Every finding on record at Silver Lake Specialized Rehabilitation and Care Ce

Based on observation, interview, and record review, the facility failed to ensure each residents received adequate supervision to prevent accidents. This was evident for one (1) (Resident #105) of four (4) residents reviewed for accidents out of 35 total sampled residents. Specifically, on 06/04/2025, Resident #105, who had severe cognitive impairment and had a history of multiple falls, had an unwitnessed fall from a wheelchair when the resident was left in the hallway without supervision. Resident #105 sustained a head laceration and was transported to the hospital and subsequently diagnosed with a cervical fracture. This deficient practice resulted in actual harm to Resident #105 that was not Immediate Jeopardy.The findings include:The facility policy titled Accident-Incident with a reviewed date of 01/2023 documented that accidents and incidents are to be written in a clear and concise manner describing the facts, equipment, hazardous conditions, deviant behavior and/or other factors involved pertaining to a specific situation. All accidents will be reviewed within 24 hours to ensure event was not related to abuse, neglect, or mistreatment.Resident #105 had diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities), syncope (fainting or passing out) and collapse, and gait and mobility abnormalities.The Minimum Data Set (a resident assessment tool) assessment dated [DATE] documented that Resident #105 had severe cognitive impairment, required substantial/maximal assistance (staff lifts or holds trunk or limbs and provides more than half the effort) for activities of daily living including sit to stand and transfers. The facility was unable to provide documented evidence of a fall risk assessment prior to Resident #105's fall occurrence on 06/04/2025.A Comprehensive Care Plan for falls/injury was initiated on 01/25/2022 for Resident #105 related to physical performance limitations. The facility interventions dated 01/26/2022 included anticipating needs, monitoring activities of the resident, and monitoring risk factors. The care plan notes documented that Resident #105 sustained falls on 05/26/2022, 03/19/2023, 04/12/2023, 05/13/2023, 10/29/2023, and 01/26/2024. The care plan was modified to add a wheelchair tab alarm (a device used to alert caregivers when an elderly or at-risk individual attempts to leave a bed or chair) on 01/24/2024.A nursing assessment form dated 10/08/2024 documented that Resident #105 had history of falls.A care plan evaluation was documented on 10/15/2024 and there was no documented evidence that interventions were updated in response to the resident's repeated falls.The Certified Nursing Assistant Clinical Accountability and Record Assignment (contains care instructions for certified nursing assistants) dated 04/2025 indicated that Resident #1 required extensive assistance of two (2) staff for transfers. There were no fall prevention instructions except for the use of tab alarm on chair and bed.A nurse's progress note dated 06/04/2025 at 6:40 AM by Licensed Practical Nurse #5, documented that at about 5:50 AM, they were in the medication room when they heard an alarm. They ran to the hallway, observed Resident #105 on the floor, and called the nursing supervisor.A nurse's progress notes dated 06/04/2025 at 6:36 AM by Registered Nurse #11, documented that they were called to the unit at approximately 5:50 AM to assess Resident #105 who fell in the hallway. The resident was assessed with a visible laceration above the right eyebrow.A medical progress note dated 06/04/2025 at 7:52 AM by Medical Doctor #1 documented that Resident #105 had a fall in the hallway while trying to stand up from the wheelchair. The resident sustained a laceration to the right eyebrow with edema and active bleeding and was sent to the emergency room for evaluation.A nurse's progress note dated 06/04/2025 at 3:54 PM documented that Resident #105 was admitted to the hospital.The hospital information and transfer form dated 06/06/2025 documented Resident #105's primary diagnosis as fracture to the second cervical vertebra (neck bone). The hospital radiology (imaging tests to create pictures of the inside of your body) report dated 06/04/2025 documented acute fracture of odontoid process ( a bone on the spine that helps in head rotation and stability to the upper spine). The hospital recommended neurosurgery (medical specialty focusing on spinal cords) follow up in two (2) weeks.The Accident/Incident Report form dated 06/07/2025 completed by Registered Nurse #11 documented that on 06/04/2025 at about 5:50 AM, Registered Nurse #11 was notified by the floor nurse that Resident #105 fell from the wheelchair. The event was unwitnessed, and the resident was unable to state how the incident occurred. The report documented that Resident #105 was confused, had impaired judgment, unable to understand and follow instructions, and required consistent redirection. The floor nurse was in the medication room, and the certified nursing assistants were providing care to other residents.The undated facility investigative summary completed by Assistant Director of Nursing #2 documented that Resident #105 sustained an unexpected fall. The summary documented that the resident stated they leaned forward attempting to reach something on the floor. The staff were summoned by the tab alarm and found the resident on the floor bleeding.During an interview on 04/14/2026 at 12:13 PM, Certified Nursing Assistant #6, who was assigned to Resident #105 on the date and time of the incident, stated on 06/04/2025 at around 6:00 AM, they took Resident #105 out of bed to wheelchair to sit in the hallway and went to other residents' rooms to provide morning care. Certified Nursing Assistant #6 stated they responded to Resident #105's chair alarm and observed the resident lying on the floor. Certified Nursing Assistant #6 stated Resident #105 was not on any monitoring. They were not aware if Resident #105 had previous falls and were not aware of any interventions or assistance that is required for Resident #105 to prevent falls. During an interview on 04/14/2026 at 9:55 AM, Certified Nursing Assistant #7 stated they were on duty at the date and time of the incident but were not assigned to Resident #105. They stated they started providing morning care to other residents at about 4:30 AM. They stated they were inside a resident's room between 6:15 AM and 6:30 AM and were about to start morning care when they heard a loud thump and saw Resident #105 on the floor, face down and bleeding from their forehead. Certified Nursing Assistant #7 stated Resident #105 needs a lot of redirection, does not try to get up from the wheelchair but would always bend forward as if reaching for something on the floor. They stated they remember Resident #105 falling once and that the resident was not on any supervision or monitoring schedule. They stated they are not aware if Resident #105 had a wheelchair or bed alarm.During an interview on 04/14/2026 at 8:55 AM, Licensed Practical Nurse #5 stated on the date of the incident, morning care was provided to Resident #105 between 4:30 AM and 5:00 AM. The resident was then taken out of bed to wheelchair and was left sitting in the hallway. They stated they do not remember why the resident was left in the hallway. They stated they could not remember the time of the incident, but they were at the nursing station when they heard a loud thump and observed Resident #105 on the floor. They stated they did not witness the fall and that they called Registered Nurse #11 to assess the resident. Licensed Practical Nurse #5 stated the resident was not on any monitoring or supervision and this was the first time Resident #105 fell on their shift. Licensed Practical Nurse #5 stated that Resident #105 had a chair alarm and that they rely on that alarm for supervision.During an interview on 04/14/2026 at 10:51 AM, Assistant Director of Nursing #2 stated they were the one who completed the investigation for Resident #105's fall occurrence on 06/04/2025. They stated they reviewed the surveillance footage and at about 5:50 AM, they observed Resident #105 in a wheelchair in the hallway leaning forward to reach for something and fall. They stated that the staff did not witness the fall and that Licensed Practical Nurse #5 was in the hallway by the medication cart, further away from Resident #105. The Assistant Director of Nursing stated the resident sustained cervical fracture as a result of the fall.During an interview on 04/14/2026 at 3:27 PM, the Director of Nursing stated that Resident #105 sustained a cervical fracture from a fall that occurred on 06/04/2025. They stated they viewed the surveillance footage and observed Resident #105 sitting in a wheelchair at the nurses' station between 5:00 AM and 7:00 AM. The Director of Nursing stated that the resident was left by the nursing station which was a high visibility area because the resident wakes up early and climbs out of bed. They stated that the surveillance footage showed Resident #105 eating and tried to pick up something that dropped on the floor and fell forward. They stated they do not remember if there were staff in the hallway but stated there are usually two (2) certified nursing assistants and a nurse on the unit.10 New York Codes, Rules and Regulations 415.12(h)(2)

Based on observation, record review, and interviews, the facility failed to provide a clean, comfortable, and homelike environment for the residents. Specifically, housekeeping and maintenance services were not maintained in four (4) (Units 1A, 3A, 3B, and 4A) of seven (7) resident units.The findings include: The following were observed from 04/09/2026 through 04/15/2026:1. The wallpapers in room [ROOM NUMBER]-A, 103-B, and 105-B were peeling from behind the headboard.2. There was a hole on the wall behind the bed in room [ROOM NUMBER]-A.3. The light fixture in the residents' shower room on the 4th Floor Unit 4-B was hanging from the ceiling. The following were observed during the day tour of 3rd Floor Units 3-A and 3-B on 04/16/2026 at 9:30 AM and throughout the Recertification Survey: 4. The double doors separating Units 3-A and 3-B were observed with chipped paint on both sides of the doors, and black marks on the lower half of the doors on the side facing Unit 3-A. 5. The doorframe of the Unit 3-B shower room located next to the treatment room was observed with chipped yellow paint.6. The door for the Unit 3-B shower room had white marks on the black colored lower half of the door. The bedside table in the shower room had chipped black paint at the base and pink colored stains on the top.7. In room [ROOM NUMBER] on Unit 3-B, the wallpaper in the bathroom was torn and there were multiple cracks in the ceiling.8. In Rooms 333, 334, 337, and 338 on Unit 3-B, the yellow wallpaper in the entryway was torn and peeling off the wall.9. In room [ROOM NUMBER] on Unit 3-A, brown and black marks were observed on the yellow wallpaper by the bathroom door. The lower half of the bathroom door had white marks on it and areas of chipped wood.10. On Unit 3-A, the blue baseboard was observed to end part way through the hallway, leaving an exposed gap where the baseboard should have been extending on both sides of the hallway next to the dining room, and rooms 301 through 311. The Maintenance Logs were reviewed for Units 3-A and 3-B from 12/29/2025 through 04/09/2026. There was no documentation listed related to any of the above concerns. On 04/16/2026 at 9:47 AM, [NAME] #1 was interviewed and stated that they were responsible for cleaning the floors and wiping down surfaces in resident rooms and the hallways on Unit 3-B. [NAME] #1 stated that their responsibilities did not include fixing chipped paint or torn wallpaper, or cleaning marks off doors, and that the Maintenance Department was responsible for identifying and fixing those concerns throughout the facility. On 04/16/2026 at 9:50 AM, Housekeeper #1 was interviewed and stated that they are responsible for mopping and sweeping Unit 3-A's resident rooms and common areas. Housekeeper #1 stated that they do not report concerns such as missing paint to anyone and that they are only responsible for reporting and remedying housekeeping-related concerns. On 04/16/2026 at 11:00 AM, Licensed Practical Nurse #1 who is a Unit Manager on Unit 3-A was interviewed and stated that the Maintenance Department was aware of the damaged exterior of the nurse's station. Licensed Practical Nurse #1 stated that the baseboard on Unit 3-A was removed when part of the wall was being painted and that it is going to be replaced but did not know when it would be replaced. Licensed Practical Nurse #1 stated that they were not sure if the Maintenance Department was aware of the areas with chipped paint or marks on walls. On 04/16/2026 at 11:55 AM, Registered Nurse #1 was interviewed and stated that the Maintenance Department inspected Unit 3-B periodically for maintenance related concerns but was unable to confirm the frequency of the maintenance inspections. Registered Nurse #1 stated that they believed that the Maintenance Department was aware of the environmental concerns on Unit 3-B but had not personally reported any of them to the department. On 04/16/2026 at 10:55 AM, the Director of Nursing was interviewed and stated that they were not aware of the environmental concerns on Units 3-A and 3-B and that staff on the units are responsible for creating maintenance tickets when they identify problems on the unit. The maintenance tickets are then reviewed daily by the Maintenance Department. On 04/16/2026 at 12:00 PM, Maintenance Staff #1 was interviewed and stated that their responsibilities included repairing paint, broken furniture, and damaged ceiling tiles or damaged walls, in resident rooms and common areas throughout the facility. Maintenance Staff #1 stated that they were aware of the environmental concerns on Units 5 and 6 and that the facility was planning on renovating the units in the future. On 04/16/2026 at 12:19 PM, the Director of Housekeeping was interviewed and stated that they are responsible for overseeing the maintenance and housekeeping departments in the facility. The Director of Housekeeping stated that they were aware of the environmental concerns on Units 3-A and 3-B and that the facility was planning to repair them as part of their ongoing renovations. The Director of Housekeeping stated that the baseboards on Unit 3-A were being replaced but they ran out of materials and were waiting for the rest of the material to arrive before completing it. The Director of Housekeeping also stated that they were planning to replace the Unit 3-A nurse's station but was unable to confirm when it would be replaced. The Director of Housekeeping further stated that the wallpaper and paint in resident rooms were torn due to wheelchair leg rests brushing against the wall and tearing it. 10 New York Codes, Rules and Regulations 415.5(h)(2)

