Every finding on record at Sapphire Nursing At Wappingers

Based on observations, record review, and interviews conducted during the Abbreviated Survey the facility did not ensure necessary care and services were provided related to medication for one (Resident #3) of three (3) residents reviewed for quality of care. Specifically, medications were not available to be administered as ordered upon admission on [DATE]. Resident #3's medication list included Buprenorphine/Naloxone, a controlled substance used for opioid dependence treatment, anticonvulsant, neuropathic pain medication, anti-anxiety medication and antiviral medications. Pharmacy delivery records provided by the facility documented medications for Resident #3 were delivered to the facility between 11/03/2025 through 11/07/2025. There was no documented evidence that the pharmacy was contacted by facility staff when Resident #3 medications were not available. There was no documented evidence of physician notification or continuous follow-up related to unavailable medications and missed doses. The Findings Include: The Facility policy titled Medication Availability and Procurement, last reviewed on 11/10/2025, documented, It is the policy of this facility to ensure that our residents are provided with all medications ordered and prescribed by a licensed prescriber, for the treatment of an approved condition. The policy further documented, Reconcile all medications at the time of admission to the facility. Resident #3 was admitted on with diagnoses including Parkinson's disease without dyskinesia, herpes viral infection of the urogenital system, major depressive disorder, bipolar disorder, and opioid dependence. The 11/06/2025 Minimum Data Set (MDS) documented Resident #3 had intact cognition. The physician's orders dated 10/31/2025 documented Resident #3 was prescribed Buprenorphine/Naloxone 4-1 mg sublingual film every 12 hours at 09:00 AM and 09:00 PM, Pregabalin 200 mg three times daily at 09:00 AM, 01:00 PM, and 05:00 PM, Clonazepam 0.25 mg daily at 09:00 AM, Valacyclovir HCL 500 mg daily at 09:00 AM, and Topiramate 50 mg at 06:00 PM. Pharmacy delivery records documented Buprenorphine/Naloxone, Valacyclovir HCL 500 mg, and Clonazepam 0.25 mg were not delivered to the facility until 11/03/2025 at 06:23 PM. The Medication Administration Record did not reflect documented administration for scheduled doses on 11/01/2025, 11/02/2025, and the 09:00 AM dose on 11/03/2025 prior to delivery. Review of Nursing progress notes did not identify documented rationale for not administering physician notification, follow-up, or any monitoring related to the missed doses. Pharmacy delivery records indicated Buprenorphine/Naloxone, Valacyclovir HCL 500 mg, and Clonazepam 0.25 mg had not yet been delivered to the facility. Review of the facility Nursing notes from 10/3/20251-11/07/2025 did not identify documented physician notification, follow-up, monitoring or substitution of other medications related to the missed doses The physician's order dated 10/31/2025 documented Resident #3 was prescribed Topiramate oral tablet 50 mg, give one tablet by mouth during the evening shift for seizure disorder management. Pharmacy delivery records show Topiramate was not delivered until 11/03/2025 at 06:23 PM. The Medication Administration Record did not reflect documented administration for scheduled doses on 11/01/2025 and 11/02/2025. Review of the facility Nursing notes from 10/3/2025-11/03/2025 did not identify documented rationale for why medications were not given, no physician notification, follow-up, or monitoring related to the missed doses were documented. The physician's order dated 10/31/2025 documented Resident #3 was prescribed Clonazepam ODT oral tablet 0.25 mg, give one tablet by mouth daily for anxiety management. Pharmacy delivery records show Clonazepam 0.5 mg were not delivered until 11/04/2025 at 06:09 PM. The Medication Administration Record did not document med administration for scheduled doses prior to the pharmacy delivery. Pharmacy delivery records indicated Clonazepam 0.5 mg and Ondansetron 4 mg was not delivered to the facility until 11/04/2025. Review of the facility Nursing notes from 10/3/2025-11/04/2025 did not identify documented physician notification, follow-up, monitoring, or other substitutions for unavailable medications. Pharmacy delivery records show Pregabalin 200 mg and Ropinirole were not delivered until 11/07/2025 at 06:12 PM. The Medication Administration Record did not reflect documented administration for scheduled doses from 11/01/2025 through scheduled doses prior to delivery on 11/07/2025. Pharmacy delivery records documented Pregabalin 200 mg and Ropinirole were delivered to the facility on [DATE] at 06:12 PM. Review of nursing progress notes did not identify documented physician notification, follow-up, monitoring, or alternate interventions related to the missed doses. There was no documented evidence that the physician was made aware of the delay in delivery of Resident #3's medications. There was no documented evidence that the pharmacy was contacted by facility staff about Resident #3 medications that were not available. Review of the Medication Administration Record and Physician progress notes from 10/31/2025 to 11/04/2025 did not identify a physician order authorizing medications to be held pending pharmacy delivery or documented physician follow-up and monitoring or alternate substitutions or a documented plan of care related to unavailable anti-seizure, antianxiety and antiviral medications during the period medications were not available for Resident #3. During an interview on 04/07/2026 at 04:55 PM, the Director of Nursing indicated the X documented on the Medication Administration Record indicates a monitoring protocol. They were unsure why a monitoring protocol would be documented without a corresponding nursing note. The Director of Nursing further stated the Physician, and the Pharmacy should have been notified when medications were not available. The Director of Nursing indicated the need for nursing staff to be educated on required/timely documentation. During an interview on 04/07/2026 at 07:55 PM, Nurse Practitioner #1 stated a note was written on 11/01/2025 to hold medications pending pharmacy arrival. Nurse Practitioner #1 stated notes are not written every day when medications are not available from the pharmacy and stated the note to hold the medications was not completed. Nurse Practitioner #1 was informed that no documentation related to holding medications on 11/01/2025 was found in the electronic medical record during surveyor review. Nurse Practitioner #1 was asked to assist in locating documents in the electronic medical record, as the surveyor found no physician documentation was not provided when requested. During the review a document titled Monthly Physician Assessment and Plan of Care (Revision) with a completed signature time stamp of 04/07/2026 at 07:32 PM was found not signed by the Nurse Practitioner #1 or the Physician. The surveyor asked for clarification regarding completion of the documents, as the documents reflected completion by staff other than a physician. Nurse Practitioner #1 stated they did not complete the forms, and they did not instruct the Infection Control nurse to complete the forms. They stated they did not know how the forms were completed and that the surveyor would need to address this with the facility. During an interview on 04/07/2026 at 08:15 PM, the Infection Control Nurse stated they completed the Monthly Physician Assessment and Plan of Care (Revision) document and the Physician History and Physical WV (Revision) document, as the documents were not completed. The Infection Control Nurse stated the documents were not filled out and signed off by the physician. The Infection Control Nurse confirmed that the Monthly Physician Assessment and Plan of Care (Revision) document reflected a signature time of 04/07/2026 at 07:32 PM and the Physician History and Physical WV (Revision) document reflected completion on 04/07/2026 at 07:33 PM. When asked authorized them to complete the documents, the Infection Control Nurse stated no authorization was provided and the documents were completed at the time indicated on the documents. The Infection Control Nurse stated the documents are to be completed by a physician. 10 NYCRR 415.18 (a)

Based on observations, record reviews, and interviews conducted during an Abbreviated Survey, the facility did not ensure that a dietitian or other clinically qualified professional was sufficiently involved in carrying out the functions of the food and nutrition services. Specifically, the facility began a project to renovate the kitchen which temporarily prevents the facility from using the kitchen to cook resident meals. As an alternative, the facility is using an outside food vendor(a local restaurant) to provide resident meals, but the arrangement is without a system that provides dietitian oversight of meal preparation and consistently ensures that meals meet the daily nutritional, therapeutic, and other special dietary needs of the residents. Kitchen renovation project began in 2025. The use of the outside vendor began 02/02/2026. The facility did not provide a contract with the Food vendor(local restaurant).On 03/30/2026 at 12:11 PM, during a tour of the kitchen in the facility basement, the surveyor observed meals obtained from an outside vendor being plated for resident meals The facility kitchen was under renovation. The surveyor observed food items including Salisbury steak, vegetables, and potatoes being removed from bulk containers and altered at the facility, including texture modification for residents requiring chopped and pureed diets. The surveyor observed meal trays assembled with corresponding meal tickets placed on the trays; however, food items were prepared in bulk and modified at the facility without evidence of diet-specific preparation from the outside vendor. During an interview on 03/30/2026 at 12:11 PM, the Food Service Director stated meals are obtained from an outside vendor due to the renovation of the facility kitchen. The Food Service Director stated communication regarding meal orders is conducted between the facility and the outside vendor. The Food Service Director stated meals are received in bulk and are altered at the facility to meet resident diet needs, including texture modification such as chopped and pureed diets. The Food Service Director stated the outside vendor is not provided with individual resident diet orders. The Food Service Director stated no hot meals are prepared in the facility and stated food preparation is limited to reheating or modifying food items after delivery. On 04/01/2026 at 4:54 PM, the surveyor observed meals obtained from an outside vendor being plated for dinner service. The surveyor observed [NAME] #1 and [NAME] #2 plating food items from bulk containers while dietary staff assembled trays with corresponding meal tickets. The surveyor observed food items altered at the facility kitchen, including texture modification, without evidence of diet-specific preparation from the outside vendor. During an interview on 03/30/2026 at 12:30 PM, the Administrator stated meals are being obtained from an outside vendor due to the renovation of the facility kitchen. The Administrator stated meals are ordered for the resident population and delivered to the facility in bulk containers for plating and distribution. The Administrator stated meals are not separated by individual resident diets at the time of ordering and are modified at the facility after delivery based on meal tickets. The Administrator stated the Food Service Director is responsible for communicating with the outside vendor regarding meal orders. The Administrator stated dietary oversight should be provided by the Registered Dietitian, as resident diets are managed by the Registered Dietitian, while the Food Service Director is responsible for meal service operations, including timely meal delivery, plating, and food temperatures. During an interview on 03/30/2026 at 3:50 PM, the Registered Dietitian stated meals are currently being obtained from an outside vendor due to the renovation of the facility kitchen. The Registered Dietitian stated they are not involved in communications with the outside vendor regarding meal orders. They stated that communication is conducted with the Food Service Director and Administrator. The Registered Dietitian stated they have not provided input regarding meal preparation, therapeutic diet requirements, or nutritional needs of residents. The Registered Dietitian stated they are responsible for ensuring residents receive meals in accordance with their prescribed therapeutic diets; however, they are not involved in overseeing meals obtained from the outside vendor and rely on facility staff to ensure residents receive appropriate meals. The Registered Dietitian stated no changes were made to monitoring systems following the implementation of meals from the outside vendor and stated they were not aware of the frequency of meals being obtained from the outside vendor. During an interview on 03/30/2026 at 4:15 PM, the owner of the restaurant providing catered meals to the facility stated communication regarding meal orders is conducted with the Food Service Director. The owner of the restaurant stated they receive menus from the facility; however, menus are not provided with individual resident diet orders or therapeutic diet requirements. All meals are prepared in the same manner as regular business operations. No food is prepared based on individual resident dietary needs. The owner stated that sometimes the facility may request to limit salt or sugar; however, there is no standardized system to measure or control the amount added. The owner stated they do not prepare separate meals for therapeutic diets and are not involved in ensuring meals meet individual resident dietary needs. During an interview on 04/01/2026 at 3:55 PM, the Food Service Director, in the presence of the [NAME] President of Clinical Services, stated they communicate directly with the outside vendor that provides meals to the facility. The Food Service Director stated they communicate with the outside restaurant on a weekly basis regarding meals to be sent to the facility. The Food Service Director stated specific resident diets are not communicated to the outside vendor and meals are sent to the facility in bulk for distribution. The Food Service Director stated meals are divided and distributed at the facility according to resident diets after delivery. The Food Service Director stated they do not collaborate with the Registered Dietitian regarding communication with the outside vendor. There is no dietitian oversight of meals obtained from the outside vendor 10 NYCRR 415.12(c)

