Every finding on record at Rebekah Rehabilitation and Extended Care Center

Based on observation, record review, and interviews conducted during the Recertification survey conducted from 09/15/2026 to 09/23/2026, the facility did not ensure sufficient nursing staff was consistently provided to meet the residents' needs in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being, as determined by resident assessments and individual plans of care. Specifically, 1). Residents and staff reported the facility was short staffed with Certified Nursing Assistants and Licensed Practical Nurses especially on weekends both days and nights, which resulted in delays in performing Activities of Daily Living and personal care. 2). The facility Payroll Based Journal for Quarter 4 (July -September 2025) also revealed excessively low weekend staffing, and 3). Review of the actual staffing schedules dated from 07/01/2025 to 09/30/2025 revealed that staffing assignments were consistently less than the projected staffing needs specified in the Facility Assessment.The findings include but are not limited to: The Payroll Based Journal Staffing Data Report for the 4th quarter of 2025 (07/01/2025 - 09/30/2025) documented that low weekend staffing was triggered.The Facility Wide Assessment which was last updated on 01/2025 documented that the Facility Assessment was intended to evaluate the facility's population and determine the resources necessary to care for residents competently during both day-to-day operations and emergencies. The facility provides care on 5 units on Floors 2 through 6 with a 213-bed capacity. Each unit has a capacity of 43 beds. There are differentiations in the resident population and focus of services provided on each of the floors. The staffing plan for each of the floors that provides direct care to the residents is based upon an assessment of the care needs of the residents.The focus of service for the 2nd Foor unit was documented as high acuity residents who required total dependence for daily living Activities and residents with enteral tube feedings.The focus of service for the 6th Floor unit was short term care residents who had fractures and / or joint replacements requiring rehabilitation services, residents who required short term intravenous therapy. The unit also included long-term care residents in need of skilled nursing services.The documented Staffing Requirement/ par level for the 2nd Floor and 6 Floor units were two (2) Licensed Practical Nurses providing direct care on all shifts and five (5) Certified Nursing Assistants on day shift.The par levels for nursing staff as documented in the Facility Assessment were as follows:Day Shift (7:00 AM - 3:00 PM):2nd Floor (bed capacity of 43) : 2 Licensed Practical Nurses, 5 Certified Nursing Assistants3rd Floor (bed capacity of 43): 2 Licensed Practical Nurses, 4 Certified Nursing Assistants4th Floor (bed capacity of 43): 2Licensed Practical Nurses, 4 Certified Nursing Assistants5th Floor (bed capacity of 43): 2Licensed Practical Nurse, 4 Certified Nursing Assistants6th Floor (bed capacity of 43): 2 Licensed Nurses, 5 Certified Nursing Assistants Evening Shift (3:00 PM - 11:00 PM):2nd Floor: 2 Licensed Practical Nurse, 4 Certified Nursing Assistants3rd Floor: 1 Licensed Practical Nurse, 3 Certified Nursing Assistants4th Floor: 1 Licensed Practical Nurses, 3 Certified Nursing Assistants5th Floor: 1 Licensed Practical Nurses, 3 Certified Nursing Assistants6th Floor: 2 Licensed Practical Nurses, 3 Certified Nursing Assistants Night Shift (11:00 PM - 7:00 AM):2nd Floor: 2 Licensed Practical Nurses, 3 Certified Nursing Assistants3rd Floor: 1 Licensed Practical Nurse, 2 Certified Nursing Assistants4th Floor: 1 Licensed Practical Nurse, 2 Certified Nursing Assistants5th Floor: 1 Licensed Practical Nurse, 2 Certified Nursing Assistants6th Floor: 2 Licensed Practical Nurse, 2 Certified Nursing Assistants A review of the weekend staffing schedule from Quarter 4 of 2025 (07/01/2025 - 09/30/2025) documented the following consistently low weekend staffing which was representative of staffing levels in additional months.The documented staffing requirement / par level for the 2nd Floor and 6th Floor units were the highest facility requirement with two (2) Licensed Practical Nurses providing direct care on all shiftsand five (5) Certified Nursing Assistants providing direct care on the day shift, which was often not met. 07/5/05/2025 (Saturday), Day Shift, Shortage of one (1) Licensed Practical Nurse on the 3rd, 4th, and 5th Floor units07/06/2025 (Sunday), Day Shift, Shortage of one (1) Licensed Practical Nurse 3rd, 4th, and 5th Floor units07/06/2025 (Sunday), Night Shift, Shortage of one (1) Licensed Practical Nurse on the 6th Floor unit07/11/2035 (Friday), Day shift, shortage of one (1) Licensed Practical Nurse on the 3rd Floor unit; and shortage of one (1) Certified Nursing Assistants on the 2nd, 4th, and 6th Floor units.07/11/2035 (Friday), Evening shift, shortage of one (1) Licensed Practical Nurse on the 6th Floor unit07/12/2025 (Saturday), Day shift, shortage of one (1) Licensed Practical Nurse on the 3rd, 4th, 5th, and 6th Floor units07/12/2025 (Saturday), Evening shift, shortage of one (1) Licensed Practical Nurse on the 2nd Floor unit07/13/2025 (Sunday), Day shift, shortage of one (1) Licensed Practical Nurse on the 3rd, 4th, 5th, and 6th Floor units; and shortage of one (1) Certified Nursing Assistant on the 2nd, 4th, 6th Floor units.07/13/2025 (Sunday), Evening shift, shortage of one (1) Licensed Practical Nurse on the 2nd Floor.07/18/2025 (Friday), Day shift, shortage of one (1) Licensed Practical Nurse on the 3rd, 4th, and 5th Floor units07/18/2025 (Friday), Night shift, shortage of one (1) Licensed Practical Nurse on the 6th Floor07/19/2025 (Saturday), Day shift, shortage of one (1) Licensed Practical Nurse on the 3rd, 4th, and 5th Floor units07/19/2025 (Sunday), Evening shift, shortage of one (1) Licensed Practical Nurse on the 2nd and 6th Floor units07/20/2025 (Sunday), Day Shift, Shortage of one (1) Licensed Practical Nurse on the 3rd, 4th, and 5th Floor units; and one (1) Certified Nursing Assistant on the 6th Floor07/20/2025 (Sunday), Night shift, Shortage of one (1) Certified Nursing Assistant on the 6th Floor unit07/26/2025 (Saturday), Day Shift, Shortage of one (1) Licensed Practical Nurse on the 3rd floor unit, 4th floor unit, 5th floor unit07/26/2025 (Saturday), Night Shift, Shortage of one (1) Certified Nursing Assistant on the 2nd Floor unit08/02/2025 (Saturday), Day Shift, shortage of one (1) Licensed Practical Nurse on the 3rd floor unit, 4th floor unit, and 5th floor unit08/02/2025 (Saturday), Night Shift, Shortage of one (1) Licensed Practical Nurse on the 2nd and 6th Floor units08/03/2025 (Sunday), Day Shift, Shortage of one (1) Licensed Practical Nurse on the 2nd, 3rd, 4th, and 5th Floor units08/03/2025 (Sunday), Evening shift, shortage of one (1) Licensed Practical Nurse on the 6th Floor unit; and one (1) Shortage of 1 Certified Nursing Assistant08/08/2025 (Friday), Day shift, shortage of one (1) Certified Nursing Assistant on the 6th Floor unit 08/09/2025 (Saturday), Day shift, shortage of one (1) Licensed Practical Nurse on the 3rd, 4th, and 5th Floor unit 08/10/2025 (Sunday), Day shift, shortage of one (1) Licensed Practical Nurse on the 2nd, 3rd, 4th, 5th, and 6th Floor units08/10/2025 (Sunday), Evening shift, shortage of one (1) Licensed Practical Nurse on the 2nd, 3rd, 4th, 5th, and 6th floor units08/23/2025 (Saturday), Day shift, shortage of one (1) Licensed Practical Nurse on the 3rd, 4th, and 5th Floor units08/30/2025 (Saturday), Day shift, shortage of one (1) Licensed Practical Nurse on the 3rd, 4th, and 5th Floor units 0/30/2025 (Saturday), Night shift, shortage of one (1) Certified Nursing Assistant on the 2nd Floor unit 09/13/2025 (Saturday), Day shift, shortage of one (1) Licensed Practical Nurse on 3rd, 4th, and 5th Floor units09/13/2025 (Saturday), Evening shift, shortage of one (1) Licensed Practical Nurse on the 6th Floor unit 09/14/2025 (Sunday), shortage of one (1) Licensed Practical Nurse on the day shift in 3rd, 4th, and 5th Floor units; shortage of one (1) Certified Nursing Assistant on the evening shift in 6th Floor; and shortage of one (1) Licensed Practical Nurse on the night shift in 2nd Floor On 01/15/2026 at 11:10 AM, Resident #53 was interviewed and stated that they have been missing therapy sessions. They stated sometimes the staff change/dress/bathe them after breakfast and by the time the aides come to help them dress and bathe, their already late for rehabilitation therapy. Resident #53 also stated they missed rehabilitative therapy sessions. Resident #53 stated that staffing is short during the nights, morning and basically all the time. There are people waiting for care and the aides are rushed. Resident #53 further stated that they also wait for care and then miss their appointmentOn 01/15/2026 at 11:57AM, Resident #158 was interviewed and stated that the facility is short in staff. There are times when there is have one nurse for the whole floor. Resident #158 stated they sometimes get their morning medications an hour later that they were supposed to. On 01/21/2026 at 9:56 AM, Licensed Practical Nurse #3 was interviewed and stated that they are short of nurses since 2024 and that the 6th floor which was a rehabilitation unit is inadequately staffed. They stated that two (2) person transfers cannot be performed timely with only three (3) aides during the day when they were supposed to have five (5). On 01/21/2026 at 1:08 AM, Certified Nursing Assistant #4 was interviewed and stated that 6th Floor is short staffed and that at times, another aide is floated to another unit leaving the 6th Floor short. They stated there are residents that required 2 people assist in transfers aside from long term care residents who are total care. They stated that there are short staffing on the evening shift as well and residents who required Hoyer lift for transfers stay in bed, and that day showers are pushed to the evening shift. On 01/23/2026 at 1:29 PM, Certified Nursing Assistant #5 was interviewed and stated that staffing is low even on weekdays on the 6th Floor with only 4 aides to take care of 43 residents. Certified Nursing Assistant #5 further stated that residents who require Hoyer lift for transfers are showered on different days because other aide gets floated to a different floor who have lesser staff. On 01/23/2026 at 12:19 PM, the Staffing Coordinator was interviewed and stated that they are aware of the short staffing and that the facility is mostly short of aides in the day shift. They stated that 2nd and 6th Floors have residents with higher acuity and need more staff. They stated they are able to obtain staff but sometimes there are call-outs. They also stated that they have nurses and aides who are on-call but there is only 50% chance that the shift will be filled up to par. On 01/23/2026 at 1:40 PM, Registered Nurse #5, who was the 6th Floor supervisor was interviewed and stated that 6th Floor staffing is usually up to par, but other floors are short and their staff will be floated somewhere else. They stated that shower schedules are sometimes moved to the evening shift or there might be a delay in getting resident out of bed. On at 01/23/2026 12:56 PM, the Director of Nursing was interviewed and stated they are aware of the facility's past and present staffing issues, and they have been hiring aggressively using 12 different staffing agencies. They stated that although weekend staffing had improved, there are still issues on weekends and days possibly related to staffing agencies bidding wars. The Director stated that at times, staff are floated to a different unit, and that the staff on the 6th Floor are the ones usually floated because they are reliable and had solid experience. On 01/23/2026 at 2:31 PM, the Administrator was interviewed and stated they are aware of the facility's low weekend staffing and was informed of current staffing complaints. They stated that the facility could not recruit enough staff to make the par level.10 NYCRR 415.13(a)(1) (i-iii)