Based on record review and interviews, the facility failed to ensure that a comprehensive person-centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs were created and implemented for each resident. This was evident for one (1) of five (5) residents reviewed for Unnecessary Medications, and two (2) of two (2) residents reviewed for Care Planning out of 35 total sampled residents. Specifically, Resident #187, Resident #41, and Resident #92 were taking anticoagulant or antiplatelet medications that carried an increased risk of bleeding and comprehensive care plans were not implemented to address the risk of bleeding associated with the medication use.The findings include:The facility policy and procedure titled Care Plans-Comprehensive with a last reviewed date of 01/2026 documented that it is the facility's policy to develop an individualized comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs. Each resident's comprehensive care plan is designed to incorporate risk factors associated with identified problems, aid in preventing or reducing declines in resident's functional status and reflect currently recognized standards of practice for problem areas and conditions. A comprehensive care plan must be developed within seven (7) days after completion of the comprehensive assessment.1. Resident #41 had diagnoses including Heart Failure and Hypertension.The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #41 took an antiplatelet medication.The Medications Order Form dated 04/15/2026 documented that Resident #41 was prescribed Plavix 75 milligrams daily for Prophylaxis. The order was originally placed on 04/01/2026.The Medication Administration Record dated 04/2026 documented that Resident #41 received Plavix 75 milligrams once daily.There was no documented evidence of an active Comprehensive Care Plan in place to address the goals and interventions associated with Resident #41's use of the Plavix medication. 2. Resident #92 had diagnoses including Heart Failure and Coronary Artery Disease.The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #92 took an antiplatelet medication.The Medications Order Form dated 04/15/2026 documented that Resident #92 was prescribed Clopidogrel 75 milligrams once daily with the order reason documented as anticoagulant. The order was originally placed on 06/20/2025 and was last renewed on 03/28/2026.The Medication Administration Record dated 04/2026 documented that Resident #92 received Clopidogrel 75 milligrams once daily.There was no documented evidence of an active Comprehensive Care Plan in place to address the goals and interventions associated with Resident #92's use of the Clopidogrel medication. 3. Resident #187 had diagnoses including Hypertension and Hyperlipidemia.The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #187 took an anticoagulant medication.The Medications Order Form dated 04/15/2026 documented that Resident #187 was prescribed Eliquis 5 milligrams every 12 hours for Transient Cerebral Ischemic Attack. The order was originally placed on 01/18/2025 and was last renewed on 04/13/2026.The Medication Administration Record dated 04/2026 documented that Resident #187 received Eliquis 5 milligrams every 12 hours.There was no documented evidence of an active Comprehensive Care Plan in place to address the goals and interventions associated with Resident #187's use of the Eliquis medication.On 04/15/2026 at 09:17 AM, Registered Nurse #1 was interviewed and stated that they were the Registered Nurse Supervisor on Resident #41, Resident #92, and Resident #187's unit. Registered Nurse #1 stated that Resident #41 and Resident #92 took antiplatelet medications to prevent blood clots from forming, and Resident #197 took an anticoagulant medication to prevent blood clots from forming. Registered Nurse #1 stated that residents taking these medications required Anticoagulant or Antiplatelet Comprehensive Care plans. Registered Nurse #1 stated that they had recently started as a nursing supervisor on this unit and were trying to catch up on creating and updating care plans for the residents on the unit.On 04/15/2026 at 09:44 AM, the Assistant Director of Nursing #2 was interviewed and stated that care plans are initiated by the Registered Nurse Supervisors upon admission or when a care need comes up during the resident's stay. Assistant Director of Nursing #2 stated that Residents #41, #92, and #147 should have had care plans in place to address the risk of bleeding associated with the use of anticoagulant or antiplatelet medications. The Assistant Director of Nursing stated that the unit that those residents resided on had been without a Registered Nurse Supervisor for a period of time and that may have contributed to the creation of this care plans being missed.On 04/16/2026 at 10:52 AM, the Director of Nursing was interviewed and stated that residents on anticoagulant or antiplatelet medications should have care plan interventions in place to address the bleeding risk and other risks associated with the use of the medications. The Director of Nursing stated that the Nurse Manager on the unit is responsible for creating the care plan. The Director of Nursing stated they did not know why care plans to address the risk of bleeding had not been created and implemented for Residents #41, #92, and #147.10 New York Codes, Rules, Regulations 415.11(c)(1)

Based on observation, record review and interviews, the facility failed to ensure that residents' Comprehensive Care Plans were reviewed and revised by the interdisciplinary team after each assessment, and revised based on changing goals, preferences, and needs of the resident. This was evident for one (1) of four (4) residents reviewed for Respiratory Care, and one (1) of two (2) residents reviewed for Falls out of 35 total sampled residents. Specifically, 1.) Resident #91's Respiratory Care Comprehensive Care Plan was not updated after their Quarterly Minimum Data Set Assessment, and 2.) Resident #105's Falls Comprehensive Care Plan interventions were not reviewed and updated after enduring multiple falls in the facility. See F-689.The findings include: The facility's policy and procedure titled Care Plans-Comprehensive with a last reviewed date of 01/2026 documented that it is the facility's policy to develop an individualized comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs. Each resident's care plan is designed to aid in preventing or reducing declines in the resident's functional status. The plan of care is evaluated in response to a significant change in the resident's physical, communicative, psychosocial, functional, or emotional status, or at least every 90 days. 1. Resident #91 had diagnoses including Chronic Obstructive Pulmonary Disease and Non-Alzheimer's Dementia. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #91 received oxygen therapy in the facility. The Respiratory Conditions Comprehensive Care Plan established 06/19/2023 documented that Resident #91 had a goal to be free from signs and symptoms of respiratory distress for 90 days. Interventions included administering oxygen as needed, and elevating Resident #91's head of bed due to their shortness of breath when lying flat. The Respiratory Conditions Comprehensive Care Plan was documented as being last updated on 12/30/2025 and was not updated following Resident #91's quarterly assessment on 03/18/2025. On 04/14/2026 at 12:20 PM, Licensed Practical Nurse #1 who was the Unit Manager on Resident #91's unit was interviewed and stated that Resident #91 utilizes oxygen therapy. Licensed Practical Nurse #1 stated that they are responsible for updating Resident #91's Respiratory Conditions care plan on a quarterly basis and that it should have been updated by 03/20/2026 following Resident #91's quarterly Minimum Data Set assessment. Licensed Practical Nurse #1 stated that they were not sure why it had not been updated. On 04/15/2026 at 09:44 AM, Assistant Director of Nursing #2 was interviewed and stated that Nurse Supervisors are responsible for updating care plans every three months and they were not aware that Resident #91's Respiratory Conditions care plan had not been updated on a quarterly basis. On 04/16/2026 at 10:52 AM, the Director of Nursing stated that the Nurse Managers are responsible for updating care plans for residents on their unit. The Director of Nursing stated they did not know why Resident #91's Respiratory Conditions care plan had not been updated on a quarterly basis. 2. Resident #105 had diagnoses that included Dementia (loss of memory, language, problem-solving and other thinking abilities), Syncope (fainting or passing out) and Collapse, and gait and mobility abnormalities. The Minimum Data Set (a resident assessment tool) assessment dated [DATE] documented that Resident #105 had severe cognitive impairment and had a fall history and had a fracture related to the fall. A comprehensive care plan for falls/injury was initiated on 01/25/2022 for Resident #105 related to physical performance limitations. The facility interventions dated 01/26/2022 included anticipating needs, monitoring activities of the resident, and monitoring risk factors. The care plan notes documented that Resident #105 had prior falls on 05/26/2022, 03/19/2023, 04/12/2023, 05/13/2023, 10/29/2023, and 01/26/2024. The care plan interventions were not updated in response to these incidents. A nurse's progress notes dated 06/04/2025 at 6:36 AM by Registered Nurse #11 documented that they were called to the unit at approximately 5:50 AM to assess Resident #105 who fell in the hallway. The resident was assessed with a visible laceration above the right eyebrow. The comprehensive care plans documented that the resident was leaning forward and sustained a fall from the wheelchair in the hallway on 06/04/2025. There was no documented evidence that the care plan interventions were reviewed and revised following the fall incident on 06/04/2025. The Certified Nursing Assistant Clinical Accountability and Record Assignment (contains care instructions for Certified Nursing Assistants) dated 04/2025 indicated that Resident #1 required extensive assistance of 2 staff for transfers. There was no documented fall prevention instructions except for the use of tab alarm on chair and bed. On 04/14/2026 at 12:45 PM, Licensed Practical Nurse #6 was interviewed and stated that their responsibility is to make sure the care plans are updated quarterly, annually, when there is a significant change, and as needed with the supervision of the Director of Nursing and Assistant Director of Nursing. They stated that Resident #105's fall interventions need not be updated because these are the intervention being used to prevent Resident #105 from falling. On 04/14/2026 at 10:51 AM, Assistant Director of Nursing #2 was interviewed and stated that the fall care plan is updated by adding the fall incident on the problem section of the care plan. They stated that there were no new interventions added to Resident #105's care plan for falls. Assistant Director of Nursing #2 stated it is the responsibility of the Registered Nurse to update the care plan. On 04/14/2026 at 3:27 PM, the Director of Nursing was interviewed and stated that the unit managers, Licensed Practical Nurses, and Registered Nurses are responsible for updating the residents' care plans. New York Codes, Rules, Regulations 415.11(c)(2) (i-iii)

Based on observation, record review, and interviews, the facility failed to ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases. Specifically, the facility failed to provide documentation of screening, administration or declination, and education of the COVID-19 vaccination for nine (9) of ten (10) staff members reviewed for COVID-19 vaccinationsThe findings include:The facility's policy and procedure titled Immunization Recommendation for Health Care Professions with a reviewed date of 01/2026 documented that up-to-date COVID-19 vaccinations are recommended by the Centers for Disease Control but are not mandatory.During the Recertification Survey, the facility failed to provide documentation that COVID-19 vaccination was offered, education was provided, and staff had the opportunity to consent or decline the vaccine nine (9) of ten (10) staff members (Certified Nursing Assistant #3, Registered Nurse #6, Respiratory Technician #2, Dietary Technician #1, and Housekeepers #2, #3, #4, Clinic Transportation Coordinator #1, Laundry Attendant #1).On 04/13/2026 at 02:02 PM, the Infection Preventionist was interviewed and stated that the facility had provided staff with the COVID-19 vaccination during the height of the COVID-19 pandemic, but they were no longer being reimbursed for the cost, so the facility no longer offers the COVID-19 vaccination to employees. The Infection Control Preventionist stated that employees complete an Annual Employee Health Screen that advises them to speak to their doctor about getting the COVID-19 vaccination and receive an annual in-service instructing them to speak with their doctor about immunizations.On 04/16/2026 at 10:50 AM, the Director of Nursing was interviewed and stated that they were aware that the facility was required to offer the COVID-19 vaccination to employees but was unable to provide an explanation for why the facility was not doing so.10 New York Codes, Rules, Regulations 415.19