Based on observations, record review, and interviews conducted during the Abbreviated Survey, the facility did not ensure food was procured, distributed, and served under sanitary conditions and at safe temperatures. Specifically, the surveyor observed the facility plating lunch meals on 03/30/2026. Hot foods were not maintained at safe temperatures during holding, as evidenced by temperatures declining below 135 F during continued plating. A test tray performed at the completion of meal service at 1:07pm on 03/30/2026 showed hot food items were not maintained at safe temperatures and were below acceptable ranges. The findings included: On 03/30/2026 at 12:11 PM, the surveyor arrived at the kitchen located in the basement of the facility and in the presence of the Food Service Director, observed [NAME] #1 plating the residents food for lunch. [NAME] #1 was observed as the only staff plating the food. The surveyor observed food items including Salisbury steak, mixed vegetables, baked potatoes, mashed potatoes, pureed chicken, pureed vegetables, and ground meat. The food was observed in metal pans placed on steno setups with canned heat underneath while plating was in progress. The surveyor observed meals were plated on disposable foam plates with plastic lid coverings during meal service. During the observation, a sterno burner was observed to go out while the food remained in the pans. The surveyor made the Food Service Director aware, and the sterno was then relit. Meals were obtained from an outside vendor due to the facility kitchen being under construction since November 2025. Food was held in metal pans on sterno setups during plating; however, a sterno burner was observed to extinguish and required relighting by the Food Service Director. Meal service was delayed, and trays were not delivered to the units at scheduled meal times. During continued plating, food temperatures declined, and a test tray completed at the conclusion of meal service showed hot food items were not maintained at safe temperatures and were below 135 F. On 03/30/2026 between 12:11 PM and 12:15 PM, the Food Service Director obtained food temperatures as follows, baked potato 165, Salisbury steak 150, mixed vegetables 130, pureed chicken 130, pureed vegetables 130, mashed potatoes 140, ground meat 130, and ground vegetables 130. On 03/30/2026 at 12:30 PM, [NAME] #1 was observed to still be plating trays for the South unit and had not yet completed meal service for that unit. [NAME] #1 was also observed to have two carts remaining to be plated for the North unit. On 03/30/2026 at 12:35 PM, [NAME] #1 was observed to have just started plating the first cart for the North unit. On 03/30/2026 at 12:40 PM, the Food Service Director obtained food temperatures while food remained in the sterno setups during continued plating. Temperatures were as follows, Salisbury steak 120, baked potato 148, mixed vegetables 118, pureed chicken 122, pureed vegetables 118, mashed potatoes 120, and ground vegetables 110. Hot foods were not maintained at safe temperatures during holding, as evidenced by temperatures declining below 135 F during continued plating. On 03/30/2026 at 12:50 PM, the first cart for the North unit was observed leaving the kitchen to be transported to the unit. On 03/30/2026 at 1:03 PM, the last tray for the second cart for the North unit was observed being placed on the cart. On 03/30/2026 at 1:07 PM, a test tray was completed with the Food Service Director. The test tray included Salisbury steak, baked potato, and vegetables. Food temperatures obtained at that time were as follows, Salisbury steak 110, baked potato 118, and vegetables 100. At the time of service, hot food items were not maintained at safe temperatures, with test tray temperatures below 135 F. On 03/30/2026 at 1:10 PM, the surveyor arrived at the South unit and observed meal trays remaining on the cart that had not yet been distributed to residents. Per facility meal service schedule, lunch trays were scheduled to arrive to the South unit at approximately 12:15 PM, and meal distribution remained incomplete at the time of observation.During an interview on 03/30/2026 at 12:11 PM, the Food Service Director stated the kitchen has been under construction since late November 2025 and that meals are being obtained from outside vendors. The Food Service Director stated lunch is catered for 7 days per week and dinner is catered for 3 days per week. The Food Service Director stated scheduled mealtimes are 12:15 PM for the South unit and 12:30 PM for the North unit. They attempt to have lunch delivered at approximately 11:00 AM to allow time for reheating and preparation prior to service. Dinner mealtimes are 5:15 PM for the South unit and 5:30 PM for the North unit. Food received from the vendor is altered at the facility to meet resident diet needs, including modifying textures such as chopped and pureed. The Food Service Director stated meal preparation started late on 03/30/2026 at approximately 12:05 PM due to one cook arriving late and the other cook leaving early. The facility usually has two cooks assigned to plate meals. The Food Service Director stated hot food temperatures were below acceptable ranges of 135 F or below during meal service on 03/30/2026. The facility has received resident complaints regarding food temperatures. The Food Service Director stated there is no equipment available to maintain food temperatures other than sterno setups after food is delivered to the facility from the vendor. Staff must continuously monitor the sterno burners to ensure they remain lit during food plating. The Food Service Director stated an industrial microwave is available to reheat food for residents upon request During an interview on 03/30/2026 at 12:45 PM, [NAME] #1 stated they were in the process of plating the food for the North unit carts. They stated meal service should be completed within 10 to 15 minutes. [NAME] #1 stated meal service was delayed on 03/30/2026. They were behind scheduled meal service times. [NAME] #1 stated they had no assistance, and they were the only staff plating food. [NAME] #1 stated the volume of trays to be plated was significant and stated it is difficult to maintain food temperatures during plating when there is only one staff member assigned to complete the process. During an interview on 03/30/2026 at 1:17 PM, Resident #5 stated that when the food arrives to the unit, it is already cold. They stated they do not ask for it to be reheated. They just eat it as it is. The food is always cold. Resident #5 also stated that not much is given for breakfast and stated they get items such as cold cereal, cottage cheese, yogurt, pancakes, and waffles. Resident #5 stated the pancakes and waffles come cut up and are cold and stated if they do not eat it, other choices are not offered. Nothing else is offered. During an interview on 03/30/2026 at 1:17 PM, Resident #6 stated that when the food comes it is a treat if you get a hot lunch. Resident #6 stated that at times the food arrives lukewarm and when a warm meal is received they eat it quickly before it becomes cold. Resident #6 further stated they do not ask for the food to be reheated. Resident #6 also stated that sometimes the food has flavor, sometimes it is too salty, and sometimes it is inconsistent. During an interview on 03/30/2026 at 4:12 PM, the Administrator stated the kitchen is currently under full renovation and is unable to be used, and therefore no food is being cooked on-site. The Administrator stated the facility began catering meals during the first week of February 2026, approximately February 2, 2026. The Administrator stated that when construction initially began in November 2025, kitchen operations were not impacted; however, as the renovation progressed, the kitchen became inoperable, requiring the facility to transition to catered meals. The Administrator stated the Food Service Director is in communication with the catering vendors regarding meal service. The Administrator did not identify an ongoing issue regarding cold food complaints. The Administrator stated food service concerns were managed by the Food Service Director and stated if delays in meal service had been communicated, additional staff could have been provided. During an interview on 03/30/2026 at 4:15 PM, the owner of the restaurant providing catered meals to the facility stated they were unsure why food is arriving to residents cold or lukewarm. The owner stated food is cooked at high temperatures, approximately 500 F, and stated that once prepared it is transferred and transported to the facility in insulated containers intended to maintain food temperatures during delivery. The owner stated that upon arrival at the facility, equipment should be in place to maintain food temperatures prior to service. The owner stated the facility places orders for trays of food and stated they are not provided with specific resident diet orders. The owner stated they do not modify meals to meet individual diet needs and do not puree or chop food. It is the responsibility of the facility to alter the food after delivery. The owner of the restaurant stated communication regarding meal orders is conducted through the Food Service Director and they have not communicated with a dietitian regarding resident diets. The owner of the restaurant stated menus are provided approximately a week in advance and meals are prepared in the same manner as regular business operations. The owner stated that at times the facility may request limiting salt or sugar; however, they do not utilize a standardized system to measure or control the amount added. The owner stated they prepare one meal per menu item and do not prepare separate meals for specific diets. It is the responsibility of the facility to portion and modify meals as needed. During an interview on 04/01/2026 at 10:52 AM, Certified Nurse Aide #1 stated meal trays arrive late on the unit. They stated they have received complaints from residents that the food is cold or that the food is not appealing. During an interview on 04/01/2026 at 11:00 AM, Certified Nurse Aide #2 stated residents have reported that meals arrive on the unit cold and residents have made complaints about food temperatures. During an interview on 04/01/2026 at 11:20 AM, Licensed Practical Nurse #1 stated they have received complaints regarding food temperatures and stated residents report that the food is cold. On 04/01/2026 at 4:54 PM, the surveyor arrived in the basement kitchen and observed [NAME] #1 and [NAME] #2 plating dinner meals. One cook observed plating food while the second cook was assisting dietary staff with tray preparation and placement of food items on trays. The surveyor observed meals were plated on disposable foam plates with plastic lid coverings during meal service. During an interview on 04/01/2026 at 5:00 PM, the Food Service Director stated a hot holding box was obtained on Monday evening, 03/30/2026, following the surveyor's initial observation, to assist with maintaining food temperatures. Prior to that time, the Food Service Director stated no dedicated hot holding system was in use and meals were maintained in delivery pans and on sterno setups until service. During an interview on 04/01/2026 at 5:41 PM, Resident #1 stated they do not like the food and stated that the food either comes cold or is not appealing. Resident #1 stated there is no consistency with meal quality. Resident #1 stated they were informed the facility does not have a working kitchen and stated they do not request reheating of the food because staff are often busy and not readily available. The Administrator was interviewed previously on 03/30/2026. A follow-up interview was unable to be conducted on 04/01/2026, as the Administrator departed the facility at approximately 2:00 PM and was unavailable for the remainder of the survey. 10 New York Codes Regulation 415.12

