Every finding on record at Rockaway Care Center

Based on observation, record review, and interviews during an abbreviated survey (459982), the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents. This was evident in one (1) of 12 residents (Resident #1) sampled for elopement. Specifically, Resident #1 left the building on 02/17/2025 at 4:03 PM after being buzzed out the exit door in the lobby by Security Guard #1. Facility staff did not become aware that Resident #1 was not in the building until 5:35 PM. On 02/18/2025 at 1:20 AM, the hospital notified Nursing Supervisor #2 that Resident #1 was in the hospital. A review of the hospital Discharge summary dated [DATE] revealed Resident #1 was admitted to the hospital with diagnoses of encephalopathy (any disease or disorder that affects brain function or structure) secondary to hypothermia (core body temperature drops below 95 degrees Fahrenheit), and acute kidney injury. This resulted in actual harm to Resident #1 that was not Immediate JeopardyThe findings include:A review of the Elopement Prevention/Wandering Behavior Management policy dated 06/09/2022 documented it is the policy of the facility to utilize all possible measures to maintain the safety and well-being of all residents. To have system and tools in place to do all that is reasonable to identify and prevent unsafe wandering and or elopement and to act quickly prudently should either occur. Elopement occurs when a resident leaves the premises or a safe area without authorization and or any necessary supervision to do so.A review of the Front Desk/Security Monitoring policy and procedure dated 01/27/2025 documented to ensure the safety and security of all residents, staff, visitors, and property within the facility by establishing clear procedures for front desk security monitoring and access control. It is the policy of the facility that the front desk serves as the primary security checkpoint. All individuals entering or exiting the facility must be screened appropriately, and all activities at the front entrance must be monitored consistently and in accordance with safety protocols. Front Desk Staff shall monitor all persons entering or exiting the facility. Ensure all visitors log in through the electronic monitoring system; Ensure visitors signs in/out; always wear a visitor badge and always maintain a visible and alert present at the front desk. Resident #1 was admitted to the facility with diagnoses of dementia (a severe decline in mental abilities), psychotic disorder (a serious mental illness where a person loses touch with reality) with delusion (a delusion is a fixed, false belief firmly held despite evidence to the contrary, often involving misinterpretations of reality) and anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome.) The Minimum Data Set (a resident assessment tool) dated 11/24/2024 documented Resident #1 ambulated independently. The Elopement Risk Assessment was last updated on 11/13/2024 and documented Resident #1 was at risk for elopement and refused to wear a wander guard.A review of an Elopement Care Plan updated on 11/13/2024, documented Resident #1 walked out of the building on 11/12/2024. Security followed Resident #1, and the police were called and responded. Resident #1 returned to the facility, and 30-minute visual checks continued. A Plan of Care note dated 11/13/2024 documented that on 11/12/2024 at 6:45 PM, Security Guard #2 reported that Resident #1 walked out the building as staff were entering the building. Security Guard #2 followed Resident #1 out of the building. Police were called and Resident #1 was returned to the building. Every 30-minute visual checks continued. A physician's order dated 01/27/2025 documented Resident #1 was high risk for elopement and 30-minute visual checks for safety. A review of the Resident Observation/Rounding Report document dated from 02/10/2025 through 02/17/2025 showed Resident #1 was being monitored every two hours as indicated by staff initials. The last entry for 02/17/2025 showed Resident #1 was last seen at 4:00 PM talking with a family member. The Resident Nursing Instructions record dated 02/2025 documented Resident #1 was on behavior monitoring for elopement and wandering on the unit.A review of the 3:00 PM - 11:00 PM Visual Checks for Residents Unit dated 02/17/2025 revealed Resident #1 was on 30-minute monitoring. Documentation on 02/17/2025 showed staff last signed for Resident #1 at 4:00 PM. Review of a nursing note by Licensed Practical Nurse #1 dated 02/17/2025 at 11:36 PM, documented during rounds they observed Resident #1 sitting quietly in the hallway at 3:35 PM. All residents were accounted for and everyone was okay. At approximately 5:35 PM Certified Nursing Assistant #1 informed them that Resident #1 was not in their room. Licensed Practical Nurse #1 immediately instructed all staff to check for Resident #1. Security Guard #1 was called and a check was done in the main Dining Room and Resident #1 was not found. Registered Nurse Supervisor #1 was notified at 5:40 PM. Code Pink (an elopement code) was activated and 911 was called. Review of a nursing note by Registered Nurse Supervisor #1 dated 02/17/2025 at 7:55 PM, documented at approximately 5:40 PM Licensed Practical Nurse #1 reported to them that Resident #1 was missing from the unit and was nowhere to be found. Code Pink was called and building searched. Police were called at 6:00 PM and arrived at 6:32 PM, all pertinent resident information and picture were given to the police. Medical Doctor #1 and Resident #1's next of kin were informed at 6:45 PM. The police reviewed the surveillance camera and called the surrounding hospitals. A review of facility Summary of Investigation dated 02/17/2025 documented on 02/17/2025, approximately 5:40 PM, Licensed Practical Nurse #1 reported to Registered Nurse Supervisor #1 that Resident #1 was missing. Code PINK (code for elopement) was called, and search was conducted. Police were called and arrived. Next of Kin was notified. At about 1:20 AM, a call was received from hospital's doctor that Resident #1 was located in the hospital. Security Guard #1 admitted that they did not follow the facility's protocol. Per facility protocol, security must screen every person prior to leaving the building to ensure that residents are not able to leave the facility. Security Guard #1 opened the front door for Resident #1 (time not documented). Security Guard #1 was asked why they opened the door for Resident #1, and they said it was a mistake. Security Guard #1 was terminated. The investigation concluded that Resident #1 had previously been identified as at risk for elopement and that Resident #1 had eloped from the facility. Prior to the incident, the staff were following preventative measures. A Hospital Patient Review Instrument dated 02/23/2025 documented primary encephalopathy secondary to hypothermia, acute kidney injury and adrenal mass.A Hospital Discharge summary dated [DATE] at 2:04 PM documented Resident #1 was brought in by Emergency Medical Services after being found on the road. In the Emergency Department, Resident #1 was found to be hypothermic with a temperature of 89 degrees Fahrenheit, tachypneic (having abnormally rapid, shallow breathing) with stable blood pressure. Lab work revealed leukocytosis (an increase in the number of white cells in the blood, especially during an infection), high anion (means there's an excess of unmeasured acidic substances in your blood), metabolic acidosis (is a serious condition where there's too much acid (or not enough base/bicarbonate) in your body fluids), likely acute kidney injury. A physician's order dated 02/28/2025 documented Resident #1 was readmitted to the facility on [DATE] at 7:30 PM.An attempt was made to interview Resident #1 on 09/12/2025 at 1:00 PM but was unsuccessful due to Resident #1's confusion. Multiple attempts were made to contact Security Guard #1 but were unsuccessful. Security Guard #1 was no longer employed by the facility. A certified letter was mailed out to Security Guard #1 on 09/12/2025 with no response to date. During an interview on 09/12/2025 at 2:42 PM, the Maintenance Director stated they did not keep a copy of the surveillance video footage of the elopement on 02/17/2025. However, they watched the surveillance video footage, and it showed Security Guard #1 opened the main front door in the lobby and Resident #1 walked out of the building. The Maintenance Director stated that they are responsible for supervision of security guards to ensure they are following the facility's policy. The Maintenance Director stated that the lobby front entrance door is equipped with a wander guard alarm system. If a resident is wearing a wander guard and enters the lobby near the front door, the alarm would be activated. The Maintenance Director stated that all who are at risk for elopement have their picture posted at the security desk. The Maintenance Director stated that all visitors must sign in and out of the facility. The Maintenance Director stated that all visitors receive a visitor's pass when they sign in, and they must return the pass upon leaving the facility. The Maintenance Director stated that security guards are responsible for monitoring the front door to ensure a resident does not leave the facility when visitors are leaving. During an interview on 11/20/2025 at 11:03 AM, Registered Nurse Supervisor #1 stated they worked on 02/17/2025 during the 3:00 PM - 11:00 PM shift and performed rounding on Resident #1's unit but do not recall seeing Resident #1. Registered Nurse Supervisor #1 stated Resident #1 was ambulatory and was able to ambulate without staff assistance. Registered Nurse Supervisor #1 stated that they do not recall Resident #1's monitoring status. Registered Nurse Supervisor #1 stated that on 02/17/2025 at 5:40 PM, Licensed Practical Nurse #1 informed them Resident #1 was not on the unit. Registered Nurse Supervisor #1 stated Code Pink was called, and a search of the entire building and surrounding areas were done. Registered Nurse Supervisor #1 stated 911 was called and responded, and the Administrator was called. Registered Nurse Supervisor #1 stated that the Administrator and police reviewed the surveillance camera footage which showed Resident #1 left the building at 4:03 PM. Registered Nurse Supervisor #1 stated the Certified Nursing Assistants were responsible for monitoring Resident #1 every 30 minutes. Subsequent interview on 12/09/2025 at 2:30 PM, Registered Nurse Supervisor #1 stated they became aware that Resident #1 was missing from the unit at 5:40 PM on 02/17/2025. Registered Nurse Supervisor #1 stated they received a call from the hospital's doctor on 02/18/2025 at 1:20 AM informing them that Resident #1 was at the hospital and requested the resident's medical record. Registered Nurse Supervisor #1 stated Resident #1 was missing for approximately 7-8 hours before Resident #1 was found. Registered Nurse Supervisor #1 stated Resident #1 was on 30-minute visual checks and was not allowed to leave the unit unsupervised. Registered Nurse Supervisor #1 stated whenever Resident #1 was not on the unit, the staff usually called the security guard at the front desk or the nursing station and recreation staff to see if resident was with them.During an interview on 11/20/2025 at 11:21 AM, Certified Nursing Assistant #2 stated on 02/17/2025 they arrived on the unit at 3:00 PM and made rounds. Certified Nursing Assistant #2 stated while they were making their rounds, Resident #1 was observed sitting in the hallway at approximately 3:05 PM. Certified Nursing Assistant #2 stated when they saw Resident #1 sitting in the hallway, Resident #1 was wearing jeans, a shirt, no jacket and crocs (slippers). Certified Nursing Assistant #2 stated they last saw Resident #1 at 4:00 PM standing in the hallway talking to another resident's family. Certified Nursing Assistant #2 stated at 4:10 PM dinner arrived on the unit, and they started serving dinner. Certified Nursing Assistant #2 stated they took Resident #1's dinner to their room at approximately 4:45 PM and that was the time they realized Resident #1 was not in their room. Certified Nursing Assistant #2 stated they did not go to search for Resident #1 and continued to give dinner to other residents. Certified Nursing Assistant #2 stated they informed Licensed Practical Nurse #1 that Resident #1 was not in their room when they returned to dining room (don't remember the time). Certified Nursing Assistant #2 stated they started searching for Resident #1. Certified Nursing Assistant #1 stated Resident #1 is not allowed to go downstairs by themself. Certified Nursing Assistant #1 stated if Resident #1 goes to recreation downstairs, the staff who have Resident #1 would need to check on Resident #1 every 30 minutes to know Resident #1's whereabouts. During an interview on 11/20/2025 at 11:40 AM, the Director of Nursing stated they were not an employee at the facility at the time of the elopement. The Director of Nursing stated Resident #1's medical record documented that Resident #1 was identified as a risk for elopement. During an interview on 09/12/2025 at 2:30 PM, the Administrator stated that on 02/17/2025, Registered Nurse Supervisor #1 called and informed them at 6:00 PM that Resident #1 was not in the building. The Administrator stated Registered Nurse Supervisor #1 informed them that they searched both inside and outside of the building and Resident #1 was not found and 911 was called. The Administrator stated Resident #1 was at risk for elopement and had removed multiple wander guards. The Administrator stated Resident #1 was placed on every 30-minute monitoring and a picture was at the security's desk. The Administrator stated Resident #1 must only come off the unit with activities staff and return to the unit by staff. The Administrator stated that the Certified Nursing Assistants were assisting other residents when Resident #1, who was ambulatory, left the unit by themself. The Administrator stated that all visitors leaving the building must stop and sign out at security and return their pass. The Administrator stated the main front door is controlled by the security guard at the front desk and that Security Guard #1 allowed Resident #1 to walk out of the building because the resident did not look like a resident. The Administrator stated that Security Guard #1 reported that they did not stop Resident #1, and they did not ask them any questions, they just buzzed them out. The Administrator stated they received a call at 11:00 PM on 02/17/2025 from the hospital informing them that they had someone matching Resident #1's description. (The hospital confirmed with Nursing Supervisor #2 at 1:20 AM that it was Resident #1). The Administrator stated Resident #1 was admitted to the hospital and returned to the facility on [DATE].During a subsequent follow-up interview on 12/09/2025 at 3:35PM, the Administrator stated when they reviewed the surveillance video, Resident #1 was wearing a winter coat, a long-sleeved shirt and long pants. The Administrator stated they did not recall what Resident #1 was wearing on their feet.During an interview on 12/10/2025 at 11:00 AM, Certified Nursing Assistant #1 stated they were working on 02/17/2025 during the 3:00 PM - 11:00 PM shift. Certified Nursing Assistant #1 stated Resident #1 was on their assignment. Certified Nursing Assistant #1 stated when they arrived on the unit at 3:00 PM, they made rounds and Resident #1 was in their room, sitting on their bed wearing a gown. Certified Nursing Assistant #1 stated at 3:30 PM they started giving care to other residents. Certified Nursing Assistant #1 stated at approximately 3:45 PM they observed Resident #1 sitting in the hallway close to their room. Resident #1 was on 30-minute visual checks. Certified Nursing Assistant #1 stated they were taking care of other residents and did not check on Resident #1 because all staff members are assigned to do the 30-minute checks. Certified Nursing Assistant #1 stated if the staff who were assigned to Resident #1 were busy, the other staff who are available can do the visual checks. Certified Nursing Assistant #1 stated during dinner at approximately 5:35 PM, Licensed Practical Nurse #1 reported Resident #1 was not in their room, and everyone started searching for Resident #1.During an interview on 12/11/2025 at 12:15 PM, the Medical Director stated they were not an employee at the facility at the time of the elopement. The Medical Director stated Resident #1 was diagnosed in the hospital with encephalopathy secondary to hypothermia. The Medical Director explained our body and brain worked at a certain temperature between 97.0 - 99.0 Fahrenheit. Medical Director stated anything above or below can cause changes in our mental status such as fatigue drowsiness and sleepiness. 10NYCRR415.12(h)(2)

