Every finding on record at Rosewood Rehabilitation and Nursing Center

Based on record review and interviews during a survey, the facility failed to ensure residents were afforded the right to formulate advanced directives including having a physician's order related to their code status (the level of medical interventions a person wishes to have started if their breathing stopped such as cardiopulmonary resuscitation or do not resuscitate), and establishing mechanisms for documentation and communicating the residents' choices to the staff responsible for their care, which had the likelihood to result in serious harm or death for nine (9) (Residents #6, 7, 8, 9, 10, 11, 12, 13, and 14) of 53 residents reviewed for advanced directives. Specifically, (a.) for Resident #'s 6, 7, 9, 10, 11, 12, and 13, there was no documented evidence of a physician's order related to the residents' code status or advanced directive; (b.) for Resident #'s 7, 9, 10, 11, and 12, there was no documented evidence of Medical Orders for Life Sustaining Treatment; and (c) for Resident #14, there was conflicting documented evidence of code status. This resulted in Immediate Jeopardy and Substandard Quality of Care to Resident #'s 6, 7, 8, 9, 10, 11, 12, 13, and 14. This is evidenced by: The policy titled Emergency Procedure Code Blue Cardiopulmonary Resuscitation, revised 01/23/2025, documented Advanced Directives are provided on admission. Before cardiopulmonary resuscitation was initiated the resident's wish for code status would be established through a code status identifier. The residents' electronic medical records would have a written Medical Doctor order and physical Medical Orders for Life-Sustaining Treatment status form. The undated Advanced Directive Policy documented upon admission and as required thereafter, residents or their legal representatives will be informed of their rights regarding advance directives. Upon admission, the facility will inquire as to whether the resident has an existing advanced directive and will document the resident's status in the medical record. Facility staff will follow advanced directives and related medical orders. Resident #6Resident #6 was admitted to the facility with diagnoses of wedge compression fracture of T11-T12 vertebra (a collapse of the vertebra), other forms of acute ischemic heart disease (occurs when plaque buildup narrows the heart's arteries, restricting blood flow and oxygen to the heart muscle), and hypertensive heart disease without heart failure (chronic high blood pressure where the heart adapts to increased workload). The Minimum Data Set (a resident assessment tool) dated 12/30/2025 documented they could understand, be understood, and were cognitively intact. Record review revealed no documented evidence of a physician order for basic life support interventions related to the resident's code status and advance directives. The Nursing Progress Note dated 01/11/2026 at 2:31 PM written by Licensed Practical Nurse #3, documented Resident #6 was unresponsive. They attempted to obtain vital signs and oxygen saturation level was 83% (normal is 95-100%). Oxygen was administered via nasal cannula at two (2) liters and oxygen saturation level dropped to 69%. Unable to obtain blood pressure. 911 was called at approximately 1:21 PM. Cardiopulmonary resuscitation was initiated by Licensed Practical Nurse #3 and #4 at 1:23 PM, until Emergency Medical Services arrived at 1:38 PM and took over Cardiopulmonary Resuscitation. A heart rhythm was obtained by Emergency Medical Services and stated they were transporting the resident to the hospital at approximately 1:56 PM. The Physician Progress Note dated 01/12/2026 at 10:44 AM written by Nurse Practitioner #1, documented they received an urgent phone call from nursing staff regarding Resident #6 who was found unresponsive. Nursing reported an inability to obtain blood pressure and no palpable pulses. No Medical Orders for Life Sustaining Treatment form or advance directive limiting resuscitation was on file at the time of the event. Nursing was immediately instructed to initiate cardiopulmonary resuscitation and treat the patient as a full code. Emergency Medical Services were activated and 911 was called. The Nursing Progress Note dated 01/12/2026 at 1:10 AM written by Licensed Practical Nurse #4, documented they called the hospital emergency department at 1:05 AM to obtain an update on Resident #6 and was informed the resident expired. During an interview on 02/03/2026 at 2:02 PM, Licensed Practical Nurse #3 stated that on 01/11/2026, Resident #6 was unresponsive, at one point had no pulse and cardiopulmonary resuscitation was started. They were unable to identify the resident's code status. Prior to the start of cardiopulmonary resuscitation, the nurse needed to know the resident's code status. The code status was checked by looking in the Medical Orders for Life Sustaining Treatment binder and in the electronic medical record. If they could not find the code status in the Medical Orders for Life Sustaining Treatment binder or electronic medical record, they treated the resident as though they were a Full Code (perform cardiopulmonary resuscitation). They were not aware of a facility policy for a resident's code status and said it was something that they were taught. The admission nurse was responsible for asking the resident what their advance directive and code status was and for completing the Medical Orders for Life Sustaining Treatment form. They stated the nurse manager was responsible for entering the resident's code status in the electronic medical record and for putting the Medical Orders for Life Sustaining Treatment form in the binder. They further stated there was a gap of time when they had no nurse manager. They did not recall calling Nurse Practitioner #1 about the resident's code status. During an interview on 02/03/2026 at 2:18 PM, Licensed Practical Nurse #4 stated they were asked to help with Resident #6 before the resident had no pulse. They checked the Medical Orders for Life Sustaining Treatment form book and there was no form for the resident. They had Licensed Practical Nurse #3 verify and they did not find a Medical Orders for Life Sustaining Treatment for the resident. Licensed Practical Nurse #4 called 911 and checked the electronic medical record and there was no code status. They stated it was unusual for a resident to have no code status in the electronic medical record. A staff member (unnamed) told them to do cardiopulmonary resuscitation because there was no other directive in place. Cardiopulmonary resuscitation was started once there was no pulse found. During an interview on 02/03/2026 at 2:45 PM, Nurse Practitioner #1 stated they were called on 01/11/2026 about Resident #6 by either Licensed Practical Nurse #3 or #4, that Resident #6 was unresponsive, and the nurse needed to know their code status because there was no Medical Orders for Life Sustaining Treatment form in the binder. They stated they knew the resident's code status was full code (cardiopulmonary resuscitation) because a Medical Orders for Life Sustaining Treatment form was completed at the time of admission and verified by Nurse Practitioner #1. The form was not in the binder on 01/11/2026 and was still missing. Nurse Practitioner #1 stated they completed the resident's admission physical examination on 12/29/2025 and did not document the resident's code status because it was not on the resident's profile in the electronic medical record. The nurse manager on the unit was responsible for putting the verified Medical Orders for Life Sustaining Treatment in the binder and then adding the code status to the resident's profile and a physician order for the code status in the electronic medical record. They stated they did not have the time to ensure the residents' code status was entered into the electronic medical record because they had residents to attend to and it was the nurse manager's responsibility to ensure it was done. It was the facility policy to treat the resident as though they wanted cardiopulmonary resuscitation if there was no advance directive or code status in place. Resident #7Resident #7 was admitted to the facility with acute and chronic respiratory failure with hypoxia (a critical condition where the lungs cannot transfer enough oxygen into the blood), chronic obstructive pulmonary disease with acute respiratory infection (a progressive, irreversible lung disease causing, obstruction, inflammation, and chronic airflow blockage), and idiopathic nonspecific interstitial pneumonitis (a group of noninfectious, chronic, or acute lung disease of unknown cause characterized by inflammation and fibrosis (scarring) in the lung tissue). The Minimum Data Set, dated [DATE], documented they could be understood, understood others, and was cognitively intact. During first floor rehabilitation unit observation on 02/02/2026 at 10:30 AM, there were no Medical Orders for Life-Sustaining Treatment forms present on the unit for Resident #7. Record review revealed no documented evidence of a physician order for basic life support interventions related to the resident's code status and advance directives. admission provider assessments dated 01/27/2025 by Nurse Practitioner #1 did not have documented evidence of code status. During an interview on 02/02/2026 at 2:30 PM, Resident #7 stated they did not receive any admission paperwork; however, they could not sign anything because they were blind and anything that required a signature would be deferred to Family Member #1. They stated they wanted to be listed as full code. Family Member #1 was present during the time of interview and stated no admission paperwork was completed and no advanced directive done. Resident #8Resident #8 was admitted to the facility with encephalopathy (a group of conditions that cause brain dysfunction), acute respiratory failure with hypoxia, pneumonitis due to inhalation of food and vomit (a condition characterized by inflammation of the lungs which can happen when food or vomit enter the airways). The Minimum Data Set, dated [DATE], documented they could be understood, understood by others, and was cognitively intact. Record review revealed no documented evidence of a physician order for basic life support interventions related to the resident's code status and advance directives. admission provider assessments dated 01/29/2025 by Nurse Practitioner #1 did not have documented evidence of code status. During an interview on 02/02/2026 at 2:46 PM, Resident #8 stated they arrived at the facility a week ago. They stated they had not signed any admission paperwork and was unsure what advanced directives were. After learning what advanced directives and code status were, they stated they would like to be listed as Do Not Resuscitate. Resident #9Resident #9 was admitted to the facility with acute respiratory failure with hypoxia, pneumonia due to coronavirus disease 2019 (lung infection due to coronavirus disease 2019 also known as COVID-19), and acute pulmonary edema (a condition where there is a too much fluid in the lungs). The Minimum Data Set, dated [DATE], documented they could be understood, understood by others and was cognitively intact. During first floor rehabilitation unit observation on 02/02/2026 at 10:30 AM, there were no Medical Orders for Life-Sustaining Treatment forms present on the unit for Resident #9. Record review revealed no documented evidence of a physician order for basic life support interventions related to the resident's code status and advance directives for Resident #9. admission provider assessments dated 01/30/2025 written by Nurse Practitioner #1 did not have documented evidence of code status.During an interview on 02/02/2026 at 2:52 PM, Resident #9 stated they did not recall signing admission paperwork. They stated they did not know what advanced directives were. After learning what advanced directives and code status and resident stated they would like to be listed as full code. Resident #14Resident #14 was admitted to the facility with diagnoses of traumatic ischemia of muscle (occurs when there is a decrease in the blood supply to a muscle due to a traumatic injury), dehydration (loss of water and salts essential to body function), and muscle weakness (generalized). The Minimum Data Set, dated [DATE], documented they could be understood and understood by others with mild cognitive impairment. Record review of Medical Orders for Life Sustaining Treatment form dated 01/22/2026, documented the resident was to have cardiopulmonary resuscitation. Nurse Practitioner #1 signed the form on 01/27/2026. Record review of physician orders for Resident #14 documented: A physician order entered by Registered Nurse #1 on 01/22/2026 for Do Not Resuscitate/Do Not Intubate (insert a breathing tube). The order was signed by Nurse Practitioner #1 on 01/23/2026. On 01/27/2026, Licensed Practical Nurse #7 entered an order for code status full code and was signed by Nurse Practitioner #1 on 01/28/2026, while the Do Not Resuscitate/Do Not Intubate order dated 01/22/2026 was still active. On 02/04/2026, the order for Do Not Resuscitate/Do Not Intubate was discontinued by Licensed Practical Nurse #7 and an order for cardiopulmonary resuscitation was entered. During an interview on 02/03/2026 at 2:45 PM, Nurse Practitioner #1 stated they had conflicting information for Resident #14, which could be bad. Residents had individual charts which recently were removed from the units and now just have a Medical Orders for Life Sustaining Treatment binder on each unit. They stated there was no oversight, and no nursing oversight. They stated the process is for staff to first go to the electronic medical records to check code status because nursing had computers open and easy access to resident orders. Nurse Practitioner #1 reviewed Resident #14's Medical Orders for Life Sustaining Treatment and they stated the orders must have been entered incorrectly. During an interview on 02/04/2026 at 10:41 AM, Licensed Practical Nurse #7 stated they were asked by someone to add the code status to the top of resident's records in electronic medical records where it was shown earlier that same day. They stated they were not sure who asked them to do so, they were passing medications at that time. They stated they saw conflicting information in the electronic medical record for Resident #14. Licensed Practical Nurse #7 stated they put Do Not Resuscitate/Do Not Intubate into electronic medical record at 10:31 AM on 02/04/26. They stated they were going to look at Resident #14's information more after their break. They stated the Medical Orders for Life Sustaining Treatment forms were done or should be done with the admission assessments. They stated if the hospital discharge summary stated Do Not Resuscitate then they will sometimes add that to the resident's chart upon admission. During an interview on 02/04/2026 at 11:01 AM, Family Member #2 stated that the Director of Nursing (unnamed) did the Medical Orders for Life Sustaining Treatment form with them. They talked with Resident #14 about what they wanted, and they signed for them because resident could not. Resident #14 made the decision to be Full Code. They only had a conversation about code status one time. Additional Interviews: During an interview on 02/03/2026 at 12:58 PM, Licensed Practical Nurse #6 stated if they found a resident unresponsive; they would call for help, check the resident's pulse, and start sternal rub. They stated code status was in the electronic medical record, but they would assign looking up code status to appropriate staff responding to code. During an interview on 02/03/2026 at 11:45 AM, Licensed Practical Nurse #4 stated if they saw an unresponsive resident, they would first check the Medical Orders for Life Sustaining Treatment on the unit. If it was not in the binder, the resident would be full code. Code information and Medical Orders for Life Sustaining Treatment should also be the same in the electronic medical records and the physical form. They stated the electronic medical records sometimes did not match the Medical Orders for Life Sustaining Treatment. They stated the Medical Orders for Life Sustaining Treatment were most accurate because they were signed by the provider. If code status for the resident was not present in the electronic medical records or the Medical Orders for Life Sustaining Treatment orders were not present on the unit, the resident would be considered a Full code. They were unsure if there was a policy for advanced directives or code status. They stated there were no annual in-services on policy updates. During a subsequent interview on 02/03/2026 at 2:45 PM, Nurse Practitioner #1 stated they signed the code status orders electronically, trusting that it was entered correctly into the electronic medical record when they signed the orders. During an interview on 02/04/2026 at 1:20 PM, Medical Director #1 stated the facility had a lot of staff turnover. They stated this was an issue in 2025, which had been addressed at that time. Medical Director #1 stated with staff leaving and new staff starting, it appeared to be a problem again. They further stated going forward they would make sure this would not happen again. During an interview 02/04/2026 at 2:07 PM, Administrator #1 stated the facility policy is to treat residents as full code when no advanced directive is in place. Administrator #1 stated that code status orders were matched to the Medical Orders for Life-Sustaining Treatment form when orders are entered into the electronic medical record. Moving forward, they would have a discussion with the Nurse Practitioner regarding the signing of orders without proper verification. Administrator #1 stated a registered nurse who began this role last week, was hired for admissions including admission assessments, initiating care plan, and Medical Orders for Life Sustaining Treatment form. Administrator #1also stated that additional registered nurses were available to provide coverage when the admissions registered nurse is off duty. Immediate Jeopardy was issued to the Assistant Administrator on 02/05/2026 at 5:15 PM. Facility Immediacy Removal Plan submitted on 02/05/2026 at 8:50 PM was approved. Immediate Jeopardy was lifted effective 02/06/2026 at 2:42 PM. The facility's immediacy removal actions included the following: On 02/05/2026 the admission Nurse was educated by the Administrator on their responsibilities to educate all residents/representees on admission/re-admission of their right to formulate advanced directives and ensuring a corresponding physician's order or code status and/or a Medical Order for Life sustaining Treatment form are entered into the resident's medical record.On 02/02/2026 and 02/03/2026, a facility-wide audit of each current resident was conducted by the facility management team to ensure that residents had physician orders for code statue and/or a Medical Order for Life Sustaining Treatment.All Residents without a Medical Order for Life Sustaining Treatment had advanced directives discussed with them or their representee by nursing staff.Corresponding Medical Order for Life Sustaining Treatment forms and physician's orders for advanced directives were entered into the electronic medical record by the unit manager and approved by the Nurse Practitioner. On 02/02/2026, the Administrator and Assistant Administrator reviewed the facility policy and Advanced Directives, and no revisions were made.On 02/05/2026, the facility initiated mandatory education to the Nurse Practitioner, all registered nurses, and a licensed practical nurse on the facility policy relating to educating all residents/representees on admission of their right to formulate advanced directives and ensuring a corresponding physician's order or code status and/or a Medical Order for Life sustaining Treatment form are entered into the resident's medical record.Education would be conducted verbally, either in person or by telephone, by the Nursing Supervisor and/or designee. Education was started on 02/05/2026 and 90% of facility staff would be educated by 02/05/2026 at 11:00 PM.Facility staff that had not been reached by telephone would not be permitted to work until they received the education.As of 02/06/2026, 95% of facility staff were educated. As of 02/06/2026, all current residents (77) had a corresponding physician's order or code status and/or a Medical Order for Life sustaining Treatment form entered into their medical record. 10 New York Codes, Rules, and Regulations 415.12(h)(1)(2)

Based on observation, record review, and interviews during a survey ), the facility failed to ensure the resident environment remained as free of accident hazards as is possible for two (2) (Resident #s 2 and 3) of three (3) residents reviewed. Specifically, on 01/29/2026 at 12:13 PM, Resident #2, who had severe cognitive impairment, had three (3) prescription medications (Sertraline HCl 50 milligram (antidepressant), Eliquis five (5) milligram (blood thinner), and Levetiracetam 500 milligram (antiseizure) in prescription medication bottles inside a plastic bag on their nightstand. Additionally, on 01/29/2026 at 12:01 PM, the front cover of Resident #3's electric baseboard heater in their bathroom was removed and laying on the floor in front of the running heater. This resulted in Immediate Jeopardy and Substandard Quality of Care for Resident #s 2 and 3, and placed all residents at risk for serious injury, serious harm, serious impairment, or death.This is evidenced by:The policy and procedure titled, Accidents and Supervision, documented the resident environment would remain as free of accident hazards as possible. Resident #2 was admitted to the facility with diagnoses of recurrent moderate major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), atrial fibrillation (an irregular heart rhythm that can lead to blood clots), and seizures (sudden burst of electrical activity in the brain that causes changes in awareness and muscle control). The Minimum Data Set (an assessment tool) dated 12/20/2025, documented that the resident had severe cognitive impairment. The resident usually made themselves understood (had difficulty communicating some words or finishing thoughts but was able if prompted or given time) and usually understand others (missed some part/intent of the message but comprehended most conversation).The undated policy and procedure titled, Administering Medications, documented medications were never left at the bedside. Medications brought in with a resident would be returned to the family/Health Care Proxy. Medications would be reordered and filled by the facility/vendor pharmacy. Review of the Medication Administration Record dated January 2026 documented Resident #2 had a physician order and received: sertraline HCl 50 milligrams, give one (1) tablet by mouth in the morning for depression. apixaban (Eliquis) five (5) milligrams, give one (1) tablet by mouth every morning and at bedtime for atrial fibrillation. levetiracetam Extended Release 24 Hour tablet 500 mg, give two (2) tablets by mouth in the morning for seizures.During an observation on 01/29/2026 at 12:13 PM, Resident #2 was asleep in bed. There was a clear plastic bag on their nightstand that contained prescription medication bottles for Sertraline 50 milligrams, Eliquis (Apixaban) five (5) milligrams, and Levetiracetam 500 milligrams. Each of the prescription medication bottles was labeled with the resident's name and contained medication.During an interview on 01/29/2026 at 1:30 PM, Certified Nurse Aide #2 stated that if medications were observed at the bedside, they would remove them and report them to the nurse.During an interview on 01/29/2026 at 1:33 PM, Licensed Practical Nurse #1 stated medications from home were locked in the medication cart and then the family would either take them home or they would be destroyed. The surveyor then brought Licensed Practical Nurse #1 to Resident #2's room and showed them the medications that were on the nightstand. Licensed Practical Nurse #1 looked at the prescription medication bottles and stated they were filled on 03/31/2025, 04/05/2025, and 09/02/2025. Licensed Practical Nurse #1 removed the medications from the room. During an interview on 01/29/2026 at 2:20 PM, Licensed Practical Nurse #2 stated they were not aware Resident #2 had medications on the nightstand and stated staff should have seen them and removed them. They stated Resident #2 was cognitively impaired and was unable to self-administer medications.During an interview on 01/29/2026 at 3:34 PM, Acting Director of Nursing/Acting Assistant Director of Nursing #1 stated the medications found at Resident #2's bedside could have caused serious harm if taken by another resident. All three (3) were lethal medications, and could have caused serious harm, depending on what was taken and how much was taken. They further stated medications brought in at the time of admission were typically brought home or destroyed. During an interview on 02/05/2026 at 1:21 PM, Family Member #3 stated they visited Resident #2 in the facility three (3) times per week. They stated a bag that contained the resident's medications was handed to them at the hospital and they were told by the Emergency Medical Technician to bring them home. When the resident was admitted to the facility, Family Member #3 gave the bag with the medications to an unnamed nurse on the first floor. The nurse told them they did not need the medications; they would be ordered at the facility and told them to put the medications in the bedside table. On 02/03/2026, staff on the second floor gave them the medications and told them to take them home because they were not supposed to be in the facility. During an interview on 02/03/2026 at 10:23 AM, Nurse Practitioner #1 stated that if a resident's medications were left in their room unattended, the resident's roommate could potentially access the medications, which could result in a medication error and increased medication risk in the facility.During an interview on 02/03/2026 at 11:40 AM, Assistant Administrator #1 stated Resident #2 did not have assessments supporting self-administration of medications. The facility recognized the need for heightened safety awareness, as residents may require additional guidance due to cognitive limitations. They stated Resident #2's unit housed long-term care residents with varying levels of cognition. Residents' roommates may have varying degrees of confusion or cognitive impairment.During an interview on 02/03/2026 at 12:53 PM, Medical Director #1 stated all medications were under the control of nursing staff. Nurses should not leave medications at the bedside and were expected to remain with the resident until all medications had been administered and taken by the resident. Upon admission to the facility, the facility should be made aware of all medications the resident was taking at home. For residents transferred from the hospital, this information was obtained through hospital discharge records. All prescribed medications were to be administered by nursing staff while the resident resided in the facility. Medical Director #1 stated they were not aware of every single issue in the facility. If medications were left at bedside, it was a nursing issue that nursing should be taking care of. Medical Director #1 stated that if a resident had medications in the room or there was concern another resident might have accessed them, Nurse Practitioner #1 was notified first or the on-call provider after hours. Resident #3 was admitted to the facility with diagnoses of ataxia (poor muscle control that causes clumsy movements and can affect walking and balance), history of falling, and spinal stenosis (narrowing of the spinal canal which results in pressure on the nerves and pain). The Minimum Data Set, dated [DATE], documented the resident was cognitively intact. The resident was able to make themselves understood and understand others. The resident used a wheelchair for mobility.During an observation on 01/29/2026 at 12:01 PM, Resident #3's bathroom door was open, and a small electric baseboard heater was visualized with the front cover removed and laying on the floor in front of the heater. The heater was producing heat along with a burning smell. Surveyor placed their hand close to the exposed heating elements, and they were hot enough to cause injury if the heating elements came in direct contact with skin or clothing. During an interview on 01/29/2026 at 1:41 PM, Certified Nurse Aide #1 was shown the heater in Resident #3's bathroom. They stated that on 01/28/2026, they saw the cover from the electric heater on the floor and stated they should have reported it to the Maintenance Department at that time but did not and they did not report it today.During an interview 01/29/2026 at 2:10 PM, Director of Maintenance #1 stated Acting Director of Nursing/Acting Assistant Director of Nursing #1 told them about the heater in Resident #3's bathroom and they put the cover back on. During an interview on 01/29/2026 at 2:20 PM, Licensed Practical Nurse #2 stated the bathroom heater in Resident #3's room was hot, and the cover was placed back on. Staff should have reported the missing cover immediately.The Immediate Jeopardy was lifted effective 02/09/2026. The facility's immediacy removal actions included the following: During an interview on 01/29/2026 at 3:34 PM, Acting Director of Nursing/Acting Assistant Director of Nursing #1 stated Resident #2's medications that the surveyor observed were 'home medications,' and were removed from their room and secured. Nurse Practitioner #1 was notified, and the family was to be notified according to facility process.During an interview on 02/03/2026 at 11:40 AM, Assistant Administrator #1 stated education had since been provided to all staff on medication administration and was currently ongoing until all staff are educated. Assistant Administrator #1 stated staff rounds occurred during care delivery, activities, therapy, and routine safety checks multiple times a day. Staff education was ongoing, including a full-house in-service, to reinforce medication safety, admission procedures, and environmental monitoring.During a subsequent interview on 02/03/2026 at 12:10 PM, Assistant Administrator #1 stated they notified Administrator #1 regarding the prescription medications left at Resident #2's bedside. Nurse Practitioner #1 was notified and determined that the medication was brought into the facility by the resident's family following a hospital discharge.On 01/29/2026, a facility-wide audit of each resident room, including drawers and cabinets, was conducted by the facility management team to ensure that no other residents had medications in their rooms. There were no findings of any medications in resident rooms during the audit.A second facility-wide audit of each resident room, including drawers and cabinets, was initiated on 02/06/2026 at 2:58 PM and completed on 02/06/2026 at approximately 4:00 PM. There were no findings of any medications in resident rooms during this audit.On 01/30/2026, Administrator #1 and Assistant Administrator #1 reviewed the facility policy, Administering Medications, and no revisions were made.On 02/03/2026, medications from Resident #2's room were given back to Family Member #3 to take home and destroy.On 02/03/2026, the facility initiated mandatory education to all staff and re-educated that residents were not to have medications in their room and if any medications were found they were to immediately be given to a nurse.Education would be conducted verbally, either in person or over the telephone by the Nursing Supervisor and/or designee.Education was started on 02/03/2026 and 90% of facility staff would be educated by 02/06/2026 at 11:00 PM.Facility staff that had not been reached by telephone would not be permitted to work until they received the education.On 02/03/2026, Director of Maintenance #1 replaced the cover on the baseboard heater in Resident #3's bathroom.On 02/03/2026, Director of Maintenance #1 conducted an audit of the electric baseboard heaters in the facility, ensuring they had covers in place.On 02/06/2026, Assistant Administrator #1 and Director of Maintenance #1 reviewed the facility Work Request Policy, and no revisions were made.On 02/06/2026, the facility initiated mandatory education to all staff regarding the process for reporting damaged, broken and/or malfunctioning equipment.Education would be conducted verbally, either in person or by telephone by the Nursing Supervisor and/or designee. Education was started on 02/06/2026 and 90% of facility staff would be educated by 02/06/2026 at 11:00 PM.Facility staff that had not been reached by telephone would not be permitted to work until they received the education.As of 02/09/2026, 93% of facility staff were educated. 10 New York Codes, Rules and Regulations 415.12(h)(1)

Based on observation, record review, and interviews conducted during a survey, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for five (5) (Resident #'s 1, 23, 24, 85, and 87) of 22 residents reviewed. Specifically,(a.) Resident #1 was hospitalized three (3) times between 11/11/2025 and 02/17/2026 related to bowel constipation. Provider instructions for bowel regimen and assessment were not followed by the facility. As a result, Resident #1 required fecal disimpaction under general anesthesia.(b.) Resident #85 had symptoms of urinary tract infection identified on 09/19/2025. The provider ordered a urinalysis (urine test) six (6) days later on 09/25/2025. The resident was diagnosed with septic shock secondary to urinary tract infection (a life-threatening, critical condition where an untreated urinary tract infection enters the bloodstream and leads to sepsis and septic shock with symptoms that include change in mental status, very low blood pressure, and decreased urine output).(c.) Resident #87 complained of a fall on 1/13/2026 on the evening shift and was not documented as assessed by a nurse. Subsequently, Resident #87 complained to their family member about the fall and was sent back to the hospital within the first 24 hours of admission.(d.) For Resident #24, the facility did not ensure administration of as needed bowel medications in November 2025 and did not notify the provider; and(e.) For Resident #23, the facility did not ensure administration of as needed bowel medications in December 2025 and January 2026.This resulted in actual harm and Substandard Quality of Care for Resident #'s 1 and 85 that was not Immediate Jeopardy. This is evidenced by:Bowel Management Policy, revised/updated July 2020, documented it was the facility's policy to provide the tools, people, and systems to ensure the bowel function of all residents was monitored and managed as indicated on an individual basis to promote regularity. Residents who demonstrated a risk for constipation would have an individualized care plan.A. Resident #1Resident #1 was admitted to the facility with diagnoses of noninfective gastroenteritis (inflammation that spreads from the stomach into the intestines and cause, pain, vomiting, and diarrhea), colitis (inflammation of the large intestine), chronic idiopathic constipation (functional bowel disorder characterized by difficult, infrequent and/or incomplete defecation), and slow transit constipation (slow movement of waste through the digestive system). The Minimum Data Set (a resident assessment tool) dated 12/31/2025, documented the resident had moderate cognitive impairment. The resident was able to make themselves understood and understand others.Care Plan for At Risk for Constipation related to impaired mobility and history of large bowel obstruction, revised 10/14/2025, documented the goal that Resident #1 would pass soft, formed stool at a frequency perceived as normal for the resident. Interventions included following facility bowel protocol for bowel management, observe medications for side effects of constipation, and notify provider of any problems.Review of physician orders and the Medication Administration Record for Resident #1 revealed the resident received the following routine medications to manage their diagnosis of constipation: Linaclotide Oral Capsule 145 micrograms once daily; Senna S Oral Tablet 8.6-50 milligrams at bedtime; Lactulose Solution 10 grams/15 milliliters, 30 milliliters twice daily.Review of physician orders for as needed bowel medications revealed Resident #1 was to receive: Milk of Magnesia 30 milliliters by mouth every 24 hours as needed for constipation if no bowel movement after two (2) days; Bisacodyl Suppository insert one (1) suppository rectally every 24 hours as needed for constipation if no bowel movement 24 hours after Milk of Magnesia; Fleet Enema insert one (1) application rectally every 24 hours as needed for constipation if no bowel movement fours (4) hours after Bisacodyl Suppository.Hospitalist Discharge summary, dated [DATE], documented Resident #1 returned from the hospital on [DATE] after being treated for severe constipation.Encounter Progress Note dated 11/13/2025 at 00:00 by Nurse Practitioner #1, documented Resident #1 was evaluated on 11/13/2025 following return from the Emergency Department with diagnosis of large stool burden. Bowel regimen and comfort focused management was to be continued as previously ordered. Nursing was to closely monitor bowel movements, abdominal distention, nausea, vomiting, and overall comfort. Continue routine assessment and family communication as clinically indicated. Plan of care updated accordingly.As of 11/13/2025 when Nurse Practitioner #1 charted, there was no documented evidence updates were made to the Care Plan for At Risk for Constipation since 10/14/2025.Review of the Follow Up Question Report (bowel movements documented each shift by the certified nurse aide), Medication Administration Record, and Nursing Progress Notes for Resident #1 dated December 2025 and January 2026 did not have documented evidence of routine assessments when there was no bowel movement, administration of as needed bowel medications per physician orders and facility policy, or reporting of bowel status to the provider.Review of Nursing Progress Notes dated 12/01/2025 to 01/08/2026 revealed no documented evidence of abdominal assessments by nursing staff.Encounter Progress Note dated 01/09/2026 at 00:00 by Nurse Practitioner #1, documented Resident #1 was re-evaluated on 01/09/2026 due to worsening gastrointestinal symptoms. Nursing reported increased episodes of vomiting with progressive abdominal distention. Upon examination, abdomen was markedly distended and firm with diffuse tenderness (pain or sensitivity is spread across a wide arear rather that being in one specific spot) to palpation. Bowel sounds were diminished. Given the worsening emesis (vomiting) and abdominal distention with concern for recurrent fecal impaction or evolving obstruction, further evaluation was required. The family was notified of the change in condition and agreed with hospital transfer.Hospital History and Physical dated 01/09/2026, documented a chief complaint of constipation, abdominal pain, bloating, and nausea. The resident was admitted with severe sepsis (the body responds improperly to an infection) and proctocolitis (inflammation of both the rectum and the lower colon). The resident had chronic idiopathic constipation Difficult, infrequent, and/or incomplete defecation) and was taking Linaclotide. The resident was supposed to take oral lactulose; however, they reported they refused it at the nursing home because they did not like the taste. It was uncertain how long the resident had refused the lactulose. Since being in the hospital, the resident had passed copious amounts of liquid stool.Physician order with start date of 11/13/2025 read for facility staff to observe that Resident #1 took all medications and notify of any refusals immediately. There was no documented evidence on the Medication Administration Records dated December 2025 and January 2026, that Resident #1 refused lactulose or that the physician was notified.The resident was discharged from the hospital on [DATE].Encounter readmission History and Physical Progress Note dated 01/20/2026 at 00:00 by Nurse Practitioner #1, documented that during hospitalization, Resident #1 was found to be septic secondary to proctocolitis in the setting of severe chronic constipation and intermittent nonadherence with their bowel regimen. Bowel regimen was adjusted with lactulose increased from twice daily to four (4) times daily in an effort to prevent recurrent constipation and colonic complications. The plan was for nursing to monitor bowel movements each shift and document stool frequency, consistency, and response to regimen. The provider was to be notified for no bowel movement greater than 24 hours, worsening abdominal distention, abdominal pain, nausea, vomiting, or decreased oral intake. Abdominal exam was to be monitored routinely. Emphasized importance of adherence with bowel regimen to nursing staff. The resident was to be followed closely during early readmission period due to high risk for recurrence given their chronic gastrointestinal disease history.There was no documented evidence of Nurse Practitioner #1's instructions for nursing staff on the Resident #1's care plan or in physician orders.Encounter Progress Note dated 01/23/2026 at 00:00 by Nurse Practitioner #1, documented the resident was seen on 01/23/2026 for follow-up after recent hospitalization for increased stool burden, which had been a chronic ongoing issue. Additional bowel protocol medications remained in place as ordered. Plan was to continue current bowel regimen with close monitoring of bowel movements and hydration status.Review of the Follow Up Question Report (bowel movements documented each shift by the Certified Nurse Aide), Medication Administration Record, and Nursing Progress Notes for Resident #1 dated January 2026 documented no bowel movements on 01/19/2026, 01/20/2026, 01/21/2026, and 01/22/2026. In January 2026, there was no documented evidence of notification to the provider when Resident #1 had no bowel movement in greater than 24 hours including but not limited to 01/24-26/2026; 01/29-30/2026; 02/10-11/2026.Nursing Progress Note dated 01/23/2026 at 6:11 AM by Licensed Practical Nurse #5, documented they placed Resident #1 on the bowel list because per documentation, it had been three (3) days since their last bowel movement. During morning rounds of 01/23/2026, the resident had an extra-large bowel movement. No further interventions were required.Review of Nursing Progress Notes dated 01/24/2026 to 02/16/2026 revealed no documented evidence of notes about the status of the resident's bowel movements, no abdominal assessments, and no notification to the provider when the resident went over 24 hours with no bowel movement.Nursing Progress Note dated 02/17/2026 at 5:30 PM by Director of Nursing #1, documented they were called to assess Resident #1, as they had a distended abdomen. Resident #1 had a distended abdomen, mild bowel sounds in all four (4) quadrants, and on palpation expressed pain with deep palpation in the lower left quadrant. Resident #1 was sent to the hospital.Hospital Discharge summary dated [DATE] documented the reason for admission and discharge diagnosis was fecal impaction. Hospital Course documented the resident presented to the Emergency Department with abdominal pain and distention. Was found to have severe stercoral colitis (a rare, severe, and potentially fatal inflammatory condition of the colon caused by extreme, chronic constipation) on Computed Tomography (computerized x-ray imaging procedure). Was unable to undergo manual disimpaction and required general anesthesia in addition to flex sigmoidoscopy (a flexible tube with a camera attached used to examine the lower large intestine) for disimpaction. During the procedure the resident was found to have severe fecal impaction.During an interview on 02/24/2026 at 2:08 PM, Certified Nurse Aide #9 stated they documented bowel movements in the electronic medical record under toileting. They reported to the nurse when a resident did not have a bowel movement in three (3) days. The nurse would then give Milk of Magnesia or another bowel medication. They stated some residents were on laxatives daily and usually had a bowel movement the next day. They stated they were familiar with Resident #1, who used to have a lot of bowel movements; licensed practical nurses had a list of residents who did not have bowel movements.During an interview on 02/24/2026 at 2:25 PM, Licensed Practical Nurse Manager #2, reviewed the electronic medical record and stated they were aware that Resident #1 had two (2) admissions to hospital, with the most recent for fecal impaction. They stated bowel protocol was triggered when there was no bowel movement after three (3) days. They stated they were not aware Nurse Practitioner #1 wanted to be notified if there was no bowel movement in greater than 24 hours and said there was no order.During an interview on 02/24/2026 at 4:03 PM, Registered Nurse #2 stated they were not responsible for the day-to-day management of a resident's bowel status and was not familiar with the clinical alerts on the computer system. Registered Nurse #2 stated they were responsible for assessments, care planning, and progress notes, and readmitted Resident #1 two (2) times for bowel related issues. They stated nurse unit managers were responsible for managing the resident's bowel status and would run a report that showed how many shifts it had been with no bowel movement. They stated the facility had standing orders for as needed bowel medications that were to be given when there was no bowel movement in two (2) days. The orders were entered into the electronic medical record by the unit managers upon admission/readmission to the facility.During an interview on 02/24/2026 at 4:35 PM, Nurse Practitioner #1 stated Resident #1 had chronic constipation and was on a daily bowel medication regimen. In addition to the routine bowel medications, the resident had orders for as needed bowel medications. Per the facility's bowel protocol, the resident was supposed to receive Milk of Magnesia if no bowel movement in 24 hours, a suppository if no bowel movement in 48 hours, an enema with notification to the provider if no bowel movement in 72 hours. They stated the resident had a hospitalization for fecal impaction and when the resident returned, they gave nursing staff specific verbal instructions for the management of the resident's bowel movements. They stated they did not recall a specific order for the instructions and stated the unit manager was ultimately responsible for managing the resident's bowel status and communicating the instructions to the unit staff. They were not aware that the as needed bowel medications were not given prior to the resident's hospitalization. They stated they were never notified of any bowel related concerns for Resident #1. They stated that given the resident's diagnoses, routine bowel medications, and history of fecal impaction, the expectation was nursing staff would utilize the bowel protocol and notification process.During an interview on 02/25/2026 at 9:51 AM with Medical Director #1, they stated most nursing home residents had a bowel regimen, and the expectation was that bowel movement status and assessments would be documented. For Resident #1 with a history of constipation and fecal impaction, the resident was at high risk and nursing staff should have been monitoring the resident closely.During an interview on 02/25/2026 at 11:05 AM, Administrator #1 stated Resident #1 had chronic constipation. They reviewed Resident #1's records and stated the resident was getting their daily bowel medications. They were not aware the resident had not received the as needed bowel medications per the facility's protocol. They stated a resident's bowel alerts were on the nurse's dashboard and the unit manager and Director of Nursing #1 were responsible for addressing them. B. Resident #85Resident #85 was admitted to the facility with diagnoses of unspecified dementia severe, without behavioral disturbance (cognitive decline with no notable behavioral, psychotic, mood, or anxiety symptoms), type two (2) diabetes mellites with hyperglycemia (when the body cannot use insulin correctly and the sugar builds up in the blood), and hypersensitive chronic kidney disease with Stage one (1) through stage four (4) chronic kidney disease, or unspecified chronic kidney disease (the presence of kidney damage or decreased kidney function). Minimum Data Set, dated [DATE], documented the resident had severe cognitive impairment. The resident usually made themselves understood and usually understand others.Record review of a peer-reviewed journal article titled, Systematic Review of Interventions to Reduce Urinary Tract Infection in Nursing Home Residents ([NAME] et al., J Hosp Med. 2017 May;12(5):356-368. doi: 10.12788/jhm.2724. Retrieved at https://pmc.ncbi.nlm.nih.gov/articles/PMC5557395/ ) noted that Several practices, often implemented in bundles, appear to reduce Urinary Tract Infections or Catheter-Associated Urinary Tract Infections in nursing home residents such as improving hand hygiene, reducing and improving catheter use, managing incontinence without catheters, and enhanced barrier precautions.A note dated 09/18/2025 with date of service 09/19/2025 by Nurse Practitioner #1, documented Resident #85 had lower back pain and family was concerned resident had a urinary tract infection. Plan was to consider sending urinalysis.A note dated 09/24/2025 with date of service 09/25/2025 by Nurse Practitioner #1, documented nursing reported decreased oral intake. Plan was to provide 240 milliliters of extra fluids with medication pass and obtain urine sample for urinalysis.Review of physician orders revealed no documented evidence of an order for a urinalysis on 09/25/2025.There was no documented evidence in a review of progress notes about the resident's condition on 09/26/2025.A note dated 09/26/2025 with date of service 09/27/2025 by Nurse Practitioner #1, documented Resident #85 was not eating or drinking and nursing staff were still unable to obtain urine sample. Plan was Rocephin two (2) grams x one (1) dose (antibiotic) intermuscular, consider intravenous fluids, and straight catheterization (a flexible tube inserted through the urethra to drain urine from the bladder) as needed to obtain urine.A note dated 09/27/2025 at 7:27 PM by Registered Nurse #4, documented provider made aware of resident lethargy (unusual decrease in consciousness), had not voided through the shift, and had no intake or output.Provider orders dated 09/27/2025 documented obtain urine analysis and culture and sensitivity. Completed 09/27/2025 at 7:30 PM.The Nurse Practitioner Note dated 09/27/2025 with date of service 09/28/2025 by Nurse Practitioner #1, documented resident was straight catheterized, had 100 milliliters of blood visible to naked eye, and was lethargic. Plan was to send resident to the emergency room.The Hospital Discharge summary dated [DATE], documented admission diagnosis of septic shock and discharge diagnosis of resolved septic shock secondary to urinary tract infection.During an interview on 02/20/2026 at 11:40 AM, Nurse Practitioner #1 stated their expectations were if they ordered a urinalysis, the sample would be obtained and sent to the lab within 24 hours.During an interview on 02/25/2026 at 9:29 AM, Medical Director #1 stated when a urinalysis was ordered their expectation would be to send the urine specimen out probably within an hour or two (2).During an interview on 02/25/2026 at AM, Director of Nursing #1 stated lab orders appeared on the dashboard in the resident's electronic medical record, and they could review the lab reports for residents who had labs obtained.C. Resident #87Resident #87 was admitted to the facility with diagnoses of unspecified fracture of head of left femur (a break in the ball-shaped upper end of the left thighbone where it connects to the hip socket), malignant neoplasm of cerebral meninges (a rare, aggressive, and cancerous tumor arising from the brain's protective membranes), and anxiety (mental health condition characterized by excessive fear that interferes with daily activities). The Minimum Data Set, dated [DATE], documented the resident was independent with making decisions regarding tasks of daily living.An Incident and Accident form dated 01/13/2026, documented Resident #87 was found on the floor during rounds and stated they fell while trying to close their door. It documented that the licensed nurse assessed Resident #87 immediately, the resident was able to move all extremities without difficulties, vital signs were stable, the resident denied any pain or hitting their head during the fall, and the family was notified. There was no documented evidence that an assessment was conducted by a registered nurse after the fall.A Nursing Note dated 01/14/2026 at 7:12 AM by Licensed Practical Nurse #12, documented Resident #87 stated they fell and refractured their hip. The resident had been in bed all shift. The resident called their family to go to the hospital. The family called 911 to take them out to the hospital around 7:10 AM. A Physician Note dated 01/15/2026 at 12:29 PM by Nurse Practitioner #1, documented on the 01/13/2026 evening shift, nursing staff reported the resident experienced a fall while attempting to close a door. At the time of the incident, nursing assessment indicated no apparent injury. The resident denied head strike, denied pain, and no acute complaints were reported. Vital signs were obtained and remained stable. No immediate transfer was deemed necessary based on clinical assessment. On the morning of 01/14/2026, the resident and family independently contacted emergency services, stating concern that the resident had re-fractured their hip and required hospital evaluation. The resident was transferred to the emergency department via emergency medical services. The on-call provider was not notified prior to the transfer. This incident was reviewed for communication processes and escalation protocols. Education and reinforcement of provider notification requirements were indicated to ensure timely clinical assessment and appropriate decision-making in future similar situations. During an interview on 02/19/2026 at 4:43 PM, Licensed Practical Nurse #12 stated Resident #87 did not fall on their shift. They stated Licensed Practical Nurse #14 took care of Resident #87 on the 3:00 PM to 11:00 PM shift when their fall occurred and did not tell Licensed Practical Nurse #12 about the fall when Resident #87 was moved to their assignment at 11:00 PM. The certified nurse aides that were working at the time told Licensed Practical Nurse #12 that Resident #87 fell but did not say when the resident actually fell. In the morning, when Family Member #5 called and stated Resident #87 fell, Licensed Practical Nurse #12 did not know what they were talking about, which was why they documented what they did. On 02/24/2026 at 11:49AM and 4:30 PM, attempts were made to contact Licensed Practical Nurse #14 but were unsuccessful and there was no option to leave a message. During an interview on 02/25/2026 at 9:29 AM, Medical Director #1 stated that when something out of the ordinary occurred, they would usually get a call from the Nurse Practitioner for clarification. During an interview on 02/25/2026 at 11:04 AM, Director of Nursing #1 stated if a resident fell, they would want a thorough investigation and explanation of what happened. The Licensed Practical Nurse should start the Incident and Accident Report, the event should be documented in the electronic health record, and the family would be notified. Ideally, it would be reviewed in morning report. During an interview on 02/25/2026 at 12:25 PM, Administrator #1 stated they were aware there were issues surrounding documentation and that staff needed to be educated on the processes regarding what to do for adverse events, reporting them appropriately, and closing the loop after things happened. 10 New York Codes, Rules, and Regulations 415.12

