Every finding on record at St Johnsville Rehabilitation and Nursing Center

Based on observations, record review and interviews conducted during the recertification survey, the facility did not ensure each resident was treated with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of their quality of life for two (2) (Resident #s 11 and 86) of 24 residents reviewed. Specifically, (a.) Resident #11 foley's catheter bag was exposed; (b.) Resident #86 heard Certified Nurse Aide #1 and Certified Nurse Aide #2 stated they had to wait and be the last one for care because they were so slow. Certified Nurse Aide #2 when asked to remove a raised toilet seat before Resident #86 used the bathroom, they replied, 'no, I am not breaking my back.' Resident #86 stated in both instances they were offended. This is evidenced by:The facility's Policy and Procedure titled, Resident Rights, revised 04/15/2025, documented residents at the facility, in accordance with Federal regulation (42 Code of Federal Regulation 483.13) and New York State Title 10 Health Code will be provided care that is dignified and in accordance with the Residents Rights. The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality.Residents have the right to be treated with dignity, respect and consideration at all times. Privacy in the treatment and care of your personal needs. Staff should interact with the resident in ways that maintain and enhance their self-esteem and self-worth. Respecting residents by speaking respectfully focusing on residents as individuals when they talk to them and addressing residents as individuals when providing care; refraining from practices demeaning to residents such as keeping urinary catheter bags uncovered, refusing to comply with a resident's request for toileting assistance.Resident #11Resident #11 was admitted to the facility with diagnoses of disease of the digestive tract, obstructive uropathy (a condition where the flow of urine is blocked, leading to the accumulation of urine in the urinary tract), and Alcoholic Cirrhosis (a late-stage, severe liver disease caused by heavy, prolonged alcohol use, where healthy liver tissue is replaced by permanent scar tissue). The Minimum Data Set (an assessment tool) dated 07/25/2025 documented the resident's cognition was intact, able to be understood and be understand others.During an observation on 08/25/2025 at 12:32 PM, Resident #11 came out of their room for lunch. Urinary catheter bag underneath wheelchair was not concealed in a dignity bag, and at times dragged on the floor.During an observation 08/25/2025 at 12:32 PM, Resident #11 came out of an Activity Room with their urinary catheter bag underneath their wheelchair; The catheter bag was not concealed in a dignity bag and at times dragged on the floor.During an interview on 08/28/2025 at 11:35 AM, Certified Nurse Aide #3 stated the catheter bag should have been in another bag and not dragging on the floor. They stated that they were unaware the catheter bag was not concealed and would immediately place the bag in a dignity bag. Certified Nurse Aide #3 also stated Resident #11 at times removed the catheter bag from the dignity bag leaving it exposed.During an interview on 08/29/2025 at 10:45 AM, Licensed Practical Nurse #2 stated the Certified Nurse Aides got residents up and dressed for the day and was not always sure if they placed catheter bag in a dignity bag. Licensed Practical Nurse #2 stated catheter bags should always be concealed for dignity, and if they noted bag was exposed, they would immediately place the catheter bag in a dignity bag. Resident #86Resident #86 was admitted to the facility with diagnoses of acute kidney failure (a condition where the kidneys suddenly lose their ability to function properly), heart failure (a condition where the heart cannot pump blood effectively enough to meet the body's needs), and chronic obstructive pulmonary disease (a group of lung diseases that cause ongoing airflow obstruction and breathing problems). The Minimum Data Set, dated [DATE] documented the resident's cognition was intact, could be understood and be understand others.The Comprehensive Care Plan titled; Activities of Daily Living, dated 4/18/2024, documented Resident #86 required assistance with Activities of Daily Living functions related to obesity, lymphedema, failure to thrive, and weakness. Interventions included: Dressing- Footwear: Substantial/maximal assistance Dressing: Lower Body: Substantial/maximal assistance Lying to Sitting: Partial/Moderate assistance; Toilet Hygiene: Dependent.During an interview on 08/26/2025 at 10:12 AM, Resident #86 stated on Saturday, 8/23/2025, they had their light on at 3:00 PM, and no one came to help until 9:00 PM. They stated their roommate was helped between 3:00 PM and 9:00 PM. Resident #86 stated Certified Nurse Aide #1 came in at 8:00 PM and told Certified Nurse Aide #2 that the reason they had left Resident #86 for last was because they took too long. They stated Certified Nurse Aide #1 told Certified Nurse Aide #2 the resident sat in the bathroom for 45 minutes. Resident #86 stated they could not control the amount of time they took in the bathroom. Resident #86 stated when they stood up at 9:00 PM, they lost their water (urinated down their legs). Resident #86 stated when they put their light on, the aide was supposed to help them to the bathroom. Resident #86 stated their roommate's commode was over the toilet seat and they told Certified Nurse Aide #2 that they did not use that. Certified Nurse Aide #2 then told the resident, Well, I'm not breaking my back to move it. Resident #86 stated they pulled the commode off the toilet themselves so they could use the toilet. Resident #86 stated Certified Nurse Aide #2 did help them get to bed after that but did not wash them up. Resident #86 stated they were so disgusted with the aide, they did not want to ask them for anything else. Resident stated Certified Nurse Aide #2 did not clean up the puddle of urine that was on the floor. They stated they usually had to wait to go to the bathroom between supper and bedtime.During an interview on 08/29/2025 at 11:30 AM, Director of Nursing #1 stated they interviewed Certified Nurse aide #1, who admitted they made the statement to save Resident #86 for last because they were so slow, but there was no malintent. They were educated about speaking where they could be overhead about residents.During an interview on 08/29/2025 at 1:52 PM, Certified Nurse Aide #1 stated they remember giving report to oncoming Certified Nurse Aide #2. They told Certified Nurse Aide #2 to provide care to Resident #86 last due to the amount of time it took to complete their care as Resident #86 was very particular. Certified Nurse Aide #1 then attempted to recant their statement stating it was not them who made the statement. During an interview on 09/03/2025 at 11:10 AM, Administrator #1 stated all staff were expected to treat all residents with dignity and respect. During 2024 the facility used agency staff often. They have hired several new nursing employees and down to only a few open positions left.10 New York Code of Rules and Regulations 415.5(a)

Based on record review and staff interviews conducted during the recertification survey, the facility did not ensure that it maintained acceptable parameters of nutritional status, provided nutrition care and services to each resident consistent with the resident's comprehensive assessment for three (3) (Resident #s 6, 48, and 107) of seven (7) residents reviewed for nutrition/hydration status maintenance. Specifically, (a.) Resident #6 had a documented weight loss of 17.7 pounds in a month, (b) Resident #48 had a documented weight gain of 22.5 pounds in a month, and (c) Resident #107 had a documented weight loss of 35.6 pounds. The significant weight changes were not confirmed by reweights or addressed by the facility's dietician or medical providers.This is evidenced by:The facility's Policy and Procedure titled, Weighing of a Resident, last revised 8/10/2015, documented a difference of plus or minus five (5) pounds from the previously recorded weight required a reweigh that same day with the assistance of the charge nurse or nurse manager. The charge nurse or nurse manager would be responsible to ensure that weights are completed as ordered. The charge nurse or nurse manager would verify a weight of plus or minus five (5) pounds. Additionally, they would report any five (5) pound weight change to the Dietician. The medical staff and dietician will review weights.Resident #6:Resident #6 was admitted to the facility with diagnoses of paraplegia (paralysis that mainly affects the legs), dysphagia (difficulty swallowing), and acute kidney failure. The Minimum Data Set (an assessment tool) dated 8/1/2025 documented the resident had moderate cognitive impairment, could sometimes understand others, and could make themselves understood.A Comprehensive Care Plan titled, Potential Nutritional Problem, last revised on 08/27/2025, documented a goal for maintaining adequate nutritional status as evidenced by maintaining stable weight.The resident's weights and Vitals Summary documented the resident weighed 212.7 pounds on 07/08/2025 and weighed 195 pounds on 8/17/2025, representing a loss of 17.7 pounds.A review of the resident's medical record revealed no documented evidence of a re-weight, nutrition assessment, medical provider, or dietician notes addressing the weight loss.During an interview on 09/02/2025 at 12:20 PM, Licensed Practical Nurse #1 stated the nurses usually entered weights in the electronic medical record and that residents should be weighed when they were admitted or readmitted . Licensed Practical Nurse #1 stated they did not know why the resident's weight was not done for almost three (3) weeks after readmission.During an interview on 09/03/2025 at 9:30 AM, Registered Dietitian #1 stated a weight should have been done on readmission, not almost three (3) weeks after readmission. They stated the resident was being discussed in weight meeting that day (09/03/2025).Resident #48Resident #48 was admitted to the facility with diagnoses of diabetes, chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and dementia. The Minimum Data Set (an assessment tool) dated 7/21/2025 documented the resident had intact cognition, could understand others, and could make themselves understood.A Comprehensive Care Plan titled, Potential Nutritional Problem, last revised on 06/11/2025, documented a goal of stabilized weight.The resident's weights and Vitals Summary documented on 7/08/2025 the resident weighed 134.7 pounds and on 8/19/2025 the resident weighed 157.2 pounds, representing a weight gain of 22.5 pounds.A review of the resident's medical record did not have documented evidence of a re-weight, nutrition assessment, medical provider, or dietician notes addressing the weight gain.During an interview on 9/03/2025 at 9:30 AM, Registered Dietitian #1 stated they felt it was an error, but the resident was sent to the hospital (on 8/26/2025) before a reweight could be obtained. They stated staff were not consistent with entering weights into the electronic medical record.Resident #107: Resident #107 was admitted to the facility with diagnoses of quadriplegia (paralysis of all four limbs), diabetes, and pulmonary hypertension (type of high blood pressure that affects the arteries in the lungs and the right side of the heart). The Minimum Data Set (an assessment tool) dated 8/01/2025 documented the resident had moderate cognitive impairment, could sometimes understand others, and could make themselves understood.A Comprehensive Care Plan titled; Nutritional Risk, last revised on 06/17/2024 documented a goal to promote nutritional intake necessary to maintain or improve current weight.The resident's weights and Vitals Summary documented on 7/08/2025 the resident weighed 239 pounds and on 08/19/2025 the resident weighed 203.4 pounds, representing a 35.6-pound loss.A review of the resident's medical record did not have documented evidence of a re-weight, nutrition assessment, medical provider, or dietician notes addressing the weight loss.During an interview on 09/03/2025 at 9:30 AM, Registered Dietitian #1 stated they asked for a reweigh for this resident and have not gotten it. They stated they did not believe the weight was accurate. They stated they sent an email to Director of Nursing #1, Unit Manager and Food Service Director when asking for a reweight.During an interview on 09/03/2025 at 10:31 AM, Director of Nursing #1 stated they had spoken to the unit managers about weights and reweights. They report the reweights were being done but were not being put in the computer so Dietitian #1 could see them.During an interview on 9/03/2025 at 12:35 PM, Registered Nurse #1 stated they would receive an email from Dietitian #1, print out a list of residents who need weights and tell the nurses and Aides. They stated all residents should be weighed the day they are admitted . They further stated that Certified Nurse Aides would write the weights down and nurses would enter them into the computer. 10 New York Code Rules and Regulations 415.12(c)(2)