Based on observation, record review, and interviews, the facility failed to develop a person-centered comprehensive care plan to meet each resident's preferences and goals; and address the resident's medical, physical, mental and psychosocial needs. This was evident for one (1) (Resident #8) of one (1) resident reviewed for activities out of 38 total sampled residents. Specifically, Resident #8's care plan for recreational activities was not initiated when the resident was readmitted to the facility after hospitalization. The findings include:The facility's policy and procedure titled Comprehensive Care Plans dated 10/2025 documented that Comprehensive Care Plans shall be periodically reviewed and revised as necessary after each comprehensive assessment or reassessment.Resident #8 was re-admitted to the facility on [DATE] with diagnoses which included Coronary Artery Disease, Heart Failure, and Renal Insufficiency. The Significant change Minimum Data Set assessment dated [DATE] documented Resident #8 was moderately impaired in cognition. The assessment also documented that resident's preferences for customary routine and activities were very important.The resident admission, transfer, and discharge records dated 09/02/2025 documented that Resident #8 was transferred to the hospital on [DATE] and was re-admitted to the facility on [DATE].The Activities - Recreation assessment dated [DATE] documented that the resident's activity preferences include arts and crafts, beauty hours, sewing and knitting, and watching television.A review of Resident #8's comprehensive care plans revealed that a care plan to address activities / recreation was not initiated when Resident #8 was readmitted to the facility on [DATE]. A therapeutic recreation care plan was only initiated on 01/23/2026. On 01/23/26 at 10:13 AM, an interview was conducted with the Recreation Director. They stated that activity care plans are initiated on admission, readmission, and if there is any change in the health status of a resident. The Recreation Director stated that Resident #8's care plan for activities / recreation was discontinued when the resident was transferred to the hospital on [DATE]. The resident was re-admitted to the facility on [DATE] and the care plan for activities was not reactivated. On 01/23/2026 at 12:20 PM, an interview was conducted with the Director of Nursing who stated that the Recreation Department is responsible for initiating each resident's care plan on activities. 10 NYCRR 415.11(c)(1)

Based on observation, record review, and interviews, the facility failed to ensure that all alleged violations involving injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, to the New York State Department of Health. This was evident for one (1) (Resident # 180) of five (5) residents reviewed for Accidents out of 38 total sampled residents. Specifically, on 01/09/2026 at approximately 9:07 PM, Resident #180 was observed sitting on the floor in the hallway with a large hematoma (a collection of clotted blood outside of the blood vessel usually caused by trauma) with an open laceration on the temple and abrasion to the left elbow. There was no witness on how Resident #180 sustained the injury and the source of injury could not be explained by the resident. The findings include:The facility's policy and procedure titled Prevention of Mistreatment, Neglect, Abuse and Misappropriation of Resident Property with a last reviewed date of 01/2024 documented all incident/accident of unknown origin will be thoroughly investigated and reported to the Department of Health within the required timelines.Resident #180 had diagnoses of acute ischemic heart disease, history of falling, and dementia.The quarterly Minimum Data Set assessment dated [DATE] documented Resident #180 had severely impaired cognition and required partial to moderate assistance for activities of daily living. On 01/16/2026 at 9:52 AM, Resident #180 was observed seated in a wheelchair, in the dining room. The left side of the face had a large and mostly fading yellowish/greenish skin discoloration. Resident #180 was unable to state how they sustained the facial discoloration. The Accident / Incident Report documented that on 01/09/2026 at 9:07 PM, Resident #180, who was cognitively impaired, was observed in the hallway, sitting on the floor, outside their room. A large hematoma and a two (2) - three (3) centimeter laceration was noted on their left temple and abrasion to the left arm near elbow was noted. Resident #180 was transferred to the emergency room. The nurse's progress notes dated 01/09/2026 at 10:42 AM documented Resident #180 was unable to verbalize how they ended on the floor. The Summary of Investigation by the Director of Nursing dated 01/13/2026 concluded that the element needed to make this incident reportable to the Department of Health have not been met. On 01/22/2026 at 10:31 AM, the Director of Nursing was interviewed and stated that the Department of Health Incident Reporting manual was used and reviewed to provide guidance on how or what to report to the Department of Health. They stated the incident was not an injury of unknown origin, there was no care plan violation, and there was no serious injury such as fracture. On 01/23/2026 at 10:42 AM, the Administrator was interviewed and stated that injuries of unknown origin that cannot be explained must be reported to the Department of Health. 10 NYCRR 415.4 (b)(2)

Based on observation, record review, and interviews, the facility failed to ensure residents remained free from physical restraints. This was evident for one (1) of two (2) (Resident #222) residents reviewed for Restraints out of 38 total sampled residents. Specifically, bed bolsters were used for Resident #222 without assessment, physician's order, and consent. The findings are:The facility's policy titled Prevention of Mistreatment, Neglect, Abuse, and Misappropriation of Resident with a last revised date of 01/2024 documented every resident has the right to be free from any physical or chemical restraints imposed for the purposes of discipline or convenience and not required to treat the resident's medical symptoms. It also documented the facility will ensure no action will be taken to control the resident's behavior or manage a resident's behavior with a lessor amount of effort by the facility and not in the best interest of the resident.Resident #222 had diagnoses of Unspecified dementia, Alzheimer's disease, and Fracture of unspecified part of neck of left femur.The admission Minimum Data Set assessment dated [DATE] documented Resident #222 was severely impaired in cognition. It also documented no physical restraint, or alarm was used for Resident #222. It further documented only Resident #222's representative participated in the assessment. Between 01/15/2026 at 10:51 AM and 01/21/2026 at 9:45 AM, there were multiple observations of Resident #222 lying in bed with bilateral upper side rails raised and bed bolsters placed beneath the bed sheet on both sides of lower half of bed.On 01/15/2026 at 10:51 AM, Resident #222's representative was interviewed and stated only the upper side rails were used when Resident #222 was admitted to the facility on [DATE]. They stated this was the first time they observed the bed bolsters tucked under the sheet. The representative stated the facility did not notify them about the use of bed bolsters.A physician's order dated 01/12/2026 documented Resident #222 was ordered to use bilateral one-half side rails/enablers up in bed to promote increased bed mobility.The Nursing - Side Rail assessment dated [DATE] documented side rails were used as enabler rail and to avoid Resident #222 from rolling out of bed.The nursing note dated 01/12/2026 documented Resident #222 was noted sitting at the edge of bed.A Comprehensive Care plan related to falls that was initiated on 01/09/2026 documented an intervention of adding bilateral bed bolsters and floor mats on 01/15/2026 as Resident #222 tried to come out bed and was at risk of fall. The Certified Nursing Assistant tasks in the computer system documented floor mats, low bed, and wedge cushions as protective measures for safety on 01/16/2026 for Resident #222.There were no physician's order, assessment, and notification to representative to use bed bolsters for Resident #222 in the medical record.On 01/21/2026 at 10:43 AM, Certified Nursing Assistant #1 was interviewed and stated Resident #222 was alert and confused. The Certified Nursing Assistant #1 also stated Resident #222 had upper bed side rails up all the time and that they placed the bed bolsters on the bilateral lower half of Resident #222's bed as per nurse instruction in their tasks to prevent Resident #222 from rolling out of bed. Certified Nursing Assistant #1 stated the bed bolsters were attached to the mattress and were placed under the sheet. Certified Nursing Assistant #1 also stated Resident #222 was unable to remove the bed bolsters or lower down the upper side rails to get out of bed by themselves.On 01/21/2026 at 11:06 AM, Registered Nurse #1 was interviewed and stated there was a time when Resident #222 placed their lower extremities out of bed. They were concerned that Resident #222 would fall out of bed, so they had decided to place the bed bolsters on both lower sides of bed to prevent Resident #222 from rolling out. Registered Nurse #1 further stated Resident #222 was unable to get out of bed when upper side rails were raised and when the bed bolsters were placed on the lower half of the bed. Registered Nurse #1 stated they did not conduct restraint assessment, they did not obtain consent from the representative, nor obtain physician's order prior to placing the bed bolsters. On 01/21/2026 at 11:41 AM, Occupational Therapist #1 was interviewed and stated Resident #222 had fine motor issue and decreased strength. Occupational Therapist #1 stated Resident #222 was unable to lower the upper side rails or get out of bed by themselves when the upper side rails were raised and when bed bolsters were placed on both sides of the bed. On 01/21/2026 at 11:44 AM, Physical Therapist #1 was interviewed and stated Resident #222 had muscle weakness and problem with standing balance. Physical Therapist #1 also stated Resident #222 was unable to get out of bed by themselves when the upper side rails were raised and when bed bolsters were in use. On 01/21/2026 at 2:39 PM, Nurse Practitioner #1 was interviewed and stated Resident #222 only had the medical order for using upper side rails. The Nurse Practitioner #1 also stated they did not order nor was aware of the use of bed bolsters.On 01/21/2026 at 11:51 AM, the Director of Nursing was interviewed and stated they were not aware bed bolsters were applied for Resident #222 without medical order, assessment, and consent. The Director of Nursing stated a restraint assessment must be completed before putting the bed bolsters; they also stated that there must be physician's order and consent from the resident representative. They stated Resident #222 would not be able to get out of bed by themselves when the upper side rails were raised and when bed bolsters were used. The Director of Nursing also stated the use of upper bed side rails and bed bolsters at lower bed would be physical restraint for Resident #222. 10 NYCRR 415.4(a)(2-7)

Based on observation, record review, and interviews, the facility failed to ensure notice of the availability of the survey results were posted in areas of the facility that are prominent and accessible to the residents and the public. Specifically, there were no posted notices throughout the five (5) resident floors of the facility about the availability of survey results. The findings are:The facility's policy titled Your Rights As A Nursing Home Resident dated August 2005 documented under Access to Information of Life at the Facility that residents have the right to examine the results of the most recent federal or state survey of the facility including any statement of deficiencies, any plan of correction in effect with respect to the facility and any enforcement actions taken by the New York State Department of Health. It also documented the results must be made available for examination in a place readily accessible.During multiple building observations conducted between 01/15/2026 at 09:43 AM and 01/16/2025 at 10:50 AM, survey results were observed in a binder in a plastic container installed on the wall across the security station in the lobby area. There were no notices posted to inform the residents and the public on any of five (5) resident units about where the survey results could be located. During the Resident Council meeting held on 01/16/2026 at 11:00 AM, seven (7) residents were in attendance, and seven (7) out of seven (7) residents (Residents #22, #63, #90, #164, #171, #208, and #211) stated they did not know where to find the survey results and that they have not seen any notice telling them where to find the survey results. The minutes of the Resident Council Meetings held on 10/20/2025, 11/25/2025, and 12/30/2025 had no documentation that information was provided to the residents on where to locate survey results. On 01/21/2026 at 12:13 PM, the Administrator was interviewed and stated they made round to the floors at least one (1) time every day. The Administrator also stated they looked for medication cart if resident information on the computer screen was displayed to residents/visitors passed by, if the staff had identity card on, and if the residents were clean. The Administrator stated they thought the posts where to find the survey results were posted on all the resident floors. The Administrator also stated they did not pay attention to the post when making round to the resident units. The Administrator stated the facility should post throughout the building to inform residents and the public where to find the survey results on the units. 10 NYCRR 415.3 (d)(1)(v)

