Director of Admissions stated it is the nurses' and social workers' responsibility to update any care plans after a room or roommate change; they stated they do not do that for Resident #5, and they should have updated the care plan. During an interview on 11/06/2025 at 11:07 AM, the Director of Nursing Services stated that social work is responsible for updating the care plan when a resident is moved to a new room or receives a new roommate. Nursing can update the care plans as well if the social worker is not available.3) The facility policy titled Behavioral Health Policy was last reviewed on 07/2025 documented substance use disorder is defined as recurrent alcohol and or drug use that causes clinically and functionally significant impairment. The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goals for care. The assessment and care plan will include goals that are person-centered and individualized. The facility will assess and develop a person-centered care plan for concerns identified in the resident's assessment. Resident #5 had diagnoses that included Cellulitis (infection of the skin) of the left Lower Limb, Psychoactive Substance Abuse with Psychoactive Substance-Induced Anxiety Disorder (the co-occurrence of a problematic pattern of substance uses and an anxiety disorder that is a direct physiological consequence of that substance use or withdrawal), and Difficulty in Walking. Resident #5's Minimum Data Set assessment dated [DATE] documented that Resident #5 had intact cognition, used a walker and wheelchair for ambulation, and was able to ambulate independently.No comprehensive person-centered care plan was developed and implemented for Resident #5 for a diagnosis of Psychoactive Substance Abuse with Psychoactive Substance-Induced Anxiety Disorder that included measurable objectives and timeframes to meet each resident's medical and nursing needs.During an interview on 11/05/2025 at 01:19 PM, Registered Nurse Supervisor #1 stated that we have a resident who has substance use disorder, and when going out, we make sure they are safe; we don't have them go out by themselves. The resident's substance use disorder was a long time ago. They stated they have not documented an assessment with resident #5; they spoke with Resident #5 verbally. We make sure they didn't bring back anything they cannot have. We look in his bags. They stated they would not say that we assess respiratory or vitals every time. The nursing staff should have been documented in the notes, and the residents should have had a care plan developed.During an interview on 11/06/2025 at 11:07 AM, the Director of Nursing Services stated that social work or nursing are responsible for developing and implementing care plans. 10 NYCRR 415.11(c)(1)

INTENT S483.30(a) The intent of this regulation is to ensure the medical supervision of the care of each resident by a physician and that orders for the resident's immediate care and needs are provided throughout the resident's stay. DEFINITIONS S483.30(a) Attending physician refers to the primary physician who is responsible for managing the resident's medical care. This does not include other physicians whom the resident may see periodically, such as specialists. Non-physician practitioner (NPP) is a nurse practitioner (NP), clinical nurse specialist (CNS), or physician assistant (PA). Nurse practitioner is a registered professional nurse currently licensed to practice in the State and who meets the State's requirements governing the qualification of nurse practitioners. Clinical nurse specialist is a registered professional nurse currently licensed to practice in the State and who meets the State's requirements governing the qualifications of clinical nurse specialists. Physician assistant is a person who meets the applicable State requirements governing the qualifications for assistants to primary care physicians.Based on record review and interviews conducted during the Abbreviated Survey (Intake 2645865) the facility did not ensure each resident was under the care of a physician. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs. This was identified for one resident (Resident #1) of twelve residents reviewed for accidents. Specifically, Resident #1 repeatedly refused Quetiapine (Seroquel, an antipsychotic) and the prescribing Psychiatric Nurse Practitioner stated they were aware of the refusals but provided no intervention plan and did not notify the Primary Care Physician. Based on record review and interviews conducted during the Abbreviated Survey (Intake 2645865) the facility did not ensure each resident was under the care of a physician. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs. This was identified for one resident (Resident #1) of twelve residents reviewed for accidents. Specifically, Resident #1 repeatedly refused Quetiapine (Seroquel, an antipsychotic) and the prescribing Psychiatric Nurse Practitioner stated they were aware of the refusals but provided no intervention plan and did not notify the Primary Care Physician.The finding is:The facility's policy titled, Physician Oversight reviewed by facility in August 2024 documented, it is the policy of the facility to ensure the physician took an active role in the supervision of resident care. Compliance guidelines included but were not limited to, a physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs.Resident #1 had diagnoses that included Dementia, Strange and Inexplicable Behavior, and Homelessness. Resident #1's Minimum Data Set assessment dated [DATE] documented Resident #1 had moderate cognitive impairment, required supervision/ touch assistance for ambulation, and was at risk for wandering behavior.There was no documented evidence that Resident #1 had a Comprehensive Care Plan for psychiatric medication.Resident #1's Comprehensive Care Plan Titled Resistance was initiated on 07/19/2025 and documented Resident #1 was at risk for resistance to care and/or medication administration related to adjusting to nursing home, dementia, and mental health issues. Interventions included but were not limited to, to document incidents of behavior and notify the social worker and the medical doctor of significant increases in behaviors and psychiatric evaluation as needed.Resident #1's Comprehensive Care Plan titled Mood was initiated on 07/24/2025 and documented Resident #1 had a mood problem related to Disease Process (Dementia). Interventions included but were not limited to monitor/record mood to determine if problems seemed to be related to external causes, to administer medications as ordered and to monitor/document for side effects and effectiveness. Resident #1's physician order dated 07/16/2025 documented to administer Quetiapine Fumarate (Seroquel, an antipsychotic medication used to treat mental health conditions) oral tablet 25 milligrams three (3) times a day for a diagnosis of Mild Dementia.Resident #1's Medication Administration Record dated July 2025 documented of 42 opportunities for the administration of the Quetiapine Fumarate 25 milligrams Resident #1 refused 12 doses.Resident #1's Medication Administration Record dated August 2025 documented of 93 opportunities for the administration of the Quetiapine Fumarate 25 milligrams Resident #1 refused 40 doses.Resident #1's Medication Administration Record dated September 2025 documented of 90 opportunities for the administration of the Quetiapine Fumarate 25 milligrams Resident #1 refused 65 doses.Resident #1's Medication Administration Record dated 10/01/2025 to 10/17/2025 documented 70 opportunities for the administration of the Quetiapine Fumarate 25 milligrams Resident #1 refused 23 doses.Psychiatric Progress Notes dated 07/21/2025, 08/11/2025, 09/01/2025, 09/22/2025, 10/06/2025, and 10/27/2025, documented Resident #1 was to continue their current medication regimen and a gradual dose reduction was not recommended because it could lead to behavioral disturbances. The Psychiatric progress notes documented Resident #1's chart was reviewed by the Psychiatric practitioner. There was no documented evidence that the Psychiatric practitioner was aware of or addressed Resident #1's numerous medication refusals.A Psychiatric Progress Note dated 10/31/2025 at 4:25 PM was completed after the practitioner was made aware of the frequency of Resident #1's medication refusals by the surveyor. The Psychiatric Progress Note Documented Resident #1 was evaluated via telehealth. Resident #1 acknowledged non-compliance with her prescribed psychotropic medications. There were no changes recommended to Resident #1's psychotropic regimen. The progress notes documented Resident #1's chart was thoroughly reviewed.During an interview on 10/28/2025 at 2:03 PM, the Medical Director stated they were the Primary Care Physician for Resident #1. The Medical Director stated they were not aware of the number doses of Quetiapine Fumarate (Seroquel) 25 milligrams missed since Resident #1 was admitted . The Medical Director stated the medication would not be effective with the number of missed doses and that would impact Resident #1's judgement.During an interview on 10/31/2025 at 11:57 AM, the Psychiatric Nurse Practitioner stated they treated and prescribed Quetiapine Fumarate (Seroquel) 25 milligrams for Resident #1. The Psychiatric Nurse Practitioner stated the medication was used to treat psychiatric disorders and the nursing staff told them Resident #1 was inconsistent with taking Quetiapine Fumarate (Seroquel) 25 milligrams. The Psychiatric Nurse Practitioner stated they (nursing staff) documented the concern in the medical record, but they did not know how many times Resident #1 refused the medication. The Psychiatric Nurse Practitioner stated the medication worked as it built up in the bloodstream and if the resident did not take it consistently then it would not give the full effect and could lead to behavioral disturbances. The Psychiatric Nurse Practitioner stated there were no changes made to Resident #1's medication because residents have the right to refuse to take their medication. 10 NYCRR 415.15(b)(1)(i)(ii)

S483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. S483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: S483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to S483.71 and following accepted national standards; S483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. S483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. S483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. S483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.Interpretive GuidelinesINTENT The intent of this regulation is to ensure that the facility: Develops and implements an ongoing infection prevention and control program (IPCP) to prevent, recognize, and control the onset and spread of infection to the extent possible and reviews and updates the IPCP annually and as necessary. This would include revision of the IPCP as national standards change; Establishes facility-wide systems for the prevention, identification, reporting, investigation and control of infections and communicable diseases of residents, staff, and visitors. It must include an ongoing system of surveillance designed to identify possible communicable diseases and infections before they can spread to other persons in the facility and procedures for reporting possible incidents of communicable disease or infections. NOTE: For purposes of this guidance, staff includes all facility staff (direct and indirect care functions), contracted staff, consultants, volunteers, others who provide care and services to residents on behalf of the facility, and students in the facility's nurse aide training programs or from affiliated academic institutions. Develops and implements written policies and procedures for infection control that, at a minimum: o Define standard precautions to prevent the spread of infection and explain their application during resident care activities; o Define transmission-based precautions and explain how and when they should be utilized, including but not limited to, the type and duration of precautions for particular infections or organisms involved and that the precautions should be the least restrictive possible for the resident given the circumstances and the resident's ability to follow the precautions; o Prohibit staff with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and o Require staff to follow hand hygiene practices consistent with accepted standards of practice. Requires staff to handle, store, process, and transport all linens and laundry in accordance with accepted national standards in order to produce hygienically clean laundry and prevent the spread of infection to the extent possible.Based on observations, record review, and interviews during the abbreviated survey (Intake ID: 2633011), the facility did not ensure it maintained an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This was identified for one (resident #12) of twelve residents. Specifically, resident #12 was on contact precautions for methicillin resistant staphylococcus aureus infection (type bacteria not treatable by most antibiotics, contagious) for a foot wound infection, without donning and doffing personal protective equipment as per physicians medical order. The findings are:The facility policy titled 'Infection Prevention and Control Policy and Prevention: Infection Prevention and Control Program' effective 12/2024, revised 09/2025 documented; the facility will provide personal protective equipment to support compliance with standard and transmission-based precautions. Any staff member that suspects a breach in infection prevention and control practice or policy is to report it to the person responsible for infection control or the director of nursing. The facility policy titled enhance barrier precautions dated 05/2024, documented: high contact resident activities include wound care, any skin opening requiring a dressing. A physician's order must be obtained for enhance barrier precautions for any resident. The facility will have discretion on how to communicate with staff to which residents require the use of precautions. Resident #12 was admitted with diagnoses that include osteomyelitis (bone infection), methicillin resistant staphylococcus aureus infection (type bacteria not treatable by most antibiotics, contagious), and diabetes mellitus type 2 (condition where body does not properly regulate blood sugar level). A comprehensive minimal data set dated [DATE], documented brief interview for mental status score of 15, indicating the resident had intact cognition.A physicians order dated 11/05/2025 documented enhanced barrier precautions and ensure appropriate personal protective equipment (gloves, gowns, face mask) is used during resident care activities. A physicians order dated 10/01/2025 documented isolation contact precautions reason for methicillin resistant staphylococcus aureus in left foot wound. A physician 's order dated 10/27/2025 documented an order for infectious disease consult regarding methicillin resistant staphylococcus aureus infection left foot wound. Resident #12's comprehensive care plan dated 06/02/2025 documented, Resident #12 had a diagnosis of methicillin resistant staphylococcus aureus infection in the wound and required isolation. Interventions documented isolation precautions: droplet, and contact precautions as ordered. A progress note dated 10/01/2025 documented on contact precaution due to methicillin resistant staphylococcus aureus (type bacteria not treatable by most antibiotics, contagious) from the wound, personal protective equipment available and isolation maintained'. An admission summary progress note dated 09/30/2025 documented that Resident #12 was on contact precautions. There is no documented evidence of a physicians order to discontinue contact precautions. A physician's order dated 11/05/2025 documented Cefepime (antibiotic used to treat a variety of serious bacterial infections) Intravenous Solution Reconstituted 2 GM intravenously every 12 hours for wound infection for 7 Days administered by Registered Nurse supervisor.During an observation on 11/04/2025 at 2:00PM, Resident #16's room door had signage and personal protective equipment. The signage on the door of the resident's room documented contact plus precautions; Staff: wear gown and gloves, additional personal protective equipment based on point of care risk assessment. During an observation on 11/04/2025 at 2:05pm registered nurse supervisor #2 walked out of resident #12's room, with a mask on and immediately crumbled the mask and placed in their pocket did not wash their hands. Registered Nurse #2 was observed bending over resident #16 without any personal protective equipment on. During an interview on 11/04/2025 at 2:05pm with Registered Nurse Supervisor #2 they stated they were providing treatment care to resident #12 and stated they were wearing a gown, gloves and a mask. They stated the resident is on contact precautions for their foot wound. They stated they discarded their gown in the garbage pail inside Resident #12's room if they were not wearing a gown, it would be a very big problem. During an interview on 11/04/2025 at 2:07pm with Registered Nurse #2, they were not wearing a gown when providing care to Resident #12. They stated the staff member (registered nurse supervisor #2) in the room with them, was also not wearing a gown. They stated they both should have been wearing a gown when providing wound care to Resident #12. They stated this can cause an issue with contamination. During an interview on 11/04/2024 at 4:08pm with Director of Nursing Services they stated the signage on the door will let the staff know what personal protective equipment to wear. They stated that all staff should wear appropriate personal protective equipment before entering a room that is on contact precautions. 10 NYCRR 415.19(a) (1-3)

