Every finding on record at Springvale Nursing & Rehabilitation Center

Based on observation, interview, and record review, conducted during the recertification survey from 8/11/2025 to 8/15/2025, the facility did not ensure proper storage, preparation, distribution, and service of food in accordance with professional standards for food safety. Specifically, 1) undated cheese and juice was stored in the refrigerator; 2) ground meat and vegetables were not dated; and 3) Food Service Workers did not wear hairnets and beard guard to prevent hair from contacting food. The findings include: A facility policy dated 5/2023 and titled Dating and Labeling Policy documented the kitchen will ensure food safety by maintaining proper dates and labels to all goods and ready to eat food products. The procedure includes label products in storage with date the package was opened, ready to eat foods must be dated with a 72-hour use by date and discarded when expired. A facility policy dated 5/2023 titled Uniform Policy documented the kitchen will ensure that Food and Nutrition department employees represent a tidy, clean professional appearance and wear a uniform that meets the established guidelines of the department. Hair nets are to be worn and completely cover hair from front to back. Facial hair coverings will be worn to cover facial hair over a 1/4 inch in length. 1) During a tour of the main refrigerator on 8/11/25 at 7:00AM, six slices of yellow cheese were observed on a shelf without a date and a pitcher of juice next to the cheese was not labeled and dated. During an interview on 8/11/25 at 7:00AM, Food Service Worker #23 stated all food should be dated and labeled and they did not know why these two items were not properly stored. 2) During an observation on 8/11/25 at 7:05AM, a small container of warmed meat and a container of warming vegetables was observed on top of a stove without a date. Writing on the plastic wrap documented for Monday but not dated. During an interview on 8/11/25 at 7:15 AM, [NAME] #42 stated they wrote for Monday on the plastic wrap on the meats and vegetables because it was for Monday lunch and they did not want anyone to use it for something else. They stated it was prepped the day before (Sunday). During an interview on 8/11/25 at 1:41 PM, the Director of Food Services stated all food in the refrigerators needed to be dated when it was opened. They did not know why the juice and cheese was not dated. They thought it might have been about to be used for the breakfast meal, and someone put it in the refrigerator temporarily. There was a routine for the refrigerator, and it was checked for undated and expired food daily. All other foods including meats and food prepared ahead of time needed to be dated with the date it was prepared. In this case Cook#42 wrote a message instead of the date. 3)During the initial tour of the kitchen on 8/11/25 at 6:55 AM, Food Service Worker #21 and #22 were observed without hairnets in place in an area where breakfast food was beginning to be plated. Food Service Worker #21 and#22 were asked why they were not wearing a hairnet, and both said they forgot to do this but should have done it before entering the kitchen. During an observation on 8/12/25 at 11:19AM Food Service Worker#24 was observed walking up to the steam tray, donning gloves and grabbing utensils, removing plastic wrap from food pans about to start the service. They had full facial hair covering both cheeks and chin; their skin was not visible through hair. They were asked why they were not wearing a cover for their beard and immediately was pulled off the line by the Director of Food Service. During an interview on 8/12/25 11:30AM with the Director of Food Service they stated they were responsible for making sure staff were ready for service which included making sure hairnets and beard guards were in place but missed it. They further stated that they had instructed all the dietary service staff to wear a hairnet when entering the kitchen. 10NYCRR 415.14(h)

Based on interviews and record review during the recertification and abbreviated surveys (2564017) from 08/11/2025-08/15/2025, the facility did not ensure that all alleged violations involving abuse or mistreatment, were reported to the Administrator of the facility immediately or within two (2) hours after the allegation was made for one of five (1 of 5) residents reviewed for abuse. Specifically, Resident #200's daughter made an allegation of verbal mistreatment/abuse by a staff member, but staff did not report the allegation to the Administrator or State Agency. Findings include:The facility Abuse Policy-Prevention and Management last reviewed 08/2025 documented that the facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation/exploitation of property. Oral, written, or gestured language, that willfully includes disparaging and derogatory terms, to the resident/patient or their families, or within their hearing distance, to describe resident/patient, regardless of their age, ability to comprehend or disability. The Shift Supervisor/Charge Nurse is identified as responsible for immediate initiation of the reporting process. The Administrator, Director of Nursing, and Risk Manager, if applicable are responsible for investigation and reporting.Resident #200 had diagnoses that included, but were not limited to, cancer, renal insufficiency, and diabetes mellitus. The Five Day Minimum Data Set, dated [DATE] documented moderately impaired cognition and no behaviors. There was no documented evidence of any grievances from Resident #200 or their family in the 2025 grievance log/book.There was no documented evidence of any incident reports for Resident #200 or their family in 02/2025 or 03/2025.There was no documented evidence of a progress note describing the incident. During a telephone interview on 08/14/2025 at 9:36 AM, Resident #200's family member stated that there was an incident involving Licensed Practical Nurse #5 when their mother, Resident #200, was a resident at the facility from 02/2025-03/2025. They stated Licensed Practical Nurse #5 was verbally insulting and used foul and inappropriate language that was directed toward them and Resident #200. They stated that they did attempt to speak with multiple staff about the incident and there were two (2) staff witnesses to the event. The facility never addressed the issues or responded to them when they asked what was being done. During an interview on 08/14/2025 at 3:23PM, the Director of Human Resources, reviewed the employee file for Licensed Practical Nurse #5 with this surveyor. Their performance reviews dated 05/15/2024 and 03/13/2025 documented that they passed their evaluations. There were no documented disciplinary actions in their file. They stated if a resident, family member, or staff witness mistreatment or receive an allegation of abuse, they had multiple avenues to report the occurrence, such as social services, human resources, and administration. Staff received education on abuse, allegations of abuse, and reporting any misconduct. During an interview on 08/15/2025 at 9:26 AM, Registered Nurse Unit Manager #2 stated that they were the covering Unit Manager on 1 [NAME] once a week. If there was an allegation of abuse, they would stop the incident, report the incident, and complete the necessary documentation. They were mandated to report all allegations of abuse. They were not witness to, or aware of, any inappropriate verbal interaction between staff and Resident #200 or their family. If there was an allegation, they would document something in the progress notes and report the incident. During an interview on 08/15/2025 at 10:15 AM, Licensed Practical Nurse #5 stated they did remember Resident #200 and the incident in question. They stated that they were passing Resident #200's room that day and made a comment to fellow staff members in the hallway about a conversation they were having about women being crazy. The staff were joking with each other. The family member thought the comment was directed at them. The family member followed them and argued with them in the hallway. Registered Nurse Unit Manager #10 advised them (Licensed Practical Nurse #5) to walk away from the family member. They completed a statement and gave it to Registered Nurse Unit Manager #10. They did not remember ever discussing the incident with Administration. During an interview on 08/15/2025 at 10:52 AM, the Director of Nursing stated they were not employed at the facility when Resident #200 was at the facility. They had not had any interaction or conversations with the family member since they started and were not aware of any incidents involving Resident #200 and staff. During an interview on 08/15/2025 at 11:10 AM, the Director of Social Work stated Resident #200's family member did report the incident in question to them involving Licensed Practical Nurse #5. They did not know that the family member felt it was directed at the resident as well. They did discuss the event with the family member, and they thought it was resolved. However, when the family member returned to the facility after Resident #200 passed away, they brought up the incident again and wanted to know what was done about it. They stated they relayed the family member's concern to Administration. They were not certain what happened after that. If there was an allegation of abuse, it should have been reported. During an interview on 08/15/2025 at 11:35 AM, the Administrator stated that they never received any reports of any incidents between Licensed Practical Nurse #5 and Resident #200 or their family. They should have been notified so they could have investigated the allegation and reported if necessary.10 NYCRR 415.4(b)(2)

Based on interviews and record review during the recertification survey on 8/11/2025 to 8/15/2025, the facility did not ensure that the resident, resident's representative(s), or representative of the Office of the State Long-Term Care Ombudsman (an official patient advocate not hired by the facility) was notified of the transfer or discharge, and the reasons for the move, in writing and in a language and manner they understand for 2 of 3 residents (Resident #189 and Resident #191) reviewed for hospitalization and discharge. Specifically, 1) the facility did not complete a discharge notice or notification of bed hold for Resident #189 when they were hospitalized . The ombudsman was not notified of Resident #189's transfer/discharge to the hospital; 2) The Ombudsman was not notified of Resident # 191's discharge to the community. Findings include:1. Resident #189 had diagnoses that included Alzheimer's disease, Cerebrovascular Accident (CVA) and atrial fibrillation. The admission Minimum Data Set (an assessment tool) dated 5/10/2025 documented resident had severe cognitive impairment.The 6/23/2025 nursing note documented the physician ordered transfer to hospital, resident's representative was notified and agreed. The 6/24/2025 physician note documented the resident was sent out to hospital for further evaluation.The 6/24/2025 nursing note documented the resident was admitted to the hospital.2. Resident # 191 was admitted with diagnoses that included major depressive disorder, bipolar disorder, and nicotine dependence. The Minimum Data Set admission assessment of 1/07/2025 documented the resident was cognitively intact. The Minimum Data Set Discharge assessment of 6/9/2025 documented return not anticipated. Resident was discharged to the community.During an interview on 08/13/2025 at 4:13 PM, the Director of Nursing stated nursing was responsible for notifying the family of the bed hold policy. The Director of Nursing reviewed Resident #189's medical record was not able to provide documented evidence that the family was verbally informed of the bed hold policy and that the family was notified of the bed hold policy in writing. The Director of Nursing further stated that the Social Worker was responsible for notifying the Ombudsman office of resident transfers and discharges.During an interview on 08/13/2025 at 4:34 PM, the Director of Social Services stated they were responsible for sending the Transfer/Discharge Notice to the Ombudsman office for all resident transfers and discharges. The ombudsman should have received all transfers and discharge notices, but they were unable to provide documented evidence that the ombudsman was notified of Resident #189 and Resident #191 transfer and discharge. The Director of Social Services stated it was an oversight on their part. 10NYCRR 415.3(i)(1)(iii)(a-c)

Based on observation, record review and interview conducted during the recertification survey 8/11/25 to 8/15/25, the facility did not ensure the accuracy of the Minimum Data Set (resident assessment tool) for one of three residents (Resident #16) reviewed for urinary catheter. Specifically, the Minimum Data Sets with reference dates of 6/22/25 (quarterly), 3/24/25 (annual) and 12/24/24 (quarterly) were coded incorrectly, indicating the resident had an indwelling urinary catheter.Findings include:Resident #16 was admitted with diagnoses including benign prostatic hyperplasia, acute cystitis, and urinary retention. The 3/26/25 Urinary Incontinence Care Plan documented occasional incontinence of bladder function with interventions to monitor for symptoms of urinary tract infection and change in continence status. Resolved from the plan of care was the Foley (urinary) Catheter/Suprapubic care plan.The 4/11/24 physician orders documented to remove the urinary catheter.The 4/12/24 nursing progress note documented the resident's urinary catheter was removed.The 6/22/25, 3/24/25 and12/24/24 Minimum Data Set documented Resident #16 had an indwelling catheter.During an interview on 08/12/25 at 12:04pm, Licensed Practical Nurse #14 stated Resident #16 had not had a urinary catheter for over a year.During an interview on 08/13/2025 at 11:36 AM, Minimum Data Set Coordinator #3 stated it was a mistake on the most recent quarterly assessment (6/22/25). When asked about the annual assessment (3/24/25) and the previous quarterly assessment (12/24/24) they stated they were not sure how it happened since they typically check for accuracy. 10NYCRR 415.11 (b)