Based on observation, record review, and interviews, the facility failed to ensure there was adequate equipment to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area. This was evident for four (4) of seven (7) units. Specifically, call bell systems did not function as designed and residents were given hand bells.The findings include: The facility failed to provide a policy on Call Bell System. The Amazon final details for order#112-2688755-440201 dated 08/02/2024 documented an order for 24 pieces of steel service handbells totaling $156.72. The Amazon final details for order#113-8372255-6099453 dated 09/15/2025 documented an order for 50 pieces of loud hand bell bulk dinner service bells totaling $48.98. A Proposal Contract by Tikva Security dated 12/19/2025 documented a proposal for multiple single patient room units, emergency bathroom units, emergency bathroom shower units and utility boxes to be ordered and installed with Tektone NC120 Visual Only Nurse Call Bell System. This document was not signed. During the Resident Council meeting held on 04/14/2026 at 10:30 AM, Residents #34, #117 and #18 stated that call bells and lights on Unit 2-A were not working. The residents further stated that the facility is aware of this and nothing has been done. The issue with nonfunctioning call bell system has been ongoing for a year. Residents have been provided with hand bells and dinner bells to ring. 1. During observation on 04/14/2026, the call bells in room [ROOM NUMBER] and 221 did not activate when pressed. The call bell system in Unit 2-A nursing station did not activate and no sound was emitted. During observation on 04/15/2026 at 12:25PM, the call bells in Rooms 203, 206, 212, 216, 217, 222 and 223 were not functioning. The call bell cord in room [ROOM NUMBER] had no cord. On 04/15/2026 at 12:27 PM, Resident # 166 was interviewed and stated they have been at the facility for over a year and the call bells in their room have not been working since then. Resident #166 stated they have to yell for the nurse to come or use the dinner bell. They stated it takes a while for staff to hear and respond. On 04/15/2026, at 12:35 PM, Resident #81 was interviewed and stated that the call bells in their room have not been working since they have been in the facility for over six (6) months. Resident #81 stated that the call bell system has to be fixed urgently because the hand bells are annoying as multiple residents ring the bell at the same time. Resident #81 further stated that staff don't always hear the bell ringing. On 04/14/2026 at 11:06 AM, Registered Nurse #8, who was the unit manager in Unit 2-A stated that there has been glitches with the call bell system since the unit opened in September 2025. Registered Nurse #8 further stated that all rooms on the floor are affected and everyone including the Administrator is aware of the nonfunctioning call bell system. On 04/14/2026 at 11:14 AM, Registered Nurse #9 was interviewed and stated that they started working in Unit 2-A in December 2025. They stated there has been issues with the call bell since they started working on the unit. On 04/15/2026 at 1:01 PM, Assistant Director of Nursing #1 was interviewed and stated that Unit 2-A reopened sometime in November or December last year after renovation at which time the call bells were not working. 2. During observation on 04/15/2026 at 11:30 AM in Unit 1-A, the call bell lights above residents' Shower A and B did not light up when the call bell was pressed. On 04/15/2026 at 11:00 AM in Unit 4-B, the emergency call bell system in the resident shower room did not light up or make a sound when pulled. The call light in room [ROOM NUMBER] was activated when the call bell was pressed but there was no sound. 3. On 04/15/2026 at 12:15 PM, the call bell in Resident #92's room (room [ROOM NUMBER]) was observed to be non-functioning. On 04/16/2026 at 09:38 AM, call bells were observed to be non-functioning in multiple resident rooms, two (2) shower rooms, and a shared resident bathroom on Unit 3-B, where the call bell did not make an audible sound or visible light when pressed. On 04/15/2026 at 12:16 PM, Resident #92 was interviewed and stated that their call bell did not work and that they used their personal cell phone to call the nurse's station when they needed assistance. On 04/16/2026 at 10:24 AM, Registered Nurse #1 who is the unit nursing supervisor, was interviewed and stated that all of the call bells in Unit 6, including all resident rooms and common areas, were non-functioning and had not worked in six (6) months. Registered Nurse #1 stated that the call bell system had overheated and was taken offline by the Maintenance Department. Registered Nurse #1 stated that residents were provided with manual bells once the electronic call monitoring system was taken offline. 4. On 04/15/2026 at 2:06 PM, the call bell system for Unit 4-B on the 4th floor was tested. The light outside the resident's rooms was on when call bell was activated. The light on the keyboard of call bell system at the nursing station was not on for Rooms 442, 445C, 445D, and 447 when call bell was activated. The call device system at the nursing station had no alert sound when the call device was activated in every room. The call bell system in every bathroom was checked and not functioning. On 04/16/2026 at 2:25 PM, Licensed Practical Nurse #3 was interviewed and stated they were the unit manager for the floor. Licensed Practical Nurse #3 also stated that the unit had issues with the call bell system since they were assigned in that unit. They stated they notified the Maintenance Department multiple times of the issue and the problem was not resolved. Licensed Practical Nurse #3 stated they were able to see the light outside the residents' rooms was on when a resident activated the call device. Licensed Practical Nurse #3 also stated all residents were provided with a handbell to use when they needed care. On 04/16/2026 at 11:30 AM, the Director of Housekeeping was interviewed and stated that the call bell system is not working on multiple units for some time and that the Administrator was aware. On 04/16/2026 at 11:18 AM, the Director of Nursing was interviewed and stated that the call bell system on multiple units are not working and that the residents had brought up this issue during resident council meetings. They stated that hand bells were given to the residents in place of the call bell. The Director of Nursing stated they do not have policy related to the call bell system. On 04/15/2026 at 1:12 PM, the Administrator was interviewed and stated that there was a short circuit on the B side of the building which triggered the call bell issue. They stated that the call bells were installed in the 1970's and that some parts of the call bell system are obsolete. They stated that an estimate was received for a new call bell system for the entire building and they are waiting to be able to afford the installation due to the facility's financial crisis. The Administrator stated that the facility does not get properly reimbursed by Medicaid and because of that priority was given to address staffing needs, medications, and wound care. The Administrator stated that they had to choose the lesser of emergencies and prioritize patient care while the call bell system was something that could wait. The Administrator stated that they are hoping to resolve the call bell system that in the next couple of weeks, but it was not the most important issue at the moment. 10 New York Codes, Rules and Regulations 415.29

Based on observation, record review, and interviews, the facility failed to ensure that a resident was cared for in a manner that maintained or enhanced dignity. This was evident for one (1) (Resident #140) of two (2) residents reviewed for Urinary Catheter out of 35 total sampled residents. Specifically, Resident #140's urinary catheter tubing was exposed on multiple observations.The findings include:The facility policy titled Urinary Catheter Care with a last revised date of 01/2026 documented that the catheter/drainage tubing must be kept covered at all times (urinary flow and tubing should not be seen). Residents with urinary catheters will be checked every shift by the unit managers and nursing supervisors to ensure dignity bag is present and the catheter drainage is well covered.Resident #140 has an active diagnoses of Non-Alzheimer's Dementia, Osteoporosis, and Hypertension.The quarterly Minimum Data Set (a resident assessment tool) dated 03/10/2026 documented that Resident #140 had severely impaired cognition, always incontinent of urine, and required substantial assistance for lower body dressing and dependent with toileting hygiene.A physician's order with a last renewed date of 04/13/2026 documented included an order for urinary catheter care every shift.A care plan for urinary incontinence and indwelling catheter was last updated on 03/12/2026. The facility interventions included keeping the catheter drainage tubing covered all times and to keep drainage bag in drainage bag covered at all times.During multiple observations on 04/09/2026 at 11:58 AM, 04/10/2026 at 10:29 AM, and on 04/13/2026 at 11:27 AM, Resident #140 was observed in the main dining room with the urinary catheter tubing exposed with visible light yellow urine noted in the tubing.On 04/13/2026 at 11:31 AM, Licensed Practical Nurse #1 was interviewed and stated they had not noticed Resident #140's urinary catheter tubing was exposed. They stated that leg bags are applied to residents with urinary catheter or a blanket is used so that the urinary catheter tube is not visible. On 04/13/2026 at 11:34 AM, Registered Nurse #7 was interviewed and stated they had not noticed that Resident #140's urinary catheter tubing was exposed. They stated that urinary drainage leg bag must be used for residents with urinary catheter so that the tubing is not exposed.On 04/15/2026 at 1:02 PM, Assistant Director of Nursing #2 was interviewed and stated that exposed urinary catheter tubing is a dignity and infection control issue. They stated that residents with urinary catheters usually have the tubing secured to the resident's leg or covered with a blanket. They stated the nursing supervisor is responsible for making rounds to ensure that residents with urinary catheters maintain their privacy.On 04/16/2026 at 11:13 AM, the Director of Nursing was interviewed and stated that leg bags as well as blankets must be used to cover any exposed urinary catheter tubing. They stated that urinary catheter tubing must be concealed in order to maintain respect and dignity of residents.10 New York Codes, Rules and Regulations 415.3(d)(1)(i)

Based on observation, record review, and interviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation result in serious bodily injury, to the State Survey Agency. This was evident for one (1) (Residents #105) of four (4) residents reviewed for accidents out of 35 total sampled residents. Specifically, Resident #105 had an unwitnessed fall on 06/04/2025 when they were observed on the floor with a laceration to the right eyebrow. The resident was transferred to the hospital and was diagnosed with a cervical fracture. Resident #105 was cognitively impaired and was unable to explain how the injury was sustained. This incident was not reported to the New York State Department of Health. See F-689. The findings include:The facility policy titled Abuse Investigations with a reviewed date of 01/2023 documented that all reports of injury of unknown source shall be promptly and thoroughly investigated by the facility management. The policy did not include protocols for reporting injuries of unknown source to the State Survey Agency.Resident #105 had diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities), syncope (fainting or passing out) and collapse, and gait and mobility abnormalities.The Minimum Data Set (a resident assessment tool) assessment dated [DATE] documented that Resident #105 had severe cognitive impairment.A nurse's progress note dated 06/04/2025 at 6:40 AM by Licensed Practical Nurse #5, documented that at about 5:50 AM, they were in the medication room when they heard an alarm. They ran to the hallway, observed Resident #105 on the floor, and called the nursing supervisor.A nurse's progress notes dated 06/04/2025 at 6:36 AM by Registered Nurse #11, documented that they were called to the unit at approximately 5:50 AM to assess Resident #105 who fell in the hallway. The resident was assessed with a visible laceration above the right eyebrow.The hospital information and transfer form dated 06/06/2025 documented Resident #105's primary diagnosis as fracture to the second cervical vertebra (neck bone). The hospital radiology (imaging tests to create pictures of the inside of your body) report dated 06/04/2025 documented acute fracture of odontoid process (a bone on the spine that helps in head rotation and stability to the upper spine). The hospital recommended neurosurgery (medical specialty focusing on spinal cords) follow up in two (2) weeks.The Accident/Incident Report form dated 06/07/2025 completed by Registered Nurse #11 documented that on 06/04/2025 at about 5:50 AM, Registered Nurse #11 was notified by the floor nurse that Resident #105 fell from the wheelchair. The event was unwitnessed, and the resident was unable to state how the incident occurred. The report documented instructions and was confused, had impaired judgment, unable to understand and follow instructions, and required consistent redirection. The floor nurse was in the medication room, and the certified nursing assistants were providing care to other residents.There was no documented evidence that the facility reported Resident #105's unwitnessed fall incident, resulting in major injury, to the New York State Department of Health.On 04/14/2026 at 10:51 AM, Assistant Director of Nursing #2 was interviewed and stated they completed the investigation for Resident #105's fall occurrence on 06/04/2025. They stated that the fall was unwitnessed and that the resident sustained a cervical fracture. Assistant Director of Nursing #2 stated they were not sure if this incident was reported to the New York State Department of Health and was not sure of the facility's policy on reporting incidents.On 04/16/2026 at 10:47 AM, the Director of Nursing was interviewed and stated that the regulation does not state that they have to report a major injury of unknown origin.10 New York Codes, Rules and Regulations 415.4(b)(2)

Based on observation, record review, and interviews, the facility failed to provide an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. This was evident for one (1) of two (2) residents (Resident #43) reviewed for Activities out of 35 total sampled residents. Specifically, Resident #43 was not provided with television stations in their preferred language. The findings include:The facility's policy titled Recreation Department dated 03/2026 documented the Recreation Department shall provide a comprehensive, individualized program of recreational, social, cognitive, sensory, spiritual, and leisure activities designated to meet the assessed needs, interests, and preference of each resident in the long-term care facility.The facility Direct Television Lineup documented the facility provided two (2) Spanish and sixty-one (61) English television channels. Resident #43 had diagnoses of Dysphagia, Anxiety Disorder, and Other nontraumatic intracerebral hemorrhage.On 04/09/2026 at 10:19 AM, Resident #43's representative was interviewed and stated Resident #43 has been in the facility for about three (3) years. The representative also stated the facility never asked them for Resident #43's activity preference. The representative further stated Resident #43 only liked to watch Mandarin television programs when back in community. The representative stated Resident #43 was non-verbal and was able to hear.From 04/09/2026 at 10:13 AM to 04/15/2026 at 12:27 PM, there were multiple observations of Resident #43 sitting in their wheelchair in their room or dining room with no ongoing activities and the television was in English channel.The Annual Minimum Data Set, dated [DATE] documented Resident #43's preferred language was Mandarin and wanted an interpreter to communicate with health care staff. It also documented that it was very important to listen to music and important to do favorite activities as per representative. It further documented that only the representative participated in the assessment.The comprehensive care plan related to Activities initiated 03/03/2023 and was last updated 01/27/2026 documented one (1) of the goals was for Resident #43 to participate in programs of choice daily.The Therapeutic Recreation assessment dated [DATE] documented that Resident #43 spoke Mandarin. and that their activity preference included music, television, and room visits.There was no documented evidence Resident #43's preference to watch television in a language they understand was established.On 04/14/2026 at 12:06 PM, Certified Nursing Assistant #2 was interviewed and stated Resident #43 was alert and responsive, non-verbal, and able to hear. The Certified Nursing Assistant #2 also stated the television was on and in English channel already when they started their shift. The Certified Nursing Assistant #2 further stated they did not change the television channel for Resident #43. The Certified Nursing Assistant #2 stated they did not know what language the television channels provided at the facility. The Certified Nursing Assistant #2 also stated Resident #43 stayed in their room most of time and the activities Resident #43 had been mainly family visit and watching television in English channel.On 04/15/2026 at 10:49 AM, Recreation Assistant #1 was interviewed and stated they completed the recreation assessment for Resident #43. They stated Resident #43 spoke Mandarin and did not understand English or Spanish. Recreation Assistant #1 further stated the facility only provided television channels in Spanish and English but no other languages. Recreation Assistant #1 stated they had no way to meet the activity preference for residents who preferred to watch television channels in other languages.On 04/15/2026 at 10:31 AM, the Recreation Director was interviewed and stated the television channels at the facility only offered English and Spanish channels. They stated they have tablets for residents to watch video channels in their preferred language if needed. The Recreation Director further stated the residents were able to have the tablet for a short time when the recreation staff were on the unit. The Recreation Director had no explanation for how the facility was able to meet residents' needs for their preferred activities of watching television in their preferred language at the time they wanted.New York Codes, Rules and Regulations 415.5(f)(1)