Based on observation, record review and interviews conducted during a survey, the facility did not ensure that that it developed, implemented, and maintained an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles. Specifically, for five (5) employees education records reviewed, one (1) employee received a comprehensive orientation with all the required educations. This is evidenced by: The Facility Assessment, dated 1/2026, documented under Staff training/education and competencies, the following topics, in addition to others, will be presented to staff: Communication, Resident Rights and facility responsibilities, Emergency planning, Person centered care, Dementia and behavioral management, substance abuse identification, trauma informed care/PTSD, proper body mechanics, Abuse, neglect, and exploitation, Infection control, Culture change, Required in-service training for nurse aides. In-service training must: Be enough to ensure the continuing competence of nurse aides must be no less than 12 hours per year. Include dementia management training and resident abuse prevention training. Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff. For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired. Identification of resident changes in condition, Cultural competency The following competencies and others will be offered to staff as necessary: Person-centered care Activities of daily living Disaster planning and procedures Infection control Medication administration Measurements: blood pressure, orthostatic blood pressure, body temperature, urinary output, etc. Resident assessment and examinations or Observations Caring for persons with Alzheimer's or another dementia Specialized care Caring for residents with mental and psychosocial disorders The Facility Assessment further specified that Certified Nurse Aides are required to complete a minimum of 12 hours of annual in-service training, including dementia care and abuse prevention education. Review of staff education records indicated inconsistent documentation of training completion.Review of staff education records showed incomplete and inconsistent documentation of the required training.Certified Nurse Aide #1's education file from the facility did not have documented evidence of annual training after January 2022. Electronic records indicated that less than 12 hours of annual education had been documented.Certified Nurse Aide #5's education file from the facility contained sign-in sheets and post-tests; however, the documentation did not clearly demonstrate completion of all annual training hours.Certified Nurse Aide #15's education file did not contain documentation indicating the aide had received annual education as required.Licensed Practical Nurse #1's education file from the facility contained partial documentation of annual education topics.Licensed Practical Nurse #12' education file did not contain documentation indicating the aide had received annual education as required.During an interview on 2/24/2026 at 10:18 AM, Licensed Practical Nurse #4 stated that education was available on the computer and that in-service talks were sometimes conducted but reported not knowing how to access education through the computer system.During an interview on 2/24/2026 at 10:25 AM, Licensed Practical Nurse #3 stated they were aware of overdue education assignments on the electronic system and reported difficulty finding time to complete them.During an interview on 2/24/2026 at 10:30 AM, Licensed Practical Nurse #8 stated education was sometimes provided through printed sheets that staff read and signed and recalled completing hand hygiene education on a laptop.During an interview on 2/24/2026 at 10:55 AM, Laundry Attendant #1 stated they had received education specific to housekeeping and laundry tasks but had not received facility-wide education such as abuse and neglect training.During an interview on 2/24/2026 at 11:02 AM, Certified Nurse Aide #10 stated they had not received education within the last year and recalled abuse and neglect training approximately three years ago.During an interview on 2/24/2026 at 2:47 PM, Licensed Practical Nurse #7 stated that as a unit manager they were not responsible for assigning education and were unsure who was responsible.During an interview on 2/24/2026 at 5:30 PM, Certified Nurse Aide #4 stated they were aware there was online education that had not been completed.During an interview on 2/24/2026 at 5:35 PM, Certified Nurse Aide #15 stated they completed abuse and neglect education one week prior and were aware of additional online training that had not yet been completed.During an interview on 2/24/2026 at 5:40 PM, Certified Nurse Aide #5 stated they were unaware of Certified Nurse Aide education requirements and had not completed training since hire.During an interview on 2/25/2026 at 11:04 AM, Director of Nursing #1 stated that staff education would be a priority. Director of Nursing #1 stated they were aware of the required annual education topics included in the facility's staff training program. These topics included abuse prevention, identifying and reporting abuse, infection control, managing challenging residents and dementia care, activities of daily living, proper body mechanics, sexual harassment, Foley catheter care, urinary tract infection awareness, medication administration, wound care, and resident rights. Director of Nursing #1 further stated that staff were expected to receive education related to abuse prevention, reporting requirements, and resident rights as part of the facility's annual training program.During an interview on 2/25/2026 at 12:25 PM, Administrator #1 stated they would work closely with Director of Nursing #1 to support the facility's staff education program. Administrator #1 stated the facility utilized an online education system to assign and track staff education. Administrator #1 reported the system was implemented in August 2025 and was used to monitor required education hours for Certified Nurse Aides. Administrator #1 further stated that certain facility-wide education topics were required for all staff, including: fire safety, resident rights, abuse, and oxygen control. Administrator #1 stated the online system tracks staff education requirements and that the Assistant Director of Nursing would be responsible for coordinating education assignments when hired. Administrator #1 also stated the facility maintained education checklists and reference materials to assist staff in understanding required training topics. 10 New York Codes, Rules, and Regulations 415.26

Based on record review and interviews conducted during a survey, the facility did not ensure that written notification was sent to the resident, resident representative, and a representative of the Office of the State Long-Term Care Ombudsman of the resident's transfer or discharge and the reasons for the move for three (3) (Resident #'s 75, 86, and 87) of three (3) residents reviewed. Specifically, (a.) for Resident #'s 75, 86, and 87 there was no documented evidence that the resident, representative, or Ombudsman received a transfer/discharge notice upon discharging from the facility; and (b.) transfer/discharge notices were not provided to the resident, resident representative, or the Ombudsman when a resident discharged home or when admitted to the hospital since December 2025.This is evidenced by: Resident #75 Resident #75 was admitted to the facility with diagnoses of noninfective gastroenteritis and colitis (inflammation of the stomach, small intestine, and/or colon), chronic idiopathic and slow transit constipation (functional bowel disorder characterized by persistent, infrequent bowel movements, hard stools, or difficult defecation without a known organic cause) and type 2 diabetes (an endocrine dysfunction causing unregulated blood glucose levels). The Minimum Data Set (an assessment tool) dated 12/31/2025, documented the resident had moderate cognitive impairment, was able to make themselves understood and understand others.A nursing progress note dated 11/11/2025 at 7:40 PM, documented per family request, Resident #75 was transferred to the hospital by emergency medical services at 4:00 PM due to pain and distended abdomenThere was no documented evidence that a transfer/discharge notice was completed for Resident #75, provided to the resident and/or resident representative, and sent to the Ombudsman. Resident #86 Resident #86 was admitted to the facility with diagnoses of metabolic encephalopathy (a broad term for acute or subacute brain dysfunction caused by chemical imbalances, systemic illness, or organ failure), Parkinson's disease (a movement disorder of the nervous system that worsens over time), and peritoneal abscess (a localized infected collection of pus, bacteria, and debris confined within the abdominal cavity). The Minimum Data Set, dated [DATE], documented the resident was understood, able to understand others, and had moderate cognitive impairments.A social work progress note dated 12/23/2025 at 4:43 PM, written by Assistant Administrator #1, documented a detailed conversation held with Resident #86's family regarding their desire to have the resident discharge against medical advice. The family had no concerns with the care provided at the facility, and they just wanted Resident #86 to be in their home environment. The progress note further documented that family was aware of the meaning of against medical advice and signed the appropriate paperwork.There was no documented evidence that a transfer/discharge notice was completed for Resident #86, provided to the resident and/or resident representative, and sent to the Ombudsman.An email from Ombudsman #1 dated 2/19/2026 at 9:49 AM, documented they had not received discharge notifications from the facility for the months of December 2025 and January 2026. It documented that they received discharge notifications for October and November 2025 on 12/12/2025. They had not received Resident #86's discharge notification.During an interview on 2/19/2026 at 11:12 AM, Assistant Administrator #1 stated the facility had not sent any discharge notifications to the Ombudsman since before Christmas 2025. They stated the former Social Worker sent discharge lists to the Ombudsman, but since there currently was no Social Worker, it was not getting done. They further stated the facility currently had an advertisement to hire a Social Worker. Resident #87 Resident #87 was admitted to the facility with diagnoses of unspecified fracture of head of left femur (a break in the ball-shaped upper end of the left thighbone where it connects to the hip socket), malignant neoplasm of cerebral meninges (a rare, aggressive, and cancerous tumor arising from the brain's protective membranes), and anxiety (mental health condition characterized by excessive fear or anxiety that interferes with daily activities). The Minimum Data Set, dated [DATE], documented the resident was independent with making decisions regarding tasks of daily living.A nursing progress note dated 1/14/2026 at 7:12 AM, written by Licensed Practical Nurse #12 documented Resident #87 stated they fell and refractured their hip. It further documented, Resident #87's family called 911 to take the resident to the hospital.During an interview on 2/18/2026 at 1:36 PM, Family Member #5 stated they called 911 to have Resident #87 sent back to the hospital because the resident reported they had a fall.There was no documented evidence that a transfer/discharge notice was completed for Resident #87, provided to the resident and/or resident representative, and sent to the Ombudsman.During an interview on 2/25/2026 at 11:04 AM, Director of Nursing #1 stated they had been working at the facility for a little over a week. They stated they were not surprised that discharge notifications had not been sent to the Ombudsman.During an interview on 2/25/2026 at 12:25 PM, Administrator #1 stated they sent discharge notifications to the Ombudsman. They stated the discharge paperwork was sent with the resident when they were sent to the hospital. 10 New York Codes, Rules and Regulation 415.3 (i)(1)(iii)(a-c)

Based on observation, record reviews and interviews conducted during a surveys, the facility did not ensure that residents were treated with dignity respect throughout the facility for two (2) (Residents #1 and #4) of two (2) residents reviewed for dignity. Specifically, (a.) staff members used derogatory language in the resident hallways of the facility; (b.) Resident #1 was called pet names by the staff, and their personal belongings had been moved by staff without their knowledge; and (c.) Administrator #1preformed a search of Resident #4's personal belongings without their permission. This is evidenced by: Policy: The facility policy titled Quality of Life/Dignity revised dated 12/2019 (unsigned) documented each resident is to be cared for in a manner promoting quality of life, dignity respect, and individuality.Implementation Residents shall be treated with dignity and respect at all times. Residents private space and property will be respected at all times1. Staff will knock and get permission prior to entering a resident room2. Staff will not handle or move resident belongings without permission Staff shall speak respectfully to residents at all times addressing each resident by name of choice. Resident #1 Resident #1 was admitted to the facility with diagnoses of unspecified encephalopathy (brain disorder (cause unknown) leading to altered brain function), acute respiratory failure with hypoxia (sudden inability of the lungs to maintain adequate oxygen levels in the blood), and generalized muscle weakness. The Minimum Data Set (an assessment tool) dated 01/30/2026, documented the resident was understood, able to understand others, and was cognitively intact. Resident #4 Resident #4 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (progressive lung disease that makes it difficult to breathe), essential primary hypertension (abnormally high blood pressure that is not the result of a medical condition), and chronic pain (pain lasting over three (3) months). The Minimum Data Set, dated [DATE], documented the resident was understood, able to understand others, and was cognitive intact. Observation: During an observation on 2/13/2026 at 11:20 AM at the first-Floor rehabilitation unit nursing station, Maintenance Director #2 stated loudly that they Can't get fucking lucky as they were walking down the hallway approximately 20 feet from the nursing station. Interview: During an interview on 02/11/2026 at 11:25AM, Resident #1 stated the staff at the facility called them honey, sweetie, and even big-butt one night, they did not like being called any of those names. They were upset that their refresh eyedrops were taken away from them that they had been administering themselves for a long time. They did not think the staff considered evaluating for them to keep the eyedrops. The staff had moved their denture cream approximately two (2) nights ago and were still unable to locate it. They added that the nurses kept trying to give them melatonin at bedtime, although they had let the nurse know they did not want it. During an interview on 02/17/2026 at 11:45 AM, Resident #4 stated Administrator #1 came into their room the previous morning and looked through three (3) of their nightstand drawers. Resident #4 stated they had to ask Administrator #1 what they were doing. Administrator #1 then explained they were looking for medications, scissors, or clippers. They proceeded to ask Resident #4 where their money was. Resident #4 stated they told them the facility had their money. Administrator #1 then asked if they had any money in the room, and they repeated the facility had their money. During an interview on 02/24/2026 at 2:25 PM, Certified Nursing Aide #3 stated when entering a resident room, they would knock and introduce themselves prior to entering. If they needed to go through a resident's belongings they would need to ask permission first.During an interview on 02/24/2026 at 2:31 PM, Licensed Practical Nurse #3 stated when entering a resident room, they would knock and introduce themselves prior to entering. If they needed to go through a resident's belongings they would need to ask permission first. If they were to see someone going through resident belongings, they would ask that person what they were looking for, receive resident permission, and notify nurse manager. During an interview on 02/24/2026 at 2:35 PM, Licensed Practical Nurse #4 stated when entering a resident room, that they would knock and introduce themselves. If they needed to go through a resident's belongings, they would need to ask for permission from the resident. If they heard inappropriate conversation in hallway by staff, they would notify nurse manager. During an interview on 02/24/2026 at 2:47 PM, Licensed Practical Nurse #7 stated when entering a resident room they would knock, introduce themselves, and then address issues that brought them to the room. If they needed to go through a resident room or belongings they would need to ask permission from resident prior. They stated if they heard inappropriate conversation in hallway, they would pull staff into their office and give them a verbal warning. If the behavior continued, they would bring the staff member to the director of nursing for further interventions. During an interview on 02/24/2026 at 2:14 PM, Certified Nursing Aide #9 stated they always ask permission if they needed to search a resident's room. They always knocked before entering a resident's room and introduced themselves. They stated cursing in front of residents or other staff was not okay, and they would address staff if they overheard it. During an interview on 02/24/2026 at 2:42 PM Licensed Practical Nurse #8 stated they would ask permission from the resident before searching a resident's belongings/drawers. During an interview on 02/24/2026 at 4:21 PM, Licensed Practical Nurse #2 stated they would talk to staff or correct them if they heard any foul language/cursing. They have witnessed staff arguing in front of the residents, and staff talking on their personal phones using foul language in front of residents. They stated both situations were dignity issues. 10 New York Codes, Rules, and Regulations 415.12(h)(1)(2)

Based on observation, record review and interviews conducted during a survey, the facility did not ensure it provided effective housekeeping and maintenance services, and the environment was maintained for two (2) of two (2) units observed. Specifically, the facility did not ensure that resident rooms were clean and in good repair. This is evidenced by: During facility observations on 2/11/2026, 2/12/2026, and 2/19/2026 it was noted: rooms [ROOM NUMBER] air conditioner/heater units were not flush with the wall creating large gaps. In room [ROOM NUMBER], the outside yard was viewable through the gap. rooms [ROOM NUMBERS] had broken privacy curtains and broken window curtain rods causing the drapery to hang incorrectly. room [ROOM NUMBER] had stained bed linens. room [ROOM NUMBER] air conditioner/heater unit had a broken grate. room [ROOM NUMBER] door was unable to close completely and would get stuck against molding. Interview: During an interview on 01/29/2026 at 1:41 PM, Certified Nurse Aide #1 stated that they should report any maintenance concerns they see to the Maintenance Department.During an interview on 2/12/2026 at 10:03 AM, Family Member #6 stated they had cleaned Resident #80 entire room, located on second floor, then the facility moved the resident to room [ROOM NUMBER]. The floor was noted to be sticky during the interview, and Family Member #6 stated it always was. During an interview on 2/13/2026 at 9:29 AM, Assistant Administrator #1 stated that there were multiple external forces that ran the building. Assistant Administrator #1 stated they had the authority to order some things, but major purchases needed to be authorized other people, such as the Director of Procurement. During an interview on 2/17/2026 at 2:15 PM, Director of Maintenance #1 stated that they had been sealing the gaps (around the air conditioner/heater) units when they found them. When the issues observed on survey were pointed out, Director of Maintenance #1 stated that they would take care of them as soon as possible.During an interview on 2/25/26 at 10:10 AM, Administrator #1 stated that they became administrator in August 2025 when the previous Administrator told them on a Friday that they would not be returning on the following Monday. Administrator #1 stated they had been identifying issues where they wanted things to change and had a major update planned for the building. New York Codes, Rules, and Regulations Title 10 S415.5(h)(4)

Based on observation, record review and interviews conducted during a survey, the facility did not ensure a quality assessment and assurance committee developed and implemented appropriate plans of action to correct identified quality deficiencies. Additionally, the facility did not develop written policies and procedures for feedback, data collection systems, and monitoring, including adverse event monitoring. Specifically, (a) the facility had repeat deficiencies in the areas of comprehensive care planning and implementation (F656), evaluation and revision of comprehensive care plans (F657), and providing flu and/pneumococcal immunizations (F883), cited during the recertification survey, completed on 6/23/2023, were implemented as indicated by the same deficiencies being issued on the current survey; (b) policies and documents provided by the facility were noted to be undated, improperly titled, were missing information, had outdated information and/or were not signed; (c) key Quality Assurance Performance Improvement components were not being implemented such as having the required participants, documenting the topics reviewed, and missing information from required departments. The facility's inability to obtain feedback, use data, and take action to conduct structured, systematic investigations and analysis of underlying causes or contributing factors of problems affecting facility-wide processes has the potential to negatively impact quality of care, quality of life, and resident safety for all residents in the facility.This is evidenced by: A. Repeat deficiencies.Facility was cited for the following on recertification survey: F656 as it pertains to the facility's failure to develop and implement a comprehensive person-centered care plan for each resident.F657 as it pertains to the facility's failure to review and revise a comprehensive person-centered care plan for each resident.F883 as it refers to the facility's failure to ensure that providing and/or documenting influenza and/or pneumococcal immunizations as required for residents. B. Policies and Documents Incomplete.The undated facility document titled, Quality Assurance Performance Improvement, documented it was the policy of this facility to establish and utilize specific systems for feedback, data collection, and monitoring inclusive of adverse events. The information would be utilized to fulfill the facility's responsibility and accountability for assessment and improvement in the quality of care and the services provided to resident's families and the community we serve. The section Feedback, Data Systems and Monitoring documented that Performance Improvement Projects (quality indicators) would be chosen based on those elements, which measured facility wide functions, involving high-volume, high risk and/or problem-prone activities. The Facility Assessment would be utilized in further determining quality indicators that were relative to the needs of the population served. The development of Performance Improvement Projects (indicators) would be based upon feedback received from the following data sources. These considerations include but are not limited to: Direct observations of the Quality Assurance Performance Improvement Committee Input from residents, families, staff, and other customers Accident/Incident reports Infection Control reports Consultant Services/reports Monthly Department Head meetings QI/QM (acronym not defined) reports; Facility Indicator Profile Report DentalFacility-wide indicators may include such areas as: Staff turnover, recruitment, and retention efforts Safety issues (related to residents and employees, visitors) Resident Grievances Other areas as identified based upon outcomes and feedback from those served The documented purpose was that the Quality Assurance Performance Improvement plan had been established to provide a planned, systemic, and ongoing quality improvement process designed to objectively monitor and evaluate the quality of resident care and to pursue opportunities for organizational improvement. Quality Assurance Performance Improvement is a process designed to systematically assess and improve important functions and work processes and their outcomes. Quality must be continuously evaluated and improved in order to meet the needs of our resident and community.The documented objectives were:1. Establish, maintain, support, and document evidence of an ongoing Quality Assurance and Performance Improvement program that included effective mechanisms for monitoring and evaluating resident care and for appropriate response to findings.2. Assist individual departments in improving care and identifying problems through the use of ongoing performance improvement projects. This was to be done by focusing on identification, analysis and resolution of problems that affected the residents of the facility.3. Evaluate the results of action taken by individual departments and maximize the efficient use of resources available within the facility.4. Centralize and expand the scope of present quality improvement activities into a more comprehensive program.5. Direct improvement efforts at processes, not individuals.The documented Design and Scope was that Quality Assurance Performance Improvement activities will be integrated and coordinated among departments within the facility; they would be designed to minimize duplication of effort; and would be cost-effective. All The document referenced above ended at All and the last two pages of the document supplied by the facility was a Quality Assurance Performance Improvement test. A second undated facility policy titled Quality Assurance and Performance Improvement (it was noted that the policy was to be five (5) pages; three (3) total were provided after multiple requests for the remaining pages) documented under Policy that it was the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven Quality Assurance Performance Improvement program that focused on indicators of the outcomes of care and quality of life and addressed all the care and unique services the facility provides. Under program Development Guidelines it was documented:1. Program Design and Scope -a. The Quality Assurance Performance Improvement program would be ongoing, comprehensive, and would address the full range of care and services provided by the facility.b. At a minimum, the Quality Assurance Performance Improvement program would:i. Address all systems of care and management practices.ii. Include the clinical care, quality of life, and resident choice.iii. Utilize the best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations that had been shown to be predictive of desired outcomes for residents of a Skilled Nursing Facility or Nursing Facility.iv. Reflect the complexities, unique care, and services the facility provides.2. Governance and Leadership -a. The governing body and/or executive leadership was responsible and accountable for the Quality Assurance Performance Improvement program.b. Governing oversight responsibilities included, but were not limited to the following:i. Approving the Quality Assurance Performance Improvement plan annually, and as needed.ii. Ensuring the program was ongoing, defined, implemented, maintained, and addressed identified priorities.iii. Ensured the program was sustained during transitions in leadership and staffing.iv. Ensured the program was adequately resourced, including ensuring staff time, equipment, and technical training as needed.v. Ensured the program identified and prioritized problems and opportunities that reflected organizational processes, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information.vi. Ensured that corrective actions addressed gaps in systems and were evaluated for effectiveness.vii. Set clear expectation around safety, quality, rights, choice, and respect.c. The Quality Assurance Audit Committee shall communicate its activities and the progress of its subcommittee activities to the governing body (if leadership role was greater than the administrator) at least quarterly, with a formal meeting no less than annually.d. The Quality Assurance Audit submit supporting documentation of ongoing Quality Assurance Performance Improvement activities to the Governing Body upon request.e. Quality Assurance Performance Improvement training that outlined and informed staff of the element of Quality Assurance Performance Improvement and goals of the facility would be mandatory for all staff.3. Program Feedback, Data Systems and Monitoring -a. The facility-maintained procedures for feedback, data collection systems, and monitoring, including adverse event monitoring.iii. The Quality Assurance Audit Committee shall select additional members to participate in various subcommittees based upon the PIP topic and participant expertise.iv. Each sub-committee should be guided by a Quality Assurance Audit Committee member who would facilitate coordination of the Performance Improvement Plan and ensure each sub-committee was adequately resourced.v. Upon conclusion of the Performance Improvement Plan, the sub-committee shall provide the Quality Assurance Audit Committee with a report, which contained a summary and analysis of activities and recommendations for improvement. 5. Program Systematic Analysis and Systemic Action -a. The facility took actions aimed at performance improvement as documented in Quality Assurance Audit Committee meeting minute and action plans. Performance/success of the actions would be monitored and documented in subsequent Quality Assurance Audit Committee or sub-committee meetings.b. To ensure improvements were sustained, the effectiveness of performing improvement activities would be monitored in Quality Assurance Audit Committee meetings in accordance with the Quality Assurance Performance Improvement plan, but no less than annually. C. Inconsistencies with required participants, documenting the topics reviewed, and missing information from required departments. The Quality Assurance Performance Improvement Committee provided in an undated list of the the following members:Nurse Manager Licensed Practical Nurse #2Nurse Manager Licensed Practical Nurse #7Maintenance Director #1Dietician #1Director of Nursing (interim) Acting Director of Nursing #1Assistant Director of Nursing (there was not an employee in this position while on survey)Activities Director #1 (employee in this role started while on survey)Therapy Director #1Director of Social Services (interim) Assistant Administrator #1Medical Director #1Food Service Manager #1Admissions Coordinator #1Business Office/Staffing Coordinator #1Assistant Administrator #1Administrator #1 A review of Quality Assurance Performance Improvement meeting sign-in sheets and minutes documented the following: For the 07/29/2025 meeting, participants included on the sign-in sheet were Administrator #1, Assistant Administrator #1 (as Director of Social Work), Therapy Director #1, Director of Nursing (no longer employed at facility), Admissions Coordinator #1, Licensed Practical Nurse #2 and #5, Acting Director of Nursing #1 (as the Minimum Data Set Coordinator), and unreadable signatures for Activities, Dietician, Business Office, Maintenance, and Housekeeping.Meeting documented as lasting 16 minutes.No audit forms were provided for the quality areas noted in the 07/20/2025 meeting. The minutes provided dated 07/2025, documented a start time of 1:17 PM and end time of 1:33 PM. Documented on the sheet provided was Minimum Data Set - Certification and Survey Provider Enhanced Reporting Review for May June and July - Residents identified for decline and two areas of Activities of Daily Living; residents will be audited for three things. -Accuracy of Minimum Data Set data, participation, and current therapy program, and evaluated for nursing restorative program. -Long term residents reviewed. Dietary: Weight loss based on Certification and Survey Provider Enhanced Reporting for May, June, July. - Weight loss reported: 0%. -Improvements indicated. -Goal was met; Immediate interventions always implemented when weight loss observed. Therapy: Wheelchair Audit. -Sixty-nine wheelchairs audited and 10 pulled for review, 100% compliant with wheelchairs being free from rips, tears, and brake functioning. Nursing: Hospitalizations. -Transfers to hospital 19 from July-August (21 month prior). -Number of hospitalizations in July- 11; 7 admitted . Shower Audits: Unit 1 -Some complaints regarding showers not being given. -Four audits completed; three residents have received shower and were satisfied. One resident stated they do not like showers and prefers bed baths. One shower refused due to not feeling well, and was provided with a shower the next day. Shower Audit: Unit 2 -One resident noting of not receiving shower due to multiple room changes and confusion relating to the new updated shower date/time. -Received a shower next day; resident was satisfied. No audit forms were provided for the quality areas noted in the 07/2025 meeting. For the 8/26/2025 meeting at 1:00 PM, participants included on the sign-in sheet were Assistant Administrator #1, Licensed Practical Nurse #2, Therapy Director #1, and Nurse Practitioner #1. The minutes provided documented a date of 8/21/2025 and Dietary: Reviewed weight loss, no resident triggered; Nursing: Shower care audit conducted-attached. Assistant Director of Nursing reported on the following: Antibiotic usage, wounds, resident dignity, medication pass, the committee self-identified that antibiotic stewardship has not been occurring. Moving forward the committee will review this on a monthly basis; Therapy: Durable Medical Equipment audit. Minimum Data Set. Activities of Daily Living audit, see attached form; Maintenance: Bathroom pull cord audit - attached. Over bed light cord audit-attached. No audit forms were provided for the quality areas noted in the 8/26/2025 meeting. For 9/24/2025 at 1:00 PM, participants included on the sign-in sheet were Assistant Administrator #1, Licensed Practical Nurse #2, Director of Social Work (no longer employed at facility), Director of Nursing (no longer employed at facility), Therapy Director #1, a Registered Dietician, and Licensed Practical Nurse #5. The minutes provided documented that in September 2025 Sept. 1st Generator load test, no reportable problems. Sept. 2nd Maintenance did a over the bed light sting audit, was 94% in compliance. [DATE]th Maintenance did a bathroom call light sting audit, was 97% in compliance. [DATE]th Maintenance started back yard pick up, Work on going by season. [DATE]th (a power company) on site to do a full generator inspection, No reportable problems. Sept. 5th (an electric company) on site to tie in cook line equipment that failed the last hood inspection, all work 100% complete and now in compliance. Sept. 11th (Elevator company) was on site to fix the pit pump, on the 12th. The problem was back, so Maintenance fixed the pump and grinder pipe problem, all working 100% correctly. (the bill from (elevator company) should not be paid claiming 2 men for 2 hrs. for $747.49). Sept. 19th Maintenance performed a 2nd Shift fire drill. All staff were educated on Alert Rescue Alarm Contain Extinguish. For the 10/22/2025 meeting, the start & end times were not recorded, participants included Assistant Administrator #1, Director of Social Work (no longer employed at facility), Registered Dietician (unable to read signature), Licensed Practical Nurse #2 and #5, and Director of Nursing (no longer employed at facility), an unreadable signature next to Activities, Food Service Manager, Housekeeping, and Maintenance, Acting Director of Nursing #1 as the Minimum Data Set Coordinator, and by phone, Administrator #1. The minutes provided documented the following: Maintenance, Generator load test, no issues, GFI (ground fault circuit interrupter) audit, replaced as needed, RTU (air-handling system Rooftop Unit) filters replaced, (fire security vendor) on site to replace heat sensor, (laundry service vendor) fixed washers, (door service vendor) fixed egress door, (contracting vendor) fixed top grill in kitchen, Reviewed emergency food supply with kitchen, New water line for juice machines; Social Work 18 total discharges, 5 residents to home, 2 residents against medical advice, 3 passed, 1 with family, 7 to hospital 3 with 4 returning, Medical Orders for Life Sustaining Treatment audit, Unit 1 completed; Minimum Data Set, Audit of planned vs unplanned discharges - report attached; Dietary, Weight changes with etiology reviewed. No audit forms were provided for the quality areas noted in the 10/22/2025 meeting. For the 11/26/2025 meeting at 1:00 PM, participants included Assistant Administrator #1, Director of Nursing (no longer employed at facility), Director of Social Work (no longer employed at facility), Director of Activities (no longer employed at facility), Therapy Director #1, and Acting Director of Nursing #1 as the Minimum Data Set Coordinator. The minutes provided dated 11/26/2025, documented the following Maintenance, GFI (ground fault circuit interrupter) audit, replaced as needed, (contracting vendor) fixed the grill top in kitchen,(fire security vendor) was on site, (elevator vendor) fixed elevator, 1st shift fire drill conducted; Social Work, 20 total discharges, 14 discharged home, 1 against medical advice, 2 lateral transfer, 2 to hospital (1/2 returned); Minimum Data Set, Activities of Daily Living audit. See attached report; Therapy, Care plan review. Continue to review and update as needed; Dietary, Weight loss report, review etiology; Environmental, Full house audit. Increase daily monitoring to ensure cleanliness. No audit forms were provided for the quality areas noted in the 11/26/2025 meeting. For the 12/23/2025 meeting at 1:00 PM, participants included Licensed Practical Nurse #2, a Registered Dietician, Food Service Manager #1, Maintenance Director #1, and Acting Director of Nursing #1 as the Minimum Data Set Coordinator. The minutes provided dated 12/2025 documented Maintenance, Stop sign audit, replaced as needed, Painted some areas that required refreshing, Therapy, Care plan audits continue. Educate therapy staff on updating care plans as needed. No audit forms were provided for the quality areas noted in the 12/23/2025 meeting. Record review of previous Recertification Survey Statement of Deficiencies issued by the New York State Department of Health revealed the facility received deficient practice statements for F656 (develop and implement a comprehensive person-centered care plan), F657 (review and revise a comprehensive person-centered care plan), F883 (providing and/or documenting influenza and/or pneumococcal immunizations). Throughout the survey, multiple requested policies and procedures were not dated for implementation or revision, did not have the name of last person to review the documents, the names listed within the policies were of staff that were no longer associated with the facility, or the role of the staff person listed was not accurate to their current position. The Facility Assessment was requested upon entry and the first version provided had both January 2026 and July 2025 listed as the date of the assessment. An updated assessment was requested, and a very similar policy was provided that had the same dates and a signature sheet that listed the previous Administrator and a previous Director of Nursing that held the position two (2) Director of Nurses prior to survey entry. The Abuse policy was requested upon entry and the first policy sent had the word DRAFT marked on it, the title was Cleaning Reporting Resident Abuse, Mistreatment, Neglect, or Misappropriation of Property and was not signed or dated in the fields provided at the end of the policy. An updated (not draft) policy was subsequently requested and the same policy without the word DRAFT was provided, it had the same title and was not dated or signed. Other policies requested that were noted to be incomplete were: Neurological check policy noted to not be dated or signed by the initiator/reviewer. Incident and Accident Reporting and Follow up policy noted to not be dated or signed by the initiator/reviewer. Smoking Policy noted to not be dated or signed by the initiator/reviewer. Accidents and Supervision policy noted to have implemented date 7/2023, no reviewed or revised date and not signed by the initiator/reviewer. Pre-Admission, Admissions, and Re-Admissions to the Facility policy noted to be not signed by the initiator/reviewer. Discharge Against Medical Advice policy noted to not be dated or signed by the initiator/reviewer. Change in a Resident Condition or Status policy was noted to have a different company logo on the header, but the facility listed was correct. The document provided had elements circled in ink and was not dated or signed by the initiator/reviewer. Conducting an Accurate Resident Assessment policy was not dated or signed by the initiator/reviewer. Controlled Substances policy noted was not on company letterhead or signed by the initiator/reviewer. Oxygen Administration policy facility name was in a different font that the other elements of the header indicative of having been electronically altered (name pasted over a different facility name), was not on facility letterhead, and was not signed by the initiator/reviewer. Discharge Summary and Plan policy was not on company letterhead or signed by the initiator/reviewer. Food Receiving and Storage policy was not on company letterhead or dated or signed by the initiator/reviewer. Complaint/Grievance policy had a different company logo on the header, the facility listed was correct, and the policy was not signed by the initiator/reviewer. Administering Medications policy was not dated or signed by the initiator/reviewer. Medical Provider Policy was not dated or signed by the initiator/reviewer. Notice of Medicare Non-Coverage and Advanced Beneficiary Notice of Non-Coverage policy was not dated or signed by the initiator/reviewer. Oxygen Administration policy utilized different facility letterheads on different pages and was not dated or signed by the initiator/reviewer. Quality Assurance Performance Improvement policy had missing pages and was not dated or signed by the initiator/reviewer. Quality of Life/Dignity policy was not on facility letterhead or signed by the initiator/reviewer. Activities of Daily Living Mobility policy e facility logo was not legible and was not signed by the initiator/reviewer. Dehydration was not on company letterhead or signed by the initiator/reviewer. Infection Prevention and Control Program policy was not signed by the initiator/reviewed. Sharps Container Safety Policy was not dated or signed by the initiator/reviewer. Visitation Policy was not dated or signed by the initiator/reviewer. Role Delineation policy was not on company letterhead or dated or signed by the initiator/reviewer. During an interview on 02/20/2026 at 12:14 PM, Acting Director of Nursing #1 stated that for the three (3) weeks that they were the Acting Director of Nursing, if a resident had an injury of unknown origin, they would report it to the Director of Nursing, Administrator, Nurse Practitioner, and to the Department of Health. They stated in their Minimum Data Set position, they had no involvement with Incidents and Accidents and was not sure what or how they did them at the facility.During an interview on 02/23/2026 at 2:24 PM, Nurse Practitioner #1 stated everyone was notified through email if someone was sent to the hospital and was probably reviewed at morning report. Nurse Practitioner #1 stated they did not have involvement with the Incident and Accident Reports. During an interview on 02/24/2026 at 2:14 PM, Certified Nurse Aide #9 stated that they did not know what Quality Assurance Performance Improvement was. During an interview on 02/24/2026 at 2:42 PM, Licensed Practical Nurse #8 was aware of the Quality Assurance meetings but did not know what was discussed or the purpose of the meeting. During an interview on 02/24/2026 at 4:21 PM Licensed Practical Nurse #2 stated that they sometimes attended the Quality Assurance Performance Improvement meetings. They would get assigned topics, subjects, or situations, such as dignity, showers, call lights; and they would do audits twice a week for a month. The Director of Nursing would discuss antibiotics, hospitalization, and falls. Each department did their own stuff. During an interview on 02/25/2026 at 9:29 AM, Medical Director #1 stated that they were at the facility for a few hours once a week. The Nurse Practitioner was in the facility doing most of the work. Medical Director #1 confirmed that it was their job to oversee the Nurse Practitioner. Medical Director #1 stated that they would get calls for advice if something complicated happened; a urinary tract infection that was resistant to a lot of antibiotics was the example provided. Medical Director #1 stated that they saw most of the Nurse Practitioner notes when they came to the facility during the week. If something unexpected happened, they would write their own note and would review notes if it was requested by the owner. Medical Director #1 stated that they attended most of the Quality Assurance Performance Improvement meetings that they were made aware of them and that attending them was part of their job. When asked about incidents and accidents, Medical Director #1 stated that they would not be informed of all of them. They sometimes were made aware if there was a reportable incident that needed to be called to the Department of Health and would expect the facility to do an investigation. The Nurse Practitioner should be notified of everything. Medical Director #1 stated that they would review incident and accident reports and sign off on them but had not signed any in the last few months. Medical Director #1 stated that falls were addressed during Quality Assurance Performance Improvement meetings because it was one of the biggest issues they faced in long-term care.During an interview on 02/25/2026 at 10:10 AM, Administrator #1 stated that they became Administrator in August 2025 when the previous Administrator told them on a Friday that they would not be returning on the following Monday. At the time they took over as Administrator, they had asked the Medical Director and Director of Nursing if there were any major infection control concerns, to which they said no. Administrator #1 stated that Director of Nursing #1 was going to be the answer to many of the issues identified during survey. Administrator #1 stated that they were already working on a new formula on how to track issues. Administrator #1 stated that when the previous Administrator was running the building, Administrator #1 was at the facility every other week. Administrator #1 stated they are now at the facility from Sunday through Thursday, every week. Administrator #1 acknowledged that residents might not know they were the Administrator. Administrator #1 stated they had been identifying issues where they wanted things to change. Administrator #1 stated they did not recall ever doing a Performance Improvement Project or Plan with any individuals in the facility.During an interview on 02/25/2026 at 11:04 AM, Director of Nursing #1 stated in the week that they had been in the building, they believed the bones were good but the facility needed revamping.During an interview on 02/25/2026 at 12:25 PM, Administrator #1 stated that they have tried to address issues that were brought to them as soon as they could. They were not aware of some of the issues that had been brought to light during survey. Administrator #1 stated they needed some new processes. Administrator #1 stated that all issues should be discussed in morning meeting and afternoon wrap up, department heads would be monitored more closely, and they would look at regulations to ensure compliance with things they did not know the regulations on. When asked if they attended Quality Assurance Performance Improvement meetings, Administrator #1 stated that they did. When asked why their signature was only on one sign in sheet. Administrator #1 stated they did not sign in. When asked if Medical Director #1 attended the meetings, Administrator #1 stated that they did. When pointed out that Medical Director #1 was not listed on any sign in sheets, Administrator #1 stated Medical Director #1 attended over the phone, but their name was left off the attendance sheets accidentally. When asked if the documents provided covered what was talked about in the meetings, Administrator #1 stated that what was provided was only a list of what was talked about, not the actual details regarding what was discussed. No more information was provided when Administrator #1 was asked for a more detailed accounting of the Quality Assurance Performance Improvement meetings. 10 New York Codes, Rules and Regulations 415.27(a-c)