Based on record review and interviews during an abbreviated survey (NY00373412, NY00374723), the facility did not ensure residents were free from abuse for 3 out of 3 residents (Resident #1, Resident # 2, Resident # 6) reviewed for abuse. Specifically, 1) On 2/26/2025 Resident #1 who had a known history of wandering, wandered into Resident # 2's room and Resident # 2 became agitated and put their hands on Resident # 1. Resident # 1 fell to the floor and kicked Resident # 2 in the leg. Resident #1 had no behavior care plan initiated before the incident. 2) On 3/11/2025 Resident # 1 was observed by staff in the doorway of their room holding their roommate(Resident # 6) by the collar. There was no documented behavior care plan was not initiated for Resident # 1 who had a known previous history of resident to resident altercation.The findings are:A review of the facility's Abuse investigation protocol/ Resident to Resident abuse policy last reviewed 5/2/2024 documented it is the policy of the facility to conduct a thorough investigation of all accusations/or reports of resident abuse to determine if a crime has been committed. Nursing Administration / Nurse administrator on call is responsible for reviewing information provided and advises if any further interventions are needed to ensure the safety of the resident. Considers room or floor change to prevent reoccurrence. Care plans for both residents must be updated to reflect risk for victimization, behaviors, aggressive behaviors, etc.Resident # 1 was admitted to the facility on [DATE] with a diagnosis that include but not limited to dementia with mood disturbances, Pre-glaucoma, and depression.A Minimum Data Set, dated [DATE] documented the Resident had a Brief Interview Mental Status score of 01/15 indicating the resident is not cognitively intact with no documented behaviors. No impairments to upper or lower extremities. Resident uses a wheelchair and walker for locomotion. Independent with eating and supervision with bed mobility and transfers. Resident is occasionally incontinent of urine and always continent of bowel.Review of an elopement/wander risk assessment dated [DATE] documented Resident #1 score was a 20 indicating the resident was a high risk for elopement/wandering.A review of all Resident # 1's care plans revealed no behavior care plan was in place.A review of Resident # 1's skin assessment dated [DATE] documented scratches to the right arm. Resident # 2 was admitted to the facility on [DATE] with diagnosis that include but not limited to Diabetes type 2, Muscle weakness, and End Stage Renal Disease.A Minimum Data Set, dated [DATE] that documented the resident had a brief interview of mental status score a 14/15 indicating the resident is cognitively intact with no behaviors present. Resident # 2 uses a wheelchair and walker for locomotion. Resident has an impairment on one side of the upper extremity. Requires set up with eating, independent with bed mobility, and supervision with transfers. Resident is occasionally incontinent of urine and always continent of bowel.A review of the facility's internal investigation conclusions / findings dated 2/26/2025 documented that on 2/26/2025 at 4:15pm, Resident # 2 grabbed Resident # 1's arm, pulled Resident # 1 out of their room and onto the ground. Resident # 1 landed on their buttocks. Resident # 1 kicked Resident # 2 in the leg in attempt to get Resident # 2 to let go of their arm. Staff intervened immediately. 911 was called immediately after assessing the resident's safety. Resident # 1 was assisted off the floor and into a wheelchair. Resident # 1 was assisted back to bed, body assessment completed by a Registered Nurse, then the resident was seen by the in-house Nurse Practitioner. Ambulance arrived with a police escort. Resident # 2 was discharged to Mid-[NAME] Regional Hospital for psychological evaluation. Resident # 2 has not returned to the facility.A review of the police case report 2025-0394 dated 02/26/2025 documented caller from the facility reports a psychiatric emergency with a patient who had been physical with another patient, and they would like to have them removed. Patient was willingly transported to Mid- [NAME] Regional for evaluation by Empress.During an interview on 5/9/2025 at 12:30pm, Certified Nursing Aide # 1 stated they worked in the facility for a while but cannot remember the date. They are usually assigned to the south side, but it depends on the needs. They are familiar with Resident # 1. Resident # 1 needs supervision and has dementia. Resident # 1 will wander into other resident's room, and they will redirect them. The resident can get agitated. Resident # 1 will become physically aggressive if you don't back off of them, but if you back off and give them space, they will calm down. Certified Nursing Assistant # 1 had not seen them initiate physical aggression toward other residents, but Resident #1 will protect themself. Certified Nursing Assistant # 1 can recall an incident between Resident # 1 and Resident # 6 where they were sitting at the table together and Resident #6 became aggressive toward Resident #1. They were separated from each other. Resident # 2 was in the facility and was on dialysis, but they are no longer in the facility. Resident # 2 would not hurt anyone because they had a good mind. If Resident # 2 became upset with someone it would be verbal, but they would not hit someone.During an interview with Licensed Practical Nurse #1 on 5/9/2025 at 1:10pm, they stated they are aware of the incident that took place between Resident # 1 and Resident # 2 on 2/26/2025. Licensed Practical Nurse #1 was at the nurses' station on the north side talking to Resident #2 and Resident # 1 was wandering the hallway. When resident #2 seen resident # 1 attempting to enter their room Resident # 2 then threatened to hit Resident # 1. Resident # 2 threw Resident # 1 on the ground. The aide came over to assist. Social worker and Director of Nursing came down to the north side unit. Resident # 1 kicked and hit Resident #2, and it escalated the situation more. 911 was called, but Licensed Practical Nurse #1 cannot remember who called them. Licensed Practical Nurse #1 usually work on the north side, so they are not familiar with all the intervention in place for Resident # 1. The facility sent Resident# 2 out to Mid-[NAME] Regional Hospital for a psychiatric evaluation and the facility did not accept the resident back. The facility did not take the resident back because they were a threat. The facility called the family to find out if they wanted to pursue charges, but they did not.During an interview with the Director of Nursing on 5/12/2025 at 10:30am they stated they started working in the facility as the Director of Nursing since 12/16/ 2024. They were notified of the incident on 2/26/2025 with resident #1 and #2 right after it happened. They went downstairs because they were still in the building. Resident # 2 was very aggressive and angry, and they were there interacting with social worker. Resident # 2 was aggressive and telling social worker to leave them alone. One of the nurses called 911, but they cannot remember which one called. The Director of Nursing waited and assisted Resident #1 back to their room. Resident # 1 had a assessment completed, but the resident did not remember the details of the incident. The Nurse Practitioner came to assess Resident # 1 and there were no noted injuries after incident. Director of Nursing stated they explained the situation to officers and Resident # 2 went to hospital for a psychological evaluation. It is the facility's Protocol that any resident-to-resident interaction is followed up by psychology/psychiatry. Resident # 1' was not's family was notified and the family did not want Resident # 2 near Resident # 1, and they wanted to press charges. The facility provided Resident # 1's family information for family to press charges. Then they collected statements and started Incident/Accident Form and reporting process. Incident occurred on 2/26/2025 and it was reported on 2/26/2025. Resident # 2 was discharged home from the hospital. The Supervisor called Mid-[NAME] for follow up on Resident # 2 and nurse at the hospital stated that Resident # 2 was discharged home on 2/26/2025. Interventions that were added after the incident was the facility put a stop sign on Resident # 2's door. there was follow up with the social worker, Nurse Practitioner, and frequent rounding. Frequent rounding is done every 2 hours so there would be no documentation in Visual (EMR system) Documentation is only signed if hourly rounding is completed. Since the incident on 2/26/2025 Resident # 1 has been good, and they wander around.During interview with Resident # 2 on 5/16/2025 at 11:00am, they stated they were in the hallway during the day of the incident, and they saw that Resident # 1 was in the doorway of their room. Resident #2 stated they grabbed Resident # 1, and they fell to the floor. Then Resident #1 while on the floor kicked them in the left leg. This all occurred in the hallway. They do not watch people well in that place. That was not the first time that Resident #1 had wandered into their room. Resident #2's roommate reported to them that Resident # 1 had laid in their bed, but Resident # 2 was not there when this occurred because they were out of the facility at the time. When they found out that Resident # 1 laid in their bed, they requested their sheets be changed. Resident # 2 stated they know that Resident # 1 has dementia but that is no excuse for them to wander in people's rooms. Resident # 1 should be watched, but the facility does not have enough help. Physical therapy was working with Resident # 2 and that was helping them. Resident #2 stated there were a few people present at the time of the incident and the police also came to the facility. Resident # 2 was sent to Mid-[NAME] Regional Hospital for a psychiatric evaluation, and they did not return to the facility. Resident # 2 was told by the facility that they that they could not return and Resident # 1's family was pressing charges on them because of the incident. Resident # 2 stated they had nowhere to go when they were discharged from the hospital.Resident # 6 was admitted to the facility on [DATE] and last re admitted to the facility on [DATE] with diagnosis that include but not limited to psychotic disorder with delusions, dementia with behavioral disturbances, and muscle weakness.A Quarterly Minimum Data Set, dated [DATE] documented Resident #6 had a Brief Interview for Mental Status score of 3/15; indicating the resident is not cognitively intact with no behaviors present. Resident had no impairment to upper or lower extremities and uses a wheelchair for locomotion. Resident is a moderate assist with eating, and maximum assist with bed mobility. Resident is frequently incontinent of urine and bowel.Review of a potential for abuse care plan for Resident #6 initiated on 9/24/2024 documented Resident is at risk for potential abuse due to immobility with an update on 3/11/2025 of Resident-to-Resident altercation. Interventions dated 9/24/2024 include encourage resident to verbalize any concerns fearsA review of the facility's internal investigation documented at approximately 1:30pm on 3/11/2025 Activity Aide # 1 was walking past room [ROOM NUMBER] and in the doorway, Resident #6 was sitting and had blood on their face. Resident #1 approached Resident # 6, Activity Aide # 1 witnessed Resident #1 pointing their finger on Resident # 6's face stating, Do you know who I am? while holding Resident # 6 by the collar. Activity Aide # 1 attempted to separate both resident but was unable to do this alone and went for assistance. Resident # 6 sustained scratches to the left side of their face and under the left eye and side of left neck. Resident # 1 had scratches to the right arm.A review of Resident # 6's skin assessment dated [DATE] documented scratches to left side of their face and above their left eye.A review of Nursing Progress notes for Resident # 6 had no documented notes about the incident that occurred 3/11/2025 between Resident # 6 and Resident # 1.A review of the facility's 5-day report submitted on 3/19/2025 documented a conclusion that the abuse was verified. Corrective Actions taken because of the verified abuse included Resident # 1 and Resident # 6 were seen by in house provider, social worker and psychiatry. 10 NYCRR 415.4(b)(1)(i)

Based on record review and interviews during an abbreviated survey (NY00360874), the facility did not ensure 1 out of 3 (Resident # 7) residents were free from significant medication errors. Specifically, Resident # 7 did not receive their physician ordered medication Enoxaparin Sodium (a medication to prevent blood clots) from 11/6/2024-11/12/2024. There were omissions on the Medication Administration Record with no documented nursing notes as to why the medications were not administered. 2) Resident #7 did not receive their medication Diazepam (a central nervous system depressant) from 11/6/2024-11/12/2024 as ordered by the physician. There was no documentation that the physician was notified or reasons why the medications were not administered. Resident #7 was transferred to the hospital on [DATE] for change in mental status. The findings are:The facility Medication Administration Policy and Procedure dated 9/1/2024 documented it is the policy of the facility to ensure that Medication Administration and documentation occurs in a timely and accurate manner.Resident # 7 was admitted to the facility on [DATE] and had diagnoses that include but not limited to trauma subdural hematoma without loss of consciousness, alcohol abuse, and major depressive disorder.A discharge Minimum Data Set, dated [DATE] documented the resident had no behaviors present. Resident required set up with eating and moderate assistance with toileting, moderate assistance with bed mobility and maximum assistance with transfers. Resident occasionally incontinent of urine and always continent of bowel.Review of the physician order dated 11/6/2024, documented the physician prescribed Enoxaparin Sodium Subcutaneous solution 30 milligrams/0.3 milliliters, give 30 milligrams subcutaneously every 12 hours, at 9 am and 9 pm for a diagnosis of personal history of traumatic brain injury.Review of the Medication Administration Record revealed Resident # 7 did not receive their medication (Enoxaparin Sodium, to prevent clotting) on 11/07/2024-11/09/2024 at 9am and 9pm and 11/10/2024 at 9am as ordered.Nurse progress notes from 11/6/2024-11/12/2024 was reviewed. There were no documented reasons as to why the doses were not administered on 11/7/2024-11/09/2024 at 9am and 9pm and 11/10/2024 at 9am.The physician order dated 11/6/2024 documented a physician order to give Diazepam (a central nervous system depressant) oral tablet 10 milligrams 1 tablet by mouth three times a daily for 180 days at 9 am, 1pm, and 5pm for a diagnosis of Anxiety.Review of the Medication Administration Record revealed omissions on for Diazepam on 11/6/2024 at 9am, 1pm, and 5pm, on 11/7/2024 and 11/08/2024 at 9am, 1pm and 5pm. The reason documented not done.Nurse progress notes from 11/6/2024-11/12/2024 were reviewed. There was no documented evidence as to why the doses of Diazepam were not administered on 11/6/2024-11/08/2024 at 9am, 1pm, 5pm as ordered.A review of a nursing progress note dated 11/13/2024 documented the resident was admitted to the hospital with a diagnosis of Altered Mental Status.A review of a nursing progress note dated 11/12/2024 at 10:43 am documented resident family member met with writer with concerns of resident's medical condition. Writer reported to resident bedside to assess the resident. Resident noted to be laying in bed in fetal position facing the wall. Writer approached the resident and attempted to get the resident's attention. Resident failed to engage with writer. Resident's pupils noted to be dilated and resident staring straight forward. Resident unable to answer basic question when asked. Responses seemed mumbled. This is a noticeable change from residents' baseline upon admission. Resident noted to have emesis on several occasions in the past few days.During an interview with Nurse Practitioner on 6/17/2025 at 11:48 am they stated usually during an omission of medications the nurses will note why the medication was not administered in a nursing progress note. Nurse Practitioner reviewed the medication administration record for Resident # 7 and stated it was 9 months ago, so they do not remember what happened with this resident's medication. It was ordered and there is no documentation why it was not administered. The Nurse Practitioner stated the diazepam was ordered for anxiety and they would have held the medication if there was no indication of anxiety. If a medication is ordered and it is out of stock, the nurses will inform the physician. The Nurse Practitioner stated they could not remember if they were informed or not. They were made aware that the resident was vomiting, and the resident was assessed. The nurses need to inform the physicians that the resident is refusing their meds and that is the facility protocol. They were not notified in this instance and there are no notes to indicate why the resident did not receive the diazepam or lovenox. Residents have the right to refuse medication, but there should be a note if the resident refuses a medication.During an interview on 6/17/2025 at 12:12pm, the Director of Nursing stated Narcotics needed for specific med pass are placed in the medication carts after the nurses complete their narcotic count at the beginning of each shift. If it requires blood pressure they will take vitals beforehand. Verify three times that it is the right medication for the right patient. If a resident refuses medication, then you would try to encourage and explain risk of not taking medication. Not, after the first refusal would you call the provider. This refusal would be put on report so that it can be monitored and passed on to the other nurses. If it continues then you notify the provider. If it is a significant medication, then you need to notify the provider. The medication nurse should notify the manager or supervisor, so they are aware of the refusal. The medication nurse can notify the provider of the resident's refusal. Nurses should document the refusal in the medication administration record and write a nursing progress note about the medication refusal. Surveyor requested for Director of Nursing to review Resident # 7's Medication Administration Record from 11/2024. Director of Nursing reviewed the medication administration record and stated they do not know what happen in this situation because they were not the director of the nursing at the time this occurred. Director of Nursing stated that if they were the Director of Nursing when this occurred, they would follow up with the nursing staff to find out what happened and if the resident refused the medication. If this was a medication error then they would also conduct a house wide in-service on medication administration, refusal and what to do in a situation where a resident refuses medication. Director of Nursing stated if after following up with the nursing staff these are true omissions; then they would write the responsible nurse up for a medication error and call the provider. However, they would need to follow up with the nurse and find out why the medication was not administered.Attempts to contact Licensed Practical Nurse # 2 on 6/16/2025 at 11:42 am was unsuccessful.Surveyor attempted to contact Licensed Practical Nurse # 3 on 6/17/2025 at 12:31 pm regarding medication omissions on the medication administration record. Calls were not returnedFormer DON did not return calls 10 NYCRR 415.12(m)(2)