Based on observations, interviews, and record reviews conducted during the recertification survey from 8/11/2025 to 8/15/2025, the facility did not ensure that the Comprehensive Care Plan was revised to reflect preventative interventions for 1 of 7 residents (Resident #64) reviewed for accidents. Specifically, Resident #64's Comprehensive Care Plan was not updated to reflect new risk reduction fall interventions implemented after a fall. Findings include:The facility policy Falls Prevention and Management, reviewed 6/2025, documented the interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. Determining causal factors leading to a resident fall is necessary to provide consistent intervention to help prevent further occurrences. Adjust/add interventions on the fall plan of care, including date of new intervention. Discuss identified trends and immediately implement appropriate measures to prevent injury. Resident #64 had a diagnosis of Alzheimer's disease, difficulty walking, osteoporosis, and history of falls. The 8/6/2025 Minimum Data Set (a resident assessment tool) documented the resident's cognition was severely impaired. The resident required supervision with transfers from sitting to standing, toileting, and walking; and one fall with injury since the prior assessment. The 8/5/2025 nursing fall/accident progress note documented that Resident #64 had an unwitnessed fall, found lying flat on floor next to the foot end of their bed, unable to state what happened due to cognition. There was swelling to the right side of the resident's forehead, and ice pack was applied to swollen area, and neuro checks completed. The nursing fall risk assessment completed 8/5/2025 documented Resident #64 with a total of 35 for risk of falling (moderate risk).The 8/5/2025 medical progress note documented Resident #64 sustained a fall, ice compression and pain medication given, sent to the emergency room, deferred x-ray, and neuro checks for 24 hours. Medical plan documented in the progress note was to redirect Resident #64 to use the call bell. The 4/10/2025 Falls care plan documented interventions effective 4/10/2025 included to provide reality orientation, floor free from clutter, rehab referral, psychiatry consult, gradual dos antidepressant, anticipate resident's activities of daily living needs, bed in lowest position. New interventions effective 8/5/2025 were a medical work up.During an interview on 08/13/2025 at 12:24 PM, Licensed Practical Nurse #14 stated certified nursing aides made rounds to check on residents when they were in their room. During an interview on 08/14/2025 at 12:10 PM, Unit Manager Registered Nurse #15 stated an intervention to put in place after a fall was more frequent rounding. They stated this did not have to be in the care plan because nursing staff knew to do it. They stated the unit had mostly residents with cognitive deficits and was staffed with 2-3 certified nurse aides on night shift, rounding could be done more frequently. During an interview on 08/15/2025 at 8:35 AM, the Director of Nursing stated an investigation using a root cause analysis to determine the underlying cause of a fall should have been conducted. Standard rounding was hourly but maybe needed to be more frequent. Updated interventions should have been added to the care plan. 10 NYCRR 415.11(c)(2)(i-iii)

Based on interviews and record review during the recertification and abbreviated surveys (2564017 and 781248/NY00353892) from 08/11/2025-08/15/2025, the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for two of seven (2 of 7) residents (Resident #199 and Resident #200) reviewed for Activities of Daily Living. Specifically, 1) Resident #199 required assistance with activities of daily living and the certified nurse aide documentation was inconsistent; 2) Resident #200 required assistance with activities of daily living and the certified nurse aide documentation was inconsistent. The facility policy Activities of Daily Living Care Supporting Resident, last reviewed 03/2025, documented residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Activities of Daily Living documentation will be completed by the Certified Nurse Aide that provided the assistance (and other licensed nursing personnel that provide assistance) by the end of each shift. If an activity was not attempted, it should be documented with a reason. 1)Resident #199 had diagnoses that included, but not limited to, dementia, depression, and anxiety.The Five-Day Minimum Data Set, dated [DATE] documented resident with severely impaired cognition, no behaviors including refusals of care, and required maximal assistance with toileting and dressing.The Quarterly Minimum Data Set, dated [DATE] documented severely impaired cognition, no behaviors including refusals of care, required supervision assist with toileting and dressing.The Functional Abilities Care Plan initiated 06/21/2024 documented resident required moderate assistance for personal hygiene and upper body dressing and maximal assistance for toileting and lower body dressing. The certified nurse aide documentation for 07/2024 documented 135 omissions for certified nurse aide care, toileting, and dressing.The certified nurse aide documentation for 08/2024 documented 70 omissions for certified nurse aide care, toileting, and dressing. During an interview on 08/13/2025 at 12:34PM, Resident #199's family member stated Resident #199 was a resident at the facility and passed away there on 09/23/2024. Resident #199 was often found soiled or wet when the resident's spouse arrived to visit and was not dressed in their own clothing. During an interview on 08/14/2025 at 10:36 AM, Certified Nurse Aide #6 stated activities of daily living documentation was completed each shift. They also sign if there was a refusal, or if the task was not completed with a reason for why it was not performed. There should not be omissions on the record. During an interview on 08/14/2025 at 11:11 AM Registered Nurse Unit Manager #15 stated there should not be any omissions on the certified nurse aide documentation. An omission indicates the care was not rendered. 2)Resident #200 was admitted with diagnoses that included, but not limited to, cancer, renal insufficiency, and diabetes mellitus. The Five-Day Minimum Data Set, dated [DATE] documented moderately impaired cognition, no behaviors including refusals of care, and required maximal assistance for toileting and moderate personal hygiene. The Functional Abilities Care Plan re-initiated 02/26/2025 documented resident required moderate assistance with personal hygiene and maximal assistance with toileting and transfers.A nursing note dated 03/01/2025 documented resident incontinent of bowel and bladder.A medical note dated 03/06/25 documented groin rash complaint, skin assessment no lesions, intact, rash, nystatin order. Nursing notes dated 03/07-03/08/2025 documented malodorous loose stool. Nursing notes dated 03/10-03/12/2025 documented persistent loose stool. The certified nurse aide documentation from 02/27-03/15/2025 documented 35 omissions for certified nurse aide care, toileting, and personal hygiene During an interview on 08/14/2025 at 9:36 AM, Resident #200's family member stated they had personally provided incontinence care for Resident #200 during their stay there. There was a day when another family member called them to report that Resident #200 was covered in feces. They went to the facility to change Resident #200, and the staff were upset that they soiled the sheets in the process. They stated that Resident #200 was dying, and they just wanted them clean and comfortable. During an interview on 08/15/2025 at 9:26 AM, Registered Nurse Unit Manager #2 stated that the certified nurse aides document the care provided for the activities of daily living. If a task was not completed, they should document not performed with a reason. There should not be any omissions on the certified nurse aide documentation. If it was not documented, it was not done. During an interview on 08/15/2025 at 10:33 AM, Certified Nurse Aide #7 stated that Resident #200 did need to be provided frequent incontinence care. They signed the activities of daily living for all areas including cares not provided with a reason. There should not be any blanks or omissions because if it was not documented it was not done. 10NYCRR 415.12(a)(3)

Based on observations, interviews, and record reviews conducted during the recertification survey from 08/11/2025 through 08/15/2025, the facility did not ensure that emergency equipment was readily available for one of two residents (Resident #125) reviewed for respiratory care. Specifically, Resident #125, who had a tracheostomy, did not have an Ambu bag (a handheld device that provides positive pressure to residents who are not breathing) at the bedside. Findings include: The facility's policy and procedure titled Tracheostomy Care, last revised in April 2025, documented an emergency tracheostomy setup was to be maintained at the resident's bedside.Resident #125 had diagnoses including chronic respiratory failure with hypoxia, tracheostomy, and dysphagia. The Quarterly Minimum Data Set, dated [DATE], documented the resident had severe cognitive impairment and was dependent on a tracheostomy and oxygen therapy.The comprehensive care plan titled Respiratory Care, dated 08/24/2024, documented maintaining the resident's airway.During an observations on 08/12/2025 at 11:00 AM, 08/13/2025 at 12:00 PM, and 08/14/2025 at 10:00 AM, Resident #125 did not have an Ambu bag at the bedside.During an interview on 08/14/2025 at 10:00 AM, Registered Nurse #9stated there was not an Ambu bag at the bedside and stated they did not know where the nearest one was. They stated the resident's tracheostomy was stable.During an interview on 08/14/2025 at 10:10 AM, Registered Nurse Unit Manager #2 stated there used to be an Ambu bag at the bedside. They stated there was no Ambu bag at the bedside and they were responsible for ensuring that one was available.During an interview with the Director of Nursing on 08/14/2025 at 12:30 PM, the Director of Nursing stated that there should have been an Ambu bag at the bedside and stated the unit manager was responsible for ensuring one was in place. 10 NYCRR 415.12(g)(2).

Based on observation, interviews and record review conducted during the recertification survey from [DATE] to [DATE], revealed that the facility did not ensure that drugs and biologicals were stored according to current professional standards for 2 out of 7 residents (Resident #60 and Resident #115) reviewed for medication storage and labeling. Specifically, 1) Resident #60 was observed three times with Carboxy-methylcellulose 0.5% eye drops, Deep Sea Nasal Spray 0.65%, and a Budesonide-Formoterol 80-4.5 micrograms/actuation metered-dose inhaler on their bedside table. 2) Resident #115's Humalog 100 units/milliliter insulin pen was observed on a medication cart on [DATE]. The insulin pen had an opening date of [DATE], which is past the manufacturer's recommendation to discard it after 28 days after the opening date and was found 17 days after the recommended discard date on the medication cart.The findings include: 1.The 3/2025 facility policy on self-administration of medications states that if a resident expresses a desire to self-medicate or is deemed appropriate for self-administration, an assessment will be completed by a nurse. This assessment will be reviewed by the interdisciplinary team before implementation. The resident's capability for self-administration will be documented either on the Medication Self-Administration Assessment or in the nurse's progress notes. Additionally, physician orders must be obtained for both self-administration of medication and for keeping medication at the bedside. Resident #60 had diagnoses including acute and chronic respiratory failure, hypoxia, depression, and anxiety disorder. The admission Minimum Data Set (an assessment tool) dated 8/11/ 2025, documented the resident had intact cognition and required assistance from one person for activities of daily living, including personal care. A review of Resident # 60 comprehensive care plan did not reveal a care plan for self-administration of medications. The [DATE] physician orders included Symbicort 80 mcg- 4-5 mcg/actuation Hydrofluoroalkane aerosol inhaler, inhale 2 puffs by inhalation route two times per day in the morning and evening. Instruct resident to rinse mouth with water after each use to prevent oral thrush; and Albuterol sulfate 2.5 mg/3ml (0.083%) solution for nebulization, inhale 3 Milliliters (2.5 Milligram) by nebulized route every four hours. The [DATE] physician orders included Refresh Optive 0.5 %-0.9% eye drops, give one drop to both eyes every six hours as needed; and [NAME] Long- Acting 0.05% Nasal Spray, 2 sprays in each nostril by intranasal route two times per day in the morning and evening as needed at 9:00 AM and 5 PM. During observations and interviews on [DATE] at 7:39 AM, [DATE] at 1:07 PM, and [DATE], at 9:46 AM, Resident #60 had Carboxy-methylcellulose 0.5% eye drops, Deep Sea Nasal Spray 0.65%, and a Budesonide-Formoterol 80-4.5 micrograms per actuation metered-dose inhaler on their bedside table. Resident #60 stated they had their medications at their bedside and took them themselves because the nurses did not administer them on time. During an observation and interview on [DATE] at 9:46 AM, Licensed Practical Nurse Unit Manager # 3 stated residents should not have their medications at the bedside without proper assessment. They stated the resident would need clearance from the medical doctor to keep the medication there and it was necessary to ensure the resident had the capacity to administer their medication correctly. During the interview, Licensed Practical Nurse Unit Manager # 3 observed the medications at Resident #60's bedside and stated to the resident that they would discuss the request for having medication at the bedside with the physicians, emphasizing that the medication should not be stored there without a physician's approval. During an interview on [DATE] at 1:43 PM, the Assistant Director of Nursing #1 stated residents should not have any medications at their bedside. They stated that the resident would need to be assessed to determine whether they had the capacity to understand how to take their medications properly, including awareness of the side effects. They also stated that a physician's order would be required for self-administration of medications. 2) The facility Medication Storage Policy, review date 2/2025, Procedure #5 documented the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. The Medication Administration/Disposition policy, review date [DATE], Procedure#9 documented the expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi dose container, the date opened shall be recorded on the container. During an observation of the 2 [NAME] medication cart on [DATE] 10:10 AM, with Licensed Practical Nurse #1, an Insulin pen for Resident #115 had an open date of [DATE]. During an interview on [DATE] at 11:50 AM, Nurse Manager #2 stated that it was the responsibility of the nurse administering the medication to check the expiration dates. They stated that the Insulin was last administered yesterday ([DATE]) and the unit manager and the pharmacy consultant that were responsible for auditing the carts. The nurse manager stated that it was an oversight that the expired Insulin pen remained in the cart. During an interview on [DATE] at 12:33 PM, Licensed Practical Nurse #1 stated that it was the responsibility of the Registered Nurse and the Unit Manager to check the expiration dates. Licensed Practical Nurse #1stated that they did not administer the medication on [DATE] as it was administered based on a sliding scale and the resident did not require it on [DATE]. They stated that it was an oversight that the medication remained in the cart and they were aware it needed to be discarded 28 days after opening. 10 NYCRR 415.18(e) (1-4)