Based on record review and interviews, the facility failed to ensure that the Minimum Data Set Assessments were electronically transmitted to the Centers of Medicare/Medicaid Services Data System within 14 days of completion. This was evident for nine (9) of 9 residents' (Residents #5, #15, #69, #124, #8, #180, #166, #155, #144) Minimum Data Set assessments. Specifically, these residents Minimum Data Set Assessments were not electronically transmitted within 14 days after the facility completed the resident's assessment. The findings include but are not limited to: The facility's policy titled Minimum Data Set with an effective date of12/2024 did not include procedure on when to submit completed Minimum Data Set assessments to the Centers for Medicare & Medicare Services.1) Resident #5 was admitted on [DATE]. The Centers of Medicare/Medicaid Services Submission Report Minimum Data Set 3.0 Nursing Home Final Validation Report, the target date for the Quarterly Minimum Data Set was 11/26/2025. The Quarterly Minimum Data Set was submitted on 01/19/2026. The report also documented Record Submitted Late: the submission date is more than 14 days after Z0500B on this new (A0050 equals 1) assessment.2) Resident #15 was admitted on [DATE]. The Centers of Medicare/Medicaid Services Submission Report Minimum Data Set 3.0 Nursing Home Final Validation Report, the target date for the Quarterly Minimum Data Set was 12/08/2025. The Quarterly Minimum Data Set was submitted on 01/19/2026. The report also documented Record Submitted Late: the submission date is more than 14 days after Z0500B on this new (A0050 equals 1) assessment.3) Resident #69 was admitted on [DATE]. Per Centers of Medicare/Medicaid Services Submission Report Minimum Data Set 3.0 Nursing Home Final Validation Report, the target date for the Annual Minimum Data Set was 12/01/2025. The Annual Minimum Data Set was submitted on 01/19/2026. The report also documented Record Submitted Late: the submission date is more than 14 days after V0200C2 on this new (A0050 equals 1) comprehensive assessment.On 01/22/2026 at 10:45 AM, the Minimum Data Set Director was interviewed and stated they were responsible for completion and submission of Minimum Data Set assessments to Centers of Medicare/Medicaid Services. They stated they were the only staff able to submit the completed Minimum Data Set assessments. The Minimum Data Set Director also stated they were on vacation from 12/09/2025 to 01/06/2026 and they failed to train the Minimum Data Set assessor to submit the Minimum Data Set in the Internet Quality Improvement and Evaluation System before they went on vacation. On 01/22/2026 at 12:30 PM, the Administrator was interviewed and stated they were not aware that the Minimum Data Set assessments were submitted late. 10 NYCRR 415.11

Based on record review and interviews conducted during an Abbreviated Survey (Incident# 641690 and Incident # 641669), the facility failed to 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. This was evident in three (3) out of nine (9) residents (Resident #7, #8, and #9) sampled. Specifically, 1) the facility Accident/Incident Report dated 03/01/2025 documented that Resident #7's family member reported to Licensed Practical Nurse on 03/01/2025 at 5:00 PM that two (2) Certified Nursing Assistants who were roughed with Resident #2 early in the morning. Registered Nurse Supervisor #2 interviewed Resident #7 on 03/01/2025 and the resident reported that Certified Nursing Assistant #2 held them by their neck and another (unidentified) Certified Nursing Assistant pulled their feet. The facility completed their investigation which was unsubstantiated. However, the facility did not submit the five (5) day investigation findings to New York State Department of Health timely. The facility reported their investigation findings on 03/10/2025 at 3:58 PM.2) the facility Accident/Incident Report dated 08/17/2024 documented that Resident #8 and Resident #9 had a verbal altercation in the dining room and Resident #9 picked up a fork and threatened to stab Resident #8. Staff immediately intervened and separated the residents and took the fork from Resident #9. The facility investigated and reported the incident to New York State Department of Health but did not submit the five (5) days investigation findings to New York State Department of Health. The findings include: The Facility's Policy and Procedure titled Prevention of Mistreatment, Neglect and Abuse and Misappropriation of Resident Property with a reviewed dated 01/2024 documented the Director of Nursing/Administrator will report to the Department of Health, within two (2) hours of any accidents/incidents where there is reasonable cause to believe that resident abuse, neglect or mistreatment has occurred. The facility has five (5) days to complete its investigation and report the findings. Resident #7 was admitted to the facility with diagnoses including Depression and Diabetes Mellitus. The Minimum Data Set (a resident assessment tool) dated 02/13/2025 documented Resident #7 had severely impaired cognition.The facility's Investigation Summary dated 03/01/2025 documented that Resident #7's family member reported to Licensed Practical Nurse #3 on 03/01/2025 at 5:00 PM that two (2) Certified Nursing Assistants who were roughed with Resident #7 early in the morning. Registered Nurse Supervisor #2 interviewed Resident #7 on 03/01/2025 via interpreter and the resident reported that Certified Nursing Assistant #2 held them by their neck and another (unidentified) Certified Nursing Assistant pulled their feet. Resident #7 was assessed and there was no redness, bruising or any marks observed on the resident's neck and feet. Resident #7 did not complain of pain. The police were notified and responded but did not make any report. Resident #7's assigned Certified Nursing Assistant #2 provided care to Resident #7 and Licensed Practical Nurse #2 assisted Certified Nursing Assistant #2 in repositioning the resident in bed. There was no other Certified Nursing Assistant who assisted Certified Nursing Assistant #2 during their care. The facility's investigation concluded that abuse did not occur. Resident #7 had poor recall and may have assumed that they were mishandled when they were receiving regular activities of daily living care. To prevent reoccurrence, the facility in-serviced the staff on gentle handling of residents and using a translation line communication with residents who speak a different language for clear communication. The facility completed their investigation and concluded that abuse did not occur. During a telephone interview on 08/26/2025 at 9:45 AM, the previous Director of Nursing #1 stated that they do not recall the incident. The previous Director of Nursing #1 stated that they do not know why the five (5) days report was submitted late. During an interview on 08 /25/2025 at 2:20 PM, the Administrator stated that they were notified of the incident by the previous Director of Nursing on 03/01/2025 (unsure of time) but was not aware the five (5) days investigation findings were submitted late. Resident #8 was admitted to facility with diagnoses including Depression, Chronic Kidney Disease and Diabetes Mellitus. The Minimum Data Set (a resident assessment tool) dated 06/25/2024 documented that Resident #8 had intact cognition.Resident #9 was admitted to facility with diagnoses including Diabetes Mellitus and Adjustment Disorder with mixed Anxiety and Depressed Mood. The Minimum Data Set, dated [DATE] documented Resident #9 had intact cognition.The facility's Investigation Summary dated 08/23/2024 documented that on 08/17/2024 at 8:40 AM Resident #8 and Resident #9 were seated at a distance from each other in the dining room. For reasons unknown, Resident #8 and Resident #9 had a verbal argument and Resident #9 picked up a fork as Resident #8 got up from their chair. Resident #9 stated that they took the fork up to defend themself if Resident #8 had attacked them. Staff immediately intervened and separated both residents. 911 was called and responded. Resident #9 was placed on fifteen-minute (15) monitoring for twenty-four hours (24). The facility's investigation concluded that abuse or neglect did not occur and that there was no physical contact between the residents. The investigation also concluded that this was that first time Resident #8, and Resident #9 had been in a verbal altercation. During a telephone interview on 08/26/2025 at 3:16 PM, previous Director of Nursing #2 stated that they do not recall incident. Previous Director of Nursing #2 stated that not all incidents called into the Department of Health requires a five (5) days submission follow up, but if the Department of Health asked them to send one, they would have submitted one. During an interview on 08 /25/2025 at 2:20 PM, the Administrator stated that they were notified of the incident of 08/17/2024. The Administrator stated that they were not aware that five (5) days investigation findings were not submitted to the New York State Department of Health. 10 NYCRR 415.4 (b)(1)(ii)

Based on record review and interviews conducted during the recertification and abbreviated (NY00322703) survey from 12/6/2023 to 12/13/2023, the facility did not ensure all alleged violations involving abuse were reported to the New York State Department of Health (NYSDOH) immediately or within 2 hours after the allegation was made. This was evident for 5 (Resident #37, #48, #52, #159, and #89) of 39 total sampled residents. Specifically, 1) Resident #37 had an unwitnessed fall with injury that was not reported to the NYSDOH, 2) Resident #159, #48, and #52 were involved in a resident to resident altercation that was not reported to the NYSDOH, and 3) Resident #89's allegation of abuse against a Certified Nursing Assistant (CNA) was not reported to the NYSDOH. The findings are: The facility policy titled Prevention of Mistreatment, Neglect and Abuse and Misappropriation of Resident Property dated 10/4/2022 documented the Director of Nursing Services (DNS) will report to the NYSDOH any Accident/Incident where there is reasonable cause to believe that resident abuse occurred. The facility policy titled Accident Prevention and Reporting dated 6/2023 documented the Director of Nursing Services (DNS) reported to NYSDOH any suspected incidence of abuse, neglect, or mistreatment. 1) Resident had diagnoses of dementia and hypertension. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #37 had severely impaired cognition. The Nursing Note dated 11/22/2023 documented Resident #37 was found lying on their back in their room on the floor and was unable to state what occurred. Resident #37 had limitation in range of motion in their right leg and was transferred to the hospital. The facility's Summary of Investigation dated 11/22/2023 documented Resident #37 was observed lying on their back on the floor in their room. Resident #37 was unable to provide a statement of occurrence. There was no documented evidence Resident #37's fall incident was reported to the NYSDOH. On 12/13/2023 04:21 PM, an interview conducted with the DNS who stated Resident #37's unwitnessed fall was not reported to the NYSDOH. The DNS stated it was clear that Resident #37's right leg injury was related to a fall because the resident had a history of falls. If abuse was suspected, the DNS would have reported to the NYSDOH within 2 hours. 39136 2) Resident #159 had diagnoses of dementia and altered mental status. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #159 was severely cognitively impaired. Resident #48 had diagnoses of dementia and anxiety disorder. The MDS assessment dated [DATE] documented Resident #48 was severely cognitively impaired. Resident #52 had diagnoses of altered mental status and dementia The MDS assessment dated [DATE] documented Resident #52 was severely cognitively impaired. The Nursing Note dated 8/22/2023 documented Licensed Practical Nurse (LPN) #2 observed Resident #159 pull Resident #52 off their bed and hit them with a hairbrush. The residents entered the hallway and Resident #48 was also hit during the altercation. The facility's Summary of Investigation dated 8/22/2023 documented the elements required to make the altercation between Resident #159, #52, and #48 a reportable event had not been met. There was no documented evidence the resident to resident altercation between Resident #159, #52, and #48 were reported to the NYSDOH. On 12/08/2023 at 2:46 PM, the DNS was interviewed and stated they and the Administrator were responsible for reporting allegations of abuse to the NYSDOH. Allegations of abuse, injuries of unknown origin, and resident-to-resident altercations resulting in injury were reportable events. The DNS stated they did not have to report every resident-to-resident altercation. On 12/08/2023 at 3:02 PM, the Administrator was interviewed and stated the DNS was responsible for reporting incidents to the NYSDOH. The Administrator was unaware of the resident to resident altercation between Resident #159, #52, and #48. The facility should have reported the incident to the NYSDOH. 44842 3) Resident #89 had diagnoses of diabetes mellitus and anxiety disorder. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #89 was cognitively intact. The facility's Summary of Investigation dated 10/12/2023 documented Resident #89 reported to Registered Nurse (RN) #4 that on 10/11/23 at 8:30 PM, Certified Nursing Assistant (CNA) #7 was too rough turning them. The conclusion documented the elements needed to make this incident reportable to the DOH have not been met. There was no documented evidence Resident #89's allegation of abuse was reported to the NYSDOH. On 12/13/2023 at 3:42 PM the DNS was interviewed and stated Resident #89's allegation of abuse was quickly investigated and there was no evidence of abuse. Therefore, the alleged abuse was not reported to the NYSDOH. 10 NYCRR 415.4(b)(2)