Based on record review and staff interview during the abbreviated survey, (NY00340966), the facility did not ensure all allegations were thoroughly investigated for 1 of 4 residents. Specifically, Resident # 3 complained of pain in the shoulder and had x ray done on 4/26/2024 that showed a displaced right scapular fracture and osteopenia and was transferred to the hospital on 4/26/2024. The hospital history and physical report documented the resident reported that while in the facility when they were being repositioned, they heard a pop in their right shoulder. The facility did not provide any incident and accident report of the incident when requested by surveyors.The findings are: Resident #3 was re-admitted on [DATE] with diagnosis that include but not limited to Parkinson's Disease, Functional Quadriplegia, and Acute Kidney Failure.A quarterly Minimum Data Set, dated [DATE] documented a Brief Interview of Mental Status Score a 15; indicating the resident was cognitively intact with no behaviors. Resident had upper and lower extremity impairment on one side and uses a wheelchair for locomotion. Resident required supervision with eating and was dependent with bed mobility and transfers. Always incontinent of urine and frequently incontinent of bowel.The facility did not provide anu incident/accident report when requested.Review of the Radiology Report dated 4/26/2024 documented there was an x ray of the right shoulder. The Impression documented a Displaced scapular fracture and Osteopenia.A review of the Hospital Transfer Sheet dated 4/26/2024 documented under clinical information that the x ray showed a fracture of the right shoulder. Resident complained of right shoulder pain and received Tylenol around the clock.Review of the Hospital History and Physical Report dated 4/26/2024 documented under chief complaint that Resident #3 stated nurses were helping her reposition in bed yesterday and they heard a pop in their right shoulder. In house x-ray showed scapular fracture.On 6/09/2025 surveyor requested all incident reports on file for the Resident from 3/2024 to 4/2024. The Administrator informed surveyor that there were no incident reports for the resident from 3/2024 through 4/2024.A review of a nursing progress note written by Registered Nurse Supervisor dated 4/26/2024 documented Resident #3's x ray report of the right shoulder showed a Displaced scapular fracture and osteopenia. Xray results reported Assistant Director of Nursing, Family and Nurse Practitioner. Resident #3 to be sent to [NAME] for further evaluation. During an interview 6/11/2025 at 9:24am with Administrator stated that they know they spoke with the resident regarding the allegation that nurses pulled on them when repositioning them. They did not think it was a fracture. The old director of nursing may have a soft file where they started an investigation, but they need to find the file to see if they can locate the file. They did not think there was an official investigation completed for the incident because the facility questioned the aides, and they reported they were not rough with the resident. They completed the first X ray in house that looked like a fracture. However, the resident was at their baseline and had their regular range of motion, and did not seem to be in any more pain than usual. Out of an abundance of precaution they sent the resident to the hospital for follow- up where the hospital did the full trauma workup. They requested for the hospital to complete the trauma workup on the resident. Eventually the hospital completed the workup on the resident, and it revealed that the resident did not have a fracture.During an interview on 6/11/2025 at 10:17am with Resident #3's family representative they stated Resident # 3 had multiple incidents in the facility that were centered around care. For example, there was an incident where they fell, and it was not clear what happened. Resident # 3's family representative stated that while in the facility the staff was trying to help them out of bed, but they slipped and fell. This incident that occurred on 4/26/2025 when they were hospitalized it was reported that they were pulled on during cares. Resident # 3's Family Representative heard this and reported it to the Director of Nursing in the facility. They were told by the Director of Nursing that they would complete an internal investigation. Resident #3's family Representative reported they never filed a formal complaint with any one about the incident, but they did report it to the Director of Nursing.

Based on record review and interviews during an abbreviated survey (NY00373412, NY00374723), the facility did not ensure residents were free from abuse for 3 out of 3 residents (Resident #1, Resident # 2, Resident # 6) reviewed for abuse. Specifically, 1) On 2/26/2025 Resident #1 who had a known history of wandering, wandered into Resident # 2's room and Resident # 2 became agitated and put their hands on Resident # 1. Resident # 1 fell to the floor and kicked Resident # 2 in the leg. Resident #1 had no behavior care plan initiated before the incident. 2) On 3/11/2025 Resident # 1 was observed by staff in the doorway of their room holding their roommate(Resident # 6) by the collar. There was no documented behavior care plan was not initiated for Resident # 1 who had a known previous history of resident to resident altercation.The findings are:A review of the facility's Abuse investigation protocol/ Resident to Resident abuse policy last reviewed 5/2/2024 documented it is the policy of the facility to conduct a thorough investigation of all accusations/or reports of resident abuse to determine if a crime has been committed. Nursing Administration / Nurse administrator on call is responsible for reviewing information provided and advises if any further interventions are needed to ensure the safety of the resident. Considers room or floor change to prevent reoccurrence. Care plans for both residents must be updated to reflect risk for victimization, behaviors, aggressive behaviors, etc.Resident # 1 was admitted to the facility on [DATE] with a diagnosis that include but not limited to dementia with mood disturbances, Pre-glaucoma, and depression.A Minimum Data Set, dated [DATE] documented the Resident had a Brief Interview Mental Status score of 01/15 indicating the resident is not cognitively intact with no documented behaviors. No impairments to upper or lower extremities. Resident uses a wheelchair and walker for locomotion. Independent with eating and supervision with bed mobility and transfers. Resident is occasionally incontinent of urine and always continent of bowel.Review of an elopement/wander risk assessment dated [DATE] documented Resident #1 score was a 20 indicating the resident was a high risk for elopement/wandering.A review of all Resident # 1's care plans revealed no behavior care plan was in place.A review of Resident # 1's skin assessment dated [DATE] documented scratches to the right arm. Resident # 2 was admitted to the facility on [DATE] with diagnosis that include but not limited to Diabetes type 2, Muscle weakness, and End Stage Renal Disease.A Minimum Data Set, dated [DATE] that documented the resident had a brief interview of mental status score a 14/15 indicating the resident is cognitively intact with no behaviors present. Resident # 2 uses a wheelchair and walker for locomotion. Resident has an impairment on one side of the upper extremity. Requires set up with eating, independent with bed mobility, and supervision with transfers. Resident is occasionally incontinent of urine and always continent of bowel.A review of the facility's internal investigation conclusions / findings dated 2/26/2025 documented that on 2/26/2025 at 4:15pm, Resident # 2 grabbed Resident # 1's arm, pulled Resident # 1 out of their room and onto the ground. Resident # 1 landed on their buttocks. Resident # 1 kicked Resident # 2 in the leg in attempt to get Resident # 2 to let go of their arm. Staff intervened immediately. 911 was called immediately after assessing the resident's safety. Resident # 1 was assisted off the floor and into a wheelchair. Resident # 1 was assisted back to bed, body assessment completed by a Registered Nurse, then the resident was seen by the in-house Nurse Practitioner. Ambulance arrived with a police escort. Resident # 2 was discharged to Mid-[NAME] Regional Hospital for psychological evaluation. Resident # 2 has not returned to the facility.A review of the police case report 2025-0394 dated 02/26/2025 documented caller from the facility reports a psychiatric emergency with a patient who had been physical with another patient, and they would like to have them removed. Patient was willingly transported to Mid- [NAME] Regional for evaluation by Empress.During an interview on 5/9/2025 at 12:30pm, Certified Nursing Aide # 1 stated they worked in the facility for a while but cannot remember the date. They are usually assigned to the south side, but it depends on the needs. They are familiar with Resident # 1. Resident # 1 needs supervision and has dementia. Resident # 1 will wander into other resident's room, and they will redirect them. The resident can get agitated. Resident # 1 will become physically aggressive if you don't back off of them, but if you back off and give them space, they will calm down. Certified Nursing Assistant # 1 had not seen them initiate physical aggression toward other residents, but Resident #1 will protect themself. Certified Nursing Assistant # 1 can recall an incident between Resident # 1 and Resident # 6 where they were sitting at the table together and Resident #6 became aggressive toward Resident #1. They were separated from each other. Resident # 2 was in the facility and was on dialysis, but they are no longer in the facility. Resident # 2 would not hurt anyone because they had a good mind. If Resident # 2 became upset with someone it would be verbal, but they would not hit someone.During an interview with Licensed Practical Nurse #1 on 5/9/2025 at 1:10pm, they stated they are aware of the incident that took place between Resident # 1 and Resident # 2 on 2/26/2025. Licensed Practical Nurse #1 was at the nurses' station on the north side talking to Resident #2 and Resident # 1 was wandering the hallway. When resident #2 seen resident # 1 attempting to enter their room Resident # 2 then threatened to hit Resident # 1. Resident # 2 threw Resident # 1 on the ground. The aide came over to assist. Social worker and Director of Nursing came down to the north side unit. Resident # 1 kicked and hit Resident #2, and it escalated the situation more. 911 was called, but Licensed Practical Nurse #1 cannot remember who called them. Licensed Practical Nurse #1 usually work on the north side, so they are not familiar with all the intervention in place for Resident # 1. The facility sent Resident# 2 out to Mid-[NAME] Regional Hospital for a psychiatric evaluation and the facility did not accept the resident back. The facility did not take the resident back because they were a threat. The facility called the family to find out if they wanted to pursue charges, but they did not.During an interview with the Director of Nursing on 5/12/2025 at 10:30am they stated they started working in the facility as the Director of Nursing since 12/16/ 2024. They were notified of the incident on 2/26/2025 with resident #1 and #2 right after it happened. They went downstairs because they were still in the building. Resident # 2 was very aggressive and angry, and they were there interacting with social worker. Resident # 2 was aggressive and telling social worker to leave them alone. One of the nurses called 911, but they cannot remember which one called. The Director of Nursing waited and assisted Resident #1 back to their room. Resident # 1 had a assessment completed, but the resident did not remember the details of the incident. The Nurse Practitioner came to assess Resident # 1 and there were no noted injuries after incident. Director of Nursing stated they explained the situation to officers and Resident # 2 went to hospital for a psychological evaluation. It is the facility's Protocol that any resident-to-resident interaction is followed up by psychology/psychiatry. Resident # 1' was not's family was notified and the family did not want Resident # 2 near Resident # 1, and they wanted to press charges. The facility provided Resident # 1's family information for family to press charges. Then they collected statements and started Incident/Accident Form and reporting process. Incident occurred on 2/26/2025 and it was reported on 2/26/2025. Resident # 2 was discharged home from the hospital. The Supervisor called Mid-[NAME] for follow up on Resident # 2 and nurse at the hospital stated that Resident # 2 was discharged home on 2/26/2025. Interventions that were added after the incident was the facility put a stop sign on Resident # 2's door. there was follow up with the social worker, Nurse Practitioner, and frequent rounding. Frequent rounding is done every 2 hours so there would be no documentation in Visual (EMR system) Documentation is only signed if hourly rounding is completed. Since the incident on 2/26/2025 Resident # 1 has been good, and they wander around.During interview with Resident # 2 on 5/16/2025 at 11:00am, they stated they were in the hallway during the day of the incident, and they saw that Resident # 1 was in the doorway of their room. Resident #2 stated they grabbed Resident # 1, and they fell to the floor. Then Resident #1 while on the floor kicked them in the left leg. This all occurred in the hallway. They do not watch people well in that place. That was not the first time that Resident #1 had wandered into their room. Resident #2's roommate reported to them that Resident # 1 had laid in their bed, but Resident # 2 was not there when this occurred because they were out of the facility at the time. When they found out that Resident # 1 laid in their bed, they requested their sheets be changed. Resident # 2 stated they know that Resident # 1 has dementia but that is no excuse for them to wander in people's rooms. Resident # 1 should be watched, but the facility does not have enough help. Physical therapy was working with Resident # 2 and that was helping them. Resident #2 stated there were a few people present at the time of the incident and the police also came to the facility. Resident # 2 was sent to Mid-[NAME] Regional Hospital for a psychiatric evaluation, and they did not return to the facility. Resident # 2 was told by the facility that they that they could not return and Resident # 1's family was pressing charges on them because of the incident. Resident # 2 stated they had nowhere to go when they were discharged from the hospital.Resident # 6 was admitted to the facility on [DATE] and last re admitted to the facility on [DATE] with diagnosis that include but not limited to psychotic disorder with delusions, dementia with behavioral disturbances, and muscle weakness.A Quarterly Minimum Data Set, dated [DATE] documented Resident #6 had a Brief Interview for Mental Status score of 3/15; indicating the resident is not cognitively intact with no behaviors present. Resident had no impairment to upper or lower extremities and uses a wheelchair for locomotion. Resident is a moderate assist with eating, and maximum assist with bed mobility. Resident is frequently incontinent of urine and bowel.Review of a potential for abuse care plan for Resident #6 initiated on 9/24/2024 documented Resident is at risk for potential abuse due to immobility with an update on 3/11/2025 of Resident-to-Resident altercation. Interventions dated 9/24/2024 include encourage resident to verbalize any concerns fearsA review of the facility's internal investigation documented at approximately 1:30pm on 3/11/2025 Activity Aide # 1 was walking past room [ROOM NUMBER] and in the doorway, Resident #6 was sitting and had blood on their face. Resident #1 approached Resident # 6, Activity Aide # 1 witnessed Resident #1 pointing their finger on Resident # 6's face stating, Do you know who I am? while holding Resident # 6 by the collar. Activity Aide # 1 attempted to separate both resident but was unable to do this alone and went for assistance. Resident # 6 sustained scratches to the left side of their face and under the left eye and side of left neck. Resident # 1 had scratches to the right arm.A review of Resident # 6's skin assessment dated [DATE] documented scratches to left side of their face and above their left eye.A review of Nursing Progress notes for Resident # 6 had no documented notes about the incident that occurred 3/11/2025 between Resident # 6 and Resident # 1.A review of the facility's 5-day report submitted on 3/19/2025 documented a conclusion that the abuse was verified. Corrective Actions taken because of the verified abuse included Resident # 1 and Resident # 6 were seen by in house provider, social worker and psychiatry. 10 NYCRR 415.4(b)(1)(i)