Based on observations, interviews, and record reviews conducted during the recertification survey from August 11, 2025, through August 15, 2025, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infection. Specifically,1) Licensed Practical Nurse #13, did not don a gown while providing wound care to Resident #165, who was on enhanced barrier precautions; 2) Home Health Aide #4 did not perform proper hand hygiene during meal service and assistance with feeding Resident #183; and 3) Home Health Aide #8 did not perform hand hygiene after feeding Resident #157 and then fed another resident during a breakfast meal. Findings include: 1) The policy and procedure titled Enhanced Barrier Precautions, last revised April 2025, directed staff to maintain enhanced barrier precautions, requiring the use of personal protective equipment, including gowns and gloves, during high-contact resident care activities such as nursing care, dressing changes, and handling medical devices. Resident #165 had diagnoses of dementia, pressure ulcer of the right heel, and peripheral vascular disease. The Quarterly Minimum Data Set, dated [DATE], documented that the resident had severe cognitive impairment and one unhealed venous ulcer. The comprehensive care plan for enhanced barrier precautions, last updated 4/28/2025, directed staff to use gowns and gloves during high-contact resident care activities, to don a gown before beginning care, and to remove the gown before leaving the patient environment. A review of the personal protective equipment competency dated 2/25/2025, revealed Licensed Practical Nurse #13 was deemed competent in using personal protective equipment. The physician’s order dated 7/14/2025, documented to maintain enhanced barrier precautions for the wound on the resident’s right heel. The physician’s order dated 7/16/2025, documented to cleanse the resident’s right heel with Dakins solution, apply collagen particles and calcium alginate to the wound base, and secure the wound with a bordered foam dressing. During an observation on 8/14/2025 at 10:00 AM. Licensed Practical Nurse#13 performed wound care on the resident’s right heel. An enhanced precaution sign was posted on the door, personal protective equipment was readily available, and a red garbage can was outside the bathroom door. At no time during the treatment did the nurse wear a gown. During an interview on 8/14/2025 at 10:15 AM, Licensed Practical Nurse#13 stated they did not wear a gown during the treatment. The nurse acknowledged that they were required to wear a gown because the resident was on enhanced barrier precautions and confirmed that they had previously been educated on the different precautions. During an interview with Registered Nurse Unit Manager#2 confirmed they were responsible for ensuring staff compliance with facility policy. The unit manager stated that all staff had been educated on enhanced barrier precautions and acknowledged that Licensed Practical Nurse#13 should have worn a gown during the treatment. 2) During an observation on 08/13/2025 at 12:34 PM, Unit 2 North nursing staff including the registered nurse unit manager, licensed practical nurse, certified nurse aides, and home health aides were serving residents lunch meal without using hand sanitizer, hand sanitizing wipes or hand washing between tray pass and set up among residents. At 12:42 PM Home Health Aide #4 was observed picking up a chair by the arms to move with bare hands, picked up Resident #6's personal bag from the floor with bare right hand, pushed Resident #183's chair to the table and touched the arm rests with bare hands. Home health aide #4 then sat to feed Resident #183 without washing or sanitizing hands. During an interview on 08/13/2025 at 12:55 PM Home Health Aide #4 acknowledged being aware of hand hygiene and removed a small bottle of hand sanitizer from their pocket to show they had sanitizer but shook head no that they did not use it at any time of passing trays or assisting feeding resident #183. During an interview on 08/14/2025 at 9:05 AM, the Assistant Director of Nursing #2 stated they conducted random audits to check that hand hygiene was completed and provided in-servicing to staff at least quarterly. During an interview on 08/14/2025 at 11:47 AM, Licensed Practical Nurse #14 stated most staff feeding training was learned as school curriculum. Assistant Director of Nursing #2 provided education on hand hygiene requirements during meals and the Unit Managers monitored to see it was followed. During an interview on 08/14/2025 at 12:26 PM Registered Nurse Unit Manager #15 stated staff should sanitize hands when passing trays from one table to the next and before assisting a resident with feeding. They monitored staff for hand hygiene during meal service. 3) During an observation on 8/11/25 at 8:45 AM in the 2 East Dining Room, Home Health Aide #8 was feeding Resident #157. They did not perform hand hygiene when finished, then went to another resident’s tray and touched items to give to that resident. (straw and milk container). During an interview on 8/11/2025 at 8:50 AM, Home Health Aide # 8 stated they did not perform hand hygiene after feeding the resident, but they did wash their hands in the sink before feeding the resident. Home Health Aide #8 also stated that they had been trained on infection control. During an interview on 08/14/2025 at 8:54 AM the Assistant Director of Nursing #2 stated that In-servicing was done with all Home Health Aides on proper hand hygiene with a return demonstration. Assistant Director of Nursing #2 stated that hand hygiene audits were done in the mornings using the annual in-service check list. §415.19(b)(4).

Based on observations, interviews and record reviews conducted during the Recertification survey on 8/11/2025 to 8/15/2025 the facility did not maintain an effective pest control program so that the facility was free of flies. Specifically, Resident #8's room was observed with several flies.Findings are:The facility policy and procedure titled Pest Control last reviewed 5/2025 documented it is the responsibility of the Maintenance Department to coordinate the control of pests with a company engaged in business of providing Pest Control Services. Pest control Company will provide the control of other insects that may be harmful to humans, equipment, supplies through direct and/or indirect contact or contamination.During an observation on 8/12/2025 at 8:50AM, flies were observed on Resident #8's room.During a subsequent observation on 8/13/2025 at 9:27AM, Resident #8's room was observed with several flies on the pillow, at the bedside chair, on the call bell cord, on the bedside table napkin, on the bed sheets, on the closet door and on the Resident #8's big toe and on the urinal cover. Resident #8 stated that there were flies in their room and they reported it to the staff.During an interview on 8/13/25 at 9:28 AM, LPN #5 stated they had seen the flies in Resident # 8's room. They stated that an exterminator came to the facility but was not sure when they come.During an interview on 8/13/2025 at 9:44AM, Registered Nurse Unit Manager #10 stated they were made aware of the flies in Resident # 8's room early last week, Monday or Tuesday. They further stated they reported the presence of several flies in Resident # 8's room to their entire clinical team specifically to the Director of Housekeeping Department and the Administrator.During an interview on 8/13/2025 at 10:01AM, the Director of Housekeeping stated they were aware of the flies in Resident # 8's room. They stated that the exterminator was in the facility on Monday, 8/11/2025 but was not sure if the exterminator went to Resident # 8's room that day.During an interview won 8/13/2025 at 10:12AM, Maintenance staff # 11 and Maintenance staff #12 both stated they were not aware of the flies in Resident # 8's room or in any other rooms in the building as it was not reported to them. They stated that the Director of Maintenance was not in the building since last week.During an interview on 8/13/2025 at 10:15 AM, with the Administrator and with the Maintenance staff, the Administrator stated that the Pest Control Company was in the facility on Monday, 8/11/2025. The Administrator stated they were not aware that there were flies in resident rooms. The Administrator stated that the Director of Maintenance was responsible for pest control in the building but was not available as they were not in the building last week. The Administrator was not able to provide documented evidence in the Pest Control log of a report for 8/11/2025. They stated that they would get the report from All State Pest Control Company. During the interview, the Administrator provided the Pest Control log. Upon review of the Pest Control log with the Administrator, the log documented dates from 1/27/25 to 7/28/25. The log had no documented evidence that Resident # 8's room or other resident rooms were checked during those dates. The Administrator stated they would contact the Pest Control Company to inspect resident rooms.On 8/13/2025 at 11:29AM, the [NAME] President of Operations provided the Pest Control report dated 8/11/25 that documented Hornet nests in patio and another in the parking lot. The report did not document that Resident #8's room or any other rooms were checked for flies.10 NYCRR 415.29(j)(5)

Based on observation, record review and interviews during the recertification survey 8/11/25-8/15/25, the facility did not ensure individuals working in the facility under the title Home Health Aides, had successfully completed a State-approved training program for feeding residents for 12 of 12 employees reviewed (Home Health Aides #4, #8, #32, #33, #34, #35, #36, #37, #38, #39, #40 and #41.) Specifically, there was no documentation the Home Health Aides received the required training to feed residents and Home Health Aide # 4 was observed feeding Residents on more than one occasion and Home Health Aide#38 and #36 were observed feeding residents on the Dementia Unit.Findings include:The facility policy titled Home Health Aide Utilization and Scope of Duties dated 9/8/22 documented Home Health Aides are to be utilized within the scope of duties outlined in their job description. Home Health Aides provide non-clinical support services that contribute to the comfort, safety and wellbeing of residents and work under the direct supervision of the Director of Nursing or designation.The undated Home Health Aide Job Description documented Home Health Aides report to the Director of Nursing, and their essential functions do not include providing any care, feeding or assisting with transfers.The facility provided certificates for the Home Health Aides which documented they completed Home Health Aide courses from an outside agency.The facility did not provide any proof the Home Health Aides had the eight hour Feeding Assistant Training approved for assisting residents with eating in a nursing home.In an email on 8/15/25 at 10:06AM from the agency that provides Home Health Aide training they documented their Home Health Aide program does not include the separate 8-hour Feeding Assistant Training approved for assisting residents with eating in a nursing home. This is a distinct course regulated by NYSDOH.Resident #62 had diagnoses which included dementia, hypertension and Alzheimer's disease. The Minimum Data Set assessment dated [DATE] documented the resident had moderate cognitive impairment and needed assistance with meals.The Physician orders dated 6/27/25 documented the resident was prescribed regular diet with thin liquids.Resident #183 had diagnoses which included Alzheimer's disease, psychosis and depression. The Minimum Data Set assessment dated [DATE] documented the resident had severe cognitive impairment and was independent with eating.The physician orders dated 7/18/25 included aspiration (choking) precautions, regular diet with thin liquids.Resident #149 had diagnoses which included hypertension, Type II Diabetes, and dementia. The Minimum Data Set an assessment dated [DATE] documented the resident had severe cognitive impairment and needed assistance with eating meals.During an observation on 8/12 at 12:47PM Home Health Aide # 4 assisted and fed Resident #62 lunch and on 8/14/25 at 8:36 AM assisted and fed Resident #183 their breakfast.During an observation on 8/14/25 at 8:33 AM Home Health Aide #36 assisted and fed Resident #149 breakfast.During an observation on 8/14/25 at 8:39 AM Home Health Aide #38 assisted and fed Resident #62 breakfast.During an interview on 8/14/25 at 8:33 AM Home Health Aide #36 stated their job was to help resident who need to be fed their meals. They spend the afternoons out on appointments with residents.During an interview on 8/14/25 at 8:47 AM Home Health Aide #8 stated they received in services done by the facility about different diets. They stated they did not get a lot of training at their school about feeding residents.During an interview on 8/12/25 at 12:47 PM Registered Nurse Unit Manager #15 stated the Home Health Aides assisted with feeding the residents meals and were trained by the Speech and Language Pathologist.During an interview on 08/13/2025 at 2:55 PM Assistant Director of Nursing #1 stated the Home Health Aides were hired for feeding and transportation. The Home Health Aides fed all types of diets including puree, chopped and modified. They stated they did not know about an eight-hour course, but the Speech and Language Pathologist did competencies with the Aides. During an interview on 8/13/25 at 3:00PM the Speech and Language Pathologist stated they did the training with the Home Health Aides and went over each item in the competency. They stated they did a competency review and were not certified to provide training in any State course. When staff were hired, they assumed they had all the credentials needed so when they did the competencies, they were just reinforcing feeding residents.During an interview on 08/14/25 at 12:10 PM the Director of Nursing stated the Home Health Aides were hired to escort residents to appointments but was aware they were feeding residents on the units. They were not aware of the eight-hour training class Home Health Aides needed before they could feed residents. 10 NYCRR 415.13(d)