i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in S483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in S483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is- (A) A change in room or roommate assignment as specified in S483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). Based on record review and interviews during the Abbreviated Survey (Intake ID 2645865) the facility did not ensure it consulted with the resident's physician when there was a significant change in the resident's physical status for one (Resident #1) of twelve residents reviewed. Specifically, the facility did not ensure Resident #1's physician was consulted when Resident #1 was transferred to the hospital after they fell from the facility's third story window.The finding is:The facility's policy titled, Notification of Changes reviewed by the facility in August 2024 documented the purpose of the policy was to ensure the facility promptly informed the resident, consulted the resident's physician; notified, consistent with their authority, the resident's representative when there was a change requiring notification. Compliance guidelines included but were not limited to, to consult with the resident's physician when there was an accident that resulted in injury or had the potential to require a physician's intervention.Resident #1 had diagnoses that included Dementia, Strange and Inexplicable Behavior, and Homelessness. Resident #1's Minimum Data Set assessment dated [DATE] documented Resident #1 had moderate cognitive impairment, required supervision/ touch assistance for ambulation, and was at risk for wandering behavior.Resident #1's Comprehensive Care Plan for Falls initiated on 07/17/2025 documented Resident #1 had the potential for falls related to cognitive impairment, psychoactive drug use, and confusion (due to a diagnosis of Mild Dementia). A Comprehensive Care Plan note dated 10/17/2025 documented Resident #1 was observed sitting on the ground at the back of the building. An intervention dated 10/17/2025 documented Resident #1 was sent to the hospital via 911.A Nursing Progress Note dated 10/17/2025 written by Registered Nurse Supervisor #4 documented at approximately 7:10 AM they were informed that Resident #1 was outside on the ground at the back of the building. Registered Nurse Supervisor #4 went outside and observed Resident #1 to be awake and verbal and 911 was called. The Medical Director was made aware.During an interview on 10/30/2025 at 11:57 AM, the Medical Director stated they were the Primary Care Physician for Resident #1, and they were not made aware of Resident #1's transfer to the hospital on [DATE] until Resident #1 was readmitted to the facility on [DATE] with multiple fractures. The Medical Director stated they should have been informed on 10/17/2025.During an interview with Registered Nurse Supervisor #4 stated they wrote the progress note that the Medical Director was made aware of Resident #1's transfer to the hospital on [DATE]. Registered Nurse Supervisor #4 stated they made the Medical Director aware via a message on a messaging application. Registered Nurse Supervisor #4 stated they did not follow up to ensure the Medical Director received the message and they should have. Registered Nurse Supervisor #4 stated they did not have documented evidence of the message being sent because the messages disappeared after a certain period of time. Registered Nurse Supervisor #4 stated they should have ensured the Medical Director was informed.During an interview on 11/06/2025 at 11:07 AM, the Director of Nursing Services stated the Primary Care Physician should be informed when there is a change in a resident's condition. The Director of Nursing Services stated they used messaging service to send a message to the Medical Director and they (the Director of Nursing Services) saw the message Registered Nurse Supervisor #4 sent. The Director of Nursing Services stated it was documented in the Nursing Progress Note that the Medical Director was informed and they (the Director of Nursing Services) recalled speaking to the Medical Director on 10/17/2025 about Resident #1's accident.During an additional interview on 11/07/2025 at 12:30 PM, the Medical Director stated they normally received a message from the facility, but the staff were told that if they did not get a confirmation to the message, they needed to call them to let them know they had a message. The Medical Director stated they were not informed of Resident #1 going out the window until Resident #1 returned to the facility on [DATE].10 NYCRR 415.3(f)(2)(ii)(a)

NTENT The intent is for the facility to develop and implement policies and procedures that: Provide annual notification to each covered individual of their obligation to comply with the reporting requirements under section 1150B(b) of the Act; Ensure reporting reasonable suspicion of crimes against a resident or individual receiving care from the facility within prescribed timeframes to the appropriate entities, consistent with Section 1150B of the Act; and Ensure that all covered individuals, i.e., the owner, operator, employee, manager, agent or contractor, report reasonable suspicion of crimes, as required by Section 1150B of the Act. The facility should provide oversight and monitoring to ensure that implement the required policies and procedures, per 42 CFR S483.12(b). In addition, the facility must report alleged violations related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property and report the results of all investigations to the proper authorities within prescribed timeframes.S483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: S483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to 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. S483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. Based on record review and interviews conducted during an abbreviated survey (Intake ID 2633011 and 2645865), the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources, were reported to the New York State Department of Health. This was evident for two (2) residents (Resident #1 and Resident #2) of twelve sampled residents. 1) Specifically, Resident #1 and Resident #2 went out on pass on 09/30/2025 and did not return to the facility at the expected documented time of 3:00PM. Resident #1 and Resident #2 were located on the morning of 10/01/2025. The incident was not reported to the New York State Department of health until 10/01/2025 5:01 PM. 2) On 10/17/2025 at approximately 7:10 AM Resident #1 exited the building from a third story window and was found on the ground below the window and was transferred to the hospital. The incident was not reported to the New York State Department of Health until 2:23 PM on 10/17/2025.The findings are:The facility's policy titled Accident/ Incident reviewed in June 2025 documented, it is the policy of this facility to maintain the safety of all residents, in as much as possible. In compliance with the New York State Department of Health regulation, the resident environment remains as free of accident hazards as it is possible, and at this facility, each resident receives adequate supervision and assistive devices to prevent accidents. The facility's policy titled Reporting to Outside Agencies reviewed 02/07/2025 documented, the New York Stated Department of Health will be notified of an elopement incident if a resident with a pass fails to return from an outing. 1) Resident #1 had diagnoses that included dementia, strange and inexplicable behavior, and homelessness. Resident #1's minimum data set assessment dated [DATE] documented Resident #1 had moderate cognitive impairment, required supervision/touch assistance for ambulation, and was at risk for wandering behavior.A facility document titled, Resident Release Form: Out on Pass documented on 09/30/2025 at 10:13 AM Resident #1 left the facility to go to neighboring town and their expected return was 09/30/2025 at 3:00 PM. Resident #2 was listed as the responsible party.There was no documented evidence Resident #1 was assessed for the capacity to go out on pass, had a physician's order to go out on pass, or had a Comprehensive Care Plan for Out on Pass.Resident #2 had diagnoses that included bipolar disorder (a mental health condition characterized by significant mood swings that include emotional highs and lows), Type 2 diabetes, chronic multifocal osteomyelitis (an inflammatory bone disease that causes pain and inflammation) of the right foot and ankle, and difficulty walking. Resident #2 was admitted to the facility for post-operative care after a right great toe (the big toe) amputation. Resident #1's Minimum Data Set assessment dated [DATE] documented Resident #2 had an intact cognition, used a walker for ambulation, and an assessment for walking was not attempted due to medical condition or safety concerns.A facility document titled, Resident Release Form: Out on Pass documented on 09/30/2025 at 10:13 AM Resident #2 left the facility to go to neighboring town and their expected return was 09/30/2025 at 3:00 PM. Resident #2 was listed as the responsible party.There was no documented evidence Resident #2 was assessed for the capacity to go out on pass, had a physician's order to go out on pass, or had a Comprehensive Care Plan for Out on Pass.A facility document titled Summary of Investigation dated 10/1/2025, documented Resident #1 was signed out on pass by their significant other (Resident #2) at 10:13am on 09/30/2025. Resident #1 was located at the local post office with their significant other (Resident #2). Resident #1 returned to the facility from and unauthorized out on pass with the significant other (Resident #2) on 10/01/2025.There was no documented evidence the police were notified that Resident #1 and Resident #2 did not return to the facility at the specified time.The Complaint/Incident Investigation Report, Intake ID 2633011 documented the facility report was completed on 10/01/2025 at 5:01 PM. There was no documented evidence that the New York State Department of Health was notified within the two-hour time frame.During an interview on 11/06/2025 at 11:07AM, the Director of Nursing Services stated they shared the responsibility for reporting incidents to the New York State Department of Health with the Administrator. The Director of Nursing Services stated the New York State Department of Health should have been notified of the incident with the two-hour time frame. The Director of Nursing Services stated the police should have been notified.During an interview on 11/06/2025 at 11:56 AM, the Administrator stated they were responsible to comply with and have knowledge of federal regulations for the facility. The Administrator stated the incident regarding Resident #1 and Resident #2 not returning from out on pass should have been reported to the police and the New York State Department of Health sooner. When asked by the surveyor what the time frame for reporting missing persons was the Administrator did not specify a time when Resident #1 and Resident #2 should have been reported missing. The Administrator stated it should have been reported sooner.2) Resident #1 had diagnoses that included Dementia, Strange and Inexplicable Behavior, and Homelessness. Resident #1's Minimum Data Set assessment dated [DATE] documented Resident #1 had moderate cognitive impairment, required supervision/touch assistance for ambulation, and was at risk for wandering behavior.A facility document titled Summary of Investigation dated 10/17/2025, documented on 10/17/2025 at approximately 7:10 AM the unit nurse went to Resident #1's room and observed the air conditioner (a window air conditioner unit) on the floor. The unit nurse looked out the window and Resident #1 was observed outside, seated on the stairs (outside stairs leading to a basement area). The Director of Nursing Services was notified at 7:12 AM and arrived at the facility at 7:20 AM. The Director of Nursing notified the Administrator of the incident. Upon facility investigation, Resident #1 tampered with/removed the air conditioner from the window and exited window, resulting in a fall with multiple injuries/fractures requiring hospitalization.The Complaint/Incident Investigation Report, Intake ID 2645865 documented the facility report was completed on 10/17/2025 at 2:23 PM. There was no documented evidence that the New York State Department of Health was notified within the two-hour time frame.During an interview on 10/17/2025 at 1:15 PM, the Director of Nursing Services stated the incident had not been reported yet. The Director of Nursing Services stated the Administrator was working on it now. The Director of Nursing Services stated they did not report the incident within the two-hour time frame because they were dealing with emergency services and interviewing staff for the investigation. The Director of Nursing Services stated they should have reported the incident within two hours of occurrence.During an interview on 10/17/2025 at 5:36 PM, the Administrator stated the Director of Nursing Services informed them of the incident regarding Resident #1 this morning but could not recall the time. The Administrator stated they did not report this incident within the two-hour time frame because they did not have access to a computer this morning.10 NYCRR 415.4 (b)(2)

Based on observation, record review and staff interviews during an abbreviated Survey (800072) initiated on 08/19/2025 and completed on 09/11/2025, the facility did not ensure the resident environment remained free of accident hazards for one (1) of two resident floors (Floor 2) reviewed. Specifically, Floor 2, a locked dementia care unit had a bottle of Isopropyl Alcohol 91% and over 30 pills of brand multivitamins accessible to residents.Findings include:Isopropyl alcohol also known as rubbing alcohol is a clear, colorless liquid. Widely used as a first aid antiseptic, surface disinfectant and solvent, it is highly flammable, and potentially toxic if absorbed through the skin, inhaled as vapor or ingested. It can lead to dizziness headache nausea, central nervous system depression and loss of consciousnessResident #1 is a [AGE] year-old male admitted to the facility 8/18/23. Medical diagnosis includes dementia anxiety disorder Diabetes type 2. Minimum Data Set, dated [DATE] documents Brief Interview Mental Status score of 5.A comprehensive care plan titled cognition dated 8/2022 documented resident has short and long term memory loss. Interventions include ensure resident safety. There were no care plans observed for self administration. There is no documented order that resident may self administer medication.During an observation 08/19/2025 of Resident #1's bedroom, the bedside table was observed with a bottle containing over 30 tablets of brand name multivitamin tablets. Additionally, the resident was observed with 91% isopropyl alcohol 16 ounces about 90% full. During an interview conducted with Resident #1 on 8/19/2025 at 10:30 AM they stated they did not know what the bottle of pills on the bedside table were or where they came from. They further stated possibly a family member brought them to eat because they were concerned about their weigh loss. When asked about the bottle of isopropyl alcohol Resident #1 replied it was water.During an interview on 8/19/2025 at 11:53 AM, License Practical Nurse #1 stated they are the primary nurse for Resident #1. Licensed Practical Nurse #1 stated she provided the resident with their medication in their room in the morning. Licensed Practical Nurse #1 stated the Resident should not have the alcohol or the bottle of vitamins at the bedside. She further stated she does not know where the resident got it from and would remove it immediately.During an interview on 08/19/2025 at 2:00 PM the Director of Nursing stated the second floor is a designated dementia unit. They further stated there should not be any medication or alcohol at the resident's bedside.10 NYCRR 415.12(h)(1)(2)