Number of residents sampled: 5Number of residents cited: 5 Based on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist. This was evident for five (5) of (5) residents (Resident #4, #10, #7, #6, and #221) reviewed for Unnecessary Medications out of 41 sampled residents. Specifically, there was no documented evidence in the clinical records of Residents #4, #10, #7, #6, and #221 that monthly Medication Regimen Reviews were completed. The findings include but are not limited to: The facility policy titled 'Medication Regimen Review' dated 12/31/2023 stated the Consultant Pharmacist will perform Medication Regimen Reviews for each resident at least monthly and for all newly admitted residents. The policy also stated the Consulting Pharmacist will document in the resident's medical record that the monthly Drug Regimen Review and whether there are any recommendations in the electronic medical record. 1.Resident #4 was admitted to the facility with diagnoses that included Alzheimer's Disease and Depression. Upon request, as part of the Medication Regimen Review documentation, the facility provided a document titled 'Unit 6 Census Detail Report' which was stamped 'Drug Regimen Review-PharmD' and dated 04/26/2025, 05/2025, 06/27/2025, and 07/2025. The facility also provided a document titled 'Point Click Care' Pharmacist-Drug Regimen Review which was dated 9/25 and listed all active residents including Resident #4. There was no signed and dated statement, by the pharmacist, in Resident #4's medical record that no irregularities were identified during the monthly reviews. 2. Resident #10 was admitted to the facility with diagnoses that included Diabetes Mellitus, Bell's Palsy, and Hypertension. Upon request, the facility provided Medication Regimen Reviews titled Census Detail Report dated 04/20/2025, 05/19/2025, 06/18/2025, 07/16/2025, 08/20/2025, and 09/15/2025. This four-page report listed all active residents including Resident #10. Affixed at the top of every page was the pharmacist's initials and a date. There was no signed and dated statement, by the pharmacist, in Resident #10's medical record that no irregularities were identified during the monthly reviews. 3. Resident #7 was admitted to the facility with diagnoses including Schizophrenia and Bipolar Disorder. A review of census lists for Unit 5 was provided by the facility and dated 04/2025, 06/2025, 08/2025, and 09/2025. The lists were stamped, signed and dated by the Pharmacy Consultant. There was no signed and dated statement, by the pharmacist, in Resident #7's medical record that no irregularities were identified during the monthly reviews. On 09/29/2025 at 3:13 PM the Director of Nursing was interviewed and stated the Pharmacist Consultant comes and sees all the residents, but the practice is that the Pharmacist consultants do not document in the electronic medical records. The Director of Nursing also stated if there were any recommendations, the Pharmacy consultants would email the Director of Nursing and the Administrator about the recommendations, otherwise they would send a checklist on which residents' charts were reviewed without recommendations. The Director of Nursing further stated there was no other documentation which stated residents medications were reviewed by the Pharmacy Consultants. On 09/29/2025 at 2:34 PM, an interview was conducted with the Pharmacy Consultant who stated that that they review medical records monthly and send irregularities to the Director of Nursing and the Administrator. The Pharmacy Consultant also stated the Medical Director is not included on the email chain. The Pharmacy Consultant further stated they do not document in each resident's medical records every month, however, they print out the census on each unit of residents with no irregularities, and they usually will stamp, sign and date the census printout and did not think any other documentation was necessary as they assumed the Director of Nursing would know. On 09/30/2025 at 3:35 PM, an interview was conducted with the Administrator who stated they receive the pharmacy recommendations by email on a monthly basis, and the Director of Nursing and the Medical Director are included on the email chain. The Administrator also stated the Pharmacy Consultant also sends a list of residents that have no irregularity and put their stamp, date and signature on them, and they do not act on those ones. The Director of Nursing then reviews recommendations with the physicians and acts on them. The Administrator stated they have a plan to change the current Pharmacy Consultant because they are not following the facility's policy on Medication Regimen Reviews, and they have discussed with them often that pharmacy records are missing, but the Pharmacy Consultant does things in their own way. 10 NYCRR 415.18(c)(2)

Based on observation, record review, and interviews conducted during the Recertification conducted from 09/24/2025 to 10/01/2025, 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 reported the facility was short staffed with Certified Nursing Assistants, especially on weekends both days and nights, which resulted in a lack of timely staff response to call bells and delays in performing Activities of Daily Living and personal care. 2). The facility Payroll Based Journal for Quarter 3 (April 1 - June 30) also revealed an excessively low weekend staffing, and 3). Review of the actual staffing schedules dated from 04/01/2025 to 06/30/2025 revealed that staffing assignments were consistently less than the projected staffing needs specified in the Facility Assessment.The findings are: The facility's policy and procedure titled 'Staffing, Hiring, Application, Process, Training', last reviewed 02/06/2025, documented that it is the policy to assure that there is sufficient qualified nursing staff available at all times to provide nursing and related services to meet the needs safely and in a manner that promotes each resident's rights, physical, mental and emotional wellbeing. Sufficient staffing for all personnel on a Twenty-Four (24) hour basis will be determined by number of residents, acuity and facility assessment. Twenty-Four (24) hour qualified staffing will be provided. 1.Resident #8 was admitted to the facility with diagnoses that included Anxiety Disorder, Depression, and Quadriplegia. The Minimum Data Set (an assessment tool) dated 09/29/2025 documented Resident #8 had intact cognition, and they required dependent assistance for toileting and showering. On 09/25/2025 at 12:55 PM, an interview was conducted with Resident #8 who stated that the facility is short staffed especially on weekends, and at nights. Resident #8 also stated it takes a longer time for staff to respond after they ring the call bell, and this happens very often. Resident #168 was admitted to the facility with diagnoses include Cerebrovascular Accident, Hemiplegia, and Hyperlipidemia. The Minimum Data Set, dated [DATE] documented Resident #168 had intact cognition, and they required dependent assistance for toileting, showering, upper/lower body dressing, and putting on footwear. On 10/01/2025 at 11:19 AM, an interview was conducted with Resident #168 who stated they have to wait a long time for staff to clean and change their incontinence brief when staffing is short on the unit. 2. The Payroll Based Journal Staffing Data Report for the 2nd quarter of 2025 (04/01/2025 - 06/31/2025) documented that low weekend staffing was triggered. The Facility Assessment, last updated August 2025 documented the facility has 6 units, with a 228-bed capacity, and each unit has a capacity of 42-47 beds. Ventilator dependent residents reside on the 3rd floor. The section of the Facility Assessment titled 'Daily Staffing Report by unit Monday to Friday' documented the following staffing pattern: 7:00 AM - 3:00 PM: 2nd Floor: 2 Licensed Practical Nurses, 4 Certified Nursing Assistants 3rd Floor: 2 Registered Nurses, 2 Licensed Practical Nurses, 4 Certified Nursing Assistants 4th Floor: 2 Licensed Practical Nurses, 4 Certified Nursing Assistants 5th Floor: 1 Licensed Practical Nurse, 4 Certified Nursing Assistants 6th Floor: 1 Licensed Nurse, 4 Certified Nursing Assistants 3:00 PM - 11:00 PM: 2nd Floor: 1 Registered Nurse, 1 Licensed Practical Nurse, 4 Certified Nursing Assistants 3rd Floor: 1 Registered Nurse,1 Practical, 4 Certified Nursing Assistants 4th Floor: 2 Licensed Practical Nurses, 4 Certified Nursing Assistants 5th Floor: 1 Licensed Practical Nurse, 3 Certified Nursing Assistants 6th Floor: 1 Licensed Practical Nurse, 3 Certified Nursing Assistants 11:00 PM - 7:00 AM: 2nd Floor: 1 Registered Nurse, 3 Certified Nursing Assistants 3rd Floor: 1 Registered Nurse, 1 Licensed Practical Nurse, 3 Certified Nursing Assistants 4th Floor: 1 Licensed Practical Nurse, 2 Certified Nursing Assistants 5th Floor: 1 Licensed Practical Nurse, 2 Certified Nursing Assistants 6th Floor: 1 Licensed Practical Nurse, 2 Certified Nursing Assistants The section of the Facility Assessment titled 'Staffing Report Weekends/Holidays' documented the following staffing pattern: 7:00 AM - 3:00 PM: 2nd Floor: 2 Licensed Practical Nurses, 3 Certified Nursing Assistants 3rd Floor: 2 Registered Nurses, 1 Licensed Practical Nurses, 4 Certified Nursing Assistants 4th Floor: 1 Licensed Practical Nurses, 3 Certified Nursing Assistants 5th Floor: 1 Licensed Practical Nurse, 3 Certified Nursing Assistants 6th Floor: 1 Licensed Nurse, 3 Certified Nursing Assistants 3:00 PM - 11:00 PM: 2nd Floor: 2 Licensed Practical Nurses, 3 Certified Nursing Assistants 3rd Floor: 1 Registered Nurse,1 Practical, 4 Certified Nursing Assistants 4th Floor: 2 Licensed Practical Nurses, 3 Certified Nursing Assistants 5th Floor: 1 Licensed Practical Nurse, 3 Certified Nursing Assistants 6th Floor: 1 Licensed Practical Nurse, 3 Certified Nursing Assistants 11:00 PM - 7:00 AM: 2nd Floor: 1 Registered Nurse, 3 Certified Nursing Assistants 3rd Floor: 1 Registered Nurse, 1 Licensed Practical Nurse, 3 Certified Nursing Assistants 4th Floor: 1 Licensed Practical Nurse, 2 Certified Nursing Assistants 5th Floor: 1 Licensed Practical Nurse, 2 Certified Nursing Assistants 6th Floor: 1 Licensed Practical Nurse, 2 Certified Nursing Assistants The Weekend /Holiday staffing reflected 6 fewer Certified Nursing Assistants, and 1 less Registered Nurse and Licensed Practical nurse despite the census remaining the same for weekdays and weekends. 3. A review of the facility's 'Daily Staffing Sheet for weekend staffing from April 2025 to June 2025 included but was not limited to the following: 04/05/2025 (Saturday) 7:00 AM-3:00 PM Shortage of 1 Licensed Practical Nurse on 2nd and 4th Floor, and 1 Certified Nursing Assistant for 2nd, 3rd, 5th and 6 th Floor units. 3:00 PM-11:00 PM Shortage of 1 Certified Nursing Assistant on the 6th floor. 11 AM-7 PM Shortage of 1 Certified Nursing Assistant 4th and 6th floor units. 04/06/2025 (Sunday) 7:00 AM-3:00 PM Shortage of 2 Certified Nursing Assistants on the 6th floor. 04/13/2025 (Sunday) 7:00 AM-3:00 PM Shortage of 1 Certified Nursing Assistant on the 6th floor. 04/19/2025 (Saturday) 7:00 AM-11:00 PM Shortage of 1 Certified Nursing Assistant on the 3rd floor. 3:00 PM-11:00 PM Shortage of 1 Certified Nursing Assistant 3rd and 6th floor units. 04/20/2025 (Sunday) 7:00 AM-3:00 PM Shortage of 1 Certified Nursing Assistant on the 2nd Floor, and 2 Certified Nursing Assistants on the 6th floor units. 3:00 PM-11:00 PM Shortage of 1 Licensed Practical Nurse on the 4th Floor, and 1 Certified Nursing Assistant on the 6th floor units. 11:00 PM-7:00 AM Shortage of 2 Certified Nursing Assistants on the 2nd Floor, and 1 Certified Nursing Assistant on the 4th and 6th Floor units. 04/26/2025 (Sunday) 11:00 PM-7:00 AM Shortage of 1 Certified Nursing Assistant on the 5th Floor, and 2 Certified Nursing Assistants on the 6th Floor units. 05/04/2025 (Sunday) 7:00 AM-3:00 PM Shortage of 1 Certified Nursing Assistant on the 4th floor. 05/10/2025 (Saturday) 3:00 PM-11:00 PM Shortage of 1 Certified Nursing Assistant on the 4th floor. 05/11/2025 (Sunday) 3:00 PM-11:00 PM Shortage of 1 Certified Nursing Assistant on the 3rd, 4th, 5th, and 6th Floor units. 05/18/2025 (Sunday) 3:00 PM-11:00 PM Shortage of 1 Certified Nursing Assistant on the 5th Floor. 05/24/2025 (Saturday) 3:00 PM-11:00 PM Shortage of 1 Certified Nursing Assistant on the 3rd Floor. 05/25/2025 (Sunday) 3:00 PM-11:00 PM Shortage of 1 Certified Nursing Assistant on the 3rd Floor and 4th floor units. 05/31/2025 (Sunday) 7:00 AM – 3:00 PM Shortage of 1 Certified Nursing Assistant on the 4th and 6th floor. 3:00 PM – 11:00 PM Shortage of 2 Certified Nursing Assistant on the 2nd floor. 11:00 PM-7:00 AM Shortage of 1 Certified Nursing Assistant on the 2nd floor and 3rd floor units. 06/07/2025 (Saturday) 7:00 AM – 3:00 PM Shortage of 1 Registered Nurses 3rd floor unit. 3:00 PM – 11:00 PM Shortage of 1 Licensed Practical Nurse on the 2nd floor unit. Shortage of 1 Certified Nursing Assistant on the 4th floor, 5th floor, and 6th floor units. 06/08/2025 (Sunday) 7:00 AM – 3:00 PM Shortage of 1 Certified Nursing Assistant on the 2nd, 3rd, 4th, 5th, and 6th floor units. 3:00 PM – 11:00 PM Shortage of 1 Certified Nursing Assistant 2nd, 4th, 5th and 6th floor units. 11:00 PM – 7:00 AM Shortage of 1 Certified Nursing Assistant 2nd, and 3rd floor units. 06/28/2025 (Saturday) 11:00 PM – 7:00 AM Shortage of 1Certified Nursing Assistant on the 3rd, 5th, and 6th floor units. 06/29/2025 (Sunday) 7:00 AM – 3:00 PM Shortage of 1 Certified Nursing Assistant on the 2nd, 3rd, 4th, and 6th floor units. 3:00 PM -11:00 PM Shortage of 1 Certified Nursing Assistant 2nd, and 3rd floors units. On 10/01/2025 at 11:47 AM, an Interview was performed with Certified Nursing Assistant #10, who stated certified nursing assistant staffing is always low especially on the weekends, and at times there are only two (2) certified nursing assistants to care for 40-45 residents on the unit. Certified Nursing Assistant #10 also stated when the staffing is low, the two (2) Certified Nursing Assistants team up and provide care for all the residents. Certified Nursing Assistant #10 further stated residents who are scheduled for showers may not receive showers on that day, so quick bed baths are given instead. On 09/26/2025 at 11:44 AM, an interview was performed with the Director of Respiratory Services who stated the ventilator unit currently has eleven (11) ventilator dependent residents nine (9) residents with tracheostomies, and the others are step-down respiratory residents who were weaned. The Director of Respiratory Services also stated they are working as the respiratory therapist for the floor, and that today's other staff on the unit include one (1) Licensed Practical Nurse and three (3) Registered Nurses but usually, the unit is staffed with two (2) Registered Nurses and one (1) Licensed Practical Nurse. The Director of Respiratory Services further stated when the unit is staffed with three (3) nurses, normally one (1) is floated to another unit. On 09/30/2025 at 9:17 AM, the Director of Nursing stated the Staffing Coordinator was not available for interview as they were currently travelling out of the country. On 09/30/2025 at 9:20 AM, an interview was performed with the Director of Nursing who stated staffing is the responsibility of the coordinator and the Director of Nursing. The Director of Nursing also stated they ask the staffing coordinator daily about staffing every morning and the coordinator shows them the schedule which includes staff call outs and no shows. Internal staff and long-term agency staff are called to work in times of shortages and there a fifty-fifty success rate. The Director of Nursing further stated when Certified Nursing Assistant staffing is low, a plan is created for certified nursing assistants to buddy up and complete the floor assignment together. If facility has low nurse staffing, the nursing supervisors will assist with treatments, picking up orders and supplies. The Director of Nursing stated the facility is using 3 staffing agencies and offering staff overtime as well, but it is still difficult to meet the required staffing levels on the weekend. On 09/30/2025 at 8:47:00 AM, an interview was performed with the Facility Administrator who stated the facility assessment was last reviewed August 25, 2025, and is an overview of the residents and the care they provide and documents the staffing and structure. The Facility Administrator also stated staffing was adjusted in August 2025, because after meeting consistently with the staffing coordinator there was a difference in the ability to staff the weekends based on the levels needed and the facility is working toward meeting these levels. The Facility Administrator further stated they are aware the Payroll Based Journal report for Quarter Two (2) 2025 triggered due to excessively low weekend staffing, and in response a full-time recruiter was hired, and they noticed a change in March 2025. The Facility Administrator stated there was a 10% increase in staffing for Quarter Two (2) 2025 but the facility was still not meeting the staffing levels for the weekend, so the facility has increased contracts with agencies to hire specifically for the weekend and is seeing some improvement. 10 NYCRR 415.13(a)(1) (i-iii)

