Every finding on record at Sullivan County Adult Care Center

Based on observations and interviews during the abbreviated survey the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents. Specifically, on 08/10/2026 at 11:48 AM surveyors observed the medication cart on Unit 4 in the hallway left unlocked, unattended. On unit 3 at 11:58 AM observed medication cart on the unit near the nursing station left unlocked, unattended.The findings are:Review of the facility's Medication Storage policy last reviewed 5/2024 documented medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication.During an observation on 08/10/2026 at 11:48 AM observed the medication cart left in the hallway unlocked and unattended. Licensed Practical Nurse # 2 observed in the hallway providing treatment to a resident's foot. At 11:50 AM Assistant Director of Nursing walked past the medication cart and noticed it was open and closed the cart. Assistant Director of Nursing returned to the cart and locked the cart. The Assistant Director of Nursing acknowledged the cart should have been locked.During an interview on 08/10/2026 at 11:54 AM with Licensed Practical Nurse #2 stated that they know the cart should have been locked, but they assisted the resident from the dining room back to the unit because they were bleeding. They forgot to lock the cart because they tried to stop the resident's foot from bleeding.During an observation on 08/10/2026 at 11:58 AM on unit 4 medication cart was next to nurse station unlocked and unattended. Unit Clerk # 3 identified that the medication cart parked near the nurse's station was assigned to Licensed Practical Nurse # 3. Licensed Practical Nurse # 3 was inside Resident # 4's far corner room with Unit Manager # 1. Licensed Practical Nurse # 3 transferred Resident # 4 to the wheelchair, Licensed Practical Nurse # 3 was then observed wheeling Resident # 4 down the hall to the dining room. 12:14 PM surveyors notify Unit Manager #1 that the medication cart is left unlocked. Unit Manger # 1 locked the medication cart and acknowledged that the medication cart should be locked at all times.During an interview on 08/10/2026 at 12:16 PM with Licensed Practical Nurse # 3 they stated there was an emergency and they had to leave the cart. Licensed Practical Nurse # 3 stated they always carry their keys for the medication cart with them and acknowledged that the cart should be locked; however, they had an emergency and were called to assist the resident.

Based on record reviews and interviews conducted during the abbreviated survey, the facility failed to implement a system to consistently and accurately reconcile controlled medications in accordance with professional standards of practice. This was evident for two out of four residents (Resident #1 and Resident #15) sampled for medication discrepancies. Specifically, (1) the entries on a narcotic count sheet for Resident #1 were changed and written over by staff that had not administered the narcotic, and (2) discrepancies were noted with entries on the inventory log of narcotics for Resident #15 that did not timely and accurately reflect if medications received by the facility were administered, destroyed, or returned to Resident #15 upon their discharge. Facility Policy Accountability of Medications and Administration last reviewed 5/2025 documented Strict accountability of all medications from origin of MD order to administration to resident will be maintained. According to this policy the Consultant Pharmacist reports any irregularities found in medication accountability to the Administrator and Director of Nursing for appropriate action. According to this policy the Nurse has a responsibility that any discrepancy with Narcotic accountability must be reported immediately to the Nursing Supervisor or Director of Nursing or Assistant director of nursing. The facility provided the Department of Health controlled Substance destruction guidance for residential health care facilities licensed as Class 3A Institutional Dispense, Limited. Medications that are prescribed and dispensed to a patient are owned by the patient, known as the end user or ultimate user. Class 3A licensees are given the lawful ability, through licensure, to take temporary custody of a patient's prescribed controlled substances. Once a patient is discharged , all medications prescribed to the patient that are in temporary custody of the Class 3A licensee, must be turned over to the patient at the time of discharge, unless they are discontinued by the practitioner who prescribed the medications. Facilities are not legally allowed to retain possession of a patient's prescribed medications after discharge unless the medication has been discontinued by the prescriber. If patients are not provided with their medications upon discharge, they may not be able to obtain a refill of the controlled substance until the current prescription time period has ended. An important step in reducing potential diversion of controlled substances is to reduce the amount of medication coming into a facility. Facilities should have a full understanding of their patient population and what their patients' medication needs are. To reduce the amount of medication at the facility, controlled substance prescriptions for patients in a hospice or a residential health care facility may be partially filled, or prescriptions may be issued for a shorter time period. A review of the narcotic count sheet for Resident #1 with a start date of administration of 6/30 for medication Morphine Sulfate 20MG/ML solution with directions 0.25ml = 5mg by mouth every four hours as needed for pain MDD (maximum daily dose) 30 mg, found that from the dates 6/30 to 7/5 there are entries of amounts that have been written over which changed the original amounts that were entered as having been administered. There is no written note, discrepancy report, or investigative report indicating why entries on this narcotic count sheet were written over and changed. A review of the facility log book, where narcotic medications are inventoried for receipt and destruction or for return purposes, it was noted on 08/11/2026 at 3:16pm that for Resident #15 the inventory of medication for 08/19/2025 showed that the facility received oxycodone/APAP (Percocet) 5-325mg 24 tablets, and for 08/20/2025 there were two line entries that showed that the facility received more blister packs of the same medication with an additional 60 tablets on each line, for a grand total of 144 tablets of Percocet all for Resident #15. Other than an entry on a narcotic count sheet that shows that tablets #24 and #23 were wasted, there was no sign out of these medications, indicating they were completed (administered), or destroyed, or sent home (with the resident). Upon the discharge of Resident #15 on 09/18/2025 at 1:49pm there is a chart note by Assistant Director of Nursing that documented: Resident #15 discharged as per plan and protocol; Resident #15's medication list reviewed; narcotics sent home with Resident #15; and all belongings sent with Resident #15. The medications that the facility received for Resident #15, 144 tablets of Percocet, were not signed out in the narcotic logbook when Resident #15 was discharged . During an interview with the Director of Nursing on 08/12/2026 at 4:20pm they stated that the Bureau of Narcotic Enforcement already came to investigate this narcotic count sheet for Resident #1. The Director of Nursing stated that on or around July 4th, 2026, Nursing Supervisor #1 called to tell them that there was something wrong with the narcotic count sheet for Resident #1, that the amount being deducted with each entry was going down by 1ml instead of 0.25ml (as per the order). The Director of Nursing stated the call was on face time, and that Nursing Supervisor #1 showed them the bottle of medication and they noted that there was more in the bottle than the inventory count sheet indicated, so they then considered that it was clear that Resident #1 was not being over medicated and that the matter was simply a transcribing error on the inventory count sheet. The Director of Nursing stated that they instructed Nursing Supervisor #1 not to touch the medication or the inventory count sheet and that they would manipulate the inventory count sheet when