Based on observation, record review and staff interviews during an abbreviated Survey (800072) initiated on 08/19/2025 and completed on 09/11/2025, the facility did not ensure that a resident maintained, to the extent possible, acceptable parameters of nutritional and hydration status. Specifically, Resident #1's weight decreased from 190 pounds in July 2025 to 168 pounds in August 2025, a total weight loss of 22 pounds in one month. This loss of over 11.5% exceeds the Centers for Medicare & Medicaid Services (CMS) guideline for a significant weight loss of 5% in 30 days. Furthermore, there is no documented evidence that the dietician implemented new nutritional interventions to address this decline prior to the survey entrance.The finding is:The policy titled Significant Weight Change/ Unplanned weight loss dated 10/22/2024 documented significant weight change is indicated by -5% in 30 days -7.5% in 90 days -10% in 180 days. Further documented when a weight loss is detected a healthcare team will do the following weekly and monthly weights for 2 weeks to determine if weigh loss remains significant. Review food intake record and estimate oral intake, initiate a 3-day caloric count, identify possible medical and psychosocial causes of inadequate nutrient intake interview resident for information and update food preferences monitor intake of foods and fluids and check laboratory data as necessary.Resident #1 is a [AGE] year-old male admitted to the facility 8/18/23. Medical diagnosis includes dementia anxiety disorder Diabetes type 2. Minimum Data Set, dated [DATE] documents Brief Interview Mental Status score of 5. Resident requires supervision or touching assistance for shower and bathing hygiene and eating. The Minimum Data Set further documents a weight of 190 pounds 74 height.The Comprehensive Care Plan titled Nutrition dated 08/01/2022 with the last revision dated 7/16/2025 documented as the goal: Resident will have no significant weight changes through the review date and the resident will consume greater than 50% of meals snacks and supplements provided through the review date. The approaches included but were not limited to: Review food/fluid preferences, menu/alternates available, and monitor intake via nutrition log.The Facilities weigh record documents the following weights: 05/01/2025 187.4 pounds06/02/2025 192.4 pounds07/01/2025 190.2 pounds08/04/2025 168.8 poundsPhysician order documented No concentrated sweets diet regular texture thin consistency, Boost glucose control three times a day for supplement 240cc three times daily effective 03/27/2025.A Nutrition progress note dated 7/16/2025 documented Resident is at risk for nutrition compromise related to dementia anxiety follow up of weigh 3/27/202185 pounds 3.2% with decrease. The note further documented improved appetite 06/25/2025.A draft physician note dated 07/25/2025 documented pt referred for evaluation for progressive weight loss weight of 185 pounds and Body mass index 23.8, weight of 212 in 2023. The note further documented Metformin was discontinued and started Invokana.A Nurse practitioner progress note dated 08/13/2025 documented follow up resident visit note for weight variance/weight gain. The note further documented: Weight Variance with mild weight loss, Dietitian following for Management and Continue with Low Fat Low Chol/No Added Salt /no Concentrated Sweet, Regular texture, thin consistency diet and GLUCERNA Supplement and well tolerated well. Dietitian following for monitoring of weight status. Weight 171.6 LBS 08/07/25 from 192.4 LBS on 06/02/25 from 187.4 LBS 5/01/25.Continue Bowel Regimen and monitor for BM. Continued Medication including Melatonin at hours of sleet for insomnia with improvement.There are no documented notes from the Dietician or change in plan of care thru 8/18/2025.During an observation with the state agency the resident weigh on 08/19/2025 resident was weight on a standing scale read 171 pounds. During an observation of lunch resident was observed to be served in his room a meal tray which included rice, beans chicken taco milk and a fruit cup. The resident did not consume any of the meal. During observation resident was offered a sandwich which he was observed to eat half of half the sandwich 25%.The Certified Nurses Accountability was reviewed for July 1-July 31, 2025, and documented resident received setup or clean up assistant with most meals on the 7-3 and 3-11 shift. The Accountability sheet further documented on average resident consumed 51-75% of meals offered during the day 9:00 AM, 1:00PM and 5:00PM.During an interview conducted on 8/19/2025 with Resident #1 they stated they have lost quite a bit of weight because their pants are falling off and their shirts do not fit. Resident #1 stated he does not like the food, so he does not eat it. Resident #1 stated that staff gives him a sandwich but thinks it might not be enough. Resident #1 does not remember if he is provided with a supplement or how often but states he does not drink much. During an interview conducted on 8/18/2025 at 2 pm with Certified Nursing Assistant #1 they stated they are the primary aid for resident #1. They stated that resident #1 has not been eating his meals and is offered a sandwich. Certified nursing Assistant #1 stated they document 50% of meals because Resident #1 eats 1/2 of the sandwich offered. They stated resident #1 does not eat any of the hot meal but will eat some of the sandwich and drink the juice. They stated they have not directly reported it, but everyone knows including the nurse and dietician that the resident is not eating his meals.Multiple attempts were made to reach the dietician and were unsuccessful.During an interview conducted with the Director of Nursing on 8/18/2025 they stated they were notified on 8/18/2025 by the dietician that the Resident had a significant weight loss. The Director of Nursing stated they did not initiate a calorie count because the Certified nursing accountability record documents the resident was eating 50% of their meals. They stated they were not aware of any new interventions in place.During an interview conducted with the medical Director on 8/18/2025 at 3:00PM they stated they can not recall the resident however if a resident has a significant weight loss they will discuss with the dietician, do a calorie count and will look medically for an underlying cause such as medication like metformin or Ozempic which can suppress appetite. If they find the resident is not finishing meals because of depression or underlying issues they will notify the family and start an appetite stimulant. 10 NYCRR 415.12(i)(1)

Based on record review, and interviews during the Recertification Survey and Abbreviated Survey (NY 00366821) initiated on 2/3/2025 and completed on 2/7/2025, the facility did not ensure that a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet the resident's need was developed and implemented for each resident. This was identified for one (Resident #55) of five residents reviewed for Unnecessary Medications. Specifically, on 9/24/2024 Resident #55 was transferred to the hospital due to unresponsiveness. The resident was readmitted on [DATE] with a diagnosis of Opioid (class of natural, semi-synthetic, and synthetic drugs) Overdose. There was no documented evidence that a comprehensive care plan with appropriate interventions was developed to prevent further potential Opioid Overdose. The finding is: The facility's Opioid Overdose Management/Use of Naloxone policy and procedure dated 12/2024 documented the facility will have Naloxone (a medicine that reverses Opiod overdose) available on each nursing unit for use in the event of an apparent or suspected Opioid overdose is identified. The Medical Director shall approve standing orders for the facility to allow the administration of Naloxone by any licensed nurse to any resident upon reasonable suspicion of Opioid overdose, without having to first obtain a verbal or written order to prevent delay in treatment that may result in resident harm. Such reasonable suspicion shall be based on the presentation of symptoms of Opioid overdose. The facility's Comprehensive Interdisciplinary Care Plan Completion of Minimum Data Set 3.0 policy and procedure reviewed 12/2024 documented that the interdisciplinary team will assess the resident holistically to develop a plan that will promote quality of care and quality of life to assist the resident in achieving goals. Resident #55 was admitted with diagnoses that included Delusional Disorder, Bi-Polar Disorder, and Alcohol Abuse. A Quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 15, which indicated intact cognition. The resident's Mood Interview score was 10, which indicated mood symptoms were present. The resident had no behavioral symptoms present and was receiving Anti-Anxiety, anti-depressants, Opioid, and hypnotic medications; indicators were present for the use of the medications. A Nurse Practitioner's note dated 9/24/2024 documented the resident was re-examined and found non-responsive to verbal as well as tactile (touch) stimuli. The resident was responsive to deep and painful stimuli. Narcan (Naloxone) Spray 4 milligram Nasal time one dose was given and within seconds the resident had opened their eyes, became slowly responsive to their name, and was moaning. 911 was activated to transfer the resident to the hospital for further treatmentfor diagnoses that included possible suspected Opioid overdose. A Health Status Note dated 9/24/2024 at 4:39 PM documented the resident was transferred to the hospital for severe lethargy. A Patient Review Instrument dated 9/30/2024 documented primary diagnoses that included but not limited to Urinary Tract Infection and Opioid overdose. During an interview on 2/7/2025 at 4:05 PM, the Minimum Data Set Coordinator stated they or the admission nurse could have initiated a care plan that addressed the drug overdose to prevent further occurrences. The Minimum Data Set Coordinator stated they usually initiated the original care plans, and the unit nurses were responsible for updating and initiating the interim care plans. The Minimum Data Set Coordinator further stated a care plan with interventions specifically addressing the Opioid overdose should have been developed. During an interview on 2/7/25 at 4:15 PM, the Director of Nursing Services stated that a care plan addressing the Opioid overdose should be developed and implemented. The Minimum Data Set Coordinator was responsible for initiating the care plans. The Director of Nursing Services stated that the Minimum Data Set Coordinator should have initiated a care plan with appropriate interventions that addressed the Opioid overdose to prevent further occurrences and if the Minimum Data Set Coordinator was not available, the Registered Nurse Supervisors could have initiated the care plan. 10 NYCRR 415.11(c)(1)

Based on observation, record review, and interviews during the Recertification Survey and Abbreviated Survey (NY 00366821), the facility did not ensure that an investigation of alleged abuse was thoroughly and timely investigated to prevent further potential abuse, neglect, exploitation, or mistreatment. This was identified for one (Resident #55) of two residents reviewed for Abuse. Specifically, on 12/28/2024 Resident #55 verbalized that a Certified Nursing Assistant scratched them during the morning care. There was no documented evidence that an investigation to rule out abuse, neglect, or mistreatment was initiated until 12/30/2024. The finding is: The facility Accident/Incident Report reviewed 1/2025 documented all accidents/incidents involving residents must be reported to the Director of Nursing Services and or Assistant Director of Nursing. An Accident/Incident Report must be completed on the shift in which the accident/incident occurred. A copy of this report is to be provided to the Assistant Director of Nursing/designee within 24 hours of such incident. Resident #55 was readmitted to the facility with diagnoses that included Bipolar Disorder, and Urinary Tract Infection. A Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score as 12, which indicated the resident had moderately impaired cognition. The resident required partial to moderate assistance for toileting, bathing, dressing, rolling left to right, and personal hygiene. There was no functional limitation in the range of motion to the upper and lower extremities. The resident's Mood Interview score was 10, which indicated mood symptoms were present. The resident had no behavioral symptoms. A Late entry note dated 1/15/2025 for 12/30/2024, entered by the Director of Nursing Services, documented that on 12/30/2024, Resident #55's representative reported that the resident had a scratch on their buttocks. A complete body check was done, and the resident's skin was found to be intact, without scratches or redness. Resident #55 then informed the Director of Nursing Services that on 12/28/2024 at approximately 7:30 AM, during care, Certified Nursing Assistant #5 squeezed the resident's fingers. The assigned Certified Nursing Assistant #4 was also present in the room. The Accident and Incident Report dated 12/30/2024 documented the resident alleged they were scratched by a Certified Nursing Assistant during care on 12/28/2024 at approximately 7:30 AM. The resident's statement on the Accident/Incident Report documented the Certified Nursing Assistant scratched me on purpose. A Summary of Investigation dated 12/30/2024 documented Resident #55 had initially reported their buttock injury, which was caused by a Certified Nursing Assistant during morning care, to the nurse on Saturday 12/28/2024. The report documented that the nurse initially examined the area and had no findings; however, Resident #55 was upset and continued to insist that they were scratched on the right buttocks. During a skin assessment, the nurse noted visible lines of indented skin on the resident's right upper thigh caused by the brief. There was no documented evidence that an investigation was initiated on 12/28/2025 including statements from the involved Certified Nursing Assistant #4 and Certified Nursing Assistant #5 to rule out abuse, neglect, or mistreatment. There was no documented evidence of a nursing progress note related to the allegations made by the resident regarding staff intentionally scratching the resident's buttock area or squeezing their finger during care. A Typed statement signed by Resident #55 dated 12/30/2024 documented that on 12/28/2024 around 7:30 AM Certified Nursing Assistant #4 and Certified Nursing Assistant #5 came to their room to change them. Certified Nursing Assistant #4 proceeded to change them while Certified Nursing Assistant #5 was standing on the left side of the room. Certified Nursing Assistant #4 closed the left side of the brief and then asked Certified Nursing Assistant #5 to assist. Certified Nursing Assistant #5 came to the right of the bed. Resident #55 told Certified Nursing Assistant #5 not to touch them as they usually have only one Aide helping them and did not want Certified Nursing Assistant #5 to assist. Resident #55 grabbed the strap of the brief with both hands to stop Certified Nursing Assistant #5. While Resident #55 was turning to their left side for Certified Nursing Assistant #4 to close the right side of the brief, Certified Nursing Assistant #5 grabbed the resident's right hand and squeezed the resident's hand hard, and with their (Certified Nursing Assistant #5) other hand they scratched the resident's right buttock. A Comprehensive Care Plan dated 1/14/2025 documented the resident has accusatory, attention-seeking, and fabrication behaviors towards staff and peers. Interventions included a two-person approach during care and to observe for changes in the resident's behavior. During an interview on 2/6/2025 at 12:26 PM, Certified Nursing Assistant #4 stated they were assigned to Resident #55 on 12/28/2024. Certified Nursing Assistant #4 stated that on 12/28/2024 the resident asked to be changed, and they informed the resident that they would get a second Certified Nursing Assistant to assist with their care. Certified Nursing Assistant #4 stated that during the brief change Certified Nursing Assistant #5 assisted with applying the brief on one side. Certified Nursing Assistant #4 stated after they had fastened the tape on the left side of the brief, Certified Nursing Assistant #5 was about to fasten the tape on the other side when the resident screamed Don't touch me, at that time Certified Nursing Assistant #5 left the room to get Licensed Practical Nurse #1. Certified Nursing Assistant #4 stated Licensed Practical Nurse #1 came and stayed in the resident's room until the care was completed. Certified Nursing Assistant #4 stated during care Resident #55 did not complain Certified Nursing Assistant #5 scratched them or squeezed their hand. During an interview on 2/6/2025 at 12:45 PM, Certified Nursing Assistant #5 stated on 12/28/2024 they had assisted Certified Nursing Assistant #4 with the care of Resident #55. Certified Nursing Assistant #5 stated the resident was a two-person approach and was upset because the resident did not want them in the room. Certified Nursing Assistant #5 stated as they were about to fasten the brief, Resident #55 grabbed the brief and said, Don't touch me. Certified Nursing Assistant #5 stated they did not touch the resident and left the room right away to get Licensed Practical Nurse #1. Certified Nursing Assistant #5 stated shortly after the incident, Registered Nurse #2 Supervisor interviewed them regarding the resident's complaint of being scratched. Certified Nursing Assistant #5 stated they had short nails and were wearing gloves during care. Certified Nursing Assistant #5 stated they did not touch the resident and did not squeeze the resident's hand. During an interview on 2/6/2025 at 1:42 PM, Registered Nurse #2, the 7:00 AM-3:00 PM shift supervisor, stated on 12/28/2024 between 9:00 AM -10:00 AM the resident called the receptionist to speak with the Supervisor. Registered Nurse #2 stated the resident reported that someone scratched them on their leg; however, the resident did not want to be touched. Registered Nurse #2 stated they observed two lines on the resident's right upper thigh that were red and looked like the lines of indented skin caused by the brief. Registered Nurse #2 stated when they assessed the resident on 12/28/24 that they did not document their assessment in the medical record. Registered Nurse #2 stated that they had forgotten to document their assessment in the chart and did not start an investigation. During an interview on 2/7/2024 at 12:00 PM, Resident #55 stated while the staff was applying their brief, they asked Certified Nursing Assistant #5 not to touch them. Resident #55 stated they held onto their brief and Certified Nursing Assistant #5 held on to their (the resident's) right hand to remove their (the resident) hand from the brief and Certified Nursing Assistant #5 squeezed their hand. The resident stated their hand was hurting for four days after the incident. Certified Nursing Assistant #5 also scratched them when they tried to remove their hand from the brief. The resident stated that the Certified Nursing Assistant #5 should have stopped when they asked them not to touch them. The Resident further stated that both Certified Nursing Assistant #4 and Certified Nursing Assistant #5 were wearing gloves during the care. During an interview on 2/7/2025 at 1:58 PM, Licensed Practical Nurse #1 stated they worked on the morning shift 7:00 AM-3:00 PM on 12/28/2024. Licensed Practical Nurse #1 stated Certified Nursing Assistant #5 reported to them that the resident did not want two persons in their room during care. Licensed Practical Nurse #1 Licensed Practical Nurse #1 stated that the resident permitted them to stay in the room until Certified Nursing Assistant #4 had completed the care. Licensed Practical Nurse #1 stated the resident did not complain to them that a Certified Nursing Assistant scratched them or squeezed their hand. During an interview on 2/7/2025 at 2:30 PM, the Director of Nursing Services stated they were made aware of the allegation by the resident's representative called them on 12/30/2024. The Director of Nursing Services stated Registered Nurse #2 did not notify or complete a report of the allegation made by the resident on 12/28/24. The Director of Nursing Services stated an investigation should have been initiated by Registered Nurse #2 who was first notified of the allegation of abuse and should have documented their assessment in the progress note. The Director of Nursing Services and the Nurse Practitioner assessed the resident on 12/30/2024 and initiated an investigation. 10 NYCRR 415.4(b)(3)