Based on record review and interviews during an abbreviated survey (NY00360874), the facility did not ensure 1 out of 3 (Resident # 7) residents were free from significant medication errors. Specifically, Resident # 7 did not receive their physician ordered medication Enoxaparin Sodium (a medication to prevent blood clots) from 11/6/2024-11/12/2024. There were omissions on the Medication Administration Record with no documented nursing notes as to why the medications were not administered. 2) Resident #7 did not receive their medication Diazepam (a central nervous system depressant) from 11/6/2024-11/12/2024 as ordered by the physician. There was no documentation that the physician was notified or reasons why the medications were not administered. Resident #7 was transferred to the hospital on [DATE] for change in mental status. The findings are:The facility Medication Administration Policy and Procedure dated 9/1/2024 documented it is the policy of the facility to ensure that Medication Administration and documentation occurs in a timely and accurate manner.Resident # 7 was admitted to the facility on [DATE] and had diagnoses that include but not limited to trauma subdural hematoma without loss of consciousness, alcohol abuse, and major depressive disorder.A discharge Minimum Data Set, dated [DATE] documented the resident had no behaviors present. Resident required set up with eating and moderate assistance with toileting, moderate assistance with bed mobility and maximum assistance with transfers. Resident occasionally incontinent of urine and always continent of bowel.Review of the physician order dated 11/6/2024, documented the physician prescribed Enoxaparin Sodium Subcutaneous solution 30 milligrams/0.3 milliliters, give 30 milligrams subcutaneously every 12 hours, at 9 am and 9 pm for a diagnosis of personal history of traumatic brain injury.Review of the Medication Administration Record revealed Resident # 7 did not receive their medication (Enoxaparin Sodium, to prevent clotting) on 11/07/2024-11/09/2024 at 9am and 9pm and 11/10/2024 at 9am as ordered.Nurse progress notes from 11/6/2024-11/12/2024 was reviewed. There were no documented reasons as to why the doses were not administered on 11/7/2024-11/09/2024 at 9am and 9pm and 11/10/2024 at 9am.The physician order dated 11/6/2024 documented a physician order to give Diazepam (a central nervous system depressant) oral tablet 10 milligrams 1 tablet by mouth three times a daily for 180 days at 9 am, 1pm, and 5pm for a diagnosis of Anxiety.Review of the Medication Administration Record revealed omissions on for Diazepam on 11/6/2024 at 9am, 1pm, and 5pm, on 11/7/2024 and 11/08/2024 at 9am, 1pm and 5pm. The reason documented not done.Nurse progress notes from 11/6/2024-11/12/2024 were reviewed. There was no documented evidence as to why the doses of Diazepam were not administered on 11/6/2024-11/08/2024 at 9am, 1pm, 5pm as ordered.A review of a nursing progress note dated 11/13/2024 documented the resident was admitted to the hospital with a diagnosis of Altered Mental Status.A review of a nursing progress note dated 11/12/2024 at 10:43 am documented resident family member met with writer with concerns of resident's medical condition. Writer reported to resident bedside to assess the resident. Resident noted to be laying in bed in fetal position facing the wall. Writer approached the resident and attempted to get the resident's attention. Resident failed to engage with writer. Resident's pupils noted to be dilated and resident staring straight forward. Resident unable to answer basic question when asked. Responses seemed mumbled. This is a noticeable change from residents' baseline upon admission. Resident noted to have emesis on several occasions in the past few days.During an interview with Nurse Practitioner on 6/17/2025 at 11:48 am they stated usually during an omission of medications the nurses will note why the medication was not administered in a nursing progress note. Nurse Practitioner reviewed the medication administration record for Resident # 7 and stated it was 9 months ago, so they do not remember what happened with this resident's medication. It was ordered and there is no documentation why it was not administered. The Nurse Practitioner stated the diazepam was ordered for anxiety and they would have held the medication if there was no indication of anxiety. If a medication is ordered and it is out of stock, the nurses will inform the physician. The Nurse Practitioner stated they could not remember if they were informed or not. They were made aware that the resident was vomiting, and the resident was assessed. The nurses need to inform the physicians that the resident is refusing their meds and that is the facility protocol. They were not notified in this instance and there are no notes to indicate why the resident did not receive the diazepam or lovenox. Residents have the right to refuse medication, but there should be a note if the resident refuses a medication.During an interview on 6/17/2025 at 12:12pm, the Director of Nursing stated Narcotics needed for specific med pass are placed in the medication carts after the nurses complete their narcotic count at the beginning of each shift. If it requires blood pressure they will take vitals beforehand. Verify three times that it is the right medication for the right patient. If a resident refuses medication, then you would try to encourage and explain risk of not taking medication. Not, after the first refusal would you call the provider. This refusal would be put on report so that it can be monitored and passed on to the other nurses. If it continues then you notify the provider. If it is a significant medication, then you need to notify the provider. The medication nurse should notify the manager or supervisor, so they are aware of the refusal. The medication nurse can notify the provider of the resident's refusal. Nurses should document the refusal in the medication administration record and write a nursing progress note about the medication refusal. Surveyor requested for Director of Nursing to review Resident # 7's Medication Administration Record from 11/2024. Director of Nursing reviewed the medication administration record and stated they do not know what happen in this situation because they were not the director of the nursing at the time this occurred. Director of Nursing stated that if they were the Director of Nursing when this occurred, they would follow up with the nursing staff to find out what happened and if the resident refused the medication. If this was a medication error then they would also conduct a house wide in-service on medication administration, refusal and what to do in a situation where a resident refuses medication. Director of Nursing stated if after following up with the nursing staff these are true omissions; then they would write the responsible nurse up for a medication error and call the provider. However, they would need to follow up with the nurse and find out why the medication was not administered.Attempts to contact Licensed Practical Nurse # 2 on 6/16/2025 at 11:42 am was unsuccessful.Surveyor attempted to contact Licensed Practical Nurse # 3 on 6/17/2025 at 12:31 pm regarding medication omissions on the medication administration record. Calls were not returnedFormer DON did not return calls 10 NYCRR 415.12(m)(2)

Based on record review and staff interview during the abbreviated survey, (NY00340966), the facility did not ensure all allegations were thoroughly investigated for 1 of 4 residents. Specifically, Resident # 3 complained of pain in the shoulder and had x ray done on 4/26/2024 that showed a displaced right scapular fracture and osteopenia and was transferred to the hospital on 4/26/2024. The hospital history and physical report documented the resident reported that while in the facility when they were being repositioned, they heard a pop in their right shoulder. The facility did not provide any incident and accident report of the incident when requested by surveyors.The findings are: Resident #3 was re-admitted on [DATE] with diagnosis that include but not limited to Parkinson's Disease, Functional Quadriplegia, and Acute Kidney Failure.A quarterly Minimum Data Set, dated [DATE] documented a Brief Interview of Mental Status Score a 15; indicating the resident was cognitively intact with no behaviors. Resident had upper and lower extremity impairment on one side and uses a wheelchair for locomotion. Resident required supervision with eating and was dependent with bed mobility and transfers. Always incontinent of urine and frequently incontinent of bowel.The facility did not provide anu incident/accident report when requested.Review of the Radiology Report dated 4/26/2024 documented there was an x ray of the right shoulder. The Impression documented a Displaced scapular fracture and Osteopenia.A review of the Hospital Transfer Sheet dated 4/26/2024 documented under clinical information that the x ray showed a fracture of the right shoulder. Resident complained of right shoulder pain and received Tylenol around the clock.Review of the Hospital History and Physical Report dated 4/26/2024 documented under chief complaint that Resident #3 stated nurses were helping her reposition in bed yesterday and they heard a pop in their right shoulder. In house x-ray showed scapular fracture.On 6/09/2025 surveyor requested all incident reports on file for the Resident from 3/2024 to 4/2024. The Administrator informed surveyor that there were no incident reports for the resident from 3/2024 through 4/2024.A review of a nursing progress note written by Registered Nurse Supervisor dated 4/26/2024 documented Resident #3's x ray report of the right shoulder showed a Displaced scapular fracture and osteopenia. Xray results reported Assistant Director of Nursing, Family and Nurse Practitioner. Resident #3 to be sent to [NAME] for further evaluation. During an interview 6/11/2025 at 9:24am with Administrator stated that they know they spoke with the resident regarding the allegation that nurses pulled on them when repositioning them. They did not think it was a fracture. The old director of nursing may have a soft file where they started an investigation, but they need to find the file to see if they can locate the file. They did not think there was an official investigation completed for the incident because the facility questioned the aides, and they reported they were not rough with the resident. They completed the first X ray in house that looked like a fracture. However, the resident was at their baseline and had their regular range of motion, and did not seem to be in any more pain than usual. Out of an abundance of precaution they sent the resident to the hospital for follow- up where the hospital did the full trauma workup. They requested for the hospital to complete the trauma workup on the resident. Eventually the hospital completed the workup on the resident, and it revealed that the resident did not have a fracture.During an interview on 6/11/2025 at 10:17am with Resident #3's family representative they stated Resident # 3 had multiple incidents in the facility that were centered around care. For example, there was an incident where they fell, and it was not clear what happened. Resident # 3's family representative stated that while in the facility the staff was trying to help them out of bed, but they slipped and fell. This incident that occurred on 4/26/2025 when they were hospitalized it was reported that they were pulled on during cares. Resident # 3's Family Representative heard this and reported it to the Director of Nursing in the facility. They were told by the Director of Nursing that they would complete an internal investigation. Resident #3's family Representative reported they never filed a formal complaint with any one about the incident, but they did report it to the Director of Nursing.