they came to the facility. The Director of Nursing stated they did not do a formal investigation, and that there was no direction received from the Administrator or the Medical Director, and that the buck stopped with them. At that point the surveyors requested the narcotic log book and on 08/12/2026 at 4:28pm noted that there were now signatures present for the Percocet the facility received for Resident #15 indicating that the medication (22 tablets + 60 tablets + 60 tablets) had been sent home with Resident #15 on 09/18/2025. The Director of Nursing stated that the Assistant Director of Nursing had just made the entries in the narcotic log book signing the medications out on 09/18/2025. The Director of Nursing stated they had no explanation for why this was not done when Resident #15 was discharged . The Director of Nursing stated that they did not know what to do when they reviewed the narcotic log book and found that the medications had not been signed out, so to resolve the matter they requested that the Assistant Director of Nursing sign the medications out now. During an interview with the Administrator on 08/17/2026 at 3:12pm they stated that they were not aware of any discrepancies and they were not made aware of the narcotic count sheet that was altered after medications were administered. The Administrator knew that the Bureau of Narcotic Enforcement had come to the facility, but they were not informed as to why they were in the facility. The Administrator stated that they know that the process is that whoever administered the medication should have been the one to adjust the mistake, that there should be witnesses and that it should be a cross out with one line not a write over. During an interview with the Unit 2 Nurse Manager on 08/18/2026 at 10:16am they stated that if there is an issue with the narcotic count sheet no one should leave, that any correction made on the narcotic count sheet should be one line and an initial of the nurse that made the error, no white out, and no writing over the numbers. During an interview with the Medical Director on 08/19/2026 at 1:14pm, they stated that they were not made aware of the narcotic count sheet error, nor were they made aware that the Bureau of Narcotic Enforcement had come to the facility to investigate anything. They stated that ideally, they should have been made aware. The Medical Director stated that they have never seen the narcotic log book for medications received and/or destroyed or sent home with a resident. When the surveyors provided the Medical Director with the log book page for their review and informed them that the medications were signed out on 08/12/2026 as opposed to when Resident #15 was discharged on 09/18/2025, they stated that they would have to call Resident #15 to determine if they indeed went home with the medication. During a follow up interview with the Medical Director on 08/25/2026 at 9:52am they stated that during a conference call with the Director of Nursing, they called and spoke with Resident #15. The Medical Director stated that Resident #15 said they took all the medications home and that they informed both the Medical Director and the Director of Nursing that they were uncomfortable with all the medications and felt like they had a lot of pills. The Medical Director stated that Resident #15 said that it was after they left the facility and were at home that they realized they did not want the pills. The Medical Director stated they called Resident #15 because they wanted to just ensure that the pills were not diverted; Resident #15 said they got all the packets of pills. The Medical Director did not ask what Resident #15 did with them. The Medical Director stated that they are going to review and discuss the process with the Director of Nursing to determine how they can safely discharge residents and not provide residents with all their medications if they don't want them. 10 New York Codes Rules and Regulations 415.22(a)(1-4)

Based on record review, and staff interviews, the facility did not have a person-centered comprehensive care plan developed to address the residents' medical, physical, mental, and psychosocial needs. This was evident for one of five residents (Resident #15) reviewed for pain. Specifically, a pain care plan was not developed and implemented for Resident #15 who had a medical order for narcotic pain medication as well as multiple diagnoses that indicated resident would benefit from pain management and treatment.The findings are:Review of the facility policy titled Pain Management last revised 1/2026 found that it is the policy of the facility to assess and treat each resident for pain on a continuing basis and to afford the resident pain relief to the extent feasible and medically appropriate. Under the section for Procedure, step one indicated that the resident pain will be assessed on admission using either the pain assessment tool (pain rating scale) or the cognitively impaired pain assessment tool (pain rating scale). For residents cognitively intact the pain assessment questionnaire and scale of 1 to 10 will be used. Step six documented that if pain is identified, a pain treatment plan will be developed and implemented.Resident #15 was admitted [DATE] and discharged home 09/18/2025. The admission assessment indicated that the resident had received scheduled pain medication. The pain assessment interview indicated that in the last 5 days the resident had not had pain or hurting at any time. The resident was assessed as having shortness of breath when laying flat, a fall in the last month prior to admission, they were at risk for developing pressure ulcers, and they had an open lesion requiring pressure reducing devices for chair and bed and application of ointments and medications. The minimum data set assessment indicated that Resident #15 was on blood thinners and diuretics (an opioid is not indicated as being a medication they are taking). Pain was not triggered as a care area assessment; resident was assessed to be cognitively intact. Resident #15 required either substantial or moderate assistance with most areas of functional ability.Pain medication orders started 08/18/2025 they were: Acetaminophen Oral Tablet 325 MG (milligrams). Give 2 tablets by mouth every 6 hours as needed for pain and give 2 tablets by mouth every 6 hours as needed for fever. Diclofenac Sodium External Gel 1 % (Diclofenac Sodium (Topical)) 4 grams. Apply to right knee topically four times a day for arthritis.Oxycodone-Acetaminophen Oral Tablet 5-325 MG (Oxycodone 5 mg with Acetaminophen 325 mg). Give 2 tablets by mouth every 6 hours as needed for pain. Maximum daily dose (MDD) 8 tablets.Chart notes regarding pain:Effective Date: 08/18/2025 16:28 / Type: Health Status Note / Text: Resident #15 arrived via stretcher mobile transportation. Resident #15 was transferred to room bed. No complaint of pain or discomfort noted.Effective Date: 08/18/2025 20:58 / Type: admission Summary (Nursing) Note / Text: Resident #15 admitted from hospital, with history of fall x 1 week along with pain and swelling of lower extremities. Resident #15 is alert and oriented x 4, and coherent in conversation. No respiratory distress. Complaint of pain in bilateral lower extremity, when touched pain level is #8. Lower extremities are edematous (swelling in legs, ankles, and feet caused by fluid buildup in the body's tissues) with a small superficial wound on frontal area of right ankle. Both lower extremities are tender upon palpation. Resident #15 stated that they have difficulty standing due to pain and swelling of extremities. Effective Date: 08/20/2025 / Type: Physician's History and Physical Note / Text: Resident #15 is admitted to facility on 08/18/2025. Resident #15 was treated at local hospital. Resident #15 is weak and at this facility for restorative care. Resident #15 with multiple medical problems including diabetes mellitus, hyperlipidemia, osteoarthritis (notably right knee), glaucoma, obstructive sleep apnea, atrial fibrillation, NSTEMI (non-ST-segment elevation myocardial infarction), and congestive heart failure (Ejection Fraction 56% on recent echocardiogram). Resident #15 was hospitalized on [DATE] after a fall resulting in a right lower extremity wound/abscess and cellulitis. Resident #15 became weak during hospitalization and is admitted for rehabilitation. Medications: reviewed, see active list: Coreg 6.25 BID (twice a day)Lasix 40 mg dailyEliquis 5 mg q12h (every 12 hours)Omeprazole 20 mg dailyPercocetCrestorThe medical provider documented that the plan for pain was take oxycodone 5 mg, 2 tablets prn (as needed) for pain management, and for Osteoarthritis pain apply Diclofenac 1% gel.During an interview on 08/18/2026 at 10:16am with Unit Manager #1 they stated that typically whoever does the admission does the baseline care plan. Unit Manager #1 stated there is a care plan for pain, if they have chronic pain or most people are at risk for pain, everyone should at least have an at risk for whatever is their pain source. Unit Manager #1 stated if a resident is on a narcotic, there should be a pain care plan implemented. Unit Manager #1 stated that you assess the person you do not just look at the medication, if they have a diagnosis that indicates they might be in pain there would be a pain care plan. Unit Manager #1 stated that if the resident has a scheduled pain medication or has osteoarthritis there should be a pain plan.There was no care plan for pain for Resident #15. 10 New York Codes, Rules and Regulations 415.11(c)(1)