Based on interview, and record reviews conducted during the Recertification survey, the facility did not ensure a performance review of every nurse aide was completed at least once every 12 months, and regular in-service education was based on the outcome of these reviews. This was evident during a review of Sufficient and Competent Nursing Staffing task. Specifically, six (6) of six (6) Certified Nursing Assistant personnel files contained no evidence of yearly performance evaluations and in-services based on the results of performance evaluations. The findings are:The facility policy and procedure titled 'Staffing, Hiring, Application Process and Training' last reviewed 02/06/2024, stated it is the policy of the facility to assure there is sufficient qualified nursing staff available at all times to provide nursing and related services to meet the needs safely and in a manner that promotes each residents rights, physical, mental and psychosocial well- being. 24 hour qualified staffing will be provided and staff replaced based on evaluation and review. Annual performance reviews will be completed annually for each staff member. Specific in-service education will be completed based on the outcome of the annual performance review.Upon review of personnel records of Certified Nursing Assistant #8, #9, #10, #11, #12, and #13, there was no documented evidence of annual performance reviews, and no in-service education completed based on the outcome of those annual performance reviews.On 10/01/2025 at 9:15 AM, an interview was conducted with the Director of Human Resources who stated it is their responsibility and that of the Director of Nursing to ensure staff performance reviews are completed yearly. The Director of Human Resources also stated they have been employed in their role for two (2) years and had not reviewed the older files of employees for compliance, as their focus had been on new hires and recruiting staff. The Director of Human Resources further stated the annual performance reviews should have been completed. On 10/01/2025 at 10:23 AM, an interview was conducted with the Director of Nursing who stated it is important performance reviews are completed, and competencies are performed as staff errors and performance issues can be identified, and then staff can be reeducated. The Director of Nursing also stated the performance reviews are forwarded to them from the Human Resources department and the nursing supervisors then complete the evaluations. The Director of Nursing further stated they have been employed as Director of Nursing in the facility since May 2025 and had not receive any request to complete performance evaluations.On 10/01/2025 at 09:50 AM, an interview was conducted with the Facility Administrator who stated performance evaluations should have been performed yearly and as needed. The Facility Administrator also stated there have been many changes made in every department in terms of leadership, and they were not focused on completing performance evaluations. The Facility Administrator further stated they take full accountability for the annual performance evaluations not being completed as the facility was onboarding at a fast pace, working on the personnel files for new hires, and ensuring those files were up to date and reviewed. 10 NYCRR 415.26(c)(2)(iii)

Based on observations, record review, and interviews conducted during the Recertification survey, the facility did not ensure the medication error rate was less than 5 percent. This was evident for 2 of 32 medications observed during the Medication Administration task. Specifically, Resident #180 was given the wrong dose of Lopressor 25 mg tablets and, Zyprexa 35 mg was also administered at the wrong time. This resulted in a medication error rate of 6.5%.The findings are:The facility policy titled 'Medication Administration' dated 9/20/2021 stated each resident will be provided with medication administration as ordered by the primary medical doctor. The policy also stated Licensed Nurses will have a medication competency done yearly as needed to ensure compliance with safe medication administration.A Medication Administration competency dated 8/18/25 for Registered Nurse #3 documented general guidelines which includes compares each medication label to medication administration record, ensures each order is correct for: medication, strength, route and time prior to pouring med.Resident #180 was admitted to the facility with diagnoses which included Hypertension and Schizophrenia.The Physician Orders dated 05/12/2025, last renewed 07/15/2025, documented Resident #180's was prescribed medications which included Metoprolol Succinate 25milligram tablets: 3 tablets orally one time a day, Olanzapine 15 milligram tablet, (part of 35 milligram dose): 1 tablet orally at bedtime and Olanzapine 20milligram tablets: give 1 tablet orally at bedtime for Schizophrenia. On 09/29/2025 at 9:44 AM, during the Medication Administration task, Registered Nurse #3 was observed administering medications Metoprolol Succinate 25 milligrams 1 tablet instead of Metoprolol Succinate 25 milligram 3 tablets, as ordered by the Physician to Resident #180. Registered Nurse #3 was also observed administering Olanzapine 35 milligram tablets to Resident #180 at 9:44 AM, when the medication was ordered to be given at bedtime.On 09/29/2025 at 10:45 AM, Registered Nurse #3 was interviewed and stated they were taught to check the five rights, and to check against the Medication Administration Record, never touch the medication, and to make sure the blister matches the Medication Administration Record. Registered Nurse #3 also stated they checked the blister pack which contained the medication but did not see it properly.On 10/01/2025 at 10:35 AM, the Infection Preventionist/ Educator was interviewed and stated all Licensed Nurses were in serviced and received orientation, and the process for medication administration involves going through a checklist which includes checking the blister packs and checking the right medications. The Infection Preventionist/ Educator also stated Registered Nurse #3 was hired in August 2025 and they completed the competencies for medication administration. The Infection Preventionist/ Educator further stated they monitor the nurses by doing spot checks and observing from a distance to see if they are following the procedure The Infection Preventionist/ Educator stated that they speak about any concerns at the Quality Assurance Performance Improvement meetings. On 10/01/2025 at 2:57 PM, the Director of Nursing was interviewed and stated in-service education for Licensed Nurses are done by the Educator, and initial education is done on Orientation and annually thereafter. The Director of Nursing also stated they have been doing in services and competencies were done which included medication administration and if there are any occurrences of noncompliance in these areas, they educate and discipline the staff. 10 NYCRR 415.12(m)(1)

Based on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure garbage and refuse were disposed of properly. Specifically, the garbage was not properly contained outside of the facility to prevent the harborage and feeding of pests. The findings are:The facility's policy and procedure titled 'Handling, Transporting and Disposing of Trash' reviewed 9/24/2025 stated trash must be stored in refuse containers that are seamless and constructed of easily cleanable material equipped with a tight-fitting lid.On 09/26/2025 at 12:19 PM, Dietary Worker #1 was observed taking garbage from the kitchen to the garbage disposal area located outside of the building. The compactor was observed without a door and exposed piled garbage bags. Multiple flies were observed on the garbage bags and around the opening of the compactor. A door was detached and observed next to the compactor.On 09/29/2025 at 10:45 AM, the compactor was observed again without a door and with door on the ground next to it. Multiple flies were noted on the garbage inside the compactor and near the opening of the compactor.On 10/01/2025 at 10:32 AM and 10:50 AM, multiple observations of the outside area revealed a black wheeled cart contained multiple bags of garbage which was uncovered and had multiple flies around it. On 09/26/2025 at 12: 35 PM, Dietary Worker #1 was interviewed and stated they are supposed to close the compactor door prior to activating the compactor but the door appears to be broken. Dietary Worker #1 also stated they did not know when the door broke and how long it has been like this.On 09/26/2025 at 12:40 PM, the Regional Food Service Director was interviewed and stated door was noticed to be broken the morning of 09/25/2025 so they immediately informed the Administrator and Maintenance Director. The Regional Food Service Director also stated they were told the company was called, and compactor would be replaced as soon as possible.On 09/29/2025 at 12:41 PM, the Food Service Director was interviewed and stated the compactor is used and closed after usage, but they noticed the latch broken sometime last week. The Food Service Director also stated they are still waiting for the company to repair the compactor, which remains currently out of order.On 10/01/2025 at 2:41 PM, the Director of Maintenance was interviewed and stated the Regional Food Service Director informed them the compactor door was broken and was not able to be closed six days ago, but they were not sure how long it had been broken. The Director of Maintenance also stated a technician from the carting company came on the same day but stated the compactor was not repairable, and the compactor was finally picked up for repairs two nights ago. The Director of Maintenance further stated the facility has a dumpster for interim use so staff should have place garbage in the dumpster and closed it and not have left it outside uncovered in a black trash cart.On 10/01/2025 at 3:00 PM, the Administrator was interviewed and stated they were notified by the storeroom staff six days ago that the compactor area was unkempt, and the compactor door latch was broken. The Administrator also stated the compactor company was notified and came to pick up the compactor two days ago on 09/29/2025. The Administrator further stated they were not aware the garbage was left outside uncovered today. 10 NYCRR 415.14(h)

Based on observation, interviews and record review conducted during the Recertification survey, the facility did not ensure the facility-wide assessment was updated to include and address the total resident population and resources that were necessary to care for those residents. This was evident during a review of Sufficient and Competent Nursing Staffing. Specifically, 1). the Facility Assessment did not identify or address care for ventilator dependent residents in the total population of services offered including respiratory therapist personnel required to meet that populations daily staffing needs, and 2). on-site hemodialysis treatment was listed as a service provided and the facility did not have a certified dialysis unit.The findings are:The facility policy and procedure titled 'Facility Assessment' last reviewed 07/15/2025, stated the facility will conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations (including night and weekends) and emergencies. The policy also stated the Facility Assessment will address/include resident population which includes the number of residents and resident capacity, the care required by the resident population: using evidence based, data driven methods that consider the type of disease, conditions, physical and behavioral health needs, cognitive disabilities, overall acuity and other pertinent facts that are present within the population, the staff competencies: necessary to provide the level and types of care needed for the resident population, and the physical environment, equipment, services and other physical plant operations that are necessary to care for this population. The policy further stated the Facility Assessment will address/include the facility's resources, including equipment (medical and non-medical), services provided, all personnel, both employees and those who provide services under contract. 1.The Resident Matrix (CMS-802) for Unit 3 documented 11 (eleven) ventilator residents resided on the unit.The Long-Term Care Facility Application for Medicare and Medicare form (Form CMS-671) dated 09/24/2025, documented under Dedicated Special Care Units there were twenty (20) Ventilator/Respiratory care beds and zero (0) Dialysis beds.The Facility Assessment, dated August 2025, documented in Facility Characteristics/Resident Profile a total bed capacity of two hundred twenty-eight (228). The Facility Assessment also documented resident care provided includes Hospice Care, Palliative Care, Respite Care, Long-Term Care, Subacute Rehabilitation, Hemodialysis, Bariatric, Dementia, Traumatic Brain Injury, PASSR Level Two (2), Cancer Treatments, Substance Use Disorders. The Facility Assessment did not include ventilator dependent residents or the staff competencies necessary to provide the level and types of care needed for the population, the ventilator equipment, associated services and other physical plant operations that are necessary to care for this population or all personnel required including the respiratory therapist.The document titled Employee Contact List documented five (5) respiratory therapist as current personnel.On 09/26/2025 at 11:44 AM, an interview was conducted with the Director of Respiratory Services who stated Unit 3 currently houses 11 ventilator-dependent residents. The Director of Respiratory Services also stated they are currently working as a full-time Respiratory Therapist on Unit 3. 2. The Facility Assessment documented onsite hemodialysis treatment was provided however the facility did not have a certified dialysis unit.On 09/30/2025 at 8:47 AM, an interview was conducted with the Facility Administrator who stated the Facility Assessment is an overview of the residents and the care provided and was last reviewed on 08/25/2025. The Facility Administrator also stated the current Facility Assessment includes all care services currently provided for the residents including ventilator services which have been provided in the facility for a decade. The Facility Administrator further stated the facility does not provide on-site hemodialysis services. Upon review of the Facility Assessment the Facility Administrator stated they did not realize that ventilator services were not listed as a service provided to the resident population and that hemodialysis was erroneously listed as a service provided. 10 NYCRR 415.26

Number of residents sampled: 7Number of residents cited: 1 Based on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure infection control practices and procedures were maintained. This was observed during medication administration for one (1) of seven (7) residents (Resident #187) observed. Specifically, Enhanced Barrier Precautions were not used when Registered Nurse #5 administered medications to Resident #187 via the gastrostomy tube.The findings are:The facility's policy titled Enhanced Barrier Precautions with a review date of 12/12/2023, stated it is the policy of this facility to adhere to the Centers for Disease Control and Prevention guidelines as related to Enhanced Barrier Precautions in order to prevent the transmission of multidrug-resistant organisms amongst residents and healthcare workers. The policy also stated the facility will implement enhanced barrier precautions during high-contact resident care with examples of high-contact resident care activities to include device care or use - central line, urinary catheter, feeding tube, and tracheostomy/ventilator.Resident #269 was admitted to the facility with diagnoses that include Multiple Sclerosis and Dysphagia.The Physician's orders dated 07/01/2025 documented orders for Enhanced Barrier Precautions Reason: G-tube/Peg tube.On 09/29/2025 at 10:17 AM, Registered Nurse #3 was observed administering medication via a Gastrostomy Tube. Registered Nurse #3 entered Resident #187's room, washed their hands, donned gloves, and prepared the medications to be administered. Registered Nurse #3 placed the medications on Resident#187's bedside table, then proceeded to administer the medications via the gastrostomy tube and flushed the tubing with water when completed. Registered Nurse #3 then discarded the containers, cleaned the bed side table, washed their hands and left Resident #187's room. At no time was Registered Nurse #3 observed wearing gown, gloves and mask as per the Enhanced Barrier Precautions.On 09/29/2025 at 10:38 AM, Registered Nurse #3 was interviewed and stated they were taught during their orientation in August 2025, that Enhanced Barrier Precautions should be used during medication administration via gastrostomy tubes. Registered Nurse #3 stated they were aware but somehow forgot to use it.On 10/01/2025 at 10:35 AM, the Infection Preventionist/Educator was interviewed and stated all Licensed Nurses were in serviced on Enhanced Barrier Precautions and Registered Nurse #3 was in serviced during their orientation in August 2025. The Infection Preventionist/Educator also stated the signage was posted on Resident #187's door indicating Enhanced Barrier Precautions were to be utilized, and this includes residents who receive medications via a feeding tube. The Infection Preventionist/Educator further stated they make rounds on the units to monitor if staff is using Enhanced Barrier Precautions and if there were any deficient practice, they would pull the nurses aside and give them an in-service on the issue.On 10/01/2025 at 2:57 PM, the Director of Nursing was interviewed and stated in-service education for Licensed Nurses are done by the Educator, and initial education is done on Orientation and annually thereafter. The Director of Nursing also stated they have been doing in-service on Enhanced Barrier Precautions and they teach the nurses Enhanced Barrier Precautions are to be maintained for residents with foley catheters, tube feedings and tracheostomies. The Director of Nursing further stated Registered Nurse #3 had a considerable number of in-services on Enhanced Barrier Precautions and should have used it during medication administration. 10 NYCRR 415.19(a)(1-3)