Based on observation, record review, and interviews conducted during a recertification and abbreviated survey (Case # 2562681), the facility did not ensure the provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, residents reported that staff would not be able to provide them care for extended periods of time. Review of the actual staffing schedule revealed that on multiple occasions from 08/11/2025 to 09/01/2025, the facility staffing levels were below the facility assessment. This is evidenced by: The Facility Assessment, last reviewed in July 2025, documented that the facility's bed capacity was 120. The section titled, Staffing Plan, documented the following staffing needs based on a full facility census per day: 18.40 Licensed Nurses and 28.67 Certified Nursing Assistants.Upon entrance to the facility on [DATE], 116 residents resided on three (3) units. Upon observation and review of the Facility Staffing Sheet, five (5) Licensed Nurses and eleven Certified Nurse Aides were on duty.During a surveyor-led group resident meeting on 08/26/2025 at 10:00 AM, six (6) residents who attended the meeting reported insufficient staffing to meet their needs. They stated that they often had to wait an extended period to get care. They stated that many times they have been left unattended for extremely long times, and the Certified Nurse Aides would say they would come back but never did. A review of staffing sheets provided by the facility from 08/11/2025 through 09/01/2025 documented that they did not meet their assessed minimum staffing on most shifts for the following:- On 08/11/2025, the nursing schedule had 6 nursing staff during the day shift, 5 for the evening shift, and 4 for the night shift for a total of 15. The Certified Nurse Aide schedule had 12 aides during the day shift, 10 for the evening shift, and 6 for the night shift for a total of 28. - On 08/14/2025, the nursing schedule had 6 nursing staff during the day shift, 5 for the evening shift, and 4 for the night shift for a total of 15. The Certified Nurse Aide schedule had 12 aides during the day shift, 9 for the evening shift, and 6 for the night shift for a total of 27. - On 08/17/2025, the nursing schedule had 4 nursing staff during the day shift, 4 for the evening shift, and 4 for the night shift for a total of 12. The Certified Nurse Aide schedule had 12 aides during the day shift, 9 for the evening shift, and 5 for the night shift for a total of 26. - On 08/20/2025, the nursing schedule had 5 nursing staff during the day shift, 5 for the evening shift, and 3 for the night shift for a total of 13. The Certified Nurse Aide schedule had 12 aides during the day shift, 9 for the evening shift, and 4 for the night shift for a total of 25. - On 08/23/2025, the nursing schedule had 4 nursing staff during the day shift, 4 for the evening shift, and 4 for the night shift for a total of 12. The Certified Nurse Aide schedule had 12 aides during the day shift, 9 for the evening shift, and 4 for the night shift for a total of 25. - On 08/25/2025, the nursing schedule had 7 nursing staff during the day shift, 7 for the evening shift, and 4 for the night shift for a total of 18. The Certified Nurse Aide schedule had 11 aides during the day shift, 10 for the evening shift, and 4 for the night shift for a total of 25. - On 08/28/2025, the nursing schedule had 7 nursing staff during the day shift, 4 for the evening shift, and 3 for the night shift for a total of 14. The Certified Nurse Aide schedule had 11 aides during the day shift, 10 for the evening shift, and 8 for the night shift for a total of 29. - On 09/01/2025, the nursing schedule had 4 nursing staff during the day shift, 4 for the evening shift, and 3 for the night shift for a total of 11. The Certified Nurse Aide schedule had 9 aides during the day shift, 11for the evening shift, and 4 for the night shift for a total of 24. During an interview on 08/27/2025 at 1:08 PM, Certified Nursing Aide #1 stated that staff were able to provide care consistently; however, the residents did have to wait for a more extended period at times.During an interview on 8/29/2025 at 1:00 PM, Administrator #1 stated that the facility assessment was based on the full capacity of the facility. They stated that at times they did not meet the assessment, but they were trying to get to that point. During an interview on 09/03/2025 at 10:30 AM, Staffing Coordinator #1 stated they determined the staffing levels per the census; it was discussed at the morning meeting what the goal for the staffing levels should be for the next day. They stated that the goal was to have a minimum of four (4) Certified Nurse Aides on each unit during the day, three (3) Certified Nurse Aides on each unit during the evening, and one (1) Certified Nurse Aide on each unit during the overnight. They stated that if they were short-staffed, they would attempt to fill the spots by offering bonuses or other incentives to get staffing at appropriate levels. They stated that they were short at times but were getting better. They stated that the Director of Nursing was bringing staff in from other areas to increase their staffing levels. They stated that they did have a nurse training program and were getting more staff from that program. 10 New York Code Rules and Regulations 415.13(a)(1)(i-iii)

Based on observations and interview conducted during the recertification survey, it was determined that the facility did not post nurse staffing information in an area accessible to all residents and visitors, as required by the posting requirements. Specifically, the posting of daily nurse staffing levels for staff working in the facility on each shift from 08/25/2025 through 09/03/2025 was located at the far end of the building. This is evidenced by: During observations from 8/25/2025 through 9/03/2025, the daily nurse staffing postings were located in a hallway at the far end of the building near the human resources office, which was not readily visible or accessible to all residents and visitors. Visitors of the B and C units would have to walk to the opposite end of the building to view the daily staffing, while visitors of the A unit were able to view when walking byDuring an interview on 9/03/2025 at 11:15 AM, Staffing Coordinator #1 stated that ever since they have worked at the facility, the daily staffing had always been posted in that location. They stated that the night nursing supervisor would post the daily staffing list. They stated that they did not know that the staffing had to be posted in a different location and mentioned that they would move it to the front reception area if needed. 10 New York Codes, Rules, and Regulations 415.13

Based on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed five (5) percent for two (2) (Resident #s and 46) of two (2) residents observed during medication administration with 25 observations. This resulted in a medication error rate of 88 percent.This is evidenced by:The facility ' s Policy and Procedure titled, Medication Nurse Routine. Revised: 12/19/2024, documented all Medication Nurse duties are performed by licensed personnel. Procedures will be performed as follows by all staff uniformly. During the medication pass read orders from electronic medical record, Compare prescription label on blister pack to medication order. Remember the five (5) rights: a) right medication b) right resident c) right time d) right dose e) right route. Also check expiration dates. Crushing medications - crush only those meds which are not on the do not crush list. i) Special considerations should be noted on the electronic medical record, (crush, takes whole in applesauce, alternate days, etcetera). The nurse is to verify the medication administration record and treatment administration record at the beginning, during, at the end of their assigned shift to ensure timely administration of medications and treatments.Resident #8Resident #8 was admitted to the facility with diagnoses of fractured femur and fractured humerus (broken hip and broken arm), chronic obstructive pulmonary Disease (a group of lung diseases that cause ongoing inflammation and damage to the airways and lungs, leading to breathing difficulties), and diabetes type 2 (a chronic condition in which the body does not use insulin effectively or does not produce enough insulin). The Minimum Data Set (an assessment tool) dated 07/22/2025 documented the resident's cognition was intact, could be understood and understand others.The Comprehensive Care Plan dated 07/08/2025 documented Resident #8 had hypertension, hyperlipidemia (elevated levels of lipids (fats) in the bloodstream) and history of bradycardia (an abnormally slow heart rate). Interventions include give medications as ordered. Observe for side effects such and effectiveness. Resident #8 had diabetes mellitus. Intervention give Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness.The Medication Administration Record dated August 2025 for Resident #8 documented Resident took medication whole. The following medications were to be administered at 8:00 AM:Diltiazem Extended Release 24 Hour 120 milligrams. Give 1 capsule by mouth in the morning for hypertension.Ezetimibe Oral Tablet 10 milligram. Give 1 tablet by mouth in the morning for hyperlipidemia.Fluticasone Propionate Nasal Suspension 50 micrograms (delivered per actuation or puff). 1 spray in both nostrilsLactobacillus Rhamnosus Oral Capsule. Give 1 capsule by mouth in the morning for probiotic.Losartan Potassium Oral Tablet 25 milligram tablet. Give 12.5 milligrams by mouth in the morning for hypertension.Meloxicam Oral Tablet 15 milligrams Give 1 tablet by mouth in the morning for arthritis pain.Montelukast Sodium Oral Tablet 10 milligrams. Give 1 tablet by mouth in the morning for allergies.oxybutynin Chloride Oral Tablet Extended Release 24 Hour 15 milligrams. Give 1 tablet by mouth in the morning for bladder spasms.Pantoprazole Sodium Oral Tablet Delayed Release 40 milligrams. Give 1 tablet by mouth in the morning for gastroesophageal reflux.Keflex Oral Capsule (Cephalexin) Give 500 milligrams by mouth three times a day for preventative for 7 Days effective 8/26/2025Aspirin Oral Capsule 81 milligrams. Give 1 capsule by mouth every morning and at bedtime for preventative.During an observation on 08/28/2025 at 9:07 AM, License Practical Nurse #2 crushed and administered the following medications to Resident #8: Diltiazem tablet Extended Release 24 Hour 120 milligrams; Keflex capsule 500 milligrams; Magnesium Oxide tablet 400 milligrams; Meloxicam tablet 15 milligram; Montelukast Sodium Oral tablet 10 milligrams; Losartan Potassium tablet 25 milligrams; Lactobacillus Rhamnosus 1 capsule; Tramadol tablet 25 milligrams; Pantoprazole Sodium Oral tablet Delayed Release 40 milligrams; oxybutynin extended release tablet 15 milligrams; Ezetimibe tablet 10 milligrams; Aspirin 81 milligrams capsule. The following medications were labeled Do Not Crush: Diltiazem, Magnesium Oxide, Montelukast Sodium, Pantoprazole Sodium Oral Tablet Delayed Release, oxybutynin extended release, and Ezetimibe tablet. Resident #8's Medication Administration Record documented medications taken whole.During an interview on 08/28/2025 at 9:25 AM, License Practical Nurse #2 stated they crushed Resident #8's medication because they took them better that way. Licensed Practical Nurse #2 was unable to provide a physician's order to crush medications for this resident. Licensed Practical Nurse #2 stated they were unaware that the above listed medications were not to be crushed. They stated they would notify the Director of Nursing.Resident #46Resident #46 was admitted to the facility with diagnoses of osteoarthritis (a common, degenerative joint disease that occurs when the cartilage that cushions the ends of bones wears down over time); hypertension (a condition where the force of blood against the walls of the arteries is consistently above normal levels, and anxiety (a common mental health condition characterized by excessive and persistent worry, fear, and unease). The Minimum Data Set, dated [DATE] documented the resident's cognition was moderately impaired, could be understood and understand others.The Comprehensive Care Plan dated 4/10/2024, documented Resident #46 is on multiple medications. Intervention: Perform a medication reconciliation report with resident and or family members/responsible party.The Medication Administration Record dated August 2025 for Resident #46 documented the following medications were to be administered at 8:00 AM:Cranberry Oral Capsule. Give 1 capsule by mouth in the morning for supplement.Norvasc Oral Tablet 10 milligrams (Amlodipine Besylate). Give 1 tablet by mouth in the morning for hypertension.Pantoprazole Sodium Oral Tablet Delayed Release 40 milligrams. Give 1 tablet by mouth in the morning for gastroesophageal reflux disease.Pepcid Oral Tablet 40 MG (Famotidine). Give 1 tablet by mouth in the morning for gastroesophageal reflux disease.Metoprolol Succinate Oral Tablet Extended Release 24 Hour 100 milligrams. Give 1 tablet by mouth in the morning for hypertension, give with 25 milligrams for total of 125 milligrams.Metoprolol Succinate Oral Tablet Extended Release 24 Hour 25 milligrams. Give 1 tablet by mouth in the morning for hypertension give with 100 milligrams for total of 125 milligrams.Senna Oral Tablet 8.6 milligrams (Sennosides) Give 2 tablet by mouth in the morning for constipation.PreserVision Oral Capsule Give 1 capsule by mouth two times a day for supplement.Tylenol Extra Strength Oral Tablet 500 milligrams (Acetaminophen). Give 2 tablets by mouth two times a day for pain.Isradipine Oral Capsule 5 milligrams. Give 1 capsule by mouth two times a day for hypertension.During an observation on 08/28/2025 at 10:15 AM, Licensed Practical Nurse #3 poured 8:00 AM medications for Resident #46. They poured medications into two separate cups; one cup was for crushed medications and the other cup was for do not crush medications. Licensed Practical Nurse #3 poured Metoprolol Succinate ER 100 milligrams into the do not crush cup. They were prompted that they poured metoprolol extended release, a do not crush medication into the crush medication cup. In an interview, Licensed Practical Nurse #3 stated they were unaware that Metoprolol extended-release drug should not be crushed. They had been crushing the medication up until this time. They notified Registered Nurse #1. Registered Nurse #1 reviewed order and medication blister package and informed Licensed Practical Nurse #3 that they should not crush metoprolol extended release. They stated they would notify the nurse practitioner for an order change.During an interview on 08/28/2025 at 9:50 AM, Licensed Practical Nurse #3 stated they had not completed 8:00 AM medication pass for Resident #46 because they were waiting for them to get dressed and out of bed. Licensed Practical Nurse #3 stated to avoid choking or aspiration they wait until residents were out of bed before administering medication. They also stated they were the only nurse passing medications on floor for 40 residents. They stated the assisting Registered Nurse Manager #1 was aware.During an interview on 08/28/2025 at 10:30 AM, Registered Nurse #1 stated they had not been informed that the 8:00 AM medications were late, and Licensed Practical Nurse #3 did not ask for help. They stated they would assist Licensed Practical Nurse #3 in completing the medication pass and get residents dressed and out of bed. During an interview on 08/28/2025 at 10:45 AM, Nurse Practitioner #1 stated they had not been notified that medications were late today or any other day in the past. They stated medication nursing staff should notify nurse practitioner or physician when medications were given late, and, that an order was required for nurse to crush medications. They stated if a resident was unable to take medications whole and medications that specifically were not to be crushed would not be ordered for that resident. An alternative medication would be prescribed, if not available in a liquid form. Nurse Practitioner stated the Minimum Data Set Coordinator was currently conducting an audit on all mediations that were not crushable. They stated Medication Administration Record would be updated if needed.During an interview on 08/28/2025 at 11:00 AM, Director of Nursing #1 stated currently they did not have a nurse educator. Director of Nursing #1 stated all nurses received medication administration training upon hire which included a preceptorship, observation and competency signoff. A medication error report will be completed for Licensed Practical Nurse #2's medication error reported today. 10 New York Codes, Rules, and Regulations 415.12 (m)(1)