Based on record review and interviews during a survey, the facility did not ensure licensed nurses and Certified Nurse Aides had the specific competencies and skills necessary to care for residents need. Specifically, based on the facility assessment of required education, (a.) education records reviewed for Certified Nurse Aides #1, 5 and 15 were incomplete; (b.) Licensed Practical Nurses #s1 and 12 education were incomplete; and (c.) there was no official person overseeing education for the facility.This is evidenced by: The Facility Assessment, dated 1/2026, documented under Staff training /education and competencies, the following topics, in addition to others, will be presented to staff: Communication, Resident Rights and facility responsibilities, Emergency planning, Person centered care, Dementia and behavioral management, substance abuse identification, trauma informed care/Post Traumatic Stress Disorder, proper body mechanics, Abuse, neglect, and exploitation, Infection control, Culture change, Required in-service training for nurse aides. In-service training must:o Be enough to ensure the continuing competence of nurse aides must be no less than 12 hours per year.o Include dementia management training and resident abuse prevention training.o Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff.o For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired. Identification of resident changes in condition, Cultural competency The following competencies and others will be offered to staff as necessary: Person-centered care Activities of daily living Disaster planning and procedures Infection control Medication administration Measurements: blood pressure, orthostatic blood pressure, body temperature, urinary output, etc. Resident assessment and examinations or Observations Caring for persons with Alzheimer's or another dementia Specialized care Caring for residents with mental and psychosocial disordersPolicies and procedures for the provision of care to our residents will be reviewed periodically to ensure that the methods we were utilizing to render that care was in line with the current practices of our industry. Staff would be provided with the opportunity to attend seminars, and educational experience will be utilized in tailoring our policies and procedures to ensure we were providing the best and most up to date care to our residents. Certified Nurse Aide #1's education file from the facility did not contain evidence that all annual educations were completed after 1/09/2022, many years after Certified Nurse Aide #1 had been employed at the facility. Certified Nurse Aide #1's electronic education record indicated that less than 12 hours of annual education had been completed by the time of survey.Certified Nurse Aide #5's education file from the facility contained multiple in-service sign- in sheets and some posttests associated with education. It could not be determined if Certified Nurse Aide #5 had completed all required annual educations from the provided information. Certified Nurse Aide #5 electronic education record indicated that less than 12 hours of annual education had been completed by the time of survey.Certified Nurse Aide #15's education file from the facility did not contain evidence that annual education was completed except for a written statement of verbal education of staff involving an incident that occurred on 2/18/2026. The electronic health records provided by the facility did not contain any education topics for Certified Nurse Aide #15.Licensed Practical Nurse #1's education file from the facility did not have documented evidence that annual educations were completed since 2022, except for one posttest provided dated 2024 and part of an answer sheet from a test that had no title. Licensed Practical Nurse #1's electronic education records documented that only two (2) of the ten (10) education topics were completed for 2025.Licensed Practical Nurse #12's education file from the facility did not have documented evidence that annual educations were completed since 2024. Licensed Practical Nurse #12's electronic education records documented that only one (1) of the six (6) education topics were completed for 2025.During an interview on 2/13/2026 at 9:29 AM, Assistant Administrator #1 stated that typically the nurse educator was the Assistant Director of Nursing. Registered Nurse #2 had been filling in for that roll since they arrived. Assistant Administrator #1 stated they did on the spot education when it was needed, and the management team in general did education when needed.During an interview on 2/19/2026 at 9:35 AM, Assistant Administrator #1 stated that Acting Director of Nursing #1 handled education. The prior Assistant Director of Nursing and Director of Nursing also worked on education. There was an electronic education system that the staff were supposed to be using. Ideally, online teaching would be set up monthly to piggyback on in-house education and be due by a particular date. There were some one (1) on one (1) educations and group in services where people signed in. With the change of staff, education did stop for a little while. The previous Assistant Director of Nursing should have been keeping a binder with the information, but when they left, Assistant Administrator #1 was not able to find any of the information. Staff should have been getting yearly education on things like precautions, safety, and resident rights.During an interview on 2/24/2026 at 10:18 AM, Licensed Practical Nurse #4 stated that education was on the computer, and they came around and did in- service talks. Licensed Practical Nurse #4 stated that they did not know how to get education on the computer.During an interview on 2/24/2026 at 10:25 AM, Licensed Practical Nurse #3 stated that they knew that they had overdue education on the electronic education system and stated they did not have enough time in the day to complete them. Licensed Practical Nurse #3 stated that they did handwashing and infection control in the last year but were not sure if they had any teaching on Quality Assurance Performance Improvement program.During an interview on 2/24/2026 at 10:30 AM, Licensed Practical Nurse #8 stated that education was printed sheets that the staff read and signed. There was also education on the electronic medical record, and there were classes. The last one Licensed Practical Nurse #8 remembered receiving was hand hygiene on the laptop.During an interview on 2/24/26 at 11:52 AM, Acting Director of Nursing #1 stated that they did not do education. Acting Director of Nursing #1 stated that there were monthly online educations, and before the previous Director of Nursing left, they would post reminders about educations near the time clock.During an interview on 2/24/2026 at 10:55 AM, Laundry Attendant #1 stated that they received education on housekeeping and laundry tasks. They had not received any house wide education, such as abuse and neglect.During an interview on 2/24/2026 at 11:02 AM, Certified Nurse Aide #10 stated that they had not received any education in the last year. They had education on abuse and neglect about 3 years ago. They stated they did not use an online platform for education that they were aware of. They read and signed sheets.During an interview on 2/24/2026 at 2:47 PM, Licensed Practical Nurse #7 stated that as the unit manager they were not responsible for assigning education and was unsure who was.During an interview on 2/24/2026 at 5:30 PM, Certified Nurse Aide #4 stated that they knew there was online education that they had not completed. Certified Nurse Aide #4 stated they had not had training for abuse, neglect, infection control, or behavior health training.During an interview on 2/24/2026 at 5:35 PM, Certified Nurse Aide #15 stated that they did abuse and neglect training a week ago and that there was online training, but they had not done it.During an interview on 2/24/2026 at 5:40 PM, Certified Nurse Aide #5 stated that they had no idea if there was Certified Nurse Aide education, had not done any since they were hired, including nothing for abuse, neglect, infection control, or dementia behavior training.During an interview on 2/25/2026 at 11:04 AM, Director of Nursing #1 stated that education was going to be their priority. Director of Nursing #1 stated they were aware that there were required annual education such as abuse, identifying and reporting, infection control, dealing with challenging residents/dementia care, activities of daily living, body mechanics, sexual harassment, foley care, urinary tract infections, medication administration, wound care, and resident rights. Everyone should have gotten abuse, reporting, and resident rights education.During an interview on 2/25/2026 at 12:25 PM, Administrator #1 stated that they would work closely and as a team with Director of Nursing #1 and the use of the online education system would make things easier. Administrator #1 stated they had accessed the online education system and that the annual education that needed to be done would be done by the Assistant Director of Nursing when they were hired. The online education system tracked the aides' required hours of education and had gone into effect in August 2025. There were house wide educations that everyone needed to do such as fire safety, resident rights, abuse, and oxygen control. Administrator #1 stated they had a checklist and cheat sheets for the things staff needed to know. Dementia training was part of resident rights. Quality Assurance was not part of nursing education. 10 New York Code of Rules and Regulations 415.26(c)(1)(iv)

Based on interview and record review during a recertification and Extended survey, the facility did not ensure that an effective training program for all new and existing staff was developed, implemented, and maintained based on the facility assessment. Specifically, for five (5) of five (5) employee files reviewed, the facility did not provide mandatory training that outlines and informs staff of the elements and goals of the facility's Quality Assurance Performance Improvement program as part of its Quality Assurance Performance Improvement program.This is evidenced by:Cross reference: F726 The Facility Assessment, dated 1/2026, documented under Staff training /education and competencies, the following topics, in addition to others, will be presented to staff: Communication, Resident Rights and facility responsibilities, Emergency planning, Person centered care, Dementia and behavioral management, substance abuse identification, trauma informed care/PTSD, proper body mechanics, Abuse, neglect, and exploitation, Infection control, Culture change, Required in-service training for nurse aides. In-service training must:o Be enough to ensure the continuing competence of nurse aides must be no less than 12 hours per year.o Include dementia management training and resident abuse prevention training.o Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff.o For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired. Identification of resident changes in condition, Cultural competency The following competencies and others will be offered to staff as necessary: Person-centered care Activities of daily living Disaster planning and procedures Infection control Medication administration Measurements: blood pressure, orthostatic blood pressure, body temperature, urinary output, etc. Resident assessment and examinations or Observations Caring for persons with Alzheimer's or another dementia Specialized care Caring for residents with mental and psychosocial disordersPolicies and procedures for the provision of care to our residents will be reviewed periodically to ensure that the methods we were utilizing to render that care was in line with the current practices of our industry. Staff would be provided with the opportunity to attend seminars, and educational experience would be utilized in tailoring our policies and procedure to ensure we were providing to the best and most up to date care to our residents. The policy did not have documented evidence that training on the Quality Assurance Performance Improvement program would be provided to staff. The facility's Quality Assurance and Performance Improvement policy, undated, did not contain any documentation of a requirement that staff would be educated on the Quality Assurance and Performance Improvement policy.Certified Nurse Aide #1's education file from the facility did not contain documented evidence that all of the annual educations had been completed after 1/09/2022, many years after Certified Nurse Aide #1 had been employed at the facility. Certified Nurse Aide #1's electronic education record indicated that less than 12 hours of annual education had been completed by the time of survey. Quality Assurance and Performance Improvement policy and procedures were not included in the list of required education.Certified Nurse Aide #5's education file from the facility contained multiple in-service sign- in sheets and some posttests associated with education. It could not be determined if Certified Nurse Aide #5 had completed all required annual educations from the provided information. Certified Nurse Aide #5 electronic education record indicated that less than 12 hours of annual education had been completed by the time of survey. Quality Assurance and Performance Improvement policy and procedures were not included in the list of required education.Certified Nurse Aide #15's education file from the facility did not contain evidence that annual educations had been done except for a written statement of verbal education of staff involving an incident that occurred on 2/18/2026, and the electronic health records provided by the facility did not contain any education topics for Certified Nurse Aide #15. Quality Assurance and Performance Improvement policy and procedures were not included in the list of required education.Licensed Practical Nurse #1's education file from the facility did not contain documented evidence that annual educations had been done since 2022, except for one posttest provided dated 2024 and part of an answer sheet from a test that had no title. Licensed Practical Nurse #1's electronic education records documented that two (2) of the ten (10) education topics were completed for 2025. Quality Assurance and Performance Improvement policy and procedures were not included in the list of required education.Licensed Practical Nurse #12's education file from the facility did not contain documented evidence that annual educations had been completed since 2024. Licensed Practical Nurse #12's electronic education records documented that one (1) of the six (6) education topics were completed for 2025. Quality Assurance and Performance Improvement policy and procedures were not included in the list of required education.During an interview on 2/13/2026 at 9:29 AM, Assistant Administrator #1 stated that typically the nurse educator was the Assistant Director of Nursing. Registered Nurse #2 had been filling in since they arrived. Assistant Administrator #1 stated they did on the spot education when it was needed. The management team in general did education when needed.During an interview on 2/19/2026 at 9:35 AM, Assistant Administrator #1 stated that Acting Director of Nursing #1 handled education. The prior Assistant Director of Nursing and Director of Nursing also worked on education. There was an electronic education system that the staff were supposed to be using. Ideally, online teaching would be set up monthly to piggyback on in-house education and be due by particular date. There were some one (1) on one (1) educations and group in- services where people signed in. With the change of staff, education did stop for a little while. The previous Assistant Director of Nursing should have been keeping a binder with the information, but when they left, Assistant Administrator #1 was not able to find any of the information. Staff should have been getting yearly educations on things like precautions, safety, and resident rights.During an interview on 2/24/2026 at 10:25 AM, Licensed Practical Nurse #3 stated that they knew that they had overdue educations on the electronic education system and stated they did not have enough time in the day to complete them. Licensed Practical Nurse #3 stated that they did handwashing and infection control in the last year but were not sure if they had any teaching on Quality Assurance Performance Improvement program.During an interview on 2/25/2026 at 11:04 AM, Director of Nursing #1 stated that education was going to be their priority. Director of Nursing #1 stated they were aware that there were required annual educations such as abuse, identifying and reporting, infection control, dealing with challenging residents/dementia care, activities of daily living, body mechanics, sexual harassment, foley care, urinary tract infections, medication administration, wound care, and resident rights. Everyone should have gotten abuse, reporting, and resident rights education.During an interview on 2/25/2026 at 12:25 PM, Administrator #1 stated that they would work closely and as a team with Director of Nursing #1. Use of the online education system would make things easier. Administrator #1 stated they had accessed the online education system and that the annual education that needed to be done would be done by the Assistant Director of Nursing when they were hired. The online education system tracked the aides' required hours of education and went into effect in August 2025. There were house wide educations that everyone needed to do such as fire safety, resident rights, abuse, and oxygen control. Administrator #1 stated they had a checklist and cheat sheets for the things staff needed to know. Dementia training was part of resident rights. Quality Assurance was not part of nursing education. 10 New York Code Rules and Regulations 415.26

Based on observation, record review and interviews conducted during a survey, the facility did not ensure that drug records were in order, that an account of all controlled drugs was maintained and periodically reconciled in four (4) of four (4) narcotic books reviewed on Units one (1) and two (2), and that nurses were properly documenting narcotic administration. Specifically, (a) for the shift-to-shift staff signature form for controlled drugs, titled Controlled Drugs-Count Record, did not consistently include the signatures of staff members at each shift change, validating the correct narcotic count; (b) Licensed Practical Nurse #8 did not document the administration of narcotics to Resident #5 at the time of administration.This is evidenced by: An undated facility policy titled Controlled Substances, documented that the facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. Additionally, nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services.An undated facility policy titled Administering Medications, documented that the individual administering the medication must initial the resident's electronic medical administration record on the appropriate line after giving each medication and before administering the next medication.During observations on 2/18/2026 at 9:59 AM, it was noted that the narcotics administered by Licensed Practical Nurse #8 to Resident #5 in the morning had not been signed for yet. A physician order dated 2/05/2026 at 8:00 PM documented to give 1 tablet of lorazepam 0.5 milligrams by mouth two times a day for anxiety and agitation.The Medication Administration Record dated February 2026, documented that on 2/18/2026, Resident #5 received their 8:00 AM dose of lorazepam from Licensed Practical Nurse #8.During observations on 2/18/2026 at 9:20 AM, narcotic sheets on both carts of Unit one (1) and two (2) were noted to not be consistently signed by two nurses shift to shift. A review of the shift-to-shift reconciliation of narcotics forms on Unit one (1) front medication cart #1 for January and February 2026 documented missing signatures for the following dates: 1/04/2026 on-coming nurse signature for 11PM-7AM shift, 1/05/2026 off-going nurse on the 11PM-7AM shift, 1/05/2026 on-coming nurse 11PM-7AM shift, 1/06/2026 off-going nurse 11PM-7AM shift, 1/07/2026 both the on-coming and off-going nurses 3 PM-11PM shift, and on-coming nurse 11PM-7AM shift, 11/08/2026 off-going nurse 11PM-7AM shift, as well as both on-coming and off-going nurses 7AM-3PM, 1/10/2026 both the on-coming and off-going nurses for the 3PM-11PM shift, 1/11/2026both on-coming and off-going nurses on 3PM-11PM shift, 1/13/2026 both on-coming and off-going nurses on 7AM-3PM shift and 3PM-11PM shift, 1/14/2026 on-coming nurse 11PM-7AM shift, 1/15/2026 off-going nurse 11PM-7AM, 1/23/2026 both on-coming and off-going nurses 7AM-3PM shift, 1/24/2026, 1/25/2026, 1/26/2026, 1/27/2026, 1/28/2026 and 1/29/2026, 1/30/2026, 1/31/2026, 2/01/2026, 2/02/2026, 2/03/2026, 2/04/2026, and 2/06/2026 both off-going and on-coming nurses 11PM-7AM shift, 2/07/2026 off-going nurse 3PM-11PM shift, 2/08/2026 both on-coming and off going nurse for 3PM-11PM shift, 2/14/2026 and 2/15/2026 both off-going and on-coming nurses 11PM-7AM shift, and 2/17/2026 off-going nurse 11PM-7AM. Additionally, one nurse signature was as both the off-going and on-coming nurse for the following dated shifts, but were not documented to be working double shifts: 7AM-3PM and 3PM-11PM shifts on 1/02/2026, 1/05/2026, , 1/24/2026, and 1/26/2026, .A review of the shift-to-shift reconciliation of narcotics forms on Unit one (1) back medication cart #2 for February 2026 documented missing signatures for the following dates: 2/01/2026 on-coming nurse signature for 11PM-7AM shift, 2/02/2026 off-going nurse on the 11PM-7AM shift, 2/03/2026 on-coming nurse 11PM- 7AM shift, 2/04/2026 off-going nurse 11PM-7AM shift, 2/05/2026 on-going nurse 11PM-7AM shift, 2/06/2026 off-going 11PM-7AM shift, 2/14/2026 on-coming nurse 11PM-7AM shift, and 2/15/2026 off-going nurse 11PM-7AM. Additionally, one nurse signature was as both the off-going and on-coming nurse for the following dated shifts, but were not documented to be working double shifts: 7AM-3PM and 3PM-11PM shifts on 2/04/2026, 2/05/2026, 2/08/2026, 2/09/2026, 2/10/2026, 2/11/2026, 2/13/2026, and 2/17/2026.A review of the shift-to-shift reconciliation of narcotics forms on Unit two (2) front medication cart #1 for January 2026 documented missing signatures for the following dates: 1/01/2026 both on-coming and off-going nurse signature for 3PM-11PM and 11PM-7AM shifts, both on-coming and off-going nurse for 3PM-11PM shift on 1/05/2026, 1/06/2026 both on-coming and off-going nurse 7AM-3PM, 3PM-11PM and 11PM-7AM shifts, 1/08/2026 both on-coming and off-going nurse on 7AM-3PM shift, 1/05/2026 on-coming nurse 11PM-7AM shift, 1/13/2026 both on-coming and off-going nurse 3PM-11PM shift, 1/15/2026 on-coming nurse 11PM-7AM, 1/16/2026 off-going nurse 11PM-7AM, 1/18/2026 both on-coming and off-going nurses for 11PM-7AM, 7AM-3PM, and 3PM-11PM shifts, 1/19/2026 off-going nurse 11PM-7AM, both on-coming and off-going nurses for 7AM-3PM and 3PM-11PM, 1/20/2026 off-going nurse 7AM-3PM shift, 1/23/2026 both on-coming and off-going nurses for 7AM-3PM and 3PM-11PM shifts, 1/30/2026 both on-coming and off-going nurses for 3PM-11PM and the off-going nurse for 11PM-7AM, 1/31/2026 off-going nurse 11PM-7AM nurse and both on-coming and off-going nurse 7AM-3PM shift. Additionally, one nurse signature was as both the off-going and on-coming nurse for the following dated shifts but were not documented to be working double shifts: 7AM-3PM and 3PM-11PM shifts on 1/09/2026, and 1/24/2026. A review of the shift-to-shift reconciliation of narcotics forms on Unit two (2) back medication cart #2 for February 2026 documented missing signatures for the following dates: 2/02/2026 on-coming nurse signature for 7AM-3PM shift, 2/06/2026 off-going nurse on the 3PM-11PM shift, 2/08/2026 off-going nurse 3PM-11PM shift, 2/09/2026 off-going nurse 3PM-11PM, 2/10/2026 both on-coming and off-going nurse 3PM-11PM shift, 2/11/2026 on-coming nurse 11PM- 7AM shift, 2/12/2026 off-going nurse 11PM-7AM shift, 2/16/2026 on-coming nurse 11PM-7AM, and 2/17/2026 off-going nurse 11PM-7AM shift. During an interview on 2/18/2026 at 9:23 AM, Licensed Practical Nurse #4 stated that the narcotic sheets should be signed by two nurses every shift when they switch off. When asked why they had not signed with another nurse on 2/17/2026, Licensed Practical Nurse #4 stated that the agency nurse who's name they did not know handed them the keys and ran out the door and would not come back to do the count. During an interview on 2/18/2026 at 9:45 AM, Licensed Practical Nurse #9 stated they kept their narcotic book in the medication storage room and took it out when they needed it.During an interview on 2/18/2026 at 9:59 AM Licensed Practical Nurse #8 stated that the facility process was to sign specific narcotic count sheets at the time of narcotic administration.During an interview on 2/25/2026 at 11:04 AM, Director of Nursing #1 stated that they expected that the nurse that handed off the keys and the nurse that took the keys needed to sign the narcotic sheets together. The narcotic count should be done every time the keys were passed.During an interview on 2/25/2026 at 12:25 PM, Administrator #1 stated that the narcotic sheets needed to be signed by 2 nurses at shift change. They could not speak to why it was not getting done. 10 New York Codes, Rules, and Regulations 415.18(b)(3)

Based on observation, record review, and interviews during the recertification survey, it was determined the governing body did not establish and implement policies regarding the management and operation of the facility. The governing body did not maintain a consistent Administrator who was responsible for the management of the facility to ensure regulatory compliance. Specifically, multiple deficiencies were identified on the recertification survey including repeat deficiencies in the areas of safe/clean/comfortable/homelike environment(F584), develop/implement comprehensive care plan(F656), care plan timing and revision (F657), and Influenza and pneumococcal immunizations (F883).This is evidenced by: Facility was cited for the following on recertification survey:F550 as it pertains to the facility's failure to resident dignity.F580 as it pertains to the facility's failure to notify providers and resident representatives about changes of condition.F584 as it pertains to the facility's failure to provide a safe, clean, comfortable and homelike environment.F600 as it pertains to the facility's failure to ensure residents were free from abuse and neglect.F609 as it pertains to the facility's failure to ensure injuries from unknown sources were reported to the State Survey Agency.F610 as it pertains to the facility's failure to all allegations of abuse, neglect, exploitation or mistreatment were thoroughly investigated.F628 as it pertains to the facility's failure to document and notify the appropriate entities of discharges and transfers. F656 as it pertains to the facility's failure to develop and implement a comprehensive person-centered care plan for each resident.F657 as it pertains to the facility's failure to review and revise a comprehensive person-centered care plan for each resident.F679 as it pertains to the facility's failure to provide activities based on comprehensive assessment, care plan, and preferences of each resident.F684 as it pertains to the facility's failure to ensure services provided met professional standards.F695 as it pertains to the facility's failure to ensure respiratory care services provided met professional standards.F711 as it pertains to the facility's failure to ensure that physician notes were entered and maintained accurately.F725 as it pertains to the facility's failure to ensure sufficient staffing services provided met professional standards.F726 as it pertains to the facility's failure to ensure competent nursing services provided met professional standards.F755 as it pertains to the facility's failure to ensure that pharmaceutical services were provided to meet the needs of each resident.F804 as it pertains to the facility's failure to ensure that food and drink were palatable, attractive, and at a safe and appetizing temperature.F812 as it pertains to the facility's failure to store, prepare, distribute, and serve food met professional food service safety standards. F851 as it refers to the facility's failure to ensure that accurate staffing information based on payroll data was submitted to Centers for Medicaid/Medicare Services.F867 as it refers to the facility's failure to ensure that the Quality Assurance Process Improvement feedback, data systems and monitoring.F883 as it refers to the facility's failure to ensure that providing and/or documenting influenza and/or pneumococcal immunizations as required for residents.F908 as it refers to the facility's failure to ensure that maintaining all mechanical electrical and patient care equipment in a safe operating condition.F940 as it refers to the facility's failure to ensure that it developed, implemented, and maintained an effective training program for all new and existing staff.F944 as it refers to the facility's failure to ensure that it included as part of its Quality Assurance Performance Improvement program mandatory training that outlined and informed staff of the elements and goals of the facility's Quality Assurance Process and Improvement program.F947 as refers to the facility's failure to ensure that in-service training for nurse aides was sufficient to ensure the continuing competence of nurse aides and be no less than 12 hours per year.The undated document titled, Quality Assurance Performance Improvement, documented it was the policy of this facility to establish and utilize specific systems for feedback, data collection, and monitoring inclusive of adverse events. The information would be utilized to fulfill the facility's responsibility and accountability for assessment and improvement in the quality of care and the services provided to resident's families and the community we serve. Under Feedback, Data Systems and Monitoring documented that Performance Improvement Projects (quality indicators) would be chosen based on those elements, which measured facility wide functions, involving high-volume, high risk and/or problem-prone activities. The Facility Assessment would be utilized in further determining quality indicators that were relative to the needs of the population served. The development of Performance Improvement Projects (indicators) would also be based upon feedback received from the following data sources. These considerations include but are not limited to: Direct observations of the Quality Assurance Performance Improvement Committee Input from residents, families, staff, and other customers Accident/Incident reports Infection Control reports Consultant Services/reports Monthly Department Head meetings QI/QM, acronym not defined, reports; Facility Indicator Profile Report DentalFacility-wide indicators may include such areas as: Staff turnover, recruitment, and retention efforts Safety issues (related to residents and employees, visitors) Resident Grievances Other areas as identified based upon outcomes and feedback from those servedThe documented objectives were:1. Establish, maintain, support, and document evidence of an ongoing QAPI program that included effective mechanisms for monitoring and evaluating resident care and for appropriate response to findings.2. Assist individual departments in improving care and identifying problems through the use of ongoing performance improvement projects. This was to be done by focusing on identification, analysis and resolution of problems that affected the residents of the facility.3. Evaluate the results of action taken by individual departments and maximize the efficient use of resources available within the facility.4. Centralize and expand the scope of present quality improvement activities into a more comprehensive program.5. Direct improvement efforts at processes, not individuals.The documented Design and Scope was that Quality Assurance Performance Improvement activities would be integrated and coordinated among departments within the facility; they would be designed to minimize duplication of effort; and would be cost-effective. AllThe document referenced above ended at All and the last two pages of the document supplied by the facility was a Quality Assurance and Performance Improvement test.During an interview on 2/12/2026 at 3:53 PM, Ombudsman #1 stated that they were at the facility weekly except for the last two weeks and they did not see the Administrator. Ombudsman #1 stated that they would go a month or more with seeing Administrator #1. Ombudsman #1 stated that Assistant Administrator #1 was administering the building and that the residents considered the Assistant Administrator the actual Administrator.During an interview on 2/13/2026 at 9:29 AM, Assistant Administrator #1 stated that Administrator #1 was at the facility periodically but always accessible and they talked multiple times a day. During an interview on 2/25/26 at 10:10 AM Administrator #1 stated that they became Administrator in August 2025 when the previous Administrator told them on a Friday that they would not be returning on the following Monday. Administrator #1 stated they had no choice but to put their name on the building as they owned 9% of the facility. At the time of taking over as Administrator, they had asked the Medical Director and Director of Nursing if there were any major infection control concerns, to which they said no. Administrator #1 stated that Director of Nursing #1 was going to be the answer to many of the issues identified during survey. Administrator #1 stated that they were already working on a new formula on how to track issues. Administrator #1 stated that when the previous Administrator was running the building, Administrator #1 was at the facility every other week. Now Administrator #1 was at the facility from Sunday through Thursday, every week. Administrator #1 acknowledged that residents might not know they were the Administrator. Administrator #1 stated they had been identifying issues where they wanted things to change. Administrator #1 stated they did not recall ever doing a Performance Improvement Project or Plan with any individuals in the facility.During an interview on 2/25/2026 at 11:04 AM Director of Nursing #1 stated in the week that they had been in the building, they believed the bones were good but the facility needed revamping. Director of Nursing #1 stated they were actively interviewing for a local administrator.During an interview on 2/25/2026 at 12:25 PM Administrator #1 stated that they have tried to address issues that were brought to them as soon as they could. They were not aware of some of the issues that had been brought to light during survey. Administrator #1 stated they needed some new processes. Administrator #1 stated that all issues should be and going forward would be discussed in morning meeting and afternoon wrap up. Administrator #1 stated that department heads would be monitored more closely and that they would look at regulations to ensure compliance with things they did not know the regulations on. 10 New York Code of Rules and Regulations 415.26(b)(3)(1)