Based on observations, record review, and interviews conducted, the facility failed to investigate an allegation of abuse and implement appropriate corrective actions to protect a resident from further abuse. This was evident for one resident (Resident #1) of four residents reviewed for abuse. Specifically, on 05/11/2026, Certified Nurse Aide #1 reported to Licensed Practical Nurse #1 and Registered Nurse Supervisor #1 that they observed Certified Nurse Aide #2 forcibly grab Resident #1 and push the resident into a wheelchair, then use the dining room table as a barrier preventing Resident #1 from getting out of the wheelchair. Certified Nurse Aide #1 also reported that they heard Certified Nurse Aide #2 repeatedly use profanities toward Resident #1. After receiving the report of the allegations, Registered Nurse Supervisor #1 did not initiate an immediate investigation, including assessing Resident #1 for physical injuries or psychosocial harm and they did not remove Certified Nurse Aide #2 from direct access to Resident #1 or other residents. The facility's failure to investigate the allegation of abuse, assess the resident and remove Certified Nurse Aide #2 from assignment posed the likelihood of harm to Resident #1 which was Immediate Jeopardy and the potential for harm to other residents in the facility. The findings Include:The facility policy titled Accidents and Incidents - Investigating and Reporting Policy, revised February 2026, documented that all accidents and incidents involving residents shall be immediately assessed, investigated, documented, and reported in accordance with federal and state regulations. Immediate actions included ensuring resident safety and providing a medical assessment, obtaining vital signs and neurological checks if indicated, notifying the Attending Physician and resident representative, and initiating an incident report immediately. The policy documented the Nurse Supervisor/Charge Nurse shall initiate investigation at the time of discovery. Investigation must include the date and time of incident, nature and extent of injury, witness statements, resident statement (if able), corrective actions taken, and follow-up documentation. The policy further documented that if the incident involves suspected abuse, neglect, exploitation, serious bodily injury, or injury of unknown origin, reporting shall occur in accordance with the Abuse, Neglect, and Injury of Unknown Origin Reporting Policy. Resident #1 was admitted to the facility with diagnoses including, but not limited to, dementia, depression, and anemia (a condition characterized by a deficiency of healthy red blood cells leading to insufficient oxygen delivery to the body tissues). The admission Minimum Data Set (a resident assessment tool) dated 04/11/2026 documented Resident #1 had moderately impaired cognition. Review of the psychosocial wellbeing Care Plan initiated 04/09/2026 documented Resident #1 had potential for abuse related to resistance of care, verbal aggression, and physical aggression. Interventions included encouragement to report any form of abuse from peers or staff members, follow facility protocol for reporting of abuse, allow to express feelings as necessary, develop a trusting therapeutic relationshipOn 05/19/2026, Certified Nurse Aide #1 submitted a report to the Department of Health complaint unit that they observed alleged verbal and physical abuse involving Resident #1 and Certified Nurse Aide #2 in the dining/dayroom area of the locked memory care unit. Certified Nurse Aide #1 alleged Certified Nurse Aide #2 forcefully grabbed Resident #1, pushed Resident #1 against the chair, used the dining room table as a restraint/barrier to prevent Resident #1 from getting out of the wheelchair, and repeatedly called Resident #1 a motherf***er. The alleged incident was reported to Licensed Practical Nurse #1 and Registered Nurse Supervisor #1 on 05/11/2026.The Facility provided a statement from Certified Nurse Aide #3 dated 05/11/2026 which documented yelling was overheard while they were providing care in the shower room to another resident.The facility provided a statement from Licensed Practical Nurse #1 dated 05/11/2026 which documented Certified Nurse Aide #1 approached them regarding inappropriate language used by Certified Nurse Aide #2 towards Resident #1 and requested to speak to Registered Nurse Supervisor #1.The facility provided a statement from Registered Nurse Supervisor #1 dated 05/11/2026 which documented Certified Nurse Aide #1 requested to speak to them regarding accusations of abuse and inappropriate language used by Certified Nurse Aide #2 toward Resident #1.The facility provided a written statement from Certified Nurse Aide #2 dated 05/11/2026 which documented Resident #1 was yelling profanities, repeatedly pulling pants down, attempting to place self on the toilet, and banging head on the table. Certified Nurse Aide #2 documented Resident #1 was brought to the dining/dayroom area for observation and redirection. Certified Nurse Aide #2 documented attempts were made to redirect Resident #1 regarding the language being used. Certified Nurse Aide #2 documented Certified Nurse Aide #1 entered the dining/dayroom area and accused Certified Nurse Aide #2 of screaming in Resident #1's face. Certified Nurse Aide #2 documented a table was positioned between Certified Nurse Aide #2 and Resident #1 and they were seated on opposite sides of the table. Certified Nurse Aide #2 documented Resident #1 was hard of hearing, and they were speaking louder so Resident #1 could hear. Certified Nurse Aide #2 documented Certified Nurse Aide #1 began yelling at Licensed Practical Nurse #1 and later at Registered Nurse Supervisor #1. Certified Nurse Aide #2 documented Registered Nurse Supervisor #1 directed staff to continue the conversation in the office. Certified Nurse Aide #2 documented while walking to the office, Certified Nurse Aide #1 shouted, So, I'm psycho? Certified Nurse Aide #2 documented a written statement was requested from them and that it was completed. Review of Resident #1's electronic medical record revealed that there was no documented evidence for the incident or report of allegations made by Certified Nurse Aide #1; that Resident #1 was assessed for physical injuries or psychosocial harm; the medical provider was notified of the allegations; or a psychiatric consultation was made. Resident #1's representative was not contacted until 05/21/2026.Review of staffing assignments showed Certified Nurse Aide #2 was not assigned to Resident #1 on 05/11/2026. However, Resident #1 was routinely assigned to Certified Nurse Aide #2 from 05/12/2026 through 05/21/2026. During an interview on 05/21/26 at 2:08 PM, Certified Nurse Aide #1 stated Resident #1 was near the nurses' station yelling profanities and asking to be toileted while their pants were down. Certified Nurse Aide #1 stated Certified Nurse Aide #2 was yelling the same profanities back to Resident #1 and aggressively pushed Resident #1 back into their wheelchair. They reported that Certified Nurse Aide #2 later placed Resident #1 in the dining/dayroom area with the wheelchair against the wall and the dining room table positioned against Resident #1, preventing the resident from getting out of the wheelchair. Certified Nurse Aide #1 stated observations were reported to Licensed Practical Nurse #1 and Registered Nurse Supervisor #1 on 05/11/2026.During an interview on 05/21/2026 at 3:18 PM, Certified Nurse Aide #3 stated they were in the shower room providing care to another resident and did not hear yelling between Certified Nurse Aide #2 and Resident #1. Certified Nurse Aide #3 stated Registered Nurse Supervisor #1 came to the unit and asked if they heard any yelling, verbal abuse, or observed physical abuse involving Resident #1 and Certified Nurse Aide #2. Certified Nurse Aide #3 stated they did not hear any yelling because they were in the shower room and Certified Nurse Aide #2 was not removed from the unit.During an interview on 05/21/2026 at 3:50 PM, Licensed Practical Nurse #1 stated that on 05/11/2026, Certified Nurse Aide #1 reported to them that they heard Certified Nurse Aide #2 verbally abuse Resident #1. They reported it to Registered Nurse Supervisor #1. Licensed Practical Nurse #1 stated a statement was requested by Registered Nurse Supervisor #1 and completed on 05/11/2026. Licensed Practical Nurse #1 stated Certified Nurse Aide #2 was not removed from the unit. Licensed Practical Nurse #1 stated they were not interviewed by Registered Nurse #1 or anyone else from the facility. During an interview on 05/21/2026 at 4:58 PM, Certified Nurse Aide #2 stated Resident #1 was sitting in the dining/dayroom area yelling and cursing and they were attempting to redirect Resident #1 regarding the language being used. Certified Nurse Aide #2 stated Certified Nurse Aide #1 accused them of cursing at and being abusive toward Resident #1. Certified Nurse Aide #2 stated Resident #1 was yelling and cursing, which was normal behavior for Resident #1. Certified Nurse Aide #2 stated Resident #1 was never pinned against the wall or blocked in by a table. Certified Nurse Aide #2 stated the incident was reported to the supervisor and the supervisor came to the unit to speak to staff separately regarding what transpired. Certified Nurse Aide #2 stated the supervisor asked whether Resident #1 was yelled at or pinned against the wall and they requested a written statement about the incident. Certified Nurse Aide #2 stated although Resident #1 was not assigned to them the night of the incident, Resident #1 was routinely on their assignment and remained on their assignment until 05/21/26 when they were reassigned to another unit.During an interview on 05/21/2026 at 5:10 PM, Registered Nurse Supervisor #1 stated Certified Nurse Aide #1 reported allegations of verbal and physical abuse involving Resident #1 and Certified Nurse Aide #2 on 05/11/2026. Registered Nurse Supervisor #1 stated Certified Nurse Aide #1 alleged Certified Nurse Aide #2 was yelling profanities at Resident #1, getting in Resident #1's face, and pushed Resident #1 into the corner of the dayroom, stating Certified Nurse Aide #2 was not dealing with Resident #1 appropriately. Registered Nurse Supervisor #1 stated the Director of Nursing was notified and staff statements were collected. Registered Nurse Supervisor #1 stated Certified Nurse Aide #2 remained on the unit following the allegations and, according to their facility policy, Certified Nurse #2 should have been sent home. Registered Nurse Supervisor #1 stated no Accident and Incident report, investigative summary, body assessment, resident assessment, or abuse investigation was completed on 05/11/2026 and law enforcement was not notified. Registered Nurse #1 stated they were overwhelmed and she dropped the ball. During an interview on 05/21/2026 at 5:31 PM, the Director of Nursing stated Registered Nurse Supervisor #1 called them on 05/11/2026 to inform them that Certified Nurse Aide #1 was yelling at Certified Nurse Aide #2 about allegations that Certified Nurse Aide #2 yelled at Resident #1. The Director of Nursing stated while on the phone, Registered Nurse Supervisor #1 was instructed to obtain staff statements. The Director of Nursing stated no investigation or Accident and Incident report was initiated because it was believed Certified Nurse Aide #1 was fabricating the allegations. The Director of Nursing stated all allegations of abuse are required to be reported to the New York State Department of Health within two hours. The Director of Nursing stated the Administrator was not notified on 05/11/2026 and that they dropped the ball.During a follow-up interview on 05/22/2026 at 3:18 PM, the Director of Nursing stated Registered Nurse Supervisor #1 was given direction on 05/11/2026 to initiate an investigation regarding the allegations involving Resident #1 and Certified Nurse Aide #2. The Director of Nursing stated Certified Nurse Aide #2 should have been removed from assignments pending the investigation. They stated when returning to the facility the following day, only staff statements were left under their office door. The Director of Nursing stated psychiatric recommendations, body assessments, and nursing assessments are supposed to be completed for allegations of abuse and acknowledged they were not documented as done. The Director of Nursing stated an assessment note should have been written and the allegations were not reported to the New York State Department of Health because it was not believed that abuse had occurred.During an interview on 05/22/26 at 4:13 PM, the Administrator stated they were not made aware of the allegations of physical/verbal abuse by Certified Nurse Aide #2 toward Resident #1 until they were contacted by the Attorney General's office. The Administrator stated while on vacation, staff communicated with them throughout the day and no concerns regarding the incident were reported. The Administrator stated statements collected on 05/11/2026 were addressing Certified Nurse Aide #1 becoming upset and leaving the shift. The Administrator stated Certified Nurse Aide #2 continued working in the facility following the allegations and was reassigned to another unit on 05/21/2026. The Administrator stated staff are trained in abuse prevention and reporting requirements.During a follow-up interview on 05/22/26 at 3:25 PM, the Administrator stated when allegations of abuse are reported, Registered Nurse Supervisor #1 is responsible for notifying the Director of Nursing and/or Administrator about the allegations. The Administrator stated allegations of abuse are required to be reported to the New York State Department of Health within two hours. The Administrator stated the alleged incident involving Resident #1 should have been investigated and an Accident and Incident report initiated. The Administrator stated statements should have been collected as part of the investigation process, and Registered Nurse Supervisor #1 should have completed a body assessment, nursing assessment, and initiated the investigation. In addition, psychiatric and/or psychological services should have been notified of the allegations involving Resident #1. The Administrator stated staff should not use foul language toward residents as a means of redirection. 10 NYCRR 415.4(b)(3) Immediate Jeopardy was called on 05/26/2026. The Facility submitted a removal plan to remove the immediacy on 05/11/2026. The facility implemented the following to remove immediacyAn investigation was initiated and reported to New York State Department of HealthResident #1 was assessed, and nursing/physician/social service documentations were completed.Staff statements and follow-up interviews were conducted. Facility provided in-service attendance and lesson plan provided to facility staff at 99%.The facility will implement a tracking system for abuse/neglect/allegation/investigation to audit all accident/incident reports Interviews were conducted with registered nurses, the Assistant Director of Nursing, the Director of Nursing, the Director of Rehab, licensed practical nurses who confirmed receiving inservice on initiating investigation and abuse. The facility's policy and procedure titled Abuse, Identification and Reporting were reviewed and no changes were made.IJ was removed on 05/28/2026 at 4:57 PM.