Based on observation, record review, and interviews conducted during the Recertification survey initiated on 2/3/2025 and completed on 2/7/2025, the facility did not ensure services provided by the facility as outlined in the comprehensive care plan (CCP) must meet professional standards of quality. This was identified for one (Resident # 20) of five residents reviewed for unnecessary medications. Specifically, Resident #20 had a physician's order for Heparin (an anticoagulant) to be administered subcutaneously. The nursing staff were not rotating the injection sites when administering Heparin. Cross Reference: F755- Pharmacy Svcs/Procedures The finding is: The Policy and Procedure for Injection Site Rotation dated October 2023 documented that rotation of the injection site is required. Resident # 20 was admitted with diagnoses that included Functional Quadriplegia. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15, which indicated the resident's cognition was intact. The Minimum Data Set assessment documented Resident # 20 received anticoagulants and injections 7 of 7 days in the look-back period. The current Physician's order documented to administer Heparin Sodium (Porcine) Injection Solution 5000 units per milliliter subcutaneously two times a day for prophylactic measures. The Medication Administration Record for January - February 2025 documented Resident #20 received Heparin injections to their lower left abdomen on consecutive days twice daily on the following days: 1/4/2025, 1/9/2025 to 1/10/2025, 1/28/2025- 1/29/2025, 2/2/2025, and 2/4/2025 to 2/7/2025. There was no documented evidence that the injection site was rotated to other sites on these dates. During an observation and interview on 2/7/2025 at 1:54 PM, Resident #20 was observed in bed with their abdomen exposed (resident preference). A quarter-size ecchymosis (bruising) to the lower left abdomen was observed. Resident # 20 stated they do not monitor where they get their injections. During an interview on 2/7/2025 at 2:00 PM, Registered Nurse #1, the medication nurse, stated Heparin injection should be administered subcutaneously and the injection site should be rotated. Registered Nurse #1 stated the injection site for Resident #20 was not rotated as required and was unable to state the reason. During an interview on 2/7/2025 at 2:27 PM, the Director of Nursing Services stated the injection site of Heparin administration should be documented accurately and the injection site should be rotated. If the Heparin injection site is not rotated, it can cause tissue damage and discomfort for the resident. During an interview on 2/7/2025 at 12:48 PM, Physician #1 stated if the injection of Heparin is not rotated bleeding, pain, and tissue damage can occur. 10 NYCRR 415.11(c)(3)(i)

Based on observation, record review, and interviews conducted during the Recertification survey initiated on 2/3/2025 and completed on 2/7/2025, the facility did not ensure pharmaceutical services met the needs of each resident including appropriately administering all drugs and biologicals in accordance with the professional standards of practice. This was identified for one (Resident # 21) of five residents reviewed for unnecessary medications. Specifically, Resident #21 was prescribed Heparin Sodium (Porcine) Injection Solution 5000 units per milliliter and the nursing staff administered the injection without rotating the subcutaneous injection sites. Cross Reference: F658- Services Provided Meet Professional Standards The finding is: The Policy and Procedure for Injection Site Rotation dated October 2023 documents that rotation of the injection site is required. The pdr.net/drug summary/ Heparin Sodium injection website for Heparin subcutaneous injection administration documented to rotate the injection site frequently. The National Library of Medicine; National Center for Biotechnology Information: Nursing Skills 2nd edition 2023 documented it is important to rotate Heparin sites to avoid bruising in one location. Resident # 20 was admitted with diagnoses that included Functional Quadriplegia. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15, which indicated the resident's cognition was intact. The Minimum Data Set assessment documented Resident # 20 received anticoagulants and injections 7 of 7 days in the look-back period. The current Physician's order documented to administer Heparin Sodium (Porcine) Injection Solution 5000 units per milliliter subcutaneously two times a day for prophylactic measures. The Medication Administration Record for January - February 2025 documented Resident #20 received Heparin injections to their lower left abdomen on consecutive days twice daily on the following days: 1/4/2025, 1/9/2025 to 1/10/2025, 1/28/2025- 1/29/2025, 2/2/2025, and 2/4/2025 to 2/7/2025. There was no documented evidence that the injection site was rotated to other sites on these dates. During an observation and interview on 2/7/2025 at 1:54 PM, Resident #20 was observed in bed with their abdomen exposed (resident preference). A quarter-size ecchymosis (bruising) to the lower left abdomen was observed. Resident # 20 stated they do not monitor where they get their injections. During an interview on 2/7/2025 at 2:00 PM, Registered Nurse #1, the medication nurse, stated Heparin injection should be administered subcutaneously and the injection site should be rotated. Registered Nurse #1 stated the injection site for Resident #20 was not rotated as required and was unable to state the reason. During an interview on 2/7/2025 at 2:27 PM, the Director of Nursing Services stated the injection site of Heparin administration should be documented accurately and the injection site should be rotated. If the Heparin injection site is not rotated, it can cause tissue damage and discomfort for the resident. During an interview on 2/7/2025 at 12:48 PM, Physician #1 stated if the injection of Heparin is not rotated bleeding, pain, and tissue damage can occur. 10 NYCRR 415.11(c)(3)(i)

Based on observation, interviews, and record review conducted during the Recertification survey initiated on 2/3/2025 and completed on 2/7/2025, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the Kitchen task. Specifically, 1) several food items were stored in the walk-in refrigerator and walk-in freezer without proper labeling and dating; multiple frozen item bags were observed with ice and frost inside their packaging; Additionally, a plastic container and milk crates in the dry storage area were observed to be dirty. 2) Cold food items including yogurt, milk, chicken salad sandwich, and egg salad temperatures were observed above 41 degrees Fahrenheit. The findings are: A facility policy and procedure titled Food Storage effective 10/2024, documented food is stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination or cross-contamination. A date marking to indicate the date or day by which a ready-to-eat, potentially hazardous food should be consumed, sold, or discarded will be visible on all high-risk food. Foods will be stored and handled to maintain the integrity of the packaging until ready for use. Plastic containers with tight-fitting covers must be used for storing broken lots of bulk foods. All containers must be legible, accurately labeled, and dated. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Refrigerated food storage: all foods should be covered, labeled, and dated. A facility policy and procedure titled Cleaning and Sanitation of Dining and Food Service Areas, effective 10/2024, documented the food service staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. Tasks shall be designated to be the responsibility of specific positions in the department. All staff will be trained on the frequency of cleaning necessary. During an initial tour of the kitchen on 2/3/2025 at 9:26 AM, the walk-in refrigerator was observed with multiple food items (tapioca pudding, and beet salad) not properly labeled and dated. The walk-in freezer was observed with multiple food items (corn, French toast, chicken nuggets, French fries, turkey burger, beef burger, pork chops, and frankfurters) not properly labeled and dated. The bags of turkey burgers, beef burgers, pork chops, and frankfurters were observed to have ice/frost build up on the inside of the packaging. There were also two packages of Perogies and a corned beef outside of their original delivery pack without a delivery date. A plastic container of jelly was not dated in the reach-in refrigerator; the edges and the lid of the container had remnants of peanut butter on it. The Food Service Director was immediately interviewed and stated the cooks are responsible for labeling and dating food returned to the freezer. The Food Service Director stated the cooks should ensure that the food packages are sealed to prevent freezer burn. The container of jelly should have been dated and the edges should have been cleaned. During an interview on 2/3/2025 at 9:35 AM, [NAME] #1 stated the cooks are responsible for labeling and dating food packages when returning to the freezer. [NAME] #1 stated food with freezer burn cannot be served and should be discarded. During a tour of the dry storage area on 2/3/2025 at 9:40 AM, a plastic tub of beef soup base was observed with black dust on the lid. The plastic tub was stored on top of milk crates which were observed with a buildup of the soup base powder along the top and edges. The Food Service Director stated that the container and the milk crates should have been cleaned. During an interview on 2/6/2025 at 3:21 PM, the Administrator stated that stored food should be labeled and dated. The Administrator stated they were not aware the kitchen was not following the food storage procedure. 2) A facility policy and procedure titled Food Temperatures effective 3/2022 last reviewed 1/2025, documented it is the policy to record food temperatures daily to ensure food is at the proper serving temperature(s) before trays are assembled. Food temperatures will be checked on all items prepared in the dietary department. Potentially hazardous cold food temperatures will be kept at or below 41 degrees Fahrenheit. No food will be served that does not meet the food code standard temperatures. Place cold menu items such as ham salad or egg salad over an ice bath in a pan and not beside a heated steam table. The Cook's Temperature Log Sheet maintained by the facility did not include evidence of cold food temperature monitoring. During an interview on 2/6/2025 at 12:25 PM, [NAME] #2 stated they only measure the temperature of cold entrees but do not take the temperature of the other cold food items that are placed on the individual resident tray such as milk, yogurt, sandwiches, etc. During the Kitchen observation on 2/6/2025 at 12:32 PM, two trays of sandwiches were not kept in an ice bath. During an observation and interview on 2/6/2025 at 12:33 PM, [NAME] #3 stated they did not keep the sandwiches (such as American cheese, egg salad, tuna salad) on ice during preparation, nor did they take the temperatures of the sandwiches. [NAME] #3 measured the temperatures of the sandwiches. The American cheese sandwich temperature was measured at 60 degrees Fahrenheit, and the chicken salad sandwich temperature was measured at 50 degrees Fahrenheit. [NAME] #3 stated the temperature of the sandwiches should be below 40 degrees Fahrenheit. During an interview on 2/6/2025 at 12:40 PM, the Food Service Director stated the proper serving temperature for cold food should be 41 degrees Fahrenheit or below. The Food Service Director stated they do not routinely measure the temperature of cold food items such as sandwiches, milk, and yogurt. During an interview and observation on 2/6/2025 at 12:45 PM, Dietary Aide #1 stated that they do not measure the temperature of the cold food items before they place the food items on the individual resident trays. Dietary Aide #1 stated they usually kept cold items in a cooler, but the cooler was broken and was never replaced. Dietary Aide #1 measured the temperature of cold food items, finding yogurt at 50 degrees Fahrenheit, milk at 50 degrees Fahrenheit, and a cup of egg salad at 60 degrees Fahrenheit. Dietary Aide #1 stated the temperature of the cold food should be less than 41 degrees Fahrenheit. During an interview on 2/6/2025 at 3:21 PM, the Administrator stated they were aware of the food temperature standards and cold food should be maintained at a temperature of 41 degrees Fahrenheit or below. The Administrator stated they did not know the Food Service Director was not monitoring the temperature of the cold food items served to the residents. 10 NYCRR 415.14(h)

Based on observations, record review, and interviews during the Recertification Survey initiated on 1/17/2024 and completed on 1/23/2024, the facility did not ensure that a clean, comfortable, and homelike environment was maintained on one of two resident floors. Specifically, two rooms on the first floor had holes in the wall. 1) Resident #10's room was observed on 1/17/2024 and 1/18/2024 with a nine-inch by nine-inch square hole in the wall behind the room entrance door and a one-inch by half of an inch hole to the bathroom door. 2) Resident #34's room was observed on 1/17/2024 and 1/18/2024 with a one-inch by half-inch hole in the wall behind the door. The findings are: The Policy and Procedure for Quality of Life-Homelike Environment dated 1/20/2023 documented the facility will maintain the resident's environment by addressing any wear and tear or repairs. The Policy and Procedure for Routine Maintenance dated 3/02/2023 documented the maintenance department will ensure that the physical environment, furniture, and equipment are maintained in good repair throughout the facility. The routine maintenance program will ensure a safe and comfortable environment for residents and staff by maintaining the facility in good repair and free of hazards as well as maintaining compliance with all applicable codes. Routine monitoring will be on a quarterly basis unless otherwise indicated. 1) Resident #10 has diagnoses of Chronic Obstructive Pulmonary Disease, Bipolar Disorder, and Cirrhosis of the Liver. The Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 14 which indicated the resident had intact cognitive function. During an environmental tour of Resident #10's room on 1/17/2024 at 11:30 AM and 1/18/2024 at 11:30 AM, a nine-inch by nine-inch hole was observed in the wall behind the resident's room entry door. A one-inch by half-inch hole was observed on the bathroom door near the bathroom door handle. Resident #10 was interviewed on 1/17/2024 at 11:45 AM and stated the broken wall and the door have been like that for four and half months and nobody came to fix the broken wall and the hole on the door. Resident #10 stated they did report the hole in the wall to someone, but they could not remember who they spoke to. Resident #10 further stated the staff were able to see the holes in the wall and on the door on a daily basis. Certified Nursing Assistant #1 was interviewed on 1/18/2024 at 3:17 PM and stated they provide care for Resident #10 and did not see the hole in the wall because it was behind the door and did not notice the hole on the bathroom door. Licensed Practical Nurse #1 was interviewed on 1/18/2024 at 3:15 PM and stated when they care for Resident #10, they pull the privacy curtain to provide privacy to the resident. Since the door was always open, they did not notice the broken part of the wall behind the door. Licensed Practical Nurse # 1 stated they did not see the hole on the bathroom door. Licensed Practical Nurse #1 further stated if they saw the holes in the wall or on the bathroom door, they would have reported their observations to the nurse manager. The Director of Maintenance was interviewed on 1/18/2024 at 3:11 PM and stated they were not made aware of the holes in Resident #10's room. The Director of Maintenance stated the holes should have been fixed. The Director of Maintenance stated they inspect the rooms daily as per the facility policy; however, they do not check behind the doors. The Director of Maintenance confirmed that Resident #10's room had a hole behind the door measuring nine inches by nine inches and the bathroom door had a hole measuring one inch by half an inch. 2) Resident #34 had diagnoses including Major Depressive Disorder and Hypertension. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 12, which indicated the resident had moderately impaired cognition. Resident #34's room was observed on 1/17/2024 at 12:15 PM. A one-inch by half-inch hole was observed on the wall behind the room entry door. The Director of Maintenance was re-interviewed on 1/23/2024 at 11:47 AM and stated they check each room every day as indicated in the facility policy. The Director of Maintenance stated they checked Resident #34's room daily; however, they did not notice the hole behind the door. The Director of Maintenance stated they should have been notified about any disrepair to the walls or doors by the unit staff. The Director of Maintenance stated they would expect anybody who notices any disrepair to enter a maintenance request in the software we utilize. Resident #34 was interviewed on 1/23/2024 at 12:10 PM and stated the hole in the wall had been there for a month. They did not recall if they reported the hole to anyone. The Administrator was interviewed on 1/23/2024 at 1:15 PM and stated they saw the hole in the wall and the hole on the bathroom door in Resident #10's room for the first time on 1/18/2024. The Administrator stated if the staff observes any maintenance issues, they have to put in a request into the system that notifies maintenance staff to address the repair. Every staff in the facility has access to the system to place a request to fix anything in the facility. There were no maintenance requests regarding Resident #10 or Resident #34's room. The Director of Nursing Services was interviewed on 1/23/2024 at 12:54 PM and stated that it is not acceptable for a resident's room to be in disrepair. All staff have access to the system to report anything that needs to be fixed. Everyone is responsible for reporting any problems they identify. The maintenance department then has the responsibility to make the repairs. 10 NYCRR 415.5 (h)(2)