Based on observation, interviews, and record review conducted during the Recertification survey from 12/06/2023 to 12/13/2023, the facility did not ensure a resident with limited range of motion received treatment and services to maintain or improve mobility. This was evidenced by 1 (Resident #141) of 2 residents reviewed for mobility out of 39 total sampled residents. Specifically, Resident #141 did not have a right elbow splint (RES) applied in accordance with Medical Doctor Order (MDO). The findings are: The facility policy titled Rehabilitation dated 03/23 documented the Certified Nursing Assistant (CNA) was responsible for donning/doffing adaptive equipment. Resident #141 had diagnoses of right Hemiplegia and Diabetes Mellitus (DM). The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #141 was moderately cognitively impaired and did not document splint or brace use. On 12/06/2023 at 10:05 AM, Resident #141 was observed lying in bed without a RES applied to their right arm. On 12/07/2023 at 11:57 AM, 12/08/2023 at 09:31 AM, and 12/08/2023 at 12:00 PM, Resident #141 was observed sitting in their wheelchair without a RES in place. The MDO dated 10/01/2023 documented Resident #141 was ordered to wear a RES at all times to prevent further contracture. Skin checks were performed every 3 hours and rehab notified if redness or irritation were present. The Comprehensive Care Plan (CCP) related to alteration in range of motion and contractures initiated 9/19/2023 documented Resident #141 had a contracture post-stroke and required a RES. On 12/08/2023 at 12:12 PM, CNA #1 was interviewed and stated they were unaware whether Resident #141 was ordered to wear a RES. Splinting devices were not indicated in the CNA Accountability Records that informed the CNA what care the resident received. On 12/08/2023 at 12:20 PM, the Occupational Therapist (OT) was interviewed and stated they informed the CNA and the Registered Nurse (RN) that Resident #141 had an MDO for RES. The OT stated they provided an inservice to the nursing staff on the resident's unit to ensure they knew how to apply splinting devices. Resident #141 had the RES in place when they went to rehab earlier and the OT forgot to put it back on the resident when the resident was transported back to their unit. On 12/08/23 at 12:36 PM, RN #1 was interviewed and stated the CNAs on the resident's unit were responsible for applying splinting devices to the residents in accordance with MDO. The instructions related to splinting were documented on the CNA Accountability Record. The CNA on the 11PM to 7AM shift usually took Resident #141 out of bed and was responsible to ensure the resident was wearing their RES. RN #1 was unaware Resident #141 was observed without their RES in place. 10 NYCRR 415.12[e][2]

Based on observations, record review, and interviews conducted during the recertification and abbreviated (NY00307221) survey from 12/6/2023 to 12/13/2023, the facility did not ensure a resident's designated representative (DR) was notified of changes in treatment. This was evident in 1 (Resident #63) of 39 total sampled residents. Specifically, Resident #63's DR was not notified when the resident's blood thinner medication was not administered in relation to subconjunctival hemorrhage. The findings are: The facility policy titled Notification of Family dated 07/2023 documented Nursing and Social Services notify family in the event of a resident change of status to ensure proper communication, including changes in medications, and medical status. Resident #63 had diagnoses of coronary artery disease and Heart Failure. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #63 was severely cognitively impaired. Medical Doctor (MD) Orders dated 11/03/2022 documented Resident #63 received Eliquis 2.5mg every 12 hours. A MD Telephone Order dated 02/22/2023, documented that Eliquis 2.5mg should be held from 02/22/2023 at 2:00PM through 02/22/23 at 10:00PM. MD Note dated 02/22/23 at 4:07 PM documented Resident #63 was seen for left eye redness, likely due to subconjunctival hemorrhage and 1 dose of Eliquis should be held. Nursing Note dated 02/23/2023 documented Resident #63 was noted with left eye redness on 2/22/2023 at 5:30 PM, supervisor was informed, and message was left in MD's communication book. A MD Telephone Order dated 02/23/2023, documented Resident #63 had redness to their left eye and an Ophthalmology consult was ordered. Nursing Note dated 02/23/2023 at 7:35 PM documented Resident #63's DR came to visit on 02/23/2023 and was upset because they were not updated on Resident #63's plan of care. There was no documented evidence Resident #63's DR was informed of a change in the resident's condition and the need to alter treatment by holding a dose of Eliquis on 2/22/2023. During an interview on 12/11/2023 at 11:15 PM, Licensed Practical Nurse (LPN) #5 stated that they reported changes in Resident #63's condition to their supervisor who was responsible for notifying the DR. During an interview on 12/11/2023 at 3:23 PM, Registered Nurse (RN) #6 stated they were responsible for informing the DR of any changes in resident status. RN #6 stated that on 02/23/2023, Resident #63's DR visited and inquired about Resident #63's left eye and RN #6 informed the DR at that time that they would need to follow up with the MD. 10 NYCRR 415.3(f)(2)(ii)(c)

Based on record review and interviews conducted during the Recertification survey from 12/06/2023 to 12/13/2023, the facility did not ensure that all allegations of abuse, including injuries of unknown origin, were thoroughly investigated. This was evident for 1 (Resident #146) of 39 total sampled residents. Specifically, there was no documented evidence an investigation was conducted for Resident #146 who sustained a left hip fracture. The findings are: The facility policy titled Accident Prevention and Reporting dated 6/2023 documented an accident/incident (A/I) will be completed for any unexpected or unintentional incident or chain of events, which may or may not result in injury or illness to the resident. The facility will investigate all A/Is to ensure the facility provided an environment that is free from hazards. Resident #146 had diagnoses of repeated falls and left femoral neck fracture. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #146 was cognitively intact. On 12/07/2023 at 12:13 PM, Resident #146 was interviewed and stated they fell from their bed in 9/2023 while trying to get out of bed without help and required hospitalization and surgery. The Nursing Note dated 9/20/2023 documented Registered Nurse (RN) #4 was informed by the dialysis center that Resident #146 was transferred to the hospital due to worsening leg pain. A Social Work (SW) Note date 9/28/2023 documented the Admissions Director (AD) followed up with Resident #146 in the hospital and was informed the resident fell from their bed in the facility during the 11 PM-7 AM shift. Resident #146 did not report the fall to anyone in the facility. There was no documented evidence the facility investigated Resident #146's left hip fracture and report that they were injured after falling from their bed in the facility. On 12/13/2023 at 1:38 PM, RN #4 was interviewed and stated Resident #146 complained of leg pain at the dialysis center and was transferred to the hospital. Resident #146 reported to the facility that they fell at the facility and didn't tell anybody. RN #4 stated an AI investigation should have been completed for this incident. On 12/13/2023 at 3:37 PM, the Director of Nursing Services (DNS) was interviewed and stated no one knows when the fall happened. Resident #146 did not report they had a fall in the facility and the DNS did not know what happened at while the resident was at the dialysis center. Resident #146 was then transferred to another facility when discharged from the hospital. 10 NYCRR 415.4(b)(3)

Based on observations, record review, and interviews conducted during the recertification survey from 12/06/2023 to 12/13/2023, the facility did not ensure an account of all controlled drugs was maintained and periodically reconciled. This was evident for 1 (Unit 5) of 5 units observed for Medication Storage. Specifically, Licensed Practical Nurse (LPN) #3 did not reconcile a narcotics supply count for Resident #357. The findings are: The facility policy titled Distribution of Controlled Substances dated 11/15/2022 documented the licensed nurse was responsible for counting all controlled drugs at the beginning of the tour of duty, and again at the end of the tour of duty, together with the respective charge nurse going off and coming on duty. The licensed nurse was responsible for recording any administered medications on the front of the appropriate drug sheet. Resident #357 had diagnoses of vertebrogenic low back pain and major depressive disorder. On 12/13/2023 at 11:50 AM, The Unit 5 medication cart was observed with LPN #3. The narcotics box contained 1 blister pack of Oxycodone 10 mg for Resident #357 with a total count of 27 tablets. A Physician Order dated 11/29/2023 documented Resident #357 was prescribed Oxycodone 10 mg give I tablet by mouth 4 times per day at 6:00 AM, 11:00 AM, 4:00 PM, and 9:00 PM. The Medication Administration Record (MAR) dated 12/13/2023 documented Resident #357 was administered 1 tablet of Oxycodone 10 mg at 11:00 AM by LPN #4. The Individual Controlled Medication Record (ICMR) dated 12/13/2023 did not document Resident #357 was administered 1 tablet of Oxycodone 10mg at 11:00 AM and documented 28 tablets were remaining in the blister pack. The controlled medication staff signage record for Resident #357 was reviewed and documented the signature of LPN #3 in the 7AM-3PM Nurse (In) section for 12/13/2023. There was no documented evidence LPN #4 counted at the beginning of their tour of duty. The total count of Oxycodone 10mg remaining was 28 tablets. On 12/13/2023 at 1:15 PM, LPN #4 was interviewed and stated they started their shift as the medication nurse at 9:00 AM and checked the count for the narcotics that they administered. LPN #4 stated they administered Resident #357 Oxycodone at 11:00 AM, signed the MAR and the blister pack, but did not sign the ICMR because it slipped their mind. On 12/13/2023 at 1:43 PM, the Registered Nurse (RN) #4 was interviewed and stated the medication nurses were instructed to sign off on the ICMR after they administer a narcotic and were required to do a narcotics count when taking over a medication cart. On 12/13/2023 at 3:33 PM, the Director of Nursing Services (DNS) was interviewed and stated they instructed the nurses to sign the ICMR after narcotic medication was administered and to conduct a narcotics count with the outgoing medication nurse. 10 NYCRR 415.18(b)(1)(2)(3)

Based on observation, record review, and interviews conducted during the Recertification survey from 12/6/2023 to 12/13/2023, the facility did not ensure services provided met professional standards. Specifically, Licensed Practical Nurse (LPN) #6 and #7 did not notify the Medical Doctor (MD) when a Symbicort inhaler was not available to provide Resident #21 with medication in accordance with MD Order (MDO). The findings are: The facility policy titled Medication Administration Policy dated 4/2017 documented the Licensed Nurses will administer medication as per provider's orders. In a case where medication is missing or not available, the nurse shall call the pharmacy for reorder and notify the supervisor and the prescriber. Resident #21 had diagnoses of End Stage renal Disease (ESRD) and Chronic obstructive pulmonary disease (COPD). The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #21 was cognitively intact. On 12/12/2023 at 10:46 AM, Licensed Practical Nurse (LPN) #6 was observed administering medications to Resident #21. LPN #6 did not administer 2 puffs of a Symbicort inhaler to Resident #21. LPN #6 then proceeded to administer medication to another resident. The MDO initiated 8/28/2023 and last renewed on 12/1/2023 documented Resident #21 received 2 puffs of a Symbicort 160 mcg-4.5 mcg/actuation HFA aerosol inhaler twice daily for COPD. The Medication Administration Record (MAR) from 12/06/2023 to 12/12/2023 documented Resident #21 was not administered 2 puffs of a Symbicort inhaler twice daily 13 out of 14 opportunities. LPN #7 documented on the MAR on 12/6/2023 Resident #21's Symbicort inhaler was unavailable. LPN #7 documented Resident #21 was administered the Symbicort inhaler on 12/7/2023 at 9 AM. On 12/12/2023 at 12;23 PM, LPN #6 was interviewed and stated Resident #21's Symbicort inhaler was not administered as per MDO because it was unavailable. LPN #6 was waiting for the pharmacy to deliver the Symbicort inhaler. LPN #6 was new to the unit and stated they were informed by LPN #7 that the Symbicort was unavailable. On 12/12/2023 at 12:55 PM, an interview conducted with the LPN #7 who stated Resident #21's Symbicort inhaler was unavailable and was not administered since 12/6/2023. The 12/7/2023 signature on the MAR documenting Resident #21 received 2 puffs of the Symbicort inhaler at 9 AM was an error because the medication has been and remains unavailable. LPN #7 reordered the Symbicort inhaler and did not inform the Registered Nurse (RN) or Medical Doctor (MD) that the inhaler was unavailable. On 12/12/2023 at 1:55 PM, an interview conducted with RN #7 who stated they were not aware Resident #21's Symbicort inhaler was unavailable. RN #7 was informed by an LPN that the Symbicort inhaler had been delivered on 12/7/2023 and the LPN threw out the canister of medication because they attempted to use it and nothing came out. RN #7 stated the LPN did not know how to use it, threw the Symbicort inhaler out, and the investigation was ongoing. On 12/12/2023 at 03:16 PM, an interview was conducted with Pharmacist who stated Resident #21's Symbicort inhaler was delivered to the facility on [DATE]. The next inhaler was not due to be delivered to the facility until 12/19/2023. The pharmacy received a new order from the facility this morning for the Symbicort inhaler and it will be delivered this evening for Resident #21. On 12/13/2023 at 04:21 PM, an interview was conducted with the Director of Nursing (DNS) who stated Resident #21's Symbicort inhaler was last delivered to the facility on [DATE]. The LPN reported the inhaler was empty and they threw it out and forgot to reorder a new one. 10 NYCRR 415.11(C)(3)(i)