Based on observation, record review, and interviews during a survey, the facility did not ensure that all alleged violations involving abuse, neglect, and injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that cause the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) for five (5) (Resident #s 75, 34, 43, 54, and 90) of nine (9) residents reviewed. Specifically, (a.) for Resident #s 75 and 34, the facility did not ensure the administrator was notified of a resident-to-resident verbal/physical altercation that included a call to 911 by Resident #75 on 6/22/2025, during the night shift. On 6/28/2025, Resident #75 told their family member about the incident, who then filed a facility complaint/grievance. The incident was not reported to the New York State Department of Health; (b.) Resident #43 reported an allegation of abuse by a Certified Nurse Aide on 2/18/2026 at 9:43 PM. The incident was not reported to the administrator within two (2) hours and was not reported to the New York State Department of Health until 2/19/2026 at 9:30 PM; (c.) Resident #54 had an unwitnessed fall on 2/19/2026 and was admitted with a hip fracture (break in upper thigh). The injury was not reported to the New York State Department of Health; and (d.) On 1/05/2026, Resident #90, was noted to have a left hip fracture with an unknown source. The injury was not reported to the New York State Department of Health. This is evidenced by: Cross-referenced to F600: Free from Abuse and Neglect Cross-referenced to F610: Investigate/Prevent/Correct Alleged Violation The undated Policy and Procedure titled, Cleaning Reporting Resident Abuse, Mistreatment, Neglect or Misappropriation of Property, documented staff were to immediately call the New York State Department of Health toll-free hotline if they witnessed or suspected abuse, mistreatment, neglect, exploitation, or misappropriation of resident property. Immediately report the incident to the nursing supervisor, director of nursing, or the administrator, who would begin the investigation. The facility would report the alleged abuse to the Department of Health in addition to the staff member. Immediate action would be taken to ensure the resident received any needed care/services and to prevent further potential abuse while the incident was under investigation. All cases were thoroughly investigated by the facility. The director of nursing would coordinate the investigation unless otherwise directed by the administrator. Whenever there was a reasonable cause to believe resident physical abuse, mistreatment, neglect, or appropriation of property had occurred by staff, or a family member, the suspecting staff member would call the New York State Department of Health: All alleged violations and injuries of unknown source were to be reported immediately, but not later than two (2) hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury. Not later than 24 hours if the allegation did not involve abuse and did not result and did not result in serious bodily injury, to the administrator of the facility and to other officials (i.e. State Survey Agency and adult protective services). Registered nurse assessment would be completed. A psychosocial assessment would be completed to identify any potential psychosocial harm. Any staff member accused of abusing, mistreating, neglecting a resident or misappropriating resident property would be immediately interviewed and then suspended from work until a thorough investigation was completed and a determination made. Resident #75: Resident #75 was admitted to the facility with diagnoses of noninfective gastroenteritis (inflammation that spreads from the stomach into the intestines and cause, pain, vomiting, and diarrhea) and colitis (inflammation of the large intestine), chronic idiopathic constipation (functional bowel disorder characterized by difficult, infrequent and/or incomplete defecation) and slow transit constipation (slow movement of waste through the digestive system). The Minimum Data Set (an assessment tool) dated 12/31/2025, documented the resident had moderate cognitive impairment. The resident was able to make themselves understood and understand others. Review of Resident #75's comprehensive care plan did not include a care plan with interventions for abuse and neglect. Resident #34: Resident #34 was admitted to the facility with diagnoses of dementia with other behavioral disturbance, parkinsonism (umbrella term that refers to brain conditions that cause slowed movements, rigidity (stiffness) and tremors (looks like trembling or shakiness), and seizures (sudden burst of electrical activity in the brain that causes changes in behavior, movements, feelings and levels of consciousness). The Minimum Data Set, dated [DATE], documented the resident had severe cognitive impairment. The resident was able to make themselves understood and understand others. Review of Resident #34's comprehensive care plan did not include a care plan with interventions for abuse and neglect. Grievance Form dated 6/28/2025, documented Family Member #4 reported a grievance. The name/signature of the staff member who received the grievance was not documented, it was blank. Description of complaint/grievance documented the grievance was filed because Resident #34 entered Resident #75's room on Sunday night, 6/22/2025 to 6/23/2025 and harassed and assaulted Resident #75 with their water bottle. Resident #75 did not feel safe that Resident #34 still resided on the same floor as them. Resident #75 told Family Member #4 they felt shaky and scared every time they saw Resident #34. They respectfully requested that Resident #34 be moved to the first-floor unit. Additionally, the form documented: To ensure abuse and neglect were ruled out promptly, did grievance require further investigation? The answer was not documented, it was blank. Investigation/Follow-up to Complaint/Grievance was not documented, it was blank. Resident/Family Follow-Up: o It was documented that the person filing the complaint/grievance was notified of actions taken and they were satisfied. An undated note by Licensed Practical Nurse Manager #2 documented a meeting was held with family and appropriate staff members. Residents had been kept in separate areas, as requested by the family. No further incidents occurred, no concerns voiced, and Resident #75 was observed to be free of anxiety due to the interaction. Review of Nursing Progress Notes dated June 2025, did not have documented evidence of resident-to-resident altercation or assessment following the incident for Resident #s 75 and 34. The Comprehensive Care Plan for Resident #s 34 and 75 did not have documented evidence of interventions to prevent recurrence of abuse. The facility could not provide documented evidence of an investigation of the incident dated 6/22/2025, during the night shift, and there was no documented evidence that the incident was reported to the New York State Department of Health. During an interview on 2/13/2026 at 3:28 PM, Family Member #4 was with Resident #75 in the dining room. Family Member #4 stated they usually only visited Resident #75 on the weekend. They stated that in June 2025, Resident #75 was calling out for help after Resident #34 had entered their room around 2:00 AM and yelled at Resident #75 and then dumped water from the resident's tall refillable water bottle onto Resident #75. No staff came to help, and Resident #75 called 911. The 911 dispatcher called the facility and staff entered Resident #75's room. They stated no one from the facility reported the incident to them. Family Member #4 stated they learned about the incident from Resident #75 when they came into the facility to address an issue with the resident's phone charger. They stated Resident #75 was still scared when they told Family Member #4 about the incident. Resident #75 acknowledged they were afraid when the incident occurred. During an interview on 2/19/2026 at 11:51 AM, Licensed Practical Nurse Manager #2, stated they were not notified of an altercation between Resident #'s 34 and 75 until they were brought into a meeting with the social worker, former administrator, former director of nursing, and resident's son and daughter, after a grievance was filed about the incident. They stated the resident's daughter was very nervous for Resident #75 because the resident was very nervous. Licensed Practical Nurse Manager #2 stated they did not know if the incident was reported to the New York Department of Health. They were not involved in any notification, investigation, or care planning for the incident. They did not investigate the incident and did not ask any staff on the unit about the incident. After the meeting with the family, they put a stop sign across Resident #75's door and entered an order to locate Resident #34 every 2 hours. During an interview on 2/19/2026 at 2:17 PM, Assistant Administrator #1 stated they were not notified of an incident between Resident #s 34 and 75. They were unable to locate an incident report or investigation but found a grievance report in the former administrator's grievance binder, made by Resident #75's family member. The incident was reportable to the New York State Department of Health, and the administrator should have been notified at the time of the incident. There should have been a full investigation that included interviews from both residents, staff, and family members. There should have been an assessment of both residents to ensure there was no harm, and they were content. During an interview on 2/25/2026 at 9:42 AM, Medical Director #1 stated resident-to-resident altercations were a common occurrence in most facilities and were not always made aware. There were times when they reviewed and signed off on incident and accident reports. They stated they were not always notified of incidents/accidents that were reportable to the New York State Department of Health. They would expect the facility to conduct an investigation of all incidents/accidents. During an interview on 2/25/2026 at 10:17 AM, Director of Nursing #1 stated they were not working in the facility when the alleged resident-to-resident altercation occurred. They would have expected staff to respond to Resident #75 when they were yelling for help. There was a flashing light above the nurse station that indicated movement down the hall, where Resident #75 resided and staff should have responded accordingly. The expectation was for staff to complete an incident/accident report and conduct a thorough investigation, especially since Resident #75 called 911. As director of nursing, they would expect a phone call from staff immediately following the incident and stated the administrator was to be notified within two (2) hours. Director of Nursing #1 stated the incident was reportable to the New York State Department of Health because Resident #75 stated they were afraid and were assaulted, because contact was made by Resident #34. The family should have been notified within (two) 2 hours of the incident. During an interview on 2/25/2026 at 11:05 AM, Administrator #1 stated they were not the administrator when the alleged altercation between Resident #s 34 and 75 occurred and was not made aware of it. They stated they would expect immediate reporting of a resident-to-resident altercation to the director of nursing and administrator, and a thorough investigation. They stated they could not fix something they did not know about. If they were doing the investigation, they would have asked the unit manager about the incident. The facility's responsibility was to ensure safety and health for all residents. Resident-to resident altercations were reportable to the New York State Department of Health. Resident #90 Resident #90 was admitted to the facility with diagnoses of dementia (a group of conditions that cause a progressive decline in cognitive abilities), peripheral vascular disease (a condition that affects the blood vessels outside of the heart), and chronic kidney disease (long-term irreversible loss of kidney function). The Minimum Data Set, dated [DATE], documented the resident had severe cognitive impairment, could be understood, and could understand others. Nursing Progress Note dated 1/01/2026 at 12:46 AM by Licensed Practical Nurse #13, documented Resident #90 was found on the floor in their bathroom. Resident #90 had a laceration to the back of their scalp and bilateral arms. The resident was coherent and at baseline. The Nurse Practitioner and the resident's family were notified. Nursing Progress Note dated 1/01/2026 at 11:01 AM by Licensed Practical Nurse #10, documented Resident #90 was found on the floor in between the bathroom door. There was bleeding noted from the back of Resident #90's head. The Nurse Practitioner was notified and ordered Resident #90 be sent to the hospital. Provider Note dated 1/02/2026 at 12:00 AM by Nurse Practitioner #1, documented chief complaint: emergency room return status post fall with head laceration. Resident #90 had a fall with positive head strike. On assessment, a laceration was noted to the posterior scalp. The area was cleansed with normal saline. No closure was required. Later, on 1/02/2026, the provider received a call from nursing reporting Resident #90 had a second fall with positive head strike. The resident sustained a larger scalp laceration with active bleeding that required closure. The resident was sent to the emergency department for evaluation and management. Resident #90 returned from the hospital with staples intact to the scalp and new orders for bacitracin (topical antibiotic ointment). Nursing Progress Note dated 1/05/2026 at 8:23 PM by Licensed Practical Nurse #13, documented Resident #90 had an x-ray completed of their bilateral hips. The x-ray showed fracture of the left hip (broken hip). The Nurse Practitioner was notified and advised the resident go to the hospital. Provider Note dated 1/05/2026 at 12:00 AM by Nurse Practitioner #1, documented Resident #90 was evaluated following reports of acute hip pain and functional decline after suspected injury. Resident reported significant pain with movement and inability to bear weight on the affected extremity. There was no report of additional trauma. Resident was being transferred from the facility to the hospital for acute evaluation of left hip pain and inability to bear weight following suspected injury. It further documented imaging was obtained and demonstrated an acute complete intertrochanteric femoral fracture with mild displacement (hip fracture). Signed by Nurse Practitioner #1 on 1/06/2026 at 10:01 AM. Nursing Progress Note dated 1/19/2026 at 10:05 PM, written by Licensed Practical Nurse #8, documented Resident #90 returned from the hospital via stretcher around 3:00 PM. Resident #90 had a fracture of the left femur and was covered with a dressing. Will monitor. Nursing Progress Note dated 1/20/2026 at 6:40 AM by Licensed Practical Nurse #5, documented Resident was a readmission to the facility with a diagnosis of left femur fracture status post-surgical procedure. The resident slept peacefully most of the shift. It further documented, when Licensed Practical Nurse #5 and a Certified Nurse Aide would reposition or provide care, Resident #90 would moan out when moved. When Resident #90 was asked if they were in pain, they did not respond. During an interview on 2/20/2026 at 10:43 AM, Licensed Practical Nurse #2 stated Resident #90 was a frequent faller. They stated Resident #90 ambulated with a walker. Licensed Practical Nurse #2 stated on 1/01/2026 Resident #90 had 2 unwitnessed falls and was sent to the hospital after the second fall because of a laceration. They stated the resident returned from the hospital on 1/01/2026 but was more confused. They stated Resident #90 was still able to ambulate with their walker. Licensed Practical Nurse #2 stated Resident #90 was fine during dinner on 1/04/2026 and then when they returned to work on the 1/05/2026, they were informed of the resident's increased pain. They stated an x-ray was done and the resident was sent out for surgery. Licensed Practical Nurse #2 stated they did not know if anything was reported about the fall, but something would have had to happen to cause the pain or change in Resident #90's condition. They further stated in their opinion Resident #90 had a fall which led to the fracture. Licensed Practical Nurse #2 stated Resident #90's fracture led to their overall decline. They stated the resident was not the same after surgery, they could no longer ambulate and used a geriatric chair. During an interview on 2/20/2026 at 12:14 PM, Acting Director of Nursing #1 stated if a resident had an injury of unknown origin, they would report it to the Director of Nursing, Administrator, Nurse Practitioner, and the Department of Health. They stated they were not familiar with Resident #90 or their fracture. During an interview on 2/20/2026 at 2:24 PM, Certified Nurse Aide #6 stated that before Resident #90 was hospitalized for the fracture, the resident was up, walking with a walker, putting on their own clothes, and would come down to socialize at the desk. They stated after Resident #90 returned from the hospital following their fracture, they did not want to eat, they could no longer stand or walk, and they did not know what was going on. They stated the resident changed a lot. An attempt to call Licensed Practical Nurse #13 was made on 2/23/2026 at 2:00 PM with no return call received. During a subsequent interview on 2/23/2026 at 2:24 PM, Nurse Practitioner #1 stated that on 1/05/2026, nursing reported pain in Resident #90's hip, so they did an x-ray which showed a hip fracture. Nurse Practitioner #1 stated it was their understanding at the time that there was no injury in between the hospitalizations. They stated the fracture could been a result of the falls on 1/01/2026. The hospital did not complete any x-rays or full body tests on 1/01/2026. They stated they were in the building when notified of the increased pain. Nurse Practitioner #1 stated they could not say whether the resident's fracture was something that should be reported to the Department of Health. They stated every member of the interdisciplinary team including the Director of Nursing and Administrator was notified via email when someone was sent to the hospital and that it was probably reviewed at morning report. During an interview on 2/24/2026 at 11:29 AM, Family Member #7 stated they were made aware of Resident #90's falls on 1/01/2026 and agreed that that resident be sent to the hospital. After Resident #90's hospital trip on 1/01/2026, they started acting like they had dementia. They were more confused. They further stated that when they went to visit, Resident #90 would not stand after their falls on 1/01/2026 and the resident complained that their leg hurt, and they massaged it. The resident did not indicate that they had pain in their hip. They stated the family felt bad that they did not pick up on it sooner, but Resident #90 was so confused. Family Member #7 stated they did not think that any kind of abuse or neglect occurred. During an interview on 2/25/2026 at 9:29 AM, Medical Director #1 stated they were made aware of falls, skin tears, etc. through Incident and Accident Reports. It was their responsibility to sign off on them. They stated falls were one of the biggest issues that they faced in long-term care. They stated they would expect the facility to complete an investigation for an injury of unknown origin, and it should be reported to the Department of Health. During an interview on 2/25/2026 at 11:04 AM, Director of Nursing #1 stated an injury of unknown origin should be reported within two (2) hours to the Department of Health, and the Director of Nursing or Administrator was responsible for reporting. They stated they would then complete an investigation for an injury of unknown origin. During an interview on 2/25/2026 at 12:25 PM, Administrator #1 stated they reported anything in the regulations that needed to be reported to the Department of Health. They stated it was a team effort on what should be reported. They stated some things such as abuse should be reported to the Department of Health within two (2) hours. Administrator #1 further stated they would report an injury of unknown origin to the Department of Health. 10 New York Code of Rules and Regulations 415.4(b)(2)

Based on observation, record review, and interviews during a survey, the facility did notensure in response to allegations of abuse/neglect they had evidence that all alleged violations were thoroughly investigated; they prevented further potential abuse/neglect while the investigation was in progress; and reported the results of all investigations to the administrator or their designated representative and to the State Survey Agency, within five (5) working days of the incident, and if the alleged violation was verified appropriate corrective action must be taken for six (6) (Resident #s 34, 43, 54, 75, 87, and 90) of 9 residents reviewed. Specifically, (a.) for Resident #s 75 and 34, the facility did not have documented evidence of an investigation of a resident-to-resident verbal/physical altercation on 6/22/2025, during the night shift; (b.) for Resident #43, the facility did not initiate an immediate investigation and prevention of further potential abuse when the resident reported they were hurt by a Certified Nurse Aide on 2/18/2026. As a result, the facility did not identify the accused staff member at the time of the report and the staff member continued to provide care to the residents; (c.) for Resident 54, the facility did not have evidence of a thorough investigation for documented falls dated 3/07/2025, 3/16/2025, 5/02/2025, 5/05/2025, 9/25/2025, 12/29/2025, and an injury of unknown origin dated 3/18/2025; (d.) for Resident #87, the facility did not have documented evidence of a thorough investigation of an unwitnessed fall dated 1/13/2026; (e.) for Resident #90, the facility did not have documented evidence of a thorough investigation for two (2) unwitnessed falls on 1/01/2026 and an injury of unknown source identified on 1/05/2026.This is evidenced by: Cross-referenced to F600: Free from Abuse and Neglect Cross-referenced to F609: Reporting of Alleged Violations The undated Policy and Procedure titled, Cleaning Reporting Resident Abuse, Mistreatment, Neglect or Misappropriation of Property, documented staff were to immediately call the New York State Department of Health toll-free hotline if they witnessed or suspected abuse, mistreatment, neglect, exploitation, or misappropriation of resident property. Immediately report the incident to the nursing supervisor, director of nursing, or the administrator, who would begin the investigation. The facility would report the alleged abuse to the Department of Health in addition to the staff member. Immediate action would be taken to ensure the resident received any needed care/services and to prevent further potential abuse while the incident was under investigation. All cases were thoroughly investigated by the facility. The director of nursing would coordinate the investigation unless otherwise directed by the administrator. Whenever there was a reasonable cause to believe resident physical abuse, mistreatment, neglect, or appropriation of property had occurred by staff, or a family member, the suspecting staff member would call the New York State Department of Health: All alleged violations and injuries of unknown source were to be reported immediately, but not later than two (2) hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury. Not later than 24 hours if the allegation did not involve abuse and did not result and did not result in serious bodily injury, to the administrator of the facility and to other officials (i.e. State Survey Agency and adult protective services). Registered nurse assessment would be completed. A psychosocial assessment would be completed to identify any potential psychosocial harm. Any staff member accused of abusing, mistreating, neglecting a resident or misappropriating resident property would be immediately interviewed and then suspended from work until a thorough investigation was completed and a determination made. Resident #34: Review of Resident #34's comprehensive care plan did not include a care plan with interventions for abuse and neglect. Resident #75: Review of Resident #75's comprehensive care plan did not have documented evidence of a care plan with interventions for abuse and neglect. Grievance Form dated 6/28/2025, documented Family Member #4 reported a grievance. The name/signature of the staff member who received the grievance was not documented, it was blank. Description of complaint/grievance documented the grievance was filed because Resident #34 entered Resident #75's room on Sunday night, 6/22/2025 to 6/23/2025 and harassed and assaulted Resident #75 with their water bottle. Resident #75 did not feel safe that Resident #34 still resided on the same floor as them. Resident #75 told Family Member #4 they felt shaky and scared every time they saw Resident #34. They respectfully requested that Resident #34 be moved to the first-floor unit. Additionally, the form documented: To ensure abuse and neglect were ruled out promptly, did grievance require further investigation? The answer was not documented, it was blank. Investigation/Follow-up to Complaint/Grievance was not documented, it was blank. Resident/Family Follow-Up: o It was documented that the person filing the complaint/grievance was notified of actions taken and they were satisfied. An undated note by Licensed Practical Nurse Manager #2 document a meeting was held with family and appropriate staff members. Residents had been kept in separate areas, as requested by the family. No further incidents occurred, no concerns voiced, and Resident #75 was observed to be free of anxiety due to the interaction. The facility could not provide evidence of a documented investigation of the incident dated 6/22/2025, during the night shift and there was no documented evidence that the incident was reported to the New York State Department of Health. During an interview on 2/19/2026 at 11:51 AM, Licensed Practical Nurse Manager #2, stated they were not notified of an altercation between Resident #34 and 75 until they were brought into a meeting with the social worker, former administrator, former director of nursing, and resident's son and daughter, after a grievance was filed about the incident. They were not involved in any notification, investigation, or care planning for the incident. They did not investigate the incident and did not ask any staff on the unit about the incident. After the meeting with the family, they put a stop sign across Resident #75's door and entered an order to locate Resident #34 every 2 hours. During an interview on 2/19/2026 at 2:17 PM, Assistant Administrator #1 stated there should have been a full investigation that included interviews from both residents, staff, and family members. During an interview on 2/25/2026 at 9:42 AM, Medical Director #1 stated they would expect the facility to conduct an investigation of all incidents/accidents. During an interview on 2/25/2026 at 10:17 AM, Director of Nursing #1 stated they were not working in the facility when the alleged resident-to-resident altercation occurred. The expectation was for staff to complete an incident/accident report and conduct a thorough investigation, especially since Resident #75 called 911. During an interview on 2/25/2026 at 11:05 AM, Administrator #1 stated they were not the administrator when the alleged altercation between Resident #s 34 and 75 occurred and was not made aware of it. They stated they would expect immediate reporting of a resident-to-resident altercation to the director of nursing and administrator, and a thorough investigation. They stated they could not fix something they did not know about. If they were doing the investigation, they would have asked the unit manager about the incident. The facility's responsibility was to ensure safety and health for all residents. Resident-to resident altercations were reportable to the New York State Department of Health. Resident #90 An Accident and Incident Report for Resident #90 dated 1/01/2026 at 12:15 AM initiated by Licensed Practical Nurse #13, documented Resident #90 had an unwitnessed fall in their bathroom. It further documented that the resident had lacerations to their scalp and their arms and that neuro checks were started. There was no documented evidence that a Registered Nurse assessment was completed for Resident #90 after their fall. Nursing Progress Note dated 1/01/2026 at 12:46 AM by Licensed Practical Nurse #13, documented Resident #90 was found on the floor in their bathroom. Resident #90 had a laceration to the back of their scalp and bilateral arms. The resident was coherent and at baseline. The Nurse Practitioner and the resident's family were notified. There was no documented evidence of a thorough investigation, including resident and staff statements following the fall. Nursing Progress Note dated 1/01/2026 at 11:01 AM, written by Licensed Practical Nurse #10, documented Resident #90 was found on the floor in between the bathroom door. There was bleeding noted from the back of Resident #90's head. The Nurse Practitioner was notified and ordered Resident #90 be sent to the hospital. A provider note dated 1/02/2026 at 12:00 AM, written by Nurse Practitioner #1, documented chief complaint: emergency room return status post fall with head laceration. Resident #90 had a fall with positive head strike. On assessment a laceration was noted to the posterior scalp. The area was cleansed with normal saline. No closure was required. Later, on 1/02/2026, the provider received a call from nursing reporting Resident #90 had a second fall with positive head strike. The resident sustained a larger scalp laceration with active bleeding that required closure. The resident was sent to the emergency department for evaluation and management. Resident #90 returned from the hospital with staples intact to the scalp and new orders for bacitracin (topical antibiotic ointment). The plan was to continue bacitracin to scalp laceration as ordered, monitor staples for signs of infection or bleeding, continue neuro checks per protocol, maintain fall precautions and safety interventions, and continue urinary tract infection treatment as previously ordered. Signed by Nurse Practitioner #1 on 1/05/2026 at 9:40 AM. There was no documented evidence that an Accident and Incident Report was initiated or completed and/or an investigation was started for Resident #90's second fall on 1/01/2026 which resulted in a positive head strike, larger scalp laceration with active bleeding, and required treatment at the hospital. A provider note dated 1/05/2026 at 12:00 AM, written by Nurse Practitioner #1, documented Resident #90 was evaluated following reports of acute hip pain and functional decline after suspected injury. Resident reported significant pain with movement and inability to bear weight on the affected extremity. There was no report of additional trauma. Resident was being transferred from the facility to the hospital for acute evaluation of left hip pain and inability to bear weight following suspected injury. It further documented imaging was obtained and demonstrated an acute complete intertrochanteric femoral fracture with mild displacement and (hip fracture). Signed by Nurse Practitioner #1 on 1/06/2026 at 10:01 AM. There was no documented evidence that an investigation or an Accident and Incident Report was initiated after Resident #90 was found to have a hip fracture to rule out possible abuse or neglect. During an interview on 2/20/2026 at 10:34 AM, Licensed Practical Nurse #2 stated they would start the incident and accident report, get statements, and then pass it along to the Director of Nursing. They stated Incident and Accident Reports were reviewed at morning report with the interdisciplinary team and then updates would be made to the resident's care plan by the Registered Nurse. They further stated this process was not happening like it should have been due to staff turnover and vacant positions. They stated an Incident and Accident Report should have been completed for Resident #90's fracture on 1/05/2026. During an interview on 2/20/2026 at 12:14 PM, Acting Director of Nursing #1 stated they had no involvement with completing Incident and Accident Reports and was not sure how they were completed at the facility. They were not sure if Licensed Practical Nurse's started Incident and Accident Reports. Acting Director of Nursing #1 stated the facility should complete an Accident and Incident Report for an injury of unknown origin as it should be investigated. During an interview on 2/23/2026 at 2:24 PM, Nurse Practitioner #1 stated nursing would handle Incident and Accident Reports and they did not have involvement with the reports. They stated their impression was that Resident #90's fracture would need an Incident and Accident Report. They stated that usually an Incident and Accident Report was completed for everything like a skin tear or bruise. They further stated they would think the facility needed to complete an Incident and Accident Report for an injury of unknown source. During an interview on 2/25/2026 at 9:29 AM, Medical Director #1 stated they were made aware of falls, skin tears, etc. through Incident and Accident Reports. It was their responsibility to sign off on them. They stated falls were one of the biggest issues that were faced in long-term care. Medical Director #1 further stated they had not seen or signed any Incident or Accident Reports in the past few months. They stated they would expect the facility to complete an investigation for an injury of unknown origin, and it should be reported to the Department of Health. During an interview on 2/25/2026 at 11:04 AM, Director of Nursing #1 stated they would complete an investigation for an injury of unknown origin. If there was a fall they would want to know where on the floor was the resident found, what footwear were they wearing, they would want a roommate interview, want to know what the resident said, statements from staff about what the resident was like before the fall. Director of Nursing #1 stated a Licensed Practical Nurse could start an Incident and Accident Report and that a video call was okay if necessary for a Registered Nurse assessment. They stated an incident or accident should be documented in both the electronic medical record and on the Incident and Accident Report form. They stated the Registered Nurse should write a note of their assessment, whether in the facility or offsite. The interdisciplinary team would complete Incident and Accident Reports together. The reports were reviewed during morning report. During an interview on 2/25/2026 at 12:25 PM, Administrator #1 stated the Director of Nursing was responsible for making sure Incident and Accident Reports were completed for injuries of unknown origin. They stated they had to follow the regulations. 10 New York Code of Rules and Regulations 415.4(b)(3)

Based on observation, record review and interviews conducted during a survey, the facility did not ensure the provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, residents stated they were not assisted with care when requested; staff stated they were unable to consistently provide and/or document incontinence care, showers, or bed baths due to being short-staffed; and an analysis of the actual staffing schedule showed that on multiple occasions from 11/30/2025 to 2/24/2025, the facility minimum staffing levels were not met based on the facility assessment.This is evidenced by: The Facility Assessment, dated 1/2026, documented that Nursing Administration required one (1) full time Registered Nurse on day shift to serve as Director of Nursing, one (1) full time Registered Nurse on day shift to serve as the Assistant Director of Nursing, two (2) full time Registered Nurses or Licensed Practical Nurses, one for each unit, to serve as Unit Nurse Manager, one (1) Registered Nurse or Licensed Practical Nurse for 3 PM-11 PM shift, and/or one (1) Registered Nurse or Licensed Practical Nurse for 11 PM-7 AM shift to serve as Nursing Supervisor and weekend staffing for Registered Nurses is 8-hour days, evenings or 8-hour nights.Direct care staff required per unit per shift (2-40 bed units) seven (7)days per week was as follows: Day shift (7 AM-3 PM) two (2) full time Licensed Practical Nurses and three (3)-four (4) full time Certified Nurse Aides; Evening shift (3 PM-11 PM) two (2) full time Licensed Practical Nurses, and three (3)-four (4) Certified Nurse Aides; Night shift (11 PM-7 AM) one (1) full time Licensed Practical Nurse, and two (2) full time Certified Nurse Aides.The facility staffing sheets provided documented that:On 11/30/2025, the nursing schedule had three (3) nursing staff during the day shift instead of four (4), and one (1) for night shift instead of two (2), with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had five (5) aides during the day shift instead of six (6), five (5) for the evening shift instead of six (6), and two (2) for the night shift instead of four (4). On 12/01/2025, the nursing schedule had no nurses for night shift, with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had four (4) aides during the day shift instead of six (6), zero (0) aides for the evening shift, and two (2) for the night shift instead of four (4). On 12/02/2025, the nursing schedule had one (1) nurse for night shift instead of two (2), with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had five (5) aides during the day shift instead of three (6), three (3) for the evening shift instead of six (6), and one (1) for the night shift instead of four (4). On 12/03/2025, the nursing schedule had no nurses for night shift, with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had four (4) aides for the evening shift instead of six (6), and one (1) for the night shift instead of four (4). On 12/04/2025, the Certified Nurse Aide schedule had five (5) aides during the day shift instead of six (6), and two (2) for the night shift instead of four (4). On 12/05/2025, the Certified Nurse Aide schedule had four (4) for the evening shift instead of six (6), and two (2) for the night shift instead of four (4). On 12/06/2025, the nursing schedule had three (3) nursing staff during the evening shift instead of four (4). The Certified Nurse Aide schedule had two (2) aides for the night shift instead of four (4). On 12/07/2025, the nursing schedule had two (2) nursing staff during the evening shift instead of four (4), and one (1) for night shift instead of two (2). The Certified Nurse Aide schedule had one (1) aide during the night shift instead of four (4). On 12/08/2025, the nursing schedule had three (3) nursing staff during the evening shift instead of four (4), and one (1) for night shift instead of two (2), with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had five (5) aides during the day shift instead of six (6), five (5) for the evening shift instead of six (6), and two (2) for the night shift instead of four (4). On 12/09/2025, the nursing schedule had one (1) nursing staff during the night shift instead of two (2), with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had one (1) aide during the night shift instead of four (4). On 12/10/2025, the nursing schedule had one (1) nursing staff during the night shift instead of two (2), with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had one (1) aide during the night shift instead of four (4). On 12/11/2025, the nursing schedule had one (1) nursing staff during the night shift instead of two (2), with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had two (2) aides during the night shift instead of four (4). On 12/12/2025, the nursing schedule had two (2) nursing staff during the evening shift instead of four (4). The Certified Nurse Aide schedule had three (3) aides during the day shift instead of six (6), and zero (0) for the night shift. On 12/13/2025, the nursing schedule had three (3) nursing staff during the day shift instead of four (4), and one (1) for night shift instead of two (2). The Certified Nurse Aide schedule had two (2) aides during the evening shift instead of six (6), and three (3) for the night shift instead of four (4). On 12/14/2025, the nursing schedule had one (1) nursing staff during the night shift instead of two (2), with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had three (3) aides during the evening shift instead of six (6), and two (2) for the night shift instead of four (4). On 12/15/2025, the nursing schedule had one (1) nursing staff during the night shift instead of two (2), with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had one (1) aide during the night shift instead of four (4). On 12/16/2025, the nursing schedule had zero (0) nursing staff during the night shift, with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had four (4) aides during the day shift instead of six (6). On 12/17/2025, the Certified Nurse Aide schedule had five (5) aides during the evening shift instead of six (6), and one (1) for the night shift instead of four (4). On 12/18/2025, the Certified Nurse Aide schedule had two (2) aides during the night shift instead of four (4). On 12/19/2025, the nursing schedule had one (1) nursing staff during the night shift instead of two (2). The Certified Nurse Aide schedule had three (3) aides during the day shift instead of four (4). On 12/20/2025, the Certified Nurse Aide schedule had zero (0) aides during the night shift. On 12/21/2025, the nursing schedule had two (2) nursing staff during the evening shift instead of four (4). The Certified Nurse Aide schedule had five (5) aides during the day shift instead of six (6), and zero (0) aides for the night shift. On 12/22/2025, the nursing schedule had one (1) nursing staff during the night shift instead of two (2), with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had one (1) aide during the night shift instead of four (4). On 12/23/2025, the nursing schedule had one (1) nursing staff during the night shift instead of two (2). The Certified Nurse Aide schedule had four (4) aides during the day shift instead of six (6), five (5) aides for evening shift instead of six (6), and two (2) aides for night shift instead of four (4).On 12/24/2025, the nursing schedule had three (3) nursing staff during the evening shift instead of four (4), and zero (0) nurses on the night shift, with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had three (3) aides during the night shift instead of four (4). On 12/25/2025, the nursing schedule had three (3) nursing staff during the evening shift instead of four (4), with one (1) Nurse Supervisor noted and one (1) nurse on night shift instead of two (2), with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had one (1) aide during the night shift instead of four (4). On 12/26/2025, the nursing schedule had one (1) nursing staff during the night shift instead of two (2), with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had zero (0) aides during the night shift. On 12/27/2025, the nursing schedule had three (3) nursing staff during the night shift but one (1) scheduled to leave at 2 AM instead of 7 AM instead of two (2) for the entire shift, with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had four (4) aides on day shift instead of six (6), two (2) aides on evening shift instead of six (6), and two (2) aides during the night shift instead of four (4). On 12/28/2025, the nursing schedule had three (3) nursing staff during the day shift instead of four (4), and zero (0) nurses on night shift, with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had four (4) aides on day shift instead of six (6), three (3) aides on evening shift instead of six (6), and two (2) aides during the night shift instead of four (4). On 12/29/2025, the nursing schedule had three (3) nursing staff during the day shift instead of four (4), two (2) nurses on evening shift instead of four (4), and no nurses on night shift, with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had five (5) aides during the day shift instead of six (6), five (5) aides on evening shift instead of six (6), and one (1) aide during the night shift instead of four (4). On 12/30/2025, the nursing schedule had two (2) nursing staff during the day shift instead of four (4), three (3) nurses on evening shift instead of four (4), and zero (0) nurses on night shift, with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had five (5) aides during the evening shift instead of six (6), and three (3) aides for night shift instead of four (4). On 12/31/2025, the nursing schedule had three (3) nursing staff during the evening shift instead of four (4). The Certified Nurse Aide schedule had one (1) aide during the night shift instead of four (4). On 1/01/2026, the nursing schedule had three (3) nursing staff during the evening shift instead of four (4), and zero (0) nurses on night shift, with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had five (5) aides during the day shift instead of six (6), and three (3) aides on evening shift instead of six (6). On 1/02/2026, the nursing schedule had three (3) nursing staff during the evening shift instead of four (4), and zero (0) nurses on night shift, with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had five (5) aides during the evening shift instead of six (6). On 1/03/2026, the nursing schedule had one (1) nurse on night shift instead of two (2), with one (1) Nurse Supervisor noted.On 1/04/2026, the nursing schedule had one (1) nursing staff during the night shift instead of two (2). The Certified Nurse Aide schedule had one (1) aide on night shift instead of four (4). On 1/05/2026, the nursing schedule had one (1) nursing staff during the night shift instead of two (2), with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had five (5) aides during the day shift instead of six (6), and four (4) aides on evening shift instead of six (6), and two (2) aides on night shift instead of four (4). On 1/06/2026, the nursing schedule had one (1) nursing staff during the night shift instead of two (2), with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had five (5) aides during the day shift instead of six (6). On 1/07/2026, the nursing schedule had one (1) nursing staff during the night shift instead of two (2). The Certified Nurse Aide schedule had five (5) aides during the evening shift instead of six (6). On 1/08/2026, the nursing schedule had zero (0) nursing staff during the night shift, with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had three (3) aides during the evening shift instead of six (6). On 1/09/2026, the nursing schedule had zero (0) nursing staff during the night shift, with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had three (3) aides during the day shift instead of six (6), and three (3) aides on evening shift instead of six (6). On 1/10/2026, the nursing schedule had zero (0) nursing staff during the night shift, with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had four (4) aides during the day shift instead of six (6), and four (4) aides on evening shift instead of six (6). On 1/11/2026, the nursing schedule had zero (0) nursing staff during the night shift, with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had four (4) aides during the day shift instead of six (6), and four (4) aides on evening shift instead of six (6). On 1/12/2026, the nursing schedule had two (2) nurses during the evening shift instead of four (4), and zero (0) nursing staff during the night shift, with one (1) Nurse Supervisor noted.On 1/13/2026, the nursing schedule had three (3) nursing staff during the day shift instead of four (4). The Certified Nurse Aide schedule had three (3) aides during the day shift instead of six (6). On 1/14/2026, the nursing schedule had three (3) nursing staff during the day shift instead of four (4), and one (1) nursing staff during the night shift instead of two (2), with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had five (5) aides during the day shift instead of six (6). On 1/15/2026, the nursing schedule had three (3) nursing staff during the evening shift instead of four (4), and one (1) nursing staff during the night shift instead of two (2), with one (1) Nurse Supervisor noted.On 1/16/2026, the nursing schedule had zero (0) nursing staff during the night shift, with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had four (4) aides during the day shift instead of six (6), and five (5) aides on evening shift instead of six (6). On 1/17/2026, the nursing schedule had three (3) nursing staff during the day shift instead of four (4), two (2) nurses on evening shift instead of four (4) and zero (0) nursing staff during the night shift.On 1/18/2026, the nursing schedule had three (3) nursing staff during the day shift instead of four (4), two (2) nurses on evening shift instead of four (4), and one (1) nursing staff during the night shift instead of two (2). The Certified Nurse Aide schedule had five (5) aides during the day shift instead of six (6), and two (2) aides for night shift instead of four (4). On 1/19/2026, the nursing schedule had one (1) nursing staff during the night shift instead of two (2), with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had five (5) aides during the day shift instead of six (6), five (5) aides on evening shift instead of six (6), and two (2) aides on night shift instead of four (4). On 1/20/2026, the Certified Nurse Aide schedule had three (3) aides during the day shift instead of six (6). On 1/21/2026, the nursing schedule had one (1) nursing staff during the night shift instead of two (2), with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had four (4) aides during the day shift. On 1/22/2026, the nursing schedule had three (3) nursing staff during the day shift instead of four (4), two (2) nurses on evening shift instead of four (4), and one (1) nursing staff during the night shift instead of two (2), with one (1) Nurse Supervisor noted.On 1/23/2026, the nursing schedule had two (2) nursing staff during the day shift instead of four (4), two (2) nurses on evening shift instead of four (4), and one (1) nursing staff during the night shift instead of two (2), with (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had three (3) aides during the day shift instead of six (6). On 1/24/2026, the nursing schedule had one (1) nursing staff during the evening shift instead of four (4), and one (1) nursing staff during the night shift instead of two (2), with one (1) Nurse Supervisor noted for both shifts.On 1/25/2026, the nursing schedule had one (1) nursing staff during the night shift instead of two (2), with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had three (3) aides during the day shift instead of six (6), two (2) aides on evening shift instead of six (6), and 0 aides for night shift. On 1/27/2026, the nursing schedule had two (2) nursing staff during the evening shift instead of four (4), and one (1) nursing staff during the night shift instead of two (2), with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had three (3) aides during the day shift instead of six (6). On 1/28/2026, the nursing schedule had one (1) nursing staff during the night shift instead of two (2), with one (1) Nurse Supervisor noted. On 1/29/2026, the nursing schedule had zero (0) nursing staff during the night shift, with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had five (5) aides during the day shift instead of six (6). On 1/31/2026, the nursing schedule had one (1) nursing staff during the night shift instead of two (2).On 2/01/2026, the Certified Nurse Aide schedule had two (2) aides during the night shift instead of four (4). On 2/03/2026, the nursing schedule had one (1) nursing staff during the night shift instead of two (2), with one (1) Nurse Supervisor noted.On 2/04/2026, the nursing schedule had three (3) nursing staff during the day shift instead of four (4), and one (1) nursing staff during the night shift instead of two (2), with one (1) Nurse Supervisor noted. The Certified Nurse Aide schedule had five (5) aides during the day shift instead of six (6). On 2/10/2026, the Certified Nurse Aide schedule had five (5) aides during the evening shift instead of six (6). On 2/13/2026, the nursing schedule had three (3) nursing staff during the evening shift instead of four (4). The Certified Nurse Aide schedule had two (2) aides for night shift instead of four (4).On 2/14/2026, the Certified Nurse Aide schedule had three (3) aides during the night shift instead of four (4). On 2/15/2026, the Certified Nurse Aide schedule had three (3) aides during the night shift instead of four (4).On 2/20/2026, the nursing schedule had one (1) nurse for night shift instead of two (2).On 2/21/2026, the Certified Nurse Aide schedule had three (3) aides for evening shift instead of four (4).On 2/22/2026, the Certified Nurse Aide schedule had five (5) aides during the evening shift instead of six (6), and two (2) during the night shift instead of four (4).On 2/23/2026, the Certified Nurse Aide schedule had five (5) aides during the day shift instead of six (6). On 2/24/2026, the nursing schedule had three (3) nursing staff during the evening shift instead of four (4). During an interview on 2/11/2026 at 11:00 AM, Resident #72 stated staffing was an issue and there was very high staff turnover. Resident #72 stated that sometimes they were scared to ask for pain medication because the staff were so busy. Resident #72 stated they shower once a week and would like more showers, but staff would get mad if they asked for more because there were not enough staff.During an interview on 2/11/2026 at 11:25 AM, Resident #1 stated that they were very suspicious of staff. They believed the facility was short staffed like every nursing home. Getting help to get set up to clean up was hit or miss and sometimes they had to wait a long time to get pain medication.During an interview on 2/11/2026 at 1:26 PM, Resident #43 stated that the facility was short staffed too often. Sometimes staff came in the morning and the bed would be soaked from overnight because no one was there to change them. Resident #43 stated they knew when they needed to go to the bathroom or be changed, they would ring their call bell, and no one would come. Staffing was short on the night shift, and it did not matter whether it was weekday or weekend. Resident #43 stated that it usually took 1/2 hour or more for staff to answer their call bell, but it happened more at night.During an interview on 2/11/2026 at 1:46 PM, Resident #4 stated that there were not enough staff, especially on the overnight shift. Resident #4 also stated that they did not always get their medications on time because of staffing issues. During an interview on 2/12/2026 at 9:15 AM, Resident #67 stated that the facility was short staffed, but the staff were nice.During an interview on 2/12/2026 at 10:03 AM, Resident #80 stated that there were not enough staff to get things done and they had to wait a long time for help. During an interview on 2/12/2026 at 10:35 AM, Resident #50 stated that the facility could use more staff.During an interview on 2/12/2026 at 3:53 PM, Ombudsman #1 stated that staffing, particularly dietary, was lacking. One day on an undated weekend, breakfast was not served until 11 AM and needed to be made by maintenance because all the kitchen staff called out. Ombudsman #1 stated that the facility staffing was inconsistent.During an interview on 2/13/2026 at 9:29 AM, Assistant Administrator #1 stated that some of the staffing issues were related to staff that did not want to work. Assistant Administrator #1 stated that they wanted staff to want to work in long-term care and they believed that improvements had been made, and they had fired the people that were not a good fit for the facility. Over the last two months they have been using more agency. Assistant Administrator #1 stated they were hoping to hire some of the agency's people that liked the facility. They were also considering trying to have the facility used as a clinical rotation for the nursing schools in the area. people that liked the facility. They were also considering trying to have the facility used as a clinical rotation for the nursing schools in the area.During an interview on 2/17/2026 at 11:14 AM, Certified Nurse Aide #16 stated that sometimes it was tough to get to all the residents in their assignment. It could be especially hard on the 3 PM - 11 PM shift when some residents become more confused. Certified Nurse Aide #16 stated that sometimes they had to finish their documentation an hour after their shift ends because there was not enough time during the shift. During an interview on 2/18/2026 at 9:57 AM, Staffing Coordinator #1 stated that they were in charge of staffing as of 2/12/2026. They were asked to help because they had knowledge and experience in staffing. Staffing Coordinator #1 stated that they pulled their numbers for the units from the facility assessment. Per unit, day shift was supposed to have three (3) Certified Nurse Aides and two (2) nurses, evening shift was three (3) aides and two (2) nurses, night shift was two (2) nurses and one (1) aide. They stated they were aware that there should be a Registered Nurse in the building for eight (8) consecutive hours every day, but they aimed to have a Registered Nurse for all three (3) shifts.Staffing Coordinator #1 stated that three (3) Certified Nurse Aides per unit was reasonable and appropriate. Four (4) aides would be great. There were days where call outs and no call/no shows would derail the staffing, but it was not as bad as they had seen in other places. Staffing Coordinator #1 believed that the staff turnover and lack of leadership caused some communication issues within the facility, and they were anticipating improvement since key positions had been filled.During an interview on 2/20/2026 at 10:46 AM, Licensed Practical Nurse #2 stated that they usually have two (2) aides on days but sometimes had three (3) or four (4). They stated they should have four (4) aides. On evenings, they usually had two (2) aides on evenings, sometimes three (3). Licensed Practical Nurse #2 stated they should have three (3) aides. On nights they had one (1) aide for each floor and one (1) Licensed Practical Nurse for both floors. If they had a supervisor, they would usually do medication passes. There were times when the supervisor was the only Licensed Practical Nurse and would have to do medication passes and be the supervisor.During an interview on 2/17/2026 at 10:36 AM, Dietary Aide #1 stated that staffing in the dietary department was normally limited and needed more staff specifically on weekends, with typically only one to two (1-2) cooks and four to six (4-6) dietary aides on weekdays.During an interview on 2/25/2026 at 11:04 AM, Director of Nursing #1 stated that the facility needed to use agency at this point. Director of Nursing #1 stated they had talked to Administrator #1 about referral bonuses. Director of Nursing #1 stated that the facility was not very big and should be able to be staffed, it was a slow process to get staff in.During an interview on 2/25/2026 at 10:10 AM, Administrator #1 stated that they would like to avoid staff turnover, but they let go of people that were not helping to move the facility forward. Administrator #1 stated they had openings on employment websites, offered sign on bonuses, and had booths at job fairs. Administrator #1 stated that they would schedule interviews, and the people would not show up, or the people would get through orientation and then not show up for their shifts. Administrator #1 stated that they had tried to work with local colleges but had not been very successful and was discussing offering referral bonuses for staff that would bring in other staff. Administrator #1 stated they believed that residents were being cared for, and that education and poor documentation were the main issues that needed to be addressed. 10 New York Codes, Rules and Regulation 415.13(a)(1)(i-iii)