Based on observations, record review and interviews conducted during the recertification survey from 8/11/2024 to 8/15/2024, the facility did not ensure that special eating equipment and utensils were provided for residents who need them. This was observed during dining observation for 1 of 6 residents reviewed for nutrition (Resident #17). Specifically, Resident #17 was observed on three occasions eating without the use of the proper assistive devices as indicated in the meal tray ticket, recommended by occupation therapy and ordered by the medical doctor.Findings include:Resident # 17 was admitted with diagnoses that included cerebral infarction, peripheral vascular diseases, and Type 2 diabetes.The Quarterly Minimum Data Set (an assessment tool) dated 08/02/2025 documented the resident had intact cognition, impairment on bilateral upper/lower extremities and required supervision assistance with eating.The Rehabilitation: Contractures Care Plan effective 7/28/2025 documented the resident had a left and right upper extremity contracture which interfere with the ability to use feeding utensils. The interventions documented that therapeutic devices including scoop plate, rocker knife, built up spoon and fork be used. The Functional Abilities: Self Care plan created 07/28/2025 documented the resident required supervision/touching assistance with eating. The interventions documented a scoop plate, rocker knife, built up spoon and fork with all meals.A dietary order renewed 07/14/2025 documented the following adaptive equipment to be used at meals included scoop plate, rocker knife, built-up spoon and fork.An Occupational Therapy Evaluation and Plan of Care created on 7/31/2025 recommended the following therapeutic devices to be used at meals: scoop plate, rocker knife, built up spoon and fork.A medical order dated 8/11/2025 documented the following adaptive equipment with all meals: scoop plate, rocker knife, built up spoon and fork.On 08/12/2025 at 11:38 AM, Resident #17 was observed using a normal plastic spoon to eat cereal in the dining room. During an interview conducted on 08/13/2025 at 10:25 AM, Certified Nurse Aide #16 stated Resident #17 was supposed to have a weighted spoon, but they used a regular spoon. On 08/13/2025 at 12:43 PM, Resident #17's food tray was observed with no rocker knife and instead had a regular knife. The meal tray ticket documented the resident was to receive the built-up spoon, fork and rocker knife.On 08/14/2025 at 12:26 PM, Resident #17's food tray was observed with no rocker knife and instead had a regular knife. The meal tray ticket documented the resident was to receive the built-up spoon, fork and rocker knife.During an interview on 8/14/2025 at 12:28 PM, Resident #17 stated they need the rocker knife during meals since they are unable to cut turkey and other meats.During an interview on 08/14/25 at 09:45 AM, the Director of Rehabilitation stated that Resident #17 was referred by the nursing staff due to a decrease in their ability to assist with activities of daily living. Resident #17 was evaluated on 7/29/2024 and the evaluation recommended physical and occupational therapy services 3 times a week and for a built-up fork and spoon with rocker knife at meals.During an interview on 08/14/2025 at 12:29 PM, the Food Service Director stated they were unaware that Resident #17 did not receive the Rocker Knife with their meal. The Food Service Director stated between 7 and 8 residents receive adaptive equipment and there was sufficient rocker knifes available. The meal ticket stated a rocker knife was required and they would check with the kitchen staff and get the resident the proper knife. 10 NYCRR 415.14 (g)

Based on interviews and record review conducted during the recertification and abbreviated (NY00359686) survey from 8/11/2025 to 8/15/2025, the facility did not ensure the resident's representative was notified when there was a need to alter the resident's treatment and transfer the resident from the facility. This was evident for 1 (Resident #194) of 4 residents reviewed for notification of change. Specifically, Resident #194's representative was not notified when the resident received intravenous hydration and was transferred to the hospital. The findings are: The facility policy titled Change in Condition dated 5/2025 documented the facility will notify the resident representative of changes in the resident's condition. Documentation of a change in the resident's condition is encouraged. Resident #194 had diagnoses of cerebral infarction (stroke) and colon neoplasm (cancer). The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #194 was moderately cognitively impaired. The Nursing Note dated 10/17/2024 documented Resident #194 had an episode of emesis and a stat abdominal x-ray was ordered. The Nurse Practitioner Note dated 10/17/2024 documented Resident #194 was administered zofran to address their nausea and vomiting and was started on intravenous hydration. The Nursing Note dated 10/18/2024 documented Resident #194 received an intravenous hydration infusion and antibiotic for a urinary tract infection. There was no documented evidence Resident #194's Representative was notified of the resident's need for intravenous hydration or antibiotic therapy. The Nursing Note dated 11/27/2024 documented Resident #194 was sluggish, had a change in mental status, and was transferred to the hospital for evaluation. There was no documented evidence Resident #194's Representative was notified of the resident's need for hospitalization. On 8/12/2025 at 11:33 AM, a telephone interview was conducted with the resident's representative who stated Resident #194 had several changes in condition and was hospitalized during their stay in the facility in 10/2024 and 11/2024. Resident #194's representatives were not informed of all the changes that occurred with the resident while at the facility. On 8/15/2025 at 9:32 AM, Licensed Practical Nurse #3 was interviewed and stated the Licensed Practical Nurses, Registered Nurses, Nurse Practitioner, and/or Medical Doctor were responsible for contacting a resident's representative and/or next of kin when there were changes in a resident's condition or was hospitalized . Resident representatives were also informed if a resident was sluggish and lethargic or had a change in vital signs. Any changes in medication orders and new orders of antibiotic therapy were also communicated to a resident's representative. The nursing staff who informed a resident's representative of changes or hospitalization were responsible for writing a note documenting the notification in the resident's medical record. On 8/14/2025 at 3:46 PM, the Medical Director was interviewed and stated the nursing staff were responsible for contacting a resident's representative and informing them of a change in the resident's condition or hospitalization. The Medical Director stated the Nurse Practitioner or Medical Doctors communicated with and notified resident representatives of changes in a resident's condition if there was a complicated or serious issue to address. On 8/15/2025 at 11:32 AM, the Director of Nursing was interviewed and stated they began working for the facility approximately 2 months ago and implemented chart auditing to improve staff documentation in the medical records. The licensed nurses, Medical Doctors, and Nurse Practitioners were all responsible for notifying a resident's representative when there were changes in a resident's condition and documenting in the medical record upon communication with the representative. 10 NYCRR 415.3(f)(2)(ii)(c-d)

Based on interviews and record review conducted during the recertification and abbreviated (NY00359686) survey from 8/11/2025 to 8/15/2025, the facility did not ensure a safe environment with protection of a resident's property from loss or theft. This was evident for 1 (Resident #194) of 6 residents reviewed for personal property. Specifically, Resident #194's personal cell phone went missing and was unable to be found during their stay at the facility. The findings are: The facility policy titled Inventory/Personal Belongings dated 1/2025 documented each resident will be offered/provided a locked drawer or equivalent with a key for small valuables. Resident #194 had diagnoses of cerebral infarction and schizoaffective disorder. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #194 was moderately cognitively impaired. The Social Work Note dated 10/14/2024 documented Resident #194 reported their phone went missing while being charged. The note documented the Director of Social Work discussed the matter with Resident #194's family member. There was no documented evidence Resident #194's cell phone was protected from loss and/or theft in 10/2024. On 8/12/2025 at 11:33 AM, a telephone interview was conducted with the Complainant who stated Resident #194's cell phone and clothing went missing at the facility in 10/2024. There was direct communication with the Administrator regarding the facility's investigation into matter. On 8/14/2025 at 10:15 AM, the Director of Social Work (and Grievance Official) was interviewed and stated they began working for the facility in 7/2024. Clothing brought to the facility was labeled by Housekeeping and documented on an inventory checklist form. A copy of the form was kept on file in the Housekeeping Department and a copy was given to the resident and/or resident's family. The forms were kept at the front desk for easy access to resident families. The Director of Social Work stated, if a resident lacked capacity, the nursing staff would take possession of a resident's valuables for safekeeping and sometimes gave the valuables to the Director of Social Work for safekeeping. Some residents and their families were adamant about a resident maintaining possession of their valuables, i.e. a cell phone. The Director of SOcial Work stated they were able to offer residents access to their cell phone kept locked in the Social Work Office on a limited basis. The Director of Social Work stated they were unaware whether Resident #194 was offered a personal storage area or lockbox for their cell phone in 10/2024 and would check with the Housekeeping Department for copies of Resident #194's inventory checklists. On 8/15/2025 at 9:32 AM, Licensed Practical Nurse #3 was interviewed and stated some residents had a bedside dresser drawer equipped with a lock for valuables and the Maintenance Department could be contacted to obtain a lockable dresser drawer for residents without one in their room. The residents were able to hold onto the keys for these drawers, or the licensed nurses could hold onto the keys if the residents were unable to do so. On 8/15/2025 at 11:13 AM, the Administrator was interviewed and stated residents were allowed to maintain possession of their cell phones and had their possessions documented on a personal property inventory checklist. The Administrator stated they could not recall the details of Resident #194's missing cell phone. Each resident had access to a lockable dresser drawer in their room to keep their valuables safe. 10 NYCRR 415.29(c)(4)

Based on interviews and record review during the recertification and abbreviated surveys (NY00382686) from 8/11/2025-8/15/2025, the facility did not ensure residents were adequately equipped to call for assistance through a communication system that relays the call directly to a staff member or to a centralized staff work area for 1 (Unit 2 East) of 5 residential units. Specifically, on Unit 2 East, the call bell system was not functioning correctly on 8/13/2025, 8/07/2025, 8/01/2025, 5/07/2025, 3/16/2025, 1/11/2025, 1/08/2025, 10/16/2024, 6/19/2024, and 2/22/2024. The findings include:During an interview and observation on 08/13/2025 at 10:44 AM, Certified Nurse Aide #16 stated the audible portion of the Unit 2 East call bell system was not working. Certified Nurse Aide #16 was observed to activate the call bell system from room [ROOM NUMBER]. It was observed that the light illuminated outside the door, but no sound was heard on the unit floor or at the centralized nurse station.During an interview on 08/13/25 at 11:20 AM, Registered Nurse Unit 2 East Manager stated the call bell system sound was not working. The sound occasionally went out. The staff was to look for call bell lights and give care to the residents. During an interview and observation on 08/13/2025 at 11:42 AM, Maintenance Worker #11 was observed working on the Unit 2 East call bell system at the nurse's station. They stated the call bell system had no sound coming from system speakers. The light above each room illuminates, the nurses station call bell system monitor indicates a call bell has been activated but no audible sound could be heard. They stated the Unit 2 East call bell system sometime required the computer to be reset to work correctly. The call bell system on Unit 2 East was upgraded to a different system than the rest of the facility several months ago.During an interview and record review on 8/14/2025 at 03:00 PM, the Director of Maintenance stated all maintenance issues for the facility were entered into The Equipment Lifecycle System (TELS) which was a building management platform designed for senior living communities. Every computer in the facility had the TELS application installed on it and all staff members could enter a maintenance issue into the system. TELS will notify all maintenance staff members that a maintenance issue has been entered. Any call bell system maintenance issue is given a high priority for repair. The Unit 2 East has had call bell system issues in the past. The module for the call bell system was not working correctly and a new call bell system was installed in Unit 2 East in May 2025. The new system required a new monitor and laptop to be installed in the centralized nurse's station. For the 8/14/2025 call bell system maintenance issue, maintenance staff determined that the speakers located at the centralized nurse's station on Unit 2 East were not working and a new set of speakers were installed. A review of the TELS work order report documents that the call bell system on Unit 2 East was not working correctly and required maintenance on the following days: 8/07/2025, 8/01/2025, 5/07/2025, 1/11/2025, 1/08/2025, 10/16/2024, 6/19/2024, and 2/22/2024. During an interview on 08/15/2025 at 12:46 PM, Assistant Director of Nursing # 2 stated they were not aware of any call bell system sound problem on Unit 2 East. They expected the staff to look for call bell lights that were on and respond as soon as possible. 10 NYCRR 415.29