Based on record review and interviews conducted during the Recertification and Abbreviated (NY00307221) survey from 12/6/2023 to 12/13/2023, the facility did not ensure the resident's comprehensive care plan (CCP) was reviewed and revised after each assessment and as needed. This was evident for 2 (Resident #187 and #63) of 39 total sampled residents. Specifically, 1) Resident #187's CCP related renal dysfunction and hemodialysis was not reviewed upon each assessment, and 2) Resident #63's CCP related to anticoagulant use was not revised to reflect a change in treatment. The findings are: A facility policy titled Resident Assessment and Care Planning dated 10/6/2021 documented the CCP shall be periodically reviewed and revised as necessary after each comprehensive assessment or reassessment. 1) Resident #187 had a diagnoses of end stage renal disease (ESRD) and diabetes mellitus (DM). A Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #187 was moderately cognitively impaired and received dialysis treatment. A comprehensive care plan (CCP) related to renal dysfunction and dialysis initiated 6/27/2023 documented Resident #187 received dialysis treatment every Tuesday, Thursday, and Saturday. There was no documented evidence the CCP was reviewed or revised upon MDS assessment dated [DATE]. An interview was conducted on 12/12/2023 at 10:29 AM with Registered Nurse (RN) #4 who stated Resident #187 received dialysis treatment 3 times weekly. RN #4 stated they were responsible for episodic CCPs and the MDS Department was responsible for updating the CCPs upon assessment. An interview was conducted on 12/12/2023 at 11:08 AM with the MDS Director who stated the MDS Department, and the RNs were responsible for reviewing and revising CCPs. After reviewing Resident #187's CCP related to dialysis, the MDS Director stated the CCP was not updated upon MDS assessment on 10/4/2023 and it should have been updated by a nurse. An interview was conducted on 12/12/2023 at 11:34 AM with the Director of Nursing (DNS) who stated the MDS Department, and the nurse managers were responsible for reviewing and revising resident CCPs. Resident #187's CCP should have been reviewed during their scheduled CCP meeting. 48907 2) Resident #63 had diagnoses of coronary artery disease and Heart Failure. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #63 was severely cognitively impaired. The CCP related to anticoagulant use initiated 09/18/2020 documented Resident #63 received Eliquis as part of their anticoagulant therapy. Medical Doctor (MD) Orders dated 11/03/2022 documented Resident #63 received Eliquis 2.5mg every 12 hours. A MD Telephone Order dated 02/22/2023, documented that Eliquis 2.5mg should be held from 02/22/2023 at 2:00PM through 02/22/23 at 10:00PM. MD Note dated 02/22/23 at 4:07 PM documented Resident #63 was seen for left eye redness, likely due to subconjunctival hemorrhage and 1 dose of Eliquis should be held. Nursing Note dated 02/23/2023 documented Resident #63 was noted with left eye redness on 2/22/2023 at 5:30 PM, supervisor was informed, and message was left in MD's communication book. There was no documented evidence Resident #63's CCP related to anticoagulant use was reviewed and revised upon changes in their treatment plan when their Eliquis was held by the MD. During an interview on 12/11/2023 at 3:23 PM, Registered Nurse (RN) #6 stated the supervisor or nurse managers were responsible for updating resident CCPs. During an interview on 12/11/2023 at 3:55 PM, the Director of Nursing (DNS) stated the RNs were responsible for updating a residents' CCPs. 10 NYCRR 415.11(c)(1)

Based on record review and interviews conducted during the Recertification survey from 12/06/2023 and 12/13/2023, the facility did not ensure laboratory services were obtained to meet the needs of a resident. This was evident for 1 (Resident #92) of 39 total sampled residents. Specifically, Resident #92 did not have Hemoglobin A1c (HbA1c) laboratory test performed every 3 months in accordance with Medical Doctor Order (MDO). The findings are: The facility policy titled Transcription of Physician's Orders dated 08/2023 documented if an MDO involves radiology or laboratory tests, the information is entered into the Electronic Medical Record (EMR), and results are ascertained. The facility policy titled Laboratory, Radiology, and Other Diagnostic/Consultants Services dated 04/2023 documented laboratory services are done timely. Resident #92 had diagnoses of peripheral vascular disease (PVD) and Diabetes Mellitus (DM). The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident's #92 was cognitively intact and received insulin injections daily. The MDO initiated 03/13/2023 and renewed 10/26/2023 documented HbA1c testing for Resident #92 every 3 months. The Comprehensive Care Plan (CCP) related to insulin-dependent DM initiated 03/14/20 documented Resident #92 had elevated blood glucose levels and blood glucose level would be monitored in accordance with MDO. laboratory results dated [DATE] documented Resident #92 had an HbA1c of 9.2% with a normal reference range of 4.0% - to 5.6%. There was not documented evidence a HbA1c laboratory test was performed for Resident #92 every 3 months in accordance with MDO following the 7/14/2023 laboratory test. On 12/12/2023 at 11:53 AM, Registered Nurse (RN) #1 was interviewed and stated they were recently assigned to Resident #92's unit and was not aware the resident did not have their HbA1c evaluated. The nurses documented in the EMR if the resident refused to have their blood drawn for laboratory testing. On 12/12/2023 at 12:08 PM, RN #2 was interviewed and stated Resident #92's original order for HbA1c testing was in 3/2023 and the EMR system only renews and keeps the order for 6 months. Resident #92's MDO for laboratory testing every 3 months was cut off after the 7/2023 HbA1c testing and did not renew. The nursing staff would have to physically put in the MDO for laboratory testing again so that new testing could be done. 10 NYCRR 415.20

Based on observations, record review, and interviews conducted during the recertification survey from 12/06/2023 to 12/13/2023, the facility did not ensure a resident was free of significant medication error. This was evident for 1 (Resident # 21) of 39 total sampled residents and 1 of 25 observed medication administration opportunities. Specifically, Resident #21 did not receive their Symbicort inhaler per Medical Doctor Order (MDO). The findings are: The facility policy titled Medication Administration Policy dated 4/2017 documented the Licensed Nurses will administer medication as per provider's orders. In a case where medication is missing or not available, the nurse shall call the pharmacy for reorder and notify the supervisor and the prescriber. Resident #21 had diagnoses of End Stage renal Disease (ESRD) and Chronic obstructive pulmonary disease (COPD). The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #21 was cognitively intact. On 12/12/2023 at 10:46 AM, Licensed Practical Nurse (LPN) #6 was observed administering medications to Resident #21. LPN #6 did not administer 2 puffs of a Symbicort inhaler to Resident #21. LPN #6 then proceeded to administer medication to another resident. MDO initiated 8/28/2023 and last renewed on 12/1/2023 documented Resident #21 received 2 puffs of a Symbicort 160 mcg-4.5 mcg/actuation HFA aerosol inhaler twice daily for COPD. The Medication Administration Record (MAR) from 12/06/2023 to 12/12/2023 documented Resident #21 was not administered 2 puffs of a Symbicort inhaler twice daily 13 out of 14 opportunities. LPN #7 documented on the MAR on 12/6/2023 Resident #21's Symbicort inhaler was unavailable. LPN #7 documented Resident #21 was administered the Symbicort inhaler on 12/7/2023 at 9 AM. On 12/12/2023 at 12;23 PM, LPN #6 was interviewed and stated Resident #21's Symbicort inhaler was not administered as per MDO because it was unavailable. LPN #6 was waiting for the pharmacy to deliver the Symbicort inhaler. LPN #6 was new to the unit and stated they were informed by LPN #7 that the Symbicort was unavailable. On 12/12/2023 at 12:55 PM, an interview conducted with the LPN #7 who stated Resident #21's Symbicort inhaler was unavailable and was not administered since 12/6/2023. The 12/7/2023 signature on the MAR documenting Resident #21 received 2 puffs of the Symbicort inhaler at 9 AM was an error because the medication has been and remains unavailable. LPN #7 reordered the Symbicort inhaler and did not inform the Registered Nurse (RN) or Medical Doctor (MD) that the inhaler was unavailable. On 12/12/2023 at 1:55 PM, an interview conducted with RN #7 who stated they were not aware Resident #21's Symbicort inhaler was unavailable. RN #7 was informed by an LPN that the Symbicort inhaler had been delivered on 12/7/2023 and the LPN threw out the canister of medication because they attempted to use it and nothing came out. RN #7 stated the LPN did not know how to use it, threw the Symbicort inhaler out, and the investigation was ongoing. On 12/12/2023 at 03:16 PM, an interview was conducted with Pharmacist who stated Resident #21's Symbicort inhaler was delivered to the facility on [DATE]. The next inhaler was not due to be delivered to the facility until 12/19/2023. The pharmacy received a new order from the facility this morning for the Symbicort inhaler and it will be delivered this evening for Resident #21. On 12/13/2023 at 04:21 PM, an interview was conducted with the Director of Nursing (DNS) who stated Resident #21's Symbicort inhaler was last delivered to the facility on [DATE]. The LPN reported the inhaler was empty and they threw it out and forgot to reorder a new one. 10 NYCRR 415.12(m)(2)

Based on record review and interviews conducted during the Recertification survey from 12/06/2023 to 12/13/2023, the facility did not ensure a comprehensive care plan (CCP) was developed and implemented to address the resident's medical, physical, mental, and psychosocial needs. This was evident for 1 (Resident #5) of 39 total sampled residents. Specifically, a CCP was not developed for Resident #5's antibiotic use. The findings are: A facility policy titled Resident Assessment and Care Planning dated 10/6/2021 documented the facility shall develop a CCP for each resident that includes measurable objectives and timetables to meet each resident's medical, nursing, and mental and psychosocial needs. Resident #5 had diagnoses of lung cancer and diabetes mellitus. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #5 was cognitively intact and received oxygen therapy. A Medical Doctor (MD) Order dated 11/7/2023 documented Resident #5 receive Azithromycin 250 mg as a prophylactic once every Monday, Wednesday, and Friday. A CCP related to alteration in respiratory status initiated 8/3/2023 and last revised 11/7/2023 documented Resident #5 was at risk for emphysema and was administered oxygen therapy. A CCP related to oxygenation and ineffective breathing initiated 8/3/2023 and last revised 11/7/2023 documented Resident #5 had labored breathing and shortness of breath. Resident #5 was administered an inhaler, nebulizer, and oxygen therapy. There was no documented evidence a CCP related to antibiotic use, Azithromycin, was developed and implemented for Resident #5. An interview was conducted on 12/13/2023 at 10:30 AM with Registered Nurse (RN) #1 who stated Resident #5 did receive antibiotic therapy and this was not documented on any of their active CCPs. There should have been a CCP related to antibiotic use developed for Resident #5. An interview was conducted on 12/12/2023 at 11:34 AM with the Director of Nursing (DNS) who stated the MDS Coordinators, and the nurse managers were responsible for developing CCPs for residents. 10 NYCRR 415.11(c)(1)