Based on observation, record review and interview conducted during the recertification survey, the facility did not ensure residents were free from significant medication errors for one (1) (Resident #8) of two (2) residents reviewed during a medication administration observation. Specifically, Licensed Practical Nurse #2 crushed and administered medications that were Do Not Crush for Resident #8.This is evidenced by:The facility's Policy and Procedure titled, Medication Nurse Routine, last revised 12/19/2024, documented all Medication Nurse duties are performed by licensed personnel. Procedures will be performed as follows by all staff uniformly. During the medication pass read orders from electronic medical record, compare prescription label on blister pack to medication order. Remember the five (5) rights: (a) right medication (b) right resident (c) right time (d) right dose (e) right route. Please check expiration dates. Crushing medications - crush only those medications that are not on the Do Not Crush List. i) Special considerations should be noted on the electronic medical record, (crush, takes whole in applesauce, alternate days, etc). The nurse is to verify the medication administration record and treatment administration record at the beginning, during, at the end of their assigned shift to ensure timely administration of medications and treatments.A government National Institute of Health study dated 02/2024, documented, Diltiazem Hydrochloride Extended-Release Capsules should be taken on an empty stomach. Patients should be cautioned that the Diltiazem hydrochloride extended-release capsules should not be opened, chewed or crushed, and should be swallowed whole.Extended-Release Diltiazem should never be crushed or chewed, according to manufacturers and health organizations including the Food and Drug Administration, Kaiser Permanente, and the Cleveland Clinic. Crushing the medication would destroy its special coating, causing the entire dose to be released at once. This could lead to a dangerous overdose and serious heart-related side effects.Reference made to https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=70293a05-d314-43fa-a2b1-398cfb39edf8Resident #8 was admitted to the facility with diagnoses of fractured femur and fractured humerus (broken hip and broken arm), chronic obstructive pulmonary disease (a group of lung diseases that cause ongoing inflammation and damage to the airways and lungs, leading to breathing difficulties), and Type Two (2) Diabetes (a chronic condition in which the body does not use insulin effectively or does not produce enough insulin to keep blood sugar levels within a healthy range). The Minimum Data Set (an assessment tool) dated 07/22/2025, documented the resident's cognition was intact, could be understood and understand others.The Comprehensive Care Plan dated 07/08/2025 documented Resident #8 had hypertension (high blood pressure), hyperlipidemia (elevated levels of fats in the bloodstream) and history of bradycardia (an abnormally slow heart rate). Interventions included to give medications as ordered and observe for side effects and effectiveness.During an observation on 08/28/2025 at 9:07 AM, License Practical Nurse #2 crushed and administered the following medications documented on the medication administration record for Resident #8: Diltiazem tablet extended Release 24 Hour 120 milligrams; Keflex capsule 500 milligrams; oxybutynin extended-release tablet 15 milligrams; Tramadol 50 milligrams, and Pantoprazole Sodium Oral Tablet Delayed Release. These medications were labeled as Do Not Crush. During an interview on 8/28/2025 at 9:25 AM, License Practical Nurse #2 stated they crushed Resident #8's medication because the resident took them better that way. License Practical Nurse #2 was unable to provide a physician's order to crush medications for this resident. License Practical Nurse #2 stated they were unaware that the above listed medications were not to be crushed. They stated they would notify Director of Nursing #1.During an interview on 08/28/2025 at 10:45 AM, Nurse Practitioner #1 stated that a provider's order was required for nurse to crush medications. If a resident was unable to take medications whole, medications that specifically were not to be crushed would not be ordered for that resident. An alternative medication would be prescribed, if not available in a liquid form.During an interview on 08/28/2025 at 11:00 AM, Director of Nursing #1 stated currently they did not have a nurse educator. They stated the Assistant Director of Nursing previously fulfilled the role. They stated they were in the process of training a unit manager to assume this responsibility. Director of Nursing #1 stated all nurses received medication administration training upon hire that included a preceptorship, observation and competency signoff. 10 New York Codes, Rules, and Regulations 415.12 (m)(2)

Based on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for five (5) of five (5) medication carts reviewed. Specifically, (a.) two (2) narcotic lock boxes were broken; (b.) two (2) expired medications were found in medication room; (c.) three (3) bottles of eye drops had no open or expiration dates; and (d.) five (5) insulin pens did not have an open and/or expiration date.This is evidenced by:The facility's Policy and Procedure titled, Medication Storage, effective 03/21/2022 documented Medications housed on premises are stored in the medication rooms or medication carts according to the manufacturer's recommendations. All medications are stored in designated areas which are sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. 1. Narcotics and Controlled Substances: Schedule II drugs and back-up stock of Schedule III, IV and V medications are stored under double-lock and key. This includes refrigerated medications, such as Marinol. Only authorized personnel have access to medication storage areas. Insulin Pens are stored in separate plastic bags in the top drawer of the medication cart if being used. Each person and type of insulin. For example: If a resident is on regular and Lantus, they both need a bag) If unused they are stored in separate plastic bags in medication room refrigerator.The facility ' s Policy and Procedure titled, Medication Nurse Routine last revised 12/19/2024, documented all Medication Nurse duties are performed by licensed personnel. Procedures will be performed as follows by all staff uniformly. During the medication pass read orders from electronic medical record, compare prescription label on blister pack to medication order. Remember the five (5) rights: a) right medication b) right resident c) right time d) right dose e) right route. Also check expiration dates.During an observation on 08/27/2025 at 1:00 PM, the Catskill Unit Medication Room Narcotic Box A/B outside lock left ajar. In an interview, License Practical Nurse #4 stated the lock had been broken for over two (2) years. The Catskill Unit medication room also contained a bottle of prescribed Listerine Original mouthwash for Resident #49 with an expiration date of 09/2024.During an observation on 08/27/2025 at 1:20 PM, Catskill medication cart C/D contained one (1) Lispro; two (2) Lantus; one (1) glargine insulin pens with no open and or expiration dates. The cart also contained one (1) bottle of Refresh eye drops with an expiration date of 08/07/2025. The Catskill medication cart A/B contained one (1) lispro insulin pen with no open and or expiration date.During an observation on 08/27/2025 at 1:50 PM, The Adirondack Unit medication room narcotic lockbox C/D outside lock was not secured leaving the outside cabinet door ajar. The Adirondack unit medication cart A/B contained one (1) bottle of timolol eye drops and one (1) bottle of Systane eye drops with no open and or expiration dates.During an interview on 08/27/2025 at 2:10 PM, Administrator #1 was made aware of the broken narcotic lock boxes on Catskill and Adirondack units. Administrator #1 stated they would immediately contact maintenance to have locks repaired.During an interview on 08/28/2025 at 10:31 AM, Director of Nursing #1 stated it was the responsibility of the medication cart nurse to ensure the medication cart was clean and orderly. All medications including insulins and eye drops should be labeled with the open and expiration dates written on the bottle. 10 New York Codes, Rules, and Regulations 415.18(d)

Based on observation, record review, and interview during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety in the main kitchen and two (2) of three (3) kitchenettes. Specifically, expired food was not discarded, a compatible test kit to measure concentration of chemical sanitizer used to manually sanitize food contact equipment (test kit) was not provided, food temperature thermometers were not calibrated, equipment was not in good repair, and equipment was not clean.This is evidenced by:During observations on 08/25/2025 at 10:17 AM: Thickened cranberry juice with use-by dates of 07/09/2025 & 08/12/2025 were found in the storeroom on the shelf with the common stock. The concentration of chemical sanitizer used to manually sanitize food equipment could not be checked; the facility did not have the correct test kit. The label on the bottle of concentrated sanitizer stated that the sanitizer is to be diluted to between 200 and 400 parts per million when sanitizing food contact surfaces. The label of the test kit for checking the sanitizer concentration did not have color graduations that exceeded 400 parts per million and could not test sanitizer concentrations exceeding the manufacturer specifications. Two (2) of three (3) food temperature thermometers were found not in calibration when tested in a standard ice-bath method as follows: 38 degrees Fahrenheit and 39 degrees Fahrenheit. The wet floor sign had cracked and broken plastic and was in disrepair. The following equipment and areas were soiled with food particles or grime: microwave oven, can opener & holder, knife holder, utility drawer, floor next to door frame in janitor closet, wet floor signs.During observations on 08/25/2025 at 3:08 PM: In the A-Unit Kitchenette, the refrigerator door gasket was split and in disrepair, and the left-most drawer and the bottom of cabinets were soiled with sticky drips of food. In the B-Unit Kitchenette, left-most drawer was soiled with sticky drips of food.During an interview on 08/25/2025 at 11:06 AM, Assistant Director of Food Service #1 stated they would calibrate the thermometers, discard the expired cranberry juice, and have the soiled items and areas found cleaned. They stated that they would contact the maintenance department to obtain a wrench for calibrating the analog thermometer and replacing the broken wet floor sign and would contact their chemical supply vendor to obtain the correct sanitizer test papers.New York Codes, Rules, and Regulations Title 10 S415.14(h)Chapter 1 State Sanitary Code Subpart 14

Based on observation, record review, and interviews during the recertification survey, the facility did not maintain a pest-free environment and an effective pest control program in the main kitchen. Specifically, insect infestation was found in the main kitchen janitor closet.This is evidenced by:During observations on 08/25/2025 at 10:17 AM, small fruit flies were found in the janitor closet around the floor sink.The document titled; Pest Control Inspection Log and dated 02/27/2025 through 07/28/2025 documented that the facility was last treated for fly infestation on 02/27/2025.During an interview on 08/25/2025 at 11:06 AM, Assistant Director of Food Service #1 stated that the pest control vendor would be contacted to address the fly issue. New York Codes, Rules, and Regulations Title 10 S415.29(j)(5)