Based on observation, record review, and interviews, the facility failed to ensure each resident received treatment and care in accordance with professional standards of practice. This was evident for one (1) (Resident #191) of one (1) resident reviewed for change in condition. Specifically, Resident #191 who had a documented allergy to Vancomycin was prescribed and administered Vancomycin for the treatment of pneumonia placing the risk at risk for an adverse allergic reaction.See F-755.The findings include:The facility's policy titled Medication Administration dated 12/2023 documented that medications shall be administered in a safe and timely manner, and as prescribed by the physician. The policy also documented that medication nurses must check and verify medication allergies prior to administering medications. Resident #191 had diagnoses that included Heart Failure, Seizure Disorder, Respiratory Failure, and Ventilator Dependence.On 04/09/26 at 11:33 AM, Resident #191 was observed in bed. The resident was on a ventilator and had a red allergy bracelet alert on the left wrist .The Quarterly Minimum Data Set (a resident assessment tool) dated 02/03/2026 documented that Resident #191 was severely cognitively impaired, dependent on ventilator, and was dependent on performing activities of daily living. A comprehensive care plan for medication allergy was initiated for Resident #191 on 04/09/2024. The care plan documented that the resident had allergy to mucomyst. The care plan was updated on 05/09/2025 to document an allergy to Vancomycin. The facility interventions included monitoring any allergic reaction and use of red charm bracelet for allergy alert.A physician's order dated 05/09/2025 documented that Resident #191 had allergy to Vancomycin.A physician's order dated 06/30/2025 included an order for Vancomycin 1 gram via intravenous piggyback every 12 hours for 10 days for cocci in cluster (types of bacteria that are grouped together). The Medication Administration Record documented that Registered Nurse #1 administered the ordered Vancomycin on 06/30/2025 at 9:00 AM. A progress note by Respiratory Therapist #1 dated 06/30/2025 at 1:55 PM documented that Resident #191 had scattered rhonchi (course rattling lung sounds usually caused by secretions), wheezing, and had an oxygen saturation of 96%. The resident was suctioned with large amount of thick yellowish secretions, albuterol was administered. Solumedrol (a medication used to treat certain allergies) was also administered.A nurse's progress note by Licensed Practical Nurse #2 dated 06/30/2025 at 3:33 PM documented that Resident #191's family member was made aware of antibiotic allergy and of the resident's increased work of breathing from this morning and expressed understanding of Solumedrol. The physician assistant was made aware and discontinued the order for Vancomycin.A medication error report dated 06/30/2025 documented that Licensed Practical Nurse #2 discovered that Resident #191 was administered Vancomycin to which the resident was allergic to. Resident #191 had increased work of breathing and was wheezing. Solumedrol was given with good effect. The reason for the medication error was failure to check the resident's allergy.On 04/14/2026 at 12:56 PM, an interview was conducted with Registered Nurse #1 who administered Vancomycin to Resident #191. They stated they do not recall the incident. They stated that resident with known allergies wear an allergy bracelet and that nurses must check first if a resident has allergies to the medication before administration.On 04/13/26 at 11:43 AM, an interview was conducted with License Practical Nurse #2 who stated that on the day of the incident, they observed Resident #191 in bed at around 10:30 AM with increased breathing that was higher than their baseline and had swollen face and lips. They stated they noticed that the resident was receiving intravenous Vancomycin at that time, and they quickly informed the physician that this resident was allergic to Vancomycin. Licensed practical Nure #2 stated the physician ordered to stop the infusion and to administer Solumedrol. They stated that the resident was not transferred to the hospital and that they closely monitored the resident who did not have any further complication after administering Solumedrol.On 04/13/2026 at 11:59 AM, an interview was conducted with Respiratory Therapist #1 who stated that they noted Resident #191 was wheezing and that the ventilator peak pressure (pressure reached in a resident's airway during the inspiratory phase of mechanical ventilation) was at 50 centimeters water (cm H2O) which was higher than their baseline of 30. Respiratory Therapist #1 stated that they were not aware that the resident received Vancomycin to which they were allergic to and that the resident's condition at that time was not something very unusual, especially for resident on ventilator and with all their medical conditions. On 04/15/2026 at 11:47 AM, an interview was conducted with Medical Doctor #1, who prescribed Vancomycin for Resident #191. They stated that they could not recall the incident. They stated that this could have been prevented if someone, from either the nursing home or the pharmacy, realized that Resident #191 was allergic to Vancomycin.On 04/15/2026 at 11:33 AM, an interview was conducted with Assistant Director of Nursing #1, who was also the Infection Preventionist, who stated that Resident #191 received Vancomycin despite being allergic to it. They stated that License Practical Nurse #2 observed Resident 191 with swollen face and lips and was wheezing; the physician was made aware and ordered to administer Solumedrol. Assistant Director of Nursing #1 stated that Resident #191 did not have any further complication after that. They stated that residents with known allergies wear allergy alert bracelets to serve as a warning and that the allergy is also documented on the resident's profile in the electronic medical record.10 New York Codes, Rules and Regulations 415.12

Based on observation, record review, and interviews, the facility failed to ensure that a resident who required respiratory care received such care, consistent with professional standards of practice and the comprehensive person-centered care plan. This was evident for one (1) of four (4) residents reviewed for Respiratory Care out of 35 total sampled residents. Specifically, Resident #91, who had a physician's order to change the oxygen tubing every three (3) days, was observed on multiple occasions between 04/09/2026 and 04/14/2026 receiving oxygen through a nasal cannula that was dated 03/27/2026. The findings include:The facility's policy and procedure titled Oxygen Tubing Change with a reviewed date of 01/2026 documented that the set-up and operation of oxygen is the responsibility of the nurse on the floor. It is the responsibility of the 11:00 PM to 7:00 AM shift nurse to change the oxygen tubing every 48 hours or more frequently if needed. New oxygen tubing should have tape applied to it that is dated and initialed. When new oxygen tubing is applied, the date and nurse's initials are documented on tape applied to the tubing.On 04/09/2026 at 10:13 AM, Resident #91 was observed in the 3rd floor day room receiving oxygen via nasal cannula connected to a portable oxygen tank. The nasal cannula was labeled with a piece of tape dated 03/27/2026.On 04/10/2026 at 12:00 PM, Resident #91 was observed in their room receiving oxygen via an undated nasal cannula. Outside of their room, a geriatric chair labeled with Resident #91's name was observed with a portable oxygen tank attached to the back of it. A nasal cannula labeled with a piece of tape dated 03/27/2026 was observed hanging off of the tank without any protective covering, with the exposed nasal prongs hanging inches away from the floor.On 04/14/2026 at 10:37 AM, Resident #91 was observed on the outdoor patio receiving oxygen via nasal cannula attached to a portable oxygen tank. The nasal cannula was labeled with a piece of tape dated 03/27/2026.Resident #91 had diagnoses including Chronic Obstructive Pulmonary Disease and Non-Alzheimer's Dementia.The Quarterly Minimum Data Set, dated [DATE] documented that Resident #91 experienced shortness of breath while lying flat and received oxygen therapy in the facility.The comprehensive care plan for respiratory conditions was initiated for Resident #91 on 06/19/2025. The facility interventions included administering oxygen as ordered by the physician and changing the oxygen tubing every three (3) days.The Treatment Order Form dated 04/15/2026 documented that Resident #91 was prescribed oxygen at a rate of two (2) liters per minute via nasal cannula every shift. The order was originally placed on 06/29/2023 and was last renewed on 04/01/2026.The physician's order as of 04/02/2026 documented that Resident #91 had a treatment order to change their oxygen tubing every 72 hours.The Treatment Administration Record dated 04/2026 documented that Resident #91's oxygen tubing had been changed on 04/03/2026, 04/06/2026, 04/09/2026, and 04/12/2026. On 04/14/2026 at 12:20 PM, Licensed Practical Nurse #1, who is a Unit Manager on Resident #91's unit, accompanied the surveyor to Resident #91's room where Resident #91 was observed receiving oxygen via a nasal cannula attached to a portable oxygen tank. The nasal cannula was labeled with a piece of tape dated 03/27/2026. Licensed Practical Nurse #1 was interviewed and stated that Resident #91's oxygen tubing was ordered to be changed every three (3) days by the evening shift nurse for infection control purposes. Licensed Practical Nurse #1 stated that Resident #91's nasal cannula tubing should have been replaced since 03/27/2026 and that they did not know nurses had signed off in the electronic medical record that the tubing had been changed on multiple dates since 03/27/2026 while the resident continued to use tubing dated 03/27/2027.On 04/15/2026 at 9:44 AM, Assistant Director of Nursing #2 was interviewed and stated that the facility's policy is for oxygen tubing to be changed every 48 hours by the unit nurse. They stated that Resident #91 should not have been observed receiving oxygen via nasal cannula dated 03/27/2026.On 04/15/2026 at 09:54 AM, the Assistant Director of Nursing #1 was interviewed and stated that the unit nurse is responsible for changing and dating resident's oxygen tubing every 48 hours. Assistant Director of Nursing #1 stated that Resident #91 uses a separate oxygen tubing for their portable oxygen tank while out of bed, and an oxygen concentrator while in bed. They stated that the tubing should be stored in a plastic bag between uses. Assistant Director of Nursing #1 stated they did not know why Resident #91 was still using the tubing that was dated 03/27/2026 after the 48-hour period.On 04/16/2026 at 10:52 AM, the Director of Nursing was interviewed and stated that oxygen tubing should be changed every 48 hours by the nurse on the unit and that they did not know why this policy was not followed for Resident #91's oxygen therapy care.10 New York Codes, Rules and Regulations 415.12(k)(6)