Based on record review and interview during an abbreviated survey (NY00355663) the facility did not ensure the resident representative was immediately informed of a significant change in the resident's physical status or a need to alter treatment significantly for 1 of 3 residents (Resident #1) reviewed for notification of changes. Specifically, Resident #1's representative was not notified when the resident had a Midline Catheter (Intravenous Catheter) inserted. Findings include: The facility notifications policy dated 1/2017 last reviewed 1/2025 documented the clinical nurse will recognize and appropriately intervene in the event of change in resident's condition. The facility will notify the resident, attending physician and representative of changes in the resident's condition and or status. Resident #1 had diagnoses including dementia, end stage renal disease, and coronary artery disease. The Quarterly Minimum Data Set (MDS) (assessment tool) dated 8/14/24 documented the resident had severely impaired cognition. The resident required moderate to maximal assistance for all activities for daily living. The Physician Order dated 9/27/2024 documented to place a Midline Catheter (catheter in the vein to administer fluids). The Nursing Progress Note from 9/27/2024 through date of discharge did not document the Midline Intravenous Catheter was placed. The Invoice from an intravenous contracting company documented a Midline Intravenous Catheter was inserted for Resident #1 on 9/27/2024. There was no documented evidence from 9/27/2024 thru discharge that Resident #1's representative was notified of a Midline Intravenous Catheter being inserted. During an interview on 3/18/2025 at 4:00 PM, Registered Nurse Manager #1 stated they remembered the physician ordered Intravenous Medication. They had attempted to place a Peripheral Intravenous Catheter but were unable. The intravenous contracting company was called to place the intravenous line. They did not remember if the resident representative was notified. During an interview on 3/19/2025 at 9:48 AM, the Assistant Director of Nursing stated if the resident had an intravenous line inserted, the representative should have been notified and there should have been a progress note. During a telephone interview on 3/20/2025 at 10:45 AM, Resident #1' Representative stated they were unaware the resident had a Midline Catheter inserted until they saw the resident in the emergency room of the hospital on 9/28/2025. The representative further stated the facility did not notify them or any other family member. During an interview on 3/20/2025 at 2:50 PM, the Nurse Practitioner stated they did not recall speaking with Resident #1's family, they expected the Unit Manager to notify the resident's representative when the Midline Catheter was placed. 10 NYCRR 415.3(f)(2)(ii)(b)

Based on observation, interview, and record review conducted during an abbreviated survey (NY00331614) the facility did not ensure that all alleged violations of abuse were reported immediately, but not later than 2 hours to the state survey agency for 1 of 3 residents reviewed for Abuse (Resident #5). Specifically, Resident #5 made an accusation of abuse on 1/15/2024 and that was not reported to the state agency until 1/17/2024. In addition, there was no documented evidence of the 5-day investigation report submission to the Department of Health either. Findings included: Resident # 4 had diagnoses including bipolar disorder, paranoid schizophrenia, and schizoaffective disorder. The admission Minimum Data Set, dated [DATE] documented moderately impaired cognition, with behaviors, and required moderate-maximum assistance with activities of daily living. The Investigation Report documented that Resident #5 called 911 on 1/15/2024 at 6:00AM and made an allegation of being beaten and raped. Law enforcement and paramedics responded to the call, and the resident was transferred to the hospital for evaluation. The allegation was documented as reported to the Department of Health on 1/16/2024 without a time indicated. The hospital report dated 1/15/2024 documented Resident #5 was examined at 7:22AM and there was no evidence of trauma, exam unremarkable aside from bizarre thought process, endorsed to telepsychiatry for evaluation. During an interview on 3/20/2025 at 1:50PM, the Administrator stated that the Director of Nursing and Assistant Director of Nursing completed the investigations. The Director of Nursing that was employed at the time of the incident is no longer at the facility. Allegations of Abuse are to be reported within 2 hours after the allegation has been made. During a telephone interview on 3/28/2025 at 1:20PM, the Assistant Director of Nursing stated they could not locate the submission information for the incident on 1/15/2024. The Director of Nursing who is no longer employed at the facility had reported that incident. The Director of Nursing would have submitted the investigation report as well, but they could not provide a confirmation number of that submission. They stated that allegations of abuse should be reported to the Department of Health within 2 hours and the investigative report should be submitted within 5 days depending on the case and if requested. 10 NYCRR 415.4(b)(2)

Based on observations, interviews, and record review during an abbreviated survey (NY00332451), the facility did not ensure that 1 of 3 residents (Resident #4) investigated for abuse received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and resident preferences to promote mental, and psychosocial well-being. Specifically, on 1/29/24, Resident #4 made an allegation of abuse. The Accident and Incident report, nursing notes and care plans documented a referral to psychiatry was made. There was no documented evidence that the referral was completed. The findings included: Resident # 4 had diagnoses that included, but were not limited to status post fall and right elbow injury triad, alcoholic cirrhosis, and hypertension. The Comprehensive Care Plan titled At Risk for Abuse dated 9/21/23 documented the resident will show no signs or symptoms of abuse. The Physician Order dated 9/21/23 documented Psychiatric Consult as needed. The admission Minimum Data Set, dated [DATE] documented intact cognition and no behaviors. The Nursing Progress Note dated 1/29/24 documented Resident#4 reported a rough interaction with the Certified Nursing Aide that provided their cares on 1/29/24. The resident was assessed by the Nurse Practitioner; no overt injury noted. Psychiatric referral made. The Medical Progress note dated 1/29/24 documented no apparent injuries observed during resident assessment. The Certified Nursing Aide was immediately removed from the unit while further investigation was completed. The Accident/Incident Report dated 1/29/24 documented Resident #4 alleged rough handling by the Certified Nursing Assistant during cares on 1/29/24. Registered Nurse assessment completed. Physician orders received for Psychiatric and Social Services follow up. The Investigation portion of the report documented that the immediate actions taken included requesting a Psychiatric Consult. There was no documented evidence of a psychiatric referral or consult related to the incident. The Comprehensive Care Plan titled At Risk for Abuse revised 1/29/24 documented the intervention to refer for psychiatric consultation. During an interview on 3/20/25 at 10:20AM, Psychiatric Nurse Practitioner #4 stated that they only completed one consultation for Resident #4 on September 30, 2023. After an accusation of abuse, they would expect a psychiatric consultation to be requested. They did not receive a referral after the 1/29/24 incident or any other time after. During an interview on 3/20/2025 at 10:45AM with Licensed Practical Nurse Unit Manager #7 stated when a Psychiatric Consultation is requested for a resident and an as needed order for a Consultation is already in place, they send a message to the Director of Nursing to add the resident to the list for the Psychiatric Nurse Practitioner. After the Psychiatric Nurse Practitioner visits, they are informed who as to who was seen. If a visit is missed, they put them back on the list. They were not employed at the facility when Resident #4 was there, so they were not able to provide a reason why the Consultation was not completed. During an interview on 3/20/25 at 12:55PM, Nurse Practitioner #3 stated that they could not recall the specific reason why a Psychiatric Consultation was not performed for Resident #4 after the incident on 1/29/24. They stated they would have requested the consultation given the circumstances of the allegation and there should have been documentation as to why the consultation was not completed. During an interview on 3/20/25 at 3:10 PM, the Director of Nursing stated that they were not employed at the facility at the time of the incident, however after an allegation of abuse they would expect a referral for a psychiatric consultation. During an interview on 3/20/25 at 3:20PM, Registered Nurse Assistant Director of Nursing #2 stated that they remember that Psychiatric referral was made at the time of the incident, but uncertain of specific circumstances as to why it was not done. 10 NYCRR 415.12

Based on record review, and interview conducted during the abbreviated survey (NY00352849) the facility did not ensure that residents remained free from abuse for one of three (Resident #7) reviewed for Abuse. Specifically, for Resident #7 with documented ongoing aggressive behaviors and refusal of medication/s, there was no documented evidence that care plan interventions were evaluated to determine effectiveness to ensure resident safety. Subsequently, on 8/28/2024 Resident #7 propelled their wheelchair hitting another resident as staff assisted the other resident up off the floor and on 9/4/2024 Resident #7 struck Resident #10 in the stomach which caused a fall and resulted in Resident #10 sustaining a left side hematoma of the head, right wrist fracture, left femoral intertrochanteric (hip) fracture. The findings include: Resident # 7 had diagnoses including dementia, anxiety disorder, and psychotic disorder. The 9/20/2023 Care Plan tited At Risk for Abuse documented identify pattern of behaviors and redirect negative behaviors. The care plan was updated on 8/29/2024 to include administer medications as per physician order, and 9/4/2024 notify and report behavior changes to the physician. The 6/18/2024 Care Plan titled Behaviors documented identify behavioral patterns, orient the resident to the daily routine, redirect negative behaviors, and notify the physician of any changes in behavior. The 08/18/2024 quarterly Minimum Data Set (an assessment tool) documented Resident #7 had severe cognitive impairment, did not exhibit behavior and received antipsychotic and antidepressant therapies. The 8/20/2024 Nursing Progress Note documented the resident was at the nursing station very agitated screaming/shouting with provocation. Verbal redirection and de-escalation was unsuccessful. Refused by mouth medications. Attempt to hit residents and staff with items, moved to their room. Resident flipped the wheelchair and attempted to move the bed in the room. Physician made aware. Order received for Ativan 1 mg 1 time dose. Behavior improved. Continue monitoring mood and behavior, safety maintained. The 8/20/2024 Physician Order documented Ativan 2 mg inject 0.5 ml intramuscularly one time. The 8/21/2024 Nursing Progress Note documented refused medications despite encouragement. The 8/26/2024 Nursing Progress Note documented behavioral issue refused medications. The 8/27/2024 Behavior Note documented continues to yell/scream and pour water on the floor. Kicking/screaming and intrusive towards others. The 8/27/2024 Medical Progress Note documented no behavioral concerns from staff-has been agitated and paranoid. Medications reviewed, stable continue current treatment. The 8/28/2024 Accident and Incident Investigation documented at 10:00 PM. Resident #7 had physical contact with another resident, identified as Resident #11. Certified Nurse Aide #6 provided a written statement indicating that Resident #7 accidentally bumped into Resident #11 while propelling their wheelchair. Additionally, a review of the Accident and Incident form from 8/28/2024 revealed that an 11:00 PM-7:00 AM 30-minute monitoring check for Resident #7 was in place. Immediate action residents were separated, and behavioral monitoring initiated. The 8/29/2024 Psychiatrist Progress Note documented this writer was asked to see the resident after an incident with another resident yesterday in which they propelled their wheelchair toward another resident. On interview the resident stated the other resident went into their room and was harassing them. Plan if violent or aggressive in the future please send to the emergency room for evaluation. Recommendations: supportive behavioral interventions, structured recreational activities, strict but supportive limit setting and continued medications. The 8/29/2024 Physician Order documented Seroquel 50 mg by mouth now. The 8/30/2024 Nursing Progress Note documented continues every 30-minute rounds. The 8/30/2024 Nursing Progress Note documented refused all medication, nurse practitioner aware, no new orders. The 8/30/2024 Medical Progress Note documented staff tried to educate the resident on importance of taking medications and the resident responded, yelling they did not need medications. Will continue to explain to the resident as to why they need medications when they are calmer. If the behavior continues the resident was to be evaluated by psychiatry. The 9/1/2024 Nursing Progress Note documented the resident refused to take medications and was aggressive with staff and residents. The 9/2/2024 Physician Order documented Ativan 2 mg inject 0.5 ml intramuscularly one time. The 9/4/2024 Accident and Incident Investigation Statement written by the nurse documented as they were at the nursing station Resident #10 appeared to walk towards Resident #7 then Resident #7 appeared to push Resident #10 to the ground and Resident #10 fell on their right side and had a knot on the right side of the head. The Summary /Conclusion documented on 9/4/2024 at 8:10 AM Resident #10 was walking in the hallway when they walked over and stood in front of Resident #7 who was sitting in a wheelchair in front of the nursing station. Resident #7 attempted to have Resident #10 leave when they accidentally struck Resident #10 in the stomach with their hands. Resident #10 lost their balance and fell to the floor, sustaining a quarter size hematoma to the left side of the forehead, no open area. Resident #10 was sent to the emergency room for evaluation and Resident # 7 was sent to the emergency for psychiatric evaluation. The incident was most likely unintentional since there was no verbal exchange prior or post incident. Resident #10 sustained a right wrist fracture and left intertrochanteric fracture from the fall. There was no documented evidence that Care Plans for Resident #7 were evaluated to determine effectiveness. During an interview on 3/20/2025 at 8:15 AM Certified Nurse Aide #6 stated it was difficult to watch all the residents at times. They stated the home health aides helped to monitor the residents to prevent them from going into other resident rooms and staff often redirected residents to where their rooms were. They stated staff tried to keep residents in the dayroom when they were up. During an interview on 3/20/2025 at 11:14 AM the Director of Recreation stated the resident usually stayed at the nursing station and did not actively participate in activities with other residents. They stated they tried to engage the resident, but the resident had verbal outbursts. They stated the resident behaviors were from too much sensory overload, chaotic environment on the dementia/behavioral unit and to move to another unit was better for the resident. During an interview on 4/18/2025 at 10:40 AM, Registered Nurse Unit Manager #3 stated the behavioral care plan for the resident had not been updated with any new interventions following the incident on 8/28/2024. They stated that behavioral symptoms were monitored on 9/4/2024. The manager stated certified nurse aides were responsible for monitoring residents for physical and aggressive behavior and reporting observations to the nurse. During an interview on 4/18/2025, at 10:55 AM, the Assistant Director of Nursing stated Resident #7 was on behavior monitoring for 30 minutes following an altercation with another resident on 8/28/ 2024 and they were evaluated by psychiatry on 8/29/2024. They stated the care plan for the resident included continue medications, along with regular structured activities that included support and set limits. They stated Resident #7's behavior care plan had not been updated with new interventions after the incident on 8/28/2024. They stated staff members rounded on the resident's unit to monitor behavior, but they were unable to locate the monitoring sheets for that resident. During an interview on 4/18/2025 at 1:45 PM, the Psychiatric Nurse Practitioner stated when Resident #7 deviated from baseline or showed signs of escalation they recommend the resident be sent to the hospital for evaluation. They stated when observed by them, Resident #7 was always in bed and did not display aggressive behavior. They stated the facility should have implemented behavioral interventions to address the needs of the resident. During a telephone interview on 4/21/2025 at 2:41 PM, the Director of Social Work stated there was a delay in moving Resident #7 from the behavior unit due to a lack of available beds. The Director of Social Work stated staff did their best to support the resident and ensure the safety of all residents by closely monitoring activities. 10 NYCRR 415.12 (h)(1)