Based on record review and interviews conducted during a Recertification Survey and Abbreviated Survey (Complaint #NY 00323806) initiated on 1/17/2024 and completed on 1/23/2024, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported to the New York State Department of Health. This was identified for one (Resident #14) of three residents reviewed for Abuse. Specifically, the facility did not report an allegation of verbal abuse to the New York State Department of Health, when Resident #14 complained that Certified Nursing Aide #2 made a derogatory remark towards them. The resident stated the remark left them feeling threatened for their well-being, disrespected, and angry. The finding is: The facility's policy titled, Resident Abuse, Mistreatment, and Neglect last reviewed March 2023 defined abuse as inappropriate physical contact with a nursing home patient or a health related facility resident. Examples of (but not limited to) resident abuse or mistreatment include sarcastic, rude, or curt remarks. Under the section Internal Investigation, the policy documented the facility completes a full investigation to ensure timely investigation and follow-up of the allegation, and to ensure timely reporting of such instances to Administration and Regulatory agencies. Resident #14 was admitted with diagnoses including Non-Hodgkin's Lymphoma, Peripheral Vascular Disease and Lymphedema. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had intact cognition. The Minimum Data Set documented that Resident #14 was able to understand and be understood. A Comprehensive Care Plan (CCP) for Abuse dated 8/16/2019, and last updated on 11/8/2023 documented the resident was at risk for abuse. The interventions included to in-service all staff on resident's special care needs, observe interaction with peers, and clearly outline care goals and activities. An untitled document dated 1/9/2023 regarding Resident #14 and Certified Nursing Aide #2, which was written and signed by the Director of Nursing Services, documented that on 1/5/2023 the Director of Nursing Services was notified by Resident #14 that Certified Nursing Aide #2 knocked loudly on their door. When Resident #14 told Certified Nursing Aide #2 not to knock loudly on their door, Certified Nursing Aide #2 said, F your mother as they (Certified Nursing Aide #2) left the resident's room. The Director of Nursing Services removed Certified Nursing Aide #2 from the resident's assignment. The Director of Nursing Services spoke with the Certified Nursing Aide #2 who denied the allegation made by Resident #14. There was no documented evidence that an accident and incident or an occurrence report was completed that included a summary conclusion that ruled out abuse, neglect, or mistreatment. Additionally, there was no documented evidence of a determination of whether the incident was reportable to the New York State Department of Health. Resident #14 was interviewed on 1/17/2024 at 1:08 PM and stated that the incident occurred approximately a year ago. Resident #14 stated that they (Resident #14) made a complaint to Certified Nursing Aide #2 that Certified Nursing Aide #2 was knocking on the door too loud and if Certified Nursing Aide #2 continued to knock that loud then they (Resident #14) do not want Certified Nursing Aide #2 in their room anymore. Resident #14 stated that Certified Nursing Aide #2 responded, Why don't you go f*** your mother. Resident #14 stated that they (Resident #14) felt disrespected and angry and stated nobody should be saying that to anyone. Resident #14 stated they informed the Director of Nursing Services and the Director of Nursing Services told them (Resident #14) the staff member would not enter their (Resident #14) room or work on the floor again. The Director of Nursing Services was interviewed on 1/23/2024 at 10:47 AM and stated Resident #14 complained to them about Certified Nursing Aide #2. The Director of Nursing Services stated they did not recall the time and date the resident made the complaint. The Director of Nursing Services stated that they interviewed Certified Nursing Aide #2 who denied that the incident took place. The Director of Nursing Services stated there was no Accident and Incident report or a grievance report related to Resident #14's allegation of verbal abuse. The Director of Nursing Services stated they will look again as there may be something in their office. The Director of Nursing Services was re-interviewed on 1/23/2024 at 2:16 PM and stated the incident was investigated on 1/5/2023 and there was no reasonable cause to believe abuse occurred; therefore, the incident was not reported to the New York State Department of Health. The Director of Nursing Services stated if the staff member did curse at Resident #14, Resident #14 would have reported the staff right away and not waited a few months. The Director of Nursing Services stated that abuse such as observations of bruises or injury, and complaints of being isolated would be reported to the New York State Department of Health. The Director of Nursing Services stated that verbal abuse was a form of abuse, and they now know that verbal abuse also needs to be reported to the New York State Department of Health. The Administrator was interviewed on 1/23/2024 at 2:38 PM and stated that they were not the Administrator at the time when the incident was reported. The Administrator stated that all alleged abuse incidents must be handled according to facility policies and regulations. The Administrator stated all allegations of abuse needed to be investigated thoroughly to determine if they were reportable to authorities including the New York State Department of Health. The Administrator reviewed all the documents provided by the Director of Nursing Services to the surveyor and stated if they (Administrator) were to investigate this incident today, they would need to obtain more information to be able to rule out abuse. The Administrator stated that verbal abuse was a form of abuse and when there was reasonable belief that verbal abuse occurred, then the incident should be reported to the New York State Department of Health. 10 NYCRR 415.4(b)(2)

Based on record review and interviews conducted during a Recertification Survey and Abbreviated Survey (Complaint #NY 00323806) initiated on 1/17/2024 and completed on 1/23/2024, the facility did not ensure that all alleged violations are thoroughly investigated in response to allegations of abuse. This was identified for one (Resident #14) of three residents reviewed for Abuse. Specifically, Resident #14 reported on 1/5/2023 to the Director of Nursing Services that they (Resident #14) were verbally abused by Certified Nursing Aide #2 a few months ago. The facility did not initiate an investigation of the allegation according to the facility policy to rule out abuse. The finding is: The facility's policy titled, Resident Abuse, Mistreatment, and Neglect last reviewed March 2023 defined abuse as inappropriate physical contact with a nursing home patient or a health-related facility resident. Examples of (but not limited to) resident abuse or mistreatment include sarcastic, rude, or curt remarks. Under the section Internal Investigation, the policy documented resident/family/visitor allegations of abuse, mistreatment or neglect will trigger an investigation. An occurrence report will be initiated. The Administrative team will determine, through a verbal and/or written summary report of findings, whether abuse is substantiated and a decision is made whether or not to notify the New York State Department of Health. Under the section titled, Reporting, a decision of a potential abuse and to notify the New York State Department of Health is made within 24 hours of the complaint followed by a computer entry to the Health Provider Network (HPN) Nursing Home Surveillance site of the facility investigation within five days. Resident #14 was admitted with diagnoses including Non-Hodgkin's Lymphoma, Peripheral Vascular Disease and Lymphedema. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had intact cognition. The Minimum Data Set documented that Resident #14 was able to understand and be understood. An untitled document dated 1/9/2023 regarding Resident #14 and Certified Nursing Aide #2, which was written and signed by the Director of Nursing Services, documented that on 1/5/2023 the Director of Nursing Services was notified by Resident #14 that Certified Nursing Aide #2 knocked loudly on their door. When Resident #14 told Certified Nursing Aide #2 not to knock loudly on their door, Certified Nursing Aide #2 said F your mother as they (Certified Nursing Aide #2) were leaving the room. The Director of Nursing Services removed Certified Nursing Aide #2 from the resident's assignment. The Director of Nursing Services spoke with the Certified Nursing Aide #2 who denied the allegation made by Resident #14. There was no documented evidence that an accident and incident or an occurrence report was completed that included a summary conclusion that ruled out abuse, neglect, or mistreatment. Additionally, there was no documented evidence of a determination of whether the incident was reportable to the New York State Department of Health. Resident #14 was interviewed on 1/17/2024 at 1:08 PM and stated that the incident occurred approximately a year ago. Resident #14 stated that they (Resident #14) made a complaint to Certified Nursing Aide #2 that Certified Nursing Aide #2 was knocking on the door too loud and if Certified Nursing Aide #2 continued to knock that loud then they (Resident #14) do not want Certified Nursing Aide #2 in their room anymore. Resident #14 stated that Certified Nursing Aide #2 responded, Why don't you go f*** your mother. Resident #14 stated that they (Resident #14) felt disrespected and angry and stated nobody should be saying that to anyone. Resident #14 stated they informed the Director of Nursing Services and the Director of Nursing Services told them (Resident #14) the staff member would not enter their (Resident #14) room or work on the floor again. Certified Nursing Aide #2 was interviewed on 1/22/2024 at 3:15 PM and stated they were on periods of extended leave for personal reasons around the time when the allegation was made. Certified Nursing Aide #2 stated they were informed of the allegation made against them by Resident #14 upon their return to the facility. Certified Nursing Aide #2 did not recall when they were told about the allegation or when they were questioned about the allegation. Certified Nursing Aide #2 stated that they were not scheduled to work in the facility the day the alleged abuse took place. Certified Nursing Aide #2 denied they verbally abused Resident #14 but was informed that they (Certified Nursing Aide #2) would be removed from Resident #14's assignment. The Director of Nursing Services was interviewed on 1/23/2024 at 10:47 AM and stated Resident #14 complained to them about Certified Nursing Aide #2. The Director of Nursing Services stated they did not recall the time and date the resident made the complaint. The Director of Nursing Services stated that they interviewed Certified Nursing Aide #2 who denied that the incident took place. The Director of Nursing Services stated there was no Accident and Incident report or a grievance report related to Resident #14's allegation of verbal abuse. The Director of Nursing Services stated they will look again as there may be something in their office. The Director of Nursing Services was re-interviewed on 1/23/2024 at 2:16 PM and stated the incident was investigated on 1/5/2023 and there was no reasonable cause to believe abuse occurred; therefore, the incident was not reported to the New York State Department of Health. The Director of Nursing Services stated that verbal abuse was a form of abuse, and they now know that verbal abuse also needs to be reported to the New York State Department of Health. The Administrator was interviewed on 1/23/2024 at 2:38 PM and stated that they were not the Administrator at the time when the incident was reported. The Administrator stated that all alleged abuse incidents must be handled according to facility policies and regulations. The Administrator stated all allegations of abuse needed to be investigated thoroughly. The Administrator reviewed all the documents provided by the Director of Nursing Services to the surveyor and stated if they (Administrator) were to investigate this incident today, they would need to obtain more information to be able to rule out abuse. 10 NYCRR 415.4 (b)(3)

Based on observations, record review and interviews conducted during the Recertification Survey initiated on 1/17/2024 and completed 1/23/2024, the facility did not ensure that each residents' environment remains as free of accident hazards as is possible. This was identified for one (Resident #11) of three residents reviewed for Accidents. Specifically, Resident #11 was not assessed to safely self-administer medications. During multiple observations on 1/17/2024 at 11:20 AM, 1/19/2024 at 12:29 PM, and on 1/22/2024 at 10:30 AM Resident #11 was observed with physician ordered medications in their room with no staff member in the vicinity. The finding is: The facility policy titled Medication Administration dated 10/31/2023 documented the nurse will observe the resident's consumption of medication. The nurse will then sign the Medication Administration Record after the medications are administered. Resident #11 was admitted with diagnoses including Asthma, Cerebral Infarction, and Bipolar Disorder. A Quarterly Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 15 which indicated the resident had intact cognition. The current Physician orders documented to administer a Nicotine mini lozenge 2 milligram, 1 lozenge by mouth every 4 hours while awake for smoking sensation. The current Physician orders documented to administer Bio-Freeze Gel 4%, apply to lower back topically two times a day for pain. A Comprehensive Care Plan dated 1/28/2022, and last reviewed (date), 1/22/2024, documented the resident is resistant to care and medication administration. Interventions included but were not limited to administering medications as per the physician's order. Resident #11 was observed in bed on 1/17/2024 at 11:20 AM. There was a Bio-freeze gel bottle and a medicine cup containing a white pill, on their bedside table with no staff in the vicinity. Resident #11 was interviewed on 1/17/2024 immediately after the observation. Resident #11 stated the white pill inside the medication cup was their nicotine pill to help them stop smoking. Resident # 11 was observed in bed on 1/19/2024 at 12:29 PM. The Bio-Freeze Gel bottle and a medicine cup that contained a white pill were seen placed on the bedside table. There was no staff in the vicinity. Resident #11 was observed in bed on 1/22/2024 at 10:30 AM. A bottle of Bio-Freeze Gel and a medicine cup containing a white pill was observed on the bedside table. There was no staff present in the vicinity. Resident #11 was re-interviewed on 1/22/2024 at 11:19 AM immediately following the observation. Resident #11 stated they were given the Bio-Freeze from the facility to apply as needed. I am given my Nicotine pill several times a day and take it when I need to. Registered Nurse #1 was interviewed on 1/22/2024 at 11:26 AM. Registered Nurse #1 went into Resident# 11's room with the surveyor and observed a bio-freeze bottle and a nicotine lozenge in a medication cup on the bedside table. Registered Nurse #1 stated, We let the resident take the lozenge and use the Bio-Freeze themselves. Registered Nurse #1 stated that Resident #11 did not have a physician's order to self-administer medications. Registered Nurse #1 then took the Nicotine lozenge and the Bio-Freeze bottle out of Resident #11's room. Registered Nurse #1 stated the medications should not be left at the bedside, and the medication nurse should stay in the resident's room while the resident takes their medications. Registered Nurse # 1 further stated Resident #11 cannot self-administer medications. The Director of Nursing Services was interviewed on 1/23/2024 at 10:35 AM. The Director of Nursing Services stated the medications should not have been at Resident # 11's bedside without a Physician's order to self-administer medications. The Director of Nursing Services stated Resident #11 can be evaluated for self-administration of medications and they (Director of Nursing Services) will educate the staff to not leave medications at a resident's bedside. Licensed Practical Nurse #1 was interviewed in 01/23/2024 at 11:21 AM. Licensed Practical Nurse #1 stated that Resident #11 should take all their medications in front of them (Licensed Practical Nurse #1), and no medications should be left at the bedside. Licensed Practical Nurse #1 further stated they informed Resident # 11 that they can no longer leave any medications at the resident's bedside. Nurse Practitioner #1 was interviewed on 1/23/2024 at 1:45 PM and stated, to their awareness, no resident can self-administer medications in this facility. Nurse Practitioner #1 stated they care for Resident #11 and the resident does not have orders to self-administer medications. Nurse Practitioner #1 further stated that no medications should be left at the bedside, and the nurse should observe the residents taking their medications. 10 NYCRR 415.12(h)(2)