Based on observation, record review and interviews conducted during a recertification survey, the facility did not ensure, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities for one (1) (Resident #14) out of three (3) residents reviewed. Specifically, Resident #14 was not offered meaningful activities that included their interests and preferences to maintain their highest practicable quality of life. This is evidenced by: The facility policy and procedure titled Activity Program Policy (undated and unsigned) documented facility would provide an individualized, ongoing activity program designed to meet the physical, mental, psychosocial, behavioral, and cognitive needs of all residents. Facility shall provide a structured person center program available 7 days a week, ensuring meaningful engagement for all residents.Demetia/Cognitively impaired residents programming will incorporate dementia-capable principles, including structured routine, sensory stimulation, reminiscence therapy, validation techniques, redirection strategies, and failure free activities. Residents who are unable to tolerate group settings will receive individual one-to-one therapy Facility shall maintain monthly Calanders, attendance logs, one-to-one visit documentation, and refusal trackingResident #14 was admitted to the facility with diagnoses of metabolic encephalopathy (diffuse brain disfunction), Alzheimer's disease unspecified (progressive mental deterioration), and muscle weakness. The Minimum Data Set (an assessment tool) dated 02/10/2026, documented the resident could usually be understood, sometimes understand others, and was severely cognitively impaired.During an observation on 02/11/2026 at 11:30 AM, Resident #14 was sitting in their wheelchair on the first floor Rehabilitation unit nursing station with no music playing or personal interactions.During an observation on 02/13/2026 at 10:55 AM, Resident #14 was sitting in their wheelchair on the first floor Rehabilitation unit nursing station with a drink on bedside table and no music playing or personal interactions.During an observation on 02/24/2026 at 2:25 PM, Resident #14 was sitting in their wheelchair outside of the first floor Rehabilitation unit nursing station with no music playing or personal interactions.There was no documented evidence of activities attendance logs provided.Care Plan revised 12/01/2025 titled Activities preferences documented preferences were to listen to music and kept informed about the news. Goal was to passively participate in group activities and one-to-one (1:1) visits. Interventions included to provide transportation to group activities.Progress notes dated 11/23/2025-02/24/2026 did not have documented evidence of one-to-one visits provided by activities.During an interview on 02/12/2026 at 3:53 PM, Ombudsman #1 stated the activities might not be meaningful for all residents.During an interview on 2/19/2026 at 9:23 AM, Licensed Practical Nurse #3 stated Resident #14 did not really participate in Bingo or group activities. They would go when movies were offered. They did not know if one-to-one (1:1) visits were happening with Resident #14.During an interview on 02/19/2026 at 2:47 PM, Licensed Practical Nurse #7 stated activities were done daily in the facility. They stated Resident #14 received one-to-one (1:1) time with nursing staff only, not activities. They stated Resident #14 spent time near the nursing station, and their family came in frequently to visit.During an interview on 02/24/2026 at 11:55 AM, Activities Director #1 stated they just started working in the facility on 02/23/2026, was unsure who had the position prior and were left no information regarding activities that had been done or were to be done in the facility. They stated they were organizing the activity office and did not have access to electronic medical records to start reviewing residents for their preferences and needs for activities. Activities Director #1 stated they believed activities were communicated with a calendar at that time and were unsure if one-to-one (1:1) activities were being done, as there was no current documentation in the activities office. They stated that day's activities listed were not something they considered activities; Chronical Pass, Independent Activities, Bible study, Hydration cart were listed on that day's calendar.During an interview on 2/24/2026 at 4:21PM, Licensed Practical Nurse #2 stated activities suck whether they had someone for activities in the building or not. They did not know who the new manager was. They stated difficult residents were excluded from group activities. One activity was to make sand candles and the male residents on their unit did not want to do that. The activity aides were not trained to deal with any kind of residents. They stated an example would be of a particular resident was supposed to use the iPad to call their family member on Mondays which had only happened about three (3) times. During an interview on 2/26/2026 at 10:10 AM, Administrator #1 stated the changeover in management staff may be part of the problem within the facility. They needed better procedures, education, and logging of information. 10 New York Codes, Rules, and Regulations 415.12(h)(1)(2)

Based on observation, record review and interviews conducted during a survey, the facility did not ensure that comprehensive care plans were revised and updated according to professional standards for four (4) (Resident #s 1, 11, 75, and 85) of 22 residents reviewed. Specifically, (a.) for Resident #1, the comprehensive care plan was not updated with new interventions after Resident #1 fell; (b.) for Resident #11, the comprehensive care plan was not updated to reflect the urinary tract infections; (c.) for Resident #75, the comprehensive care plan was not updated to reflect the hospitalization on 11/11/2025,1/09/2026, and 2/17/2026 for repeated issues with constipation; and (d.) for Resident #85, the comprehensive care plan was not updated to reflect the resident's admission to the hospital for urinary tract infection and urosepsis.This is evidenced by: A facility policy titled Care Planning Process, date revised 8/2018, documented that an individualized comprehensive care plan would include measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs was developed for each resident. Further documented, in pertinent part, that (11) Assessments of residents were ongoing, and care plans were revised as information about the resident and the resident's condition changed; (12) The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: (a) When there has been a significant change in the resident's condition. (b) When the desired outcome is not met (c) When the resident has been readmitted to the facility from a hospital stay; and (d) At least quarterly. Resident #1 Resident #1 was admitted to the facility with the diagnoses of encephalopathy (a disease in which the functioning of the brain was affected by some agent or condition), unspecified, acute respiratory failure with hypoxia (life-threatening medical emergency where the lungs could not adequately oxygenate the blood), and pneumonitis due to inhalation of food and vomit (lung inflammation caused by inhaling food, vomit, or saliva into the airways, leading to infection). The Minimum Data Set (an assessment tool), dated 1/30/2026, documented that the resident was able to understand others, be understood and was cognitively intact. The comprehensive care plan for at Risk for Injury related to falls, dated initiated 1/29/2026 documented Resident #1 fell on 2/08/2026 at 12:30 PM and 7:00 PM. Had one new intervention added on 2/08/2026 that documented no description provided. There were no other documented inventions updated, changed or added and no description provided was not expounded on. Resident #75 Resident #75 was admitted to the facility with diagnoses of noninfective gastroenteritis and colitis (inflammation of the stomach, small intestine, and/or colon), chronic idiopathic and slow transit constipation (functional bowel disorder characterized by persistent, infrequent bowel movements, hard stools, or difficult defecation without a known organic cause) and type 2 diabetes (an endocrine dysfunction causing unregulated blood glucose levels). The Minimum Data Set, dated [DATE], documented the resident had moderate cognitive impairment, was able to make themselves understood and understand others. A grievance form dated 6/28/2025, written by Family Member #4 on behalf of Resident #75, documented Resident #34 entered Resident #75 room Sunday night/early Monday morning (6/22/2025-6/23/2025) and harassed and assaulted the resident with Resident #75's water bottle. Resident #75 did not feel safe that Resident #34 still resided on the same floor as them. They requested that Resident #34 be moved to the first floor. There was no documented evidence that a care plan for abuse or at risk for abuse was updated or revised after Resident #75 was identified as the victim of a resident-to-resident altercation that occurred in June 2025. Resident #85 Resident #85 was admitted to the facility with the diagnoses of chronic kidney disease (a long-term progressive loss of kidney function), stage 3 unspecified, age-related osteoporosis without current pathological fracture (a loss of bone density associated with age progression), unspecified dementia, severe (a progressive neurological disease-causing memory loss). The Minimum Data Set, dated [DATE], documented that the resident was usually able to understand others, was usually understood, and was so significantly cognitively impaired, they were unable to complete the exam. On 9/28/2025, Resident #85 was admitted to the hospital with urosepsis (a systemic shut down of major organ function), related to a urinary tract infection and re-admitted to the facility on [DATE] for comfort care. Resident #85's comprehensive care plan did not have documented evidence of revised care plan to include area related to risk of urinary tract infection prevention or recent hospitalization for urosepsis. During an interview on 2/24/2026 at 10:18 AM, Licensed Practical Nurse #4 stated that care plans were updated by Registered Nurse #2. Prior to Registered Nurse #2, whoever was the Director of Nursing or any Registered Nurse in the building would be able to update the care plan. Additionally, the people in charge of the care area requiring the update could update their section. During an interview on 2/24/2026 at 10:31 AM, Licensed Practical Nurse # 8 stated that care plans were updated through the unit managers, or the staff would consult with the director of the care area needing an update like rehabilitation. During an interview on 2/24/2026 at 11:52 AM, Acting Director of Nursing #1 stated that they had been updating care plans. Registered Nurse #2 was in charge of it and there were some other people that were able to update them. During an interview on 2/25/2026 at 11:04 AM, Director of Nursing #1 stated care planning was a significant issue in the facility due to not having enough staff. They also stated the facility would be interviewing for an Assistant Director of Nursing. During an interview on 2/25/2026 at 12:25 PM, Administrator #1 stated a care plan was used to make sure the resident was safe and was a blueprint of how to care for a resident. Care plans should be individualized. If there was something that the staff didn't do, it would be something that they would work toward in the future. Administrator #1 additionally stated that everyone could make mistakes, and they were fixable. 10 New York Code of Rules and Regulations 415.4(a)(2-7)

Based on record review and interviews conducted during a survey, the facility did not ensure that comprehensive care plans were developed and implemented for residents according to professional standards for eight (8) (Resident #'s 2, 9, 11, 14, 34, 43,75 and 86) of 22 residents reviewed. Specifically, (a.) Resident #2's comprehensive care plan did not contain care areas that reflected the bowel needs of the resident, the side effects of the psychotropic medications taken by Resident #2 or signs and symptoms of hypertension for which the resident took medications; (b.) Resident #9 receiving an anti-depressant and a corresponding mood or psychiatric care plan was not developed and implemented that indicated its use; (c.) Resident #11's comprehensive care plan did not contain care areas that reflected the urinary tract issues Resident #11 regularly experienced, including but not limited to temporary foley catheters and urinary tract infections; (d.) Resident #14's comprehensive care plan did not contain care areas that highlighted complications and signs and symptoms of issues related to the Alzheimer's Medications being given to them; (e.) for Resident #34, care plan for abuse was not developed after the resident was identified as the aggressor in a resident-to-resident altercation; (f.) Resident #43 had a diagnosis of obstructive sleep apnea and a care plan for respiratory care was not developed and implemented; (g.) Resident #75 a care plan for abuse or at risk for abuse was not developed and implemented after they were identified as the victim in a resident-to-resident altercation; and (h.) for Resident #85 an advanced directive care plan was not developed, although the resident had a completed MOLST (medical orders for life sustaining treatment) form.This is evidenced by: The facility policy titled Care planning process reviewed 08/2018 documented that individualized comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs were to be developed for each resident. Each resident's comprehensive care plan was to be designed to: (1.) incorporate identified problems; (2.) incorporate risk factors associated with identified problems; (3.) build on resident's strengths; (4.) reflect the resident's expressed wishes regarding care and treatment goals; (5.) reflect treatment goals, timetables and objectives in measurable outcomes; (6.) identify the professional services that are responsible for each element of care; (7.) aid in preventing or reducing declines in the resident's functional status and/or functional levels; (8.) enhance the optimal functioning of the resident by focusing on a rehabilitative program; and (9.) reflect currently recognized standards of practice for problem areas and conditions. Resident #34 Resident #34 was admitted to the facility with diagnoses of dementia (a group of conditions that cause a progressive decline in cognitive abilities), Parkinsonism (a clinical syndrome characterized by a combination of movement-related symptoms, most notably bradykinesia, rigidity, resting tremors, and postural instability), and age-related physical debility (the gradual decline in physical function and strength that occurs with aging). The Minimum Data Set (an assessment tool) dated 12/25/2025, documented the resident was understood, able to understand others, and had severe cognitive impairment. A grievance form dated 6/28/2025, written by Family Member #4 on behalf of Resident #75, documented Resident #34 entered Resident #75 room Sunday night/early Monday morning (6/22/2025-6/23/2025) and harassed and assaulted the resident with Resident #75's water bottle. Resident #75 did not feel safe that Resident #34 still resided on the same floor as them. They requested that Resident #34 be moved to the first floor. During an interview on 2/19/2026 at 11:51 AM, Licensed Practical Nurse #2 stated that on 6/29/2025 an order was entered for the Certified Nurse Aides to complete safety checks on Resident #34 every 2 hours. There was no documented evidence that a care plan for abuse or at risk for abuse was developed and implemented with interventions after Resident #34 was identified as the aggressor in a resident-to-resident altercation that occurred in June 2025. Resident #43 Resident #43 was admitted to the facility with diagnoses of obstructive sleep apnea (most common sleep-related breathing disorder), diabetes mellitus type 2 with hyperglycemia (when the body cannot use insulin correctly and the sugar builds up in the blood), hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side (paralysis or weakness on one side of the body). The Minimum Data Set, dated [DATE], documented the resident could usually be understood and could usually understand others with intact cognition.A Report of Consultation dated 8/19/2025, documented Resident #43 had a diagnosis of obstructive sleep apnea, and the recommended plan of care documented patient needed an auto continuous positive airway pressure machine.A physician order dated 10/18/2025, documented apply continuous positive airway pressure mask and turn machine on at bedtime. Continuous positive airway pressure setting: 12-20 on H2O (water). There was no documented evidence that a care plan for respiratory care was developed or implemented for Resident #43, although they had a diagnosis of obstructive sleep apnea and used a continuous positive airway pressure machine to manage their diagnosis. Resident #75 Resident #75 was admitted to the facility with diagnoses of noninfective gastroenteritis and colitis (inflammation of the stomach, small intestine, and/or colon), chronic idiopathic and slow transit constipation (functional bowel disorder characterized by persistent, infrequent bowel movements, hard stools, or difficult defecation without a known organic cause) and type 2 diabetes (an endocrine dysfunction causing unregulated blood glucose levels). The Minimum Data Set, dated [DATE], documented the resident had moderate cognitive impairment, was able to make themselves understood and understand others. A grievance form dated 6/28/2025, written by Family Member #4 on behalf of Resident #75, documented Resident #34 entered Resident #75 room Sunday night/early Monday morning (6/22/2025-6/23/2025) and harassed and assaulted the resident with Resident #75's water bottle. Resident #75 did not feel safe that Resident #34 still resided on the same floor as them. They requested that Resident #34 be moved to the first floor. During an interview on 2/19/2026 at 11:51 AM, Licensed Practical Nurse #2 stated they implemented a stop sign across Resident #75's door after they were made aware of the grievance. There was no documented evidence that a care plan for abuse or at risk for abuse was developed and implemented with interventions after Resident #75 was identified as the victim of a resident-to-resident altercation that occurred in June 2025.During an interview on 2/24/2026 at 9:51 AM, Licensed Practical Nurse #8 stated if they noticed that something needed to be added to a resident's care plan, such as fall risk they would notify the unit manager.During an interview on 2/25/2026 at 11:04 AM, Director of Nursing #1 stated care planning was a significant issue at the facility. They stated they did not have many Registered Nurses to assist with care planning but were interviewing for an Assistant Director of Nursing. They further stated care planning would be part of their education plan and followed with audits.During an interview on 2/25/2026 at 12:25 PM, Administrator #1 stated care plans should be individualized. They further stated care plans assured residents were safe and cared for accordingly. 10 New York Code of Rules and Regulations 415.11(c)(1)

Based on observation, resident and staff interviews, review of facility policies and procedures, staffing records, resident records, accident and incident reports, and the facility's maintenance records during a survey, it was determined the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The administration failed to ensure the facility was in compliance with the following regulatory requirements, which affected or had potential to affect all residents in the facility. These failed practices directly impacted 35 of 35 residents sampled (Resident #s 1, 2, 3, 4, 5, 8, 9, 10, 11, 12, 14, 19, 25, 29, 31, 32, 33, 34, 35, 43, 44, 49, 50, 52, 53, 61, 64, 67, 70 , 72, 75, 80, 82, 90). Specifically, the lack of effective oversight and planning on the part of facility administration had the potential to adversely affect the health and safety of all residents residing in the facility. This is evidenced by: Deficiencies related to ineffective administration:Please refer to F550 as it pertains to the facility's failure to resident's dignity.Please refer to F580 as it pertains to the facility's failure to notify providers and resident representatives about changes of condition.Please refer to F584 as it pertains to the facility's failure to provide a safe, clean, comfortable and homelike environment.Please refer to F600 as it pertains to the facility's failure to ensure residents were free from abuse and neglect.Please refer to F609 as it pertains to the facility's failure to ensure injuries from unknown sources were reported to the State Survey Agency.Please refer to F610 as it pertains to the facility's failure to ensure all allegations of abuse, neglect, exploitation or mistreatment were thoroughly investigated.Please refer to F628 as it pertains to the facility's failure to document and notify the appropriate entities of discharges and transfers. Please refer to F656 as it pertains to the facility's failure to develop and implement a comprehensive person-centered care plan for each resident.Please refer to F657 as it pertains to the facility's failure to review and revise a comprehensive person-centered care plan for each resident.Please refer to F679 as it pertains to the facility's failure to provide activities based on comprehensive assessment, care plan, and preferences of each resident.Please refer to F684 as it pertains to the facility's failure to ensure services provided met professional standards.Please refer to F695 as it pertains to the facility's failure to ensure respiratory care services provided met professional standards.Please refer to F711 as it pertains to the facility's failure to ensure that physician notes were entered and maintained accurately.Please refer to F725 as it pertains to the facility's failure to ensure sufficient staffing services provided met professional standards.Please refer to F726 as it pertains to the facility's failure to ensure competent nursing services provided met professional standards.Please refer to F755 as it pertains to the facility's failure to ensure that pharmaceutical services were provided to meet the needs of each resident.Please refer to F804 as it pertains to the facility's failure to ensure that food and drink were palatable, attractive, and at a safe and appetizing temperature.Please refer to F812 as it pertains to the facility's failure to store, prepare, distribute, and serve food met professional food service safety standards. Please refer to F837 as it refers to the facility's failure to ensure that a governing body or designated persons functioning as a governing body, was legally responsible for establishing and implementing policies regarding the management and operation of the facility.Please refer to F851 as it refers to the facility's failure to ensure that accurate staffing information based on payroll data was submitted to Centers for Medicaid/Medicare Services.Please refer to F867 as it refers to the facility's failure to ensure that the Quality Assurance Process Improvement feedback, data systems and monitoring.Please refer to F883 as it refers to the facility's failure to ensure that providing and/or documenting influenza and/or pneumococcal immunizations as required for residents.Please refer to F908 as it refers to the facility's failure to ensure that maintaining all mechanical electrical and patient care equipment is in safe operating condition.Please refer to F940 as it refers to the facility's failure to ensure that it developed, implemented, and maintained an effective training program for all new and existing staff.Please refer to F944 as it refers to the facility's failure to ensure that it included as part of its Quality Assurance Performance Improvement program mandatory training that outlined and informed staff of the elements and goals of the facility's Quality Assurance Process and Improvement program.Please refer to F947 as it refers to the facility's failure to ensure that in-service training for nurse aides was sufficient to ensure the continuing competence of nurse aides and be no less than 12 hours per year.During an interview on 2/12/2026 at 3:53 PM, Ombudsman #1 stated that they were at the facility weekly except for the last two weeks, and they did not see the Administrator. Ombudsman #1 stated that they would go a month or more without seeing Administrator #1. Ombudsman #1 stated that Assistant Administrator #1 was administering the building and that the residents considered the Assistant Administrator #1 the actual Administrator.During an interview on 2/13/2026 at 9:29 AM, Assistant Administrator #1 stated that Administrator #1 was at the facility periodically but always accessible, and they talked multiple times a day. During an interview on 2/25/26 at 10:10 AM, Administrator #1 stated that they became Administrator in August 2025 when the previous Administrator told them on a Friday that they would not be returning on the following Monday. Administrator #1 stated they had no choice but to put their name on the building as they owned nine (9%) of the facility. At the time of taking over as Administrator, they had asked Medical Director #1 and the previous Director of Nursing if there were any major infection control concerns, to which they said no. Administrator #1 stated that Director of Nursing #1 was going to be the answer to many of the issues identified during survey. Administrator #1 stated that they were already working on a new formula on how to track issues. Administrator #1 stated that when the previous Administrator was running the building, Administrator #1 stated prior to becoming the administrator, they were at the facility every other week. Administrator #1 stated they were now at the facility from Sunday through Thursday, every week. Administrator #1 acknowledged that residents might not know they were the Administrator. Administrator #1 stated they had been identifying issues where they wanted things to change.During an interview on 2/25/2026 at 11:04 AM, Director of Nursing #1 stated in the week that they had been in the building, they believed the foundation was solid but the facility needed revamping. Director of Nursing #1 stated they were actively interviewing for a local administrator.During an interview on 2/25/2026 at 12:25 PM, Administrator #1 stated that they have tried to address issues that were brought to them as soon as they could. They were not aware of some of the issues that had been brought to light during survey. Administrator #1 stated they needed some new processes. Administrator #1 stated that all issues should be, and going forward would be discussed in morning meeting and afternoon wrap up, and department heads would be monitored more closely. Administrator #1 stated that they would look at regulations to ensure compliance with things they did not know the regulations on. 10 New York Code of Rules and Regulations 415.26(a)

Based on observation, record review and interviews conducted during the survey, the facility did not ensure that each resident received, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. This was evident for three (3) of 35 residents sampled (Resident #s 75, 85, 87) and residents residing in the facility. Specifically, (a) for Resident #75, the facility did not monitor or medicate the resident, causing multiple admissions to the hospital for constipation; (b) for Resident #85, the facility delayed testing and treatment of a urinary tract infection causing the resident to go to the hospital with urosepsis; and (c) no meaningful activities were provided to the facility residents, resulting in lack of mental stimulation. This is evidenced by: Cross Reference:Please refer to F550 as it pertains to the facility's failure to resident dignity.Please refer to F580 as it pertains to the facility's failure to notify providers and resident representatives about changes of condition.Please refer to F584 as it pertains to the facility's failure to provide a safe, clean, comfortable and homelike environment.Please refer to F600 as it pertains to the facility's failure to ensure residents were free from abuse and neglect.Please refer to F656 as it pertains to the facility's failure to develop and implement a comprehensive person-centered care plan for each resident.Please refer to F679 as it pertains to the facility's failure to provide activities based on comprehensive assessment, care plan, and preferences of each resident.Please refer to F684 as it pertains to the facility's failure to ensure services provided met professional standards.A facility policy titled Quality of Life/Dignity, date last revised 12/2019, documented that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. The policy further documented in pertinent parts, (5) Residents shall be assisted in attending the activities of their choice, including activities outside the facility. (9) Staff shall give verbal staff to staff communication (e.g. change of shift reports) shall be conducted outside the hearing range of residents and the public.Multiple observations were made of residents sitting in common areas. Activities posted on the activity calendar included daily Chronicle Pass (the facility resident paper), Hydration carts, Puzzles, and Coffee Carts.During an interview on 2/24/2026 at 4:21PM, Licensed Practical Nurse #2 stated activities stink whether they had someone for activities in the building or not. They did not know who the new manager was. They stated difficult residents were excluded from group activities. One activity was to make sand candles and the male residents on their unit did not want to do that. The activity aides were not trained to deal with any kind of residents. They stated an example would be of a particular resident was supposed to use the iPad to call their family member on Mondays which had only happened about three (3) times. Resident #75:Resident #75 was admitted to the facility with diagnoses of noninfective gastroenteritis (inflammation that spreads from the stomach into the intestines and cause, pain, vomiting, and diarrhea) and colitis (inflammation of the large intestine), chronic idiopathic constipation (functional bowel disorder characterized by difficult, infrequent and/or incomplete defecation) and slow transit constipation (slow movement of waste through the digestive system). The Minimum Data Set, dated [DATE], documented the resident had moderate cognitive impairment. The resident was able to make themselves understood and understood others.Resident #75 returned from the hospital on [DATE] after being treated for severe constipation. The facility did not ensure close monitoring of bowel movements, routine assessments when there was no bowel movement, administration of as needed bowel medications per physician orders and facility policy, and reporting of bowel status to the provider. As a result, the resident was sent to the hospital on 1/9/2026 and diagnosed with severe sepsis due to proctocolitis. The facility did not ensure notification to the provider when there was no bowel movement in greater than 24 hours, routine abdominal assessments, and administration of as needed bowel medications. As a result, the resident was sent to the hospital on 2/17/2026 and diagnosed with severe fecal impaction that required fecal disimpaction under anesthesia.Resident #85:Resident #85 was admitted to the facility with diagnoses of unspecified dementia severe, without behavioral disturbance (cognitive decline with no notable behavioral, psychotic, mood, or anxiety symptoms), Type 2 Diabetes Mellitus with hyperglycemia (when the body cannot use insulin correctly and the sugar builds up in the blood), and hypersensitive chronic kidney disease with Stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease (the presence of kidney damage or decreased kidney function). Minimum Data Set, dated [DATE], documented the resident had severe cognitive impairment. The resident usually made themselves understood and usually understood others.Nurse Practitioner note dated 9/18/2025 with date of service 9/19/2025 by Nurse Practitioner #1, documented Resident #85 had lower back pain and family was concerned resident had a urinary tract infection. Plan was to consider sending urinalysis (urine test).Provider orders dated 9/27/2025 documented, obtain urine analysis and culture and sensitivity. Completed 9/27/2025 at 7:30 PM.Nursing Note dated 9/28/2025 at 3:48 AM, documented resident sent to emergency room at 3:35 AM, urine from straight catheterization obtained was dark red. Resident was lethargic and was not answering questions. Nurse Practitioner #1 was made aware and ordered resident to be sent to emergency room. Resident emergency contact and Director of Nursing made aware.Hospital Discharge summary dated [DATE], document admission diagnosis of septic shock and discharge diagnosis of resolved septic shock secondary to urinary tract infection.Resident #87:Resident #87 was admitted to the facility with diagnoses of unspecified fracture of head of left femur (a break in the ball-shaped upper end of the left thighbone where it connects to the hip socket), malignant neoplasm of cerebral meninges (a rare, aggressive, and cancerous tumor arising from the brain's protective membranes), and anxiety (mental health condition characterized by excessive fear or anxiety that interferes with daily activities). The Minimum Data Set, dated [DATE], documented the resident was independent with making decisions regarding tasks of daily living. An Incident and Accident form dated 1/13/2026, documented Resident #87 was found on the floor during rounds and stated that they had fallen while trying to close their door. The immediate action taken documented the licensed nurse assessed Resident #87 immediately, the resident was able to move all extremities without difficulties, vital signs were stable, the resident denied any pain or hitting their head during the fall and the family was notified. A Nursing Note dated 1/14/2026 at 7:12 AM by Licensed Practical Nurse #12, documented the resident stated they fell and refractured their hip. The resident had been in bed all shift. The resident called their family to go to the hospital. The family called 911 to take them out to the hospital around 7:10 AM. A Physician Note dated 1/15/2026 at 12:29 PM by Nurse Practitioner #1, documented on 1/13/2026 evening shift, nursing staff reported the resident experienced a fall while attempting to close a door. At the time of the incident, nursing assessment indicated no apparent injury. The resident denied head strike, denied pain, and no acute complaints were reported. Vital signs were obtained and remained stable. No immediate transfer was deemed necessary based on clinical assessment. On the morning of 1/14/2026, the resident and family independently contacted emergency services, stating concern that the resident had re-fractured their hip and required hospital evaluation. The resident was transferred to the emergency department via emergency medical services. The on-call provider was not notified prior to the transfer. This incident had been reviewed for communication processes and escalation protocols. Education and reinforcement of provider notification requirements were indicated to ensure timely clinical assessment and appropriate decision-making in future similar situations. During an interview on 2/12/2026 at 3:53 PM, Ombudsman #1 stated there was inconsistency with quality of care in the facility.During an interview on 2/25/2026 at 9:29 AM, Medical Director #1 stated that the facility couldn't control the lab timing, just how fast they could get the urine to the lab. Medical Director #1 stated that they oversaw the nurse practitioner and wasn't overly involved unless it was complicated and they needed help. Medical Director #1 stated they reviewed notes when they needed to follow up with a resident, if something unexpected happened or if it was requested by owner. Medical Director #1 also stated that they were not always in the loop or called for every incident or accident and asking them to comment on a resident-to-resident incident would be like asking them what they ate seven (7) months ago. Medical Director #1 stated they hadn't signed any incident and accident reports in the last few months and also stated they signed off on them.During an interview on 2/25/2026 at 11:04 AM Director of Nursing #1 stated they attributed a lot of the issues found on survey as a lack of staff education and the need for staff.During an interview on 2/25/2026 at 12:25 PM Administrator #1 stated that they tried to address everything that was brought to them as soon as they could. Administrator #1 stated that they knew incidents and accidents were an issue and needed a new system, was surprised to learn that notification of resident changes was an issue, the facility staff needed to follow the regulations, and the that staff needed to be educated on the processes regarding what to do for adverse events, reporting them appropriately, and closing the loop after things happened. 10 New York Codes, Rules and Regulations 415.5