Based on record review and interviews during an abbreviated survey (NY00355610, NY00353621, NY00356241) the facility did not ensure residents' right to be free from abuse for 4 of 4 residents (Resident #1,#2, #3, #4) reviewed for abuse. Specifically, (1) on 9/7/2024 Resident #1 who was assessed as having aggressive behavior walked up to Resident #2 in the dining room and pushed them from behind. Resident #2 complained of back pain, was given Tylenol, and sent to the emergency room for evaluation. On 9/26/2024 Resident #1 struck Resident #2 on the right ear, and they sustained an abrasion. First aid was administered to Resident #2, and Resident #2 was transferred to the emergency room for further evaluation. The corrective action for both incidents with Resident #1 and Resident #2 documented to keep the residents separated. There were no specific interventions on the care plan to address the behaviors and the investigation concluded that there was no cause to believe any alleged resident abuse or mistreatment occurred. (2) On 10/3/2024 during staff rounds at 11:20PM, Resident #3 and Resident #4 who had been identified as severely cognitively impaired and wanderers were found in bed together. Resident #3 was observed lying on Resident #4 in a supine position with their shirt on and pants pulled down to their knees. Resident #4 was transferred to the emergency room for evaluation following the incident and Resident #3 was transferred to another unit and placed on 1:1 supervision for 72 hours.There was no specific interventions on the care plan to address the residents' wandering behaviors prior to the incident. The investigation concluded that there was no cause to believe any alleged resident abuse or mistreatment occurred. The findings are: The Facility Abuse Policy-Prevention and Management last reviewed 8/2024 documented the facility prohibits the mistreatment and abuse of residents by anyone including staff, family friends, visitors, etc. The Facility has designated and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse. The facility must provide a safe environment and protect residents from abuse. A resident-to-resident altercation should be reviewed as a potential situation of abuse. A mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. 1)Resident #1 was admitted on [DATE] and last readmitted on [DATE] with diagnoses including but not limited to Schizophrenia, Muscle Weakness and Anxiety Disorder. A Quarterly Minimum Data Set (an assessment tool that measures health status) dated 8/23/2024 documented the resident had severe cognitive impairment. No behaviors noted. The Resident was ambulatory and required supervision with eating, toileting, bed mobility and transfers. Review of a resident-to-resident altercation-aggressor care plan initiated 5/18/2024 and last revised 9/28/2024 documented Resident # 1 was physically aggressive and attempted to hit another resident. Interventions listed on 5/18/2024 included - ensure the safety of the resident, other residents, and staff members. Interventions listed on the 9/7/2024 care plan included -keep separated from Resident #2 at all times. Resident #1 was sent to the hospital for a psychiatry evaluation on 9/28/2024. Review of a behavior symptoms-physical abuse care plan dated 9/26/2024 documented Resident #1 will show a decrease in episodes of physical abuse. Interventions listed included to notify and report behavioral changes to physician and transfer to the emergency room for further evaluation. Review of the accident/incident investigation dated 9/7/2024 documented at 1:15 PM Resident #1 got up from a chair in the dining room, walked over to Resident #2 and pushed them from behind. The investigative summary documented Resident #1 was involved in an altercation with Resident #2 on the unit, they were kept separated by staff. No visible injury. The investigation summary concluded there was no cause to believe any alleged resident abuse, neglect or mistreatment had occurred. Review of an accident/incident report dated 9/26/2024 at 8:15 AM documented Resident #2 reported to the Registered Nurse on the unit that they were struck on the ear by another resident on the unit. Resident #2 was noted to have a small abrasion to the right auricle, no other injuries were noted. The physician ordered to send Resident #2 to the emergency room for evaluation. The investigative summary documented Resident #2 reported that Resident #1 struck them on their right ear, small abrasion noted. Ear cleansed with normal saline, and Band-Aid applied with bacitracin. The physician ordered for the Resident#2 to be transferred to the emergency room for further evaluation. The investigation concluded there was no cause to believe any alleged resident abuse, neglect or mistreatment had occurred. 2) Resident #2 was admitted with diagnoses including but not limited to Dementia, Age-related Cognitive Decline and Muscle Weakness (generalized). A Quarterly Minimum Data Set (an assessment tool that measures health status) dated 8/27/2024 documented the resident had severe cognitive impairment. The resident required a walker for locomotion. The resident required set up assistance for eating and bed mobility and supervision for toileting and transfers. Review of a resident-to-resident altercation (victim) care plan initiated 2/20/2024 documented Resident #2 would be kept apart from other residents. Interventions listed included investigate all injuries to resident. Review of a behavior care plan initiated 5/28/2024 documented Resident #2 will have a reduction in behavior episodes. Interventions listed included monitor for changes in mood behavior, psychiatric consult, re-direct as needed and remove from others when angry. Review of the accident/incident investigation dated 9/7/2024 at 1:15 PM documented Resident #2 had an altercation with Resident #1. Resident #2 complained of back pain and was medicated with Tylenol and transferred to the emergency room for evaluation. The investigative summary documented Resident #2 had an altercation with Resident #1 and they were kept separated. Resident #2 returned to the facility. The investigation concluded that there was no cause to believe any resident abuse, neglect or mistreatment had occurred. Review of an accident/incident report dated 9/26/2024 at 8:15 AM documented Resident #2 reported to the Registered Nurse on the unit that they were struck on the ear by another resident on the unit. Resident #2 was noted to have a small abrasion noted to the right auricle, no other injuries were noted. The physician ordered to send Resident #2 to the emergency room for evaluation. The investigative summary documented Resident #2 reported that Resident #1 struck them on their right ear, small abrasion noted. Ear cleansed with normal saline, and Band-Aid applied with bacitracin. The investigation concluded there was no cause to believe any alleged resident abuse, neglect or mistreatment had occurred. 3) Resident #3 was admitted with diagnoses including but not limited to Dementia, Adjustment Disorder and Cognitive Communication Deficit. A Quarterly Minimum Data Set (an assessment tool that measures health status) dated 9/25/2024 documented the resident had severe cognitive impairment. The resident was independent with eating and bed mobility and required supervision with toileting and transfers. Review of an at risk for elopement care plan dated 4/17/2023 documented Resident #3 was at risk for elopement due to their diagnosis of Dementia and ambulatory status. The goal as of 5/20/2023 documented Resident #3 would have decreased episodes of wandering evidenced by increased participation in supervised therapeutic activities. Interventions listed included place resident next activity staff during programs, provide verbal cues and redirect as needed and provide escort to therapeutic activities of choice and meals. Review of a cognitive communication deficit care plan dated 4/22/2023 documented Resident #3 would maintain present level of communication. Interventions listed included allow increased time for resident to respond, ask yes or no questions, provide non-distracting environment, and talk to resident while providing care. Review of an accident/incident report dated 10/3/2024 at 11:20 PM documented Resident #3 was observed lying on Resident #4's in a supine position with their shirt on and pants pulled down to their knees. A body assessment was done and there were no signs of trauma, swelling redness or skin break down noted. The immediate intervention documented frequent rounding and close observation. .The investigative summary dated 10/3/2024 documented Resident #3 was observed lying on Resident #4 in a supine position with shirt on and pants pulled down to their knees. Body assessment done, no signs of any trauma, swelling, redness or skin break noted. The investigation concluded that there was no cause to believe any alleged resident abuse, neglect or mistreatment has occurred. 4) Resident #4 was admitted with diagnoses including but not limited to Dementia, Cerebral Infarction and Altered Mental Status. An End of Stay Prospective Payment System Minimum Data Set (an assessment tool that measures health status) dated 9/3/2024 documented the resident had severe cognitive impairment. The resident was independent with eating, toileting, bed mobility and transfers. Review of a behavior care plan initiated 10/3/2024 documented Resident #4 was observed in the bed with another resident. Interventions listed included assess for an sign and symptoms of trauma/pain, hospital transfer as needed, monitor for changes in mood/behavior, offer emotional support and reassurance as needed, provide opportunity to express feelings and concerns, and re-direct as needed. Review of a at risk for abuse care plan last revised 10/4/2024 documented Resident #4 would show no signs of physical abuse. Interventions listed included assessment and body checks are indicated, family notification, offer emotional support as needed and redirect negative behavior. Review of a cognitive impairment care plan initiated 7/4/2024 documented Resident #4 had a Brief Interview of Mental Status score of 3 with severe impairment in making decisions regarding daily life. Review of an at risk for elopement care plan dated 7/4/2024 documented Resident #4 was at risk for elopement. The goal dated 7/5/2024 documented Resident #4 would have decreased episodes of wandering evidenced by increased participation in supervised therapeutic activities. Interventions listed included place resident next activity staff during programs and provide verbal cues and redirect as needed. The investigative summary dated 10/3/2024 documented on 10/3/2024 at approximately 11:20 PM, Resident #4 was observed lying with Resident #3 side by side. Body check done. No signs of any trauma. Swelling, redness or skin break down noted. Denies any pain/discomfort. No indication of pain/discomfort. No signs/symptoms of fear/emotional distress noted. The investigation revealed that here is no cause to believe any alleged resident abuse, neglect or mistreatment has occurred. Review of an accident/incident investigation dated 10/4/2024 documented the following interventions: staff intervened immediately, investigation initiated, the Administrator and the Director of Nursing notified, nurse manager body assessment completed, Resident #4 was transferred out to the emergency room for further evaluation and returned within 12 hours, law enforcement was notified, social services notified and assessed the residents and no signs of psychosocial harm, psychiatry and psychology follow up requested, families notified, Resident #3 was transferred to a different unit immediately and was placed on one to one for 72 hours for monitoring. During an interview on 12/30/2024 at 9:23 AM, Registered Nurse #1 stated they've been working in the facility since May 2023 as the supervisor covering unit 2 East. Registered Nurse #1 stated on 9/7/2024 and 9/26/2024(the days of the incidents), they were covering 2 [NAME] as well. Registered Nurse #1 stated Resident #2 reported they were pushed from behind by Resident #1 and complained of back pain. The resident was given Tylenol and the physician ordered to transfer the resident to the hospital for further evaluation. Registered Nurse #1 stated on 9/26/2024 Resident #2 reported to them that they were struck on the right ear by Resident #1. Registered Nurse #1 stated Resident #2 had a small abrasion on their right ear and the physician was notified and ordered to transfer the resident to the hospital for further evaluation. Registered Nurse #1 stated the incident was unwitnessed and the residents were separated and assessed for injury after the incident. Registered Nurse #1 stated a pain assessment, and a skin assessment were also completed. Registered Nurse #1 stated in their opinion, the incidents that occurred on 9/7/2024 and 9/26/2024 were abuse, because in both incidences Resident #2 was hurt by Resident #1. During an interview on 12/30/2024 at 12:27 PM, the Assistant Director of Nursing #1 stated they are responsible for completing the investigative summary conclusion and that abuse is suspected if a resident is found with an injury of unknown origin, a resident-to-resident altercation or there is a report of abuse. The Assistant Director of Nursing #1 stated Resident #1's Brief Interview of Mental Status score was low, and they do not feel that the resident had any intention to harm Resident #2. The Assistant Director of Nursing #1 stated Resident #1 has a long history of psychiatric problems, but they do not feel that they were intentionally trying to hurt anyone. Resident #1 does not have the capacity to foster intent to harm and they separated the residents after the incident. The Assistant Director of Nursing #1 stated they do not think Resident #1 is out to hurt anyone and they feel it is the resident's way of getting someone to look at them or respond to them. The Assistant Director of Nursing #1 stated Resident #1 even comes up to the staff and taps them on the arm, trying to get the staff to give them attention. The Assistant Director of Nursing #1 stated this is why their investigation conclusions revealed there was no cause to believe any alleged resident abuse had occurred. During an interview on 12/30/2024 at 12:53 PM, the Administrator stated they have been in the facility for 1 year and 1 month now. The Administrator stated their process of handling resident-to-resident incidents depends on the severity of the incidents. The Administrator stated they ensure all residents are safe, and staff immediately separate the residents involved in the incident. The Administrator stated if the incident is behavior related or a resident sustains an injury, then they will send the resident to the hospital for evaluation and notify the physician and the resident's families. The Administrator stated basically they will follow the protocol for incident and accident. The Administrator stated Resident #3 and Resident #4 had dementia and when they were found together in bed, they were separated. Resident #3 was immediately moved off the Dementia unit and the residents were found to have no injuries or evidence of trauma after they were assessed by the physician. Resident #4 was sent out to the hospital for evaluation and there were no signs of penetration. The Administrator stated neither resident was able to state what occurred and the facility could not prove they knew what they were doing. During a telephone interview on 1/10/2025 at 9:35 AM Certified Nurse Assistant #1 stated all the residents on the Dementia unit walk up and down the halls, but the residents had never been seen in that manner before. During a telephone interview on 1/24/2025 at 2:49 PM the Assistant Director of Nursing #1 stated rounds are done regularly on the dementia units. If there is something that needs behavior monitoring, the resident is placed on continuous monitoring or 1:1 supervision. The Assistant Director of Nursing #1 stated 1 to 1 monitoring and close supervision is also provided when a resident needs more support or if they are exhibiting behaviors. The Assistant Director of Nursing #1 stated there is recreational programs for the residents and home health aides are assigned on the unit to monitor the residents. The Assistant Director of Nursing #1 stated Resident #3 and Resident #4 were on a locked unit so there was always some type of supervision being provided. The frequency of the rounds on the Dementia unit varies from every 15 minutes, to hourly, to every 2 hours. When residents are in bed, rounds are made regularly. The Assistant Director of Nursing #1 stated they are not sure how Resident #3, and Resident #4 ended up in bed in Resident #4's room, but they were not there and cannot say for sure. The Assistant Director of Nursing #1 stated Resident #3 was placed on continuous 1:1 monitoring for 72 hours after the incident. The Assistant Director of Nursing #1 stated Resident #3 is quick and there have been no further incidents with Resident #3 since the incident on 10/3/2024. Resident #3 and Resident #4 are back to their normal selves. 10 NYCRR 415.4(b)(1)(i)