Based on observations, record review and staff interviews during the Recertification Survey initiated on 1/17/2024 and completed on 1/23/2024, the facility did not ensure that a resident who needs respiratory care is provided such care consistent with professional standard of practice. This was identified for one (Resident #22) of three residents reviewed for Respiratory Care. Specifically, Resident #22 had a Physician's order for Oxygen to be administered at 2 Liters per minutes via nasal cannula. On 1/18/2024 and on 1/19/2024 the resident was observed receiving 4 Liters of Oxygen, not 2 Liters of Oxygen therapy as prescribed by the Physician. The finding is: The facility's Oxygen Administration Policy dated 10/2023 documented an order will be obtained from the Physician for Oxygen use and to adjust the oxygen gauge to the prescribed flow rate as per the Physician's order. Resident #22 was admitted with diagnoses that included Obstructive Sleep Apnea, Shortness of Breath, and Anxiety Disorder. A Quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 15 which indicated the resident had intact cognition. The Minimum Data Set documented the resident had no behavioral symptoms or rejection of care. The Minimum Data Set further documented the resident was on a non-invasive Mechanical Ventilator. A Comprehensive Care Plan dated 2/4/2022 and last updated 1/20/2024 documented the resident had a potential risk for altered respiratory status due to Sleep Apnea. Interventions included to give continuous positive airway pressure and Oxygen therapy as ordered, and to check the Oxygen setting at the beginning on the shift. A Physician's order dated 9/12/2023, and last renewed on 1/23/2024, documented to administer Oxygen at 2 liters per minute via nasal cannula every shift for Shortness of Breath. A Physician's order dated 1/21/2024 documented to administer Oxygen at 2 liters per minute, connect to continuous positive airway pressure. During a tour conducted on 1/18/2024 at 10:15 AM on the first-floor nursing unit, Resident #22 was observed asleep in bed. The resident was receiving Oxygen from an Oxygen concentrator via a continuous positive airway pressure nasal pillow (a small soft insert that fits into the nostrils and delivers pressurized air) at 4.0 liters per minute. A subsequent observation was made on 1/19/2024 at 10:20 AM. The resident was observed asleep in bed and was receiving Oxygen therapy from an Oxygen concentrator via a continuous positive airway pressure nasal pillow at 4 liters per minute. Certified Nursing Assistant #3 was interviewed on 1/19/2024 at 10:28 AM. Certified Nursing Assistant #3 stated that they have cared for Resident #22 for 4 years and that the resident has always been on Oxygen. Certified Nursing Assistant #3 stated they were not responsible for adjusting the Oxygen gauge on the Oxygen concentrator; the nurses were responsible to make sure the resident was receiving Oxygen as ordered by the Physician. Certified Nursing Assistant #3 stated that they did not know how much Oxygen the resident was receiving and that they did not touch the gauge on the Oxygen Concentrator. Resident #22 was interviewed on 1/19/2024 at 12:35 PM. The resident stated that they were on Oxygen therapy and thought they should be receiving Oxygen at 3 liters per minute. The resident stated that they were legally blind and would not be able to adjust the Oxygen gauge. The resident stated that the Certified Nursing Assistants do not adjust the Oxygen gauge; that they believe only the doctors and nurses can adjust the Oxygen gauge. Nurse Practitioner #1 was interviewed on 1/23/2024 at 1:35 PM and stated they were assigned to the care for the resident. Nurse Practitioner #1 stated when there is an order in place for Oxygen therapy, the expectation is the nurses will administer Oxygen as ordered by the Physician. During an observation conducted with Registered Nurse #3 on 1/19/2024 at 2:08 PM, Resident #22 was observed receiving Oxygen therapy from an Oxygen concentrator via a continuous positive airway pressure nasal pillow at 4 liters per minute. The Physician's order was reviewed on 1/19/2024 at 2:12 PM by Registered Nurse #3, which revealed Oxygen was to be administered at 2 liters per minute. Registered Nurse #3 stated the medication nurse was responsible for checking the Oxygen at the beginning of their shift to ensure the resident was receiving Oxygen therapy as ordered by the Physician. Licensed Practical Nurse #2 was interviewed on 1/23/2024 at 2:41 PM. Licensed Practical Nurse #2 stated they were the medication nurse on 1/18/2024 and 1/19/2024. Licensed Practical Nurse #2 stated they did not make rounds on 1/18/2024 and 1/19/2024 to check the Oxygen settings for accuracy. Licensed Practical Nurse #2 stated they did not check the Oxygen setting because there was a charge nurse on duty and that they expected the Registered Nurse in charge to check the resident's Oxygen setting to ensure that the residents were receiving Oxygen as ordered by the Physician. The Director of Nursing Services was interviewed on 1/23/2024 at 2:43 PM. The Director of Nursing Services stated that the medication nurse was responsible for checking the Oxygen flow rate at the beginning of their shift and to sign off on the Medication Administration Record indicating the resident was receiving Oxygen at the correct flow rate. The Director of Nursing Services stated if there were two nurses on the unit, the nurse in charge would check the Oxygen flow rate. The Director of Nursing Services further stated that the resident should have been receiving Oxygen as ordered by the Physician. 10 NYCRR 415.12(k)(6)

Based on observation, interviews and record review conducted during an abbreviated survey NY00313378 the facility failed to provide the resident's environment remain as free of accident hazards for one of four residents reviewed for accidents (Resident #1). Specifically, the facility did not ensure the effectiveness of the screw that was installed in the resident's window track as a restrictor to limit how far the window would open. Subsequently, Resident #1, who had a history of elopement and suicidal ideation prior to admission, was able without manipulating the window in their room open and jumped out the window hitting a concrete surface. Resident #1 sustained multiple fractures of the spine, left ribs, left acetabulum, left scapula, and left sacrum. This resulted in actual harm to Resident #1 that is not Immediate Jeopardy. The finding is: The facility's policy and procedure (P&P) titled Accident/Incident reviewed on [DATE] documented the facility was to maintain the safety of all residents in as much as possible. The resident's environment was to be free of accident hazards as possible, and each resident was to receive adequate supervision and assistive devices to prevent accidents. High risk factors for safety problems are identified on admission and throughout placement. The facility's P&P titled Preventative Maintenance Policy dated [DATE] documented that a preventative maintenance program was to be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The policy further documented that the Maintenance Director or designee shall perform daily rounds through-out and will include inspection of all items of equipment, safety checks of all means of egress, call bell checks, window inspection and safety environment checks. All rounds will be documented on the maintenance tracking system. Resident #1 was admitted to the facility with diagnoses including Schizophrenia, Major Depression, Auditory Hallucination, and Dementia. The admission Minimum Data Set (MDS-an assessment tool) dated [DATE] documented Resident#1 had a Brief Interview for mental Status (BIMS) indicating intact cognition. The Discharge MDS dated [DATE] documented resident required supervision for transfers, walking and locomotion. The Comprehensive Care Plan (CCP) dated [DATE] titled Behavior documented the resident had potential for behavior issues secondary to history of restlessness which led to elopement from adult home residence and thoughts of suicidal ideation. Continuous 15-minute check was added on [DATE] and anti wandering monitor device placement and function was added on [DATE]. Registered Nurse Supervisor (RNS #1) documented on [DATE] at 8:54 PM documented that at 4:05 PM a staff member reported that Resident #1 was found outside of the facility on the ground near the facility dining room door on the lower level. The NN further documented that Resident #1 was assessed, was able to move all extremities but was unable to recall occurrence secondary to their diagnosis of Dementia. The Physician was notified and ordered to send Resident #1 to the emergency room (ER). They spoke with the Physician at 7:40 PM and that the Hospital ER X-rays revealed multiple left rib fractures, left hip fracture and small left pneumothorax (A condition when air leaks into the space between the lungs and chest wall). A review of the hospital computerized tomography (CT - images of bones, organs, and soft tissue) dated [DATE] documented Cervical Spine with acute fractures of left C7 (lower part of cervical spine), and T1 transverse processes (TP), multiple left sided ribs fractures. The CT of the chest, abdomen and pelvis documented small left pneumothorax, fractures of the left transverse processes of C7 and T12 and medial aspects of the 1st and 2nd ribs, fractures of lateral aspect of the left 3rd through 7th ribs, subcutaneous (beneath the skin) air in the left chest wall and lower neck, comminuted left anterior acetabulum (socket of the hip bone) fracture, additional fractures involving the left scapula (shoulder blade) and left sacrum. X-ray of pelvis and left hip dated [DATE] documented left pelvic fracture. X-ray of left shoulder and left scapula documented displaced left 3rd to 7th rib fractures at the axillary line. The hospital Behavior Health consult dated [DATE] for Resident #1 documented the patient reported they did not fall off second floor, but that they opened the window and jumped because they felt hopeless. The patient stated that they tried to kill themselves by jumping from window in Nursing Home. During an interview on [DATE] at 4:40 PM with Resident #1 at the hospital, they stated they had a relapse due to mental illness. Resident #1 stated, I opened the window and jumped out of the window. I was able to open the window without resistance. I jumped out because I don't want to live anymore. I did not tell anybody, I almost died. Resident #1 stated the facility called an ambulance and brought them to the hospital. The facility's 5-day investigative report submitted on [DATE] documented on [DATE] at approximately 4:00 PM Dietary aide (DA) #1 discovered Resident #1 laying on the ground without clothes on near the lower-level exit of dining room. DA #1 immediately called for help and DA #2 responded and then Licensed Practical Nurse (LPN) #1 and Registered Nurse (RN) #1 responded. RN #1 reported that the resident was observed on ground laying on their back with visible abrasions noted to both knees and their right foot. Resident #1 did not respond when asked what occurred. RNS #1 immediately called for emergency services. The investigative summary further documented that upon inspection by facility staff the window in the resident's room was found to slide open all the way. It was discovered that although a screw was in place to prevent the window from opening past 6 inches, the bottom of the window had scratches and chips which may have allowed the window to go over the screw. During an interview on [DATE] at 1:04 PM with the Director of Environmental Services (DES) they stated that all windows were checked daily to make sure they could not be opened more than 5 inches. The windows have screens but are not a safety measure. The DES stated that Resident #1 was able to remove the screw but did not know what happened. The DES stated they went back in the room on the same day and the safety piece was in place. The window was not able to open more than 5-6 inches. At subsequent interviews on [DATE] at 11:24 AM and [DATE] at 10:40 AM the DES stated that they checked the window in Resident #1's room on [DATE] around 9:00 AM and the window was secured. The Administrator informed DES on [DATE] at approximately 10:00 PM-10:30 PM that the window had been forced opened over the screw. During an observation with the Director of Environmental Services (DES) on [DATE] at 1:20 PM the lower-level dining room was noted with a double door that was alarmed with a keypad to deactivate the alarm. An observation of the area where the resident was found revealed it was a concrete surface located on the lower level outside of the facility's dining room and directly below the resident's room window. The DES measured the distance from the concrete surface to Resident #1's room window as being 12 feet. Observations and measurements were made from inside Resident #1's room with facility maintenance staff (MS) #1. MS #1 demonstrated that the window moves to the left and right and that the windowsill was 41.5 inches above the floor. In addition, it was also noted that from the windowsill it was 13 feet to the concrete surface below the window. A review of the facility computer generated Daily Inspection form/log dated [DATE]-[DATE] indicated that when completing a work order, the employee attests that all items noted on the form have been checked and are in safe operation. The form/log created on Saturday [DATE] documented that the daily check was done by the Director of Environmental Services (DES) on [DATE]. The form/log indicated Status Closed, which signifies that the daily checks were completed. The form/log did not document the specific rooms or windows that were checked. A review of Residents Windows Daily Log' documented window openings shall be designed to prevent accidental falls when open or shall be provided with security screens. Acceptable practice is that the windows do not open more than 6 inches. The log documented that the windows were checked on [DATE] and then on [DATE]. The log did not document specific room(s) that were checked. During an interview on [DATE] at 5:06 PM with the Dietary Aide (DA) #1 they stated on [DATE] at around 3:30 PM they exited from the lower level of the facility to put stuff in their car. They heard a sound and saw the resident naked lying on their back on the concrete. Resident #1's body was perpendicular to the door, and they were trying to move their head and hands. DA #1 ran to the kitchen and called DA #2 and reported what they had observed. During an interview on [DATE] at 5:24 PM with RN #1 they stated on [DATE] the resident was in bed during rounds with a blanket on. RN #1 stated a kitchen staff informed them that they saw a man lying on the ground. RN #1 and LPN #1 found the resident lying on their back, trying to move. RN #1 wrapped Resident #1 in a blanket because it was cold. 911 responded and the Resident #1 was transported to the hospital. During an interview on [DATE] at 2:50 PM with the Director of Nursing (DON) they stated Resident #1 had a history of suicidal ideation and elopement from a previous facility. Resident #1's behavior at the facility involved walking in the hallway, going to living room, and being easily redirected. Resident #1 had history of agitation but no behavior at the facility. Resident #1 was removing clothes that day. Resident #1 had an anti wandering device in place on admission, however, they made no attempts to exit the building. Resident #1 had no verbalizations of wanting to hurt self and was seen by Psychiatrist. On [DATE] RNS #1 and LPN #1 reported to DON that the resident was found outside by the dining room on the ground, and they did not know how Resident #1 got out of the facility. DON stated that with the Administrator they checked the doors and windows. The window in Resident #1's room was noted with scratches and the top of the screw that was set in the window track was pressed down and damaged, as if something had rubbed against it. They did not know if it was due to normal wear and tear. The DON stated that the Administrator moved the window, and the window opened beyond the screw, and added that it is possible that someone could get through the window. DON stated that based on injuries they think that Resident #1 fell from a height. During an interview on [DATE] at 11:25 AM with the Administrator they stated DON reported that the resident was found outside the building. They were not sure if the resident jumped out of the window or went out of the door. Administrator stated they came to the facility on [DATE] and went to Resident #1's room around 10:00 PM with the DON. Administrator stated they saw the bottom of the window was worn from wear and tear and they opened the window, and it went pass the screw. Administrator stated they were shown the daily inspection log and stated from the log that they cannot tell which rooms were checked, but that a log entry should be an indication that all residents' rooms were checked. The Administrator added that the alarms that were heard the day of the incident were around the same time that the Resident #1 was found. During an interview on [DATE] at 1:32 PM with the Medical Director (MD) they stated they specialized in critical care. MD stated that the DON reported the incident to them. MD state that they think Resident #1 jumped out of the facility. MD stated they reviewed the hospital records and the resident sustained C7, L1-7 fracture of the whole spine, left acetabulum and left scapula. MD stated the injuries sustained were from a fall and were all on one side. MD stated they told the Administrator the injuries were consistent with a fall from a window rather than a door. MD stated they were given a copy of the facility's investigative summary and stated it is interesting that the facility could not conclude how the Resident #1 was found to be outside on the ground. During a subsequent phone reinterviewed on [DATE] at 10:13 AM with DON they stated that they were not sure if Resident #1 removing their clothes was a new behavior for Resident #1. DON was informed by staff that Resident #1 walked on hallway and took off their gown but was redirected easily. DON did not think that Resident #1 needs more than 15 minutes monitoring just because Resident #1 was restless, if the staff were able to redirect Resident #1 and staff called the Medical Doctor. 483.25 (d)(1)(2)