Based on observation, record review and interviews during an abbreviated survey (Case # NY 00323131), the facility did not ensure a cognitive impaired resident's right to be free from physical abuse. This was evident in 1 of 4 residents sampled (Resident #1). Specifically, on 08/28/23 at 06:53 PM, the facility's camesurveillance ra recording showed a physical altercation in the nursing unit hallway between Resident #1 and Licensed Practical Nurse (LPN) #1. They were seen pushing each other back and forth. Resident #1 stumbled but did not fall. At 06: 53 PM, LPN #1 placed their right hand over Resident #1's right shoulder and their left hand under Resident #1's left side of the chest and pulled Resident #1 into a room that was not Resident #1's room. At 06:57 PM, Resident #1 exited the room and entered the hallway holding their right arm. Resident #1 showed their arm to Resident #2's family member who was visiting Resident #2. At 6:58 PM, LPN #1 exited the room and entered the hallway. Registered Nurse Supervisor (RNS) #1 did a physical assessment on Resident #1 and saw a laceration to the left side of their forehead and right elbow. The Medical Doctor and the family were notified, and images of the bones (X-rays) were ordered. The findings are: The Facility's Policy and Procedure on Prevention, Mistreatment, Neglect and Abuse and Misappropriation of Resident's Property with a revised date of 10/22, documented the facility will anticipate, identify, and prevent abuse and neglect by screening and training of employees, identify and investigate complaints, provide quick and appropriate response to complaints including preventative and/or corrective actions, and protect individuals from abuse during investigations of allegations. The Facility's Accident/Incident (A/I) report, dated 08/28/23 at 7:10 PM, documented that Resident #1 fell in the hallway, after displaying behavior and trying to attack LPN #1. LPN #1 redirected Resident #1 to a resident's room. Resident #1 was examined for level of consciousness and range of motion. Resident #1 sustained a laceration to their left lateral eyebrow. Due to their cognitive status, Resident #1 was unable to explain what happened. Resident #1 was admitted to the facility from their home, with diagnoses including Non-Alzheimer's Dementia and Depression. The Minimum Data Set, (MDS, a resident assessment tool) dated 05/22/23, documented that Resident #1 had severe cognitive impairment and wandering behaviors. A Comprehensive Care Plan (CCP) for Resident Abuser/ Victim updated on 05/26/23, documented interventions to redirect Resident #1 as needed to ensure safety of resident and peers. A Behavior CCP updated on 07/18/23, documented that Resident #1 wandered into another room and undressed themselves. LPN #1 approached Resident #1 and tried to redirect Resident #1 and Resident #1 became angry and aggressive. Resident #1 began yelling then punched and pushed LPN #1. A CCP for Falls updated on 08/28/23 around 7:10 PM, documented that Resident #1 was moving from room to room and was getting agitated when LPN #1 tried to stop Resident #1 from entering other residents' rooms. Resident #1 got angry and attacked LPN #1. Resident #1 loss their balance in the process and fell on to the floor. On examination, Resident #1 sustained a small laceration at the lateral aspect of the left eyebrow, and a skin tear at the right elbow. The Bleeding was stopped, and a band-aide applied. Resident #1 kept giving different explanations when asked what happened. The Medical Doctor was notified. A nursing progress note, written by RNS #1 dated 08/28/23 around 7:10 PM, documented that Resident #1 was moving from room to room, and Resident #1 was getting agitated when LPN #1 tried to stop them from entering other resident's room. Resident #1 attacked LPN #1, loss their balance in the process and fell on to the floor. On examination, Resident #1 sustained a laceration at the lateral aspect of the left eyebrow and a skin tear to the right elbow. The bleeding was stopped, and a band aid applied. Resident #1 give bizarre stories when asked what happened. The Medical Doctor and the family were notified. An X-ray of facial bones and right elbow was ordered. During an interview on 09/12/23 at 3:13 PM, RNS #1 stated that Certified Nursing Assistant (CNA) #1 called them to the nursing unit urgently and they observed Resident #1 bleeding from their left eyebrow. They applied pressure until the bleeding stopped and placed a dressing to the opening. RNS #1 stated that they ask LPN #1 what happened. LPN #1 told them Resident #1 was going into other resident's rooms and LPN #1 tried to stop Resident #1 and then Resident #1 attacked them. RNS #1 stated that LPN #1 stated that they pulled away and Resident #1 fell . RNS #1 stated that they asked LPN #1 if they were going to do an incident for themselves since Resident #1 attacked them and LPN #1 said no. RNS #1 stated that they did a body assessment on Resident #1 and thought that it was suspicious that Resident #1 did not have swelling or discoloration after falling, but RNS #1 just went by what LPN #1 said had happened. RNS #1 stated that they notified the family and doctor. The Medical Doctor ordered x-ray of the facial bones and neurological checks. RNS #1 stated that they questioned CNA #1 and CNA #1 stated that they saw Resident #1 bleeding and called RNS #1. During a telephone interview on 09/12/23 at 3:21 PM, LPN #1 stated that Resident #1 had a habit of going into other resident rooms. LPN #1 stated that they tried to redirect Resident #1 but Resident #1 became agitated, angry, and stated that LPN #1 could not tell them what to do. Resident #1 entered another resident's room and LPN #1 followed them to redirect Resident #1. LPN #1 stated that Resident #1 punched them in their face, head, bilateral breast, and arm. LPN #1 stated that CNA #1 heard LPN #1 and Resident #1 in the room and CNA #1 came into the room and asked if everything was okay. LPN #1 stated that they told CNA #1 that everything was okay. LPN #1 stated that they grabbed Resident #1's wrist. LPN #1 stated after they let go of Resident #1's wrist, and Resident #1 started punching them again. LPN #1 stated that they could not stop the attack. LPN #1 stated that they had to step back and move to the side to stop the attack. LPN #1 stated that Resident #1 fell , they went down face forward. LPN #1 stated that they heard the family member of Resident #2 yelling to CNA #1 from the hallway to go to room because Resident #1 was attacking the nurse. LPN #1 stated that when CNA #1 entered the room a second time, LPN #1 stated that they told CNA #1 to call RNS #1. LPN #1 stated that they ran out when Resident #1 fell and do know how Resident #1 got up. LPN #1 stated that Resident #1 had a laceration on left eye and left elbow. RNS #1 tended to Resident #1 when they arrived on the unit and asked Resident #1 what happened. LPN #1 stated that they were not directly next to Resident #1 and RNS #1 because they did not want to be attacked again. LPN #1 informed that there was surveillance footage that captured them being aggressive to Resident #1 and LPN #1 stated that they tried to redirect Resident #1 from entering another room. LPN #1 stated that they did not grab Resident #1. LPN #1 stated that they did not shut the door and that the door must have shut by itself. LPN #1 could not comment on why they were in the room for about 8 minutes. LPN #1 stated that they did not meet with Resident #1 after the incident, but video footage revealed that Resident #1, CNA #1, and LPN #1 were standing together. During an interview on 9/12/23 at 3:43 PM, CNA #1 stated that they were performing care to Resident #2 in another room. CNA #1 stated that they observed the door for another room was closed and heard noise. CNA #1 stated that they opened the door and saw Resident #1 and LPN #1 standing in the room. CNA #1 stated that they walked out and shut the door. CNA #1 stated that Resident #2's family member approached them and told CNA #1 to follow them. CNA #1 stated that the door to a resident's room was open, and they saw Resident #1 chasing LPN #1 from the A side of the bed to the B side of the bed. CNA #1 stated that they saw blood running down Resident #1's face so CNA #1 ran to the nurse's station and called RNS #1 to come to the unit because Resident #1 was bleeding. CNA #1 stated that they did not go back to the room. CNA #1 stated that RNS #1 arrived on the unit within 2 minutes and started applying first aid. CNA #1 stated that RNS #1 called Registered Nurse (RN) #1 to assist. CNA #1 stated that the facility teaches staff that when residents display behaviors, they must try to calm them by redirection and if behavior persist walk away. During a telephone interview on 09/15/23 at 1:41 PM, Director of Nursing (DON) #1 stated that Resident #1's family member requested Resident #1 be sent to the hospital after Resident #1's family member heard that Resident #1 fell . DON #1 stated that Resident #1 was transferred to the hospital on 08/29/23. DON #1 stated Resident #1's family member called the facility and stated that that the hospital personnel stated that Resident #1's injuries did not align with a fall. DON #1 stated that they reviewed the video after obtaining that information. DON #1 stated after viewing the surveillance footage, the interaction and the dragging of Resident #1 by LPN #1, the resulting injury which was a laceration to left eyebrow and right elbow and the time that LPN #1 and Resident #1 were in the room together (which was 8 minutes) led to the conclusion that an abuse occurred. DON #1 stated that while they watched the video, Resident #1 did not appear aggressive in their opinion and believes that LPN #1 should have walked away. DON #1 stated that Resident #1 wanders on the unit and can be aggressive but when redirected by staff, Resident #1 will walk away. DON #1 stated that LPN#1 was taking off schedule pending investigation after receiving information from Resident #1's family member, LPN #1was terminated. DON #1 stated that when the incident occurred, LPN #1 stated that Resident #1 had a fall. 10 NYCRR 415.4(b)(1)(i)