Based on observation, interview and record review, the facility failed to prevent the development, and subsequent deterioration, of avoidable pressure sores (pressure ulcers) for residents who were assessed to have risk for the development of pressure sores (Residents #136 and #188). Specifically: 1) a) Failure to identify and address individual risk factors for a resident who was placed on bed rest to promote healing of an existing pressure sore resulted in the onset of two new pressure sores and b) Failure to promptly identify, report, assess, revise care plan interventions and appropriately treat these newly developed pressure sores resulted in deterioration to Stage 3 pressure sores for Resident #136. 2) a) Failure to identify and address specific risk factors for a resident with limited mobility following hip surgery resulted in the development of a Stage 2 pressure sore with mild pain on the resident's heel. b) Failure to develop effective care plan interventions following discovery of the Stage 2 pressure sore resulted in deterioration to an unstageable, infected pressure sore with mild pain for Resident #188. This was evident for two out of three residents with facility acquired onset of pressure sores out of fourteen residents with pressure sores and resulted in actual harm that was not immediate jeopardy (Residents #136 and #188). The findings are: 1. Resident #188 is [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nursing Admission/Re-Admission record completed on 2/10/14, hospital transfer records including the Patient Review Instrument of 2/10/14 and the facility Physician's Admission record of 2/11/14 indicated that the resident had no pressure sores at the time of admission. The Braden Scale (used for predicting pressure ulcer risk) assessment conducted on 2/10/14 identified the resident to be at risk for development of pressure ulcers with a score of 18 (a risk score of 15-18 indicated that the resident was at risk). An addendum to this risk assessment record directed that frequent turning, maximal remobilization, protection of the heels and use of a pressure-reduction support surface if the resident was bed or chair-bound should be implemented for a resident at risk. The facility Pressure Ulcer Prevention and Management protocol also instructed to initiate turning and positioning every two hours, use of heel protection, "heel ups", off-loading of heels off the bed surface and the use of pressure redistribution support surfaces such as an air mattress and gel cushion on the chair. The resident's care plans for Impaired Skin Integrity and Total Hip Precautions were initiated on 2/11/14 and had numerous interventions including to assess and document the resident's skin condition on weekly skin rounds. There was no documented evidence that interventions were developed or addressed in the care plans for turning and repositioning or off-loading of pressure to the resident's heels. There was no documented evidence that the resident was educated about turning and positioning, off-loading of pressure to the heels or other methods of pressure sore prevention. According to the admission MDS (Minimum Data Set; a resident assessment tool) of 2/17/14, the resident had a BIMS (Brief Interview for Mental Status) score of 15 out of 15 on a test used to measure attention, orientation and ability to recall information. The MDS assessment identified that the resident had no pressure ulcers but was at risk of developing pressure ulcers. The MDS assessment also noted risk factors including immobility and dependence on others to perform activities of daily living, specifically, that the resident was non-ambulatory, had functional limitation in range of motion of the lower extremity on one side and required extensive assistance with bed mobility, transferring, personal hygiene, dressing and toileting. Certified Nursing Assistant's Activities of Daily Living flow sheets indicated that the resident was turned and repositioned on 7 of 57 shifts for the period from 2/11/14 to 2/28/14. There was no documented evidence in the flow sheets that devices or measures were in place to off-load pressure from the resident's heels during that period of time. An entry in the Nursing Progress Notes revealed that a Stage 2 pressure ulcer was noted on the resident's left heel on 3/4/14. (The nurse who documented this entry was not available for interview). The Nurse Practitioner then ordered to "float heels on pillow while in bed, otherwise open heel shoes to left heel while out of bed." A subsequent note in the Skin Integrity Wound Care Record indicated that the pressure ulcer on the left heel had deteriorated to an unstageable pressure ulcer on 3/7/14. The use of [MEDICATION NAME] (an oral antibiotic) and Santyl (an ointment used for wound cleaning and removal of nonliving tissue) were initiated. 3/7/14 physician's orders [REDACTED]. There was no documented evidence in the resident's care plan that interventions for turning and positioning, boots, pillows, "heel ups" or other means of off-loading of pressure on the resident's heels were initiated following identification of the Stage 2 pressure ulcer or deterioration to an unstageable pressure ulcer. The CNA accountability documentation record for March 2014 had instructions for the use of heel ups when the resident was in bed. There was no documented evidence in the Certified Nursing Assistant's Activities of Daily Living flow sheets that prescribed off-loading boots, a pillow, heel up device, or other measures were in place to off-load pressure from the resident's heels. Additionally, the flow sheets indicated that the resident was turned and repositioned on 11 of 48 shifts from 3/1/14 to 3/16/14. An entry in the Skin Integrity Wound Care Record, dated 3/13/14, identified that the left heel ulcer had not improved, "base now with eschar and with pain...aggressive wound care in place..." Additionally, an Interdisciplinary Progress Notes entry, dated 3/14/14, noted, "left heel necrotic (dead tissue) area 4 cm long x 4 cm wide, skin intact, tender to touch, treatment continues." The resident was observed in bed on 3/14/14 at 7:45 AM. No boot, pillow, heel up, specialty pressure relief mattress, other device or means of off-loading pressure from the bed surface for the resident's heels was in place. The Licensed practical Nurse assigned to the resident's care (LPN #5) was interviewed on 3/14/14 at 8:00 AM, following the above observation. LPN #5 stated that the resident had a heel up pressure relieving device but that it was in the closet because the resident had refused to use it. There was no documented evidence that use of a heel up device had been attempted, that the resident had refused use of the device or that the resident had been educated about the benefits of a heel up device, pillow or boot in pressure ulcer prevention. The resident was again observed in bed on 3/17/14 at 7:25 AM and 7:50 AM. No boot, heel up, pillow, or other device for off-loading pressure on his heels was in place. The Registered Nurse MDS coordinator (RN #5), who stated that she was responsible for initiating the resident's care plans at the time of admission, was interviewed on 3/17/14 at 8:15 AM. RN #5 stated the she assessed the resident with a functional limitation of range of motion of the left lower extremity following the hip surgery and admission. RN #5 stated that the resident had risk factors for developing pressure ulcers including that he had a slight pedal [MEDICAL CONDITION] and required the extensive assistance of one person with bed mobility, transfer, toileting and personal hygiene. RN #5 further stated that she did not consider the use of any off-loading measures for the resident's heels or pressure-relieving devices for the resident's feet at the time of the admission assessment and care plan development following the left hip surgery. RN #5 stated that the team was waiting for the Nurse Practitioner (NP) to recommend appropriate pressure-relieving devices because of the left [MEDICAL CONDITION] and surgery. RN #5 stated that it was not until 3/4/14 (twenty-two days after admission on 2/10/14), when the resident had already developed a Stage 2 heel pressure ulcer, that a heel-up device or heel protector was recommended. The Nurse Practitioner (NP) was interviewed on 3/17/14 at 8:55 AM and stated that a complaint by the resident led to the discovery of the pressure sore on his heel. The NP stated that the resident informed a nurse that he had left heel pain, the nurse then inspected the heel and documented in the communication book that the resident had a small opening about the size of a quarter on the left heel, the NP read the communication book and assessed the resident's skin on 3/4/14. The NP stated that, upon inspection on 3/4/14, the resident had developed a Stage 2 pressure ulcer on the left heel and that the NP then ordered to "float heels on pillow while in bed, otherwise open heel shoes to left heel while out of bed." Additionally, The NP stated that the resident was complaining of slight heel pain, the pressure ulcer had subsequently developed eschar formation and looked infected which required initiation of an antibiotic. The NP further stated that she was not contacted by the MDS coordinator, any nursing staff member or other member of the team to order any pressure-relieving devices after the resident's recent left hip surgery and admission. During a dressing change observation on 3/17/14 at 9:15 AM, the left heel pressure ulcer measured approximately 4 cm x 4 cm, was noted to have black eschar formation on the wound bed and slight redness of the surrounding area. The resident stated, during the dressing observation, that his left heel felt tender, had minimal pain and that he was unable to step or put pressure on his left foot without the use of a specially made shoe provided by Physical Therapy. The current Registered Nurse unit manager (RN #2) was interviewed on 3/18/14 at 8:00 AM. RN #2 stated that the former RN unit manager (RN #1) was responsible for ensuring that the resident's care plan was updated to include new interventions to address the new pressure ulcer. RN #2 stated that pillows were used when the stage 2 pressure ulcer developed and a heel up foam device was applied when it became unstageable. RN #2 further stated that an air mattress, turning and repositioning and use of heel protectors should have been implemented prior to the development of the Stage 2 pressure ulcer on 3/4/14. During further interview, RN #2 stated that the Certified Nurse Aides assigned to care for the resident were supposed to remove the resident's socks to inspect his feet every shift. CNA #1, who was assigned to care for the resident on the 7-3 day shift on 3/3/14 and 3/4/14, prior to the discovery of the pressure ulcer, was interviewed on 3/17/14 at 10:00 AM and on 3/18/14 at 9:25 AM. CNA #1 stated that the resident was turned and positioned when she cared for him but could not say how often she turned and repositioned the resident. CNA #1 stated that, during morning care on 3/3/14 and on 3/4/14, the resident told her to be careful with his left foot. CNA #1 stated that she did not remove the resident's sock to see what was going on. CNA #1 further stated that the 11-7 night shift CNA (CNA #2) usually assisted the resident to dress and put on his socks in the morning. CNA #1 stated that, during her tour with the resident, she did not remove the resident's socks to inspect the resident's feet to ensure that the resident had no skin breakdown. CNA #1 further stated that there was no need to inspect the resident's skin, including the feet, because the 11-7 shift CNA (CNA #2) had informed CNA #1 that there was nothing new or anything wrong with the resident. CNA #2, who was the assigned to care for the resident on the 11-7 night shift on 3/3/14, was interviewed via telephone on 3/18/14 at 11:40 AM. CNA #2 stated that she did not recall the frequency that the resident was turned and repositioned. CNA #2 stated that she helped the resident to dress and put on his socks on the morning of 3/4/14. CNA #2 stated she did not observe any skin breakdown on the resident's left heel. The Physical Therapist was interviewed on 3/18/14 at 11:55 AM and stated that he initiated use of a heel-relief orthotic shoe when the pressure ulcer on the left heel was identified so that the resident would be able to ambulate without causing pressure or pain on the left heel. 2. Resident #136 has [DIAGNOSES REDACTED]. According to the comprehensive MDS (Minimum Data Set) assessment dated [DATE], and the most recent quarterly MDS assessment dated [DATE], the resident required extensive assistance to perform activities of daily living was frequently incontinent and had no functional loss in range of motion. The resident's comprehensive care plan was dated 1/7/14 and was revised on 2/24/14. The care plan noted that the resident was at risk for pressure sores related to Diabetes, incontinence, friction and shearing and that the resident had a Stage 2 pressure sore on the right buttock. Interventions included assessment of risk factors and use of a pressure reducing mattress. The resident was observed lying on her side in bed with a pressure reducing mattress in place during random observations on 3/14/14. Clinical record review revealed a note entered by a Licensed Practical Nurse (LPN #1) on 3/16/14 at 8:00 AM. The entry stated that a Certified Nurse Aide called LPN #1 to observe the resident's knees, which showed the presence of reddened areas, and a pillow was placed between the resident's knees to off-load pressure. There was no documented evidence that a Registered Nurse, Nurse Practitioner, Physician or any qualified health professional was promptly notified of the new onset of potential pressure sores. There was no documented evidence that the potential pressure sores were assessed or that treatment was ordered. The care plan was not revised to include the use of a pillow or other interventions to address off-loading of pressure to the resident's knees or to promote healing of the pressure sores on the resident ' s knees. The resident was observed in bed on 3/17/14 at 11:55 AM. No pillow was in place between the resident's knees. Gauze dressings were wrapped around each of the resident's knees. A Licensed Practical Nurse (LPN #2) provided care to the resident at that time. LPN #2 removed the wrapped gauze from each knee and an open area with a visible application of ointment was noted on each knee. LPN #2 identified the ointment as [MEDICATION NAME]. The resident's current physician's orders [REDACTED]. LPN #2 then described the open areas on each knee as Stage 1 pressure sores that occurred as a result of the resident's knees coming in direct contact with each other. (This description was inconsistent with the definition of a Stage 1 pressure sore as the skin is intact in Stage 1 pressure sores). Following the observation above, a unit Registered Nurse (RN #4) observed the wounds on the resident's knees in the presence of LPN #2. RN #4 stated that she was not aware of the onset of the wounds and that they were not Stage 1 pressure sores. RN #4 stated that she would have the Nurse Practitioner (NP) assess the wounds. LPN #1 was interviewed on 3/17/14 at 11:58 AM and stated that she did not verbally inform an RN or other professional of the presence the reddened areas on the resident's knees and did not include the change in skin condition in the 24-Hour Report. LPN #1 stated that she documented her observation in the communication book for the Nurse Practitioner (NP). The NP then assessed the resident ' s skin condition, upon request approximately 28 hours after redness of the resident ' s knees was identified. The NP documented the following pressure sores in the Skin Integrity Wound Care Record: -Right medial knee: Stage 3, measuring 1.5 cm x 1.0 cm with 90% granulation and 10% eschar; surrounding skin to be [DIAGNOSES REDACTED] (redness) - Left medial knee: Stage 3, measuring 1.5 cm x 1.0 cm with 90% yellow brown plaque and 10% red surrounding skin. The NP was interviewed after assessment of the resident's pressure sores. The NP stated that she had no knowledge of the development of these pressure sores. The NP further stated that there was no specific schedule or time for review of the communication book. RN #4 was further interviewed on 3/18/14 in the morning. RN #4 stated that the resident had been placed on bed rest for the past five days or so and was being turned from side to side to promote healing of the pressure ulcer on her buttock. (The pressure sore on the buttock was assessed to be unstageable and to measure 3 cm x 2 cm on 3/13/14). Additionally, RN #4 stated that LPN #1 should have promptly informed an RN on duty of the change in the skin condition of the resident's knees on 3/16/14. There was no documented evidence that the potential for pressure from both knees being in direct contact was identified as a risk factor for the development of pressure sores, particularly after the resident was placed on bed rest, and that the resident's care plan was revised to address this risk factor. 415.12(c)(1)