Based on observation, interview, and record review conducted during the Recertification survey, the facility did not ensure a building elevator was maintained in a safe working condition. This was observed in one (1) of three (3) elevators (Elevator #2) observed. Specifically, Elevator #2 was broken and out of service for over 10 months, causing delays and restricting resident movement around the facility, including attending medical appointments. The findings are: Observations conducted from 09/24/2025 to 10/01/2025 between the hours of 10:00 AM and 3:00 PM revealed Elevator #2 was not in good working condition. A security staff was positioned inside Elevator #2 to move passengers from floor to floor and the unit staff were observed paging the front door security staff to send Elevator #2 to various units when needed. Facility is a six floored building with 3 elevators located near the lobby. There were 2 passenger elevators (Elevator #1 and #2, and Elevator #3 was designated as a service elevator and used primarily for transporting goods, equipment, and staff only. On 09/26/2025 at 2:30 PM, during the Resident Council meeting six out of eight residents in attendance verbalized they have had concerns about the broken elevator for over 10 months. These residents stated only Elevator #2 is not in working condition and this prevented them from attending programs in the facility. Resident #35 stated they were stuck inside Elevator #2 a while back and it took the facility more than 30 minutes to get them out, and the situation with the elevator has still not been resolved. On 09/26/2025 at 03:10 PM, an interview was conducted with the Director of Recreation who stated they were aware of the broken elevator, however, residents or family had not complained to them. The Director of Recreation also stated they experience delays moving residents around in the facility and they just have to wait or page for the elevator where they need it. On 09/30/2025 at 11:34 AM, an interview was conducted with the Director of Maintenance Services who stated there are three elevators in the facility, Elevator #1 is for the kitchen and emergencies, Elevator #2 has been damaged for over 10 months, and Elevator #3 is currently working without problems. The Director of Maintenance Services also stated they have had some complaints from residents, family members, and staff and they were all assured it will be fixed soon. The Director of Maintenance Services further stated the Administrator was aware of the issues with the elevator and was working on it. The Director of Maintenance Services stated the part needed to repair the elevator is hard to get, and they are working on it but are not able to tell when it will be fixed. On 09/30/2025 at 04:01 PM, an interview was conducted with the Administrator who confirmed Elevator #2 was broken and out of service for over 10 months. The Administrator also stated Elevator #1 is used for emergency and to move items around and can be used when they have events at the facility like birthday parties. The Administrator further stated Elevator #2 has been out of service since November 2024 and it takes 6 to 8 months to get the piston that is broken at the base of the elevator. The Administrator stated they have been receiving complaints about the elevators, and they try to accommodate residents and family members as much as possible by having someone operate Elevator #3 and cover all of the units. The Administrator concluded the elevator is under repair now and should be fixed in 60 days. 10 NYCRR 415.29

Based on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure residents who needed respiratory care were provided care that was consistent with professional standards of practice. This was evident for one (1) of two (2) residents (Resident #78) reviewed for Respiratory Care out of a total sample of 41 residents. Specifically, Resident #78 was observed with an undated oxygen nasal cannula and an undated nebulizer mask and tubing. The findings are:The facility policy titled 'Oxygen Therapy' reviewed on 07/30/2021 stated residents will be provided with oxygen therapy as ordered by the Medical Doctor. When a resident uses oxygen on an as needed basis, the tubing will be labeled and placed in a zip locked bag until needed for use. When a resident has nasal cannula tubing for the concentrator, and a 2nd for use the oxygen tank, the tubing not in use must be secured in a plastic bag (dated and changed weekly). The 11-7 nurse will change and date all oxygen delivery equipment on Sunday.Resident #78 was admitted to the facility with diagnoses that include Chronic Obstructive Pulmonary Disease and Respiratory Failure.The Quarterly Minimum Data Set (an assessment tool) dated 08/11/2025, documented Resident #78 had moderately impaired cognition for daily decision making, shortness of breath or trouble breathing when sitting at rest and when lying flat, and required oxygen administration while a resident at the facility.A Physician Order dated 07/10/2025 documented Oxygen administration via nasal cannula, four (4) liters per minute continuously.A Physician Order dated 07/15/2025 documented change and label oxygen tubing on concentrator once a week every night shift every Tuesday.On 09/25/2025 at 11:35 AM, Resident #73 was observed with nasal cannula tubing connected to an oxygen concentrator, and no date was noted on the tubing.On 09/26/2025 at 3:28 PM, an observation of Resident #78 was performed with Licensed Practical Nurse #7. Resident #78 was observed resting in bed, receiving oxygen through an undated nasal cannula. The Medication Administration Record dated September 2025, documented change and label oxygen tubing on concentrator once a week. Entries were documented on 09/02/2025, 09/09/2025 and 09/23/2025, however there was no entry for 09/16/2025.On 09/26/2025 at 3:30 PM, an interview was conducted with Licensed Practical Nurse #7 who stated the oxygen nasal cannula should be dated weekly by the night nurses, but all shifts should make sure the tubing is dated. On 09/26/2025 at 2:55 PM, an interview was conducted with Registered Nurse #5, the nursing supervisor, who stated all nursing staff and nursing supervisors who round, should be looking at the oxygen tubing dates for compliance on all shifts.On 09/26/2025 at 3:17 PM, an interview was conducted with the Director of Nursing who stated all oxygen tubing should be changed and dated every Wednesday night. The Director of Nursing also stated the nurses on all shifts, including the nursing supervisors who perform rounds, should be observing the tubing to ensure compliance with weekly changing and dating of the tubing. 10 NYCRR 415.12(k)(6)

Number of residents sampled: 2Number of residents cited: 1 Based on observation and staff interviews conducted during the Recertification survey, the facility did not ensure that a resident was cared for in a manner that maintained or enhanced dignity. This was evident for one (1) of two (2) residents (Resident #12) reviewed for Catheter out of a sample of 41 residents. Specifically, Resident #12's foley catheter drainage bag and tubing were not covered with a privacy bag.The findings are:The facility policy titled 'Indwelling Foley Catheters' last reviewed 09/02/2022 stated a drainage bag cover should be utilized to maintain resident dignity.The facility policy titled 'Resident Right to Privacy and Dignity', last reviewed 01/2025 stated that residents are treated in a dignified manner and their privacy rights are upheld as outlined in the Resident [NAME] of rights.Resident #12 was admitted to the facility with diagnoses which include Obstructive uropathy, Seizure Disorder, and Acute kidney failure.The admission Minimum Data Set (an assessment tool) dated 08/06/2025 documented Resident #12 had severely impaired cognitive skills for daily decision making, and they required extensive assistance of 2 staff members for bed mobility, transfer, dressing, toilet use, and personal hygiene, and had an indwelling catheter.The Physician order dated 08/13/2025 documented foley catheter care every shift, monitor urine output and document amount in every shift for neuromuscular dysfunction of bladder. During multiple observations on 09/24/2025 at 10:54 AM, and 09/25/2025 at 1:06 PM, Resident #12 was observed lying in bed. Resident #12's foley catheter drainage bag and catheter tubing were observed with amber urine draining into the bag which was visible from the hallway as it was not contained in a privacy bag.On 09/26/2025 at 11:59 AM, Registered Nurse #2 was interviewed and stated they were not aware Resident #12's foley drainage bag had no cover. Registered Nurse #2 also stated Resident #12 is the only resident on the unit that has a foley catheter, and they should have put the cover, but it was an oversight.On 10/01/2025 at 11:56 AM, Licensed Practical Nurse #4 was interviewed and stated they were not aware there was no privacy cover on the foley bag, and the bag must be covered at all times because it preserves a resident's dignity. On 10/01/2025 at 2:46 PM, the Director of Nursing was interviewed and stated they were not aware Resident #12's foley had no privacy cover. The Director of Nursing also stated it is the responsibility of the staff on the unit, especially the nurse, to make sure foley catheters have privacy cover for dignity concern. 10 NYCRR 415.5(a)

Number of residents sampled: 2Number of residents cited: 1 Based on observation, record review, and interviews during the Recertification survey, the facility did not ensure the resident is offered a therapeutic diet when there is a nutritional problem, and the health care provider orders a therapeutic diet. This was evident for one (1) of two (2) residents (Resident #225) reviewed for Hydration out of 41 total sampled residents. Specifically, Resident #225, who had a physician's order for thickened liquid, was observed drinking coffee and water without a thickener.The findings are:The facility's policy titled 'Aspiration Precautions' reviewed on 5/31/23 stated it is the policy of this facility to identify residents who are at potential risk for aspiration and to implement interventions that will prevent aspiration and easily alert staff of who those residents are. The policy also stated the resident's meal tickets will be updated by the Food Service Director/Dietitian to indicate the diet texture, thicken liquid consistency order, if indicated.Resident #229 was admitted to the facility with diagnoses that include Altered Mental Status, Cerebral Vascular Accident, and Dementia.The Physician's Orders dated 09/22/2025 documented Resident #225's was prescribed a Carb Consistent/Heart Healthy diet, Pureed 4 texture, Nectar/Slightly Thick 1 consistency, aspirations precautions The Comprehensive Care Plan Titled Nutrition, created 09/19/2025, documented Resident requiring therapeutic diet of consistent carbohydrate, heart healthy puree consistency, nectar thickened liquids. Goals included resident will tolerate diet as ordered through review date. Interventions include provide and serve diet as ordered. A Speech Language Pathology Evaluation and Plan of Treatment dated 9/22/25 documented treatment of swallowing dysfunction and /or oral function for feeding, 3 to 5 times a week, duration of 4 weeks. Recommendation includes diet recommendations- liquids nectar thick liquids, solid=pureed consistency, and supervision for oral intake- occasional supervision. An Initial Dietary assessment dated [DATE] documented Resident #225 was receiving a consistent carbohydrate heart healthy diet, pureed diet consistency, mildly thick fluid consistency. The assessment also documented Resident #225 complained of difficulty or pain when swallowing. The assessment further documented Resident #225 was admitted on consistent carbohydrate, heart healthy diet regimen puree diet consistency with nectar thick liquids. Self-fed after tray prep with encouragement given to ensure meal completion.During a dining observation on 09/24/2025 at 12:50 PM, Resident #225's meal tray ticket documented nectar thick liquids, carb consistent/no added salt-puree. Two (2) packets of unopened thickener, one (1) cup of non-thickened coffee and one (1) cup non thickened water were observed on the tray. There was no staff observed adding thickener to Resident #225's coffee and water. Resident #225 was observed holding their cup and took three sips of coffee with no thickener added.On 10/01/2025 at10:40 AM, Registered Nurse #3 was interviewed and stated for residents with aspiration precautions who require thickened liquids, the thickener package comes up from dietary and it is the Certified Nursing Assistants' responsibility to add thickener to the residents' drink. Registered Nurse #3 also stated Certified Nursing Assistants know how much thickener to use, and the nurses would verify it. The Registered Nurse #3 further stated they monitor the Certified Nursing Assistants at different times to ensure compliance by doing rounds and giving shift reports.On 10/01/2025 at 10:45 AM, Registered Dietician #1 was interviewed and stated they did the initial assessment of Resident #225 who is on a pureed diet with nectar thick liquids. Registered Dietician #1 also stated Resident #225 gets thickened juices and water on their tray, and the thickened packet is for the coffee and the tea. The Certified Nursing Assistants and the Licensed Nurses are responsible for thickening those liquids for residents who need it. Registered Dietician #1 further stated they do periodic rounding to ensure the residents' foods are consistent with their diet, but they are not responsible for any in-services related to the thickener or aspiration precautions.On 10/01/2025 at 2:45 PM, Licensed Practical Nurse #5, who was in the dining room at the time of the observation, stated certified nursing assistants are responsible for thickening the liquids for residents who require thickened liquids, and whomever prepares the residents' tray would add the thickener. Licensed Practical Nurse #5 also stated they did not know who prepared Resident #225's lunch tray on 09/24/2025. Licensed Practical Nurse #5 further stated the certified nursing assistants report to them, and they make round and is in the dining room during meals to see what is going on at mealtimes.On 10/01/2025 at 2:57 PM, the Director of Nursing was interviewed and stated Certified Nursing Assistants are responsible for adding the thickener in the residents' drink when they serve the resident's meal tray. The Director of Nursing also stated all Certified Nursing Assistants received in-service education and were trained that if there was a thickener on the tray, then it was supposed to be added to the liquids on the tray. 10 NYCRR 415.12(i)(2)

Based on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure a Quality Assurance and Performance Improvement program identified and prioritized problems and opportunities that reflect organizational process, functions, and services provided to residents. Specifically, 1.) the facility had pattern deficiencies in the areas of Resident Rights, Sufficient Nursing Staff, Pharmacy Services, Administration, Infection Control and Physical Environment, and 2). There were repeated deficiencies from the last survey conducted from 07/20/2023 through 07/27/2023. (Refer to F604 and F880)The findings are:The facility's Quality Assurance and Performance Improvement Plan with a revision date of 07/08/25 documented the plan was designed to provide guidance in assessing and improving overall quality of care and quality of resident life. Focus areas will include all systems that affect resident and family satisfaction, quality of services and care provided, and all areas that affect the quality of people living and working in the organization. The Administrator will ensure the Quality Assurance and Performance Improvement Plan is reviewed minimally on an annual basis.1. For pattern deficiencies, cross refer to F725, F759, F838, F880 and F908.2. For repeated deficiencies, cross refer to F604 and F880.On 09/29/2025 at 03:18 PM, an interview was conducted with the Director of Nursing who stated the staff reports physical environment, care issues, and other issues to them. The Director of Nursing also stated the Quality Assurance and Performance Improvement committee is working to identify issues and to get them resolved and ensures compliance with regulations and enhance the quality of care to residents. The Director of Nursing further stated the Quality Assurance and Performance Improvement committee ensured the corrective measures for physical restraint was successful based on the audit they did periodically, however their focus was on bed rails, not on hand mittens. The Director of Nursing the issue that was identified on infection control last survey was also different from the current concern identified on this survey. On 10/01/2025 at 03:23 PM, an interview was conducted with the Administrator who stated the Quality Assurance and Performance Improvement committee meets monthly and as needed to identify problems in the facility through Resident Council meetings, family complaints, accidents, and incidents. The Quality Assurance and Performance Improvement committee analyzes what could have led to the problem and then make the necessary corrections. The Administrator also stated staffing was a big concern, but it had gotten better recently. The Administrator further stated they have multiple online partners with whom they post job postings, and they offer bonuses to those who make referrals, and they saw a big change when they started improving the rates. The Administrator stated they have an ongoing audit every month regarding physical restraints, but the facility never had issues with hand mittens. The Administrator also stated the pharmacy consultant is not willing to document in the medical records and was not in favor of utilizing the electronic medical record for documentation. When the facility would call the pharmacy consultant for clarification, they would not respond and since the pharmacy consultant was not willing to adjust their policy practice, they secured a new contract with another company. The Administrator further stated the facility tracks performance by bringing it to the team and move on if effective, if not effective then they continue to do Quality Assurance and Performance Improvement until compliance. The Administrator concluded that the issues with physical restraints and infection control are a huge task, and they need to continue to train new staff and continue the ongoing efforts in this regard.10 NYCRR 415.27 (a-c)