Based on observations, record review, and interviews conducted during a Survey, the facility did not ensure a resident's right to be free from abuse for one (1) Resident #1 of four (4) residents reviewed for abuse. Specifically, on 05/11/2026, Certified Nurse Aide #1 reported observing Certified Nurse Aide #2 forcibly grab Resident #1, and push the resident against a wheelchair, using the dinning room table as a barrier preventing Resident #1 from getting out of the wheelchair and repeatedly used profanities towards Resident #1. Certified Nurse Aide #1 reported the allegation of verbal and physical abuse involving Resident #1 and Certified Nurse Aide #2 to Registered Nurse Supervisor #1 and Licensed Practical Nurse #1. Certified Nurse Aide #2 was not removed from the unit and continued to be assigned to care for Resident #1 from the date of the allegation until 05/21/2026 during the onsite visit when Certified Nurse Aide #2 was reassigned.The Findings include: The facility policy titled Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Residents' Property, revised 02/2026, documented the facility will investigate all incidents, grievances/complaints. The investigation process will include: statements from staff, witnesses, residents, interviews with staff witnesses, resident medical record review if applicable, and review of employee record. All findings of investigation will be documented. Investigative reports will summarize the findings and outcome as well as note any corrective action or follow-up. The policy further documented the facility will protect all residents during any investigation by reassigning staff and/or providing counseling to residents. The policy further documented that in the event suspicion of abuse is being investigated, the staff member will be suspended or reassigned until the investigation is complete. Resident #1 was admitted with diagnoses including, but not limited to, dementia, depression, and anemia. The 04/11/2026 admission Minimum Data Set documented Resident #1 had moderately impaired cognition. During an observation on 05/21/2026 at 02:50 PM, Resident #1 was observed seated at a table in the dayroom on Unit 2 with peers. Resident #1 appeared pleasant and in no apparent distress. Surveyor attempted to speak with Resident #1 regarding the alleged incident; however, Resident #1 was unable to recall the incident. Review of the psychosocial well-being care plan initiated 04/09/2026 documented Resident #1 had the potential for Abuse related to resistance to care, verbal aggression and physical aggression. Interventions included allowing Resident #1 to express feelings of being fearful, anxious, as necessary; developing a trusting, therapeutic relationship; encouraging Resident #1 to report any form of abuse from peers or staff members; and following facility protocol for reporting Abuse, Mistreatment or Neglect. Review of the behavior care plan revised 04/24/2026 documented Resident #1 had the potential to be verbally aggressive toward staff when frustrated or confused related to difficulty understanding situations, unmet needs, or communication breakdowns. Interventions included analyzing key times, places, circumstances, triggers, and what de-escalates behavior and documenting findings. Review of Resident #1's Electronic Medical Record revealed staff statements were obtained regarding the allegations of abuse on 05/11/2026. Review of a statement dated 05/11/2026 from Certified Nurse Aide #3 documented they overheard yelling while providing care in the shower room. Review of a statement dated 05/11/2026 from Licensed Practical Nurse #1 documented Certified Nurse Aide #1 approached them regarding inappropriate language toward Resident #1 and requested to speak to the Registered Nurse Supervisor. Review of a statement dated 05/11/2026 from Registered Nurse Supervisor #1 documented Certified Nurse Aide #1 requested to speak regarding accusations of abuse and inappropriate language toward Resident #1 involving Certified Nurse Aide #2. Review of staffing assignments showed Certified Nurse Aide #2 was not assigned to Resident #1 on 05/11/2026. However, Resident #1 remained routinely assigned to Certified Nurse Aide #2 following 05/11/2026 through 05/21/2026. There was no documented evidence of a resident assessment, physician notification, psychiatric/psychology consult, accident and incident report, an investigation summary, law enforcement notification, care plan review/update, or abuse investigation related to the allegations involving Resident #1 on 05/11/2026. During an interview on 05/21/2026 at 02:08 PM, Certified Nurse Aide #1 stated Resident #1 was near the nurses' station yelling profanities and asking to be toileted with pants down. Certified Nurse Aide #1 stated Certified Nurse Aide #2 was yelled the same profanities back to Resident #1, aggressively pushed Resident #1 back into the wheelchair, and later placed Resident #1 in the dining/dayroom area with the wheelchair against the wall and the dining room table positioned against Resident #1, preventing Resident #1 from getting out of the wheelchair. Certified Nurse Aide #1 stated observations were reported to Licensed Practical Nurse #1 and Registered Nurse Supervisor #1 on 05/11/2026. During an interview on 05/21/2026 at 03:18 PM, Certified Nurse Aide #3 stated no yelling heard involving Resident #1 and Certified Nurse Aide #2 because they were in the shower room providing care. Certified Nurse Aide #3 stated Certified Nurse Aide #1 approached them regarding the incident and asked whether any yelling had been heard. Certified Nurse Aide #3 stated Registered Nurse Supervisor #1 came to the unit and asked if any yelling was heard or verbal/ physical abuse of Resident #1 by Certified Nurse Aide #2 was observed. Certified Nurse Aide #3 stated Certified Nurse Aide #2 was not removed from the unit. During an interview on 05/21/2026 at 03:50 PM, Licensed Practical Nurse #1 stated there was an incident on 05/11/2026. An agency Certified Nurse Aide reported that Certified Nurse Aide #2 was verbally abusive to Resident #1. Licensed Practical Nurse #1 stated the allegation was reported to them and they immediately reported it to Registered Nurse Supervisor #1. Licensed Practical Nurse #1 stated a statement was requested and completed on 05/11/2026. Licensed Practical Nurse #1 stated Certified Nurse Aide #2 was not removed from the unit. During an interview on 05/21/2026 at 04:58 PM, Certified Nurse Aide #2 stated Resident #1 was sitting in the dining/dayroom area yelling and cursing and they were attempting to redirect Resident #1 regarding the language being used. Certified Nurse Aide #2 stated Certified Nurse Aide #1 accused Certified Nurse Aide #2 of cursing at and being abusive toward Resident #1. Certified Nurse Aide #2 stated Resident #1 was yelling and cursing, which was normal behavior for Resident #1but they did not pin Resident #1 against the wall or blocked in by a table. Certified Nurse Aide #2 stated the incident was reported to the supervisor and the supervisor came to the unit to speak with staff separately regarding what transpired. Certified Nurse Aide #2 stated although Resident #1 was not assigned to them the night of the incident, but they have been working on Resident #1's unit and Resident #1 has been routinely assigned to them since the incident until 05/21/2026. Certified Nurse Aide #2 stated they were reassigned to another unit on 05/21/2026. During an interview on 05/21/2026 at 05:10 PM, Registered Nurse Supervisor #1 stated Certified Nurse Aide #1 reported the allegations of verbal/ physical abuse involving Resident #1 and Certified Nurse Aide #2 to them on 05/11/2026. Registered Nurse Supervisor #1 stated Certified Nurse Aide #1 alleged Certified Nurse Aide #2 was yelling profanities at Resident #1, getting in Resident #1's face, and pushed Resident #1 into the corner/dayroom area. Certified Nurse Aide #1 stated Certified Nurse Aide #2 was not dealing with Resident #1 appropriately. Registered Nurse Supervisor #1 stated the Director of Nursing was notified