Based on observation, record review and staff interviews during the recertification survey, the facility did not ensure that two of four residents reviewed for pressure ulcers received necessary assessment and care to prevent the development of new pressure ulcers and deterioration of pressure ulcers (Residents #46 and # 210). Specifically: 1) A Braden Scale pressure ulcer risk assessment was not completed on admission, and the use of heel pressure devices was not implemented based on assessment of mobility deficit, according to facility policy and procedure for Resident #46. Subsequently, Resident #46 developed a Stage 2 pressure ulcer to the left heel that deteriorated to a Stage 4 pressure ulcer. 2) Resident #210, with [DIAGNOSES REDACTED]. The facility did not fully assess and monitor the pressure ulcer, and did not implement use of a specialty mattress to promote healing. The wound subsequently deteriorated to a Stage 3 pressure ulcer. Additionally, Resident #210 was admitted without pressure ulcers to the heels. The facility did not ensure that the use of heel pressure devices was implemented timely, as per policy and procedure, to minimize the risk of pressure injury resulting in a Deep Tissue Injury (DTI) of the right heel. This resulted in actual harm for Resident #46 and Resident #210 that is not immediate jeopardy. The findings are: The facility Policy and Procedure for Skin Ulcers/Wound updated 6/2015 documented residents with mobility/activity deficits to utilize heel pressure devices while in bed and a specialty mattress. Residents are identified for specific factors that may place them at risk for developing pressure ulcer on admission. All residents are assessed for pressure ulcer risk using the Braden Scale. Scoring of the Braden Scale - Very high risk - total score less than 9, high risk score 10-12, moderate risk 13-14, and mild risk score 15-18. The evaluation/care of pressure ulcers requirements included re-evaluation at least every seven days and all pressure ulcers to be assessed by a Registered Nurse. 1) Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 indicating moderate cognitive impairment. The MDS assessment noted the resident required extensive physical assistance of two persons for bed mobility, extensive assistance of one person to transfer and was totally dependent on one person for locomotion. The MDS assessment also noted that the resident was admitted without any pressure ulcers, was at risk for pressure ulcer development, and pressure reducing devices for chairs and bed were in place. The Admission Body Skin Checklist dated 10/13/17 was completed by a Registered Nurse (RN #5) and documented that the resident's skin was intact. There was no documented evidence that a Braden Scale pressure ulcer risk assessment was completed at the time of admission. The Comprehensive Care Plan (CCP) for Skin Integrity dated 10/13/17 identified the problem of potential for skin impairment related to skin failure secondary to failure to thrive secondary to End Stage Dementia. The CCP did not include interventions for the use of pressure reduction devices to off-load pressure to the resident's heels. physician's orders [REDACTED]. A Licensed Practical Nurse (LPN #6) documented in the progress notes on 10/29/17 that a blood-filled blister was noted to the left heel. A Wound Care Physician consult note dated 10/30/17 documented a left heel assessment and described a Stage 2 left heel pressure ulcer measuring 4 centimeters (cm) x 8 cm x 0.1 cm - intact serosanguinous (clear, yellowish pale red liquid that occurs in wound healing) blister - drained of fluid, intact [MEDICATION NAME] tissue underneath. The consultant documented a plan for treatment with [MEDICATION NAME] (an antibiotic ointment used to avoid or treat skin infection) and a dry, clean dressing daily and to, Off load with heel booties. The CCP was updated to include interventions for use of heel boots on 10/30/17 and to off-load heels on 10/31/17. A 7 AM - 7 PM LPN entry documented that heel booties were in place on 11/1/17. The Physician ordered comfort measures only on 10/31/17 including but not limited to Do Not Intubate (DNI), Do Not Resuscitated, No Tube Feeding, and Pain Management. Wound Care Physician notes documented deterioration and persistence of the left heel pressure ulcer as follows: 11/6/17 - Deep Tissue Injury (DTI: a localized area of intact skin with dark discoloration such as purple/maroon, or a blood-filled blister) measuring 4 cm x 9 cm. 11/13/17 - 7 cm x 9 cm x (unavailable measurement of wound depth) with 50 % black necrosis (death of body tissue) and 50 % Deep Tissue Injury (DTI) .enlarging area, complaints of pain barely touching foot/leg .(resident) needs arterial work up to rule out (r/o) [MEDICAL CONDITIONS] and r/o Osteo ([DIAGNOSES REDACTED], infection of the bone). 8/8/18 - Stage 4 measuring 4.4 x 3.5 x 0.2 with light serosanguinous drainage, 75 % slough and 25 % granulation. Apply Santyl ointment (an enzymatic agent used to break up dead skin and tissue and promote healing) once daily, cover with dry protective dressing and wrap with gauze, bilateral boots, float heels. A Braden Scale assessment dated [DATE] (10 months after admission) documented a score of 10 which indicated that the resident was at high risk for the development of pressure ulcers (A score of 12 or less represents high risk). A Physician order [REDACTED]. Wound care to the left heel was observed with the Wound Care Physician and two LPN's on 8/15/18 at 2:30 PM. The left heel pressure ulcer was assessed as a Stage 4 measuring 4 x 3 cm x (unavailable measurement of wound depth). The wound was covered with slough (90%) and had a strong odor. The wound care physician debrided the ulcer (removal of dead, damaged or infected tissue to promote healing of remaining tissue). The Registered Nurse Supervisor (RNS) was interviewed on 8/14/18 at 2 PM and stated that the resident should have been high risk for heel skin breakdown because the resident was immobile in bed and because of the resident's admitting [DIAGNOSES REDACTED]. The Director of Nursing Services (DNS) was interviewed on 8/14/18 at 3 PM and stated a Braden Scale should have been completed by the admission RN. The resident was admitted without any pressure ulcers. The resident was at high risk for skin breakdown due to limited bed mobility and should have had his heels off loaded to prevent a pressure ulcer. The RN that completed the Admission body skin checklist on 10/13/17 (RN #5) was interviewed on 8/15/17 at 3:30 PM. She stated she worked on a per diem basis and could not recall why she did not off load the heels. The attending Physician was interviewed on 8/15/18 at 10:30 AM and stated, because of the resident's low protein levels on admission, decreased mobility and comfort care, staff should have ensured to offload the resident's heels from the bed to prevent pressure ulcers. The Wound Care Physician was interviewed on 8/15/18 at 2 PM and stated residents who are immobile in bed should have their heels offloaded to prevent pressure ulcers to the heels. 2) Resident #210 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS assessment dated [DATE] documented the resident's BIMS Score as 15 which indicated intact cognition. The resident had no assessed behavior problems or rejection of care. The resident was not incontinent, required extensive assistance of one staff member for bed mobility, transfer, and toileting. The MDS documented the resident had one unhealed area of DTI. The presence and location of a DTI was not noted in Nurse's notes, physician progress notes [REDACTED]. A Braden Scale pressure ulcer risk assessment dated [DATE] documented a score of 16 which indicated the resident was at mild risk for developing pressure ulcers. A Pressure Ulcer/Impaired Skin Notification Form dated 7/24/18 completed by RN #4 documented the resident was admitted with pressure ulcers described as Coccyx Stage 2 that measured 1.5 cm and Right Ankle that measured 2.0 cm, and dry discoloration to both feet and toes. The coccyx and ankle ulcer descriptions lacked complete assessment data for measurements of length X width X depth of the ulcers and there was no documented assessment of the Stage of the ankle ulcer. There was no documented evidence in the Resident Baseline Care Plan Summary, physician's orders [REDACTED]. A physician's orders [REDACTED]. An Admission Nurse's Note dated 7/24/18 documented the wound to the coccyx and the right ankle were assessed, and treatment was initiated. A CCP dated 7/24/18 for Pressure Ulcer documented a right ankle scabbed area and a Stage 2 to the coccyx on admission secondary to [MEDICAL CONDITION]. A Resident Baseline Care Plan Summary dated 7/25/18 documented to administer treatment to Coccyx wound as ordered. A physician's orders [REDACTED]. A Comprehensive Care Plan (CCP) dated 7/27/18 for Skin Integrity documented the resident had the potential for impairment related to immobility related weakness and [MEDICAL CONDITION]. Interventions included to turn and position the resident every two to four hours and PRN (as needed), provide Panacea mattress, provide foam wheel chair cushion, treatment as ordered by the Physician. The CCP was updated on 8/2/18 to include a Stage I Pressure Ulcer to the bilateral heels and noted non-blanchable redness to bilateral heels. The interventions included to turn and position the resident every two hours, provide pressure relief mattress, Roho (a pressure relief device for wheelchairs) cushion, vitamins/supplements and treatments per order and right and left heel offload boots were initiated, 9 days after admission. A physician's orders [REDACTED]. The CCP documented on 8/3/18 use of a specialty mattress, an Alternating Air mattress, was initiated, 10 days after admission. A Nurse's note dated 8/6/18 at 10:00 PM documented the coccyx wound was assessed and the wound bed was pink with dark area in the middle. Santyl daily was continued and the Physician was aware. The right ankle wound was noted to be healing nicely, and the condition of the right heel was changed; a DTI was noted. Skin prep with bulky dressing applied. Heel booties to be applied at all times, may remove with care. Staging of the coccyx and ankle ulcers was not assessed and documented. Description of the right ankle wound bed and surrounding tissue was not done. Assessment of coccyx, ankle and heel wound measurements were not documented. The physician's orders [REDACTED]. A physician's orders [REDACTED]. The CCP was updated on 8/6/18 and noted the status of the right heel pressure ulcer deteriorated to a DTI. The Registered Nurse Supervisor in training (RN #3) was interviewed on 8/14/18 at 12:28 PM. RN #3 stated he accompanied the Wound Care Physician on weekly wound rounds. RN #3 stated the pressure ulcer CCP was last updated 8/2/18 when orders were received from the Physician to initiate heel booties for the resident. Resident #210 was observed with heel booties in place seated in her wheel chair and interviewed on 8/15/18 at 1:55 PM. The resident stated that she had a pressure ulcer prior to admission and was concerned that it was not getting better. The resident stated that she had a regular mattress for more than a week when she was first admitted . The resident further stated that her wound was measured on admission and then once more sometime last week and that she was never seen by the Wound Care Physician. The 3:00 PM - 11:00 PM RN Supervisor (RN #4) was interviewed on 8/14/18 at 2:32 PM and stated she completed the Admission Assessment and that the resident had a stage 2 pressure ulcer to the coccyx. RN #4 stated that she completed the Pressure Ulcer/Skin Notification Form and documented the measurements when she completed the form. RN #4 stated that the Director of Nursing Services (DNS) and Physician were notified. RN #4 stated that the process was that she verbally notified the Physician and the DNS and then placed copies of the Notification Form in the mail boxes of the designated disciplines. RN #4 stated wounds were measured weekly on wound rounds by the Wound Care Physician, however last week she and RN #3 completed the treatment and measurements. RN #4 stated that she could not recall if she did the measurement for Resident #210 or if RN #3 did the measurement and why the measurement was not documented in the Nurse's note. RN #4 stated that there was a deterioration of both the coccyx wound and right heel. The RN stated the Coccyx was now a Stage 3 and the right heel was now a DTI. The DNS was interviewed on 8/14/18 at 3:09 PM and stated that she was not aware the resident was admitted with a pressure ulcer. The DNS stated that RN #4 told her she made copies of the the Pressure Ulcer/Skin Notification Form on admission and put them in the appropriate mailboxes but she did not get one. The DNS stated there was a delay in doing weekly wound measurements. The DNS stated when she became aware the resident had pressure ulcers, she instructed RN #4 to assess the wound which included measurements. The DNS stated the expectation was that the measurements be included in the Nurse's note when the assessment was done. The DNS further stated that an air mattress is ordered for residents who are at high risk for pressure ulcer, who have an existing pressure ulcer, and residents with multiple comorbidities. The DNS stated that the resident had a regular mattress on admission and that there was a delay in initiating the air mattress. The DNS stated she would have ordered a specialty air mattress on admission if she knew about the wound. The Wound Care Physician was interviewed on 8/15/18 at 2:26 PM. The Physician stated that he had not spoken to the resident himself, but the staff reported to him the resident had refused to be seen on two occasions. The Physician stated that he was sure the resident had seen him in passing in the hallway but did not know he was the Wound Care Physician and that he had not followed up to introduce himself to the resident to let her know who he was as he had several other residents waiting to be seen. The Physician stated that the resident might have been in therapy or at activity at the time of his visit and that he did not go back to the resident at a later time. The Physician stated that he had not actually met the resident until 8/15/18, and that it was his first time seeing the residents wounds. The Physician presented the following measurement and description of the resident's wound: right heel measured 1.5 cm x 1.5 cm dark colored DTI. Left heel intact, Sacrum Stage 3 measured 1 cm x 1cm x .3 cm and wound bed clean, no undermining. 415.12(c)(2)