Based on observation, record review and interview during an abbreviated survey (Case #NY 730) conducted on 11/20/21, the facility failed to provide adequate staffing to meet the needs of the residents on 2 of 2 units. Specifically, on 11/20/2021, the facility failed to provide nursing staff to pass resident medications and attend to residents' medical needs from 7:58 AM until 10:30 AM, after the night shift nurses left the facility, leaving the facility with no licensed nursing staff. This resulted in no actual harm with the likelihood for more than minimal harm that is Immediate Jeopardy to resident health and safety. This had the potential to affect all 75 residents in the facility. The Immediate Jeopardy was lifted on 11/23/2021. This was evidenced by: The Facility assessment dated [DATE], documented the Staffing Plan as follows: - Weekend staffing for Registered Nurses (RN) included 12-hour shifts from 7:00 AM to 7:00 PM on both Saturday and Sunday. - The 7-days per week staffing plan for direct care included: 1. Day Shift (7:00 AM to 3:00 PM), 2 Full time Licensed Practical Nurses (LPN) on each unit and 4 Certified Nurse Assistants (CNAs) on each unit. 2. Evening Shift (3:00 PM to 11:00 PM), 2 full time LPNs and 4 CNAs on each unit. 3. Night Shift (11:00 PM to 7:00 AM), 1 full time LPN on each unit and 2 CNAs on each unit. The undated Policy and Procedure for Staffing documented the Nursing Staffing Department was responsible for scheduling staff based on the predetermined ratios. Staff schedules were to encompass a 4-week period and were to be issued at least 2 weeks in advance of the scheduled start date. Daily staffing sheets were to be printed and issued to RN Supervisors prior to the start of each shift. Replacements for nursing staff call-ins may entail the use of overtime and/or agency staff. The Daily Staffing Sheet dated 11/19/2021 documented Licensed Practical Nurse (LPN) #2 (assigned to Unit 1) and Registered Nurse (RN) #3 (assigned to Unit 2) were scheduled to work the Night Shift (11:00 PM to 7:00 AM). The Daily Staffing Sheet dated 11/20/2021 had no LPNs scheduled for the Day Shift (7:00 AM to 3:00 PM) and RNS #2 scheduled to come in at 12:00 PM. Staffing Agency Shift History records documented LPN #2 began work on 11/19/2021 at 5:15 PM and left on 11/20/2021 at 7:58 AM. A Staffing Agency Shift History record documented RN #3 began work on 11/19/2021 at 11:07 PM. The Check Out time was blank. The facility Roster Matrix (used by the facility to list current residents and to note pertinent care categories for each resident) dated 11/20/2021, documented there were 36 residents on Unit 1 and 39 residents on Unit 2 for a total of 75 residents in the facility. The following information was identified on the Matrix: - 10 residents were on insulin - 3 residents used respiratory medication - 1 resident received nutrition through a tube On 11/21/2021, the facility provided an undated list of 40 residents on anticoagulant (blood thinner) medication. During an interview on 11/20/2021 at 10:50 AM, the Regional Emergency Management Services Director stated Emergency Medical Services (EMS) had been notified that the 2 nurses from the night shift left the facility before day shift nurses arrived, leaving 4 CNAs on each unit to care for the residents. During an interview on 11/20/2021 at 10:55 AM, the Emergency Services (ES) #1 Supervisor reviewed the incident command timeline and stated EMS received a call from a resident on 11/20/2021 at 9:08 AM, and EMS arrived at 9:12 AM. Upon arrival, there were no nurses in the building, but there were nurse aides on each unit. Paramedics and Emergency Medical Technicians (EMT) from 3 ambulance companies and local police were in the facility. The EMTs were on the units observing and checking on the residents. The Administrator arrived onsite at 10:15 AM, and at the time of the interview RNS #2 was in the building. The ES #1 Supervisor also stated Activities Aide (AA) #2 provided them with a copy of the staffing sheet that had been posted in a binder at the front desk and that there were no nurses scheduled for the Day Shift until 12:00 PM. During an interview on 11/20/2021 at 11:15 AM, the Administrator stated that, at 9:30 AM, they received a call from AA #2 notifying them that EMS and police were in the facility because there were no nurses. The 2 agency nurses (nurses contracted from a staffing agency) from the night shift left the facility without reporting to another nurse and without counting narcotics. The Administrator stated they arrived at the facility at 10:15 AM, and RNS #2 arrived at 10:30 AM. During an interview on 11/20/2021 at 11:55 AM, Certified Nurse Aide (CNA) #5 stated they arrived at the facility at 7:00 AM on 11/20/2021 and worked on Unit 1. At 7:30 AM LPN #2 asked who was coming on the Day Shift to relieve them. CNA #5 checked the schedule posted in a notebook at the front desk and there were no nurses on the schedule until 12:00 PM. LPN #2 said they were calling their staffing agency, then locked the medication room and narcotic lock box keys in the medication room and left the building around 7:45 AM. During an observation on 11/20/2021 at 12:15 PM, on Units 1 and 2, staff were setting residents up with their afternoon meals. Emergency Medical Staff (EMS) were assisting the one Registered Nurse to administer late morning medication to 75 residents. During an interview on 11/20/21 at 12:30 PM, CNA #1 stated RN #3 was upset when no nurse came to relieve them at 7:00 AM. RN #3 left the facility at 7:30 AM. After the nurse left, residents received basic care from the CNAs, but no one was available to give the residents their medication. During an interview on 11/20/21 at 12:35 PM, CNA #2 stated they were assigned to Unit 2 on the Day Shift on 11/20/2021. The posted schedule for 11/20/2021 had 8 CNAs for the Day Shift but no nurses were on the schedule for either the 1st or 2nd Units. At 7:30 AM, RN #3 locked the medication cart keys in the medication room and left the building. CNA #2 stated one of the residents who wanted pain medication and needed insulin called 911. During an interview on 11/20/2021 at 12:43 PM, the Registered Nurse Manager (RNM) #1 (the RNM on Unit 2) stated the Administrator called at 9:30 AM on 11/20/2021 to tell RNM #1 that there were no nurses in the facility. RNM #1 stated they lived an hour away and arrived at 10:30 AM. RNM #1 stated none of the residents had received morning insulin. RNM #1 stated they proceeded to give medication and obtained orders from the Medical Director (MD). RNM #1 stated, they worked to ensure the safety of the residents and the CNAs were giving care. RNM #1 stated medications were over 3 to 4 hours late. RNM #1 stated they were not able to do any detailed assessments, but the residents appeared to be safe. The residents that required insulin prior to receiving breakfast had eaten but, there was nothing that could be done. RNM #1 stated they gave the insulin coverage ordered by the MD as soon as they knew trays were being brought to the resident. RNM #1 stated they did not get or receive any orders for any of the residents on Unit 1 and stated they did not know who was doing that. During an interview on 11/21/2021 at 12:45 PM, Register Nurse (RN) #3 stated that, prior to leaving the facility at 7:30 AM on 11/20/2021, they left a voicemail and sent an email to the staffing agency to inform them they were leaving the facility and that there was no facility nurse to relieve them, or to assist RN #3 with clocking out. Because there was no facility nurse, RN #3 was unable to clock out. RN #3 told the CNAs they were leaving because it was RN #3's agency policy not to stay in a facility past the scheduled shift. RN #3 stated they did not call anyone from the facility prior to the leaving the facility because there were no phone numbers posted. During an interview on 11/22/2021 at 8:40 AM, Licensed Practical Nurse (LPN) #2 stated they were scheduled to work on Unit 1 from 3:00 PM on 11/19/2021 to 7:00 AM on 11/20/2021. They arrived at the facility at 5:30 PM on 11/19/2021 and left the faciity on [DATE] at 8:00 AM. LPN #2 stated when they left the facility there was no nurse to relieve them. LPN #2 called the staffing agency and the agency told LPN #2 they could leave the facility because LPN #2 had worked 2 shifts. LPN #2 told the agency there was no nurse to relieve them and no one to count off medications with and that they were going to lock the keys in the med room. LPN #2 locked the keys for the medication carts in the medication room. LPN #2 stated they did not call any facility staff, but the CNAs tried to call the on-call staff for the facility and did not get a response. LPN #2 stated they thought there was a nurse upstairs when they left. During an interview on 11/23/2021 at 3:37 PM, Registered Nurse Supervisor (RNS) #2 stated they received a text message from the Administrator on 11/19/2021 at 4:30 PM, saying there were no nurses available for the 11/20/2021 Day Shift. The Administrator requested RNS #2 to come in at 12:00 PM instead of at 3:00 PM on 11/20/2021. When RNS #2 arrived at 12:32 PM on 11/20/2021 paramedics were in the facility providing resident care. RNS #2 stated no nurses had been scheduled for 11/20/2021. Most medications for the residents on Unit 1 were 2 to 4 hours late and some medications were not administered until the next dose was due, or not at all. These medications included insulin, anticoagulants, anti-[CONDITION(S)] medication, and pain medication. The MD was called to discuss the medications, and the MD said they were aware of the situation and that they would get back to the RNS, but the MD did not call back. No new orders were received concerning medications that would cover the late medication administration or coverage for the residents who missed doses of medication or required insulin and had not received the Finger sticks. During an interview on 11/22/2021 at 11:50 AM, the Staffing Coordinator stated they and the Administrator had been going back and forth all day on 11/19/2021 trying to schedule nurses for the day shift on 11/20/2021. Around 3:30 PM on 11/19/2021, LPN #2, who was scheduled to work the night shift, was asked via text message if they could stay through the first medication pass in the morning on 11/20/2021, but LPN #2 said they could not stay. The Staffing Coordinator also sent a text message and left a voice message asking RN #2 if they could work at 7:00 AM on 11/20/2021, but RN #2 did not respond. The Staffing Coordinator stated the hope was that RN #2 would come in at 7:00 AM even though RN #2 had not responded to the text message or the voice message. The Staffing Coordinator stated that, by the end of the evening on 11/19/2021, no one from the staffing agency had signed up for the open shifts on 11/20/2021. The Staffing Coordinator stated the Administrator was aware on 11/19/2021 there were no nurses scheduled to come in at 7:00 AM and that RNS #2 was scheduled to work at 12:00 PM on 11/20/2021. During an interview on 11/22/2021 at 1:50 PM, the Administrator stated, they worked with the Staffing Coordinator all day on 11/19/2021 on the staffing schedule for 11/20/2021. The Administrator stated they knew at some point on 11/19/2021 that RN #1 was scheduled to come in around 12:00 PM on Saturday. The Administrator stated the way they left it on 11/19/2021 was that the Staffing Coordinator was in contact with the staffing agency and RNS #2 would be coming in at 12:00 PM on 11/20/2021. The Administrator also stated that on 11/19/2021, they were aware there were no nurses scheduled to work in the facility from 7:00 AM to 12:00 PM on 11/20/2021. The Administrator stated it was their understanding if there were any issues, the Administrator would have been called or the acting Director of Nursing would have been called. During an interview on 11/21/2021 at 9:07 AM, the Medical Director (MD) stated that on 11/20/2021 at 10:00 AM they were notified that the night nurses had left the facility with no other nurse's present. The MD stated there would likely be no negative outcome from once or twice daily medications being given a few hours late. In the case of residents with diabetes, a missed dose of insulin could easily be made up, likely with no consequence. On 11/20/2021, the MD spoke with RNM #1 and reviewed the residents on insulin and the actions to take and gave a verbal order to give all morning medications to the residents. The MD stated they were not aware of any negative resident outcomes on the morning of 11/20/2021. 10 NYCRR 415.13(a)(1)(i-iii)

Based on observations, record review, and interviews during a standard and extended recertification survey the facility failed to ensure that it established and maintained an Infection Control Program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection for two (2) of two (2) units reviewed for wound care. Specifically, the facility failed to ensure that licensed facility staff followed recognized infection control practices (e.g., hand hygiene, use of standard precautions) for the prevention of cross contamination while providing wound care for three residents (#11, #25 and #61). This is a repeat deficiency from the recertification surveys conducted on 5/30/13. This resulted in Immediate Jeopardy to the resident health and safety as evidenced by the following: An undated Policy and Procedure titled "Standard Precautions/Contact Precautions documented to wash hands after touching blood, bodily fluids, secretions, excretions, and contaminated items whether or not gloves are worn, It documented to wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid the transfer of microorganism to other patients or environments, and that it may be necessary to wash hands between tasks and procedures on the same patient to prevent cross-contamination of different body sites. A undated Policy and Procedure titled "Infection Control", documented that hands should be washed before and after resident contact and after removing gloves. It documented that gloves must always be used as an adjunct to and not a substitute for hand washing. An undated Policy and Procedure titled "Dressings, Dry /Clean" documented to wash and dry hands thoroughly and put on clean gloves. It documented that after removing old dressing, pull a glove over the dressing and discard into a plastic or biohazard bag then wash and dry hands thoroughly before applying clean gloves to cleanse the wound. It documented to clean from the least contaminated area to the most contaminated area. It documented to remove gloves and to wash and dry hands after the procedure. Resident #25 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the Brief Interview for Mental Status (BIMS) as 15 (cognitively intact). Hospital and Community Patient Review Instrument (H/C-PRI) dated 11/5/14 documented a Stage 4 decubitus (pressure ulcer) in the sacral area, a Stage 4 pressure ulcer on the left buttock, contact precautions-MRSA (Methicillin-resistant Staphylococcus aureus) wound, VRE ([MEDICATION NAME]-resistant [MEDICATION NAME]) in the urine, and [MEDICATION NAME] (antibiotic) 500 mg po (by mouth) bid (twice daily) for VRE, MRSA, and wounds. There was no documented evidence in the Comprehensive Care Plan that the resident had VRE and MRSA and was on contact precautions. An undated Policy and Procedure for Infection Control documented Resident's with "Super bugs" ( MRSA, VRE) will be placed on contact precautions. In addition these residents would be placed in private rooms. It documented that Personal Protective Equipment (PPE) such as gowns, goggles, or masks should also be used in addition to gloves if contact with the resident's source of infection was expected. Resident Physical Assessment Admission/Re-Admission/Transfer form dated 11/6/14 documented that the resident has VRE in urine, and MRSA in wounds. A Physician order [REDACTED]. Wound Assessment/Notification Form dated 11/6/14 documented left hip/buttock unstageable 6 cm x 3 cm x 0.5 cm with yellow slough, flank near colostomy stage II 3.5 cm x 0.5 cm x 1 cm, and abdominal midline surgical incision 9 cm x 3 cm x 1.2 cm. Daily Routine Card (used by care givers to provide care) dated 11/6/14 documented precautions for VRE in urine and MRSA in wounds. A Comprehensive Care Plan (CCP) for Skin Impairment dated 11/6/14 documented a Stage III pressure ulcer on the left medial buttock, an unstageable pressure ulcer on the left hip, a surgical wound on the abdomen, and 2 open areas on the right side related to surgery. A Physician order [REDACTED]. A Physician order [REDACTED]. A Physician order [REDACTED].) with instructions to apply to old drain site right flank one time a day and prn (as needed) after cleanse with wound cleanser, and cover with one 2x2 (gauze) and abd (abdominal) pad. A Physician order [REDACTED].) with instructions to apply to posterior old drain site right flank one time a day and prn after cleanse with wound cleanser, and cover with 2x2 and abd pad. A Physician order [REDACTED].) with instructions to apply to abdomen one time a day after cleanse with wound cleanser, and cover with 4x4 (gauze) and lge (large) bordergauze. Wound Tracking Flow Sheet dated 12/23/14 documented an unstageable pressure ulcer on left hip. Wound Tracking Flow Sheet dated 12/23/14 documented a Stage III pressure ulcer on the left medial buttock. Weekly Wound (Non-pressure)/Skin Condition Report dated 12/23/14 documented an abdominal incision. Weekly Wound (Non-pressure)/Skin Condition Report dated 12/23/14 documented an old drain site on the right flank. Weekly Wound (Non-pressure)/Skin Condition Report dated 12/23/14 documented an old drain site posterior to right flank. An observation on 12/30/14 at 7:30 am of the Registered Nurse-Nurse Manger (RN-NM) during wound rounds found that the RN-NM did not wash her hands before donning gloves and gown prior to entering this resident's (who was on contact precautions) room. During the obervation of the abdominal wound dressing change on 12/30/14, the RN-NM was observed using the same pair of gloves to remove the existing abdominal wound dressing and to cleanse the wound with wound cleanser. The RN-NM removed her gloves, did not wash her hands, and with un-gloved hands applied wound gel via an applicator bottle to the abdominal wound. The RN-NM left the room to get normal saline from the unit's clean treatment cart located in the hallway to the right of the resident's room. The RN-NM did not wash her hands, nor did she remove the protective gown prior to leaving the resident's room. The RN-NM re-entered the resident's room, did not wash her hands and donned sterile gloves. The RN-NM applied the normal saline to the sterile gauze, placed the gauze on the abdominal wound, and then measured the wound using the ruler that is on the outside of a cotton swab wrapper. The RN-NM removed her gloves, did not wash her hands, and then donned non-sterile gloves. During the continued observation of the right flank dressing changes, the RN-NM removed the existing dressings covering the right flank (side) surgical drain sites and cleansed the wounds with wound cleanser without changing gloves. The RN-NM measured the wounds using the same cotton swab wrapper, applied the wound gel via applicator bottle, removed the gloves, did not wash her hands, and donned sterile-gloves. The RN-NM placed sterile gauze over the wounds, removed her gloves, did not wash her hands, and covered the wounds with an abdominal pad and tape using ungloved hands. The RN-NM left the room to get Santyl from the unit's clean treatment cart that was outside of the resident's room. The RN-NM did not wash her hands, nor did she remove the protective gown prior to leaving the resident's room. The RN-NM re-entered the resident's room, and did not wash her hands. During the left hip/buttock and left medial dressing changes, the RN-NM measured the wound using the same cotton swab wrapper and measured the inside of the wound bed for tunneling using a cotton swab with ungloved hands. The RN-NM donned a pair on gloves without first washing her hands. The RN-NM packed the left medial buttocks with gauze dressing and then without changing gloves, applied Santyl to the left hip/buttock wound, covered the wound with sterile gauze, and removed her gloves. The RN-NM did not wash her hands, and applied a protective dressing over both wounds with ungloved hands. Without washing her hands, the RN-NM put some wound care supplies in the resident's night stand and then brought the remainder of the supplies outside of the resident's room. The RN-NM did not remove the protective gown, nor did she wash her hands prior to leaving the resident's room, surveyor did not see where RN-NM went as surveyor was removing isolation gown and washing hands when nurse exited room. When surveyor exited the room the RN-NM was outside the room not wearing an isolation gown. The RN-NM stated that she washes her hands somewhere else because she doesn't want to touch anything in the resident's room. During an interview on 12/31/14 at 1:55 pm with the RN-NM, the RN-NM stated that she knows that she forgot to do a few things during the dressing changes because she was nervous that she was being watched. RN-NM did not elaborate on the comment but was on her way to re-education for their infection control practice issues identified by surveyors. Resident #11 The resident was admitted to the facility on [DATE], on antibiotic therapy, post surgical debridement of infected right trochanteric pressure ulcer, with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) documented the resident to have a BIMS (brief interview mental status) score of 9 (moderately impaired). Review of the wound tracking sheets indicated the resident was admitted from the hospital on [DATE] with a Stage III pressure area to the R hip, and a deep tissue injury (DTI) to the right heel present on admission. The date of origin was documented as unknown. The intervention for the right hip documented a Negative Pressure Wound Treatment ([DEVICE] set at 125 mm/ hg continuous). On 12/12/2014, wound tracking sheets were started for new Stage II areas on the inner and outer right buttock. On 12/16/14, a Stage II area developed on the left buttock. Observation of the dressing changes on 12/30/2014: The URN (unit registered nurse) without washing her hands, put on clean gloves and positioned the resident on his left side to prepare for the dressing change to the wound site on the right hip. The vacuum pump dressing was removed and the tubing was taken out of the wound site. The URN coiled the tubing in her gloved hand, then picked the vacuum pump off the floor with the soiled gloves and placed the vacuum pump on the bed to remove the dirty canister (container to hold drainage removed from the wound with negative pressure). She then took the canister into the bathroom. The URN returned to the bedside and put on clean gloves, the wound was exposed and foam packing from the wound had to be removed. The packing was removed and some of the foam from the wound fell on to the bed. The URN without washing her hands, changed gloves which she pulled from her pocket, and proceeded to start preparing the dressing for the wound. The URN rinsed the wound site and decided the dressing she pulled for the wound was the wrong size, then left the room and went to the unit's clean treatment cart for 2 x 2' s. There were no 2 x 2' s on the cart. The DON (Director of Nursing) entered the room at that time with the 2x2's, and placed the packages on the bed. The URN then proceeded to rinse the wound bed, and wet the dressing, placed the dressing in the wound bed and covered the wound with [MEDICATION NAME]. The URN then proceeded to clean and dress the buttock wounds. During an interview with the URN at approximately 2:30 pm on 12/30/14, she was asked why she placed the dirty vacuum container on the residents bed to empty the canister, she stated she did not even realize that she had done that. The URN was then asked if she had pulled the gloves she used from the box on the treatment cart, she stated no, she keeps a supply in her pocket as she is always changing gloves. During the interview with the DON on 12/30/14 she stated that the facility did not have a policy on sterile /clean dressings for the wound vac system until today 12/30/14. Additionally the DON stated that the URN should have washed hands changed gloves and by not doing so, she cross contaminated the wounds. During an interview on 12/30/14 at 3:30 pm the Infection Control Nurse (ICN) stated that there were many breaks in infection control. The ICN stated that staff should have done hand washing before and during the dressing change, as well as changing gloves. Resident #61 The resident was admitted to the nursing home on 1/4/13 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having moderately impaired cognitive skills for daily decision making. It documented that the resident usually understood and was usually understood by others. During an observation of a Negative Pressure Wound Treatment (wound vac) for Resident #61 on 12/29/14 at 10:25 am, the surveyor noted that the wound vac was on the night stand with part of the drainage tubing resting in the resident's bed pan that was also on the night stand. During a dressing observation on 12/29/14 at approximately 10:45 am the DON donned gloves without washing her hands to remove the dressing from the resident's posterior left hip wound, that was applied by LPN (licensed practical nurse) #1. She opened a new wound vac set up on the over bed table without cleaning the surface, applying a barrier, washing her hands or changing gloves. The DON then removed the soiled dressing while wearing the same gloves, went to the bathroom, retrieved a paper towel out of the holder, and handed it to the CNA (certified nursing assistant) to document the wound measurements on. The CNA removed her gloves and put the paper towel on the over bed table next to the opened wound vac supplies to document the measurements that the DON called out. The DON then picked up the new sponge with her soiled gloves, opened the night stand drawer and removed a pair of scissors and cut the sponge. Without changing gloves or cleansing the wound the DON placed the sponge in the deep portion of the wound then cut another piece and placed it on the top portion of the wound. While the DON was getting the clear adhesive dressing, the top piece of foam fell from the hip wound onto the resident's linens that were soiled with serosanguinous drainage. LPN #1, who standing in front of the resident and holding the resident over toward her during the procedure, picked up the sponge from the bed with her soiled gloves and placed it back in the wound. During this time the DON was holding the clear dressing and telling the LPN which way to put the dressing because the LPN was in front of the resident and did not have a good site line as to where the wound was. The DON then covered the sponge with the clear covering and then reconnected the new tubing from the wound to the tubing that was attached to the vacuum and partially in the resident's bedpan. The DON removed her gloves and without washing her hands picked up a single use bottle of saline that was also on the night stand, next to the bedpan, opened it and when she saw that the seal was still intact under the cap, she recapped the saline and placed it back on the stand for future use. Additionally, the DON used her ungloved hands to remove the soiled bed linens. During an interview on 12/30/14 at 11:15 am the Infection Control Nurse (ICN) stated that there were many breaks in infection control. The ICN stated that staff should have done hand washing before and during the dressing change, as well as changing gloves. The scissors should not have been taken out of the drawer and used to cut the foam dressing, and when the foam dressing dropped on the soiled linens it should have been discarded and not placed back in the wound. During an interview on 12/30/14 at 1:40 pm the DON stated she should have washed her hands during the procedure and that she probably should have cleaned the scissors prior to using them. The DON further stated that she did not see the LPN pick up the sponge and thought that she did remove her gloves once because she left the room to get the doctor. Additionally the DON stated that she should not have used bare hands when handling the resident's soiled bed linens. Finding # 1 During a medication pass observation on 12/30/14 at 8:35 am, the LPN (Licensed Practical Nurse) dropped a pill on the floor, picked it up and put it in the garbage then continued to pour medications without washing her hands. During an interview on 12:30/14 at 9:15 am the LPN stated that she did not touch the floor when she picked up the pill from the floor but that she could have used hand sanitizer. During an interview on 12/30/14 at 11:15 am the Infection Control Nurse (ICN) stated that the LPN should have washed her hands after picking up the pill from the floor. 10NYCRR 415.19(a)(1-3)

Based on medical record review and staff interviews, during a standard and extended recertification survey it was determined that the facility Quality Assurance (QA) Program failed to have a process that readily identified issues that had the potential to cause serious harm to residents. The facility failed to ensure that a system was in place to ensure that accepted professional practices were utilized for wound care and failed to implement hand hygiene (hand washing) practices consistent with accepted standards of practice, to reduce the spread of infections and prevent cross-contamination. This is a repeat deficiency from the recertification surveys conducted on 5/30/13. This resulted in Immediate Jeopardy to resident health and safety. This was evidenced by: Refer to Infection Control- F 441 prevent the development and transmission of disease and infection, Scope and Severity - L During an interview on 12/30/14 at 1:00 pm the Administrator stated he was not aware that there was an infection control issue with dressing changes. The Director of Nursing (DON) and Nurse Manager should know when to wash hands and change gloves. The DON is the QA Coordinator. During an interview on 12/30/14 at 1:40 pm the DON stated she should have washed her hands during the procedure and that she probably should have cleaned the scissors prior to using them. DON stated that the facility did not have a policy on sterile /clean dressings for the wound vac system until today (12/30/14). During an interview on 12/30/14 at 3:30 pm the Medical Director stated he was not aware of an infection control problem or risks of cross contamination in the facility. He had not observed any problems with staff not following infection control procedures. The wound vac (vacuum assisted closure) dressing should be a sterile procedure. During an interview on 12/30/14 at 4:00 pm the DON stated that she is in charge of QA. Infection Control reports monthly to the committee on the tracking and trending of infections. There have been no audits done on dressing changes in the recent past. Wounds are not reported in QA. 10 NYCRR 415.27(a-c)

Based on interview and record review during an extended recertification survey, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for two (2) of two (2) units reviewed. Specifically, the facility failed to ensure that accepted professional practices were utilized for wound care and failed to implement hand hygiene (hand washing) practices consistent with accepted standards of practice, to reduce the spread of infections and prevent cross-contamination. This is a repeat deficiency from the recertification surveys conducted on 5/30/13. This resulted in Immediate Jeopardy to resident health and safety. This was evidenced by: Refer to Infection Control- F 441 prevent the development and transmission of disease and infection, Scope and Severity - L During an interview on 12/30/14 at 1:00 pm the Administrator stated he was not aware that there was an infection control issue with dressing changes. The Director of Nursing (DON) and Nurse Manager should know when to wash hands and change gloves. During an interview on 12/30/14 at 1:40 pm the DON stated she should have washed her hands during the procedure and that she probably should have cleaned the scissors prior to using them. Additionally the DON stated that she should not have used bare hands when handling the resident's soiled bed linens. DON stated that the facility did not have a policy on sterile /clean dressings for the wound vac system until today 12/30/14. During an interview on 12/30/14 at 3:30 pm the Medical Director stated he was not aware of an infection control problem or risks of cross contamination in the facility. He had not observed any problems with staff not following infection control procedures. During an interview on 12/30/14 at 3:00 pm the Infection Control Nurse (ICN)/Staff Development Coordinator provided the DOH Surveyor with the lesson plan for Infection Control and the signature sheet dated 5/8/14 and 5/9/14. ICN stated the signatures showing who attended the inservice did not include the DON or the Nurse Manager's signature. There was no other Infection Control Inservice offered in 2014. 10NYCRR415.26

Based on record review and staff interview during a partial extended abbreviated survey (Case # NY 830) the Administration failed to operate in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for two (#s- 3 and 5) of six resident's reviewed. Specifically for Resident #3, the administration failed to ensure a thorough investigation of an alleged diversion of narcotic pain medication was completed and failed to remove the accused employee from working. For Resident #5, the administration failed to thoroughly investigate two missing [MEDICATION NAME] (a narcotic pain medication) patches, failed to remove accused staff from working, and failed to report the incident to appropriate officials. This was widespread and resulted in no actual harm with the potential for serious harm to affect all residents that is an immediate jeopardy to resident health and safety. This was evidenced by: Refer to F225, Staff treatment of [REDACTED]. Refer to F520, Quality Assurance, Scope and Severity-L, Administration Interviews revealed that staff did not take appropriate action upon the discovery of alleged diverted narcotic pain medication. Staff were not following facility policy regarding the initiation of an investigaton and removing the accused employee from their work duties immediately. Further investigation showed the administration failed to ensure that thorough investigations were completed, accused staff were removed immediately pending investigation, and that incidents were reported to the appropriate officials. During a telephone interview on 11/14/13 at 9:10 am the former DON stated she was made aware of the alleged diversion of narcotic pain medication on 9/22/13 at 4:30 am by LPN #1. She stated LPN #1 had called her at home and was upset the RNS confronted her. She stated LPN #1 remained on duty until the end of her shift and was not sent home. She further stated she was aware of the missing [MEDICATION NAME]es, that a lot was going on at the time; the facility was going through their plan of correction and she had a consultant in the building working with her. She stated she obtained statements regarding the incident, and that LPN #1 had found one of the patches on the floor, which was suspicious, and she assumed she had taken the other one. She stated LPN #1 resigned after that so the problem was gone. She further stated she did not report the incident to the Department of Health or the Bureau of Narcotic Enforcement, but now knows it should have been reported. During an interview on 11/14/13 at approximately 4:00 pm the Director of Nurses (DON) and Administrator stated that they were aware of these incidents, however they thought the former DON had done a more thorough investigation, but could not locate it. They stated they had a consultant in the building at the time and thought she had helped the former DON with these investigations. The Administrator stated the facility policy and procedure was not being followed in regard to investigating incidents and removing accused staff from their work duties. He further stated that the incidents were not reported to the appropriate officials and stated he would submit a report to the Bureau of Narcotic Enforcement. The DON expressed confusion regarding what kind of medication errors and/or discrepancies should be reported to the Department of Health. She further stated this was a good learning experience for her to assist with dealing with these kinds of issues in the future in her new role as DON. 10 NYCRR 415.26