Based on record review and interviews conducted during the recertification and abbreviated survey (Case # 684171), the facility did not ensure the residents' right to be free from abuse and neglect for two (2) (Resident #s 89 and 109) of two (2) residents reviewed for abuse and neglect. Specifically, (a.) on 6/10/2025, Resident #89 who was care planned to be observed closely when not in their room, was left unattended and struck Resident #109 with their walker; and (b.) on 6/22/2025, Resident #89 was sprayed in the face with hot sauce by Resident #63. This is evidenced by: The Facility's Policy titled; Resident Abuse Prevention, dated 05/2025, documented that the purpose was to provide residents, families, and staff information on how and to whom they may report concerns, incidents, and grievances without the fear of retribution. The policy documented that the facility shall identify, correct, and intervene in situations in which abuse, neglect, mistreatment, or misappropriation of property may be more likely to occur. Procedures documented included, but were not limited to, supervision of staff, which shall include identification of inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents while giving care, or directing residents in need of toileting to urinate or defecate in their beds or briefs, and counseled when performance is not acceptable.Resident #89Resident #89 was admitted to the facility with Alzheimer's disease (a progressive brain disorder that primarily affects memory, thinking, and behavior), dementia with behavior disturbances (behavioral and psychological symptoms that accompany dementia, affecting a significant portion of those living with the condition), and hypertension (a condition where the force of your blood against the walls of your arteries is too high). The Minimum Data Set, dated [DATE], documented that Resident #89 rarely or never made themselves understood, rarely or never understand others, and had severe cognitive impairment.The Comprehensive Care Plan for behaviors, dated 06/02/2025, documented on 11/08/2021 that Resident #89 had behavior issues as evidenced by screaming, yelling, and causing distress to self and others related to their Alzheimer's Disease, Dementia, and was hard to redirect at times. On 2/15/2022, Resident #89 was care planned to be closely observed when not in their room. The facility's Investigative Report dated 6/22/2025 documented that Resident #89 was standing next to Resident #63, whom they were not supposed to be near due to a prior incident in December of 2024. Staff noticed that Resident #89 was nearby and went to separate them. Before the staff person was able to reach them, the Resident #63 sprayed hot sauce into Resident #89's eyes. During the investigation, the staff asked the resident why they had sprayed the sauce in Resident #89's eyes, and Resident #63 stated it was because the resident wanted hot sauce. Staff assessed the resident, flushed their eyes, and moved them back to their own unit. During an interview on 08/27/2025 at 3:35 PM, Certified Nurse Aide #1 stated that they were feeding another resident in their room when they heard the incident and did not see the actual act. They came out of the room and noticed the resident with a red substance on their face being escorted by the nurse. They stated that Resident #89 resided on the A unit and wandered the facility a lot and was supposed to be closely watched, as there have been multiple incidents with them and other residents.During an interview on 08/29/2025 at 3:15 PM, Certified Nurse Aide #2 stated they were not working that day of the incident but knew the residents well. They stated that Resident #89 wandered a lot throughout the facility and should have been observed when not on the unit. They stated they were unsure whether or not they were being observed. uring an interview on 8/29/2025 at 10:25 AM, Licensed Practical Nurse #3 stated that they remembered the incident. They stated that Resident #89 was next to the other resident when they attempted to move them and separate them. They stated that they did not get to them in time, and Resident #89 was sprayed in the face with hot sauce. They stated that they removed the resident, rinsed the patient's face, and flushed their eye. They stated that they reported the incident to their supervisor. Attempted phone interview on 09/02/2025 at 12:35 PM with Registered Nurse #2, who was the Director of Nursing at the time of the incident, was unsuccessful. Resident #109Resident #109 was admitted to the facility with dementia with behavior disturbances (behavioral and psychological symptoms that accompany dementia, affecting a significant portion of those living with the condition), chronic obstructive pulmonary disease (a group of lung diseases that cause airflow obstruction and breathing difficulties), and hypertension (a condition where the force of your blood against the walls of your arteries is too high). The Minimum Data Set, dated [DATE], documented that Resident #109 sometimes made themselves understood, sometimes understand others, and had severe cognitive impairment.The facility's Investigative Report dated 6/10/2025 documented that Resident #109 was walking in the hall toward Resident #89. Resident #89 struck Resident #109 with their walker, and Resident #109 retaliated and struck Resident #89 with a closed fist. The report documented that the force of both strikes was not strong enough to cause injury, and residents were separated. It was documented that neither resident was in their respective units. A review of progress notes dated 6/10/2025 at 4:52 PM, documented that Resident #109 was ambulating down the B unit hallway when Resident #89 started to hit them with their walker. Resident #109 turned and struck Resident #89 in the face with a closed fist. Nursing aides immediately separated residents. Upon assessment, Resident #109 did not have any injuries and had no recollection of the incident due to memory impairment.During an interview on 08/27/2025 at 3:35 PM, Certified Nurse Aide #1 stated that they remembered the incident and saw it happen. They stated that Resident #89 struck Resident #109 with their walker, and Resident #109 then struck Resident #89. They immediately responded and separated both residents. They stated that the residents reside in unit A and frequently wander the facility. They stated that they frequently saw Resident #89 striking individuals with their walker or running into them in the hallway. During an interview on 08/29/2025 at 3:15 PM, Certified Nurse Aide #2 stated that they remembered the incident and saw it happen. They stated that Resident #89 struck Resident #109 with their walker, and Resident #109 then struck Resident #89. They immediately responded and separated both residents. They stated that the residents reside in unit A and frequently wander the facility. They stated that they frequently see Resident #89 striking individuals with their walker or running into them in the hallway. During an interview on 09/02/2025 at 12:10 PM, Director of Nursing #1 stated there should be a mechanism to monitor behaviors if that's what the care plan says. Attempted phone interview on 09/02/2025 at 12:35 PM with Registered Nurse #2, who was the Director of Nursing at the time of the incident, was unsuccessful. 10 New York Codes, Rules and Regulations 415.4(b)(1)(i)

Based on observations, record review and interviews during a recertification and abbreviated (Case #684171) survey, the facility did not ensure the facility implemented a comprehensive person-centered care plan for each resident for one (1) (Resident # 89) of 24 residents reviewed for comprehensive care plans. Specifically, supervision was not provided for the resident as directed by the comprehensive care plan for Resident # 89. This is evidenced by:The Policy and Procedure titled; Interdisciplinary Care Planning, last reviewed 4/16/2025, stated the interdisciplinary team would develop comprehensive care plans and the care plan must reflect intermediate steps for each outcome objective and staff would use these objectives to monitor resident progress. Also, that using the resident's diagnosis sheet, the care plan would be completed pm which problems were active and applied to the resident's diagnosis/illness.Resident #89 was admitted to the facility with Alzheimer's disease (a progressive brain disorder that primarily affects memory, thinking, and behavior), dementia with behavior disturbances (behavioral and psychological symptoms that accompany dementia, affecting a significant portion of those living with the condition), and hypertension. The Minimum Data Set, dated [DATE], documented that Resident #89 rarely or never made themselves understood, rarely or never understand others, and had severe cognitive impairment.Resident #89's census documented the resident resided on the A unit throughout their facility stay.The Comprehensive Care Plan titled; (Resident) is/has the potential to be physically aggressive related to anger, dementia, poor impulse control last reviewed 6/05/2025 Intervention close observation when not in room dated 7/09/2021.The Comprehensive Care Plan titled, Resident requires assistance with ADL functions included the intervention requires one to one supervision when ambulating off unit for safety and re-direction, dated 1/30/2024.The Task List Documented Resident #89 required one to one supervision when off the unit ambulating for safety initiated 10/3/2023.Resident #89 was involved in multiple resident-to-resident interaction involving physical abuse on 12/22/2024, 6/10/2025 and 6/22/20205.The Incident Report dated 12/22/2024 documented Resident #89 was found in another resident's room on another unit after an altercation. The report documented staff was alerted Resident #89's location after Resident #89 was heard crying out.The Incident Report dated 6/10/2025 documented Resident #89 was walking down the hallway on the B unit when they started hitting another resident with their walker.The Incident Report dated 6/22/2025 documented Resident #89 was near a resident on another unit they had had a documented negative interaction with before and was not separated until an incident had occurred.During an interview on 08/27/2025 at 3:35 PM, Certified Nurse Aide #1 stated that the resident resided on the A unit and wandered the facility a lot and was supposed to be closely watched, as there have been multiple incidents with them and other residents. During an interview on 08/29/2025 at 3:15 PM, Certified Nurse Aide #2 stated that Resident #89 wandered a lot throughout the facility and should be observed when not on the unit. They stated they were unsure whether or not they were observed at the time of the incidents.During an interview on 09/02/2025 at 12:10 PM, Director of Nursing #1 stated that interventions on a resident's care plan were to be implemented as written. 10 New York Codes, Rules, and Regulations 415.11(c)(1)

Based on observation, record review, and interview during the recertification survey, the facility did not ensure garbage and refuse was disposed properly. Specifically, the garbage dumpsters were not placed on hard & level surfaces, and one dumpster was not rodent proof.This is evidenced by:During observations on 08/25/2025 at 10:50 AM, 1 of 4 dumpsters did not have a drain plug and was not rodent proof, and four (4) of four (4) dumpsters were placed on gravel and dirt lawn and not on a hard & level surface (as stated on the directions posted on the dumpster).During an interview on 08/25/2025 at 11:06 AM, Assistant Director of Food Service #1 stated they would contact the maintenance department have hard level surfaces installed for the dumpsters and the missing drain plug installed. New York Codes, Rules, and Regulations Title 10 S415.14(h)Chapter 1 State Sanitary Code Subpart 14-1