and staff statements were collected. Certified Nurse Aide #2 remained on the unit following the allegations but according to facility policy, they should have been sent home. During an interview on 05/21/2026 at 05:31 PM, the Director of Nursing stated Registered Nurse Supervisor #1 called on 05/11/2026 to inform them that Certified Nurse Aide #1 was yelling at Certified Nurse Aide #2 about allegations that Certified Nurse Aide #2 yelled at Resident #1. The Director of Nursing stated while on the phone, Registered Nurse Supervisor #1 was instructed to obtain staff statements. No investigation or Accident and Incident report was initiated because it was believed Certified Nurse Aide #1 was fabricating the allegations. During a follow-up interview on 05/22/2026 at 03:18 PM, the Director of Nursing stated Registered Nurse Supervisor #1 was given direction on 05/11/2026 to initiate an investigation regarding the allegations involving Resident #1 and Certified Nurse Aide #2. The Director of Nursing stated Certified Nurse Aide #2 should have been removed from assignments pending the investigation. When they returned to the facility the following day, only staff statements were left under their office door. The Director of Nursing stated psychiatric recommendations, body assessments, and nursing assessments are supposed to be completed for allegations of abuse and acknowledged they were not documented as done. During an interview on 05/22/2026 at 04:13 PM, the Administrator stated they were not made aware of the allegations of abuse verbal/physical abuse by Certified Nurse Aide #2 against Resident #1 until they were contacted by the Attorney General's office on 05/21/2026. The Administrator stated statements were collected on 05/11/2026 to address Certified Nurse Aide #1 becoming upset and leaving their shift. The Administrator stated Certified Nurse Aide #2 continued working in the facility following the allegations and was reassigned to another unit on 05/21/2026. During a follow-up interview on 05/22/2026 at 03:25 PM, the Administrator stated the alleged incident involving Resident #1 should have been investigated and an Accident and Incident report should have been initiated. Registered Nurse Supervisor #1 should have completed a body assessment, written a nursing assessment, and initiated an investigation. Psychiatric/ psychological services should have been made aware of the allegations involving Resident #1. Staff should not use foul language toward residents as a means of redirection. During an interview on 05/26/2026 at 02:58 PM, Psychiatrist #1 stated Psychiatrist #1 saw Resident #1 on 05/26/2026 due to the allegations of abuse. Psychiatrist #1 stated this was the first time they were made aware of the incident. Psychiatrist #1 stated Resident #1 was very confused and disoriented and was unable to communicate. Psychiatrist #1 stated they expect to be notified of allegations of abuse so that residents can be evaluated timely. During an interview on 05/27/2026 at 02:28 PM, the Medical Director stated the Medical Director was made aware of the allegations on 05/21/2026. The Medical Director stated they expect to be notified right away about incidents of abuse so that the resident can be evaluated timely for harm. The Medical Director stated when Resident #1 was seen there were no injuries, however, Resident #1 was confused and could not recall the incident. Resident #1 has advanced dementia. The Medical Director stated arguing in front of residents can cause psychological harm and if that happens, residents should be evaluated. 10 NYCRR 415.4(b)(1)

Based on observations, record review, and interviews conducted during the Abbreviated Survey, the facility failed to ensure that alleged violations involving abuse were reported to the Department of Health immediately, but not later than 2 hours after the allegation if the events that caused the allegation result in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not result in serious bodily injury, and report the results of the investigation to the Department of Health within 5 working days. This was evident for one (1) Resident #1 of four (4) residents reviewed for abuse. Specifically, on 05/11/2026, Certified Nurse Aide #1 reported an alleged physical/verbal abuse of Resident #1 by Certified Nurse Aide #2 to Licensed Practical Nurse #1 and Registered Nurse Supervisor #1. Certified Nurse Aide #1 reported observing Certified Nurse Aide #2 forcibly grab Resident #1, force Resident #1 into a wheelchair, place a dining room table in front of Resident #1 to prevent movement, and repeatedly use profanities toward Resident #1. The facility did not report the allegation to the New York State Department of Health until 05/21/2026.The Findings include:The facility policy titled Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Residents' Property, revised 02/2026, documented, The facility will report any Incident and/or violation where Abuse, Neglect, mistreatment, or misappropriation of property is suspected to the New York State Department of Health according to protocol. The policy further documented, If the crime involves serious bodily injury, it must be reported immediately, but no later than 2 hours after forming the suspicion or if the crime does not appear to cause serious bodily injury you must report it within 24 hours of forming the suspicion. The policy further documented, Investigation Summary Report must be submitted to NYDOH within 5 business days.Resident #1 was admitted to the facility with diagnoses including, but not limited to, dementia, depression, and anemia.The admission Minimum Data Set (a resident assessment tool) dated 04/11/2026 documented Resident #1 had moderately impaired cognition.During an interview on 05/21/2026 at 02:08 PM, Certified Nurse Aide #1 stated Resident #1 was near the nurses' station yelling profanities and asking to be toileted while pants were down. Certified Nurse Aide #1 stated Certified Nurse Aide #2 was yelling the same profanities back to Resident #1, aggressively pushed Resident #1 back into the wheelchair, and later placed Resident #1 in the dining/dayroom area with the wheelchair against the wall and the dining room table positioned against Resident #1, preventing Resident #1 from getting out of the wheelchair. Certified Nurse Aide #1 stated observations were reported to Licensed Practical Nurse #1 and Registered Nurse Supervisor #1 on 05/11/2026.Review of facility documentation revealed the allegation involving Resident #1, reported on 05/11/2026, was not reported to the New York State Department of Health until 05/21/2026.During an interview on 05/21/2026 at 04:13 PM and on 05/22/2026 at 03:25 PM, the Administrator stated they were not made aware of the incident involving allegations of abuse involving Certified Nurse Aide #2 allegedly being verbally and physically abusive toward Resident #1 until contacted by the Attorney General's office on 05/21/2026. The Administrator stated the facility process for reporting is that when the supervisor gets a report, they will call the Director of Nursing and Administrator to inform them and the Administrator or the Director of Nursing will report to the New York State Department of Health. The Administrator stated the alleged incident of abuse should have been investigated and reported.During an interview on 05/21/2026 at 05:10 PM, Registered Nurse Supervisor #1 stated Certified Nurse Aide #1 reported allegations of verbal and physical abuse to them on 05/11/2026. Registered Nurse Supervisor #1 stated the Director of Nursing was notified on 05/11/2026.During an interview on 05/21/2026 at 05:31 PM, the Director of Nursing stated office staff who are mandated reporters know they are required to report allegations of abuse and staff are left with instructions regarding reporting requirements. The Director of Nursing stated the allegations were not reported to the New York State Department of Health because it was not believed that abuse had occurred. 10 NYCRR 415.4(b)(2)