Based on observation, record review, and interviews, the facility failed to ensure that medications were dispensed in a safe manner and in accordance with professional standards of practice. This was evident for one (1) (Resident #191) of one (1) resident reviewed for change in condition. Specifically, the facility failed to ensure that the pharmacy identified and acted upon Resident #191's documented drug allergy to Vancomycin prior to dispensing, resulting in the delivery and administration of Vancomycin to Resident #191 with a known allergy to the medication.See F-684.The findings include:The facility failed to provide a policy related to pharmacy services.Resident #191 had diagnoses that included Heart Failure, Seizure Disorder, Respiratory Failure, and Ventilator Dependence. The Quarterly Minimum Data Set (a resident assessment tool) dated 02/03/2026 documented that Resident #191 was severely cognitively impaired, dependent on ventilator, and was dependent on performing activities of daily living. A comprehensive care plan for medication allergy was initiated for Resident #191 on 04/09/2024. The care plan documented that the resident had allergy to mucomyst. The care plan was updated on 05/09/2025 to document an allergy to Vancomycin. The facility interventions included monitoring any allergic reaction and use of red charm bracelet for allergy alert.A physician's order dated 05/09/2025 documented that Resident #191 had allergy to Vancomycin.A physician's order dated 06/30/2025 included an order for Vancomycin 1 gram via intravenous piggyback every 12 hours for 10 days for cocci in cluster (types of bacteria that are grouped together). The Medication Administration Record documented that Registered Nurse #1 administered the ordered Vancomycin on 06/30/2025 at 9:00 AM.A medication error report dated 06/30/2025 documented that Licensed Practical Nurse #2 discovered that Resident #191 was administered Vancomycin to which the resident was allergic to. Resident #191 had increased work of breathing and was wheezing. Solumedrol was given with good effect. The reason for the medication error was failure to check the resident's allergy.On 04/13/26 at 11:43 AM, an interview was conducted with License Practical Nurse #2 who stated that on the day of the incident, they observed Resident #191 in bed at around 10:30 AM with increased breathing that was higher than their baseline and had swollen face and lips. They stated they noticed that the resident was receiving intravenous Vancomycin at that time, and they quickly informed the physician that this resident was allergic to Vancomycin. Licensed practical Nure #2 stated the physician ordered to stop the infusion and to administer Solumedrol. They stated that the resident was not transferred to the hospital and that they closely monitored the resident who did not have any further complication after administering Solumedrol.On 04/15/2026 at 11:47 AM, an interview was conducted with Medical Doctor #1, who prescribed Vancomycin for Resident #191. They stated that they could not recall the incident. They stated that this could have been prevented if someone, from either the nursing home or the pharmacy, realized that Resident #191 was allergic to Vancomycin.On 04/14/2026 at 11:58 AM, an interview was conducted with Registered Pharmacist #1, the Pharmacy General Manager, who stated that Resident #191's medical profile dated 05/09/2025 showed that Resident #191 was allergic to Vancomycin, but the pharmacy system did not prevent them from dispensing the medication. They stated this was a system error in both the nursing home and the pharmacy that should have been prevented. They stated that the Vancomycin allergy was listed on the electronic physician order that was received by the pharmacy, abut since it was a new allergy for Resident #191, it was not updated in the dispensing system, and was not flagged when they were filling the prescription.On 04/15/2026 at 11:33 AM, an interview was conducted with Assistant Director of Nursing #1, who was also the Infection Preventionist, who stated that Resident #191 received Vancomycin despite being allergic to it. 10 New York Codes, Rules and Regulations 415.18(a)

Based on observation, record review and interviews conducted during an abbreviated survey (2691440). the facility failed to ensure that a resident was free from abuse. This was evident for one (1) of seven (7) residents (Resident #1) sampled for abuse. Specifically, on 12/11/2025 at 5:23:43 PM the facility's surveillance camera footage shows Certified Nursing Assistant #1 approach Resident #1 in the dayroom and pulled the dayroom table away from Resident #1's wheelchair. At 5:23:56 PM, Certified Nursing Assistant #1 was observed hitting Resident #1 on the back of their head with an open hand and Resident #1's head falls forward. At 5:24 PM, Certified Nursing Assistant #1 pushed Resident #1's wheelchair to the dayroom exit door and stop. At 5.24.12 PM, at the dayroom exit door Certified Nursing Assistant #1 was observed taking items out of Resident #1's wheelchair when Resident #1 throw a cup of liquid on Certified Nursing Assistant #1. Certified Nursing Assistant #1 then hit Resident #1 on their upper arm two times with a white paper plate. The findings are:The facility's Policy and Procedure on the Abuse Prevention Program dated 01/2023, documented residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Any case in which abuse, neglect, mistreatment, exploitation or misappropriation of resident's property has been identified via the investigation or abuse cannot be ruled out will be reported promptly to the New York State Department of Health for further investigation.Resident #1 was admitted to the facility with diagnoses of dementia, restlessness and agitation, major depressing disorder, and obsessive-compulsive disorder. The Minimum Data Set (a resident assessment tool) dated 09/25/2025, documented that Resident #1's cognition was moderately impaired.A review of the Comprehensive care plan for abuse prevention dated 07/16/2025, documented interventions to intervene as necessary to ensure safety of residents, remove resident from area of the aggressor. Nursing Home Facility Incident Report dated 12/11/2025 documented while reviewing the camera footage of another incident in the unit dayroom, Certified Nursing Assistant #1 was seen tapping Resident #1 on the head on 12/11/2025 at 5:23 PM. Certified Nursing Assistant #1 was taking Resident #1 out of the dayroom after dinner when Resident #1 began calling Certified Nursing Assistant #1 rude, offensive and vulgar names repeatedly. Certified Nursing Assistant #1 was immediately removed from the unit and replaced with another staff member. Resident #1 was evaluated for injury and no injury noted and did not feel fearful. Facility investigation conclusion documented there was cause to believe abuse had occurred. Nursing progress note dated 12/11/2025 at 8:35 PM, written by the Director of Nursing documented when reviewing the camera footage on 12/11/2025 at 5.45 PM, they observed Certified Nursing Assistant #1 tapping Resident #1 in the back of their head. Resident #1 was assessed immediately with no visible injury. Resident #1 denied having any pain or discomfort. Emotional support and referred to psychiatry and psychology for assessments.A documented titled 'CNA Clinical Accountability Record and Assignment' dated 10/1/25, 11/1/25, and 12/1/25 documented instructions to approach/speak to resident calmly.During an interview on 12/16/2025 at 10:04 AM, Resident #1 stated Certified Nursing Assistant #1 did not tapped their head, Certified Nursing Assistant #1 slapped them on their head, and it hurt. Resident #1 stated they did not tell anyone about their headache. Resident #1 stated Certified Nursing Assistant #1 pulled their wheelchair out of the dayroom and took them to their room. Resident #1 stated Certified Nursing Assistant #1 is the only staff member who ever hit them. During an interview of five (5) residents (Resident #2, #3, #4, #5, #6) assigned to Certified Nursing Assistant #1, they all stated they have no issues with Certified Nursing Assistant #1 or any other staff. No one abused them and they have never witnessed any staff abusing residents. During an interview on 12/16/2025 at 11:21 AM, Certified Nursing Assistant #1 stated the incident happen shortly after supper at approximately 5:45 PM to 5:50 PM. Certified Nursing Assistant #1 stated there was a verbal altercation between Resident #1 and Resident #2. Certified Nursing Assistant #1 stated Resident #1 accused Resident #2 of eating with their hand and called Resident #2 derogatory words. Certified Nursing Assistant #1 stated Resident #2 started getting restless and they did not want any physical altercation between both residents, so they move Resident #1 away from Resident #2. Certified Nursing Assistant #1 stated that Resident #1 started cursing at them using derogatory words (such as black bitch and to go back to their country). Certified Nursing Assistant #1 they raised their hand and slap Resident #1 in their head. Certified Nursing Assistant #1 stated they took Resident #1 to their room after the incident. Certified Nursing Assistant #1 stated they have never done this before, and they know that what they did was wrong. Certified Nursing Assistant #1 stated they have been working at the facility for three and half years and received in-service on abuse prevention.During an interview on 12/16/2025 at 2:59 PM, Director of Nursing stated on 12/11/2025 at 5:45 PM, while reviewing the surveillance camera footage of another incident they observed Certified Nursing Assistant #1 was seen tapping Resident #1 in the back of their head. The Director of Nursing stated that they immediately remove Certified Nursing Assistant #1 from the unit and evaluated Resident #1 for any injury. The Director of Nursing stated they were no visible injury noted. Director of Nursing stated Resident #1 was not fearful of staff members. Director of Nursing stated them, and the Director of Social Service interviewed Resident #1 and Resident #1 was unable to recall having any incidents with staff, however, they recalled an incident with another resident. Staff members provided emotional support to Resident #1. The Director of Nursing stated Resident #1 was referred to psychiatry and psychology for assessments but has not been seen yet.During an interview on 12/17/2025 at 11:11 AM, the Director of Social Service stated while the Director of Nursing was reviewing the camera for a previous verbal dispute with Resident #1 and another Resident #2, they observed Certified Nursing Assistant #1 hitting Resident #1. The Director of Social Service stated that them and Director of Nursing immediately went to the unit and removed Certified Nursing Assistant #1 off the unit. The Director of Social Service stated that they viewed the camera footage and Certified Nursing Assistant #1 confirmed that they hit Resident #1 because Resident #1 was calling them and using derogatory words to them. The Director of Social Service stated that Certified Nursing Assistant #1 was immediately suspended. The Director of Social Service stated that they interviewed Resident #1 and Resident #1 did not remember the staff member who hit them. The Director of Social Service stated Resident #1 could only recall the incident with the other resident. The Director of Social Service stated that they offered emotional support and visited Resident #1 daily. The Director of Social Service stated that Resident #1 reported not being fearful. During an interview on 12/17/2025 at 2:00 PM, the Administrator stated they watch the video in the dayroom. The Administrator stated they reported the incident to Department of Health, but they never reported the incident to local law enforcement. The Administrator stated they observed Certified Nursing Assistant #1 tapping Resident #1 on their head, but they did not think it was reported incident for law enforcement. 10 NYCRR 415.4(b)(1)(i)

Based on interview and record review conducted during an abbreviated survey (2691440), the facility did not ensure that an alleged violation involving abuse, neglect, mistreatment, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involved abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials including to the State Agency and adult protective services where state law provides for judications in long term care facilities) . This was evident for one (1) out of seven (7) residents (Resident #1) sampled for abuse. Specifically, on 12/11/2025 at 5:23:43 PM the surveillance camera footage shows Certified Nursing Assistant #1 approach Resident #1 in the dayroom and pulled the dayroom table away from Resident #1's wheelchair. At 5:23:56 PM, Certified Nursing Assistant #1 was observed hitting Resident #1 on the back of their head with an open hand and Resident #1's head falls forward. At 5.24.12 PM at the dayroom exit door Certified Nursing Assistant #1 was observed taking items out of Resident #1's wheelchair when Resident #1 throw a cup of liquid on Certified Nursing Assistant #1. Certified Nursing Assistant #1 went on to hit Resident #1 on their upper arm two times with a white paper plate. The facility did not report the alleged incident to local law enforcement. The findings include:The facility's policy and procedure titled Abuse Investigation dated 01/2023 document that all reports of resident abuse, neglect, mistreatment, sexual abuse, willful, exploitation, misappropriation of resident's property, adverse event, person center care, resident representative, and injury of unknown source shall be promptly and thoroughly investigated by the facility management. It also documented the facility will report any incident and/or violation where abuse, neglect, mistreatment neglect, sexual abuse, willful, exploitation, misappropriation of resident's property, adverse event, person centered care or resident representative is suspected to the New York State Department of Health according to protocol. Additionally, Federal law (1150B of the Social Security Act)' requires that any individual employee having reasonable suspicion that a crime has occurred against a resident is required to report the suspicion to Law Enforcement and the State Agency. It the crime involves serious bodily injury it must be reported immediately, but no later than 2 hours after forming the suspicion or if the crime does not appear to cause serious bodily injury you must report it within 24 hours of forming the suspicion. Resident #1 was admitted to the facility with diagnoses of dementia, restlessness and agitation, major depressing disorder and obsessive-compulsive disorder. Minimum Data Set (a resident assessment tool) dated 09/25/2025, documented that Resident #1's cognition was moderately impaired.Nursing Home Facility Incident Report dated 12/11/2025 documented while reviewing the camera footage of another incident in the unit dayroom, Certified Nursing Assistant #1 was seen tapping Resident #1 on the head on 12/11/2025 at 5:23 PM. Certified Nursing Assistant #1 was taking Resident #1 out of the dayroom after dinner when Resident #1 began calling Certified Nursing Assistant #1 rude, offensive and vulgar names repeatedly. Certified Nursing Assistant #1 was immediately removed from the unit and replaced with another staff member. Resident #1 was evaluated for injury and no injury noted and did not feel fearful. Facility investigation conclusion documented there is cause to believe abuse has occurred. During an interview on 12/16/2025 at 2:59 PM, Director of Nursing stated on 12/11/2025 at 5:45 PM while reviewing the surveillance camera footage of another incident they observed Certified Nursing Assistant #1 was seen tapping Resident #1 in the back of their head. Director of Nursing stated that they immediately remove Certified Nursing Assistant #1 from the unit. Evaluated Resident #1 for any injury. Director of Nursing stated they were no visible injury noted. Director of Nursing stated the Administrator is the one who is responsible for reported the incident to the different agency. During an interview on 12/17/2025 at 2:00 PM, the Administrator stated they were informed by Director of Nursing of the alleged incident and watch the video in the dayroom. The Administrator stated they reported the incident to Department of Health, but they never reported the incident to local law enforcement. Administrator stated they observed Certified Nursing Assistant #1 tapping Resident #1 on their head, but they did not think they should have reported the incident to local law enforcement. 10 NYCRR 482.12(c)