Based on record review and interviews during an abbreviated survey (NY00342534) the facility did not ensure residents right to be free from abuse for 1 out of 3 residents (Resident #1) reviewed for abuse. Specifically, on 8/5/2024 Resident #2 who was known to be physically/verbally abusive wandered into Resident #1's room, threw their items on the floor, tried to take away their walker and punched them with a closed fist on their arm. Resident #1 reported they were punched on the right arm by Resident #2. Resident #1 was assessed with no injuries and Resident #2 was discharged to the hospital for further evaluation. Findings include: The facility abuse, neglect and exploitation of resident's policy dated 7/12/2018 and last reviewed/revised 4/2020 documented it is the policy of the facility that acts of physical, verbal, and mental abuse directed against residents are absolutely prohibited. Each resident has the right to be free from verbal, sexual, physical, and mental abuse. Residents will not be subjected to abuse by anyone, including but not limited to, staff and other residents. Comprehensive policies and procedures have been developed to aid the facility in the prevention of abuse, neglect, exploitation, mistreatment, or misappropriation of property of the residents. 1)Resident #1 was readmitted to the facility on [DATE] with diagnosis including but not limited to malignant neoplasm of endometrium, Acute Embolism and Thrombosis of Unspecified Deep Veins of Left Lower Extremity. An annual Minimum Data Set, dated dated dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 15/15, associated with intact cognition. No behaviors noted. The Resident was independent for eating, bed mobility and transfers, required moderate assistance for toileting and used a wheelchair or a walker for locomotion. Resident #1 was occasionally incontinent of urine and continent of bowels. Review of a behavior care plan dated 8/7/2024 documented the resident was a victim of a resident-to-resident altercation and had unsolicited physical contact by another resident. The goal was the resident will be separated from the aggressor and would not be victimized by other resident, will suffer no emotional effects. Interventions included to assess for injury, keep the resident separated from other aggressor residents, provide emotional support, assess for feelings of fear or lack of safety, and provide social work counseling. Review of an accident/incident investigative form statement dated 8/7/2024 at 6:20 PM written by the Director of Nursing documented Resident #1 was sitting on their bed when another resident wandered into their room and hit them with a closed fist around the shoulder area. Review of the 5-day investigative conclusion submitted by the facility documented the findings were verified and Resident #2 was transferred to the hospital for increase agitation and later returned to the facility. The care plans for Resident #1 and Resident #2 were updated with instructions to keep the residents apart. Resident #2 to be redirected when wandering into resident's rooms and frequent visual checks to be initiated. 2) Resident #2 admitted to the facility on [DATE] diagnosis including but not limited to Neurocognitive disorder with Lewy bodies, Dementia and Personal History of Traumatic Brain Injury. A 5-day Minimum Data Set, dated dated dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 99 associated with severe cognition impairment with making daily decisions. The resident exhibited verbal and physical behaviors directed towards others. Resident #2 required partial assistance with ambulation, eating and bed mobility, was dependent for toileting and required supervision for transfers. A cognitive impairment care plan dated 7/29/2024 documented Resident #2 experienced severe cognitive deficits, recent decline in cognitive status, Lewy body dementia, impaired decision-making ability, poor insight/reasoning and poor impulse control. The goal was to promote/improve alertness and awareness with interventions to anticipate the resident's needs, provide orientation and cueing as needed, provide calming environment reduce stimulus and psychiatry and psychology consult and treatment as indicated. A behaviors care plan dated 8/7/2024 documented Resident #2 exhibited combativeness, confusion, wandering, physically abusive and aggressive behaviors. The goal was episodes of aggression would be decreased by redirection. Interventions listed included educate staff, resident/representative on behavioral interventions and consequences as indicated, observe and document behaviors every shift and psychiatric evaluations as indicated. A resident-to-resident altercation (aggressor) care plan dated 8/7/2024 documented Resident #2 was physically aggressive and made unwanted physical contact with another resident. The goal was Resident #2 would be kept apart from Resident #1 and would not display any further physical aggression toward other residents. Interventions listed included keep resident apart from other residents, provide 1:1 supervision until calm, psychiatric consult as ordered, remove resident from situation utilizing calm approach and send to hospital for evaluation of increased agitation and aggressive behaviors. Review of an accident/incident investigative form dated 8/5/2024 documented at 6:20 PM Resident #2 was visiting with their wife and wandered into Resident #1's room. Resident #2 struck Resident #1 with a closed fist around their shoulder area. During an interview on 8/26/2024 at 10:35 AM Resident #1 stated on 8/5/2024 they were in the bathroom in their room, and they heard things being thrown to the floor. They exited the bathroom and found Resident #2 in their room, and they asked Resident #2 to stop and get out of their room. Resident #2 instead, tried to grab their walker and punched them in the arm. Resident #1 stated Resident #2's wife came and removed Resident #2 from the room. Resident #1 stated Resident #2 terrorized them and other residents for days, but after this incident the facility sent the resident out for evaluation. Resident #2 returned to the facility after a few hours, but the resident is no longer in the facility. Stated the Velcro stop sign was at the entry of their room, but Resident #2 just pulled it down and came in that day on 8/5/2024. Resident #1 pointed to a fading brownish bruised area on their right upper arm and showed a picture in their cellphone of a deep purple ecchymosis area to the right upper arm, and stated this was from the incident and is now going away. Resident #1 stated the Director of Nursing was in the building when the incident occurred on 8/5/2024 and they had Resident #2 immediately removed from the building. During an interview on 8/26/2024 at 3:45 PM the Director of Nursing stated they were in the building on 8/5/2024 when the incident occurred between Resident #1 and Resident #2. They were called by Licensed Practical Nurse #1 stating that Resident #2 went into Resident #1's room and struck them. They assessed Resident #1 and had Resident #2 sent out for evaluation. The Director of Nursing stated Resident #1 was a little shaken up after the incident, but they were not injured. The Director of Nursing stated Resident #1 did express concern with Resident #2's behaviors. Resident #2 was transferred out to another facility on 8/9/2024. The Director of Nursing stated they observed Resident #1 and there was no injury noted to Resident #1. The Director of Nursing stated on 8/5/2024 the day of the incident with Resident #1, Resident #2 was with their wife and wandered away from them and went into Resident #1's room. 10 NYCRR 415.4(b)(1)(i)

Based on observations, record review and interviews during a recertification survey 4/8/24-4/17/24, the facility did not ensure residents received treatment and care in accordance with professional standards of quality for 4 of 6 residents (Residents #14, #27, #54 and #56) reviewed for quality of care. Specifically, 1) Resident #14 vascular wound dressing was not changed daily as ordered and was observed on 4/12/24 with a date of 4/9/24 on the dressing. 2) Resident #54 did not have post hospitalization appointments scheduled for follow up care. 3) Resident #56's order for compression stockings was not carried out and a follow up urology appointment was not scheduled. 4) Resident #27 did not receive daily wound care as ordered on 8 of 19 days from 3/29/24 to 4/16/24. Findings include: 1) Resident #14 was admitted with diagnoses including adult failure to thrive, venous insufficiency, and hypothyroidism. Resident #14's Minimum Data Set (an assessment tool) dated 3/23/24 documented the resident had moderate cognitive impairment and was dependent on staff for assistance with hygiene and toileting, and required cueing for eating. The Physician's orders dated 3/08/24 document to cleanse the vascular wound to left lower extremity with normal saline or wound cleanser, apply Silver Alginate, cover with a gauze pad, and wrap with Kling. Change the dressing daily and as needed. The nursing care plan for vascular wound initiated 7/22/22 documented to provide treatments as ordered. During a Resident Council meeting on 4/9/24 at 10:24 AM, the resident stated they had a wound dressing on their leg that went days without being changed. On a second interview with the resident 4/10/24 at 10:13 AM they stated they had a wound on their left foot that was not always changed and sometimes it could be a few days without changing. The Treatment Administration Record from 3/8/24-3/31/24 documented no evidence the treatment was completed on 3/8,3/9,3/10,3/11, 3/13,3/14,3/19,3/20. The April 2024 Treatment Administration Record documented no evidence the treatment was completed on 4/1,4/2,4/3, 4/6,4/7,4/11/24. During a wound dressing change observation on 4/12/24 at 9:42 AM with the Staff #15 (wound care nurse) the old dressing on the left lower leg was wet with brown color on outside of the Kling which was loosely in place. The silk tape over the Kling had date of 4/9/24 written on it. When interviewed during the dressing change, Staff #15 stated they saw the resident on Monday, Wednesday and Friday and was not sure why it had not been changed since 4/9/24. During an interview on 4/12/24 at 12:17 PM, Staff #11 (Licensed Practical Nurse) stated the leg dressing change should have been done everyday and they did not know why it was not done. Staff #7 (Licensed Practical Nurse Unit Manager) stated they were not aware the dressing changes were not being done. Staff #7 stated that the expectation would be that if the dressing change was not done on the day shift it would be done on the evening shift. 2) Resident #54 was admitted from the hospital with diagnoses that include respiratory failure, atrial fibrillation, dysphagia, septicemia. The Minimum Data Set (an assessment tool) dated 2/25/24 documented the resident had moderate cognitive impairment, with impairment on upper extremity, and a percutaneous endoscopic gastrostomy tube (feeding tube) in place. During an interview with Resident #54 on 4/17/24 at 9:06 AM they stated they did not know why they still had the feeding tube as it was not being used. They stated they had not been to see the gastroenterologist or the cardiologist and was told it had to wait until they were discharged . Review of the resident discharge instructions from the hospital on 1/30/24 documented the resident had a gastrostomy tube in place after a cerebrovascular accident. The discharge instructions documented a follow up appointment was made by the hospital for the resident for July 1, 2024 at 11:30 with the cardiologist. Additional instructions included to schedule appointments with the gastroenterologist and the neurologist to be seen in 1-2 weeks. Review of the resident's recorded revealed no documented evidence the appointments with the gastroenterologist and the neurologist were made. On 2/17/24 the resident was hospitalized and returned to the facility on [DATE] with discharge instructions to schedule an appointment with the maxillofacial surgeon within 2 weeks. Further review of the resident's recorded revealed no documented evidence the appointment with the maxillofacial surgeon was made. During an interview on 4/17/24 at 9:35 AM, Staff#7 (Licensed Practical Nurse Unit Manager) stated they reviewed the discharge instructions and stated the follow up appointments were not needed and were listed on the discharge instructions for billing purposes. During an interview on 4/17/24 at 1:02 PM, the Assistant Director of Nursing stated the Staff #7 was new to the role and needed more training. 3) Resident #56 was admitted [DATE] with diagnoses including quadriplegia after fall with fractured cervical (neck) vertebrae, neurogenic bladder, subluxation of right shoulder. The Minimum Data Set, dated dated dated [DATE] documented the resident was cognitively intact and had impairment of bilateral upper and lower extremities. The resident was totally dependent on staff for all activities of daily living, wore an Aspen collar and required a mechanical lift to transfer out of bed. The resident had a Foley catheter. Urology consult: The hospital discharge instructions dated 2/23/24 documented the resident had a Foley catheter and to follow up with urology for urodynamic testing. Review of the resident's record revealed no documented evidence that urology was contacted. The resident care plan for Foley(Urinary Incontinence) initiated 2/27/24 had interventions that included urology consult as indicated. During an interview on 4/11/24 at 12:55 PM, Staff #7 stated they were not aware of a visit to the urologist and stated the resident had not left the building since their admission in February. The Staff #7 stated the discharge instructions were reviewed on admission and the urology order was missed. Compression stockings: The Physician orders dated 2/23/24 documents TED anti-embolic stocking to extremities before getting out of bed daily. The Treatment Administration Record was reviewed from 2/23/24-4/17/24 and documented the stockings were not in place 38 of 55 days. The Certified Nurses Assistant Care Guide listed the anti-embolic stockings. Observations were made on 4 /11/24 at 1:00 PM , 4/12/24 at 8:59 AM, and 4/16/24 at 10:15 AM, the resident was in their wheelchair and the anti-embolic stockings were not worn. During an interview with Resident #56 on 4/16/24 at 10:15 AM, they stated they had the anti-embolic stockings before coming to the facility but did not get them at this facility and did not know why. During an interview on 4/11/24 at 01:00 PM, Staff#8 (Certified Nurse Aide) stated the resident did not have the stockings and did not know why they were on their Care Guide. During an interview on 4/12/24 at 11:31 AM, Staff #11 (Licensed Practical Nurse) stated they did the medications first in the morning then moved on to the treatments. Staff #11 stated they signed off on treatments including stockings. Staff #11 stated they had not seen a pair of stockings for the resident but would put in an order. Order placed 4/14/24. As of 4/17/24 the resident had not received the stockings. During an interview on 4/16/24 at 10:39 AM, Staff # 7 (Licensed Practical Nurse Unit Manager) they stated they did not know what happened to the stockings. Staff #7 then went into the Resident #56 and asked the resident if they liked the stockings and Resident #57 stated the stockings made their legs feel good. During an interview on 4/15/24 04:26 PM, the Nurse Practitioner they stated they were not aware the resident was not provided the stockings. 10NYCRR 415.12 49255