Based on record review and interviews conducted during the Abbreviated (459994) and Recertification survey, the facility did not ensure the services provided or arranged by the facility as outlined by the comprehensive care plan, met professional standards of quality. This was evident for one (1) of two (2) residents (Resident #229) reviewed for Hydration out of a total of 41 sampled Residents. Specifically, a Comprehensive Metabolic Panel laboratory test was ordered for Resident #229 on 04/09/2025, there was no documented evidence that blood test was performed. The findings are: The facility policy titled 'Laboratory and Diagnostic Test' reviewed 04/01/2025, stated it is the policy of the facility that all diagnostic interventions will be provided as ordered by the physician. The physician/designee will identify, and order laboratory testing based on the resident's monitoring needs. The license nursing staff will process test requisitions. The laboratory providers will report test to the facility. The results of diagnostic testing will be reviewed by the nursing and medical staff and changes will be made to the Resident's plan of care as indicated. The registered nurse supervisor or designee reviewing laboratory results every shift will ensure that the laboratory specimen has been collected, completed with results, reviewed on the dashboard, and then the order discontinued once completed. The registered nurse supervisor or designee will run a report on a regular basis to ensure no outstanding labs are identified. Resident #229 was admitted to the facility with active diagnoses of Hypernatremia and Hyperosmolality.A Physician Order initiated on 02/06/2025 and renewed on 04/09/2025 documented a laboratory test order for a Comprehensive Metabolic Panel and Complete Blood Count testing.A Comprehensive Metabolic Panel Laboratory Result dated 02/07/2025, documented an abnormal/high Sodium Value of 146 millimole/liter with a reference range of 136-145 millimole/liter and an abnormal/high Calculated Osmolality of 304.81 milliosmoles/liter with a reference range of 275.00-295.00 milliosmoles/liter.There was no documented evidence that the Comprehensive Metabolic Panel and Complete Blood Count laboratory tests ordered on 4/9/2025 were performed.There was no documented evidence that the licensed nurses, physician, or the nurse practitioner followed up on the Comprehensive Metabolic Panel and Complete Blood Count testing that were ordered on 4/9/2025.Nursing Progress Notes dated 5/3/2025 and 5/5/2025, documented Resident #229 was awake with confusion and refused breakfast and lunch.A Physician Laboratory Order initiated on 05/05/2025, documented an immediate (STAT) one time order for Comprehensive Metabolic Panel and Complete Blood Count. laboratory testsA Comprehensive Metabolic Panel Laboratory Final Result dated 05/05/2025 documented an abnormal/high Sodium Value of 170 millimole/liter with a reference range of 136-145 millimole/liter and an abnormal/high Calculated Osmolality of 364.72 milliosmoles/liter with a reference range of 275.00-295.00 milliosmoles/liter.A Nursing Progress Note dated 05/06/2025 documented Resident #229 had a sodium level elevated at 170mEq/L and the Nurse Practitioner was made aware of the results.A Physician Order initiated on 05/08/2025, documented a medication order for an infusion of intravenous fluid of Dextrose five percent (5%) in water (D5W) at one hundred twenty-five cubic centimeters per hour for two days (125cc/hr. x 2 days).A Nursing Progress Note dated 05/06/2025, documented the administration of intravenous fluids, Dextrose five percent (5%) in water (D5W), was started for Hyperosmolality and Hypernatremia.A Physician Transfer Order initiated on 05/07/2025, documented transfer Resident #229 to the hospital. Reason: Hypernatremia and Acute Kidney Injury.On 09/30/2025 at 4:45 PM, an interview was performed with the Medical Director who stated the laboratory tests ordered in February for Resident #229 were slightly elevated and at that level there should not have been a two month wait to repeat the laboratory tests. The Medical Director also stated if laboratory test were ordered in April, when the resident was seen by the provider the next month, the provider should have been able to determine from reviewing the record that the laboratory tests previously ordered were not performed. The Medical Director further stated follow up on the test results should have been performed and that the nurse practitioner who ordered the laboratory tests in April and did not follow up on the results is no longer employed by the facility. On 10/01/2025 at 12:16 PM, an interview was performed with the Director of Nursing who stated the process for follow up on laboratory testing includes receipt of an order by the provider. The nursing supervisor enters the order in the electronic medical record, and a laboratory requisition is created, printed and placed in the lab book for the laboratory technician to pick up, remove the requisition from the laboratory book and obtain the specimen. The Director of Nursing also stated that in the daily twenty-four (24) hour report meeting, the need for laboratory tests and a possible change in condition should be reported and the nursing staff and the provider should be following up to ensure the laboratory tests were performed and the results obtained. The Director of Nursing further stated that laboratory tests to measure sodium and Osmolality levels for Resident #229 were ordered on 04/09/2025 but the laboratory specimen were not obtained. 10 NYCRR 415.11(c)(3)(i)

Number of residents sampled: 2Number of residents cited: 1 Based on observations, record reviews, and interviews conducted during the Recertification and abbreviated survey (460002), the facility did not ensure residents were free from physical or chemical restraints imposed for purposes of discipline or convenience and that were not required to treat the resident's medical symptoms. This was evident for one (1) of two (2) residents (Resident #9) reviewed for Physical Restraints out of 41 sampled residents. Specifically, Resident #9 was observed by facility staff in their bed restless and agitated while on a mechanical ventilator, with each hand inside a pillowcase wrapped with tape around their wrists. The findings are: The facility policy titled 'Restraints' dated 07/08/25 stated it is the policy of the facility to promote and maintain residents' highest practicable well-being in a restraint free environment and only utilize a physical restraint in a circumstance in which the resident has medical symptoms that may warrant the use of a restraint. The facility policy also stated the facility would assess and review the use of any physical restraint to ensure that the least restrictive device is utilized with ongoing assessment for the reduction or elimination of the restraint. The facility would then ensure interventions are in place to minimize or eliminate the medical symptom and/or underlying problems causing the medical symptom. The facility policy further stated the use of hand mittens without proper protocols will be considered a physical restraint. Resident #9 had diagnoses which included Acute Respiratory Failure, Cardiovascular Accident, Seizure disorder, Anxiety disorder, Ventilator and Gastrostomy Tube Dependent. The Quarterly Minimum Data Set (an assessment tool) dated 06/19/2025 documented Resident #9 had severely impaired cognition and required extensive assistance of one person for transfers and toilet use. The Minimum Data Set assessment further documented limb restraints were not used.On 09/26/2025 at 10:07 AM, Resident #9 was observed in bed, alert and awake. Resident #9 was interviewed and stated they were happy their health was improving. Resident #9 also stated they could not recall the incident of pillowcases on their hands however, they recalled bilateral gloves were used on their hands and removed a while ago because they got better. The Facility Reported Incident (#460002) dated 07/02/2025 documented at approximately 9:30 AM on 07/02/2025, Licensed Practical Nurse #6 observed Resident #9 in bed with each hand inside pillowcases and tape wrapped around the resident's wrists. Resident #9 was also observed restless and agitated while under the mechanical ventilator. Licensed Practical Nurse #6 immediately informed Registered Nurse #2 (Supervisor) about the incident and quickly assessed the resident who sustained no injury. Registered Nurse #2 then used scissors to cut the tape around the resident wrists and remove resident's hand from the pillowcases. The Facility Investigative Summary dated 07/09/2025 documented that upon investigation, it was determined Respiratory Therapist #1 who worked on 07/01/2025 from 7:00 PM to 7:00 AM shift applied hand restraints by putting Resident #9's hands inside the pillowcase wrapped with tape. The summary also stated Respiratory Therapist #1 stated Resident #9 decannulated themselves three times during the night shift and all their efforts to get the resident hand mittens was unsuccessful, so Respiratory Therapist #1 then place the resident hand in pillowcases and wrapped tape around the resident's wrist. The Investigative Summary concluded Respiratory Therapist #1 violated facility restraint protocol and the facility terminated Respiratory Therapist #1. Review of documents in the medical records dated 06/12/2025 to 07/01/2025 contained no evidence Resident #9 used a limb restraint, and there was no Physician's order for the use of a limb restraint. On 09/26/2025 at 10:35 AM, an interview was conducted with the assigned Certified Nursing Assistant #7 who stated they worked from 7AM to 3 PM on 07/02/25 which was their regular schedule. Certified Nursing Assistant #7 also stated Resident #9 was confused and agitated when they were first admitted to the facility and had attempted to pull out the tracheostomy out before, so they always make frequent observations of them. Certified Nursing Assistant #7 further stated they did not observe Resident #9 with pillowcases on their hands because they had not yet been to the Resident #9's room at the time of incident. On 09/30/2025 at 10:07 AM, an interview was conducted with Licensed Practical Nurse #6 who observed Resident #9 with pillowcases on their hands. Licensed Practical Nurse #6 stated they worked from 7:00 AM to 3:00 PM on 07/02/2025 as a medication nurse, and when they entered Resident #9's room, they observed the resident appeared restless, each hand was placed inside a pillowcase and wrapped with tape at the resident's wrist, and they immediately informed the supervisor. Licensed Practical Nurse #6 also stated Resident #9 was unable to communicate at that time due to being maintained on a ventilator but at times was able to make some body gestures to communicate. Licensed Practical Nurse #7 further stated Resident #9 was not admitted with hand mittens and had never used hand mittens prior to the incident.On 09/30/2025 at 11:20 AM, an interview was conducted with the Director of Respiratory Therapy who stated they assessed Resident #9 when they were first admitted to the facility and Resident #9 was not admitted with hand mittens. The Director of Respiratory Therapy also stated Resident #9 was on full ventilator and could not talk, has made great progress, and now has a tracheostomy only. The Director of Respiratory Therapy further stated Resident #9 used to be agitated and was prescribed Ativan as needed because they had attempted to pull the tracheostomy out. The Director of Respiratory Therapy stated Respiratory Therapist #1 has been working here for over 5 years and knows the protocol for initiating hand mittens.On 10/01/2025 at 03:43 PM, an interview was conducted with the Director of Nursing who stated they take the facility restraint policy very seriously and everyone is constantly in-serviced on it. The Director of Nursing also stated they were informed about the restraint incident involving Resident #9 and at the completion of investigation, they concluded Respiratory Therapist #1 did not follow the facility restraint protocol. The Director of Nursing further stated Resident #9 had agitated behavior and was receiving Ativan as needed for safety, and it was never brought to their attention that Resident #9 may need hand mittens. 10 NYCRR 415.4(a)(2-7)

Based on observations, record reviews, and interviews conducted during the Recertification survey, the facility did not ensure that the services provided or arranged by the facility as outlined by the comprehensive care plan, met professional standards of quality. This was evident for one (1) of two (2) residents (Resident #9) reviewed for Physical Restraint out of 41 sampled residents. Specifically, there was no documented evidence bilateral hand mittens for Resident #9 were released every two-hours as per Physician's order. The findings are: The facility policy titled 'Restraints' dated 07/08/25 stated it is the policy of the facility to promote and maintain residents' highest practicable well-being in a restraint free environment and only utilize a physical restraint in a circumstance in which the resident has medical symptoms that may warrant the use of a restraint. The facility policy also stated staff would monitor and document the use of physical restraint on resident's medical records as indicated by the Interdisciplinary team. Resident #9 had diagnoses which included Acute Respiratory Failure, Cardiovascular Accident, Seizure disorder, Anxiety disorder, Ventilator and Gastrostomy Tube Dependent. The Quarterly Minimum Data Set (an assessment tool) dated 06/19/2025 documented Resident #9 had severely impaired cognition, and they required extensive assistance of one person for transfers and toilet use. The Minimum Data Set assessment further documented limb restraints were not used. On 09/26/2025 at 10:07 AM, Resident #9 was observed in bed, alert and awake. Resident #9 was interviewed and stated they were happy their health was improving. Resident #9 also stated they could not recall the incident of pillowcases on their hands however, they recalled bilateral gloves were used on their hands and removed a while ago because they got better. The Physician's order dated 07/22/2025 and discontinued on 09/10/2025 documented Bilateral Hand Mittens-Restraint type for pulling the trach out. Release every 2 hours for 10 minutes for Range of Motion and Skin Check. The Respiratory Note dated 07/27/2025 documented Resident #9 was ventilator dependent with prescribed settings, no sign of distress noted. Head of bed elevated, gastrostomy tube is intact and patent, aspiration precautions maintained. Bilateral mittens in place to prevent pulling at trach, release every 2 hours for 15 minutes. Plan of care on going. The Comprehensive Care plans for Physical Restraint, initiated on 07/10/2025, documented the resident will no longer required hand mittens due to improved behavior. Hand mittens were discontinued on 09/10/2025. The Registered Nurse note dated 09/10/2025 documented Resident #9 was reevaluated, no behavioral issues noted recently. Order was obtained from physician by a nursing supervisor to discontinue hand mittens and to continue 30-minute monitoring.Review of the medical record contained no documented evidence bilateral hand mittens for Resident #9 were released every 2 hours as per Physician's order. On 09/26/2025 at 10:35 AM, an interview was conducted with assigned Certified Nursing Assistant #7 who stated Resident #9's bilateral hand mittens were put in place as Resident #9 was agitated and restless. Certified Nursing Assistant #7 also stated they were not responsible for applying or monitoring the hand mittens, as they believe the nurses apply them. On 09/30/2025 at 10:07 AM, an interview was conducted with Licensed Practical Nurse #6 who stated hand mittens are generally monitored by the medication nurse and release of mittens is supposed to be documented on the Treatment Administration Record. Licensed Practical Nurse #6 could not explain why and how documentation of the application and removal hand mittens was not found on the Treatment Administration Record and stated maybe it had not been linked with the Treatment Administration Record so documentation could be done. On 09/30/2025 at 10:55 AM, an interview was conducted with Registered Nurse #2 who stated they do not give medication, however, supervise nursing staff. Registered Nurse #2 also stated hand mittens monitoring is documented on the Treatment Administration Record and signed for by medication nurse. Registered Nurse #2 further stated they reviewed Resident #9's record and could not find any documentation that the hand mittens were monitored. On 10/01/2025 at 03:43 PM, an interview was conducted with the Director of Nursing who stated they could not find documentation regarding monitoring of the hand mittens for Resident #9. The Director of Nursing also stated it is the responsibility of the nursing supervisor to ensure care plans, and all other relevant documentation is in place. The Director of Nursing further stated the Certified Nursing Assistant and medication nurses are supposed to monitor any physical restraint device, and this should be documented on both the Certified Nursing Assistant and Treatment records 10 NYCRR 415.11(c)(3)(i)