Based on medical record review and staff interview during a partial extended abbreviated survey (Case # NY 830) the facility failed to ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property were thoroughly investigated, and failed to prevent further potential abuse while the investigation was in progress for two (#3 and #5) of six residents reviewed. Specifically for Resident #3, the facility failed to investigate an alleged diversion of narcotic pain medication; failed to remove the accused employee from working. For Resident #5, the facility failed to investigate two missing [MEDICATION NAME] (a narcotic pain medication) patches; failed to remove accused staff from working; failed to report the incident to appropriate officials. This was widespread and resulted in no actual harm with the potential for serious harm to all residents that is an immediate jeopardy to resident health and safety and is substandard quality of care. This is a repeat deficiency from the partial extended abbreviated survey on 8/26/13 , which was cited at Immediate Jeopardy and the 5/30/13 recertification survey. This was evidenced by: The Policy and Procedure (P&P) Investigation and Protection, revised 11/2010 documented every incident reported on the Incident Accident Report form shall be investigated immediately and thoroughly. The nursing supervisor for the shift on which the event occurred will: begin the investigation immediately, will report to the scene of the incident immediately and secure it until all pertinent evidence/ information has been captured, will assure the safety of the resident and any other residents in the area, will interview the affected resident as well as other residents, staff, or other people who may have any knowledge of the incident, will document all relative facts, including the date and time the alleged incident likely occurred, will assemble all relevant documents, will consult with the Director of Nursing (DON) for the need of additional action, will provide the DON with a preliminary summary of the incident. The DON will: oversee the investigation of the alleged incident, order a more thorough investigation if circumstances warrant, ensure that a comprehensive report of the incident investigation is completed, report the incident and investigation to administration, and ensure preventative measures are stressed to ensure all residents are safe. The P&P Investigation of Significant Clinical Event, revised 8/2013 documented upon identification of a clinical event, the Nurse Manager and or Nursing Supervisor will initiate an investigation. All such events will be investigated fully, as warranted by the circumstances of the event, to rule out abuse and/or neglect. Investigation will include, at a minimum: record review by DON/designee, interview of all involved personnel, when possible, interview of residents. If after investigation a determination that abuse/ or neglect may have occurred, the appropriate State agencies will be notified. The P&P Controlled Substances, revised 8/2012 documented controlled substances will be stored in a minimum of a double-locked narcotic cabinet affixed to a wall in a locked medication room on the nursing units. Licensed nurses will conduct and document a narcotic count at the beginning and end of each shift, before passing the narcotic keys. The narcotics count will be conducted in the following manner: All narcotic counts will occur in the medication rooms, both nurses will look at both the individual narcotic records and the medication when confirming the count, all narcotics in both the medication carts and the wall-mounted narcotic box will be counted, the count will be conducted in a manner that goes from page to page in the Narcotic Control Binder looking for the medication that matches the page, nurses will sign the Control Count Verification form, located in the front of each individual narcotic record after completing the narcotic count, signatures indicate that the count was completed as described above. Keys to the medication room, narcotic cabinets, and medication cart will not be passed from one nurse to another without a narcotic count. When administering narcotics, licensed nurses will sign out each dose on the resident and drug specific narcotic record. Initials are not acceptable. Nurses must sign their name and indicate their status. A medication incident report will be completed for any discrepancies in the narcotic count. Resident #3 The facility failed to investigate an alleged diversion of narcotic pain medication and remove the accused employee from working. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as cognitively intact. The physician's order [REDACTED]. [MEDICATION NAME] HCl 5mg two tablets by mouth every four hours while awake, alternate with [MEDICATION NAME]. The Control Record of Narcotics or Sedatives, initiated 9/16/13 for Resident #3 ' s [MEDICATION NAME] pain medication did not contain any documented evidence that the resident' s pain medication was removed or received at 12:00 am or 4:00 am on 9/22/13. The Control Record of Narcotics or Sedatives, initiated 9/10/13 for Resident #3's [MEDICATION NAME] pain medication did not contain any documented evidence that the resident's pain medication was removed or received at 2:00 am on 9/22/13. The Medication Administration Incident Report, dated 9/22/13 at 4:00 am documented there was a blank on the resident's medication administration record (MAR) for medication that was given. It further documented "[MEDICATION NAME] HCl 5mg 2 tablets by mouth every four hours PRN (as needed) and [MEDICATION NAME] APAP 10/325mg every four hours, which was due at midnight. Called to resident's room with complaints of inability to sleep, LPN #1 (Licensed Practical Nurse) on break, check of MAR and narcotic sheet did not note removal of medications. Count with LPN #1 showed medications had been removed, but appear to have been given but not signed for. All medications in MAR between 12:00 am and 4:00 am had not been signed for, but nurse states given. Resident indicates receiving pain medications at midnight and a little before 3:00 am. Medication not signed for verified with union representative at 4:00 am." The rest of the Medication Administration Incident Report was left blank and not signed by LPN #1. There was no documented evidence that a statement was obtained from LPN #1 regarding the medication administration incident. In the Nursing Notes dated 9/22/13 at 4:15 am, the Registered Nurse Supervisor (RNS) documented called to resident's room due to inability to sleep, which resident states "never happens." Resident questioned as to whether he had received his midnight and 2:00 am dose of narcotic pain medication, resident stated he had received medications. In the Nursing Notes dated 9/22/13 at 6:00 am, LPN #1 documented patient up all night complaining of not being able to sleep, stated he changed tea's from decaffeinated to regular caffeinated but he said " only had with meals so I don't think that's it. " I informed patient that he hasn't had caffeinated tea in over four weeks and that it could make a difference going back to caffeinated tea. No complaints of pain noted this shift, medicated as ordered. In a fax dated 9/23/13 to the former DON from the RNS, the RNS documented on Saturday the 21st of September she was the nursing supervisor for LPN #1. After completing her narcotic count and taking control of the medication cart, LPN #1 stated she was going down to pass medications, taking the cart down into the area of rooms 116-122. This was at approximately 11:45 pm-midnight. After approximately 10-15 minutes, RNS had noticed the medication administration book for the rooms of 114-128 sitting atop the nursing station ledge. This was the area which LPN #1 stated she was going to pass medications in. RNS proceeded to take the book down to her, first noticing that the light for that area was off in the hallways. RNS immediately turned the light on. LPN #1 had just exited a resident's room. RNS stated she had found the MARs, and how was it possible that LPN #1 would be administering medications without this. LPN #1 replied she " had a good memory." At approximately 3:45 am Resident #3 informed the RNS that he was having difficulty sleeping, which he stated he never experiences. RNS asked if he had received his narcotic pain medication, which he informed the RNS he had at midnight and approximately 2:45 am. RNS then went to the MARs for his room and discovered that none of his medications had been signed for, including the narcotics he stated he had been given. RNS then reviewed the remainder of the MARs to discover that there were 12 total pills needed to be administered for the residents in rooms 114-128 between the hours of midnight and 6:00 am. Not a single medication due to have been administered for midnight and 2:00 am had been signed for. RNS approached the union representative to ask for his assistance in verifying the medications were not signed for and then took the narcotic log sheet and MARs to photocopy. LPN #1 returned at this time from the outside with copious amounts of clear drainage coming from her bilateral nares; she was squeezing her nares and sniffing inward. RNS asked her why she had not signed the MARs for any resident due to have midnight or 2:00 am medications; LPN #1 stated that her shift was not over and she had the right to sign them before the end of her shift. RNS informed her this was poor nursing practice and that should something had happened to LPN #1 and someone else had taken over the cart; we could only make the determination that no one had received their medications, as nothing had been signed. At this time the RNS and LPN #1 counted Resident #3's narcotics which were consistent with two of the [MEDICATION NAME] medications being punched out per his order for 2:00 am and one [MEDICATION NAME] being punched out for his midnight dose; both of which were not documented in the narcotic log as being removed or administered. RNS asked LPN #1 how she felt the scenario would appear to her; a resident is informing me that he is not feeling the effects of his narcotics, as he normally does, they are punched but not signed, and LPN #1 returns from break with copious amounts of drainage from her nostrils. That rather than blowing her nose as someone with an allergic reaction or sinus condition would do, LPN #1 was plugging her nostrils and snorting inward. LPN #1 then asked if RNS was accusing her of taking the medications, at which time the RNS stated she had no proof of such, but that LPN #1's behaviors could possibly warrant someone to consider requesting a drug screen. LPN #1 started demanding RNS call the DON which RNS stated she was not going to do at 4:30 am, and that LPN #1 was to continue administering her medications and signing them. RNS did not feel that LPN #1 was unsafe to do so at that time. RNS stated to LPN #1 that she was concerned that there have been many poor exhibits of nursing processes throughout the night, and that LPN #1 needed to behave as a professional nurse. RNS further stated to LPN #1 that she never in her career experienced working with a nurse such as LPN #1, and her lack of thoroughness, which was unacceptable; that LPN #1 was to continue passing medications and keep her remarks to herself. There was no documented evidence of a thorough investigation or investigative summary regarding the alleged diversion of Resident #3's narcotic pain medication. The Professional Discipline Complaint Form completed by the RNS 9/23/13, signed by the former DON 9/24/13, and faxed to the Office of the Professions 9/30/13 documented that on 9/22/13 LPN #1 was noted to have not signed medications, specifically distributed to a resident at midnight and 2:00 am of the same day. This was discovered by the RNS at 4:00 am after responding to a comment at approximately 3:45 am by resident, who stated that he was unable to sleep, which he reported as unusual for him. Upon the RNS review of the MARs at 4:00 am it was discovered that the MARs were not initialed for any medications that were due for administration between midnight and 4:00 am. Also, at approximately 12:45 am on the same date, LPN #1 was found to be administering medications without use of the MARs The MARs were discovered on the nursing station. When the RNS approached LPN #1 regarding not using the MARs when passing medications, LPN #1 stated she had a "good memory." There was no documented evidence that the incident was reported to the Department of Health. During an interview on 11/14/13 at 10:00 am the RNS stated that LPN #1 had been acting very strange the night of 9/22/13. She stated LPN #1 had a routine and always started passing medication in the front of the unit and worked her way toward the back of the unit. She stated this night LPN #1 started passing medications in the back of the unit. RNS was sitting at the nursing station and noticed that LPN #1 did not have the MAR with her to pass medications. She stated she went toward the back of the unit to give LPN #1 the MAR and noticed the lights were off where she was passing medications. She further stated LPN #1 responded to her that she had a "good memory." At around 3:00 am Resident #3 rang that he was having trouble sleeping. At this time she discovered LPN #1 had not signed for his narcotic medications and the count was okay if she gave them, but again they were not signed for. RNS stated she questioned the diversion of the resident's narcotic pain medication secondary to LPN #1's behavior that night and history. She stated she did not remove LPN #1 from working on the unit that night as she didn't feel LPN #1 was under the influence or unsafe to finish the medication pass. She stated she monitored LPN #1 and checked on Resident #3 who fell asleep. She further stated she notified the former DON on 9/22/13 at 6:22 am. During a telephone interview on 11/14/13 at 9:10 am the former DON stated she was made aware of the alleged diversion of narcotic pain medication on 9/22/13 at 4:30 am by LPN #1. She stated LPN #1 had called her at home and was upset the RNS confronted her. She stated LPN #1 remained on duty until the end of her shift and was not sent home. She further stated she believed LPN #1 left after that. During an interview on 11/14/13 at approximately 3:00 pm the DON and administrator stated they had thought the former DON had taken care of this incident. They further stated LPN #1 had resigned and was asked not to come back upon receipt of her resignation. Resident #5 The facility failed to investigate two missing [MEDICATION NAME] (a narcotic pain medication) patches, remove accused staff from working, and report the incident to appropriate officials. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed the resident as cognitively intact. The physician's orders [REDACTED]. The Control Record of Narcotics or Sedatives initiated 9/3/13, documented that on 9/11/13 at 9:00 pm one patch was removed to place on the resident leaving the amount of [MEDICATION NAME]es remaining at a total of 7 patches. On 9/12/13, an entry not timed, documented "visualized by " with two RN signatures, and the amount of [MEDICATION NAME]es remaining at a total of 5 patches. On 9/13/13 at 11:30 pm it was documented " found 1 on floor " and "corrected count to 6 " with two RN and LPN #1's signatures. During an interview on 11/13/13 at 10:15 am the DON stated that she was aware that two [MEDICATION NAME]es had been missing, however she was the Nurse Manager on the unit at the time. She stated that one of the [MEDICATION NAME]es was found on the floor in the medication room by LPN #1 when she came on shift, which was suspicious. She stated she would look for the investigation completed by the former DON. The Medication Administration Incident Report dated 9/12/13 at 3:30 pm documented an inaccurate narcotic count, during shift change narcotics count, 2 [MEDICATION NAME]es were missing. The rest of the Medication Administration Incident Report was left blank. In a written statement provided by the facility, undated, LPN #1 documented on 9/12/13 at approximately 7:30 am her and LPN #2 counted narcotics, took approximately 30 minutes without incident, count completed all correct. On 9/12/13 at approximately 11:30 pm she counted narcotics, count completed all correct. She was informed of a discrepancy in narcotic count on 9/12/13 at approximately 3:00 pm during shift change. She didn't have any information on discrepancy. In a written statement provided by the facility dated 9/12/13 LPN #2 documented in the morning she counted the [MEDICATION NAME]es and there were 7 patches. Then, at the end of the shift it is missing 2 [MEDICATION NAME]es. In a written statement provided by the facility, undated, LPN #3 documented while doing beginning of shift narcotic count Resident #5's [MEDICATION NAME] count was off by 2. She had placed a patch on Resident #5 last evening and the count was 7. She counted the narcotics at 11:00 pm with LPN #1 and the count was 7. When she came in today at 3:00 pm the count was only 5. On a few occasions, LPN #1 would not compare paper to blisters and just say that the count was right. She would make her stop and compare both the sheets and blister to assure the count is correct. In a written statement provided by the facility dated 9/16/13 LPN #3 documented during the change of shift count on 9/12/13 at 11:00 pm she told LPN #1 about the missing [MEDICATION NAME]es and continued to count. At the end of the count LPN #3 mentioned that her back hurt. LPN #1 offered her something for her pain, stating she found some pain pills in her house and had them in her car. LPN #1 told her she could have them and that she could get anything for her that she wanted. She told LPN #1 no, that she had medication from her doctor. A review of the staffing sheets for September of 2013 documented that LPN #2 continued to work at the facility after the discovery of two missing [MEDICATION NAME]es. During an interview on 11/14/13 at 11:30 am a representative for the agency LPN #2 works for stated that she was not aware of a narcotic count discrepancy that occurred while LPN #2 was working for the facility. She stated the facility should have reported this to her and that LPN #2 still goes there to work for them. She further stated LPN #2 did not have a history of issues with narcotics, but she has had to speak with LPN #2 regarding medication errors where she had not properly gone over the "five rights" while administering medications. During an interview on 11/14/13 at 11:40 am LPN #2 stated that she counted narcotics with LPN #1 at the beginning of her 7-3 shift on 9/12/13. She stated she removed the [MEDICATION NAME]es and counted them one by one. She stated she had the correct amount of 7 patches. She put the [MEDICATION NAME]es back into the narcotic cabinet, as she did not need them for her shift. She did not give her keys to anyone and as far as she knew she was the only one with keys to the narcotic cabinet. She could not recall if she went back into the narcotic cabinet at any time before the end of her shift. She stated as she was doing the narcotic count with LPN #3 at 3:00 pm they noticed there were only 5 [MEDICATION NAME]es. She stated she did not know how this happened, but LPN #3 stated it wasn't the first time this had occurred, that other people have the key to the narcotic cabinet, and "they" know what's going on. She stated she was not aware that they had found one of the patches on the floor in the medication room and stated that sounded weird as they looked everywhere in the medication room and could not locate the missing patches. During an interview on 11/14/13 at 12:10 pm LPN #3 stated that when she counted off narcotics at 11:00 pm with LPN #1 there were 7 [MEDICATION NAME]es and when she counted at 3:00 pm with LPN #2 there were only 5 patches. She stated one patch was found in the medication room crumbled up and on the floor later, which was impossible, they tore that room apart looking for the missing patches. She further stated that LPN #1 often rushed through the narcotic count and she would make her slow down so she could visualize the narcotic medication and the narcotic count log sheet to be sure the count was correct. During an interview on 11/14/13 at 10:00 am the RNS stated that she was not involved in the investigation regarding the two missing [MEDICATION NAME]es, but she heard about it through word of mouth and that one of the patches showed up a week later or something. She stated that on 9/12/13 she was working and noted that RN #1 was in the building at 1:00 am, which was odd. When she questioned why RN #1 was in the building she stated she had to do an in-service. Later in the night, she saw RN #1 and LPN #1 in the medication room together. At this time she intervened and stated it was inappropriate for RN #1 to be in the medication room with LPN #1 and told her to get out and go home. She further stated she notified the former DON of this on 9/12/13 at 7:15 am. During an interview on 11/14/13 at 9:10 am the former DON stated she was aware of the missing [MEDICATION NAME]es, that a lot was going on at the time; the facility was going through their plan of correction and she had a consultant in the building working with her. She stated she obtained statements regarding the incident, and that LPN #1 had found one of the patches on the floor, which was suspicious, and she assumed she had taken the other one. She stated LPN #1 resigned after that so the problem was gone. She further stated she did not report the incident to the Department of Health or the Bureau of Narcotic Enforcement, but now knows it should have been reported. During an interview on 11/14/13 at approximately 3:00 pm the DON and Administrator stated they had thought the former DON had taken care of this incident with the help of a consultant they had in the building at the same time. They thought there was a more thorough investigation, but could not locate it. They further stated LPN #1 had resigned and was asked not to come back upon receipt of her resignation. 10 NYCRR 415.4(b)(1)(2)(3)

Based on record review and staff interview during a partial extended abbreviated survey (Case # NY 830) the facility failed to ensure the quality assessment and assurance (QA)committee identified issues that had the potential to cause serious harm to residents. Lack of an effective system resulted in inadequate investigations of alleged diverted narcotics and allowed the potential for further narcotic diversion to continue. Interviews revealed that staff did not take appropriate action upon the discovery of alleged diverted narcotic pain medication. Staff were not following facility policy regarding the initiation of an investigation and removing the accused employee from their work duties immediately. Further investigation showed the administration failed to ensure that thorough investigations were completed, accused staff were removed immediately pending investigation, and incidents were reported to the appropriate officials. The QA committee did not monitor and investigate these concerns although the facility has been repeatedly deficient in F225, concerning investigation and reporting. This was widespread and resulted in no actual harm with the potential for serious harm to all residents that is an immediate jeopardy to resident health and safety. This was evidenced by: Refer to F225, Staff treatment of [REDACTED]. Refer to F490, Administration, Scope and Severity-L, Administration During an interview on 11/14/13 at approximately 2:00 pm , both the Administrator and Director of Nursing ( DON) stated that there was no procedure in the reconciliation of narcotics upon delivery to the facility. The DON stated that the narcotics are delivered to the nursing unit and checked in by the receiving nurse. The Administrator stated he was not aware of any current problems, but believed the incidents of questionable diversion that occurred in September were resolved and taken care of by the previous DON. During an interview on 11/14/13 at approximately 4:00 pm the Director of Nurses (DON) and Administrator stated that they were aware of these incidents, however they thought the former DON had done a more thorough investigation, but could not locate it. They stated they had a consultant in the building at the time and thought she had helped the former DON with these investigations. The Administrator stated that the facility policy and procedure was not being followed in regard to investigating incidents and removing accused staff from their work duties. He further stated that the incidents were not reported to the appropriate officials and stated he would submit a report to the Bureau of Narcotic Enforcement. The DON expressed confusion regarding what kind of medication errors and/or discrepancies should be reported to the Department of Health. She further stated this was a good learning experience for her to assist with dealing with these kinds of issues in the future in her new role as DON. 10 NYCRR 415.27(a-c)

Based on medical record review and staff interviews during a partial extended abbreviated survey (Complaint # NY 828), the facility did not thoroughly investigate and did not report when a resident's (Resident #1's) tube feedings, medications and adequate hydration was discontinued without orders or guidelines to restart. Specifically, the facility did not thoroughly investigate and did not report when Resident # 1 did not receive previously ordered tube feedings, some medications and adequate hydration from 7/26/13 to 7/30/13. This had the potential to affect all of the residents in the facility. This resulted in no actual harm, with the potential for serious harm that is Immediate Jeopardy to residents' health and safety and is Substandard Quality of Care. This is evidenced by the following: Resident # 1 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent minimum data set ((MDS) dated [DATE] assessed the resident to have long and short term memory impairment and to be totally dependent on staff for nutrition and hydration. On a facility provided document, titled "Disciplinary Report" dated 7/30/13, a licensed practical nurse (LPN#1's) name is entered on the line for the staff member being disciplined. In the explanation section, the author, the registered nurse unit manager (RNUM), documented, "On 7/26/13 you discontinued [MEDICATION NAME] 1.5 tube feed. Resident went without tube feed/nutrition and hydration for three days." On a facility provided document titled "Medication Incident Report," dated 7/30/13 the RNUM, documented in the description section of the report, "[MEDICATION NAME] 1.5 [MEDICATION NAME] 5 times daily discontinued 7/27/13 11p-7:00a shift. (Resident #1) Went without tube feed for three days." In the section for "recommendations to prevent reoccurrence," the RNUM documented: "Do not make significant changes without prior authorization of nurse manager." During an interview on 8/8/13 at 11:00am, a RNUM stated that on Friday morning, 7/26/13, she noted that Resident # 1 was congested and was running a temperature. The resident's respiratory rate was in the low thirties and he had copious secretions, requiring frequent suctioning. The RNUM contacted the doctor (MD#1) and received an order for [REDACTED]. The RNUM thought there was a very slight improvement in the resident's condition at the end of her shift and after giving report to the evening supervisor and describing the resident's condition, she left the building for the day. On Saturday evening (7/27/13) the RNUM called the facility to check on the resident and was told by the registered nurse supervisor (RNS #1) that someone had obtained an order the evening before to discontinue all of the resident ' s medications. The RNUM stated that she was not told at that time that the resident's tube feedings had also been discontinued and she did not ask about tube feedings. The RNUM instructed RNS # 1 to contact the on-call doctor and have the resident's antibiotic restarted. The RNUM stated that it was not until Tuesday morning (7/30/13) when a diet technician asked why the resident's tube feedings had been discontinued, that she became aware that the resident had not received any tube feeding since 7/26/13. The RNUM stated that she immediately contacted MD#1 and had the Resident's tube feedings and medications restarted. During an interview on 8/8/13 at approximately 1:00pm, a licensed practical nurse (LPN#2) stated that she was working the 3:00pm to 11:00pm shift on 7/26/13. She had assisted in the care of Resident # 1 during the evening and thought he was congested and sick but did not think the resident was actively dying. LPN#2 was surprised when RNS#2 told her the doctor had given an order to stop the resident's medications and tube feedings. LPN# 2 stated that RNS#2 did not have computer access and could not enter doctor's orders and asked LPN#2 if she would enter the orders. LPN# 2 was not familiar with the process of entering orders and so she waited and asked the night shift LPN (LPN#1) to enter the orders when she came on duty at 11:00pm. During an interview on 8/8/13 at approximately 1:30pm, a licensed practical nurse (LPN#1) stated that she was working the 11:00pm to 7:00am shift on 7/26/13 and when she came on duty at 11:00pm, LPN #2 asked her to enter orders into the computer that RNS #2 had taken from MD#1, concerning the care of Resident #1. The orders were to discontinue Resident #1's tube feedings and medications. LPN #1 called her night shift supervisor to verify that it would be acceptable to enter orders that RNS#2 had taken from the MD#1 and was told that she should enter the doctor's orders. LPN # 2 stated that she was surprised that the doctor had stopped the resident's medications and tube feedings because she did not think the resident was that "bad." During a second interview on 8/8/13 at approximately 3:00pm, the RNUM stated that she was not aware that Resident #1's tube feedings had been discontinued until the morning of July 30, 2013, when the diet technician came to her and asked why the resident was not receiving tube feedings. When the RNUM verified that the tube feedings had been discontinued on 7/26/13, she called the doctor and asked if she could restart the tube feedings. The RNUM stated she was very concerned that the resident had been without tube feeding from July 26 to July 30, 2013 and she investigated the situation. She explained that her investigation of the incident involved looking at the computer to see who had entered the orders to discontinue the tube feedings and medications and then writing a disciplinary report for that LPN (LPN #1). The RNUM stated that she wrote the disciplinary report on LPN#1 because the resident's tube feedings and medications had been discontinued for three days and the LPN had not notified a supervisor. The4 RNUM defined supervisor as a Nurse Manager or Director of Nursing (DON). The RNUM stated that she had not spoken to anyone involved in the situation; not the RN supervisors, LPNs (including LPN #1) or anyone else involved, to obtain more information. After writing the disciplinary report she gave it to someone in the human resources department and did not know what happened to it afterward. She did not report to the Facility Administrator about the situation. During an interview on 8/8/13 at approximately 3:00p the facility DON stated that she had been on vacation when the resident's tube feedings and medications had been discontinued and was not aware of it until she returned on 8/5/13. She had not initiated an investigation into the situation after her return because she had been busy catching up on other things that had gone on during her absence. During an interview on 8/8/13, at approximately 4:30pm, the facility Administrator (FA) stated that he became aware that Resident #1's tube feedings and medications had been discontinued when he heard it in morning report on 7/29/13 or 7/30/13. He had immediately asked the RNUM to look into the reason the medications and tube feedings had been discontinued. He stated he had not heard any more about the situation after that morning. He assumed that the RNUM had taken care of the investigation. During an interview on 8/13/13 at approximately 2:00pm, the facility Medical Director (Med Dir) stated that he was not aware that Resident # 1's tube feedings and medications had all been stopped on 7/26/13, until he was called on August 8, 2013 and told that the health department investigator was in the facility and looking into the situation. The Med Dir stated that it was completely unacceptable that the resident's tube feedings and medications had been stopped and that Resident #1 had received minimal to no hydration from 7/26/13 to 7/30/13. It was his expectation that if there was a condition that warranted holding feedings and medications that they would be held for a short period of time. The Med Dir stated the feedings and medications should have been placed on hold and the resident should have been re-assessed and a determination could then have been made when to restart both. The Med Dir stated he had spoken with the doctor (MD#1) involved and asked why orders were given to discontinue tube feedings, hydration and medications. MD #1 had reported to the Med Dir that he believed he had given an order to hold the tube feedings, not to discontinue them but could not be sure exactly what words he had used when giving the order. 10NYCRR 415.4

Based on medical record review and staff interviews during a partial extended abbreviated survey for a complaint (#NY 828), the facility failed to ensure that necessary care and services were provided to maintain at their highest practicable physical, mental and psychosocial well-being, in accordance with their comprehensive assessment and plan of carefor 1 (Resident # 1) of 4 residents reviewed. Specifically, the facility failed to ensure that Resident #1, who was unable to take anything by mouth, received his previously ordered tube feedings and medications when they were suddenly discontinued. Subsequently, the resident did not receive nutrition, adequate hydration and only few medications for more than three days. This had the potential to affect all of the residents in the facility. This resulted in no actual harm, with the potential for serious harm that is Immediate Jeopardy to residents' health and safety andis Substandard Quality of Care. This is evidenced by the following: Resident # 1 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] assessed the resident to have long and short term memory impairment and to be totally dependent on staff for nutrition and hydration. On a facility provided document, titled "Disciplinary Report" dated 7/30/13, a licensed practical nurse (LPN#1's) name is entered on the line for the staff member being disciplined. In the explanation section, the author (the registered nurse unit manager, RNUM), documented, "On 7/26/13 you discontinued [MEDICATION NAME] 1.5 tube feed. Resident went without tube feed/nutrition and hydration for three days. On a facility provided document titled "Medication Incident Report," dated 7/30/13 the RNUM, documented in the description section of the report, "[MEDICATION NAME] 1.5 [MEDICATION NAME] 5 times daily discontinued 7/27/13 11p-7:00a shift. (Resident #1) Went without tube feed for three days." In the section for "recommendations to prevent reoccurrence," the RNUM documented: "Do not make significant changes without prior authorization of nurse manager." On a doctor's order sheet for Resident #1, with orders entered into the computer on 7/26/13 at 11:21pm, the Resident's tube feeding were had been discontinued. On 7/26/13 at 11:21pm the following medications have been discontinued: Aspirin, [MEDICATION NAME], Comtan, [MEDICATION NAME], [MEDICATION NAME], Requip, Multivitamins and [MEDICATION NAME] via nebulizer. On doctors ' orders, entered into the computer on 7/30/13 at 11:41am, [MEDICATION NAME] 1.5 feeding, 237 milliliters (ml) with a 60ml water flush before and after the [MEDICATION NAME], had been restarted for five times a day. A review of the supervisors twenty-four hour report from, 7/26/13 to 7/30/13 revealed there was no documentation mentioning that Resident # 1's tube feeding, water and some medications had been discontinued. During an interview on 8/8/13 at 11:00am, a RNUM stated that on Friday morning, 7/26/13, she noted that Resident # 1 was congested and was running a temperature. The resident's respiratory rate was in the low thirties and he had copious secretions, requiring frequent suctioning. The RNUM contacted the doctor (MD#1) and received an order for [REDACTED]. The RNUM thought there was a very slight improvement in the resident's condition at the end of her shift and after giving report to the evening supervisor and describing the resident's condition, she left the building for the day. On Saturday evening (7/27/13) the RNUM called the facility to check on the resident and was told by the registered nurse supervisor (RNS #1) that someone had obtained an order the evening before to discontinue all of the resident's medications. The RNUM stated that she was not told at that time that the resident's tube feedings had also been discontinued and she did not ask about tube feedings. The RNUM instructed RNS # 1 to contact the on-call doctor and have the resident's antibiotic restarted. The RNUM stated that it was not until Tuesday morning (7/30/13) when a diet technician asked why the resident's tube feedings had been discontinued, that she became aware that the resident had not received any tube feeding since 7/26/13. The RNUM stated that she immediately contacted MD#1 and had the Resident's tube feedings and medications restarted. During an interview on 8/8/13 at approximately 12:30pm, a registered nurse supervisor (RNS #2) stated that she was an agency nurse and was scheduled to work at the facility for the first time on Friday, 7/26/13 as the evening shift RN supervisor. After receiving shift report from the RNUM, she went to the unit to assess Resident # 1. RNS #2 recalled thinking Resident #1 had symptoms of fluid volume overload and the resident might benefit from holding his tube feedings. RNS #2 called MD#1, who gave an order to hold all of Resident #1 ' s tube feedings and medications. She then advised the evening shift licensed practical nurse (LPN#2) of the doctor ' s order and asked LPN #2 to enter the doctor's order into the computer. RNS #2 explained that because this was her first time working at the facility, she did not yet have computer access and was unable to enter orders in the computer. RNS#2 stated that she thought she had instructed LPN#2 that the tube feedings should be held, not discontinued, but could not say for sure. RNS#2 assessed Resident#1 toward the end of her shift and thought the resident seemed improved. She added that it was her expectation that the registered nurses that followed her would have done an assessment of Resident #1 and been in contact with the doctor to determine what the resident's needs were, with regard to tube feedings and medications. RNS #2 stated that she was shocked to hear that Resident # 1's condition had started to improve over the weekend and no one had restarted his tube feedings or adequate hydration until Tuesday, July 30. During an interview on 8/8/13 at approximately 1:00pm, a licensed practical nurse (LPN#2) stated that she was working the 3:00pm to 11:00pm shift on 7/26/13. She had assisted in the care of Resident # 1 during the evening and thought he was congested and sick but did not think the resident was actively dying. LPN#2 was surprised when RNS#2 told her the doctor had given an order to stop the resident's medications and tube feedings. LPN# 2 stated that RNS#2 did not have computer access and could not enter doctor's orders and so asked LPN#2 if she would enter the orders. LPN# 2 was not familiar with the process of entering orders and so she waited and asked the night shift LPN (LPN#1) to enter the orders when she came on duty at 11:00pm. During an interview on 8/8/13 at approximately 1:30pm, a licensed practical nurse (LPN#1) stated that she was working the 11:00pm to 7:00am shift on 7/26/13 and when she came on duty at 11:00pm, LPN #2 asked her to enter orders into the computer that RNS #2 had taken from MD#1, concerning the care of Resident #1. The orders were to discontinue Resident #1's tube feedings and medications. LPN #1 called her night shift supervisor to verify that it would be acceptable to enter orders that RNS#2 had taken from MD#1 and was told that she should enter the doctor's orders. LPN # 2 stated that she was surprised that the doctor had stopped the resident's medications and tube feedings because she did not think the resident was that "bad." During an interview on 8/8/13 at approximately 2:00pm, an LPN (LPN#3) stated that when she came into work on Saturday (7/27/13) at 7:00am and was told that Resident #1's tube feedings and medications had been stopped on Friday (7/26/13) evening, she was " blown away." LPN#3 stated that she did not think Resident # 1 was actively dying and was very surprised that the doctor would have stopped everything. LPN#3 thought that stopping Resident #1's tube feedings and medications might have been a " huge misunderstanding." LPN#3 recalled that on Sunday afternoon (7/28/13), a member of the family noted that Resident #1 was having jerking movements and wondered if it might be because he was off his [MEDICAL CONDITION] medication. LPN#3 arranged for the family member to speak with the RN Supervisor who contacted the doctor and obtained an order to restart the resident's [MEDICAL CONDITION] medication five times a day and to flush the resident's tube with 60cc's of water before and after the medication was given. LPN#3 stated that after that order was obtained, that at least the Resident was getting some hydration. During a second interview on 8/8/13 at approximately 3:00pm, a registered nurse unit manager (RNUM) stated she was not aware that Resident #1's tube feedings had been discontinued until the morning of July 30, 2013, when a diet technician asked why the resident was no longer receiving tube feedings. When the RNUM verified that tube feedings had been discontinued and the resident had not received nutrition, only some medications and little hydration since 7/26/13, she called the doctor for new orders to restart. The RNUM was very concerned that the resident had been without tube feeding from July 26 to July 30, 2013 and she investigated the situation. She explained that her investigation consisted of, looking at the computer to see who had entered the orders to discontinue the tube feedings and medications and then writing a disciplinary report for that LPN (LPN #1). The RNUM stated that she wrote the disciplinary report on LPN#1 because the resident's tube feedings and medications had been discontinued for three days and the LPN had not notified a supervisor. The RNUM defined "supervisor" as a Nurse Manager or Director of Nursing (DON). The RNUM stated that she had not interviewed anyone during her investigation; not the RN supervisors, LPNs (including LPN#1), or anyone else involved, to obtain more information. After writing the disciplinary report, she gave it to someone in the human resources department and did not know what happened to it afterward. She was not aware that it was a registered nurse supervisor and not LPN#1 who had asked for and received the order to stop all of the resident ' s tube feedings, medications and hydration. She did not report back to the Facility Administrator about the situation after her investigation. During an interview on 8/8/13 at approximately 3:00p the facility Director of Nursing (DON) stated that she had been on vacation when the resident's tube feedings and medications had been discontinued and was not aware of same until she returned on 8/5/13. She had not initiated an investigation into the situation after her return because she had been busy catching up on other things that had gone on during her absence. In a second interview on 8/28/13, the DON stated that she was aware that there was no mention of Resident # 1's tube feedings, water and medications being discontinued on the supervisor's twenty-four hour report, from 7/26/13 to 7/30/13. She added that she had great concerns that so many licensed staff were aware of the tube feedings, water and medications being discontinued and that no one had contacted the doctor, Medical Director, Administrator or herself. Although she was on vacation, she is available to staff 24/7, to discuss clinical issues. During an interview on 8/8/13, at approximately 4:30pm, the facility Administrator (FA) stated that he became aware that Resident #1's tube feedings and medications had been discontinued when he heard it in morning report on 7/29/13 or 7/30/13. He had immediately asked the RNUM to look into the reason the medications and tube feedings had been discontinued. He stated he had not heard any more about the situation after that morning. He assumed that the RNUM had taken care of the investigation. During an interview on 8/13/13 at approximately 2:00pm, the facility Medical Director (Med Dir) stated that he was not aware that Resident # 1's tube feedings and medications had all been stopped on 7/26/13, until he was called on August 8, 2013 and told that the health department investigator was in the facility and looking into the situation. The Med Dir stated that it was completely unacceptable that the resident ' s tube feedings and medications had been stopped and that Resident #1 had received minimal to no hydration from 7/26/13 to 7/30/13. It was his expectation that if there was a condition that warranted holding feedings and medications that they would be held for a short period of time. The Med Dir stated the feedings and medications should have been placed on hold and the resident should have been re-assessed and a determination could then have been made when to restart both. The Med Dir stated he had spoken with the doctor (MD#1) involved and asked why orders were given to discontinue tube feedings, hydration and medications. MD #1 had reported to the Med Dir that he believed he had given an order to hold the tube feedings, not to discontinue them but could not be sure exactly what words he had used when giving the order. 10NYCRR 415.12

Based on record review and staff interviews the Administration failed to ensure that the facility operated in a manner that enabled it to effectively use its resources to maintain the highest practicable well-being and safety of each resident during a partial extended abbreviated survey (Complaint #NY 828). Specifically, administration failed to have an effective operational system in place to ensure that adequate nutrition, hydration and medications were administered to support and maintain resident health; failed to identify standards of practice for nutrition, hydration and medications and failed to adequately investigate and then report to the New York State Department of Health (NYSDOH) when Resident #1, who was unable to take anything by mouth, did not receive his tube feedings and most medications after they were suddenly discontinued from 7/26/13 to 7/30/13. This had the potential to affect all of the residents in the facility. This resulted in no actual harm, with the potential for serious harm that is Immediate Jeopardy to resident's health and safety. This is evidenced by the following: Refer to F-309, scope and severity-L: Quality of Care Refer to F-225 scope and severity - L: Resident Behavior and Facility Practices During an interview on 8/8/13, at approximately 4:30pm, the facility Administrator (FA) stated that he became aware that Resident #1's tube feedings and medications had been discontinued when he heard it in morning report on 7/29/13 or 7/30/13. He had immediately asked the RNUM to look into situation to find out why the medications and tube feedings had been discontinued. He stated he had not heard any more about the situation after that morning and he assumed the RNUM had taken care of the investigation. He did not report the situation to the NYSDOH because there was a doctor ' s order to discontinue the tube feedings and medications. During an interview on 8/13/13 at approximately 2:00pm, the facility Medical Director (Med Dir) stated that he was not aware that Resident # 1's tube feedings and medications had all been stopped on 7/26/13, until he was called on August 8, 2013 and told a NYSDOH investigator was in the facility and looking into the situation. The Med Dir stated that it was completely unacceptable that the resident ' s tube feedings and medications had been stopped and that Resident #1 had received minimal to no hydration from 7/26/13 to 7/30/13. It was his expectation that if there was a condition that warranted holding feedings and medications that they would be held. They should have been placed on hold and the resident should have been re-assessed and a order written for when to restart both. During an interview on 8/8/13 at approximately 3:00p the facility Director of Nursing (DON) stated that she had been on vacation when the resident's tube feedings and medications had been discontinued and was not aware of same until she returned on 8/5/13. She had not initiated an investigation into the situation after her return because she had been busy catching up on other things that had gone on during her absence. In a second interview on 8/28/13, the DON stated that she was aware that there was no mention of Resident # 1's tube feedings, water and medications being discontinued on the supervisor's twenty-four hour report, from 7/26/13 to 7/30/13. She added that she had great concerns that so many licensed staff were aware of the tube feedings, water and medications being discontinued and that no one had contacted the doctor, Medical Director, Administrator or herself. Although she was on vacation, she is available to staff 24/7, to discuss clinical issues. 10NYCRR 415.26