Based on record review and interview conducted during the recertification survey conducted from 4/08/24 to 4/17/24, the facility did not ensure certified nurse aide performance reviews were completed at least once every 12 months for 5 of 5 (Staff #'s 8, 9, 16, 17, and 18) certified nurse aides reviewed. The findings are: There was no documented evidence that Staff #8, 9, 16, 17, and 18 had performance reviews completed at least once every 12 months. During an interview on 04/11/24 at 03:35 PM, the Assistant Director of Nursing stated that they became employed by the facility on 2/28/23 and became the staff educator in September 2023. The Assistant Director of Nursing stated certified nurse aide performance reviews had not been done prior to and since they became employed at the facility; and staff competencies should be done every 12 months and as needed. During an interview on 04/11/24 at 03:40 PM, the Director of Nursing stated that certified nurse aide performance reviews had not been done and should have been done. The Director of Nursing stated that staff performance was not being monitored and there had been complaints from residents and visitors about the staff. During an interview on 04/16/24 at 02:43 PM, Staff #8 (Certified Nurse Aide) stated that they had been working at the facility for over [AGE] years and had never received a performance review. 10NYCRR 415.26 (c)(2)(iii)

Based on observation, record review and interview conducted during a recertification survey from 4/8/24-4/17/24, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infections for 5 of 5 residents (#22, #8, #14, #56, and #18) reviewed for infection control. Specifically, 1) staff did not change gloves after touching a resident and/or assistive device and before handing out Resident #8's food tray and staff were observed using the same hand while feeding Resident #22 and Resident #8; 2) staff did not wear a gown during a dressing change for Resident #14 on Enhanced Barrier Precautions; 3) staff did not wear a gown during a treatment for Resident #56 on Enhanced Barrier Precautions and 4) there was no documentation that oxygen tubing was changed weekly and as needed for Resident #18. The findings are: The facility policy for Infection Prevention and Control Program dated 3/21/24 documented the program was a facility wide effort involving all disciplines and individuals and was an integral part of the quality assurance and performance improvement program. The undated facility policy for Enhanced Barrier Precautions documented precautions were used as an infection prevention and control intervention to reduce the spread of multi drug resistant organisms to residents. 1. Resident #22 had diagnoses of dementia, seizure, and Alzheimer's disease. Resident #22's Minimum Data Set (a resident assessment and screening tool) dated 3/4/24 documented the resident had severe cognitive impairment and was dependent on staff for eating. Resident #8 had diagnoses of dementia, alzheimer's disease, and dysphagia (difficulty swallowing). Resident #8's Minimum Data Set, dated dated dated [DATE] documented the resident had severe cognitive impairment and needed assistance from staff for eating. During a meal observation on 4/9/24 at 12:45 PM Staff #8 (Certified Nurse Assistant) was wearing gloves and touched Resident #28's wheelchair, touched the brake adjusted the chair, touched the brake, parked the chair, then walked over to the food truck, opened the door and removed a tray. Staff #8 placed Resident #8's tray, touched Resident #8 on the shoulder/hand and removed their gloves. Staff #8 applied a new pair of gloves without performing hand hygiene and proceeded to feed Resident #22 and Resident #8 using the same right hand. Staff #8 was then observed holding Resident #22's spoon, putting it down and picking up Resident #8's spoon to feed the resident. During an interview on 4/17/24 at 9:26 AM Staff# 7 (Licensed Practical Nurse Unit Manager) stated they monitored and watched staff in the dining room to make sure infection control practices were maintained. During an interview on 4/17/24 at 1:22 PM Staff #8 stated they were right-handed and had a slip up and further stated you caught me. When asked about wearing the gloves Staff #8 stated it was something new and they were confused about when to wear the gloves. 2. Resident #14 had diagnoses of hypothyroidism, anxiety disorder and venous insufficiency. The Minimum Data Set, dated dated dated [DATE] documented the resident had impaired cognition and had a foley catheter. The physician orders dated 4/1/24 documented Enhanced Barrier Precautions for lower leg extremity wound every shift. During a wound dressing observation on 4/12/24 at 9:42 AM, Staff #15 (wound care nurse) without the use of a gown, applied gloves and after removing the old dressing leaned over to inspect the wound causing their identification badge to come in contact with the wound drape and the residents leg before resting on Staff #15's shirt. During an interview on 4/12/24 at 9:45 AM Staff #15 stated they should have been wearing a gown the whole time when doing the wound treatment but forgot. Staff #15 stated they did not noticed their identification badge coming in contact with the resident and wound drape but if they had a gown on that would not have happened. 3. Resident #56 was admitted [DATE] with diagnoses including quadriplegia after fall with avulsion fracture of C7, neurogenic bladder, and subluxation of right shoulder. The Minimum Data Set, dated dated dated [DATE] documented the resident was cognitively intact and had impairment of bilateral upper and lower extremities and had a foley catheter. There was no documented evidence in the physician orders to indicate the resident was on Enhanced Barrier Precautions. During a treatment observation on 4/16/24 at 10:27 AM Staff #7 gathered supplies and explained the procedure to the resident. Staff#7 washed hands, donned gloves and performed the treatment. The Staff #7 was not wearing a gown at the time they performed the treatment. The resident#56 had signage on the door for Enhanced Barrier Precautions. During an interview with Staff #7 4/16/24 at 10:27 AM they stated they were supposed to wear the gown even if it is just skin prep and stated they usually do but at the time was nervous and was still getting used to the new precautions. During an interview on 4/17/24 at 9:26 AM Staff# 7 (Licensed Practical Nurse Unit Manager) stated the Enhanced Barrier Precautions came out in March and the staff were in serviced. 10 NYCRR 415.19(b)(4) 47626

Based on observation, record review and interview conducted during the recertification survey from 4/8/2024-4/17/2024, the facility did not ensure that sanitary conditions were being maintained in the main kitchen area. Specifically, 1) undated and unlabeled food were in the freezer; 2) the dishwasher was not reaching the appropriate temperature; 3) staff were storing personal food in the refrigerator used for the residents' meals; 4) the exhaust wall fan was covered with dust and grease debris; 5) staff were not wearing beard cover while serving the residents their meals; and 6) tuna fish in a stainless steel container and lettuce were on the same shelf in the refrigerator. The findings include: The facility policy entitled Food Receiving And Storage Issued 6/26/2018 stated food services, or other designed staff, will always maintain clean food storage areas. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). Uncooked and raw animal products and fish will be stored separately in drip proof containers and below fruits, vegetables and other ready to eat foods. On 4/8/24 at 9:57 AM, during the initial tour of the kitchen, the following was observed: - a sealed plastic bag with sausage patties undated and unlabeled in the freezer been stored on the top shelf. - a low temperature dishwasher not reaching the appropriate final rinse water temperature at 120 degrees, but has a final water rinse temperature at 110 degrees. (A low temperature dishwashing machine final rinse water temperature ranges from 120-150 degrees.) - staff stored their personal food in refrigerator 1 and refrigerator 2, the same refrigerators used for facility food storage and for the residents' meals. - the exhaust fan on the wall was soiled with dust and grease debris blowing on a rack where clean dishes were stored. - the dietary aide was not wearing a beard cover/restraint while serving the residents their meals in the dining room. - tuna fish was prepared and left in a stainless steel bowl was covered with a plastic wrap next to and on the same shelf with a container of lettuce. During an interview on 4/8/24 at 09:59 AM the Food Service Director stated the unlabeled and undated sausages patties were used within the week and were left over. The Food Service Director stated if the dish washing machine did not work, they would contact the vendor and would use disposable plates and utensils until the dish washer was repaired. During an observation on 4/8/24 at 1:05 PM the Dietary Aide was not wearing a beard cover while serving the resident's their lunch trays. At that time the Food Service Director stated the staff did not know they should be wearing a beard cover. During an observation on 4/12/24 at 11:18 AM during a follow-up of the kitchen area the Food Service Director was not wearing a beard cover. At that time the Food Service Director stated they ordered the beard covers and were waiting for them to be delivered. During an observation on 4/12/24 at 11:20 AM during a follow-up of the kitchen area, staff's personal food was noted in 2 refrigerators which were used to store residents' food. The Food Service Director stated that staff's food should be stored in the staff refrigerator. 10 NYCRR 415.14 (h)

Based on record review and interviews conducted during the Recertification and Abbreviated surveys (NY0322448, NY00308142 and NY00320376) from 4/08/24 to 4/17/24, the facility did not ensure that there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, upon review of the staffing schedule for multiple days and on all three shifts of staffing for each unit, the facility did not provide adequate staffing to meet the needs of the residents. The findings are: Review of the facility policy titled Staffing, Sufficient and Competent Nursing dated 11/2/18 documented that out facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. Review of the Facility-Wide assessment dated [DATE], and reviewed by the Quality Assurance Agency/Quality Assurance and Performance Improvement committee on 3/20/24, did not provide a staff to resident ratio for comparison and did not provide the number of staff required to work on each of the two units. Facility-Wide Assessment for Nursing Staff documented: - Certified nurse aides: minimum number needed per day was 7. - Licensed practical nurse/Registered nurse: minimum number needed per day was 4. - Total number of facility nursing staff: minimum number needed per day was 11 and the maximum number needed per day was 34. - Total number of Agency nursing staff: minimum number needed per day was 0 and the maximum number needed per day was 0. During an interview on 04/09/24 at 1:30 PM, Resident #31 stated that during the whole month of February 2024 and some of March 2024, they did not get a shower because the facility was so short staffed. Resident #31 stated that on the weekends there was sometimes only one certified nurse aide working in the whole building, residents did not get out of bed, and resident were screaming requesting assistance with cares. During an interview on 04/11/24 at 1:35 PM, the Director of Nursing stated that the nursing staffing scheduling was not being done correctly prior to 3/15/24 when the previous scheduler was employed at the facility. The Director of Nursing stated that the previous scheduler was doing the nursing staffing scheduling on a day to day basis and not on a month by month basis as it should have been done. The Director of Nursing stated the nursing staffing schedule was supposed to be printed a month in advance and the scheduler was responsible for filling in the empty slots with per diems and agency staff, and making sure the facility was staff efficiently. During an interview on 04/11/24 at 01:40 PM, Staff #1 (staffing coordinator) stated they started the staffing coordinator position on 3/18/24 and that they did not receive any documentation or old schedules and the nursing staffing scheduling book was blank. During an interview on 04/11/24 at 02:45 PM, Staff #1 (staffing coordinator) stated they could not provide a staffing plan and was unaware if one was available. During an interview on 04/11/24 at 03:18 PM, Staff #19 (Human Resource Director) stated the facility did not have a staffing plan in place as there was a staffing conflict with the previous staffing coordinator. They stated with the new staffing coordinator the facility plans to repair the staffing issues. During an interview on 04/12/24 at 11:00 AM, Staff #2 (certified nurse aide) stated at times there was only one certified nurse aide in the whole building to cover both units during the night shift. During an interview on 04/12/24 at 11:47 AM, Staff #5 (receptionist) stated: - at times the facility had only 2 certified nurse aides working. This happened on the weekends and occasionally on the weekdays when someone had time off. - sometimes there was not a registered nurse in the building. - residents had called the receptionist desk when their call lights were on and staff were not answering, and staff complained about the call lights. - residents called the receptionist desk to ask for assistant with care such as toileting. During an interview on 04/16/24 at 02:29 PM, Staff #10 (certified nurse aide) stated that they were employed by an agency and that they have been working alone since 2 PM due to another certified nurse aide going home at 2 PM. Staff #10 stated that they were always working alone and there was a huge problem with staffing in the facility. During an interview on 04/17/24 at 09:57 AM, the Director of Nursing stated that on both units the minimum nursing staffing needed on day shift was two certified nurse aides and one licensed practical nurse. The minimum staffing needed on evening shift was two certified nurse aides and one licensed practical nurse per unit, and the minimum nursing needed on night shift was one certified nurse aide and one licensed practical nurse. The Director of Nursing stated that they and the Assistant Director of Nursing were in the building Monday-Friday on the day shift and the facility tried to have one registered nurse supervisor in the building on the evening shift but was not always able. The Director of Nursing stated that they did employ agency nursing staff and was not sure why the Facility-Wide Assessment did not indicate the agency staff was a part of the staffing. 415.13(a)(1)(i-iii)