F 309 G Based on observation, interview and record review during an abbreviated survey the facility did not ensure that each resident received necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically one (Resident #1) of three residents reviewed for an accurate and complete assessment was observed with change in condition (drooling and leaning to one side) by a family member. The family member notified the Licensed Practical Nurse (LPN #3) regarding the change in Resident #1's condition. There is no documented evidence of assessment or that the RN supervisor or physician was notified regarding the change in condition. Subsequently Resident #1 was found kneeling on the floor by his bed side on [DATE] at 7:40 AM without palpable pulse and without respiration and was pronounced at 7:42 AM. The cause of death per the certificate of death was documented as [MEDICAL CONDITIONS]. This resulted in actual harm that is not Immediate Jeopardy. Complaint ID Number: # NY 455 Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS- a clinical assessment tool) dated [DATE] documented moderately impaired decision making ability. Resident #1 required extensive assistance of two people with bed mobility and transfers and supervision with set up help for eating. The Comprehensive Care Plan (CCP) dated [DATE] documented [MEDICAL CONDITION]: [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION] and [MEDICAL CONDITION]. Interventions included to monitor signs and symptoms of cardiac distress and report changes to physician. The CCP dated [DATE] documented diabetes mellitus. Interventions included to monitor for weakness, excessive changes in personality, nervousness and tremors. The CCP dated [DATE] documented Failure to Thrive. Interventions included assess for signs and symptoms of depression and notify physician. The medical record lacked documented evidence of a change in condition (symptoms reported by family), family's concerns and an assessment related to change in condition prior to or on [DATE]. The 24 hours report dated [DATE] lacked documented evidence of changes in Resident #1's clinical condition. The Nursing Progress Note (NPN) dated [DATE] documented that at 7:40 AM, Resident #1 was found without heart beat and respirations, pupil fixed and dilated. Pronounced by MD (wound care physician) at 7:42 AM. The Nursing Progress Note dated [DATE] documented late entry by LPN #1: resident found at approximately 7:40AM on the floor sitting on his knees with his head positioned between the mattress and the side rail. Removed resident's head from between the mattress, resident removed from the floor with a Certified Nursing Assistant (CNA), resident pronounced at approximately 7:40AM. The undated summary of facility investigation documented that after a diligent re-enactment of the incident, the probable cause was that resident had expired in bed, and because of the alternating pressure mattress, resident's body was ejected from the bed and came to rest in a kneeling position next to bed. Resident's head was actually resting on the edge of the rail and mattress. the resident expired due to natural causes and his head was resting or leaning near the rail. The facility lacked documented evidence of a policy and procedure related to change in condition. During an interview with the 7:00 AM-3:00 PM shift Licensed Practical Nurse (LPN #1), Charge Nurse, on [DATE] at 12:27 PM, LPN #1 stated that resident was alert and was able to make his needs known. The resident had difficulty speaking secondary to stroke, he also had weakness on one side (couldn't recall which side). On [DATE], at approximately 7:30 AM-7:40 AM, Resident #1 was found on the right side of his bed on his knees when LPN #1 went to his room to prepare him for wound rounds. She observed Resident #1 with his head between the air mattress and the side rail. The resident had ½ side rail and the air mattress (alternate air mattress). LPN #1 stated that she went to Resident #1 and removed his head between the mattress and the side rail; he was warm to touch, and color was pale without any cyanosis. LPN#1 further stated that that she had no difficulty moving his head from between the mattress and the side rail. The LPN #1 stated that Resident #1 was non-ambulatory and was not at risk for falls. LPN #1 stated that Resident #1 used the side rail for bed mobility as he held the side rail with his left hand during bed mobility. He was not able to move himself in bed without staff assistance. During an interview with Assistant Director of Nursing (ADON) on [DATE] at 3:56 PM, the ADON stated that she was not aware of any changes in Resident #1's clinical condition and she didn't recall assessing Resident #1 or calling Resident #1's physician for change in clinical condition for Resident #1 on [DATE]. During an interview with Resident #1's Family member (#1) on [DATE] (AM), she stated that she visited Resident #1 on [DATE] at approximately 10 AM. She found Resident #1 in the hallway in the wheelchair slumped over. He was moaning, drooling and did not recognize her or his grandchildren, which was unusual. His right eye was red and inflamed. She spoke to a nurse (did not recall name) who stated that the resident was being treated for [REDACTED].#1 had further questions but was told to speak with the charge nurse (LPN #1). Family member #1 told LPN #1 that they needed to speak to the doctor. The CNA and Recreation staff member were also present. Family member #1 had staff place Resident #1 back to bed. Family member #1 called Family member #2 and told him what was going on. Family member #2 called and asked that a physician see the resident. The next day Resident #1 expired. During a subsequent interview with LPN #1 on [DATE] at 12:20 PM, LPN #1 stated that she received a call from Resident #1's son on [DATE] in the morning (could not recall specific time). The son stated that Resident #1 did not look good and he wanted some blood work done for the resident. LPN#1 went to check on Resident #1, he looked fine to me. LPN #1 stated that she did not perform any vital signs or evaluate the resident because when she looked at him he was sitting straight. LPN #1 further stated that she did not notify the Registered Nurse Supervisor nor the physician regarding Resident #1's family concerns for change in his condition. LPN #1 also stated that she endorsed (gave) the report to the evening charge nurse (LPN #2) to notify Resident #1's physician of family's concerns and to get orders for stat blood work as requested by Resident #1's son. LPN #1 stated that she forgot to document the family's concerns and her evaluation in Resident #1's medical record. During an interview with the Primary Care Physician (PMD) on [DATE] at 12:37 PM, the PMD stated that he did not recall getting a call regarding Resident #1's change in condition and family's concerns on [DATE]. The PMD stated that if the nurses would have informed him of family requesting blood work he would have given a telephone order for the same. The PMD could not recall if he had given a telephone order for blood work for Resident #1 on [DATE] (no documented evidence of physician orders [REDACTED]. During an interview with the 3:00 PM-11:00 PM shift LPN #2 on [DATE] at 1:29 PM, LPN#2 stated that she did not recall any changes in Resident #1's condition. LPN#2 stated that she did not receive any report regarding any changes in Resident #1's concerns or any directives to call the physician for blood work. During an interview with the 7:00 AM-3:00 PM LPN #3 Medication Nurse, on [DATE] at 1:42 PM, LPN #3 stated that Resident #1's family member came to her with concerns regarding a change in Resident #1's condition; drooling and leaning on one side while sitting in the chair. LPN #3 stated that she went to Resident #1's room and asked the assigned CNA #3 if she thought there were any changes in his condition. The assigned CNA #3 said that Resident #1 was fine and that there were no changes in his condition. LPN #3 further stated that she notified LPN #1 of the family's concerns. When LPN #1 went to resident #1's room, Family member #1 had already left. LPN #3 denied notifying the nursing supervisor of changes in Resident #1's condition. During an interview with the assigned 7:00 AM-3:00 PM shift CNA #3 on [DATE] at 11:30 AM, CNA #3 stated that on [DATE] Resident #1 did not look like himself, he looking tired and out of it. CNA #3 stated that she informed LPN #3 of a change in Resident #1's condition. A family member went to LPN #3 and notified her of Resident #1's condition. LPN #3 came to the resident's room and instructed CNA #3 to place Resident #1 back to bed. CNA #3 stated that LPN #3 did not take any vital signs for the resident after she was notified of a change in Resident #1's condition. CNA #3 further stated that Resident #1 usually fed himself after tray set up, but, on [DATE] he was not able to feed self, appetite was fair normally he ate good, LPN #3 was notified of the changes in appetite. During an interview with the assigned 3:00 PM-11:00 PM shift CNA #4 on [DATE] at 1:05 PM, CNA #4 stated Resident #1's appetite was usually good and he fed himself after tray set up. On [DATE] he ate poorly and had to be fed. Resident #1 had loose stools (not watery) three to four times during the evening shift. CNA #4 could not recall if she notified the charge nurse regarding poor appetite or loose stools. During an interview with the Recreation Aide (RA) on [DATE] at 3:40 PM, the RA stated that she went to escort Resident #1 to activities on [DATE] in the morning at approximately 10:00 AM. Resident #1 was sitting in the hallway on the unit, he was not looking good, he kept pointing to his stomach and was not like himself. He looked very tired. Resident #1 could not attend activities that day and was placed back to bed at Family member 1#'s request. 415.12

Based on staff interviews and record review during an abbreviated survey, the facility did not ensure a resident's physician was notified when the resident had a significant change in condition and there was a need to alter treatment. Specifically, one (Resident #1) of three residents reviewed for notification of changes was noted as moaning and drooling on [DATE] by a family member and the assigned Certified Nursing Assistant (CNA) at approximately 10 AM. The family member notified the Licensed Practical Nurse (LPN #3) regarding the change in Resident #1's condition. The Primary Care Physician was not notified of the changes in his condition. Subsequently Resident #1 was found kneeling on the floor by his bed side on [DATE] at 7:40 AM without palpable pulse and without respiration and was pronounced at 7:42 AM. The cause of death per the certificate of death documented as [MEDICAL CONDITIONS]. Additionally, the representative/family and Resident #1's physician were not informed of Resident #1's condition at the time of his death on [DATE]. Resident #1 was found on the floor kneeling with his head between the bed frame and side rail. This resulted in actual harm that is not Immediate Jeopardy. Complaint ID Number: NY 455 Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS- a clinical assessment tool) dated [DATE] documented short and long term memory problem with moderately impaired decision making ability. Resident #1 required extensive assistance of two people with bed mobility and transfers and supervision with set up help for eating. The medical record lacked documented evidence of a change in condition, family's concerns and an assessment related to change in condition prior to or on [DATE]. The medical record lacked documented evidence of physician's orders [REDACTED]. The 24 hours report dated [DATE] lacked documented evidence of changes in Resident #1's clinical condition. The facility lacked documented evidence of a policy and procedure related to change in condition. The Nursing Progress Note (NPN) dated [DATE] documented that at 7:40 AM Resident #1 was found without heart beat and respirations, pupil fixed and dilated, pronounced by MD (wound care physician) at 7:42 AM. The Certificate of Death dated [DATE] documented immediate cause of death: [MEDICAL CONDITION]-non traumatic. The NPN dated [DATE] documented late entry by LPN #1: resident found at approximately 7:40 AM on the floor sitting on his knees with his head positioned between the mattress and the side rail. Removed resident's head from between the mattress, resident removed from the floor with a Certified Nursing Assistant (CNA), resident pronounced at approximately 7:40 AM. During an interview with the 3:00 PM 11:00 PM shift Registered Nurse Supervisor (RNS #2) on [DATE] at 3:14 PM, RNS #2 stated she worked 8:00 AM-3:00 PM on [DATE], Resident #1 was already pronounced, she called the family and notified them of his death but did not explain the circumstances as she was not involved in the incident. During an interview with the 7:00 AM-3:00 PM Assistant Director of Nursing (ADON) on [DATE] at 3:56 PM, the ADON stated that she was not aware of any changes in Resident #1's clinical condition and she didn't recall assessing Resident #1 or calling the physician for change in clinical condition for Resident #1. The ADON stated that she did not call the family regarding resident #1's death she instructed RNS #2 to call the family. During an interview with Resident #1's Family member (#1) on [DATE] (AM), she stated that she visited Resident #1 on [DATE] at approximately 10 AM. She found Resident #1 in the hallway in the wheelchair slumped over. He was moaning, drooling, leaning on one side and pointing to his stomach and did not recognize her or his grandchildren, which was unusual. His right eye was red and inflamed. She spoke to a nurse (did not recall name) who stated that the resident was being treated for [REDACTED].#1 had further questions but was told to speak with the charge nurse (LPN #1). Family member #1 told LPN #1 that they needed to speak to the doctor. The CNA and Recreation staff member were also present. Family member #1 had staff place resident #1 back to bed. Family member #1 called Family member #2 and told him what was going on. Family member #2 called (LPN #1) and asked that a physician see the resident. The next day Resident #1 expired. The family was notified of Resident #1's death on [DATE] at approximately 8 AM. They were told the resident expired due to [MEDICAL CONDITION]. About 13 days later on [DATE] the family was told (by the DON) that the resident was found in a kneeling position with his head against the side rails at the time of his death. During an interview with the 7:00 AM-3:00 PM shift Licensed Practical Nurse (LPN#1), Charge Nurse, on [DATE] at 12:20 PM LPN #1 stated that she received a call from Resident #1's son on [DATE] (time unknown) who stated that Resident #1 did not look good and wanted some blood work done for the resident. LPN#1 went to check on Resident #1 he looked fine to me. LPN #1 stated that she did not perform any vital signs or evaluate the resident because when she looked at him he was sitting straight. LPN #1 further stated that she did not notify the Registered Nurse Supervisor nor the physician regarding Resident #1's family concerns for change in his condition. LPN#1 stated that she did not call the family on [DATE] to notify them about his condition at the time of his death. During an interview with the Primary Care Physician (PMD) on [DATE] at 12:37 PM, the PMD stated that he did not recall getting a call regarding Resident #1's change in condition and family's concerns on [DATE]. The PMD stated that if the nurses would have informed him of family requesting blood work he would have given a telephone order for the same. The PMD could not recall if he had given a telephone order for blood work for Resident #1 on [DATE] (medical record lacked documented evidence of physician order [REDACTED]. Later that day ([DATE]) he was called (could not recall name) and was notified that Resident #1 was found on the floor. Many days later (date unknown) the PMD received a call (could not recall name) informing him that Resident #1 was found with his head between the railing and the mattress. The PMD stated that he completed the death certificate based on the information provided to him by the facility. At the time of completing the death certificate the PMD was not aware of the circumstances (Resident #1's head between the mattress and bed railing). During an interview with CNA #1 on [DATE] at 2:04 PM, CNA #1 stated that she responded to a call for help by LPN #1 on [DATE] to Resident #1's room, the resident was observed kneeling on the floor and LPN #1 holding him from the back. Resident #1 was pronounced by the physician. LPN #1 instructed CNA #1 to not tell the family that resident had fallen. 415.3(e)(2)(ii)(b)