Based on record review and interviews conducted during the Abbreviated (459971) and Recertification survey, the facility did not ensure a comprehensive person-centered care plan for each resident was developed and implemented, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs. This was evident for one (1) of two (2) residents (Resident #223) reviewed for Hospitalization out of 41 sampled residents. Specifically, there was no comprehensive care plan developed for tracheostomy care for Resident #223.The findings are:The facility policy and procedure titled 'Comprehensive Care Planning', last reviewed 10/16/2023, stated each resident will have a comprehensive person-centered care plan developed that is in compliance with Federal and State regulations. The facility will establish an interdisciplinary team care planning process to ensure resident care and treatment is planned appropriately for the resident's needs and condition, impairment, disability or disease process in a timely, systematic and comprehensive manner. Based on a comprehensive interdisciplinary assessment, the interdisciplinary team will address individualized resident needs to include physical, psychosocial, cognitive, functional, activities, emotional, spiritual, cultural, and communication needs. Services and care are identified and planned to meet resident's care goals. interdisciplinary team members who will provide care or service are also identified. Individual care and treatment goals are identified. Resident #223 was admitted to the facility with active diagnoses that included Non-Traumatic Brain Injury and Respiratory Failure with Tracheostomy.The admission Minimum Data Set (an assessment tool) dated 11/23/2024, documented Resident #223 was severely cognitively impaired, had shortness of breath or trouble breathing when lying flat, and received respiratory treatments including oxygen administration and tracheal suctioning.A Physician Treatment Order dated 12/05/2024, documented Oxygen 21% to be administered by tracheal collar 24 hours a day.A Physician Treatment Order dated 12/13/2024, documented suction tracheal secretions every shift and as needed.A Physician Treatment Order dated 12/13/2024, documented perform tracheal care every shift and as needed.There was no documented evidence a comprehensive care plan was created to address the treatment plan, goals, and interventions specifically associated with the tracheostomy tube.On 10/01/2025 at 2:42 PM, an interview was conducted with Registered Nurse #2, the nursing supervisor for the ventilator unit who stated the tracheostomy care plan should be entered at admission for all residents who are admitted to the facility with a tracheostomy tube. Registered Nurse #2 also stated that at admission, the Registered Nurse or Minimum Data Set assessment nurse enters the care plans. Registered Nurse #2 further stated all clinical staff providing tracheostomy care and treatments should check the medical chart every day to ensure the care plan associated with the residents' diseases, care, and treatments are entered and updated as needed. Registered Nurse #2 stated if the tracheostomy care plan is not present in the medical record or not updated, the care plan has to be entered to guide the associated care and treatments and outline the goals of care for the resident. On 10/01/2025 at 2:19 PM, an interview was conducted with the Director of Nursing who stated Registered Nurses and the Minimum Data Set assessment nurse who start and or complete the admission process for the resident is to enter the care plans. The Director of Nursing also stated at admission all standard care plans are entered and within twenty-four (24) to forty-eight (48) hours additional care plans are entered related to the resident's specific disease processes and treatments that are required and performed. The Director of Nursing further stated Registered Nurse supervisors are to review the care plans and make sure they are entered and updated. The Director of Nursing stated Resident #223 should have had a tracheostomy care plan entered into the medical record that addressed the tracheostomy care, the associated treatments, and the goals of the care. 10 NYCRR 415.11(c)(1)

Based on observations, record review, and interviews during an abbreviated survey (NY00376954), the facility failed to ensure that a resident who displayed or was diagnosed with mental disorder or psychosocial adjustment difficulty, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. This was evident in 1 out of 10 residents (Resident #1) sampled for behavioral health. Specifically, from [DATE] through [DATE], Resident #1 who had a diagnosis of Huntington's Chorea Disease (a neurological disorder that causes nerve cells in the brain to break down and die, leading to uncontrolled movements, cognitive decline, and personality changes) exhibited and verbalized suicidal ideation with increased agitation and behavioral disturbances. On [DATE], [DATE], and [DATE], Resident #1 was observed by the facility's nursing staff attempting to open their room window and the windows in other resident rooms, successfully removing the bottom panel from their window on [DATE], while verbalizing they wanted to jump out of the window. The resident was transferred to the hospital emergency room via emergency transport after each incident for behavioral evaluation. Upon return from the hospital on [DATE] at 12:20 AM the resident was placed back in the same room and their care plan was not updated with new interventions to address the resident behavior and suicidal ideation. On [DATE] at 2:58 AM, Certified Nursing Assistant #1 observed the bottom window panel on the floor of the resident's room and Resident #1 was outside of the window, hanging from the window ledge. Resident #1 then let go and fell from the 4th floor window. This deficient practice resulted in Resident #1's death that was immediate jeopardy. The findings are: The facility Policy and Procedure titled Behavioral Health Management dated [DATE], documented the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The policy further documented the facility will utilize non-pharmacological interventions as appropriate as part of the person-centered plan of care. Resident #1 was admitted to the facility with diagnoses including Non-Alzheimer's Dementia and Huntington's Disease (brain disorder that causes nerve cells to break down). The Minimum Data Set, dated [DATE] documented Resident #1 had intact cognition. A Nursing Progress Note dated [DATE] at 5:27 AM by Registered Nurse Supervisor #2, documented Resident #1 was observed going from room to room agitated trying to open and break windows. Resident #1 was observed banging their head on the windows and was a danger to themself. Emergency services was called, and Resident #1 left the unit on a stretcher to the hospital at 5:20 AM. A Prehospital Care Report Summary - Fire Department of New York dated [DATE] revealed when Emergency Services arrived at the facility, Resident #1 was lying on the floor being restrained by Police Officers. The police stated that staff reported Resident #1 was trying to jump out the window but was unable to open the window. Nursing Progress Note by Registered Nurse #1 dated [DATE] at 6:45 PM, documented Resident #1 returned from the emergency department at 4:00 PM. The note further documented that the resident was sent to the hospital for evaluation due to suicidal ideation and behaviors. The resident was sent back with no changes in medication and no documentation indicating the Resident was not a danger to self at this time. Resident #1 stated they did not want to kill themself. The resident stated they were frustrated and made remarks out of frustration. Resident #1 was immediately evaluated by Psychologist #1 and placed on 1:1 monitoring. A Patient Visit Information Follow-up and Referral Instructions (from the emergency department) dated [DATE] documented that Resident #1 should return to the emergency department if symptoms or condition worsened. Recommended to follow up with primary physician. A Progress Note by Psychology Consultant #1 dated [DATE] at 6:54 PM, documented staff reported Resident #1 became agitated and was attempting to harm self. The resident was transferred to the hospital for evaluation and was later readmitted to the nursing home. Resident #1 admitted to self-injurious behaviors, but was unable to provide any insight as to their motivation or any events that may have triggered self-injurious behaviors. Resident #1 denied any intent to harm self at this time, and verbally contracted for safety. Staff reported increased withdrawal/avoidance behaviors. Resident declined psychological services at this time. A Physician Comprehensive Monthly note by Physician #1 (Resident #1's primary physician) dated [DATE] at 12:49 PM, documented that they were following up on Resident #1's functional status. There were no complaints in the morning, Resident #1 denied pain secondary to abscess (gum). Chief complaint: functional impairment. Physician #1 documented the resident's history prior to being admitted to the facility. The note did not mention Resident #1's emergency room visit on [DATE] and there was no recommendation for monitoring for safety. A Physician's progress note dated [DATE] at 5:41 PM by Physician #2, documented Resident #1 was seen and examined. Clinically stable. Resident #1 returned from the hospital due to suicidal attempt. The resident has no behavioral issues now, on Abilify and Celexa. Referred to psychologist and psychiatrist for further evaluation. No side effect of medication, continue current medication. A Psychiatry note/follow up dated [DATE] at 3:29 PM, documented Resident #1 started pulling down shades and trying to open windows. Resident #1 reported they were angry with their roommate because their roommate made a feculent odor. Psychiatrist #1 recommended to increase the Ability from 20 milligrams to 30 milligrams daily. Physician #2 progress notes dated [DATE] at 11:01 AM documented date of service [DATE], Resident #1 was clinically stable and was seen by psychiatrist. Recommendation reviewed and agreed to continue Abilify for psychosis and chorea related to Huntington's disease. Increased Ability to 30 milligrams daily. Will monitor. Continue Celexa 20 milligrams daily to address poor impulse control which contributes to behavior problems. Resident Medication Administration Record reviewed on [DATE], Abilify 20 milligrams daily was increased to 30 milligrams daily. A Nursing Progress Note dated [DATE] at 2:53 AM by Registered Nurse Supervisor #2 documented Resident #1 was very agitated, destroying property and stating they will jump out of the window. Resident #1 was very combative and could not be redirected. The Resident was a danger to themself and others. Emergency services was called, and the Resident was taken out of the facility with police officers at around 2:30 AM. A Prehospital Care Report Summary - Fire Department of New York dated [DATE] revealed when Emergency Services arrived at the facility, staff reported Resident #1 was aggressive and was trying to jump out of the window to kill themself. The resident was calm with crew but was in handcuffs with police prior to emergency service arrival. Resident #1 was transported to the hospital without incident. A Nursing Progress Note dated [DATE] at 1:45 PM by Registered Nurse Supervisor #1 documented Resident #1 was transferred to the hospital emergency department for the same behaviors displayed three days ago, physically aggressive behaviors with suicidal ideations. Resident returned calm and cooperative. No recommendations and no changes in medication. A Patient Visit Information (Hospital Discharge Summary) dated [DATE], documented Resident #1 was observed in the emergency department overnight. Resident #1 was calm and cooperative, and they did not observe any aggressive behavior or suicidal behaviors in the emergency room. Resident #1 was not a danger to themself or others at this time and was psychiatrically cleared for discharge. Resident #1 to continue all home medications and follow up with their primary provider at the facility. As recommended on [DATE], Ability 20 milligrams to be decreased to 10 milligrams daily due to the risk of akathisia, restlessness, and agitation. There is no documented evidence the facility reviewed the recommendation of [DATE] for Abilify to be decreased to 10 milligrams. Medical record reviewed from [DATE] to [DATE], revealed no documented evidence Resident #1 was seen and evaluated by a Physician. A Nursing Progress Note dated [DATE] at 8:28 PM by Registered Nurse Supervisor #3 documented at 7:35 PM, they responded to a call from the unit and observed Resident #1 pacing in their room. The room was freezing, the window was on the floor with the window screen torn. Resident #1 stated they opened their window to put a soda can outside to get cold. Resident #1 was laughing inappropriately with a gazed look. Physician #1 was informed, and emergency services was called. 1:1 monitoring was provided for safety until emergency services arrived. Resident #1 was transported for psychiatric evaluation at 8:00 PM. A Prehospital Care Report Summary - Fire Department of New York dated [DATE] revealed facility staff reported that Resident #1 pushed out the mesh screen of a window in their room. Staff stated Resident #1 was suicidal. Resident #1 reported they were not hearing any voices and does not want to hurt themself or others. The Accident/Incident Report dated [DATE] at 2:58 AM documented Certified Nursing Assistant #1 was doing their rounds and observed Resident #1 jumped from the window. The facility's investigation documented that at 7:35 PM on [DATE], the window panel was found on the floor in Resident #1's room with the mesh screen partially torn. Resident #1 stated they had opened the window to put their can of soda outside to get cold. Given Resident #1's behavior and history, staff deemed Resident #1 a danger to self and others and obtained an order to transfer them to the hospital for evaluation, and resident left the facility at 8:00 PM. The window panel was reinserted by Certified Nursing Assistant #3 and placement was confirmed by Housekeeper #1. Resident #1 returned to the facility at approximately 12:20 AM. Thirty-minute visual monitoring was ongoing. At 2:58 AM, Certified Nursing Assistant #1 opened Resident #1's room door for scheduled room checks and observed Resident #1's hands gripping the windowsill from outside the window. The facility concluded that the event was unforeseeable, an isolated act likely resulting from Resident #1's neuropsychiatric condition. There was no documented evidence the facility initiated or updated Resident #1's care plan to identify and develop interventions for the [DATE], [DATE], and [DATE] suicidal ideations. A Nursing Progress Note by Licensed Practical Nurse #2 dated [DATE] at 7:17 AM, documented Resident #1 returned from the hospital emergency room at 12:20 AM and was placed on 30 minutes rounds. At about 2:58 AM, Certified Nursing Assistant #1 (making rounds) went into Resident #1's room and observed the Resident at the window and the Resident immediately jumped from the window. Registered Nurse Supervisor #2 was notified. The Resident was lying on ground awake and in stable condition. Emergency services was called, and police officers and ambulance personnel came and took over. A Prehospital Care Report Summary - Fire Department of New York dated [DATE] when emergency service arrived Resident #1 was lying supine (on their back) on the sidewalk surrounded by Police Officers. Resident #1 jumped out of the open window on the fourth floor, approximately a 40- foot fall. Resident #1 was transferred to the hospital. No visible injuries. During an interview on [DATE] at 10:15 AM, the Director of Maintenance stated that they were not aware Resident #1 had removed their room window on [DATE]. They became aware of the issues on [DATE] after Resident #1 was transferred to the emergency room. During a telephone interview on [DATE] at 11:25 AM, Certified Nursing Assistant #1 stated they arrived at the facility and made rounds at approximately 11:00 PM on [DATE]. Resident #1 was already transferred to the hospital. They stated that they checked Resident #1's room and nothing was broken, the window was closed, but the mesh was not in the window panel. Certified Nursing Assistant #1 stated that Resident #1 returned to the facility between midnight -12:15 AM on [DATE]. Certified Nursing Assistant #1 stated they and Certified Nursing Assistant #2 took turns checking on Resident #1 every 30 minutes. They stated they went back to check on Resident #1 on [DATE] at 2:58 AM and Resident #1's room was cold; their body was outside the window and their hands were holding onto the windowsill. They stated Resident #1 then let go of the windowsill before they could reach them. They stated they observed the bottom window panel on the floor, but did not see the window mesh. They stated Resident #1 had closed their room door. During a telephone interview on [DATE] at 12:36 PM, Licensed Practical Nurse #1 stated they worked on [DATE] on the 3:00 PM to 11:00 PM shift. They stated Resident #1 transferred from Unit 6 to Unit 4 on [DATE]. Licensed Practical Nurse #1 stated Resident #1 was not on the unit when they conducted rounds, but they received a report from the off-going nurse (Licensed Practical Nurse #7) who stated Resident #1 was in the dining room eating on the first floor at approximately 5:00 PM. Licensed Practical Nurse #7 also reported that Resident #1 verbalized suicidal ideation and was on close monitoring. Licensed Practical Nurse #1 stated Resident #1 returned to the unit between 5:00 PM and 6:00 PM (exact time unsure) Licensed Practical Nurse #1 stated they observed Resident #1 pacing back and forth in their room between 7:15 PM and 7:30 PM and requested a pillow. Licensed Practical Nurse #1 stated they instructed Certified Nursing Assistant #4 to give Resident #1 a pillow. Licensed Practical Nurse #1 stated Certified Nursing Assistant #4 called out from Resident #1's room and when they arrived in the room, they observed the bottom window on the floor and the mesh screen was torn. Licensed Practical Nurse #1 stated they instructed another staff (Certified Nursing Assistant #3) to stay with Resident #1 while they paged the Registered Nurse Supervisor #3 and Housekeeper #1. Licensed Practical Nurse #1 stated Resident #1 remained at the nursing station with them for close observation until the emergency service arrived and transferred Resident #1 to the emergency room. They stated Certified Nursing Assistant #3 put the window back in the frame. During an interview with the Director of Nursing on [DATE] at 1:32 PM, they stated that Resident #1 should have been placed on 1:1 monitoring. During a telephone interview on [DATE] at 1:47 PM, Housekeeper #1 stated they were called to Resident #1's unit and responded between 7:00 PM and 8:00 PM. Housekeeper #1 stated License Practical Nurse #1 informed them that Resident #1 took their room window out of the wall. Housekeeper #1 stated they then entered Resident #1's room and observed the window slightly out of the window frame and it was not aligned properly. Housekeeper #1 stated they pushed the window into the frame, but it was still loose. They stated Licensed Practical Nurse #1 informed them that the window was on the floor and Certified Nursing Assistant #3 put the window back into the frame. Housekeeper #1 stated they documented the window was out in the maintenance book. During a telephone interview on [DATE] at 2:38 PM, Registered Nurse Supervisor #2 stated Licensed Practical Nurse #2 informed them at approximately 3:00 AM on [DATE], that Resident #1 fell out of the window. They stated they went outside the building and saw Resident #1 lying on the ground. Registered Nurse Supervisor #2 stated they called 911 at 3:02 AM or 3:03 AM and the police arrived followed by Emergency Medical Staff. They stated they informed the administrative team at 3:15 AM on [DATE]. They stated prior to the incident, they evaluated Resident #1 upon their return from the hospital at approximately 12:03 AM - 12:05 AM on [DATE] and Resident #1 was calm prior to the incident and was being monitored visually every 30 minutes. During a telephone interview on [DATE] at 3:54 PM, Physician #1 stated Resident #1 did not voice suicidal concerns to them. Physician #1 stated they were informed by a staff nurse each time Resident #1 was transferred to the hospital, however, they cannot recall who informed them or the time they were informed. Physician #1 stated they did not call the hospital to inquire about sending Resident #1 back to the facility after they verbalized suicidal ideations. They stated the hospital psychiatrist evaluated Resident #1 and documented Resident #1 was not at risk for suicide. They stated the facility staff maintained Resident #1 on close monitoring. They stated Resident #1 was not on 1:1 monitoring, but considering what had happened, having Resident #1 on 1:1 would have helped. An interview on [DATE] at 3:18 PM with both the Director of Nursing and the Administrator revealed they were not informed of Resident #1's transfer to the hospital on [DATE] and [DATE]. The Administrator and Director of Nursing stated when the resident returned from the hospital emergency room on [DATE] at 12:20 AM, Registered Nurse #2 did not implement the 1:1 monitoring; instead, they placed the resident on 30-minute monitoring. During a telephone interview on [DATE] at 11:38 AM, Psychiatrist #1 stated Resident #1 was evaluated every quarter and as needed. They stated Resident #1 had Huntington's disease which affected the resident behavior. Psychiatrist #1 stated Registered Nurse Supervisor #1 asked them to evaluate Resident #1 because the resident attempted to open a window and was sent to the emergency room. Psychiatrist #1 stated they recommended increasing Abilify to 30 milligrams on [DATE] after they evaluated the resident. They stated Resident #1 was taking Ability for Huntington's Disease. The Psychiatrist stated they were not aware of the emergency room recommendation dated [DATE] to decrease the Abilify to 10 milligrams. Psychiatrist #1 stated Abilify was approved for the diagnosis and was helpful in diminishing impulsivity and outbursts, therefore, they would not have deceased the Abilify to 10 milligrams. The Psychiatrist stated the Abilify did not contribute to the suicidal ideation. Psychiatrist #1 stated their role was to provide pharmacological management; they do not have a role to tell nursing staff to how manage resident's behavior. During a telephone interview on [DATE] at 12:55 PM, Physician #2 stated they did not review the emergency room discharge summary of [DATE]. They stated they evaluated Resident #1 on [DATE] and reviewed the Psychologist consultation on [DATE]. They stated they did not receive any calls from the facility after [DATE] because they were on maternity leave. During an interview on [DATE] at 1:08 PM, Certified Nursing Assistant #3 stated on [DATE] (unable to recall the time), Licensed Practical Nurse #1 asked them for assistance because Resident #1 wanted to go out of the window. They stated when they entered Resident #1's room they observed the window on the floor, and they put the window back in the frame and locked the window. Certified Nursing Assistant #3 stated they left the room after putting the window back into the frame, but Resident #1 and Licensed Practical Nurse #1 remained in the room. During a telephone interview on [DATE] at 2:45 PM, the Medical Director stated they were not aware of any recommendations made by the hospital for Resident #1 as they were not aware of the [DATE], [DATE], and [DATE] hospital emergency room transfers. The Medical Director added that the Administrator notified them that Resident #1 was transferred to the emergency room after the incident on [DATE]. During an interview with the Administrator on [DATE] at 3:18 PM, they stated they were not aware of the resident's multiple emergency transfers to the hospital. They were informed of the [DATE] incident when staff told them the window was damaged. They were told by Registered Nurse #3 at 8:34 PM (on [DATE]) that Resident #1 was returning from the hospital and would be placed on 1:1 supervision. 10 NYCRR 415.12(f)(1)