Based on record review and interview during a recertification survey conducted from 4/8/2024-4/17/2024 the facility did not ensure that they provided written notice of the facility's Bed Hold policy upon transfer to all residents or residents' representative(s) for 1 of 2 residents (Resident #54) reviewed for hospitalization . Specifically, Resident #54 and/or their representatives were not provided written notice of the bed hold upon discharge to the hospital. The findings are: The Policy and Procedure dated 11/12/2019 and titled Bed Hold documented: The facility will notify the designated representative and / or the resident of the facility's bed reservation policies, in writing, at the time of admission and at the time of transfer. Resident #54 had Diagnosis's of cerebral vascular accident, dysphagia, and seizures. The 5 Day Minimum Data Set (an assessment tool) dated 2/25/2024 documented the resident had moderately impaired cognition. The nursing progress note dated 2/17/2024 documented the family requested that the resident be sent to the hospital. The nursing progress note dated 2/23/2024 documented that the resident returned from the hospital. There was no documented evidence that Resident #54 and/or their representative was given written notice of the bed hold policy. During an interview on 4/16/24 at 1:39 PM Staff #6 (Social Worker) stated they did not send notice of bed hold to any resident unless they were private pay. During an interview on 4/16/24 at 1:43 PM the Administrator stated the facility should give residents and/or resident representatives the notice of bed hold when a resident was discharged to the hospital. 10 NYCRR 415.3(h)(4)(i)(a)

Based on observation, interview, and record review conducted during the recertification survey from 4/08/24 to 4/17/24, it was determined for 1 of 1 resident (Resident # 11) reviewed for personal property, the facility did not ensure grievances were resolved in a timely manner. Specifically, the facility lacked documentation that a thorough investigation was completed or that there was timely resolution after Resident #11's report of missing clothing. The findings are: The facility Policy and Procedure titled Investigation of Grievance/concerns reviewed 11/20/23 documented that the facility would complete a prompt, thorough investigation of all grievances. Resident #11 was admitted with diagnoses of chronic obstructive pulmonary disease, bipolar disorder, and atrial fibrillation. The Quarterly Minimum Data Set (MDS an assessment tool) dated 3/5/2024 documented the resident was cognitively intact and had continuous behaviors. The social work progress note dated 3/27/2024 documented they would look into the resident's missing clothes. There was no documented evidence that a grievance was completed during March 2024. During an interview on 04/8/2024 at 10:00 AM Resident #11 stated their clothing was missing and they told the social worker, but had not heard anything back. During an interview on 4/11/24 at 11:31 AM Staff #6 (Social Worker) stated missing clothes were documented on a missing personal and misappropriation of property form, not a grievance form. Staff #6 stated they had only 1 report of missing property for the current year and were unaware of any other missing property. When asked about Resident #11's clothing Staff #6 stated they were unaware of Resident 11's missing clothing. When the progress note from 3/27/2024 was reviewed, Staff #6 could not say why a grievance or missing property form was not completed or why when asked initially they said no missing property had been reported. During an interview on 4/11/24 at 11:45 AM the Administrator stated if the facility was not able to locate the missing property quickly, they would fill out a form to ensure an investigation was done. The Administrator stated if after an investigation they were unable to locate the property, they would replace the items or reimburse the resident . The Administrator stated an investigation should have been documented and either a missing property or a grievance form completed. 10 NYCRR 415.3(c)(1)(i)

Based on record review and interview conducted during the recertification and abbreviated survey (NY00315011) conducted from 4/08/24 to 4/17/24, the facility did not ensure that the written description of the facility policy to implement advance directives was followed for one of one residents (Resident #0) of reviewed for Advance Directives. Specifically, cardiopulmonary resuscitation was administered and the resident was not sent to the hospital as per request for Resident #0 with orders for Do Not Resuscitate and orders to send to the hospital if necessary. The finding are: The facility policy titled Advanced Directives dated 5/4/18, documented the facility will honor the wishes of the resident/representative regarding medical concern, by honoring the existing advanced directives of the resident as well as offering the resident/representative the opportunity to make changes to existing advanced directives. Resident #0 was admitted with diagnoses including acute sepsis, acute hyperkalemia, and altered mental status. The Admission Minimum Data Set, dated dated dated [DATE] documented the resident had severely impaired cognition. The care plan titled Advanced Directives dated 4/4/23, documented do not resuscitate/do not intubate. Interventions included review advanced directives, choices, and options with the resident/representative. The medical orders for life sustaining treatment (MOLST) for Resident #0 was signed by the designated representative, two witnesses, and the medical provider on 4/5/23 and documented Do Not Resuscitate and send to the hospital if necessary. The physician orders dated 4/5/23 documented Do Not Resuscitate. The social worker progress note dated 4/5/23 documented Do Not Resuscitate and Do Not Intubate. The physician progress note dated 4/6/23 documented Medical Orders for Life Sustaining Treatment, Do Not Resuscitate and Do Not Intubate. The nursing progress note dated 4/14/23 documented the resident had increased anxiety, was yelling out for help, and was frequently asking staff to stay with them because they were scared. The nursing progress note dated 4/17/23 documented the resident was unresponsive in bed in the morning, 911 was called and cardiopulmonary resuscitation was started. Resident was evaluated by registered nurse and found to be without pulse and respiration. During an interview on 04/09/24 01:30 PM, Resident #31 stated that on multiple days prior to Resident #0 expiring, they observed Resident #0 yelling out for staff and requesting to go to the hospital due to complaints of not feeling well, and that the wishes were ignored. Resident #31 stated that on 04/17/24, they observed staff in Resident #0 room resuscitating Resident #0, and that it was an traumatizing experience for them. Resident #31 stated that they asked the previous Administrator why staff did not send Resident #0 to the hospital as per their request and were told by the Administrator that Resident #0 had a Do Not Resuscitate order and therefore, staff were unable to send them to the hospital. During an interview on 04/15/24 at 01:55 PM, the Director of Nursing stated that if a resident had Do Not Resuscitate order, staff should not have perform cardiopulmonary resuscitation and that staff determined the advanced directives by the red dot on the outside of the resident room door and their bracelet . Additionally, the Director of Nursing confirmed that the Medical Orders for Life Sustaining Treatment for Resident #0 documented to send to the hospital if necessary and that Resident #0 should have been sent to the hospital if they requested. During an interview on 04/15/24 at 02:51 PM, Staff # 3 (Licensed Practical Nurse) stated if the progress note documented that they performed cardiopulmonary resuscitation on Resident #0, that was what occurred. Staff # 3 (Licensed Practical Nurse) stated that the Medical Orders for Life Sustaining Treatment document if a resident had Do Not Resuscitate instructions and that if Resident #0 had requested to go to the hospital, their wishes should have been honored. During an interview on 04/16/24 at 10:48 AM, Nurse Practitioner #1 stated that cardiopulmonary resuscitation should not have been initiated on a resident that had a Do Not Resuscitate order. Nurse Practitioner #1 stated that they were informed that the nurse had initiated cardiopulmonary resuscitation prior to the chart being reviewed, and then after the chart was reviewed, they realized that Resident #0 had a Do Not Resuscitate order. 10 NYCRR 415.3(e)(1)(ii)

Based on observation, record review and interview during a recertification survey 4/8/24-4/17/24, the facility did not ensure residents had the right to a dignified existence for 8 of 8 residents reviewed for dining (Residents #54, #40, #39, #19, #25, #49, #56 and #28). Specifically, 1)clothing protectors were applied to Resident # 54, #40, #39, #19, #25, and #49 without first obtaining the residents permission; and 2) staff were observed standing over Resident #56 and #28 while feeding the residents their lunch. Findings include: The facility policy titled Resident Rights dated 2/27/18 documented all residents will be treated with kindness, respect, and dignity. The facility policy titled Preparing Resident for Meal dated 8/30/18 documented to inquire if the resident would like to wear a clothing protector in order to prevent spills of food items from staining clothes. 1. Resident #54 had diagnoses of atrial fibrillation, cerebrovascular accident, and dysphagia (difficulty swallowing). The Minimum Data Set (assessment tool) dated 2/25/24 documented the resident had moderate cognitive impairment -Resident #40 had diagnoses of Type II Diabetes Mellitus, dementia, and hypertension. The Minimum Data Set, dated dated dated [DATE] documented the resident had severe cognitive impairment and fed themselves. -Resident #39 had diagnoses of hypertension, dementia, and Type II Diabetes Mellitus. The Minimum Data Set, dated dated dated [DATE] documented the resident had moderate cognitive impairment and fed themselves. An observation was made on 4/11/24 at 12:18 PM of Staff #14 (Certified Nurse Aide) placing a clothing protector over the head of Residents #54, #40, and #39 without asking permission. Staff #14 stated they put the clothing protectors on every resident daily. Staff #14 stated they did not ask the residents prior to placing the clothing protector because all residents get them. During an interview on 4/17/24 at 09:10 AM, Resident #54 stated they were bothered by it and would like to be told and asked before the clothing protector was applied. 2. Resident #56 had diagnoses of quadriplegia, neurogenic bladder, and alcohol abuse. The admission Minimum Data Set, dated dated dated [DATE] documented the resident was cognitively intact and was dependent on staff for eating. During an observation on 4/9/24 at 12:38 PM, Resident #56 was in their room being fed by Staff #13 (Certified Nurse Aide) and on 4/11/24 at 01:05 PM Resident #56 was in the hallway being fed by Staff #13. During both observations Staff #13 stood over Resident #56. During an interview on 4/9/24 at 12:40 PM and 4/11/24 at 1:05 PM, Staff #13 stated they were aware they should sit while feeding residents but they preferred to stand. During an interview on 4/12/24 at 9:15 AM, Resident #56 stated they would like to see the person who was feeding them, but were unable to raise their head due to a prior neck surgery and use of a neck collar. -Resident #28 has diagnoses of major depressive disorder and obstructive uropathy. The Minimum Data Set, dated dated dated [DATE] documented the resident had moderate cognitive impairment and needed assistance from staff with activities of daily living. During an observation on 4/11/24 at 01:02 PM Staff #8 (Certified Nurse Aide) was standing over Resident #28 while feeding them their lunch. During an interview on 04/11/24 01:10PM, Staff #8 stated they were standing while feeding residents because there were so many residents that required assistance. Staff #8 stated they should sit while assisting but choose to stand. During an interview on 04/17/24 at 09:24 AM, Staff #7 (Licensed Practical Nurse Unit Manager) stated the certified nurse aides had been trained to ask for permission prior to applying the clothing protectors. Staff #7 stated staff should be seated while assisting residents with their meals, but stated sometimes there were no chairs. 10 NYCRR 415.3

Based on staff interviews and record review during the recertification survey conducted from 4/8/2024-4/17/2024 the facility did not ensure that required documentation was sent to the receiving provider at the time of a hospital transfer for 1 of 2 residents (Resident #54) reviewed for hospitalization . Specifically, there was no documented evidence that a transfer summary was completed/sent when Resident #54 was transferred to the hospital. The findings are: Policy and Procedure dated 11/1/2017 titled Admission/Discharge/Transfer documented: when a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider. Resident #54 was admitted with diagnoses which include history of cerebral vascular accident, dysphagia, and seizures. The 5 Day Minimum Data Set (an assessment tool) dated 2/25/2024 documented the resident had moderately impaired cognition. The nursing progress note dated 2/17/2024 documented the family requested that the resident be transferred to the hospital. There was no documented evidence that a transfer summary was completed. There was no evidence that documentation including the contact information of the practitioner/resident representative, advance directive information, special instructions/precautions/medications, comprehensive care plan goals, and other necessary information was sent with the resident. During an interview on 4/16/24 at 11:55 AM after reviewing the electronic medical record the Assistant Director of Nursing stated that they were unable to locate the transfer to the hospital documentation. 10 NY CRR 413.3(h)(1)(ii)(a-c)