Based on record review and interviews conducted during the Abbreviated Survey, the facility failed to ensure Resident #1's Comprehensive Care Plan was reviewed and revised following assessment and as necessary to reflect changes in the resident's needs for one (1) (Resident #1) of four (4) residents reviewed for care planning. Specifically, following allegations of verbal and physical abuse of Resident #1 by Certified Nurse Aide #2, the resident's psychosocial well-being, risk to be victimized/aggressor, and behavior care plans were not reviewed or revised. Review of the psychosocial well-being and risk to be victimized/aggressor care plans revealed they were last revised on 04/09/2026. Review of the behavior care plan revealed it was last revised on 04/24/2026.The Findings Include: The facility's Comprehensive Care Planning Policy, revised 02/2026 and reviewed on 05/26/2026, documented, Comprehensive care plans shall be reviewed and updated with significant change in condition and when desired outcomes are not achieved. The policy further documented, Care plans shall be current, accurate, and reflective of the resident's present condition. All updates shall be documented in the medical record. Resident #1 was admitted to the facility with diagnoses including, but not limited to, dementia, depression, and anemia. The admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 had moderately impaired cognition.Review of the care plan for risk to be victimized or aggressor revised 04/09/2026 documented Resident #1 was at risk to be victimized, or aggressor related to impaired judgment and confusion. Interventions included, but were not limited to, encouraging Resident #1 to utilize positive outlets, keeping Resident #1 within viewing distance for observation as much as possible in activities, the day room, and nursing station, monitoring changes in mood or behavior triggered by environmental factors including noise, crowds, or other residents with behavioral symptoms, and monitoring well-being without environmental restrictions. The care plan was not reviewed or revised following the allegations of verbal and physical abuse of Resident #1 by Certified Nurse Aide #2 reported on 05/11/2026. Review of the care plan on 05/29/2026 revealed no documented evidence the care plan had been reviewed or revised. Review of the psychosocial well-being care plan revised 04/09/2026 documented Resident #1 had the potential for abuse related to resistance to care, verbal aggression, and physical aggression. Interventions included, but were not limited to, allowing Resident #1 to express feelings of being fearful or anxious as necessary, developing a trusting therapeutic relationship, encouraging Resident #1 to report any form of abuse from peers or staff members, and following facility protocol for reporting abuse, mistreatment, or neglect. The care plan was not reviewed or revised following the allegations of verbal and physical abuse of Resident #1 by Certified Nurse Aide #2 reported on 05/11/2026. Review of the care plan on 05/29/2026 revealed no documented evidence the care plan had been reviewed or revised. Review of the behavior care plan revised 04/24/2026 documented Resident #1 had the potential to be verbally aggressive toward staff when frustrated or confused related to difficulty understanding situations, unmet needs, or communication breakdowns. Interventions included analyzing key times, places, circumstances, triggers, and what de-escalates behavior and documenting findings. The care plan was not reviewed or revised following the allegations of verbal and physical abuse of Resident #1 by Certified Nurse Aide #2 reported on 05/11/2026. Review of the care plan on 05/29/2026 revealed no documented evidence the care plan had been reviewed or revised. During an interview on 05/21/2026 at 02:08 PM, Certified Nurse Aide #1 stated Resident #1 was near the nurses' station yelling profanities and asking to be toileted while pants were down. Certified Nurse Aide #1 stated Certified Nurse Aide #2 was yelling the same profanities back to Resident #1, aggressively pushed Resident #1 back into the wheelchair, and later placed Resident #1 in the dining/dayroom area with the wheelchair against the wall and a dining room table positioned in front of Resident #1, preventing Resident #1 from getting out of the wheelchair. During an interview on 05/29/2026 at 02:00 PM, the Infection Control/Quality Assurance Nurse stated they assisted with the Accident/Incident report completion process related to the 05/11/2026 allegations of verbal and physical abuse involving Resident #1 after becoming aware of the allegations on 05/21/2026. The Infection Control/Quality Assurance Nurse stated care plans should be reviewed and updated to reflect Accident and Incident investigations and the resident's current plan of care. The Infection Control/Quality Assurance Nurse acknowledged Resident #1's behavior, psychosocial well-being, and risk of being victimized or aggressor care plans were not reviewed or revised following the 05/11/2026 allegations of verbal and physical abuse involving Resident #1 and stated the care plans should have been updated to reflect the allegations and resident-specific interventions should have been added. During an interview on 05/29/2026 at 02:57 PM, Registered Nurse #3 stated they were the Unit Manager on Unit 2 and assisted on Units 3 and 4 as needed. Registered Nurse #3 stated they were not aware of the 05/11/2026 allegations of verbal and physical abuse involving Resident #1 and were not made aware of the allegations until staff received education regarding abuse and reporting requirements. Registered Nurse #3 stated they were not aware of the specific details of the allegations. Registered nurses review, update, and revise resident care plans. Care plans are updated to reflect residents' current needs, changes in condition, and new incidents, including Accident and Incident reports. Part of the Accident and Incident process includes reviewing and updating the resident's care plan and notifying the resident's family. Registered Nurse #3 stated care plans are reviewed and revised to ensure they accurately reflect the resident's current needs and plan of care. 10 NYCRR 415.11(c)(1)

Based on record review and interviews conducted during the Abbreviated Survey, the facility failed to ensure nursing staff possessed the competencies and skill sets necessary to provide nursing and related services to residents for one (1) (Certified Nurse Aide #1) of nine (9) facility staff records reviewed for mandatory training requirements. Specifically, Certified Nurse Aide #1 was assigned resident care duties and worked on 05/11/2026; however, the facility was unable to provide documentation verifying completion of required orientation and mandatory training, which included, but was not limited to, Abuse/Neglect/Exploitation Prohibition, Behavioral Care Services/Cognitive Impairment/Dementia Training, and Trauma Informed Care.The Findings Include: The facility's Education and Training of Nursing Personnel Policy documented, The facility uses a competency-based approach to nurse and nurse aide staffing and will conduct regular competency reviews to ensure that nursing personnel are adequately trained. The policy further documented, New employees of the facility will attend Orientation and receive necessary mandatory training and on-the-job training as needed. On 05/22/2026 at 12:58 PM, the facility's mandatory orientation and in-service training documentation for Certified Nurse Aide #1 was requested from the Assistant Director of Nursing/Staff Educator. Review of the documentation provided revealed no documented evidence that Certified Nurse Aide #1 completed the facility's required orientation and mandatory training. The facility was unable to provide documentation verifying completion of training which included, but was not limited to, Abuse/Neglect/Exploitation Prohibition, Behavioral Health Training: Dementia Care, Trauma Informed Care and Managing Difficult Behaviors, Communication Training, and other mandatory orientation and in-service training