Based on observation, interviews and record review conducted during an abbreviated survey (NY 603), the facility did not ensure that a resident was free from physical abuse. This was evident for 1 out of 3 residents sampled (Resident #1). Specifically, a facility staff member witnessed a Certified Nursing Assistant (CNA) being physically abusive to Resident #1 in the dining room. The facility did not initiate an investigation immediately and the CNA continued working with residents from 02/29/2020 through 03/03/2020. The findings including: The facility's policy and procedure entitled Prevention of Mistreatment, Neglect and Misappropriation of Resident Property, effective 01/12/2017, documents that all employees must report abuse, neglect, and mistreatment to their immediate supervisor. The policy documents that the nursing supervisor will initiate an incident/accident report, obtain all statements from staff involved, interview the resident, and notify the Director of Nursing. The policy documents that the Director of Nursing will report to the Department of Health any accident/incidents where there is reasonable cause to believe that resident abuse, neglect, or mistreatment has occurred. The policy documents that all staff upon observing or receiving information regarding an act of alleged abuse or neglect, must immediately report the information to their supervisor. The policy documents that if evidence indicates abuse, neglect, etc., report must be made to: Department of Health, Bureau of Long-Term Care, via HCS website. The facility's Accident/Incident Report, for Resident #1, dated 02/24/2020, did not revealed any documented injuries. The facility's undated Investigation into an Occurrence of Abuse summary documented that a weekend supervisor left a statement in the nursing office at the end of the supervisor's shift, on 03/01/2020. The statement indicated that Resident #1 was roughed up by a CNA. The CNA was alleged to have been CNA #1. The plan at that time was to speak to the CNA to find out what occurred and re-educate the CNA on handling the resident carefully, and to anticipate the resident responses so the CNA could move away when the resident became aggressive. On 03/03/2020 the Assistant Director of Food Services sent an email to the Director of Nursing. The email stated that at approximately 12:50PM on Saturday 03/01/2020, a dietary staff member observed CNA #1 attempting to get Resident #1 to sit in the chair, approximately three times. On the third try, Resident #1 threw a bowl of soup on CNA #1. As per the dietary worker, CNA #1 then grabbed Resident #1 by the arms and threw the resident against the wall in the dining area. The investigation documented that the resident was observed with discoloration to the upper left arm and lateral right thigh with lump. Also documented was that Resident #1 had a fall on 02/24/2020, but that discoloration presented as if they had occurred recently. The resident was assessed by the Nurse Practitioner (NP) with no other injuries. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 03/24/2020 identified Resident #1 with short term and long-term memory problem and severely impaired decision-making ability. Resident #1 required extensive assistance of 1 staff with most areas of Activities of Daily Living (ADL) needs. Nursing Progress notes dated from 02/25-02/27/2020, documented that Resident #1 was status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 had no complaints of pain and no delayed visible injury. A Nurse's Progress note (written by a supervisor) dated 03/01/2020 at 1:23 PM documented that this writer was informed this morning 03/01/2020 that Resident #1 threw soup on one of the staff yesterday 02/29/2020. Resident #1 was alert and responsive, ambulating in the hallway. Monitored closely. A Weekly Skin Check Note dated 03/01/2020, revealed that Resident #1 had a small bruise to the right cheek. The Registered Nurse was notified. A Nurse's Progress note dated 03/03/2020, documented that Resident #1's family member came to visit and questioned a scratch mark to Resident #1's cheek. The Nursing Supervisor came to the unit to evaluate Resident #1. An order was placed for [MEDICATION(S)] to face. Resident #1's family member checked Resident #1's body. A Nurse's Progress note dated 03/03/2020 revealed Resident #1 was seen for a contusion on the right thigh, cause unknown, and that the resident's order for Aspirin will be discontinued. Review of the Care Plan Activity Report revealed a care plan, entitled Social Service/Resident Abuser/Victim, for Resident #1, dated 10/18/2018. The care plan revealed that Resident #1 was physically abusive, had aggressive/destructive behavior, and was easily agitated. The care plan had no interventions to prevent abuse. Additionally, the care plan was not updated to reflect on the abuse allegations. During an interview on 09/03/2021 and 10/06/2021, Dietary Worker (DW) #1 stated that he/she was in the dining room behind the steam table on 02/29/2020 when he/she heard a commotion in the dining room. DW #1 stated that he/she looked to see what was going on and observed CNA #1, who was in the far-right corner of the dining room, hitting Resident #1. DW #1 stated that CNA #1 grabbed Resident #1 by the arms and proceeded to hit Resident #1 2-4 times. DW #1 stated that he/she observed CNA #1 swinging his/her arms several times towards Resident #1. DW #1 stated that after CNA #1 finished hitting Resident #1, CNA #1 turned around and walked out of the dining room. DW #1 stated that he/she immediately reported the incident to the Food Service Supervisor (FSS) who went to the dining room. DW #1 stated that he/she was unable to tell if CNA #1's hand or arm contacted with Resident #1's face; he/she could only see CNA #1 from behind and Resident #1 in front of CNA #1. DW #1 reported that Resident #1 could be heard screaming out. During an interview on 09/03/2021 at 11:58 AM, the FSS stated that he/she was on the floor conducting rounds during lunchtime on 02/29/2020. The FSS stated that DW #1 called him/her to come quickly because something was going on. The FSS reported that he/she went to the dining room but did not observe anything going on. The FSS stated that he/she observed CNA #3 cleaning soup from off the floor. The FSS reported that he/she asked DW #1 what happened and DW #1 informed him/her that he/she observed CNA #1 hitting Resident #1 in the dining room. The FSS contended that he/she attempted to contact the Food Service Director (FSD) but was unsuccessful. The FSS reported that he/she notified the FSD on 03/01/2020. The FSS stated that the investigation into the abuse was initiated on 03/02/2020 when all the department heads came into work on 03/02/2020. During an interview on 09/03/2021 at 1:11 PM, the Nursing Supervisor (NS) stated that on 02/29/2020, he/she was about to enter the dining room when he/she observed CNA #1 exiting the dining room with soup on his/her uniform. The NS stated that he/she asked CNA #1 what happened, and CNA #1 said, Nothing. The NS stated that he/she did not recall when he/she was notified and did not recall who notified him/her regarding the abuse allegation. The NS stated that he/she called the Director of Nursing Service (DNS), but the DNS did not answer the phone, so he/she wrote a statement and left it in the DNS's mailbox. The NS stated that he/she attempted to notify the DNS of the abuse allegation on 03/01/2020 and the DNS's voicemail was full. During an interview on 09/03/2021 at 2:12 PM, CNA #1 stated that Resident #1 would throw items at staff all the time. CNA #1 stated that he/she was working in the dining room during lunch on 02/29/2020, when he/she observed that Resident #1 had all the utensils. Resident #1 refused to give the utensils to the staff. CNA #1 stated that he/she took one of the spoons away from Resident #1, so he/she could give it to another resident. CNA #1 stated that after he/she took the spoon away from Resident #1, the resident took the bowl of soup off the table and threw it on CNA #1. CNA #1 stated that Resident #1 had the utensils and attempted to cut him/her with the utensils. CNA #1 stated that he/she took Resident #1 to the closest corner and stood behind Resident #1. CNA #1 reported that he/she placed his/her arms over Resident #1's shoulders and grabbed the utensils away from Resident #1. CNA #1 stated that he/she did not hit Resident #1 and did not grab Resident #1 by the neck. CNA #1 stated that he/she was trying to retrieve the utensils. CNA #1 stated that he/she left the dining room to clean the soup off his/her uniform when he/she saw the NS. The NS asked what happened and he/she told the NS that Resident #1 threw the soup on him/her. CNA #1 stated that the incident took place on Saturday (02/29/2020) and that he/she completed the shift and worked through Monday (03/02/2020). CNA #1 stated that he/she went to work on Tuesday (03/03/2020) and was called at noon by the DNS and was asked to write a statement. During an interview on 09/03/2021 at 2:44 PM the DNS stated that the NS left a letter regarding an allegation of abuse involving Resident #1. The DNS stated that he/she did not get the letter until 03/03/2020, because the letter was placed in the mailbox. The DNS stated that on 03/03/2020, the FSD notified him/her about the abuse allegations involving Resident #1 and CNA #1. The DNS stated after receiving the email from the FSD on 03/03/2020, the abuse allegation was reported to the Department of Health (DOH). The facility also initiated the investigation. The DNS stated, if the NS was aware of the abuse allegation, the NS should have removed CNA #1 from the floor and started the investigation. The DNS stated that the NS attempted to leave a message, that the voicemail was full. The DNS stated that CNA #1 continued working until 03/03/2020 when the investigation was started. 415.4(b)(I)(i)