Based on record review and interviews during an abbreviated survey (Case #NY00302790), the facility did not ensure the resident's right to be free from abuse for 1 (Resident #1) of 3 residents reviewed. Specifically, the facility did not ensure Resident #1, who was cognitively impaired, was free from abuse on 9/23/2022, when Certified Nurse Aide (CNA) #1 hit Resident #1 on their buttock. CNA #1 had nudged Resident #1's upper arm with their upper arm. Resident #1 hit CNA #1 on their buttock, CNA #1 hit Resident #1 on their buttock and Resident #1 fell on to Resident #2, who was recovering from a neck fracture. This is evidenced by: Refer to F609 The Policy and Procedure (P&P) titled, Recognizing Signs and Symptoms of Abuse/Neglect dated 2/2022, documented the policy assured that the facility would not condone any form of resident abuse or neglect. The P&P titled, Reporting Abuse to Facility Management dated 2/2022, documented the definition of abuse was the willful infliction of injury, unreasonable confinement, intimidation, punishment with resulting physical harm, pain, or mental anguish. Physical abuse was defined as hitting, slapping, pinching, kicking, etc. The P&P titled, Resident Abuse Prevention dated 2/2022, documented the IDCP (interdisciplinary care plan) Team monitored staff on all shifts to identify inappropriate behaviors toward residents (i.e. using derogatory language, rough handling of residents, ignoring residents while giving care, directing residents who need toileting assistance to urinate of defecate in their clothing/beds, etc.) Resident #1 was admitted to the facility on [DATE], with diagnoses of dementia with behavioral disturbance, generalized muscle weakness, and difficulty walking. The Minimum Data Set (MDS-an assessment tool) dated 8/2/2022, documented the resident's cognitive skills for daily decision making were moderately impaired. The Comprehensive Care Plan (CCP) last revised 7/12/2022, documented the resident enjoyed spending time with some male peers on the unit. Due to their diagnosis of dementia, the resident was at risk of being a victim of inappropriate behavior and due to their history, was at risk for being an aggressor of inappropriate behavior. CCP interventions documented to set limits on behavior; tell the resident that touching confused or non-consenting individuals was not acceptable, direct the resident to where peers were socializing appropriately, and to respect the resident's choices. Resident #2 was admitted to the facility with diagnoses of dementia without behavioral disturbance, fracture of base of skull, and displaced dens (odontoid process; a unique peg-like structure of the C2 (second cervical vertebrae) in the neck. The MDS dated [DATE], documented the resident's cognitive skills for daily decision making were severely impaired. The CCP last revised 9/23/2022, documented the resident had an actual fall with injury from bed on 8/22/2022, and was sent to the hospital and admitted with a neck fracture. The Incident Report dated 9/23/2022 at 5:04 PM by Registered Nurse Supervisor (RNS) #1 documented it was brought to their attention that Resident #1 hit CNA #1's buttock and CNA #1 hit Resident #1 on their buttocks. This caused Resident #1 to fall onto Resident #2's lap. CNA #1 attempted to hold Resident #1 up and released the resident once on their feet, and then Resident #1 hit CNA #1. The Incident and Accident (I/A) Statement Form; Licensed Nurse Statement dated 9/23/2022 at 5:04 PM by Licensed Practical Nurse (LPN) #1, documented resident (#4) on A unit brought to their attention that the aide hit Resident #1 and knocked the resident into another resident. The I/A Statement Form; Witness Form dated 9/23/2022 at 5:04 PM, documented Resident #4's verbal statement. Resident #4 saw some of the incident. They saw Resident #1 fall and the CNA trying to hold them up after they fell on Resident #2's lap. Resident #4 stated that CNA #1 was bragging about hitting them. The Event Note dated 9/23/2022 at 6:41 PM by Registered Nurse Supervisor (RNS) #1, documented it was brought to their attention that Resident #1 was noted hitting CNA #1's buttock and in turn, CNA #1 hit Resident #1's buttock, causing them to fall onto Resident #2's lap. CNA #1 went over to Resident #1 to get them up and held the resident under their arms until they were on their feet. After CNA #1 released Resident #1, the resident hit CNA #1. RNS #1 went to the unit to assess the resident and they stated that they did not want them to. The resident did not appear in any pain, however, appeared guarded and anxious. RNS #1 would re-approach when the resident was calm. The Director of Nursing (DON) and Nurse Practitioner (NP) were made aware. The Telemedicine Visit dated 9/23/2022 by the NP #1, documented the chief complaint/nature of presenting problem was an altercation with a staff member. It was brought to NP #1's attention that Resident #1 was noted hitting CNA #1's buttock and in turn, CNA #1 hit Resident #1's buttock, causing the resident to fall on Resident #2's lap. CNA #1 went over to Resident #1 to get them up and held the resident under their arms until they were on their feet. After CNA #1 released Resident #1, the resident hit CNA #1. The physical exam documented per nursing assessment and video assessment the resident did not appear to be in any pain however appeared guarded and anxious. The diagnosis, assessment, and plan documented abuse of elderly; no injuries were noted from the fall or the encounter. The Nursing Note dated 9/23/2022 at 9:44 PM by RNS #1, documented the resident was willing to have vital signs taken but would not allow staff to look at their skin to assess for any bruising or skin changes. A video labeled Ring_ANurse_20220923_1704 showed: - Resident #2 and a resident later identified as Resident #3 were sitting in chairs that were in close proximity to each other and were positioned across from the nurse station. Resident #1 was standing and was bent over Resident #3. - CNA #1 left the nurse station, walked over to Resident #1, and then positioned themselves between Resident #1 and Resident #3. Resident #1 was standing to the left of CNA #1. - CNA #1 then nudged Resident #1 with their left upper arm and made contact with Resident #1's right upper arm. - Resident #1 then hit CNA #1 on their left buttock with their right open hand and immediately turned and took a step towards Resident #2. - CNA #1 then hit Resident #1 on their right buttock with their left open hand. Resident #1 immediately fell forward onto Resident #2's chest and lap. - Resident #9 immediately alerted CNA #2 who was sitting at the nurse station in front of a computer monitor and pointed towards Resident #1. - CNA #1 then grabbed Resident #1 under their arms from behind and lifted the resident off of Resident #2 and then tried to get Resident #1 to stand up. CNA #1 then yanked the resident upward several times to get the resident to stand up. - CNA #2 then went over to Resident #1 and CNA #1 and then the resident stood up. A video labeled Ring_ANurse_20220923_1705 showed: - After Resident #1 stood up, CNA #1 was bending backwards and appeared to be laughing. Resident #1 appeared to be upset and attempted to hit CNA #1 but did not make contact and then hit CNA #1 on the hand/forearm. CNA #2 then walked Resident #1 away from CNA #1. - CNA #1 then motioned for CNA #2 to assist them with Resident #3. CNA #1 then patted CNA #2 on their right buttock two times and then began to bend backwards and appeared to be laughing. The New York State (NYS) Incident Report dated 10/3/2022 at 2:13 PM by the local law enforcement agency officer documented they were dispatched to the facility for reported abuse of an elderly resident by a former staff person. Upon arrival they met with the caller, the Administrator (ADMIN). The ADMIN reported that on 9/23/2022, CNA #1 had struck Resident #1 and had since been fired due to the incident. A documented interview dated 10/4/2022 by the Assistant Director of Resident and Family Services (ADRFS) documented they interviewed Resident #4 regarding an incident that occurred on 9/23/2022, when the agency aide, CNA #1 was found to have hit Resident #1. Resident #4 stated they did not observe the actual hit, however, did witness the resident falling as a result of the alleged hit. Resident #4 stated that they also heard CNA #1 bragging about the incident to fell ow coworkers afterward. Resident #4 stated they heard CNA #1 say, I just gave [them] a little tap. The NYS Arrest Report for CNA #1 documented an arrest date of 11/18/2022 for offense date 9/23/2022. It documented that on the above date and time CNA #1 was charged with endangering the welfare of an incompetent or physically disabled person in the second degree. During an interview on 12/2/2022 at 2:25 PM, CNA #2 stated they were familiar with the abuse policy and said that abuse was not tolerated in the facility. They were on the computer documenting and heard yelling. CNA #2 stated that they did not think anything of it because CNA #1 was always loud, and it was their normal tone. Resident #9 then pointed over to where CNA #1 and Resident #1 were because the resident was on top of Resident #2, and Resident #9 said look. CNA #2 looked over and saw Resident #1 on top of Resident #2 and then saw CNA #1 pick Resident #1 up and the resident was trying to sit on the floor. CNA #1 was shaking the resident; had the resident by their underarms and made a motion like when you would scoop something up, to get them to stand. CNA #2 stated that the way the aide handled the resident was abuse. CNA #2 then went over and got the resident to stand up by talking to them. CNA #1 then just walked away, and CNA #2 went back to documenting. The nurse was on their break at that time. CNA #2 stated they did not tell anyone about the incident because they were waiting for the nurse to come back. There were no other nurses on the unit. CNA #2 stated that it happened at 4:00 or 4:30 PM, and RNS #1 and the DON were in the building at the time. CNA #2 stated that it did not occur to them to call either one of them. CNA #2 stated they had abuse training when they were first hired in 2020. CNA #2 stated that Resident #4 told LPN #1 about the incident. CNA #2 stated the resident was alert and oriented and had their mind. CNA #2 watched the video footage and saw CNA #1 leaning over Resident #3 and then Resident #1 hit CNA #1's buttock and then CNA #1 hit Resident #1's buttock. Resident #1 then fell on to Resident #2. CNA #2 did not believe that anyone got hurt. CNA #2 stated that they felt like the way that CNA #1 tried to stand the resident up could have been done nicer, with not so much shaking. CNA #2 stated that CNA #1 walked away and was talking about it, saying I just hit their butt. They hit my butt then I hit theirs. No one in the facility talked to CNA #2 about the incident, they just wrote a statement. CNA #2 stated that Resident #4 was first person to tell LPN #1 about the incident because they liked to be the first to tell everything. CNA #2 stated that LPN #1 pulled them to the side to confirm what Resident #4 told them. CNA #2 stated that they thought CNA #1 was laughing because of the hitting, because that is what CNA #1 was mostly bragging about. CNA #2 stated they had not seen CNA #1 being abusive toward residents but heard things about the way they treated residents. CNA #2 stated that CNA #1 had given multiple skin tears because they were rough with the residents. During an interview on 12/5/2022 at 9:52 AM, Resident #4 stated that they were the one who told LPN #1 about the incident with Resident #1. Resident #4 stated that LPN #1 was at lunch during the incident. There were two aides on the unit, CNA #s 1 and 2. CNA #1 went over to Resident #1. Resident #4 was sitting to the right of them and was looking straight ahead until Resident #2 let out a big yell. They then saw Resident #1 on top of Resident #2. CNA #1 then stood behind Resident #1 and tried to lift them up by putting each arm under the resident's armpits and then pulling up on the resident to get them to stand up. Resident #1 would not stand up right away and it took about 15-20 seconds to get them to stand up. Resident #1 then turned around and hit CNA #1 because they were frustrated. While this was happening, CNA #1 was laughing and stated, I don't know why they flew so hard; I did not hit them that hard. Resident #4 stated that what really ticked them off was that CNA #1 went behind the nurse station and just started talking to CNA #2 and were BS-ing about stupid stuff. Resident #4 stated that it was not right that no one was doing anything about what had just happened to Resident #1. Resident #4 stated that as soon as LPN #1 came back to the unit, they told them LPN #1 about it. Resident #4 stated that LPN #1 did the right thing and at least told someone about it. The DON and RNS #1 then came to the unit to walk CNA #1 out. Resident #4 stated that CNA #1 told LPN #1, While you were gone, I gave Resident #1 a tap. Resident #4 stated that Resident #1 would cry once in a while and would pack up her belongings. The resident's husband was a different unit and passed away. The residents were on separate units because they did not always treat each other nice. Resident #1 liked Resident #3, who looks like their husband and held their hand and kissed them on the lips. Resident #3 usually reached out to hold Resident #1's hand and kissed them back. Resident #4 stated that Resident #1 was not aggressive. Resident #4 stated that they had never seen CNA #1 act inappropriately towards residents but had heard about the aide causing skin tears on residents. During an interview on 12/5/2022 at 3:40 PM, LPN #1 stated they were off the unit and was taking their lunch break at the time of the incident. LPN #1 stated that when they returned to the unit, CNA #1 was sitting at the nurse station and was nonchalant and stated, Resident #1 patted me on my buttock, and I patted them on their buttock. LPN #1 stated they did not know what to make of what CNA #1 had just told them. LPN #1 stated they took it in for a minute and then saw Resident #4, who LPN #1 stated had their mind and the resident stated that CNA #1 hit Resident #1 and the resident fell over into Resident #2. LPN #1 then asked CNA #2 if CNA #1 had hit Resident #1 and they said yes and that the resident fell into Resident #2. LPN #1 stated they then left the unit and reported it to the DON. LPN #2 stated they did not remove CNA #1 from the unit because they did not see the incident and did not know if it actually happened. LPN #1 stated the DON watched the video footage and then went to the unit with RNS #1. LPN #1 was not aware of any injury to Resident #1 and stated that Resident #2 wore a neck brace due to some sort of cervical fracture. LPN #1 stated that CNA #1 was rough with the residents; instead of gently guiding them and taking by the hand, CNA #1 would grab them by the arms. LPN #1 stated that CNA #1 also had a gruff tone in their voice. LPN #1 stated that CNA #1 would repeatedly say that they did not like being on the unit and that they wanted to go home. LPN #1 did not report CNA #1's behaviors. During an interview on 12/5/2022 at 1:25 PM, the Assistant Director of Resident and Family Services (ADRFS) stated they interviewed Resident #4 on 10/4/2022, at the direction of the Administrator (ADMIN). The ADRFS stated they documented the interview. The ADRFS stated the ADMIN asked them to have a general conversation with Resident #4 to see if the resident had witnessed anything on the day of the incident. The ADRFS stated they were not aware of the incident until a day or so before the request from the ADMIN. The ASRFS stated Resident #1 was pretty confused and would have moments of clarity. During an interview on 12/5/2022 at 4:10 PM, the Administrator (ADMIN) stated they were not made aware of the incident on 9/23/2022, because they were involved with a personal matter. The ADMIN stated it was not reported to the police until 10/3/2022, because they were not involved in the investigation. The ADMIN stated that it was reported to the police upon their return to work. During an interview on 12/6/2022 at 11:12 AM, RNS #1 stated they were in the DON's office giving report when LPN #1 came in and said CNA #1 was bragging about hitting Resident #1 and that they also heard the same thing from Resident #4. RNS #1 and the DON reviewed the camera footage. RNS #1 stated it was in fact what happened. RNS #1 stated that the video footage showed CNA #1 in the corner of the unit across from the nurse station and was standing in front of Resident #3 and Resident #1 was in close proximity. Resident #1 then hit CNA #1 on their bottom and then CNA #1 hit Resident #1 on their bottom, causing Resident #1 to fall onto Resident #2. RNS #1 stated they attempted to assess Resident #1 following the incident, but the resident would not let them do the assessment or get vital signs. RNS #1 stated Resident #1 was very distraught and very upset and was obviously bothered by it. RNS #1 stated they did not know if a Social Worker (SW) saw the resident following the incident. RNS #1 stated that CNA #1 was on the nursing unit during the time they were reviewing the video footage. RNS #1 stated the facility policy was they should remove the alleged perpetrator from the situation, take them off the schedule, and investigate. RNS #1 stated CNA #1 was not immediately removed because no one actually saw the hit and CNA #1 was bragging about giving each other love taps. RNS #1 stated they determined it was abuse, the moment they saw it on the camera footage and immediately went to the unit and brought CNA #1 to the office and then they left the facility. RNS #1 stated that abuse training was not done following the incident and stated, There was no excuse for it. RNS #1 stated that the DON called the police but not immediately and stated the Administrator (ADMIN) was not working due to personal reasons on 9/23/2022 and did not return until 10/3/2022. When the ADMIN returned to work, they asked RNS #1 and the DON if they reported it to the police and they said no because they reported it to the DOH and it did not cross their minds to call the police. RNS #1 stated the DON then called the police. During an interview on 12/6/2022 at 11:55 AM, the Director of Resident and Family Services (DRFS) stated Resident #1 had a habit of getting into other's space and substituted Resident #3 for their husband, who was a resident and passed away. Resident #1 would get very territorial, when thinking that Resident #3 was their husband. The DRFS stated they were not informed about the incident. The DRFS stated if they knew about it, they would have interviewed Resident #1 and stated the only resident that was interviewed was Resident #4 by the ADRFS on 10/4/2022. The DRFS stated that there were very few residents that were able to give information, but it certainly should have been looked at. The DRFS stated Resident #1 was being followed by Psychology and they and the ADRFS would have facilitated Psychology/Psychiatry involvement if they had known. During an interview on 12/8/2022 at 11:43 AM, NP #1 stated they were notified about the incident on the day that it occurred. NP #1 stated they could not go into the facility due to medical reasons and had a telemedicine visit with the resident that day. NP #1 stated they did not review the video footage. NP #1 stated Resident #1 was assessed with no injury. NP #1 stated it was the resident's usually behavior to gravitate towards men, especially ones that they believed were their husband. During an interview on 12/13/2022 at 3:17 PM, the DON stated LPN #1 came to the office and said they were told by an aide that CNA #1 was bragging about love tapping Resident #1. The DON immediately reviewed the camera footage and saw where CNA #1 was over by Resident #1 who was by Resident #3. The DON stated that Resident #1 was usually by Resident #3. CNA #1 was trying to assist Resident #3. Resident #1 then hit CNA #1 on their buttock and CNA #1 hit them back, either on the right hip or right buttock, and Resident #1 fell and landed on Resident #2's lap. The DON immediately went to the unit with RNS #1 and asked CNA #1 to come to their office. The DON told CNA #1 that they saw them hit Resident #1 and that they fell , and it could be considered abuse. CNA #1 then told the DON that they were being ridiculous and continued to say that it was just a love tap. The DON showed CNA #1 on the camera that striking Resident #1 caused them to fall. CNA #1 stated uh ah (no). The DON stated that they asked CNA #1 to write a statement and CNA #1 stated they would give their statement when the NYS Department of Health (NYSDOH) called them. The DON told CNA #1 that they had to leave the building and then they called the Agency. The DON stated that they notified the resident's family and the NP. The DON stated Resident #1 did not have behaviors that would have provoked the incident. The DON stated they did not report the incident to the Administrator (ADMIN) on 9/23/2022, because the ADMIN was dealing with personal matters. The DON stated the ADMIN was not available but was the administrator of record (AOR) at the time of the incident. The DON stated the incident was reported to the NYSDOH on 9/23/2022. The DON stated they did not think about calling the police at the time of the incident and stated they knew they should have for a suspected crime, and they did suspect a crime had occurred. The DON stated they were told that CNA #1 had kind of a negative attitude but did not address it and then CNA #1 was out of the building for a while, and they had forgotten about it. The DON stated the nurses or supervisor, if the nurses were on break, usually supervised the aides. The DON stated they did not notify Social Services because it was late on a Friday, and they were not in the building. The DON stated that normally they would talk about things in AM report but did not know why they did not discuss it. During an interview on 12/13/2022 at 3:52 PM, CNA #1 stated they had been a CNA for [AGE] years, worked for an Agency, and had been working in the facility for a while. CNA #1 stated they were familiar with Resident #1 and stated without prompting that they did not know if the resident had dementia or not. CNA #1 stated the resident knew CNA #1 and they made each other laugh. CNA #1 stated, Resident #1 would pat me on my bottom, and I would pat them on theirs. CNA #1 stated that on 9/23/2022, Resident #1 was playing with another resident's (#3) Foley (urinary catheter). CNA #1 stated they told Resident #1 sweetheart you can't do that and then Resident #1 patted my bottom and then tried to get away. CNA #1 then stated, I patted Resident #1 on their bottom and the resident tripped over Resident #2's feet and fell in their lap. CNA #1 stated they tried to pick Resident #1 up from behind because the other resident (#2) would have knocked them to the floor. CNA #1 stated Resident #1 would not stand up and then they asked CNA #2 to help stand the resident up. CNA #1 stated that after they stood the resident up, CNA #1 was laughing but not at Resident #1 and stated they were not even thinking about the resident at the time. CNA #1 stated they were not bragging about hitting Resident #1 and said it was a lie. CNA #1 stated, I like to joke but I don't want to see anyone get hurt and stated they would never hurt a resident. CNA #1 stated the resident fell because they tripped over the other resident's feet, and they did not get hurt. During an interview on 12/16/2022 at 9:25 AM, the Medical Director (MD) #2, stated that no one from the facility called them about the incident but was aware because incident reports were completed electronically, and MD #2 saw and read the incident report. MD #2 stated they did not review the video footage. MD #2 stated that CNA #1's report of routinely patting each other on the buttock was inappropriate. MD #2 stated that it was unfortunate that one Agency employee caused the facility to be under investigation for abuse. 10 NYCRR 415.4(b)(1)(i)