Based on observation, interview and record review, significant errors in the administration of pain medications occurred in that these medications were not administered in a timely manner to relieve severe pain experienced by a resident. This resulted in actual harm that is not immediate jeopardy for one Resident #220. The findings are: An agency LPN (Licensed Practical Nurse) was observed preparing to give medications to Resident #220 at 9:29AM on 2/17/11. At that time, the resident stated that she had "a lot of pain." The LPN asked the resident to rate her level of pain on a scale of 1 - 10 and the resident stated that she had a pain level of 8. The LPN looked in the medication cart for a tablet of [MEDICATION NAME], a narcotic medication that was ordered for the resident to be given as needed for pain. The [MEDICATION NAME] was not available. The LPN then told the RN Nurse Manager that the resident had generalized pain and that the [MEDICATION NAME] was not available. The LPN stated that the resident also had an order for [REDACTED]. The LPN informed the resident, at 9:38AM, that the RN was arranging to get the medication and that she would have it soon. The resident stated, "Please get the medicine because it's a lot of pain." The LPN then prepared medications and gave them to another resident. At 9:48AM, the RN informed the LPN that she had gotten an order for [REDACTED]. The LPN did not immediately go to the resident to administer her [MEDICATION NAME]. The LPN began a lengthy procedure of preparing medications for another resident (Resident #219) at 10:02AM, including crushing numerous medications for administration via a feeding tube. At 10:29AM, a CNA (Certified Nurse Aide) came and told the LPN that Resident #220 was unable to get up because she needed her pain medicine first. The LPN stated that she just got the resident's pain medicine and would give it to her soon so that she could get up (The LPN had the [MEDICATION NAME] for 30 minutes as of that time). The LPN then finished preparing and administered medications to Resident #219 at 10:39AM, including giving him eye drops and a respiratory treatment. The LPN then proceeded to the room of Resident #220 at 10:41AM. The LPN left the room to retrieve the blood pressure machine. At that time, the surveyor observed the resident in bed with slight facial grimacing and some generalized tension of her muscles. The surveyor asked the resident how would she rate her pain on a scale of 1 - 10? The resident stated, "Now, it's a 10. Today it has been bad, a 10 now." The LPN returned with the blood pressure machine at 10:44AM and took the resident's vital signs. At that time the resident stated, "I'm in a lot of pain." The LPN prepared multiple medications and administered them along with the [MEDICATION NAME] at 10:52AM, 83 minutes after the resident had stated that her pain level was 8 and 53 minutes after the pain medicine had been available for the LPN to give to the resident. The resident stated, "Was that the pain medicine? I'm in a lot of pain." The LPN then stated that she needed to apply a [MEDICATION NAME] to the resident's skin for local pain control in the affected area of the resident's body. The LPN stated that she did not know where to apply the patch because she did not know what was the resident's affected area. The LPN stated that there were no instructions in the medication book to indicate where to apply the patch and that she needed to find out where the resident's patch went. The resident's current 2/17/11 Physician's Medication Orders and Medication Administration Records (MAR) were then reviewed and included instructions to apply a [MEDICATION NAME] daily and to remove it after 12 hours, putting it on at 9:00AM and taking it off at 9:00PM. The resident's Physician's Admission/Readmission Evaluations, completed on 1/24/11 and 2/17/11 stated that the resident had neck and upper back pain. The LPN was interviewed at 12:15PM on 2/17/11 regarding the delay in administering [MEDICATION NAME] to the resident when she was experiencing severe pain. The LPN stated that she should have given the [MEDICATION NAME] to the resident as soon as the RN obtained it. She stated that she felt badly that the resident was in pain and that she had apologized to the resident for not having the medication available right away. She stated that she did not give the medication to the resident right away because she is not familiar with the residents on this unit and she was overwhelmed. The LPN was also interviewed at that time, 12:15PM, regarding application of the resident's [MEDICATION NAME] that was scheduled to be applied at 9:00AM. The LPN stated that she had not yet applied the [MEDICATION NAME] because she reviewed the resident's MARs and asked other nurses on the unit and she had still been unable to determine where the patch was intended to be applied. The LPN was further interviewed at 1:40PM on 2/17/11. She stated that, at 1:00PM, she asked the resident where was the location of her pain and the resident stated it was in her right shoulder and back area, so she applied the patch to that area. The RN was interviewed at 1:50PM on 2/17/11. She stated that the resident's [MEDICATION NAME] should be applied for pain in the upper right side of her back by her neck. She stated that the LPN had not asked her about the placement of the resident's patch and she had not been informed that there was a delay in administration of the [MEDICATION NAME] or the [MEDICATION NAME]. 415.12(m)(2)