Based on observations, record review, and interviews during an abbreviated survey, (NY00376954), the facility failed to ensure that the physician reviewed the resident's total program of care, including medications, at each visit. This was evident in one (1) out of ten (10) residents (Resident #1) sampled for quality of care. Specifically, Resident #1 who exhibited increased agitation with behavioral disturbances secondary to Huntington's Disease, verbalized suicidal ideation from [DATE] to [DATE]. Resident #1 was transferred to the hospital emergency department on [DATE], [DATE], and [DATE]. A Patient Visit Information (Hospital Discharge Summary) from the hospital emergency department dated [DATE], documented as recommended on [DATE], Abilify 20 milligram to be decreased to 10 milligram daily due to the risk of akathisia restlessness, and agitation. There was no documented evidence that a physician reviewed the hospital emergency room discharge summary and recommendation. There were no physician's interventions recommended after Resident #1 transfers to the emergency department on [DATE] and [DATE]. The Psychiatrist was not notified of the recommendation of [DATE] for Abilify to be decreased from 20 milligrams to 10 milligrams. Record review of the medical notes revealed no documented evidence Resident #1 was seen and evaluated by a Physician from [DATE] to [DATE]. On [DATE] at 2:58 AM, Resident #1 jumped from their room window and was found lying on facility grounds. Resident #1 was transferred to the emergency room where they expired. The findings are: The facility policy titled Medical Service Policy dated [DATE] documented the attending physicians shall oversee the comprehensive medical care of all assigned residents, ensure the delivery of timely, coordinated, and ethical care consistent with federal, state, and facility standards. The policy further documented that the physicians must maintain regulatory compliance with CMS F-tags F710 through F714, F841, F842, and F865. The facility policy titled Psychoactive Medications dated [DATE] documented in procedure (21) the Primary Physician will review the recommendations made by the Psychiatrist and incorporate these in the medical record. Resident #1 was admitted to the facility with diagnoses including Non-Alzheimer's Dementia (forgetfulness) and Huntington's Disease (brain disorder that causes nerve cells to break down). The Minimum Data Set, dated [DATE] documented Resident #1 had intact cognition. A Nursing Progress Note dated [DATE] at 5:27 AM by Registered Nurse Supervisor #2 documented Resident #1 was observed going from room to room agitated trying to open and break windows. Resident #1 was observed banging their head on to the windows and was a danger to themself. 911 was called and Resident #1 left the unit on a stretcher to the hospital at 5:20 AM. A Nursing Progress Note by Registered Nurse #1 dated [DATE] at 6:45 PM documented Resident #1 arrived from the emergency department at 4:00 PM. The Resident was sent to the hospital for evaluation due to suicidal ideation and behaviors. The resident was sent back with no changes in medication and no documentation if the Resident was a danger to self at this time. Resident stated they did not want to kill themself. The Resident stated they were frustrated and made remarks out of frustration. The Resident was immediately evaluated by Psychologist and placed on 1:1 monitoring. A Progress Note by Psychology Consultant dated [DATE] at 6:54 PM documented staff reported Resident #1 became agitated and was attempting to harm self. The resident was transferred to the acute care facility for evaluation and was later readmitted to the nursing home. Resident #1 admitted to self-injurious behaviors, but was unable to provide any insight as to their motivation or any events that may have triggered self-injurious behaviors. Resident #1 denied any intent to harm self at this time, and verbally contracted for safety (a legally binding agreement made without any written documentation). Staff reported increased withdrawal/avoidance behaviors. Resident declined psychological services at this time. A Prehospital Care Report Summary - Fire Department of New York dated [DATE] revealed when 911 arrived at the facility, Resident #1 was lying on the floor being restrained by Police Officers. The police stated staff reported Resident #1 was trying to jump out the window but was unable to open the window. A Physician Comprehensive Monthly note by Physician #1 (Resident #1's primary physician) dated [DATE] at 12:49 PM documented that they were following up on Resident #1's functional status. There were no complaints in the morning, Resident #1 denied pain secondary to abscess (gum). Chief complaint: functional impairment. There was no mention of Resident #1's emergency room visit or recommendation for monitoring for safety. A Psychiatrist noted dated [DATE] at 3:29 PM documented they evaluated Resident #1 and increased Abilify (antipsychotic used primarily to treat mood disorders and schizophrenia) to 30 milligrams. A Nursing Progress Note dated [DATE] at 2:53 AM by Registered Nurse Supervisor #2 documented Resident #1 was very agitated, destroying property and stating they will jump out of the window. Resident #1 was very combative and could not be redirected. The Resident was a danger to themself and others. 911 was called and the Resident was taken out of the facility at around 2:30 AM. A Physician's progress note dated [DATE] at 11:01 AM (for services provided on [DATE]), by Physician #2 documented Resident #1 was clinically stable and was seen by psychiatrist. Recommendation reviewed and agreed to continue Abilify for psychosis and chorea related to Huntington's disease. Increased Ability to 30 milligrams daily. Will monitor. Continue Celexa 20 milligrams daily to address poor impulse control which contributes to behavior problems. There was no mention of Resident #1 being transferred to the hospital emergency room on [DATE] at 2:30 AM, there was no mention of the emergency room discharge summary and recommendation to decrease Abilify. A Nursing Progress Note dated [DATE] at 1:45 PM by Registered Nurse Supervisor #1 documented Resident #1 was transferred to the hospital emergency department for the same behaviors displayed three days ago, physically aggressive behaviors with suicidal ideations. Resident returned calm and cooperative. No recommendations and no changes in medication. Documentation revealed Resident is not a danger to self or others at this time. A Patient Visit Information (Hospital Discharge Summary) dated [DATE] documented Resident #1 was observed in the emergency department overnight. Resident #1 was calm and cooperative, and they did not observe any aggressive behavior or suicidal behaviors in the emergency room. Resident #1 was not a danger to themself or others at this time and was psychiatric cleared for discharge. Resident #1 to continue all home medications and follow up with their primary provider at the facility. As recommended on [DATE], Ability 20 milligram to be decreased to 10 milligram daily due to the risk of akathisia restlessness, and agitation. There was no documented evidence that medical staff were aware of the hospital's recommendation of [DATE] to decrease Abilify from 20 milligrams to 10 milligrams. A review of the resident's Medication Administration Record revealed Resident #1 was receiving Abilify 20 milligrams daily and Celexa 20 milligrams daily by oral route from [DATE] through [DATE]. There was no documented evidence that Resident #1 was being monitored to determine the effectiveness of the medication. A Nursing Progress Note dated [DATE] at 8:28 PM by Registered Nurse Supervisor #3 documented at 7:35 PM, they responded to a call from the unit and observed Resident #1 pacing their room. The room was freezing, the window was on the floor with window screen torn. Resident #1 stated they opened their window to put a soda can outside to get cold. Resident #1 was laughing inappropriately with a gazed look. 1:1 monitoring was provided for safety. Medical Doctor was informed and 911 was called. Resident #1 left for psychiatric evaluation at 8:00 PM. Medical record review revealed no documented evidence Resident #1 was seen and evaluated by a Physician from [DATE] to [DATE]. A Nursing Progress Note by Licensed Practical Nurse #2 dated [DATE] at 7:17 AM documented Resident #1 returned from the hospital emergency room at 12:20 AM and was placed on 30 minutes rounds. At about 2:58 AM, Certified Nursing Assistant #1 (making rounds) went into Resident #1's room and observed the Resident at the window and the Resident immediately jumped from the window. Registered Nurse Supervisor #2 was notified. The Resident was lying on ground awake and in stable condition. 911 called and Police Officers and ambulance came and took over. A Prehospital Care Report Summary - Fire Department of New York dated [DATE] when emergency service arrived Resident #1 was lying supine on the sidewalk surrounded by Police Officers. Resident #1 jumped out of the open window on the fourth floor, approximately 40 feet fall. Resident #1 was transferred to the hospital. No visible injuries. During a telephone interview on [DATE] at 3:54 PM, Physician #1 stated Resident #1 did not voice suicidal concerns to them. Physician #1 stated they were informed by a staff nurse each time Resident #1 was transferred to the hospital, however, they cannot recall who informed them or the time they were informed. Physician #1 stated they did not call the hospital to inquire about sending Resident #1 back to the facility after they verbalized suicidal ideations. They stated the hospital psychiatrist evaluated Resident #1 and documented Resident #1 was not at risk for suicide. They stated the facility staff maintained Resident #1 on close monitoring. They stated Resident #1 was not on 1:1 monitoring, but considering what had happened, having Resident #1 on 1:1 would have helped. During a telephone interview with Registered Nurse Supervisor #1 on [DATE] at 9:38 AM, Registered Nurse Supervisor #1 stated there were no recommendation on the emergency room Discharge summary dated [DATE]. They stated the form documented if the symptoms got worse the resident should return to the emergency room. Registered Nurse Supervisor #1 stated the emergency discharge form dated [DATE] documented that Resident #1 was not a danger to their self or others. They stated they did not see the recommendation documented to decrease Abilify to 10 milligrams. They stated every time Resident #1 returned from the hospital, they informed Physician #2. During a follow interview on [DATE] at 1:45 PM, Physician #1 stated they were informed by the nurse (can't recall the time or who informed them) that the hospital discharge summary recommended medication adjustment but cannot recall what the recommendation was. Physician #1 stated they were made aware of Resident #1 having erratic behavior and the goal was to have then evaluated by the Psychiatrist, so they can adjust their medication. They stated they cannot recall if Resident #1 was seen by the Psychiatrist in-house, but Resident #1's condition became concerning, so they were sent to the hospital for evaluation. They stated they do not recall if Resident #1 had labs done. During a telephone interview on [DATE] at 12:55 PM, Physician #2 stated they did not review the emergency room discharge summary of [DATE]. They stated they evaluated Resident #1 on [DATE] and reviewed the Psychologist consultation on [DATE]. They stated they did not receive any calls from the facility after [DATE] because they were on maternity leave. During a telephone interview on [DATE] at 11:38 AM, Psychiatrist #1 stated Resident #1 was evaluated every quarter and as needed. They stated Resident #1 had Huntington's disease which affected the resident behavior. Psychiatrist #1 stated Registered Nurse Supervisor #1 asked them to evaluate Resident #1 because the resident attempted to open a window and was sent to the emergency room. Psychiatrist #1 stated they recommended increasing Abilify to 30 milligrams on [DATE] after they evaluated the resident. They stated Resident #1 was taking Ability for Huntington's Disease. The Psychiatrist stated they were not aware of the emergency room recommendation dated [DATE] to decrease the Abilify to 10 milligrams. Psychiatrist #1 stated Abilify was approved for the diagnosis and was helpful in diminishing impulsivity and outbursts, therefore, they would not have deceased the Abilify to 10 milligrams. The Psychiatrist stated the Abilify did not contribute to the suicidal ideation. Psychiatrist #1 stated their role was to provide pharmacological management; they do not have a role to tell nursing staff to how manage resident's behavior. During a telephone interview on [DATE] at 2:45 PM, the Medical Director stated they were not aware of any recommendations made by the hospital for Resident #1 as they were not aware of the [DATE], [DATE], and [DATE] hospital emergency room transfers. The Medical Director added that the Administrator notified them that Resident #1 was transferred to the emergency room after the incident on [DATE]. 10 NYCRR 415.15 (b)(2)(iii)