Based on observation, record review, and interviews during an abbreviated survey (Case # NY00302790) the facility did not ensure that it implemented written policies and procedures that ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act; that each covered individual reported to the State Agency and one or more law enforcement entities any reasonable suspicion of a crime against any individual who is a resident of the facility, not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury for 1 (Resident #1). Additionally, the facility did not ensure that all alleged violations were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation result in serious bodily injury for 2 (Resident #s 1 and 2) of 3 residents reviewed. Specifically, for Resident #1, the facility's policy for reporting abuse was not implemented on 9/23/2022 when Certified Nurse Aide (CNA) #1 hit Resident #1 on their buttock and when the abuse was not reported to local law enforcement until 10/3/2022 and for Resident #2, the facility did not report Resident #2 had sustained a neck fracture from a fall out of bed on 8/22/2022 to the New York State Department of Health (NYSDOH). This is evidenced by: Refer to F600 The Policy and Procedure (P&P) titled Reporting Abuse to State Agencies and other Entities/Individuals dated 2/2022, documented the Director of Nursing; Director of Family Services; and the Education Coordinator were responsible for notifying the State Licensing/Certification Agency responsible for surveying/licensing the facility; Department of Health; resident's representative; law enforcement officials; resident's attending physician; facility's Medical Director (verbally and written), should there be an alleged/suspected violation or substantiated incident of mistreatment, neglect, injuries of unknown origin, abuse, misappropriation of resident property, including resident-to-resident abuse. It documented the agencies were to be notified verbally once it was determined that there was sufficient evidence to believe that abuse occurred. The appropriate agencies/individuals were to be provided with a written report of the findings of the investigation. If the findings revealed abuse occurred, the written report would include corrective actions taken by the facility to prevent abuse from recurring. The P&P titled Accident & Incident Program last revised 3/3/2017, documented it was the policy of the facility to promote a safe resident care environment. All employees were required to follow the abuse protocols of the facility, reporting any potential or actual acts of abuse, neglect, mistreatment, misappropriation of a resident as defined in the NYSDOH Incident Reporting Manual, to their supervisor, administrator of the facility, and ensure investigations were reported to the NYSDOH or self-report using the complaint hotline. Resident #1: Resident #1 was admitted to the facility on [DATE], with diagnoses of dementia with behavioral disturbance, generalized muscle weakness, and difficulty walking. The Minimum Data Set (MDS - an assessment tool) dated 8/2/2022, documented the resident's cognitive skills for daily decision making were moderately impaired. The facility's Incident Report dated 9/23/2022 at 5:04 PM, written by Registered Nurse Supervisor (RNS) #1 documented it was brought to their attention that Resident #1 hit CNA #1's buttock and CNA #1 hit Resident #1 on their buttocks. This caused Resident #1 to fall onto Resident #2's lap. CNA #1 attempted to hold Resident #1 up and released the resident once on their feet, and then Resident #1 hit CNA #1. The facility's Incident and Accident Statement Form/Witness Form dated 9/23/2022 at 5:04 PM, documented Resident #4 saw some of the incident. Resident #4 saw Resident #1 fall and the CNA trying to hold them up after they fell on Resident #2's lap. Resident #4 stated that CNA #1 was bragging about hitting Resident #1. During an interview on 12/5/2022 at 4:10 PM, Administrator (ADMIN) stated they were not made aware of the incident on 9/23/2022, because they were involved with a personal matter. ADMIN #1 stated it was not reported to the police until 10/3/2022, because they were not involved in the investigation. ADMIN #1 stated that it was reported to the police upon their return to work. During an interview on 12/6/2022 at 11:12 AM, Registered Nurse Supervisor (RNS) #1 stated the Director of Nursing (DON) called the police but not immediately and stated ADMIN was not working due to personal reasons on 9/23/2022 and did not return until 10/3/2022. When ADMIN returned to work, they asked RNS #1 and the DON if they reported it to the police and they said no because they reported it to the DOH and it did not cross their minds to call the police. RNS #1 stated the DON then called the police. During an interview on 12/13/2022 at 3:17 PM, DON stated they did not report the incident to ADMIN on 9/23/2022, because the ADMIN was not working that day. DON stated ADMIN was not available but was the Administrator of Record (AOR) at the time of the incident. DON #1 stated the incident was reported to the NYSDOH on 9/23/2022. DON stated they did not think about calling the police at the time of the incident and stated they knew they should have for a suspected crime, and they did suspect a crime had occurred. DON stated the nurses supervised the aides and if the nurses were on break, the supervisor would supervise the aides. Resident #2: Resident #2 was admitted to the facility with diagnoses of dementia without behavioral disturbance, fracture of base of skull, and displaced dens (odontoid process; a unique peg-like structure of the C2 (second cervical vertebrae) in the neck. The MDS dated [DATE], documented the resident's cognitive skills for daily decision making were severely impaired. The Comprehensive Care Plan (CCP) dated 7/1/2022 and revised on 8/23/2022, documented Resident #2 was non-compliant with the use of the bed remote and often put the bed up in a higher position than needed. The CCP last revised 9/23/2022, documented the resident had an actual fall with injury from bed on 8/22/2022, and was sent to the hospital and admitted with a neck fracture. Review of the Incident Report dated 8/22/2022 at 11:20 PM by RNS #2, documented they assessed Resident #2 following an unobserved fall out of bed. The resident was bleeding from their nares and had a small laceration noted to their right forehead. The resident complained that their head was hurting. The resident had poor safety awareness and was independent with ambulation and transfers. The Nursing Note dated 8/23/2022 at 3:17 AM, documented the nurse spoke with the ER nurse and the resident was being transferred to another hospital with a fractured neck. Review of the fall investigation summary dated 8/22/2022 by ADMIN, documented Resident #2 fell out of bed and sustained a fracture to the base of the skull. Staff indicated the bed was in the highest position when the fall occurred, and the resident had to urinate at the time of the fall. ADMIN documented that a care plan violation was not identified, and equipment malfunction was ruled out. Abuse and neglect were also ruled out. During an interview on 12/5/2022 at 12:19 PM, ADMIN stated they did not report the incident to the NYSDOH because the fall was not caused by an equipment malfunction. During an interview on 12/13/2022 at 3:17 PM, DON stated they were not aware of the incident on 8/22/2022, because they were on vacation. 10 NYCRR 415.4(b)(2)