Based on observations, record review, and interviews conducted during the recertification survey from 12/6/2023 to 12/13/2023, the facility did not ensure infection control practices were maintained. This was evident for 1 (Resident #238) of 2 residents reviewed for urinary catheter out of 39 total sampled residents and the Main Dining Room (MDR). Specifically, 1) the Foley catheter (FC) tubing for Resident #238 was touching the floor, and 2) hand hygiene was not performed for multiple residents eating lunch in the MDR. The findings are: The facility policy titled Catheter Care, Urinary dated 01/2023 documented FC tubing and drainage bag are kept off the floor. The facility policy titled Hand Hygiene- Hand Sanitizer dated 1/2022 documented use hand hygiene to prevent the spread of infection. 1) Resident #238 had diagnoses of myocardial infarction and heart failure. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #238 was moderately cognitively impaired. On 12/11/23 at 08:11 AM, 11:02 AM, and 12:16 PM, Resident #238 was observed in bed with their FC drainage bag exposed and visible from the hallway. The FC tubing connecting Resident #238 to the drainage bag was on the floor. The Comprehensive Care Plan (CCP) related to indwelling catheter dated 11/30/2023 documented Resident #238's FC required monitoring. Physician's Order dated 11/30/2023 documented Resident #238 received FC care every shift. On 12/11/2023 at 12:16 PM, an interview was conducted with the Certified Nursing Assistant (CNA) #1 who stated Resident #238 was provided with FC care every shift. FC tubing should not be on the floor. CNA #1 had no explanation for Resident #238's FC tubing being on the floor. On 12/11/2023 at 12:24 PM, an interview was conducted with Licensed Practical Nurse (LPN) #2 who stated they perform frequent rounds on the unit and FC tubing should not be on the floor. LPN #2 attended to other residents on the unit this morning and did not observe Resident #238 and their FC drainage bag. On 12/13/2023 at 12:20 PM, an interview was conducted with the Director of Nursing (DON) who stated Resident #238's FC tubing should not have been on the floor. 41709 2) On 12/06/2023 at 11:16 AM, observation of the MDR was conducted while residents and staff prepared for lunch service. Residents did not perform hand hygiene prior to Dietary Aide (DA) #3 serving juice, tea, coffee, and water. Resident #102 entered the MDR and was seated at a table without being offered hand hygiene. Resident #27 was in a wheelchair with bibs in their lap and was going to each table to hand out bibs to the residents. Resident #27 was observed licking their left hand before picking up each bib in their lap and then handing it to residents. A staff member placed Resident #238 at a table and did not off hand hygiene. Resident #11 entered the MDR, sat down at a table, and was offered juice without being offered hand hygiene. There were 7 tables of residents who were served beverages prior to hand hygiene being offered. Resident #102 was seated at one of the tables and was interviewed during the observation. Resident #102 stated they ate in the MDR every day and has never been offered hand wipes or other forms of hand hygiene before meal service. On 12/06/2023 at 11:41 AM, an interview was conducted with Certified Nursing Assistant (CNA) #5 who stated they were assigned to assist with meal service in the MDR and was on break prior to coming to the MDR. When CNA #5 came back from break and entered the MDR, they saw that lunch service had already begun. CNA #5 saw that residents had already been served beverages, did not see that hand wipes were given to residents, and began offering hand wipes to residents. Serving should not begin until residents' hands were clean. Resident #27 was not assigned to give out the bibs but wants to be helpful and decided to give out the bibs teach residents. On 12/06/2023 at 12:07 PM, an interview conducted with Dietary Aide (DA) #3 who stated they were responsible for serving the beverages during lunch service. CNAs were responsible for cleaning residents' hands. DA #3 was not responsible for hand hygiene and did not know if staff provided resident with hand hygiene before DA #3 began serving the beverages. DA #3 was just told by the nurse that residents must have clean hands before the beverages are served. On 12/06/2023 at 11:43 AM, an interview was conducted with Registered Nurse (RN) #6 who stated residents' hands should be cleaned before beverages are served in the MDR. The nursing staff communicated with the dietary staff to ensure residents' hands were cleaned prior to serving. RN #6 explained to the dietary staff that residents' hands needed to be wiped before the start of lunch service. On 12/12/2023 at 01:18 PM, an interview was conducted with the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) who stated residents entering the MDR for meals can use the hand wipes or hand sanitizer located on the wall. Nursing staff were responsible for ensuring residents had clean hands prior to meal service. The CNA assigned to the MDR was supposed to give residents a hand wipe as they enter the MDR. Resident #27 wanted to feel useful by handing out bibs to residents. The ADON/ICP will teach Resident #27 how to properly handout bibs without licking their hand in between. The ADON/ICP stated they did not make rounds to observe meal service on 12/6/2023. 10 NYCRR 415.19(a)(1-3)

Based on observation, record review, and interviews conducted during the recertification survey from 12/06/2023 to 12/13/2023, the facility did not ensure a clean, comfortable, and homelike environment was maintained. This was evident for 4 of 4 resident floors (Floors 1, 2, 3, 4) reviewed for Environment. Specifically, 1) the 1st Floor had stained walls and curtains, missing and mismatched paint, missing baseboards, torn wallpaper, , and a dirty air conditioning (AC) unit, 2) the 2nd Floor had tables with mismatched and missing paint and rust, 3) the 3rd Floor had missing baseboards, mismatched and missing paint, and chipped and missing veneer on shelves , and 4) the 4th Floor had tables with mismatched and missing paint. The findings are: The facility policy titled Preventative Maintenance for Residents Rooms dated 1/2023 documented the Maintenance workers conducted one audit per floor each workday and completed the maintenance inspection checklist for that room. From 12/06/23 10:47 AM to 12/12/2023 at 10:39 AM, the following were observed on the 1st Floor: - room [ROOM NUMBER] had a sink with a missing right handle and 2 cracked tiles along the bottom edge. - room [ROOM NUMBER] had an AC unit covered in black debris along the top and inside the grates. - room [ROOM NUMBER] had a missing portion of baseboard on the right side of the room, brown water stain on the window drapes, peeling and brown stained paint on the walls, an outlet cover not detached from the wall, stained window blinds, and a wall outlet exposed with a taped sign Do Not Use above it that was not easily visible. - room [ROOM NUMBER] had multiple unpainted drywall patches, chips, and dents in a column by the room door, and ripped wallpaper in the bathroom that exposed mesh in the ceiling. - room [ROOM NUMBER] had torn wallpaper and discolored ceiling tiles. - room [ROOM NUMBER] had unpainted sections of dry wall. - The pantry had several unpainted patches along the wall and missing veneer under the sink. 2) On 12/13/2023 at 12:17 PM, the 2nd floor dining room was observed with a rusty overbed table and 7 tables with mismatched and missing black and brown paint. 3) From 12/08/2023 at 02:39 PM to 12/13/2023 at 12:05 PM, the following was observed on the 3rd Floor: - the hallway by room [ROOM NUMBER], 321, 317, 318, and 301 had missing baseboards and mismatched unpainted areas throughout the hallway. - the pantry sink and microwave area had cracked and missing veneer on the shelves. The ceiling light had no cover with wires and light bulb exposed. - the floor dining room had 5 tables with missing and mismatched paint. 4) On 12/12/2023 at 11:07 AM and 12/13/2023 at 2:00 PM, the following was observed on the 4th Floor: - room [ROOM NUMBER] had an overbed table with mismatched paint. - room [ROOM NUMBER] had a bedside table with mismatched and missing paint. - room [ROOM NUMBER] had a bedside table with mismatched and missing paint. During an interview on 12/13/23 at 12:23 PM, CNA #9 stated that they have not noticed paint on table before. During an interview on 12/13/23 at 12:25 PM, CNA #6 stated that from time to time see and missing paint and tables old and a pleasant environment is important if was at home clean and safe environment and resident enjoy self if messy don't want to eat and e 2 years, 1 year painted day room walls done and pictures and nothing done with tables. During an interview on 12/13/23 at 12:34 PM, RN #6 did not notice missing paint would have reported it. They would notify their supervisor and make and entry in the maintenance book. During an interview on 12/13/2023 at 01:51 PM, the Maintenance Assistant (MA) stated repair requests were written in a logbook. The MA did not notice the condition of room [ROOM NUMBER]. MA stated room [ROOM NUMBER]'s door was closed, and they did not know what the vents looked like. The MA was unsure when the tables in the dining rooms were painted. The MA stated the tables did not look good. The MA was not able to address the overbed and bedside tables because they were busy doing other things. 10 NYCRR 415.12(h)(1)(2)

Based on observations, record review, and interviews conducted during the Recertification survey from [DATE] to [DATE], the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was evident during review of the kitchen. Specifically, 1) a 5-pound container of expired cottage cheese was in the kitchen refrigerator, 2) the 3rd floor pantry contained expired honey-thickened juices, and 3) the 4th floor pantry had an expired quart of milk. The findings are: The facility policy titled Food, Supply Storage and Receiving dated ,d+[DATE] documented all foods were labeled to ensure proper stock rotation and fresh food for the residents. During the initial observation of the kitchen refrigerator on [DATE] at 09:30 AM, one container of 5-pound low fat cottage cheese with a use-by date of [DATE]. The 3rd floor pantry was observed on [DATE] at 02:47 PM and contained 15 containers of 4-ounce honey-thickened apple juice with use-by dates of ,d+[DATE], ,d+[DATE], and ,d+[DATE], 2 containers of honey-thickened cranberry juice with use-by dates of [DATE] and [DATE]. On [DATE] at 04:03PM, the 4th floor pantry refrigerator contained a quart container of whole milk with a use-by date of [DATE]. On [DATE] at 10:15 AM, Dietary Aide (DA) #1 was interviewed and stated they stocked the kitchen refrigerator twice weekly upon delivery. DA #1 looks at expiration dates and writes the delivery date in the items. Older food items were placed in front of newer items to be used first. DA #1 informed their supervisor within a few months of items' use-by dates. DA #1 stated they did not notice the expired cottage cheese in the kitchen refrigerator. On [DATE] at 03:14 PM, Certified Nursing Assistant (CNA) #9 was interviewed and stated that there were 5 residents on the 3rd floor that drank honey-thickened liquids. CNA #9 checked the dates on the thickened beverages in the pantry every 3 days to ensure they were discarded by their expiration date. The morning shift checked this pantry refrigerator and CNA #9 did not check this refrigerator as part of the evening shift routine. CNA #9 did not have an explanation for the expired honey thickened liquids in the pantry refrigerator. On [DATE] at 03:34 PM, Licensed Practical Nurse (LPN) #4 was interviewed and stated 11PM to 7AM shift was responsible for clearing out the pantry refrigerators of expired items. LPN #4 did not have time to check the pantry refrigerators. On [DATE] at 03:47 PM, the Registered Dietitian (RD) was interviewed and stated nursing and dietary staff should work together. The Dietary Department brought food items to the unit and Nursing staff should discard the expired items. Nursing staff were responsible for pantry refrigerators. The RD did not check these refrigerators. The Food Service Director (FSD) was also responsible for checking for expired food and beverages. On [DATE] at 09:55 AM and [DATE] at 04:21 PM, the FSD was interviewed and stated they conduct daily rounds to check for and dispose of expired foods. The FSD did not notice the cottage cheese was expired. The FSD stated they periodically check the pantry refrigerators. Other staff were also responsible for checking the pantry refrigerators. 10 NYCRR 415.14(h)

Based on observations, record review, and interviews conducted during the Recertification survey from 12/6/2023 to 12/13/2023, the facility did not ensure the resident's right to participate in the development and implementation of their person-centered plan of care. This was evident for 1 (Resident #121) of 39 total sampled residents. Specifically, Resident #121 was not invited to attend their scheduled Comprehensive Care Plan (CCP) meetings. The findings are: The facility policy titled Interdisciplinary Care Plan Conference dated 01/2023 documented residents and health care agents/family members were invited to participate in admission, annual, significant change, and discharge meetings. All quarterly meetings were held with the interdisciplinary team members. Resident #121 had diagnoses of anemia and paraplegia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #121 was cognitively intact. On 12/06/2023 at 11:32 AM, Resident #121 was interviewed and stated they were not invited to their CCP meetings since their admission to the facility. There was no documented evidence Resident #121 was invited to or attended their scheduled CCP meetings. On 12/12/2023 at 12:13 PM, an interview was conducted with the Director of Social Worker (DSW) who stated residents were invited to annual, significant change, admission, and discharge CCP meetings. Residents were not invited to quarterly CCP meetings. On 12/12/2023 at 01:11 PM, an interview was conducted with the Assistant Director of Nursing (ADON) and stated the social workers were responsible for inviting residents to the CCP meetings. The ADON did not know that residents were not invited to all the scheduled meetings. On 12/13/2023 at 12:25 PM, the Director of Nursing (DON) was interviewed and stated residents were not invited to the quarterly CCP meetings and these were only held with the interdisciplinary team members. The DON stated they did not know residents should be invited to all the CCP meetings. 10 NYCRR 415.11(c)(2)(i-iii)