Based on observation, record review and interviews conducted during the Recertification and Abbreviated Complaint Survey (NY 394 , NY 895), the facility did not ensure residents' Comprehensive Care Plans (CCP) were reviewed and revised by the interdisciplinary team after each assessment. Specifically, there was no documented evidence the CCP related to Falls was updated to accurately reflect residents who had multiple falls and subsequent injuries. This was evident for 3 of 3 residents reviewed for Falls. (Resident #151, #169 and #260). The findings are : The facility Policy and Procedure titled Resident Assessment and Care Planning was revised on 03/2018 and documented upon admission and periodically thereafter, the facility will conduct a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity. Based on the results of these assessments, the facility shall develop and keep current an individualized comprehensive care plan to meet each resident's needs. 1) Resident #169 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum data set 3.0 assessment dated [DATE] identified the residnet as moderately impaired with her cognition with a brief interview for mental status score of 9 (BIMS),with intact long term memory and impaired short term memory . Resident have moderate -independent decision making. On activities of daily living (ADLS) needing and set up and supervision with transfer , locomotion on and off unit with use of device . On 09/17/2021 at 11:27 AM and subsequent days during the survey period , residnet was observed in her room , seated in bed watching Television on the news channel. At times she was observed walking to the Dinning room and in the unit with the use of a cane . During meal time , after set -up , resident is independent with eating . On 09/20/2021 at 12:00 PM ,Resident was observed in the room , in bed asleep with 2 1/2 side rails (SR ) up . State Agency (SA) revisited at 12;58 PM and found resident seated and after set up , feeding self . Resident noted with swelling and ecchymosis of both periorbital areas , unable to open the left eye and swelling of left frontal area . An immediate interview with the LPN # 5 states resident fell last night . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/19/2021 , the physician ordered clean laceration on the forehead with normal saline solution (nss) , apply [MEDICATION(S)] every shift till healed . The Comprehensive Care Plan (CCP) for Falls dated 02/16/2021 documented : related to unsteady shuffling gait , declining ADLS , Urinary incontinent , impaired judgement use of assuasive device , Cardiac dysrthymia impaired hearing and status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Goal set was -- resident will be free of any serious injury and free from further falls/accidents . Interventions listed were : Provide safe and secure clutter free environment / encourage resident to use glasses . encourage to call for assistance . keep call light with in reach , monitor and redirect resident during behavioral issues , monitor labs , PT/OT referral , Psych consult , Staff to observe and monitor resident frequently when wandering on the unit for safety . The CCP for Ambulation documented- Resident # 169 has decreased ambulation status, supervision required. Goal set : resident will improve maintain ambulation to supervision of 1 person using RW /cane . Interventions : monitor for changes in functional status and refer to PT for re-evaluation as needed Provide resident with assistance / verbal Review of the CCP on falls reveals no revision done to prevent or minimize the incidents of falls . The CCP was last updated on 02/21/2021 . Review of the medical records from 05/01/2021 to 09/22/2021 reveals the following : A Nursing note dated 05/25/2021 at 2:00 PM documented responded to housekeeping staff that resident was lying on the floor . Observe lying on the floor on the right side of the bed in supine position . Registered Nurse Supervisor (RNS) was notified and assessment done . No injuries , with good range of motion (ROM) , neuro check every 4 hours for 48 hours , Nurse Practitioner (NP) informed d and next of kin (NOK ) informed . A Nursing note dated 07/20/2021 documented Resident # 169 was noted laying on the floor in the hallway by her room . Chief complaint of back pain ,with no visible injuries . Seen by NP Progress note Nursing dated 08/26/2021 documented Resident # 169 observed with discoloration to left side of her body and on her left temple . RNS made aware Progress note Nursing dated 08/30/2021 at 5:05 AM documented I heard a thump and went to the room and resident #169 is observed sitting on the floor , both feet outstretched and her back against the chest drawer . the floor noted with water spill . With small laceration to left side of the head with small abrasion to left shoulder with no swelling MD informed and transferred to [NAME] ED for head injury evaluation R/O Head trauma . Progress note Nursingdated 09/19/2021 at 11:47 AM documented called to see resident # 169 on the floor in front of the elevator . ' On investigation , resident states [NAME] trying to get a taxi. Resident #169 with a knot on her right forehead above the right eye . Ice pack applied . NS made aware . Progress note Nursing dated 09/19/2021 by the Nursing Supervisor documented asked to assess resident found on the floor with her cane at her side with hematoma on the right side of the forehead , cold compress applied , neuro check initiated NP informed . Progress note Nursing dated 09/20/2021 documented S/P incident found near the elevator with discoloration to right forehead, abrasion above right eyebrow, eye swelling with ecchymosis . neuro check in place . Review of the behavioral note dated 06/23/2021 documented Resident observed talking loudly to herself with an invisible person at times , afraid to go to her room because the Television (TV) is watching her and that people want to harm Resident #169. Behavioral note dated 08/11/2021 documented Resident # 169 with disruptive behavior , yelling at residents and staff what did I do to you . On 09/20/2021 at 12:00 PM , an interview was conducted with the Nurse Practitioner # 4 and stated I was informed about the resident's fall yesterday and I ordered cold compress , neuro check and observation . I an about to make my rounds in that unit , and will evaluate the resident. After reevaluating the resident , an order was made to transfer resident to the hospital for further evaluation status post [MEDICAL RECORD OR PHYSICIAN ORDER] On 09/22/2021 at 2:35 PM an interview was conducted with LPN # 5 on update and revision of Care plans and stated The Registered Nurse Unit Supervisor (RNUM) are responsible for the update of the Care plans . On 09/22/2021 at 3;10 PM an interview was conducted with RNUM # 1 and stated I am just came on board and it is my responsibility to update the CCP. State Agency (SA) asked her about resident # 169 .After reviewing the medical records and care plans , RNUM admitted that there has been no update done on resident's care plan , specifically on the falls that occurred . 2) Resident #260 (NY 895) was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) 3.0 assessment dated [DATE] identified Resident #260 had severely impaired cognition. The resident required extensive assist of 1 person for walking in the room and corridor and locomotion on and off unit. Resident #260 was not steady during walking and transitions and only able to stabilize with staff assistance when moving from a seated to standing position, moving on and off toilet, and surface to surface transfer. Resident #260 had no range of motion impairment. The [NAME] Fall Risk Evaluation dated 9/12/20 documented the resident was at high risk for falls and a prevention protocol should be initiated immediately and documented on the CCP. Resident #260's score was 15 (score of 10 or greater indicates high risk). The Comprehensive Care Plan (CCP) for Fall, initiated 04/14/2020, documented the resident was at risk for falls related to being ambulatory with wandering behavior, history of (h/o) dizziness, declining Activities of Daily Living (ADLS), antianxiety/antidepressant or [CONDITION(S)] drug use, urinary incontinence, poor coordination /balance, weakness, fatigue after ambulating all day, impaired cognition, dementia with behavior disturbance, and non -compliance with instructions. The CCP further documented Resident #206 likes to walk with other residents and hold their hand in the hallway. Resident #206 does not listen to staff and gets agitated and angry when redirected. The initial care plan goal was to prevent injury. The CCP was updated on 09/12/2020 with a goal to heal from injury following a fall with injury on 9/12/2020. The interventions included: Identify cause of falls if any, monitor labs, toileting every 2-4 hours, use of wanderguard, ensure adequate lighting in room and bathroom, administer medications as ordered and monitor side effects, provide safe and secure clutter free environment, keep hallway clear of obstacles, provide appropriate footwear, monitor resident frequently ensuring safety, discourage resident from holding hands with other residents while walking, refer to MD and Psychiatrist for medication review, Psychiatry consultation and f/u, Monitor closely for wandering behavior. All interventions add after 4/17/20 were repeats of previous interventions already included in the CCP with the exception of keep resident close to CNA for close monitoring, a PT evaluation ordered 11/5/20, and transfer to the hospital on 12/10/20. Review of the medical records including the Accident/Incidents (A/I) reports from 09/01/2020 to 12/31/2020 documented the following : Progress notes dated 09/12/2020 at 11:09 PM documented Resident # 260 is awake and confused walks the hallway aimlessly during the day. Resident was observed in supine position on the floor in the Hallway. Resident reported feeling dizzy, tripped on the scale and fell hitting the posterior aspect of the head sustaining a small hematoma with mild redness. No LOC (loss of consciousness) /Cold compress applied, neuro check started NP (Nurse Practitioner) and son notified. The facility was unable to provide an Accident/Incident report (A/I) for this date to the state agency. On 9/12/20, the Fall CCP was updated with the intervention to provide safe and clutter-free environment (previously documented), frequent rest periods, and offer finger foods was added. Progress note dated 09/21/2020 at 11:45 AM documented Resident #260 was sitting on the scale complaining of pain to bilateral jaw, right neck and hip. Resident's son and the NP were informed. X-rays requested. The A/I dated 09/21/2021 documented Resident #260 was alert but confused and had a fall in the hallway. Resident #260 was not using any devices. Assessment was done, and Resident #260 complained of pain of bilateral jaw and right hip. On evaluation, the resident had positive range of motion to bilateral upper and lower extremities. The resident was seen and evaluated by the NP who ordered X-rays of bilateral hips,pelvis and skull and right elbow. Progress note dated 10/01/2021 (weekly behavioral note) documented Resident #260 continues to walk aimlessly throughout the halls looking for some one to walk with she attaches herself and to others. Progress notes dated 10/08/2020 at 3:15 PM documented Resident #260 was noted lying on the floor at the entrance of the day room bleeding from the scalp. Resident #260 lost their balance and fell on the floor hitting their head against the door. On examination, there was no LOC, but the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . MD was notified with order to send to hostal for laceration of the scalp. A Progress Note dated 10/9/2020 documented Resident #260 was readmitted to the facility at 4:45 AM with 2 staples and negative CT scan, indicating no fracture. The family and physician were notified. On 10/13/20 the Fall CCP was updated with the intervention to ensure non-skid footwear (appropriate footwear was already an intervention on the CCP) Progress note dated 10/24/2020 at 3:23PM documented Resident #260 was previously seen ambulating aimlessly on unit with friends when suddenly a loud thud was heard. Resident was found in a sitting position on the floor in the hallway by the dining room calling for help. Immediate assement with no visible injuries, redness, or trauma. Resident #260 was assisted and transported to their room and made comfortable. Safety measures maintained and monitored closely. Review of the A/I dated 10/24/2020 documented Resident #260 was cognitively impaired and had a fall sitting on the buttocks with left foot straight in front of them and right foot bent. On assessment, the resident was able to move all extremities without limitations. They were seen and evaluated by the NP with no injuries. Family was informed. Resident was confused and agitated with intermittent combativeness. Progress note dated 11/05/2020 at 10:50 AM documented the resident was lying on the left side. Review of the A/I report dated 11/05/2020 documented Resident #260 was cognitively impaired, alert, and agitated. Resident #260 was discovered lying on their left side in the dayroom with their head resting on anther resident's shoes. On assessment with no visible injuries, all extremities with full range of motion. Tylenol was administered for pain. On 11/5/20, the Fall CCP was updated with the intervention of PT evaluation on 11/5/20. Progress note dated 11/24/2020 at 7:00 PM documented Resident #260 was walking hand in hand with another resident on the unit, tripped over the weighing scale, and went onto the floor. The resident quickly got up and started walking again. No injury noted. On 11/24/20, the Fall CCP was updated with the intervention to ensure hallway is cleared of obstacles, but the CCP already had the intervention to keep the hallway clear of obstacles. Progress note dated 12/08/2020 at 3:07PM documented Resident #260 was found on the floor in room [ROOM NUMBER] with 2 unit residents trying to get Resident #260 up. There was no LOC or no injuries, and the NP was notified. Review of the A/I dated 12/08/2020 documented resident was cognitively impaired, no injuries noted. The CCP would include close monitoring. new? A Progress note dated 12/10/2020 at 3:09 PM documented Resident #260 was pushed to the floor by another resident and sustained a laceration on the occipital area. Seen and evaluated with order for transfer to the hospital. The A/I dated 12/10/2020 documented, resident was cognitively impaired with a fall in the hallway and found with bleeding at the back of the head (occipital area). Assessment documented a presence of the laceration, with good ROM of all extremities. Resident was send to the hospital. The psychiatric evaluation on 12/10/2020 documented resident with history of (h/o) behavioral disturbance on psyche meds . Recent behavior documented in EMR seen walking alone as others were in the DR unable to engage in meaningful conversation with resident. Lorazepam used previously on several occasions as stat interventions Some response from [MEDICATION(S)] Appears agitated, speech pressured unable to obtain verbal output. Psychotic. Psyhc meds : Trazadone 50 mg / [MEDICATION(S)] 0.25 mg BID Findings : Gait -- ambulatory / affect anxious /labile /Thought process -- disorganized Thought content -- delusions Paranoid -- yes attention and concentrations -- poor DX : depression /dementia vascular with behavioral / anxiety psychotic. Assessment/Plan : cont current medications would use low dose atypical anti-psychotic medications to attenuate psychotic sx like [MEDICATION(S)] /[MEDICATION(S)] /Behavioral management as possible / monitor mood , appetite behavior. Progress Note dated 12/11/20 documented Resident #260 was readmitted on [DATE] at 12:50 AM with 3 staples. Progress Note dated 12/11/2020 at 8:20 AM resident was observed in bed confused, agitated and restless with laceration to the left eyebrow. A/I dated 12/11/20 at 8:10 AM documented the resident was found lying facedown on the the floor on the left side of the bed in their room. Resident #260 exited the bed and fell , sustaining a laceration of the left eyebrow. The MD note of 12/16/2020 documented Alzheimer's dementia with gradual decline in adls . S/P repeated falls : multiple fall during interim. ED visit on 07/01/2020 Ct head negative .Continue fall precautions and continue physical therapy . The Nurse Practitioner (NP) note dated 12/17/2020 documented Residesnt #260 was readmitted with frequent falls. The resident had a repaired left orbital area laceration. The resident was on the [CONDITION(S)] medications Trazadone /[MEDICATION(S)] /ROS -unable to obtain due to cognitive dysfunctions. The Assessment and Plan section documented Resident #260 had mechanical falls most likely related to Dementia with excessive activity. Fall and safety precautions, PT/OT eval., transfers with extensive assist x 1, and monitor delayed deficits. Progress note dated 12/20/2020 documented resident was awake, agitated and combative. Resident #260 was observed pulling herself on the floor in the hallway bleeding profusely from wounds on the face on closer examination. The resident had an open open wound to above the left brow line, laceration to the mid forehead and mid bridge of the nose with moderate bleeding. The resident was transferred to the hospital. On 09/21/2021 at 2;40 PM, an interview was conducted with the Registered Nurse Unit Manager/Educator (RNUM #3) assigned to the unit. RNUM #3 stated Resident #260 has dementia with behavioral issues. Resident #260 walks a lot and cannot fully understand. Resident #260 also walks with other residents and has frequent falls. RNUM #3 reviewed the CCP and confirmed there were no updates or revisions to the CCP after Resident #260 had falls. RNUM #3 stated the CCP updates and revisions are done by the Unit Manger and the RN Supervisors. RNUM #3 stated the resident has had no change in mental or physical status in the last 5 to 6 months. Further interview , the RNUM # 3 stated the CCP should have been updated and review after any incident . CCP are reviewed , quarterly , annually and whenever there is an incident and reviewing this CCP on Resident # 260 , I dont see any revisions made from the several falls she had. 3) Resident # 151 (NY 394) was diagnosed with Alzheimer's Disease and history of falling. The Quarterly Minimum Data Set (MDS) dated [DATE], documented the resident had severely impaired cognition and 2 falls with no injury since admission/entry or reentry to facility. The Nursing Progress Notes dated 2/13/21, 2/19/21, 7/12/21, 7/27/21, and 8/15/21, documented Resident #151 had falls. The Accident/Incident reports dated 2/13/21, 2/19/21, 7/12/21, 7/27/21, and 8/15/21 documented Resident # 151 had falls. 9/17/21 1:45PM Surveyor observed Resident # 151 sitting in wheelchair in room. Spouse visiting with resident. Resident did not verbally respond to surveyor's questions. Resident appeared well groomed and calm. 9/20/21 11:30 AM Observed Resident # 151 sitting in wheelchair in room. Resident was calm. No agitation observed. The Comprehensive Care Plan (CCP) related to Falls was updated 8/20/21 and documented Resident #151 had 2 falls - 7/12/21 and 8/15/21. There was no documented evidence the CCP was reviewed, revised, and accurately reflected resident after falls that occurred on 2/13/21, 2/19/21, and 7/27/21. The CCP was not updated with new interventions after each fall. On 09/21/21 at 11:04 AM, Registered Nurse (RN) #1 was interviewed and stated RN Nurse Managers are responsible for updating care plan interventions when a resident has a fall. RN #1 was unable to to locate updated interventions for Resident #151 for falls on 2/13/21, 2/19/21 and 7/27/21 and was not working at the facility at the time the falls occurred. On 09/21/21 at 11:56 AM, Director of Nursing (DON) was interviewed and stated the RN Nurse Manager is responsible for updating care plan interventions when a resident has a fall. 415.4(a)(2-7)