Based on record review and interviews during an abbreviated survey (Case # NY00302790), the facility did not ensure each resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (Resident #2) of 4 residents reviewed. Specifically, for Resident #2. the facility did not ensure their policy for Accident/Incident Reporting was followed when Resident #2 fell forward onto Resident #2's chest/lap on 9/23/2022 and was not assessed by a Nurse Manager, a Nursing Supervisor or a Registered Nurse. This is evidenced by: Refer to F600 The Policy and Procedure (P&P) titled Accident/Incident Reporting - Resident dated 2/2022, documented the Nurse Manager; Nursing Supervisor; Registered Nurse would assess the resident for any injury, completed follow up and vital signs, and implemented immediate intervention as indicated. Resident #2: Resident #2 was admitted to the facility with diagnoses of dementia without behavioral disturbance, fracture of base of skull, and displaced dens (odontoid process; a unique peg-like structure of the C2 (second cervical vertebrae) in the neck. The The Minimum Data Set (MDS-an assessment tool) dated 7/12/2022, documented the resident's cognitive skills for daily decision making were severely impaired. The CCP last revised 9/23/2022, documented the resident had an actual fall with injury from bed on 8/22/2022, and was sent to the hospital and admitted with a neck fracture. The Incident Report dated 9/23/2022 at 5:04 PM by Registered Nurse Supervisor (RNS) #1 documented it was brought to their attention that Resident #1 hit CNA #1's buttock and CNA #1 hit Resident #1 on their buttocks. This caused Resident #1 to fall onto Resident #2's lap. Review of the Progress Notes dated 9/23/2022, did not document an assessment of Resident #2. During an interview on 12/6/2022 at 11:12 AM, RNS #1 stated they did not assess Resident #2 following the incident with Resident #1 on 9/23/2022, because they considered it to be a soft fall. RNS #1 stated they were more focused on Resident #1. During an interview on 12/8/2022 at 11:43 AM, the Nurse Practitioner (NP) #1 stated they did not assess Resident #2 because of the way the incident was described by RNS #1. NP #1 stated they were told that Resident #1 had leaned back onto Resident #2's lap and barely touched Resident #2. During an interview on 12/13/2022 at 3:17 PM, the Director of Nursing (DON) stated Resident #2 was not assessed for injury following the incident with Resident #1 on 9/23/2022. The DON stated that their primary goal was to make sure the Certified Nurse Aide (CNA) #1 was out of the building and Resident #1 was ok. The DON stated they were aware that Resident #2 had a fall in August with cervical fracture and that the resident had also fallen in the AM on 9/23/2022. The DON stated in retrospect, Resident #2 should have had an assessment. During an interview on 12/16/2022 at 9:25 AM, the Medical Director (MD) #2 stated that even if Nursing did not do a complete head-to-toe assessment of Resident #2 following the incident, they could have asked the resident how they were and documented that in a note. MD #2 stated that they would have liked to see a one line note about the resident, rather than nothing at all. MD #2 stated that it was probably an oversight because they were focused on what had occurred with Resident #1. 10 NYCRR 415.12

Based on record review and interviews during an abbreviated survey (Case #NY 916) , the facility did not ensure allegations of abuse and mistreatment were thoroughly investigated, and did not prevent further potential abuse, for 1 (Resident #9) of 4 residents reviewed. Specifically, for Resident #9, the facility did not investigate the resident's allegation that a certified nursing assistant (CNA) was rough during care on 4/5/2022, and did not remove the alleged perpetrator from care. The alleged perpetrator continued to have access to other vulnerable residents. This is evidenced by: Resident #9: Resident #9 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment) dated 4/7/2022, documented the resident could be understood and could understand others with a Brief Interview for Mental Status (BIMS) score assessed to be 15/15, significant of intact cognition. The Resident Abuse Prevention and Reporting Policy and Procedure dated 2/2022, documented the facility will assure all alleged/suspected abuse is thoroughly investigated. During the investigation of abuse the resident will be protected from harm by the following measures. Employees accused of abuse may have a change of duties that do not involve resident contact or may be suspended until the findings of the investigation have been reviewed by the Administrator. The policy further documents resident abuse prevention assures the facility will not condone any form of resident abuse and will continually monitor the facility's policies, procedures, training programs, system, etc., to assist in preventing resident abuse. Resident #9 Comprehensive Care Plan (CCP) for Activities of Daily Living (ADL's) implemented 3/31/2022 documented Resident #9 was a 2-person extensive assist for bed mobility. An Admission Progress Note dated 3/31/2022 at 12:30 PM, documented that the resident was alert and oriented, pleasant, cooperative and is an extensive assist for all ADL's. It documented the resident complains of number 10 generalized pain, screams with any type of movement or repositioning, has vascular wounds noted to their right lateral lower leg, left lateral lower leg, and left posterior lower leg, has a SDTI (suspected deep tissue injury) noted to bilateral heels, maceration to bilateral buttocks down to posterior thighs and has an unstageable (pressure ulcer) noted to their right gluteal fold. A Grievance/Recommendation Information report dated 4/5/2022 at 2:00 PM, documented Resident #9 requested to see the Director of Social Work (DSW). Resident #9 requested a meeting for the purpose of filing a complaint against CNA (certified nursing assistant) #3. The resident was interviewed bedside with a family member present. Resident #9 reported the CNA #3 had answered their call light around 2:00 AM on 4/4/2022. The resident reported needing help with positioning their legs, that were up on a wedge. Resident #9 reported CNA #3 whipped the covers off them, grabbed the pad that was under them and yanked it out from under them. The sudden movement caused them a great deal of pain and was pulled so hard that they ended up diagonal in bed. CNA #3 threw the covers over them and left the room without saying another word. Resident #9 did not want CNA #3 to provide care to them in the future. Review of the resident's medical record from 3/31/2022 through 5/9/2022, did not include documentation of an investigation regarding the resident's allegation that a CNA was rough with care. Resident #9's written statement dated 4-6-2022 documented the following: On April 4, 2022 approximately 10:00 PM CNA #3 answered the call bell and requested adjustment to the wedge pillow under my legs. CNA #3 rudely whipped the blanket and sheet off me and stated they didn't know what I was talking about and stated You look square to me. I further requested adjustment of the wedge and just as I thought CNA #3 was going to leave the room and ignore my request they turfed back around and grabbed the pad with great force which threw my very painful left hip up in the air and came crashing down on the mattress while I screamed loudly in major pain. CNA #3 whipped the blanket and sheet over me and walked out with no apology. Monday was not the first time I felt intimidated by CNA #3. I reported this to the DSW. I do not want that CNA to ever touch me again. The treatment CNA #3 gave me, I consider abuse. Resident #9 was no longer in the facility during this survey dated from 7/11/2022 to 7/21/22. During an interview on 7/13/2022 at 11:15 AM, CNA #6 stated Resident #9 reported the alleged abuse to them in the morning. CNA #6 encouraged the resident to write a statement about the abuse as the resident did not want CNA #3 to take care of them. This was reported to the DSW and the DON the morning of 4/5/2022 by CNA #6. CNA #6 reported the abuse to the NYSDOH hotline on 4/26/2022 when it was apparent no investigation was done, and the facility had not reported the allegation of abuse to the state. During an interview on 7/13/2022 at 4:01 PM, the DSW stated a grievance was completed about the incident reported by Resident #9 on 4/5/2022. All grievances are reviewed with the DON and the Administrator. CNA #9 can be gruff with residents. Residents either love the CNA or are not happy with the CNAs approach. CNA #3 has worked for the facility for a long time. The DSW stated they were unaware if the facility further investigated the concerns of the resident. Resident #9 was given the DOH hotline number. I expected them to call and report the incident even though CNA #3 was going to be removed from providing care to the resident. Resident #9 prepared a hand written statement that was given to the DON after the DSW met with the resident and family on 4/5/2022. The DSW was unable to say what occurred after that with the matter. The New York State Department of Health Intake Information sheet printed on 4/26/22, documented a staff member reported the resident reported abuse incident to the DON and the Social Worker on 4/5/2022. During an interview on 7/14//2022 at 1:51 PM, the DON stated the 4/05/2022 incident reported by Resident #9 should have been investigated. Without an investigation important details of non-compliance could be missed. A residents CCP would be updated and reflect goals and interventions needed to address concerns. This didn't happen. A Grievance was handled by the DSW and reported by staff after Resident #9 complained about care by CNA #3. Resident #9 gave a hand written statement about the incident to staff and it was reviewed by Administration. The facility should have done an investigation and the staff member should have been removed from all patient care until the investigation was completed. That is the policy and the regulation on reporting abuse and allegation of abuse. During an interview on 7/14/2022 at 2:26 PM, the Administrator stated the alleged allegation of abuse had not been thoroughly investigated. The DSW spoke with the resident and a grievance was completed. Resident #9 had not used the word abuse to anyone. The grievance process had resulted in CNA #3 being removed from caring for the resident. No formal investigation had been done and the staff member had not been suspended from caring for other residents. The Administrator stated they would need to review the complaint to refresh the matter and how and why it was handled the way it was. During an interview on 7/19/2022 at 12:30 PM, the Nurse Practitioner (NP) stated they were aware of the allegation of abuse made by Resident #9 against CNA #3. The NP stated she made a bedside visit to the resident after the grievance was made and the resident recounted the concerns. The NP believed the DON, DSW, and Administrator were following up on the complaint. An allegation of harm should be reported to the State and should be investigated to determine if abuse occurred. During the investigation staff is removed from resident care until an outcome is determined. NYCRR483.12(c)(2)-(4)