Based on observation, record review, and interview conducted during the recertification survey from 12/6/2023 to 12/13/2023, the facility did not ensure that the Minimum Data Set 3.0 (MDS) assessment accurately reflected a resident's status. This was evident for 1 (Resident #68) of 39 total sampled residents. Specifically, the MDS assessment for Resident #68 did not accurately reflect the resident's use of a physical restraint. The findings are: Resident #68 had diagnoses of diabetes mellitus and non-Alzheimer's dementia. The MDS assessment dated [DATE] documented Resident #68 was severely cognitively impaired and did not document the resident used restraints. On 12/06/2023 at 11:54 AM and 12/13/2023 at 12:41 PM, Resident #68 was observed wearing bilateral hand mittens. The Physicians Order dated 7/21/2023 documented Resident #68 used bilateral hand mittens to prevent them from pulling at tubes. The Certified Nursing Assistant (CNA) Accountability Record from 7/2023 to 12/2023 documented Resident #68 used bilateral hand mittens. The Comprehensive Care Plan (CCP) related to restraints initiated 7/25/2023 documented bilateral hand mittens were used with Resident #68. There was no documented evidence Resident #68's use of hand mittens accurately assessed on the 11/30/2023 MDS assessment. During an interview on 12/13/2023 at 01:02 PM, CNA #10 stated Resident #68 uses the bilateral hand mittens to prevent them from pulling at their Gastrostomy and trach tubes. During an interview on 12/13/2023 at 01:37 PM, the MDS Assessor stated Resident #68 was ordered to use hand mittens as needed and did not use physical restraints. Hand mittens were documented as a restraint in the MDS. Resident #68 did not use hand mittens at the time the MDS Assessor filled out their MDS assessment for 11/30/2023. The MDS Assessor stated it was an oversight that they did not capture Resident #68's use of hand mittens on the MDS. 10 NYCRR 415.11(b)

Based on observation, record review, and interviews conducted during the Recertification Survey from 12/06/2023 to 12/13/2023, the facility did not ensure that resident was cared for in a manner that maintained their dignity. This was evident for 1 (Resident #238) of 2 residents reviewed for Urinary Catheter out of 39 total sampled residents. Specifically, Resident #238 had a Foley catheter (FC) bag that was exposed and in public view. The findings are: The facility policy titled Catheter Care, Urinary dated 01/2023 documented the FC collection bag is kept inside a dignity bag cover at all times, except while providing care, to maintain resident dignity. Resident #238 had diagnoses of myocardial infarction and heart failure. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #238 was moderately cognitively impaired. On 12/11/23 at 08:11 AM, 11:02 AM, and 12:16 PM, Resident #238 was observed in bed with their FC drainage bag exposed and visible from the hallway. The FC tubing connecting Resident #238 to the drainage bag was on the floor. Resident #238's drainage bag was not contained in a dignity bag. The Comprehensive Care Plan (CCP) related to indwelling catheter dated 11/30/2023 documented Resident #238's FC required monitoring. Physician's Order dated 11/30/2023 documented Resident #238 received FC care every shift. On 12/11/2023 at 12:16 PM, an interview was conducted with the Certified Nursing Assistant (CNA) #1 who stated Resident #238 was given FC care every shift and all residents with FCs should have a dignity bag to cover their FC drainage bag. CNA #1 was unable to provide a reason that Resident #238's FC drainage bag was not in a dignity bag. On 12/11/2023 at 12:24 PM, an interview was conducted with Licensed Practical Nurse (LPN) #2 who stated they perform frequent rounds on the unit and FC drainage bags should be contained in dignity bags. LPN #2 attended to other residents on the unit this morning and did not observe Resident #238 and their FC drainage bag. On 12/12/2023 at 01:16 PM, an interview was conducted with the Assistant Director of Nursing (ADON)/Infection Control Preventionist (ICP) who stated staff were aware FC drainage bags should always be kept in a dignity bag. The supervisors on the units were responsible for monitoring the staff to ensure they were doing the right thing when giving care to residents. 10 NYCRR 415.5

Based on observation, record review and staff interview, the facility failed to ensure that the resident received the necessary care and services to attain and maintain the highest practicable physical well-being. Specifically, 1) A resident was not assessed for pain prior to the start of wound care to a stage 4 pressure ulcer, or during wound care when resident exhibited signs of pain. The unit LPN (Licensed Practical Nurse) utilized a pulling and tugging motion while attempting to remove the gauze that had adhered to the wound bed, resulting in pain to the resident. When the resident exhibited facial grimacing, facial redness and retraction of his buttocks and right leg, the LPN did not stop the wound care to re-evaluate the resident's comfort, and continued to pull on the gauze causing the resident continued pain. This was evident for 1 of 2 residents reviewed for Pressure Ulcers. (Resident # 291) This resulted in actual harm that is not Immediate Jeopardy. The findings are: Resident # 291 was admitted to facility on 2/19/16 with [DIAGNOSES REDACTED]. The Admission MDS (Minimum Data Set) dated 2/29/16 documented: hearing and vision impaired, cognition severely impaired, total assistance for ADL's, always continent of urine, always incontinent of bowel, vent dependent, [MEDICAL CONDITIONS], no pain, at risk for pressure ulcer-one stage 2 pressure ulcer with the most severe tissue -granulation tissue. The resident was observed on 6/03/2016 at 10:41 AM lying on back, with his eyes open, face, lips and nail beds pink. Trachea to vent with respirations even, unlabored and chest expansion symmetrical. On 6/06/2016 at 8:00 AM, a wound care observation of the residents stage 4 sacral pressure ulcer, and unstageable pressure ulcer to the right hip was conducted, and the following observed: The unit LPN (Licensed Practical Nurse), assisted by two CNA's (Certified Nurse Assistants) for positioning, removed the visibly soiled dressing to the right hip. The inner aspect of the dressing and border gauze were saturated with a moderate amount of gray exudate, there was a granulating wound border and black necrotic tissue which covered approximately ninety percent of the wound bed. The LPN then proceeded to cleanse the wound with normal saline, apply Santyl ointment and a dry protective dressing. Wound care was then provided to the residents stage 4 sacral pressure ulcer. The outer border gauze was visibly soiled with exudates which the LPN removed, exposing a large, round sacral wound. A granulated wound border was observed and the wound bed was beefy red. There was a wad of gauze saturated with sero-sanguinous exudate in the center of the wound. When the LPN attempted to remove the gauze, it was noted to be adhered to the wound. The LPN began to pull and tug on the gauze in an effort to dislodge it from the wound bed. When the LPN began to use force by pulling on the gauze, the resident was observed retracting his right buttock, hip and right leg. His face became flushed and facial grimacing was evident. In addition, the LPN did not utilize normal saline to moisten the gauze. The SA (State Agency) then interceded to prevent further discomfort to the resident. An observation of the residents [MEDICATION NAME] was conducted on 6/06/2016 at 8:44 AM. When the LPN pulled on the residents gown that was tucked behind his shoulders, to facilitate visualization of the patch, the resident retracted his shoulder and exhibited facial flushing. The [MEDICATION NAME] was intact to the right upper arm, was covered by a clear dressing, dated and initialed. When the nurse readjusted his gown, the resident's agitation diminished. The Nursing Admission assessment dated [DATE] documented: Clinical Status-Ventilator dependent, Pain-site-sacrum-suspected. Source-exacerbation (with) movement. Medication: [MEDICATION NAME] Patch. The assessment further documented: skin status- impaired- sacral stage 4-8.5 x 6.3 x 1.5 and unstageable right hip-4.2 x 4.5 (centimeters). At risk for pain, pressure ulcers, communication deficit and functional deterioration, total dependence for ADL (Activities of Daily Living) self-performance. The readmission (Medical) history and physical examination [REDACTED]. At risk for breakdown. The examination further documented decubitus ulcer measurements: Stage 4-sacrum- 8.5 x 6.3 x 1.5 (centimeters) and Unstageable right hip- 4.2 x 4.5. The Comprehensive Care Plans (CCP) dated 3/12/16 documented: Self care deficit-evidenced by total dependence in bed mobility, transfer, dressing, eating r/t (related to) cognitive deficit. Intervention: two person assistance in bed mobility. The CCP dated 5/14/16 documented: Discomfort/pain all or part of the time related to: pressure areas. Goal: Be pain free. Interventions: Administer medications as ordered, Evaluate effectiveness of pain medication, Identify factors which increase pain, reposition. The care plan Outcome Evaluation dated 5/14/16 documented: [MEDICATION NAME] 25 microgram patch to chest wall every 72 hours secondary to pain & (and) decubiti. Discontinue [MEDICATION NAME] 25 mcg. [MEDICATION NAME] 50 mcg to chest wall every 3 days. Hospital Information and Transfer Form dated 5/13/16 documented: Additional Pertinent Information-[MEDICATION NAME] 1 tab every 6 hours for pain. Physician order [REDACTED]. Tylenol 325 mg=2 tablets) (Gr x) (Grains ten) (gastrostomy) every 6 hours as needed for pain or temp greater than 100.5. Santyl to sacrum daily after normal saline wash & Dry Protective Dressing (Revised 5/25/16-Removal and disposal of patch w/2 nurses signature required-check integrity of patch & placement on going and off going each shift) RT (Right) Hip-cleanse with normal saline and apply Santyl daily c DPD [MEDICATION NAME] 25 mcg to chest wall every 72 hours (revised 5/25/16) Interim physician's orders [REDACTED]. discontinue [MEDICATION NAME] 25 mcg/hr. [MEDICATION NAME] 50 mcg/hr to cw q 3 days-start tomorrow Physician's (monthly) Orders dated 5/25/16 documented: [MEDICATION NAME] (Tylenol) 325 mg tablet-2 tabs via PEG (Percutaneous Endoscopic Gastrostomy) tube every 6 hours as needed for pain or temp > 100.5. Max (Maximum dose 3 GM/24 hrs) The Medication Administration Records dated 5/25/16 to 6/3/16 were reviewed. There was no documented evidence that the resident was pre-medicated with Tylenol for pain prior to wound care that was provided to the stage 4 sacral pressure ulcer or unstageable pressure ulcer to the right hip from 5/25/16 to 6/6/16. There was also no documented evidence that Tylenol was administered prior to the provision of wound care on 6/6/16. The Wound Care Specialist Initial Evaluation dated 5/25/16 documented: Patient has a wound on their sacrum--Presents with an unstageable (due to necrosis) of the sacrum of at least 1 days duration-there is light serous exudates. Unstageable Necrosis- Wound size- 5 x 8 x 1.5 cm (centimeter) (depth) Surface area- 400.00 cm2 (centimeters squared)- Thick adherent devitalized necrotic tissue: 60 %-Granulation tissue: 40 % Unstageable Necrosis of Right Hip-Wound size 4 x 4 x Not Measurable cm. Surface area: 16.00 cm2- Exudate: Light Serous-Thick adherent devitalized necrotic tissue: 100 %. Dressing: Santyl-Once Daily, Dry Protective Dressin-Once Daily The Integrated Progress Notes dated 6/6/16 at 10:00 AM documented: Nursing: During dsg (dressing) change increased muscle retraction noted, awake and responsive to tactile and painful stimuli. Currently on [MEDICATION NAME] 50 mcg/hr q 72 hr. Spoke to (name of medical doctor) T/O (telephone order) obtained to increase [MEDICATION NAME] to 100 mcg/hr q 72 hr-1st (first) dose today and [MEDICATION NAME] 5/325 mg 1 tab via peg every 8 hrs as needed, family made aware of medication adjustment. Will monitor for effectiveness. Physician order [REDACTED]. Increase [MEDICATION NAME] to 100 mcg/hr may use existing supply- (Two- 50 mcg/hr patch) [MEDICATION NAME] 5/325 mg- 1 tablet via peg q 8 hr/prn. An interview was conducted with the LPN (who performed the wound care) on 6/06/2016 8:55 AM. The LPN stated that she has been employed at facility for twenty-six years and had been provided inservice training regularly by the Inservice Coordinator related to a variety of mandatory facility topics. She was unable to recall the last inservice that she received on wound care. The LPN further stated that if gauze adheres to the wound, she was taught to moisten the gauze with normal saline to prevent the disruption of new tissue growth and to minimize patient discomfort and added that she was nervous and had forgotten to do so. The RN/NM (Registered Nurse/Nurse Manager) was interviewed on 6/06/2016 at 9:02 AM. The RN stated that the residents Physician was notified about the expression of pain during the wound care observation and ordered to increase the [MEDICATION NAME] Patch to 50 mcg as well as [MEDICATION NAME] to address breakthrough pain. The RN further stated that she was responsible for conducting pain assessments every three months which includes direct observation of the resident for facial grimacing and other non verbal signs of pain during wound and routine care. The last pain assessment that was conducted was 5/20/16 which documented no pain. The RN further stated that she wasn't aware that the resident required medication for breakthrough pain and thought the increase of [MEDICATION NAME] to 50 mcg was adequate. The assigned CNA (Certified Nurse Assistant) (present during the wound care observation) was interviewed on 6/06/2016 9:20 AM. The CNA stated that the resident requires total care and is turned and positioned every two hours from left to right with pillow supports applied between his legs for comfort and to prevent the development of additional pressure ulcers. The CNA further stated that during the wound care observation today (6/6/16), she observed the resident's face turning red and that he displayed the same behaviors previously, when the nurses provided wound care. He gets red in the face and jerks away indicating that he must be in pain. The CNA also stated that she did not mention or discuss the residents responses to the nurses because they saw the same thing that I saw, so I figured that they took care of his pain. The RN/Inservice Director was interviewed on 6/06/2016 at 12:26 PM. The Director stated that she conducts classroom wound care inservice training every six months and direct wound care observations are conducted once per year with the assistance of the QA (Quality Assurance) nurse who is an LPN. The Director further stated that the nurses are taught to premedicate the resident thirty minutes before wound care to enhance patient comfort during the procedure. In addition, the nurses are taught that if the gauze sticks to the wound, they are instructed to use normal saline to loosen the gauze so that it is moist and more easily removed to prevent pain and removal of healthy tissue. The Director of Nursing (DNS) was interviewed on 6/06/2016 at 12:41 PM. The DNS stated that the facility policy is that the nurses are responsible for assessing the resident for pain prior to starting wound care, to ensure that the resident is covered for potential pain. This includes ensuring that they are pre-medicated and assessing for nonverbal signs of pain for residents who are unable to verbally communicate their discomfort, as well as an assessment afterwards related to tolerance of the procedure. If the nurse observes that gauze has become stuck to the wound, they are taught to moisten the gauze with saline before trying to remove it to prevent damage to the tissue and prevent any pain to the resident. We will re-inservice them about wound care techniques, pain assessment and appropriate interventions for residents with pressure ulcers. The attending Physician was interviewed on 6/06/2016 at 1:07 PM. The Physician stated that his usual practice is to order [MEDICATION NAME] one tablet thirty minutes before wound care to ensure resident comfort. He further stated that he was not aware that the resident was experiencing breakthrough pain during wound care which the [MEDICATION NAME] may not have been adequate to relieve. Now that the [MEDICATION NAME] has been ordered, the nurses can give it before the wound care so he will be comfortable and won't be retracting and exhibiting other signs of pain. The Physician further stated that he had not directly observed the nurses performing wound or routine care. The facility Policy and Procedure for Dressing Changes for Ulcers and Wounds dated 2/2011 documented: Responsibility of the Licensed Nurses: checks physician's orders [REDACTED].>medicate resident for pain as per MD (Medical Doctor) order, if applicable. Documentation: How the resident tolerated the procedure, any complaints (e.g. pain or discomfort) made by the resident related to the procedure. 415.12