Based on record review and interview during the extended recertification survey it was determined that the facility failed to have an effective system in place to ensure physician orders [REDACTED]. Lack of an effective system resulted in 7 ( # 5, 13, 24, 29, 80, 81, 85) of 12 newly admitted residents not receiving significant necessary medications. Significant medication omissions included [MEDICATION NAME]( an anticoagulant), [MEDICATION NAME] ( an anticonvulsant and for pain), [MEDICATION NAME] ( used to treat [MEDICAL CONDITION]), [MEDICATION NAME] ( used for [MEDICAL CONDITION]), [MEDICATION NAME] ( a diuretic), [MEDICATION NAME] ( used to treat [MEDICAL CONDITION]), [MEDICATION NAME] ( all used for treating hypertension), [MEDICATION NAME] ( an antipsychotic), [MEDICATION NAME] ( used to treat [MEDICAL CONDITION]), [MEDICATION NAME] ( used to treat [MEDICAL CONDITION] disorder), [MEDICATION NAME] (an antibiotic), [MEDICATION NAME] and [MEDICATION NAME] Insulin (used to treat Diabetes), [MEDICATION NAME] ( an antiplatelet drug), [MEDICATION NAME] ( an antidepressant) all of which were not given the evening of admission. Fingerstick blood sugars were not performed for Residents # 24 and # 85 the evening of admission therefore it could not be determined if Resident # 85 needed sliding scale insulin. Additionally Resident # 5, admitted to the facility on [DATE] was ordered to receive [MEDICATION NAME] 2 times a day but received it only 1 time a day until 5/30/13. This had the potential to effect all newly admitted /readmitted residents. This resulted in no actual harm but has the potential for serious harm that is immediate jeopardy to the health and safety of the residents and is Substandard Quality of Care. This is a repeat deficiency from the previous survey of 4/27/12. This is evidenced by: The facility Policy and Procedure- PH77 for Medication " Unavailable", undated, documented under Policy: it is the policy of this facility that in the event that a medication is unavailable for any reason, the facility shall act promptly to notify appropriate practitioners and the pharmacy to obtain new supplies. The facility shall investigate all instances where medications are not available, to assess whether appropriate actions were taken to insure continuity of care. Under Procedure it documented 1. the nurse upon identifying that a medication is apparently unavailable, immediately notifies the nursing supervisor. The nursing supervisor 1. shall check all areas where medications are stored to insure medication is actually not available. 2. Upon determining that medication is unavailable, shall take the following actions: A. inform Prescriber/Attending. B. Inform Pharmacy or backup/emergency Pharmacy and obtain medications (along with any new orders the prescriber may deem necessary). C. Document actions and prescriber orders on 24 hour report, physician (MD) order sheet and chart. The Pharmacy Consultant shall review all active Medication administration record (MAR's) each month, and document all instances where medications are charted as unavailable. The facility provided the list of medications available in the Emergency Kit for box 102 with a service date of 4/8/13. This list included [MEDICATION NAME] and other antibiotics, [MEDICATION NAME] and [MEDICATION NAME] along with approximately 25 other medications. Resident #24 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as understood, sometimes able to understand, and as having moderate cognitive impairment. The Nursing Admission Assessment to the unit was completed 4/30/13 at 2:30 pm by the Assistant Director of Nursing (ADON). The hospital Transfer Summary dated 4/30/13 documented the following medications: [REDACTED]. Physician's admission orders [REDACTED]100 four times a day. A physician's orders [REDACTED]. The MAR beginning on 4/30/13 documented [MEDICATION NAME] 10 mg at 9:00 pm, but the box to be initialed by the medication nurse after administration of this medication was left blank for the 4/30/13 9:00 pm dose. It documented [MEDICATION NAME] 1 mg at 5:00 pm, but the box to be initialed by the medication nurse after administration of this medication was left blank for the 4/30/13 5:00 pm dose. It documented [MEDICATION NAME] 625 mg two times a day at 9:00 am and 9:00 pm, but the box to be initialed after administration of the medication was left blank for the 4/30/13 9:00 pm dose. It documented [MEDICATION NAME] 300 mg two times a day at 9:00 am and 9:00 pm, but the box to be initialed after administration of the medication was left blank for the 4/30/13 9:00 pm dose. It documented [MEDICATION NAME] 5 mg at 9:00 pm, but the box to be initialed after administration of this medication was left blank for the 4/30/13 9:00 pm dose. It documented [MEDICATION NAME] 0.25 mg two times a day at 9:00 am and 9:00 pm, the box to be initialed after administration of this medication was left blank for the 4/30/13 9:00 pm dose. It documented [MEDICATION NAME] 25/100 four times a day at 8:00 am, 12:00 pm, 4:00 pm, and 8:00 pm, the box to be initialed after administration of the medication was left blank for the 4/30/13 8:00 pm dose. Additionally, the MAR beginning on 4/30/13 documented Fingerstick Blood Sugars(FSBS) four times a day before meals and at bedtime ( 07:30 am, 11:30 am, 4:30 pm, and 9:00 pm) , and to call the physician if the fingerstick reading was below 70 or above 200, but the boxes to be completed for the fingerstick readings and the initials by the medication nurse were left blank for the 4/30/13 fingersticks that were to be done at 4:30 pm and 9:00 pm. There was no documented evidence of a physician's orders [REDACTED]. A Nursing Note dated 4/30/13 at 5:00 pm documented that the resident was admitted at 2:30 pm and a Nursing Note dated 4/30/13 documented that the resident was seen by the physician with orders obtained. The Nursing Notes for 4/30/13 and 5/1/13 included no nursing documentation that medications had not been administered as ordered by the physician. The unit 24 hour reports dated 4/30/13 and 5/1/13 were reviewed and contained no documentation regarding the resident's evening medications having not been administered on 4/30/13 or about any delay in the arrival of the resident's medications on admission or the physician being contacted. Medication Error Reports were reviewed for April and May and there was no documented evidence of Medication Error Reports having been completed for those medications that had not been administered to the resident on the day of admission. During an interview on 5/29/13 at 11:45 am, the ADON stated that when resident's were admitted from the hospital, they come in with a history and physical transfer summary form. She stated that the nurse receiving the admission should read through the whole summary to determine the necessary medications. She stated that the facility always tried to get admission medications in as soon as possible, and that the resident's medications should be reviewed within an hour or two from arrival to the facility. She stated that after the medications were reviewed, a call to the physician was made to obtain orders for them and then the nurse was responsible for putting these medications into the computer system where they are then sent directly to the contracted pharmacy services. She stated at the same time these medication orders are sent to the pharmacy, the medication orders will also go directly onto the computerized MARs and Treatment Administration Records, which the nursing staff then print out. She stated that there was always three runs from the pharmacy each day for medication deliveries. She stated the first delivery was between 2:00 pm to 3:00 pm, the second delivery was at approximately 9:00 pm, and the last delivery was in the middle of the night between 12:00 am to 2:00 am. She stated that if a nurse was passing medications and the resident's medications were unavailable after the second delivery, then she would expect that the nursing staff would call the physician to let them know the medications had not arrived and to ask if it was okay to give these medications whenever they arrived from the pharmacy. When shown the blanks on the MAR for the evening Resident #24 was admitted , the ADON stated it appeared as if the resident did not receive his medications on that evening. The ADON also stated she would have expected the evening nurse to have called the pharmacy after the second delivery on the evening the resident was admitted , to request a late delivery. The ADON also stated the nurse should have then called the resident's physician to request either an order to hold the resident's medications that evening, or to administer the medications late. The ADON stated all of this should have been documented in the resident's medical record. She stated she could not explain why this resident's evening medications were not administered on admission. During interview on 5/29/13 at 3:00 pm, the Medical Director stated he expected newly admitted residents to receive their medications within 4-6 hours after admission. The Medical Director also stated if the resident's medications were not available at dosing times, he expected the nurses to call him, and that he would then make a determination of whether to hold the medication, or have the nurse administer the medication late. The Medical Director also stated he could not recall receiving any recent calls regarding medications not available for residents on admission. During an interview on 5/30/13 at 8:20 am, the Registered Nurse Supervisor working the night of 4/30/13 into 5/1/13 stated she didn't know that the resident's evening medications were not available on the day of admission. She stated that sometimes admission medications were not entered into the computer system until two to three hours after residents came into the facility. She stated it had never been passed along to her in report that this resident's admission medications had not arrived. She stated that if she had been told about this she would have called the pharmacy directly. During an interview on 5/30/13 at 10:30 am, the Licensed Practical Nurse (LPN) #1 working on the 3:00 pm to 11:00 pm shift on 4/30/13, stated that the facility did receive new admissions and readmissions on the 3:00 pm to 11:00 pm shift often. She stated that the supervisors usually obtained the admission medication orders and in the past few months the facility had a few bumps in the road where there had been a lot of turnover in evening supervisors. She stated that the supervisors were responsible for putting resident medication orders into the computer. She stated she would need to call the physician for instruction on what to do if she was passing medication and came upon medication unavailability. She stated she would first report it to the supervisor, that the supervisor would call the physician, and then stated she would first call the pharmacy prior to this to see where the medication was. She stated that if the medication was not going to be at the facility for administration, she would tell the supervisor and the supervisor would call the physician to see if it was okay to hold the medication until the next day. She stated that the medication administration nurse's should probably document in the Nursing Notes if the supervisor had been notified of a medication being not available, and that it was likely the supervisor would also write a Nursing Note if the physician was notified about medication unavailability. She stated, if it was not written, then it wasn't done. She stated she could not remember this resident having had unavailable medication on admission to the facility. She stated she just learned that if medications for a resident were unavailable, then the nurses needed to obtain an order from the physician to administer the medications when they arrived. During interview on 5/30/13 at 5:10 pm the pharmacy representative stated that on 4/30/13 the resident's medications were signed for by the facility at 11:30 pm indicating the medications were delivered to the the facility at that time. Resident # 85 The facility did not ensure medications, including insulin, were available and provided to the resident on the evening of admission. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. No MDS was available for review. Social Work admission progress notes dated 5/25/13 documented the resident as alert and oriented to time, place and person. The social worker also documented the resident had fully intact short term and long term memory. Physician orders [REDACTED]. daily, [MEDICATION NAME] 10 units subcutaneously before each meal , FSBS four times a day and at bedtime with coverage based on finger stick blood sugar. The physician order [REDACTED]. between 351 and 400 10 units will be given, if the FSBS is above 400 or below 70 to call the physician. The MAR dated 5/24/13 to 5/29/13 documented the resident was to receive [MEDICATION NAME] 18 units subcutaneously twice daily at 7:30am and 7:30pm, [MEDICATION NAME] 10 units subcutaneously before each meal at 7:30am, 12:00pm, and 5:00pm, FSBS at 8:00am, 12:00pm, 5:00pm and 9:00pm with coverage based on the FSBS. The MAR documented that if the FSBS is between 70 and 140 no units will be given, if the FSBS is between 141 and 200 2 units will be given, if the FSBS is between 201and 250 4 units will be given, if the FSBS is between 251 and 300 6 units will be given, if the FSBS is between 301 and 350 8 units will be given, if the FSBS is between 351 and 400 10 units will be given, if the FSBS is above 400 or below 70 to call the physician. The MAR also documented the resident was to receive [MEDICATION NAME] 25mg/200mg one capsule two times daily at 9:00am and 9:00pm, Antiacid (Tums) one tablet by mouth two times daily at 9:00 am and at 9:00 pm, and [MEDICATION NAME] 875 mg one tablet by mouth two times daily at 9:00 am and at 9:00 pm. The MAR dated 5/24/13 documented blanks or "x's" (meaning not given) in the boxes for; [MEDICATION NAME] 18 units due at 7:30 pm, [MEDICATION NAME] 10 units due at 5:00pm, [MEDICATION NAME] 25 mg/200 mg due at 9:00pm, Antiacid due at 9:00pm, and [MEDICATION NAME] 875 mg due at 9:00pm. The MAR further documented a FSBS was completed at 5:00pm, results 325, at which time the box is initialed and 10 units given. The MAR documented the box for 9:00pm FSBS was blank as was the box for initialing. There was no documentation in the nurses notes dated 5/24/13 and 5/25/13 regarding the missed evening doses for 5/24/13. There was nothing about a supervisor being informed, the physician being called or the pharmacy being contacted. The 24 hour shift report dated 5/24/13 contained no documented evidence as to whether medications listed above were available or unavailable. During an interview on 5/30/13 at 8:15 am the resident stated she could remember receiving insulin the day she was admitted to the facility, but could not recall at what time and how much insulin. During an interview on 5/30/13 at 5:00 pm the resident's LPN# 4 stated a finger stick was done for the resident and insulin was administered based on the FSBS. The LPN stated the results of the finger stick should be on the 24 hour report. The LPN stated she thinks she did the 9:00pm finger stick and the 5:00pm [MEDICATION NAME], but could not remember if she gave the 9:00pm insulin. The LPN stated she could not remember if [MEDICATION NAME] was available, but thinks the facility was waiting for medications to come in, but could not remember. The LPN stated if medications were not available the emergency kit should have been checked and if not in the emergency kit she would have let the supervisor know. The LPN stated if she had a chance to call the pharmacy she would or would have the supervisor call as it is always busy on the nursing unit. The LPN stated that if medications were delivered they would have signed something like a packing slip when she received the medications. The LPN stated she could not be sure what happens to the packing slip. During an interview on 5/30/13 at 7:40am the 11:00pm-7:00am Registered Nurse Supervisor stated insulin was ordered for this resident but it did not appear to be given as well as the other medications. The night supervisor stated, in reference to the MAR, that blanks or "x"'s in the corresponding box for date and time on the MAR means the medication was not available or not given. The night supervisor further stated the insulin should have been given because it is readily available. She stated they can give stock medications and if medications are not here in the evening the LPN should let the supervisor know. She stated that the previous evening she was called for a medication that was not available, however could not remember the last time she was notified before that. She stated they could use medications from the Emergency kit. She stated that medication orders needed to be put in earlier, that is the problem. During interview with the pharmacy representative on 5/30/13 at 5:10pm they stated the residents orders were sent to them at 4:38 pm. Then the facility signed as receiving the medications at 10:04 pm. On 5/30/13 at approximately 3:30 pm the Medication Error Reports for March, April and May were requested from the DON. She stated there were none for March and provided the April and May reports. There were no Medication Error Reports for the resident not receiving medications the evening of admission. Resident #5 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no MDS available. The resident Nursing Admission assessment dated [DATE] documented the resident was alert and oriented to person only. A social work progress note dated 5/29/13 documented that the resident was evaluated by psychiatry on 5/27/13 and was determined to lack the capacity to make medical decisions. Finding 1 Physician orders [REDACTED]. The MAR for 5/22/13 documented [MEDICATION NAME] 80 mg at 9:00pm, but there was an "x" in the box with no explanation on the back of MAR, in nurse's notes, or on 24 hour report. It documented [MEDICATION NAME] 200mg two times a day at 9:00am and 9:00pm, but there was an 'x" in the box marked 9:00pm with no documentation on the back of the MAR, nurse's note, or on the 24 hour report. It documented [MEDICATION NAME] 10mg two times a day at 9:00pm but there was an" x" in the box with no explanation on the back of MAR, in nurse's notes, or on 24 hour report. It documented [MEDICATION NAME] 0.4mg once a day at 9:00pm, but there was an "x" in the box with no explanation on the back of MAR, in nurse's notes, or on 24 hour report. The nursing notes dated 5/22/13 and 5/23/13 contained no documented evidence that the MD, pharmacy, or supervisor were contacted regarding the unavailability of the 9:00pm medications. The 24 hour report dated 5/22/13 and 5/23/13 contained no documented evidence that the MD, pharmacy, or supervisor was contacted regarding the availability of the 9pm medications. On 5/30/13 at 3:30pm Medication Error reports were requested of the DON. There were no Medication Error Reports completed for those medications that were not administered on the day of admission. During a telephone interview on 5/30/13 at 3:00pm the resident's 3-11 shift LPN#3 stated that the supervisor would give her the completed MAR and she would fill the administration times in. She would not call the pharmacy because the resident got there late and his medications would probably not get there until after her shift. She further stated that [MEDICATION NAME] could sometimes be obtained from the supervisors emergency box. The LPN stated that on 5/22/13 she was given the MAR by the supervisor and she remembers that the times were already in and the 9:00 pm medications were already "x'd" out. She further stated that she did not question this and does not remember who the supervisor was that gave her the MARs. The LPN reported that if the resident needed a medication like "Insulin" on 3-11, that she would use an unopened vial of insulin if there was one available on the unit. During an interview on 5/30/13 at 4:00pm the 3-11 Supervisor stated that she would complete a medication reconciliation record. It entailed writing down the list of medications that the resident was on in the hospital. She would then contact the MD and go over the medications with the MD and make any changes if the MD indicated. The MAR would then be generated and given to the medication nurse to write in the medication administration times. The hospital would send over a medication data sheet that would let them know the last time a medication was administered. If a medication was needed she would check the emergency medication box and if not available would call the pharmacy for a stat run, or the MD would be called. She further stated that she was not the person who filled out the times on the MAR for this resident on 5/22/13, she did not recognize the hand writing and that she did not recall receiving a call from the nurse about medications that were not available. During an interview on 5/30/13 at 4:15pm the DON stated that if an order was entered late to the pharmacy and not available that the MD should be called, the medication circled in the MAR and the reason documented on the back of the MAR. She further stated that there should also be a note written in the progress notes. The DON stated that the resident arrived prior to their admission nurse who comes in at 5:00pm. Finding 2 The medication reconciliation record dated 5/22/13 documented that the resident was to receive [MEDICATION NAME] 10mg 2 times daily. The physician's orders [REDACTED]. It further documented that it was verified by 3 nurses. An RN on 5/23/13 at 7:19pm, on 5/23/13 on 11-7 shift, and on 5/25/13 on 3-11shift by an LPN. The MAR with a beginning date of 5/22/13 documented that the resident was to receive [MEDICATION NAME] 10mg by mouth two times daily, but in the hour column it was only documented to be given at 9:00pm. The medication was signed for at 9:00pm for 7 days. There was no evidence that the medication was given twice a day since admission on 5/22/13, until the surveyor informed the facility on 5/30/13. During an interview on 5/30/13 at 3:00pm the Resident's 3-11 LPN# 2 stated that once orders are obtained they are checked by three staff members. She stated that a check consisted of comparing the physician's orders [REDACTED]. She further stated that she checked and signed the physician orders [REDACTED]. During an interview on 5/30/13 at 4:00pm the 3-11 Supervisor stated that the MAR was compared with the physician orders [REDACTED]. When she was shown the discrepancy between the physician orders [REDACTED]. During an interview 5/30/13 at 4:15pm the DON stated that physician orders [REDACTED]. She further stated that it did not have to be nurses from each shift. When shown the MAR, she had no explanation for the error. During a telephone interview with the pharmacy representative on 5/30/13 at 5:10pm they stated that they received the orders in the pharmacy on 5/22/13 at 7:12pm and they were signed as received by the the facility on 5/22/13 at 10:27pm. Resident #80 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS of 5/15/13 assessed the resident was understood and able to understand with a BIMS of 7/15 (severely impaired cognitive skills). Physician orders [REDACTED]. The MAR documented [MEDICATION NAME] 220 micrograms HFA inhaler two times a day at 9:00am and 9:00pm. It documented [MEDICATION NAME] sodium 5000 units/milliliter(ml) one ml subcutaneously every twelve hours at 9:00am and 9:00pm. It documented [MEDICATION NAME] 10 mg 1/2 tablet two times daily at 9:00am and 9:00pm. It documented [MEDICATION NAME] 25mg 1/2 tablet two times daily at 10:00am and 10:00pm. All of the above medications had a start date of 5/9/13 the day after the residents admission.. The nursing notes dated 5/8/13 and 5/9/13 contained no documented evidence that the MD, pharmacy, or supervisor were contacted regarding the unavailability of the 9:00pm medications. The 24 hour report dated 5/8/13 and 5/9/13 contained no documented evidence that the MD, pharmacy, or supervisor was contacted regarding the unavailability of the 9:00pm medications. The Emergency Box list of medications with a service date of 4/8/13 for box number 102 lists [MEDICATION NAME] 5000 units/ml as 2 doses present. On 5/30/13 at 3:30pm Medication Error reports were requested of the DON. There were no Medication Error Reports completed for those medications that were not administered on the day of admission. During an interview on 5/29/13 at 10:00am the Registered Nurse Manager, who is listed in the physicians orders as having placed the orders in the computer, stated that the effective date and time on the top of the physician's orders [REDACTED]. She further stated that the Telephone order section on the physician's orders [REDACTED]. Several attempts were made on 5/29/13 in the afternoon to interview the nurse manager regarding the start date on the resident's MAR, but she was unavailable for interview. During an interview on 5/29/13 at 11:00am the DON stated that they try to get new admissions early so they can get their medications. They are put in the computer and there is a cut off time for that day. Pharmacy deliveries will go until 2:00am if needed. Most times the LPN checks the medications into the pharmacy computer and whoever is putting the medications into the computer will generate a MAR and give it a start date. During an interview on 5/30/13 at 10:35am the resident's LPN #1 stated that if medications were not available she would document on the back of the MAR and in the chart. She did not recall why she did not get her medications on day of admission and did not recall notifying the supervisor that the medications were not available. During an interview on 5/29/13 at 10:55am the ADON stated that medication orders put in the computer would automatically be generated to the MAR. If a resident had an evening medication ordered on day of admission it would be given. She stated she did not know why they would not have been given but that she would call the medical doctor for an order to give the medications when they arrived from pharmacy if it was a late delivery. During a telephone interview with the pharmacy representative on 5/30/13 at 5:10pm they stated that they received the orders in the pharmacy on 5/8/13 at 7:52pm and they were signed as received by the the facility on 5/9/13 at 12:12am. 10 NYCRR 415.12 (m)(2)

Based on record review and interview the Administration failed to use its resources effectively and efficiently to attain or maintain the highest practical physical, mental and psychosocial well being of each resident during the extended recertification survey. Specifically: the Administration failed to ensure that newly admitted / readmitted residents were provided routine and emergency medication in a timely manner as ordered by the physician, the administration failed to have an effective system in place to ensure that physician's orders [REDACTED]. This had the potential to effect all newly admitted /readmitted residents. This resulted in no actual harm with a potential for serious harm that was identified as immediate jeopardy. This is evidenced by: Refer to Significant medication Errors- F 333- scope and severity - K During interview on 5/29/13 at 3:00 pm, the Medical Director stated he expected newly admitted residents to receive their medications within 4-6 hours after admission. The Medical Director also stated if the resident's medications were not available at dosing times, he expected the nurses to call him, and that he would then make a determination of whether to hold the medication, or have the nurse administer the medication late. The Medical Director also stated he could not recall receiving any recent calls regarding medications not available for residents on admission. During interview on 5/30/13 at 11:14 am the Administrator stated that pharmacy does three runs to the facility. He thought 5:30 pm was the cut off time for getting orders in so that medications would come in that evening, but was not sure. He stated that if they miss the cut off the medications would be there in the morning. He stated that if medications did not come in that evening they could get a stat order to obtain medications and they have a emergency box of medications in case of emergency. He stated the doctor would be contacted to find out what to do for medications that are not in. He stated the nurse should follow the medications not available policy. The Administrator stated he was aware that medications being unavailable was a concern. He stated that they had found the problem in QA (Quality Assurance) and then started doing a QA audit on new admission charts. He stated they look at everything in the chart but they do not look at the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] During interview on 5/30/13 at 11:30 pm the Director of Nurses (DON) stated she was not aware of the medications not available on admission problem to any large amount. She stated they had found that on occasion medications would not come in on time. She stated that if a new admission comes in at 7:30 pm for example, they may not get the orders in on time so they can't get processed until late and the medications will come in the morning. She stated that a few weeks back there was a report on the 24 hour report sheets of medications not available and they did an inservice about that. She also stated they go through the chart of new admissions the next day. She thought this started on 5/2/13. She stated they are looking at documentation in the charts but do not look at the MARs. On 5/30/13 the facility provided a copy of the inservice done on Medications "Unavailable". This was the policy documented in F 333 and was dated as being done on 5/7/13. There were only 7 signatures of people being inserviced and one of them was the DON. During interview on 5/29/13 at 3:00 pm, the Medical Director stated he expected newly admitted residents to receive their medications within 4-6 hours after admission. The Medical Director also stated if the resident's medications were not available at dosing times, he expected the nurses to call him, and that he would then make a determination of whether to hold the medication, or have the nurse administer the medication late. The Medical Director also stated he could not recall receiving any recent calls regarding medications not available for residents on admission. 10NYCRR415.26

Based on record review and interview he facility failed to provide a quality assessment and assurance program (QA) that readily and effectively identified issues with the potential to cause serious harm to the health and safety of residents during the extended recertification survey. Specifically: residents who were newly admitted or readmitted did not receive their physician ordered medications on the evening shift of their admission/readmission. Lack of a effective system resulted in residents not receiving significant necessary medications. This had the potential to effect all newly admitted /readmitted residents. This resulted in no actual harm with a potential for serious harm that was identified as immediate jeopardy. This is evidenced by: Refer to Significant medication errors F 333 -scope and severity- K During interview on 5/29/13 at 3:00 pm, the Medical Director stated he expected newly admitted residents to receive their medications within 4-6 hours after admission. The Medical Director also stated if the resident's medications were not available at dosing times, he expected the nurses to call him, and that he would then make a determination of whether to hold the medication, or have the nurse administer the medication late. The Medical Director also stated he could not recall receiving any recent calls regarding medications not available for residents on admission. During interview on 5/30/13 at 11:14 am the Administrator stated that the pharmacy does three runs to the facility. He thought 5:30 pm was the cut off time for getting orders in so that medications would come in that evening, but was not sure. He stated that if they miss the cut off the medications would be there in the morning. He stated that if medications did not come in that evening they could get a stat order to obtain medications and there is an emergency box of medications. He stated the doctor should be contacted to find out what to do for medications that are not available. He stated the nurse should follow the " Medications Not Available Policy". The Administrator stated he was aware that medications were not available on admission. He stated that they had found the problem in QA (Quality Assurance) and then started doing a QA audit on new admission charts. He stated they look at everything in the chart but they do not look at the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] During interview on 5/30/13 at 11:30 pm the Director of Nurses (DON) stated she was not aware of the medications not available on admission problem to any large extent.. She stated they had found that on occasion medications would not come in on time. She stated that if a new admission comes in at 7:30 pm for example, they may not get the orders in on time so they can't get processed until late and the medications will come in the morning. She stated that a few weeks back there was a report on the 24 hour report sheets of medications not available and they did an inservice about that. She also stated they go through the chart of new admissions the next day. She thought this started on 5/2/13. She stated they are looking at documentation in the charts but do not look at the MARs. On 5/30/13 the facility provided a copy of the inservice done on Medications "Unavailable". This was the policy documented in F 333 and was dated as being done on 5/7/13. There were only 7 signatures of people being inserviced and one of them was the DON. 10NYCRR 415.27(a-c)

Based on record review, resident observation and staff interview during a complaint investigation (NY 469) the facility did not ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable. Specifically, one resident (# 1) of two residents reviewed was found to have developed black, unstageable areas to his heels, right heel 5 centimeters (cm) by 3.5 cm and the left heel 5 cm by 3 cm. Additionally, this resident was not turned and positioned by staff members, and had no preventive devices to protect his lower extremities while in bed, which he could not move independently. This resulted in actual harm that is not immediate jeopardy. This is evidenced by: The policy and procedure (P&P) entitled Pressure Ulcer Risk Assessment, dated as revised 12/2010 documented all residents will be assessed for risk of pressure ulcer development utilizing the Braden Scale. The P&P entitled Pressure Ulcer Prevention, dated as revised 9/2010 documented that residents do not develop pressure ulcers, unless clinically unavoidable. A resident who had an ulcer receives care and services to heal the ulcer and prevent additional ulcers. Policy included: residents skin will be checked by the CNA daily using the daily skin integrity check form and at least weekly by the nurse on bath days. Risk factors included: immobility or decreased immobility, nutritional problems, and impaired mental state. The P&P entitled Prevention of Heel Ulcers for Special Groups, dated as revised 05/08 documented it is the policy to have a plan in place for prevention of heel ulcers on special groups of residents that are at risk for such issues. Purpose included: to identify special groups who are at high risk for development of heel ulcers. Preparation included, residents with the following medical conditions are to be considered at high risk for heel ulcer development, these included: residents unable to reposition their own lower extremities. Heels are to be inspected with am and pm care for the following: redness, pain, bogginess, and discoloration. The P&P entitled Turning Schedule, dated as revised 9/2008 documented it is the policy of the facility that any resident identified as high risk for skin breakdown will be placed on a Turning Schedule. Procedure included: identified residents will be turned side-to-side while in bed every two hours, and the shift charge nurse will be responsible for assuring compliance. The P&P entitled Pressure Ulcer Protocol, dated as revised 10/2010 documented all residents will be assessed for pressure ulcers on admission, re-admission, and an ongoing basis. Residents will be placed on the pressure ulcer protocol upon identification of a pressure area. Procedures documented includes: as soon as wound or skin area is identified a discovery form will be filled out, copies of the discovery form are to be sent to the members of the skin team, a pressure ulcer tracking sheet is to be initiated, an appropriate treatment will be selected, additional interventions shall be instituted at this time, resident will be seen weekly by skin team, and weekly a skin team meeting will be held with all members of the team. The Job Description and Duties Guide for Certified Nurse Aides (CNA) documented responsibilities: utilizes nursing assistant care sheets as a guide for the delivery of care, check skin for changes and complete shower sheet, provides basic skin care, positions residents in bed/chair. Resident # 1: The Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident has long and short term memory problems, is severely impaired in his decision making, and has moderate difficulty with hearing according to the Minimum Data Set (MDS), dated [DATE]. The Wound Assessment/Notification Form dated 2/5/13 documented Resident had unstageable, suspected deep tissue injury (SDTI) to his bilateral heels, necrotic/eschar. The nurse notes dated 2/5/13 at 4:00 pm documented that CNA notified nurse that resident had two blackened heels. Bilaterally left heel 5 centimeters (cm) x 3 cm, right heel 4 cm x 3.5 cm. Physician saw areas and orders received. The Incident report dated 2/5/13 documented Resident noted to have unstageable black areas on both heels. Documented foot rest discontinued, waffle boots started, heels up cushion started, and skin prep every shift. The investigation summary signed by the Director of Nursing (DON) on 2/12/13 documented that disciplinary action was taken with the CNA who did not remove the Resident's socks when she performed the Resident's bed bath the evening prior to the discovery of the wounds. CNA reported the Resident is very combative with care and does not like his legs or feet touched. The investigation summary documented the Licensed Practical Nurse (LPN) who was responsible to perform a skin check stated he did not do a skin check because the resident received a bed bath. LPN received a disciplinary action. The Wound Care Specialist Evaluation, dated 2/6/13, and signed by the Wound Physician documented [AGE] year old male patient has an unstageable DTI (deep tissue injury) of the heel of unknown days of duration. The right heel is documented as 3 cm x 5 cm unstageable DTI. The left heel is documented as 3 cm x 5 cm unstageable DTI. Dry protective dressing and skin prep, once daily was ordered for both heels. The Venous Doppler (ultrasound to examine the blood flow in the major arteries and veins) report of the bilateral lower extremities, that was performed on 2/13/13 documented no [MEDICAL CONDITION] is identified. The Arterial Doppler report of the bilateral lower extremities, that was performed on 2/13/13 documented no arterial occlusions are identified. The Physician orders [REDACTED]. The Diagnostic Summary Sheet dated 1/26/13 documented the Resident had the following Diagnosis: [REDACTED]. The Braden Scale for Pressure Sore Risk, Part 2 dated 11/4/12 documented if any of the below are checked, resident is high risk for skin breakdown. The following were checked: bed mobility requires extensive to total assistance, transfer requires extensive to total assistance, and incontinence. The Comprehensive Care Plan (CCP) entitled Skin Impairment, dated 11/4/12 documented Potential problem, evidenced by rash, and related to impaired immobility and incontinence. Interventions included: note skin every shift and notify physician of any redness or breakdown, turn and position (T&P) every two hours while in bed, pressure reducing mattress, offload heels on pillows when in bed. The CCP entitled Activity Daily Living (ADL) Function Care Plan, dated 1/22/13 documented problem of decreased strength and cognitive deficits. Adaptive devices include multi-podus boots when out of bed. Intervention included; bed mobility requires extensive assistance. The Rehab Communication/CNA Care Care (a CNA guide to physical assistance and devices required in caring for the resident), dated 1/11/13 documented non-ambulatory status, geri chair with foam cushion, alarm in bed, mats on floor, velcro alarm seatbelt in chair, assistance of one staff member with bed mobility. There is no documentation in regards to instructions or devices for the lower extremities or a turn and position plan. The Resident Daily Routine Card (a CNA guide for assistance needed with ADL care), dated 1/17/13 documented under skin care to moisturize feet daily, shower on Monday, dress upper and lower body. Special instructions included: elevate legs when out of bed. There is no documentation in regards to instructions for the lower extremities when in bed or a turn and position plan. The Resident Daily Routine Card dated 2/19/13 documented additional interventions from the previous card: off load heels at all times, blue multi-podus boots, heels up cushion. There is no documentation in regards to instructions for the lower extremities when in bed or a turn and position plan. On 2/20/13 at 9:30 am Resident was observed lying in his bed, positioned on his back with his legs extended straight and a heels up cushion under his ankles and lower legs. Observation of Nurse Manager (NM) measuring the areas to the Resident's heels revealed the right heel had a 3 cm x 5 cm black area which appeared to be hard and dry. Resident's left heel had a 3 cm x 3 cm black area which appeared to be hard and dry. During an interview on 2/20/13 at 9:45 am, NM stated every day the Resident's received a daily wash-up which includes their face, hand, buttocks and peri area. Residents receive a full bath or shower weekly. NM does expect the CNAs to look at the whole body every day. During an interview on 2/20/13 at 10:15 am, LPN # 1 stated the areas were black, hard and dry when they were first discovered and there was some cracking around the edges. LPN stated that the CNAs should be looking at the entire body of the residents, every day. During an interview on 2/20/13 at 11:30 am, NM stated the Resident's feet should be moisturized daily by the CNA who should be looking at the feet as well. NM did state that if the CNAs were moisturizing the feet they would have felt those areas on both heels. Stated that the nurses on the units were responsible to monitor that the care is getting done. NM further stated that the dopplers were ordered following the discovery of the areas and there are no circulatory issues with the Resident's legs. NM stated that there were no issues with Resident # 1's appetite or fluid intake. Stated he should be turned and positioned every two hours when in bed, that he only has independent movement of his upper extremities. NM stated that the staff failed to look at his heels daily. During an interview on 2/20/13 at 11:45 am, CNA # 1 stated she did moisturize the resident's feet. Stated that when staffing was good they would have the time to actually look at the residents feet, but when there was less staff they would lotion without looking. CNA stated that Resident # 1 does not move on his own, he can move his arms but cannot turn or move his legs. He lays on his back whenever in bed. During an interview on 2/20/13 at 1:00 pm, Physical Therapy Aide (PTA) stated the multi-podus boots are to be worn at all times. Resident was presently on a PT program to monitor his comfort in the Barco Chair. PTA stated the Resident is unable to move himself in the bed and should be repositioned every two hours. During an interview on 2/20/13 at 2:30 pm, DON stated staffing was improving, that the facility had hired new CNAs and LPNs. DON stated she did not know why the Braden Scale assessment was only done once, but they should be done on a quarterly basis. She stated that weekly team meetings were not done as documented in the P&P for Pressure Ulcer Protocol, and she is not sure why this was not done. Stated that someone definitely did not do what should have been done on this man. During an interview on 2/20/13 at 3:00 pm, LPN # 2 stated Resident # 1 should be turned and positioned every two hours because he does not move himself. LPN stated that Resident # 1 gets a weekly shower and his skin is assessed by a nurse. LPN stated he worked the evening prior to the discovery of the heel areas. He stated that because the Resident had a bed bath, he did not know he had to do a skin check. LPN stated he did not think the Resident was getting turned and positioned. During an interview on 2/20/13 at 3:15 pm, CNA # 2 stated Resident # 1 cannot move himself in the bed, he can use his arms and can be combative, and will hit and pinch. States it takes two staff members to turn him and he is only turned for care. Stated he does not spend a lot of time in bed on evening (3:00 pm to 11:00 pm) shift, but when he is in bed it is always on his back, with his heels on the bed. CNA did give a bed bath the evening prior to the discovery of his heel areas, instead of a shower and told the nurse. The nurse never came in to do a skin check. Resident does not like to have his privates or feet touched so she did not take his socks off during the bed bath. During an interview on 2/21/13 at 8:20 am, CNA # 3 stated on the night (11:00 pm to 7:00 am) shift they turn and position all residents every two hours. Stated Resident # 1 can move his upper extremities and cannot move his legs. Stated the Resident only gets turned when the Resident allows and even then he will not allow a pillow behind him. Stated prior to the heel areas being discovered there were no interventions in place to prevent skin breakdown. Resident spent most time on his back. During an interview on 2/21/13 at 9:45 am, CNA # 4, stated the areas were noted on his heels when changing his socks and reported to the nurse. CNA had Resident the day before and took his socks off then, stated did not notice the areas then. CNA stated the time varied when the Resident got up in the morning and he was not repositioned before getting up. Resident was unable to reposition himself. CNA never saw Resident # 1 positioned on his side. 10 NYCRR 415.12(c)(2)

Based on record review and staff interview, it was determined during a post-survey revisit that the facility did not ensure a resident who enters the facility without pressure sores did not develop pressure sores in 1 (#2) of 2 residents reviewed. Specifically, the facility did not complete a thorough assessment of a pressure sore. This resulted in no actual harm but had the potential for more than minimal harm that is not immediate jeopardy. This is evidenced by the following: Resident # 2 The resident was admitted to facility on 3/29/13 with [DIAGNOSES REDACTED]. Minimum Data Set (MDS) information dated 4/5/2013 assessed the resident with severe cognitive impairment, Brief Interview for Mental Status score of 3 and is able to understand and be understood. The resident was assessed with [REDACTED]. Nursing notes dated 4/12/13 documented at 6:30 pm (1830) that it was reported to the family that the resident has two small areas in her buttocks measuring 2 centimeters (cm) by 1 cm and 1 cm by 1 cm. No other nursing notes were available documenting the pressure ulcers. The 24 hour nursing report dated 4/12/13 documented on the 7:00 am to 3:00 pm shift the resident needs [MEDICATION NAME] applied to buttocks surrounding [MEDICATION NAME] every shift. The 3:00 pm to 11:00 pm shift documented the resident has 2 new areas open measuring 2 cm by 1 cm and 1 cm by 1 cm. The Comprehensive Care Plan (CCP) for skin impairment dated 4/1/13 documented under problem an actual excoriated area related to incontinence. The goal/time frame documented the resident will not develop a pressure area with a time frame of 90 days. The outcome section documented on 4/1/13 an excoriated rectal area was noted, the physician was notified by the doctor book, and barrier cream was applied. No open areas were documented as having been discovered on 4/12/13. The initial nutrition risk assessment dated [DATE] documented the resident had a Stage 2 pressure ulcer to the left gluteal area noted while in the hospital and an unstageable pressure ulcer to the right great toe. No further documentation involving pressure ulcers were available in dietary notes. The resident physical assessment form dated 3/29/13 documented no areas of breakdown or pressure ulcers in the buttocks or gluteal folds area. The Policy and Procedure (P and P) for Pressure Ulcer Protocol revised 10/2010 documented that it is the policy of the facility that all residents will be assessed for pressure ulcers on admission and an ongoing basis. The P and P documents under procedure that as soon as a wound is identified a discovery form is filled out completely. The discovery form may be initiated by a Licensed Practical Nurse, but must be completed by a Registered Nurse. The P and P documented that copies of the discovery form are then sent to the members of the skin team including dietary, physical therapy, nurse practitioner, unit manager, and a representative from nursing administration. The P and P further documents a pressure ulcer tracking sheet is to be initiated at the same time the discovery team is completed. The Nurse Manager and/or Registered Nurse designee (i.e. supervisor on the shifts) will assess the pressure area and document findings on the Pressure Ulcer Tracking Sheet. No Pressure Ulcer Tracking Sheet could be found documenting a full assessment of the pressure ulcers to the buttocks areas. During an interview on 4/16/13 at 10:00 am the Certified Nursing Assistant (CNA) stated the CNA's will check skin condition daily and will notify the nurse of the condition of the skin. The CNA stated she does not document the condition of the skin because the nurse does that. During an interview on 4/16/13 at 10:25 am the Dietary Technician (DT)stated she could not find any document that reported the formation of the pressure ulcer and likely was not notified. The DT stated that she is notified promptly by receipt of copy of the Wound Assessment/ Notification sheet of the development of a pressure ulcer. During an interview on 4/16/13 at 10:35 am the Director of Nursing (DON) stated a Registered Nurse is responsible for fully assessing a newly discovered pressure ulcer, initiating the discovery form, and initiating a Pressure Ulcer Tracking sheet. The DON stated the form titled Wound Assessment/Notification Form is the form used a the discovery form. The DON stated she could not find the discovery form and Pressure Ulcer Tracking sheet so they were probably not completed. The DON stated the documentation of the pressure ulcer to the buttocks areas involving an assessment was incomplete as it did not contain a description of the wound. The DON stated facility nurses were inserviced on the process for identification, and beginning treatment of [REDACTED]. The DON stated there has multiple turnovers in nursing so the facility is constantly training new people to the process. 10 NYCRR 415.12(c)(1)