Based on record review and interviews during an abbreviated survey (Case #NY 916), the facility did not ensure allegations of abuse and mistreatment were reported within 2 hours after the allegation was made for 1 (Resident #9) of four residents reviewed for abuse and neglect. Specifically, for Resident #9, the facility did not report an allegation that a staff member was rough during care to the New York State Department of Health (NYSDOH) within 2 hours after it was reported to the Director of Nursing (DON), Director of Social Worker, (DSW) and the Administrator on 4/5/2022. This is evidenced by: Resident #9: Resident #9 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 4/7/2022, documented the resident could be understood and could understand others, with a Brief Interview for Mental Status (BIMS) score assessed to be 15/15, significant of intact cognition. The Resident Abuse Prevention and Reporting policy and procedure dated 2/2022 documented the facility will assure all alleged/suspected violations and all substantiated incidents of abuse will be properly reported to appropriate state agencies and other entities or individuals required by law. It further documents the DON and Director of Family Services notifies the following persons or agencies (verbally and written) should an alleged/suspect violation of abuse be reported: a. State Licensing /Certification Agency responsible for surveying/licensing the facility, b. Department of Health, c. Resident's representative, d. law enforcement officials, e. Residents attending physician, and f. the Facilities Medical Director. The policy further documents resident abuse prevention assures the facility will not condone any form of resident abuse and will continually monitor the facility's policies, procedures, training programs, system, etc., to assist in preventing resident abuse. Review of New York State Department of Health Intake Information Sheet dated on 4/26/22, documented a staff member reported the residents allegation of abuse to the DON and the Social Worker on 4/5/2022. An Admission Progress Note dated 3/31/2022 at 12:30 PM, documented that the resident was alert and oriented, pleasant, cooperative and is extensive assist for all ADL's It documented the resident complains of number 10 generalized pain, screams with any type of movement or repositioning, has vascular wounds noted to their right lateral lower leg, left lateral lower leg, and left posterior lower leg, has a SDTI (suspected deep tissue injury) noted to bilateral heels, maceration to bilateral buttocks down to posterior thighs and has an unstageable noted to their right gluteal fold. The Comprehensive Care Plan for Activities of Daily Living (ADL's) implemented 3/31/2022 documented Resident #9 was a 2 person extensive assist for bed mobility. Resident #9's written statement dated 4-6-2022 documented the following: On April 4, 2022 approximately 10:00 PM CNA #3 answered the call bell and requested adjustment to the wedge pill under my legs. CNA #3 rudely whipped the blanket and sheet off me and stated they didn't know what I was talking about and stated You look square to me. I further requested adjustment of the wedge and just as I thought CNA #3 was going to leave the room and ignore my request they turfed back around and grabbed the pad with great force which threw my very painful left hip up in the air and came crashing down on the mattress while I screamed loudly in major pain. CNA #3 whipped the blanket and sheet over me and walked out with no apology. Monday was not the first time time I felt intimidated by CNA #3. I reported this to the DSW. I do not want that CNA to ever touch me again. The treatment CNA #3 gave me, I consider abuse. A Grievance/Recommendation Information report dated 4/5/2022 at 2:00 PM, documented Resident #9 requested to see the Director of Social Work (DSW). Resident #9 requested a meeting for the purpose of filing a complaint against CNA (certified nursing assistant) #3. The resident was interviewed bedside with a family member present. Resident #9 reported the CNA #3 had answered their call light around 2:00 AM on 4/4/2022. The resident reported needing help with positioning their legs, that were up on a wedge. Resident #9 reported CNA #3 whipped the covers off them, grabbed the pad that was under them and yanked it out from under them. The sudden movement caused them a great deal of pain and was pulled so hard that they ended up diagonal in bed. CNA #3 threw the covers over them and left the room without saying another word. Resident #9 did not want CNA #3 to provide care to them in the future. The Comprehensive Care Plan for Activities of Daily Living (ADL's) implemented 3/31/2022 documented Resident #9 was a 2 person extensive assist for bed mobility. Resident #9 was no longer in the facility during this survey dated from 7/11/2022 to 7/21/22. During a telephone interview on 7/13/2022 at 11:15 AM, CNA #6 stated Resident #9 reported the alleged abuse to the CNA #6 on the morning of 4/5/2022. CNA #6 encouraged the resident to write a statement about the abuse that occurred because the resident did not want CNA #3 to take care of them and it appeared nothing had been done. The CNA #6 reported the alleged abuse to the DSW and verbally reported the residents complaint to the DON as well on 4/5/2022. CNA #6 confirmed they reported the abuse to the NYSDOH Hotline on 4/26/2022 when it was apparent no investigation was done, CNA #3 wasn't disciplined or suspended, and the facility had not reported the allegation of abuse to the State. Resident #9 did write a statement but CNA #6 wasn't sure who the resident gave it to. The facility never informed CNA #6 the outcome of the complaint they reported. During an interview on 7/13/2022 at 4:01 PM, the DSW stated a grievance was completed about the incident reported by Resident #9. All grievances are reviewed with the DON and the Administrator. CNA #9 can be gruff with residents. Residents either love the CNA or are not happy with the CNAs approach. CNA #3 has worked for the facility for a long time. The DSW stated they were unaware if the facility reported the incident to the State. Resident #9 was given the DOH hotline number. I expected them to call and report the incident even though CNA #3 was removed from providing care to the resident. During an interview on 7/14//2022 at 1:51 PM, the DON stated the 4/05/2022 incident reported by Resident #9 should have been submitted within 24 Hours to the NYSDOH. A Grievance was handled by the DSW and reported by staff after Resident #9 complained about care by CNA #3. The facility should have reported the allegation and done an investigation. The staff member should have been removed from all patient care until the investigation was completed. That is the policy and the regulation on reporting abuse and allegation of abuse. During an interview on 7/14/2022 at 2:26 PM, the Administrator stated the alleged allegation of abuse had not been reported to the State per regulation. There was confusion as to whether abuse had occurred. Resident #9 had not used the word abuse to anyone. A grievance process had resulted in CNA #3 being removed from caring for the resident. No investigation had been done and the staff member had not been suspended from caring for residents. During an interview on 7/19/2022 at 12:30 PM, the Nurse Practitioner (NP) stated they were aware of the allegation of abuse made by Resident #9 against CNA #3. The NP stated a bedside visit was made to the resident who recounted the concerns. The NP believed the DON, DSW, and Administrator were following up on the complaint. An allegation of harm should be reported to the State and should be investigated to determine if abuse occurred. 10 NYCRR415.4(4)

Based on record review and interview during the recertification survey and abbreviated survey (Case #NY 486) dated 7/13/2022 through 7/19/2022, the facility did not ensure it established a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and determined that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 3 (Unit A, Unit B, and Unit C) of 3 units reviewed. Specifically, the facility did not ensure incoming and outgoing nurses were consistently signing the Controlled Drug and Narcotic Change of Shift Audit form (count sheet- a sheet that documented a list of all narcotics on the unit, which residents the drugs belonged to, the amount remaining of each narcotic, the date the count was done (each sheet covers 7 days/3 shifts per day), and a place for the incoming and outgoing nurses to sign each shift that all narcotics had been accounted for) and that there was a system in place to ensure medications were reconciled. This is evidenced by: A facility policy titled, Medication Nurse Routine revised 6/30/2022, documented nurses would count narcotics. The on-coming nurse counts the medications in the blister packs and records the amount on the shift to shift count sheet. The off-going nurse compares the amount counted with the individual resident's descending inventory sheet and both should match. Unit A, Unit B and Unit C each had 2 medication carts (A/B & C/D). For each medication cart, there were 42 opportunities every week for nurses to sign the Controlled Drug and Narcotic Change of Shift Audit form. These records documented the following: -Unit A: 7/1/2022 - 7/7/2022, the A/B cart included 25 of 42 possible signatures and the facility did not provide a count sheet for the C/D cart. -Unit B: 7/1/2022 - 7/7/2022, the A/B cart included 25 of 42 possible signatures and the C/D cart contained 28 of 42 possible signatures. -Unit C: 7/1/2022 - 7/7/2022, The facility did not provide a count sheet for the A/B cart. An undated count sheet for the 7 days it was in use for the C/D cart, contained 19 of 42 possible signatures. This sheet was to account for the following filled controlled substance prescriptions: 1- [MEDICATION(S)], 2- [MEDICATION(S)], 1- [MEDICATION(S)], 6 -[MEDICATION(S)], 2- [MEDICATION(S)], 1-[MEDICATION(S)], and 1- provisil. During an interview on 7/18/2022 at 2:35 PM, Licensed Practical Nurse (LPN) #2 stated the in-coming and out-going nurses were supposed to sign after counting. LPN #2 did notice blanks but thought maybe it was agency nurses who did not sign. During an interview on 7/19/2022 at 12:20 PM, the Director of Nursing (DON) stated nurses signed the narcotic in on count sheet at shift change. There was not a process to check to ensure staff were signing the medication sheets. A lot of the nurses did double shifts and may not sign the second shift. The keys did not change hands, so the DON did not expect the nurses to sign again, but the DON could not tell if a blank was due to a nurse doing a double shift or if the nurse just did not sign. 10NYCRR 415.18(e)

Based on record review and interview during the recertification survey dated 7/13/2022 through 7/19/2022, the facility did not ensure foods brought to residents was in accordance with adopted regulations. Specifically, the facility did not provide information to families and other visitors on safe food handling practices, such as safe cooling and reheating processes, hot and cold holding temperatures, preventing cross contamination, and hand hygiene, of food that they bring to residents. This is evidenced is as follows: The policies and procedures titled Food brought in by visitors dated 11/2017 and Foods Brought in from Visitors and dated 11/19/2019 did not document that families and other visitors were provided information on safe food handling practices, such as safe cooling and reheating processes, hot and cold holding temperatures, preventing cross contamination, and hand hygiene, of food that they bring to residents. During an interview on 7/19/2022 at 9:25 AM, the Administrator stated the facility did not provide information on safe food handling to families and visitors who brought food to residents.

Based on observation, interview and record review during a recertification survey dated 7/13/2022 through 7/19/2022, the facility did not ensure residents had the right to self-administer medications if the interdisciplinary team, determined that this practice was clinically appropriate for 1 (Resident #223) of 1 resident reviewed. Specifically, the facility did not ensure Resident #223 was assessed to determine if self-administration of medication was clinically appropriate prior to leaving [MEDICATION(S)] (an inhaled medication used to treat wheezing and shortness of breath caused by breathing problems such as asthma or [CONDITION(S)]) at the resident's bedside for them to self-administer. This was evidenced by: Resident #223: Resident #223 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Social Work note dated 7/15/2022, documented the resident was admitted today and appeared to be alert and oriented x 3 (person, place and time). A facility policy titled Self-Administration of Medication revised 5/2004, documented the facility would assess each resident to determine if they were capable of self-administration of medication. Nursing was responsible for identifying the correct medications and instructions on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During a medication storage observation on 7/19/2022 at 11:40 AM, on A Unit (the dementia unit) there was an empty Ziploc bag in the top drawer of the medication cart labeled with a prescription label for [MEDICATION(S)] belonging to Resident #223. Licensed Practical Nurse (LPN) #1 stated the resident kept that medication at their bedside. During an observation on 7/19/2022 at 11:53 AM, the resident was in their room, sitting in a wheelchair. When asked about their inhaler, the resident stated they had their inhaler in their pocket and showed the surveyor the inhaler. Resident #223 stated they administered their inhaler themself. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] Aerosol 160-4.5 micrograms (MCG)/[MEDICATION(S)], inhale 1 puff twice daily for [CONDITION(S)] -[MEDICATION(S)] powder breath activated, inhale 2 puffs orally every 6 hours as needed for shortness of breath/wheezing. May keep at bedside after proper demonstration of use. A Self-Administration Evaluation form (a form used to determine the capability of a resident to self-administer their medications) dated 7/17/2022, documented No -(STOP HERE) under the question, Does the resident want to self-administer his/her own medications. The question, Is the resident able to safely self-administer medications, was blank. During an interview on 7/19/2022 at 11:40 AM, LPN #4 stated they did not know if the resident was assessed for their ability to self-medicate. During a follow up interview on 7/19/2022 at 12:10 PM, LPN #4 stated they had another resident who self-administered medication and that resident had a sheet in their room to document when they took their medications. LPN #4 stated they did not document when Resident #223 took their medication. Resident #223 did not have a sheet in their room to document their self-administration. During an interview on 7/19/2022 at 12:20 PM, the Director of Nursing (DON) stated the Self-Administration Evaluation form dated 7/15/2022, was done before the resident received the order for the [MEDICATION(S)]. The DON stated they could not find a completed assessment that showed the resident was able to manage [MEDICATION(S)] at the bed side, but a new evaluation should have been completed prior to medications being left at the bedside. 10NYCRR 415.3 (e)(1)(vi)