Based on staff interviews and record review during an abbreviated survey, the facility did not ensure that a resident received the necessary care and services required to maintain the highest practicable well-being. This was evident for 1 of 4 sampled residents (Resident #1). Specifically, Resident #1, who was at risk for falls, was placed in a recliner by staff, which was not part of the care plan. The recliner had no chair alarm attached. Subsequently, the resident fell out of the recliner and sustained a subarachnoid hemorrhage and vertebral fracture. This resulted in actual harm that is not Immediate Jeopardy. Complaint # NY 701 The findings include: Resident #1 was an [AGE] year-old male who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 dated 11/20/2014 documented that the resident ' s cognitive skills for daily decision making were severely impaired. The resident scored 5 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS documented that the resident required an extensive assist with two-person physical assist for walking in room and transfers and total assist with one-person physical assist for locomotion. The Fall Risk assessment dated [DATE] documented that the resident was assessed as low risk for falls. The Nursing Plan of Care (NPOC) dated 9/26/2014 documented that the resident was at risk for falls related to unsteady gait. The NPOC documented that the interventions to prevent falls included proper footwear, assistance for transfers, clutter-free environment, good lighting, and call bell use. The Accident/Incident (A/I) Summary dated 10/21/2014 documented that the staff found the resident sitting on the floor next to the bed. The resident had no visible injury. The resident was issued a bed alarm. The A/I Summary dated 10/26/2014 documented that the staff responded to the alarm and found the resident lying in between the bed and wheelchair. The resident had no visible injuries. The resident was issued a floor mat. The review of the resident ' s Fall Risk Assessments and progress notes had no documented evidence that the resident ' s fall risk was reassessed after the fall incidents on 10/21/2014 and 10/26/2014. The updated NPOC documented that on 10/21/2014 the resident was provided with a bed and chair alarm. On 10/26/2014 the resident was provided with floor mats. The Certified Nursing Aide (CNA) Assignment Sheet documented that the following fall preventive interventions were implemented: bed and chair alarm on 10/21/2014 and floor mats on 10/24/2014. The Bed/Chair Alarms Tabs Monitor Accountability forms from October 2014 to December 2014 revealed no documented evidence that the staff checked Resident #1 ' s bed and chair alarm for placement or functionality from 10/21/2014 to 12/14/2014. The Bed/Chair Alarms Tabs Monitor Accountability forms revealed that Resident #1 was not included on the list of residents placed on chair and bed alarms. The Physician of Physical Therapy (PT)' s progress note dated 12/6/2014 documented that the resident ambulated with unsteady gait and that the resident used a wheelchair and a rolling walker for locomotion. The resident ' s medical record from 9/23/2014 to 12/14/2014 had no documented evidence that a recliner was recommended or ordered for Resident #1. The Accident/Incident Report dated 12/14/2014 documented that at 8:15AM the resident fell from the recliner in the day room. The resident sustained [REDACTED]. The MD ordered to transfer the resident to the emergency room (ER) for possible sutures. The ER record dated 12/14/2014 documented that the resident was diagnosed with [REDACTED]. The hospital treatment record dated 12/14/2014 documented that the [MEDICAL CONDITION] required 14 sutures. The facility ' s Investigation Summary dated 12/15/2014 documented that the resident was placed in the recliner for comfort. The 11PM-7AM CNAs left the resident next to the bed attached to the TABS bed alarm, as the recliner did not have an alarm. The 7AM-3PM CNA transported the resident in the recliner to the day room. The 7AM-3PM CNA stated that the resident was not attached to any alarm at this time. In the day room, the resident fell to the floor from the recliner face down on his right side. The facility concluded that two CNAs failed to report to the nurse that the resident needed an alarm on the recliner chair. The facility ' s Policy and Procedure (undated) on Alarm Device documented that the alarm/safety devices will be documented on the care plan and ADL (Activities of Daily Living) sheet and that issues with alarms must be reported immediately to the charge nurse/supervisor. The Policy documented that the CNAs must check the alarms every shift and sign the accountability sheet. On 2/6/2015 at 12:01PM an interview was conducted with the Registered Nurse Supervisor (RNS). The RNS stated that the CNAs were aware that the resident required using a bed and chair alarm as evident on the CNA Assignment Sheet. The RNS further stated that it was an oversight on the part of the supervisor that the name of the resident was not included on the ADL sheet of the residents on bed/chair alarm prior to the time the resident fell and sustained injuries. On 2/6/2015 at 1:00PM an interview was conducted with CNA #1, who was assigned to the resident during the 7AM-3PM shift on 12/14/2014. CNA #1 stated that he was aware that the resident required using a bed and chair alarm to prevent falls. He stated that on the morning of 12/14/2014, he observed that the resident was in a recliner. He stated that the resident was usually in a wheelchair. He stated that he found out that the night shift Licensed Practical Nurse (LPN) instructed the night shift CNA to place the resident in the recliner. CNA #1 stated that he transported the resident in the recliner from the bedroom to the day room for breakfast. He stated that he did not observe any alarms on the recliner and that he did not check the recliner for an alarm placement before he took the resident to the day room. CNA #1 stated that he did not check the CNA Assignment Sheet. CNA #1 stated that he was aware that the resident required a chair alarm, but he also stated that he thought that the alarm was discontinued at some point since he did not see the resident ' s name on the alarm monitoring sheet. He stated that it was his mistake for not checking for an alarm placement. On 2/19/2015 at 11:40AM an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that the nurse updated the care plan after the resident had the fall incidents in October 2014, but the fall risk assessment was not completed again at that time. The ADON stated that the physician's order [REDACTED]. The ADON stated that the resident had no order for a recliner, but the LPN instructed the CNAs to use the recliner for the resident ' s comfort. The ADON stated that the CNAs should have told the nurse that the resident needed an alarm on the recliner. On 2/19/2015 at 12:48PM an interview was conducted with the LPN, who was on duty during the 11PM-7AM shift on 12/14/2014. The LPN stated that she instructed the CNAs to place the resident in a recliner to make him more comfortable even though the resident did not exhibit any changes in condition. She stated that she gave that instruction just to make the resident more comfortable. The LPN stated that she was aware that the resident used a chair alarm. She stated that the CNAs who transferred the resident from the bed to the recliner did not inform her that the recliner had no alarm. She stated that she did not check if the alarm was placed on the resident ' s recliner. The LPN stated that she was not sure if a bed/chair alarm monitoring was done for Resident #1 prior to the fall incident on 12/14/2014. On 2/24/2015 at 3:39PM an interview was conducted with CNA #3. CNA #3 stated that he assisted CNA #2 to transfer the resident from the bed to the recliner at around 7:00AM on 12/14/2014. CNA #3 stated that the recliner did not have a chair alarm, so he attached the bed alarm to the recliner. He stated that he did not tell the LPN that a bed alarm was attached to the recliner. On 2/25/2015 at 8:41AM an interview was conducted with CNA #2, who was assigned to the resident during the 11:00PM -7AM shift on 12/14/2014. CNA #2 stated that he and CNA #3 transferred the resident from the bed to the recliner as instructed by the night shift LPN. CNA #2 stated that the resident was left in a lying position on the recliner and that pillows were used to support him. He stated that the resident used both bed and chair alarms. He stated that the recliner had no alarm, so CNA #3 attached a bed alarm to the recliner and left the resident next to the bed. He stated that he did not tell the LPN that there was no chair alarm on the recliner and that a bed alarm was attached to the recliner. He stated that he did not inform CNA #1 that a bed alarm was attached to the recliner. When asked about the bed/chair alarm monitoring, CNA #2 stated that he could not recollect whether he documented that he monitored the resident ' s alarms. On 4/14/2015 at 12:00PM an interview was conducted with the Physician of PT. The Physician stated that he last evaluated the resident on 12/6/2014 when the resident was discharged from PT and placed on the floor ambulation program. The Physician stated that the resident was to continue using a wheelchair and a rolling walker. The Physician stated that the resident did not require a recliner at that time. The Physician stated that his understanding was that the nursing staff gave the resident a recliner for comfort on 12/14/2014 because the resident exhibited a decline in his medical status, although he was not notified that the resident ' s condition had declined. On 4/14/2015 at 1:50PM an interview was conducted with the Director of Nursing (DON). The DON stated that Resident #1 used a TABS alarm device that was hooked onto the headboard and the metal clip at the end of the cord of the device was clipped to the mattress spring. With this device, if the resident attempts to get out of bed, the magnetic cord will detach from the device, which will activate the alarm. On 12/14/2014, CNA #3 attached the metal clip of the cord to the resident ' s clothing on the back without removing the alarm device and hooking it onto the recliner. The DON stated that CNA #3 did not inform the nurse or CNA #1 that the cord from the bed alarm device was attached to the resident. 415.12