Based on observations, record review, and interviews during an abbreviated survey (NY00360059), the facility did not ensure that a resident care plan was reviewed and revised by the interdisciplinary team. This was evident in one (1) out of ten (10) residents (Resident #2) sampled. Specifically, on 11/11/2024 Resident #2 alleged Certified Nursing Assistant #5 hit them on their head and pushed them to the ground on the evening of 11/10/2024. The facility investigated the allegation and concluded that the abuse allegation was inconclusive. Resident #2's care plan was not reviewed and revised to reflect the allegation of abuse and it's outcome. The findings include: The facility's Policy and Procedure titled Comprehensive Care Planning dated 03/10/2025, documented the facility utilizes an interdisciplinary team to provide an individualized comprehensive resident assessment and care planning process in order to maximize and maintain every resident's functional potential and quality of life. The care plan is revised when appropriate to reflect the resident's current needs based on evaluation and episodic changes to include medication changes, physician order changes, behavior/mood state changes, accidents and/or incidents. Resident #2 was admitted to the facility with diagnoses including Hypertension and Bipolar Disorder. Minimum Data Set (a resident assessment tool) dated 09/27/2024 documented Resident #2 had a Brief Interview of Mental Status score of 13 out of 15, indicating intact cognition. A Comprehensive Care Plan for Risk for Abuse dated 09/20/2024, documented interventions to observe for changes in customary routines and encourage resident to voice concerns to staff regarding their peers. The care plan was not updated to reflect the alleged abuse incident on 11/10/2024. Record review reveals there were no new interventions implemented since 09/21/2024. The facility's Accident/Incident Report dated 11/11/2024 at 10:30 AM documented Resident #2 reported to the Social Worker that they were hit on the head and pushed to the ground by Certified Nursing Assistant #5 on the evening of 11/10/2024. Resident #2 was assessed and there were no redness or injuries noted. The facility conducted their investigation and determined abuse was inconclusive. During an interview on 04/07/2025 at 1:32 PM, Director of Nursing stated the admitting nurse, and the Minimum Data Set Coordinator are responsible for initiating the care plans and the unit manager are responsible for updating the care plans. They stated the Minimum Data Set Coordinator, Supervisors and disciplinary team ensures that the care plans are updated. During an interview on 04/21/2025 at 2:58 PM, Registered Nurse Supervisor #6 stated the abuse care plan was not updated because it was an oversight. 10 NYCRR 415.11(c)(1)

F689 SS=G Based on observation, interviews and record review conducted during an abbreviated survey (NY 261) from [DATE] to [DATE], the facility staff failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents. This was evident in 1 out of 5 residents sampled (Resident #1). Specifically, Resident #1 had a history of restless behavior with a previous fall on the floor in the facility. Resident #1 was not adequately supervised; Resident #1 was kept on the standard 2 hourly monitoring. As a result, on [DATE] at 05:38 AM, Resident #1 was observed on the floor at the bedside unresponsive and without pulse with the inner [CONDITION(S)] cannula dislodged and attached to the ventilator tubing. Facility staff last saw Resident #1 in bed 1 hour and 28 minutes prior to observing Resident #1 on the floor. Resident #1 subsequently was pronounced deceased on [DATE] at 6:28 AM. This resulted in actual harm that is not immediate jeopardy. The findings are: Review of the facility's policy and procedure entitled Accident/Incident, last revised in ,d+[DATE] documented: The purpose is to identify residents at risk for falls/injury and implement preventative measures to reduce resident's risk for injury; and to investigate the etiology of discoloration, skin breaks and injuries experienced by a resident. It is the policy of the facility to promote safety and security of all residents through Quality Management System. Incident/ Accident prevention and promotion of resident safety will be accomplished by In-service to all staff with focus on safety/prevention of accident/incident, the accident and incident investigation. Residents will be identified as high risk upon admission/ readmission and significant change documented on the Resident Care Plan and the Certified Nursing Assistant Accountability Record. Review of the facility's policy and procedure entitled Rounding, last reviewed on [DATE] documented: All residents on the unit and in the facility will be monitored every two hours, or more as needed by nursing staff. The purpose is to have accountability of all residents on the unit and in the facility. To ensure the safety of all residents always and identify potential problems. A staff member (CNA or licensed staff) will be assigned on a two-hour basis to complete the Resident Observation Report. Staff members will ensure that all residents are safe and harm free when monitoring resident's status. Review of the facility's policy and procedure entitled Behavioral Health Services, last reviewed on [DATE] documented: Each resident must receive, and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. If it is determined to be necessary, the social worker will schedule the resident for a special behavior care plan meeting. Resident #1 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)]-Ventilator Dependent, [CONDITION(S)] Accident (CVA), [CONDITION(S)], Anxiety Disorder, and History of [CONDITION(S)]. The Minimum Data Set (MDS, a resident assessment tool) dated [DATE] identified Resident #1 with short term and long-term memory problems and a severely impaired decision-making ability. Resident #1 required total assistance of 2 staff with most areas of Activities of Daily Living (ADL) needs. Review of the Risk for Fall or Injury related to Psychiatric Disorder and Incontinence Care Plan for Resident #1 was initiated on [DATE] and documented interventions that included anticipate resident's needs and maintain a safe environment with the bed in the lowest position. The Care Plan was updated on [DATE] to reflect a fall from the bed on [DATE], with transfer to hospital for evaluation. Review of the Behavioral Symptoms Actual Restlessness/ Agitation Care Plan for Resident #1 initiated [DATE] and updated on [DATE] documented interventions which included observe and redirect resident as needed, approach resident in a calm manner and Psychiatric Consult. Review of the Nursing Progress Note dated [DATE] at 3:01 AM, documented that at approximately 1:30 AM, Resident #1 was observed on the floor at the right side of bed with the ventilator attached. Resident #1 appeared agitated. No sign of respiratory distress. The Supervisor and Physician were informed. Resident #1 was transferred to hospital by ambulance at 02:35AM. Review of the Nursing Progress Note dated [DATE] at 3:05 PM documented that Resident #1 returned to the facility at 12:48 PM. Review of the Nursing Progress Note dated [DATE] at 8:31 PM documented that Resident #1 was noted throwing foot off bed and attempting to get out of bed. Bed at lowest position and floor mats at bedside. Physician informed, [MEDICATION(S)] (lorazepam) 1mg ordered stat. Review of the Physician order dated [DATE] at 8:44PM documented Lorazepam 1mg stat for Anxiety Disorder. Review of the Fall Risk Evaluation dated [DATE] documented a total score of 10 indicating that Resident #1 was in the high-risk category for falls. Review of the Psychiatry Consult Note dated [DATE] at 2:07 PM documented that Hospital records reflect [CONDITION(S)], Alcohol Withdrawal [CONDITION(S)], Cardiovascular accident, and remote Traumatic Brain Injury (TBI). Resident #1 had order for [MEDICATION(S)] 50 mg twice daily from hospital, noted to be restless. [MEDICATION(S)] intended to address restlessness but can drive self-endangering behavior. Resident nods and gestures. Continue present [MEDICATION(S)] for now. Can consider [MEDICATION(S)] Gradual Dose Reduction (GDR) in 2 weeks. Review of the Nursing Progress Note dated [DATE] at 1:57PM documented that Resident #1 was very restless. Resident #1 was on vent with prescribed settings and oxygen saturation was 97%. Review of the Resident Observation/ Every two hours Rounding Report from [DATE] to [DATE] documented: Resident #1 was last seen by staff on rounds on [DATE] at 4:08 AM. Review of the Nursing Progress Note dated [DATE] at 7:15AM documented that Resident #1 was last seen alert, awake and connected to the ventilator at 4:10 AM. Resident #1 was observed on the floor and disconnected from the ventilator at 5:38AM. Emergency Code E and cardiopulmonary resuscitation was initiated at 5:38 AM, the automated external defibrillator was placed but no shocks were advised. The Emergency Medical Services arrived and continued resuscitation at 5:54 AM. Resident #1 was pronounced deceased at 6:28 AM. Review of the Nursing Progress Note dated [DATE] at 7:44AM documented by Registered Nurse #1 stated that the writer was called at 5:38AM. Resident #1 was on floor, unresponsive with the ventilator disconnected, no ventilator alarm sounded. CPR started, Defibrillator used, Code E and 911 called. The Emergency Medical Services arrived at 5:54 AM and took over. The Resident pronounced deceased at 6:28AM by EMT. Review of the Facility's Investigative Summary dated [DATE] documented that Resident #1 was found lying prone on the floor of his room on [DATE] at 5:38AM. Resident #1 was disconnected from the ventilator however the inner cannula was still connected to the ventilator tubing. The unit RN assessed Resident #1, Cardiopulmonary Resuscitation (CPR) was initiated and Emergency Medical Services was called. The Fire Department of New York (FDNY) Emergency Medical Technician (EMT) arrived at 5:54AM and continued to resuscitate Resident #1 and later pronounced Resident #1 deceased at 6:28 AM. The resident had a known behavior of restlessness while in bed and placing himself on the floor as well as attempting to remove the [CONDITION(S)] tube during care. During an interview on [DATE] at 2:09PM, Certified Nursing Assistant #2 (CNA #2) stated that they were assigned to the ventilator side of the unit with CNA #1 on [DATE]. CNA #2 stated that they were not assigned to Resident #1, but they would check on Resident #1 while passing by because Resident #1 was restless and tried to get out of bed. CNA #2 stated that they checked Resident #1 when they passed by to answer a call-in nearby room around minutes to 4:00AM and observed Resident #1 sleeping in bed. CNA #2 further stated that shortly after 5:30 AM, they were going to provide care to another resident and saw Resident #1 on the floor from the hallway. CNA #2 added that they called CNA #1, RN #1, and the Respiratory Therapist. During an interview on [DATE] at 2:25PM, CNA #1 stated that they were assigned to Resident #1 on [DATE]. CNA #1 further stated that Resident #1 was restless at times and would attempt to get out of the bed at times. CNA #1 stated that they checked Resident #1 around 12:30AM-12:45 AM on [DATE], Resident #1 was asleep in bed. CNA #1 stated that they checked Resident #1's incontinence brief between 1:30AM-2:30 AM. Around 3:10 AM-3:20 AM, Resident #1 was in bed and semi-awake. CNA #1 also stated that they saw Resident #1 in bed asleep when they passed by around 4:10 AM. CNA #1 added that CNA #2 called them around 5:30AM when Resident #1 was on the floor on their stomach. Resident #1's ventilator tubing was disconnected from Resident #1 and on the bed. During an interview on [DATE] at 3:20PM, the unit 3PM-11PM Charge Nurse (RN #2) stated that Resident #1 had a call bell in place on the left side of the bed. Resident #1 was alert and capable of activating the call bell. Resident #1 was [CONDITION(S)] with the right hand functional. RN #2 stated Resident #1 was found on the left side of the bed and the bed was in the lowest position. RN #2 also stated that all residents on the vent unit were rounded every two hours. Residents with behaviors like agitation were rounded hourly. There was no response from RN #2 when asked whether Resident #1 should have been on hourly monitoring as Resident #1 was agitated. During an interview on [DATE] at 9:25 AM, Registered Nurse #1(RN #1) stated that they were the charge nurse on the 11:00PM-7:00AM shift when Resident #1 was observed on the floor on [DATE]. RN #1 stated that at 11:30PM, they observed Resident #1 in bed with the eyes opened and connected to the ventilator. RN #1 stated that they observed Resident #1 in bed still awake in bed at 1:00 AM and later at 3:00 AM, Resident #1 was lying calmly in bed and appeared to be sleeping. RN #1 stated that Resident #1 was able to turn and position self in bed. RN #1 stated that Resident #1 had 2 upper side rails and floor mats at bedside. RN #1 stated that while in another resident's room, they were called to Resident #1 at around 5:38AM. Resident #1 was observed lying on the floor on their stomach at the door side of the bed. RN #1 observed that Resident #1 was disconnected from the ventilator. RN #1 assessed the resident, there was no pulse or bleeding. The staff transferred Resident #1 back to bed, RN #1 started chest compressions and Respiratory Therapist #1 (RT #1) managed the airway. The Nursing Supervisor called Emergency Medical Services. The automated external defibrillator was applied but no shocks were advised. The Emergency Medical Services arrived within minutes and continued to perform cardiopulmonary resuscitation. Resident #1 was pronounced deceased by Emergency Medical Services During an interview on [DATE] at 9:50 AM, Registered Nurse Supervisor #1(RNS #1) stated that they were aware that Resident #1 had periods of restlessness, moving self, and pushing self from the bed. The facility implemented the ultra-low bed in the lowest position, floor mats and 2 upper side rails. RNS #1 stated that they were called to the unit at 5:38AM and arrived on the unit around 5:39 AM. RN #1 and the RT started CPR. Resident #1's inner cannula was out; the RT placed the inner cannula back in. They called Code E and 911. FDNY EMS worked on Resident #1 for a while before pronouncing Resident #1 deceased . During an interview on [DATE] at 5:05 PM, the Director of Nursing (DON) stated that they were familiar with Resident #1's care since Resident #1 had restless behavior and a previous fall on [DATE]. The DON stated that changes were made to Resident #1's care on [DATE]. The changes were to increase the [CONDITION(S)] medications, place floor mats at bedside and place the bed in the lowest position. The DON stated that Resident #1 was on two hourly monitoring and the monitoring frequency was not increased. The residents on the ventilator unit were on the standard two hourly monitoring. The DON stated that the facility sent the ventilator to the company for evaluation. The facility concluded that there was no violation in Resident #1's care plan. The DON stated that since the incident with Resident #1, the frequency of the monitoring of all the residents in the vent unit was changed to every 30 minutes. 415.12 (h) (1) (2)