requirements. During an interview on 05/21/2026 at 02:08 PM, Certified Nurse Aide #1 stated 05/11/2026 was their first day working at the facility as agency staff. Certified Nurse Aide #1 stated they did not receive orientation, a training packet, or sign any orientation documents. Certified Nurse Aide #1 stated they did not receive training related to abuse and neglect, dementia care, behavioral health, trauma-informed care, or managing difficult behaviors prior to being assigned resident care duties. Certified Nurse Aide #1 stated they were assigned to provide resident care on Units 2 and 3 on 05/11/2026. During an interview on 05/22/2026 at 12:58 PM, the Assistant Director of Nursing/Staff Educator stated agency staff are required to complete the same mandatory orientation and in-service training as facility staff, which includes, but is not limited to, Abuse/Neglect/Exploitation Prohibition, Behavioral Health Training: Dementia Care, Trauma Informed Care and Managing Difficult Behaviors, and other mandatory orientation and in-service training requirements. The Assistant Director of Nursing/Staff Educator stated staff are required to complete training modules, sign training documentation, and complete post-tests which are maintained in employee files. The Assistant Director of Nursing/Staff Educator stated they were unable to locate documentation verifying Certified Nurse Aide #1 completed the facility's required orientation and mandatory training. The Assistant Director of Nursing/Staff Educator stated they recalled introducing Certified Nurse Aide #1 to staff and providing an orientation to the facility; however, they were unable to locate documentation verifying completion of the required orientation packet and mandatory training. During an interview on 05/27/2026 at 03:50 PM, the Administrator stated all staff who perform employment duties within the facility are required to complete mandatory orientation and in-service training. The Administrator stated staff are provided the facility's mandatory orientation and in-service training by the Staff Educator prior to working independently. The Administrator stated Certified Nurse Aide #1 should have received the facility's mandatory orientation and in-service training prior to providing resident care and documentation of completion should have been maintained in the employee file. The Administrator stated they were unsure why the documentation could not be located and stated if the training had been completed, the documentation should have been available in Certified Nurse Aide #1's employee file. During an interview on 05/27/2026 at 04:02 PM, the Director of Nursing stated they were responsible for overseeing the Staff Educator and ensuring staff received required training. The Director of Nursing stated staff are required to complete mandatory orientation and in-service training prior to providing resident care. The Director of Nursing stated Certified Nurse Aide #1 should have completed the facility's mandatory orientation and training before caring for residents. The Director of Nursing stated staff who have not completed required orientation and training should not be assigned resident care duties because the training provides staff with the knowledge and skills necessary to care for residents. 10 NYCRR 415.13(c)

Based on record review and staff interviews conducted during a survey, the facility failed to ensure that the resident environment was free of accident hazards and/or that each resident received adequate supervision to prevent accidents for three (3) of six (6) residents reviewed for accidents (Resident #1, #2, & 3). Specifically, 1) On 11/01/2024, Certified Nurse Assistant #2 did not follow the care plan and attempted to transfer Resident #1 by themself as a stand pivot and the resident fell, hit their head, and subsequently required transfer to the hospital. 2) On 12/26/2025, Resident #2 was provided with morning care, was unable to walk and had a significant bruise on their right hip. Resident #2 was sent out to the hospital for x-rays, and it was determined that they had a fractured right hip. There was no indication of how this occurred, no facility investigation, and no report to the New York State Department of Health. 3) On 12/15/2025, Resident #3 was noted to have a bruise on their left leg, was transferred to the emergency department on 12/19/2025 and diagnosed with a fracture of unknown origin to their left tibia and fibula. Each incident resulted in actual harm to Residents #1, #2 and #3 respectively, that was not Immediate Jeopardy. The undated facility policy titled Activities of Daily Living (ADL) Total Care Policy documented that the purpose of the policy is to establish guidelines for providing comprehensive assistance with Activities of Daily Living (ADLs) to residents or patients. It aims to ensure that each individual's basic needs are met while promoting dignity, independence, and comfort. Under subheading number five (5) ADL Assistance Procedures, subheading number five (5) Mobility and Transferring, the policy aims to ensure that the environment is free of hazards to prevent falls. The undated facility policy Mechanical Lift documented that the standard is a mechanical lift will be used appropriately and safely to facilitate transfer of residents. Resident #1Resident #1 was first admitted with diagnoses, including but not limited to, traumatic subdural hemorrhage (brain injury occurring when blood collects between the brain and its outer lining) without loss of consciousness, unspecified dementia mild with mood disturbance, and muscle weakness. Review of care plan initiated 07/08/2022 documented that resident needs assistance with Activity of Daily Living due to limited mobility and dementia. The documented intervention for chair/bed to chair transfer is that Resident was dependent on two-person assistance. The 10/24/2024 annual Minimum Data Set (a resident assessment tool) documented that Resident #1 was moderately cognitively impaired. They had a wheelchair as their mobility device, they required substantial maximal assistance for rolling left and right, they were dependent for chair to bed transfer (meaning the resident does none of the effort to complete the activity and helper does all of the activity). The 11/01/2024 Accident and Incident report for the incident with Resident #1 is numbered as 1355 and is titled as a witnessed fall, and it is documented under nursing description: called to resident's room. Resident lying in bed on their back. Open area to left side of forehead above left eye 4 centimeters x 3 centimeters x 0.3 centimeter. Wheelchair next to bed. Bedside table next to nightstand. Complaint of pain to left shoulder. Resident stated I don't know what happened, I fell. The statement from Certified Nurse Assistant #2 on 11/01/2024 documented while transferring resident into their wheelchair for lunch, resident's one leg twisted and the resident fell onto the floor. Resident #1 hit their head on the bedside table, and the garbage can and landed on their left side. The statement from Certified Nurse Assistant #2 documents that they were unable to stop the fall from happening. Resident #1 had nonskid socks on at the time of fall. Call bell on bed. The Interdisciplinary Team review done on 11/04/2024 documented that based on hospital records, medical chart review, and staff statements/interviews, resident had a fall which resulted in a laceration to the resident's forehead. Per the resident's care plan, they are a 2-person assist with transfers, and Certified Nurse Assistant #2 did not follow this, and they stated during the interview that they were not aware of the resident being a 2-person assist for transfer because they did not look. The Plan of Care per the Interdisciplinary Team meeting documented that the resident received sutures to their forehead that would be removed by the facility Nurse Practitioner or medical provider, the resident was put on the case load for physical therapy and at that time, it was recommended that the resident was downgraded to a 2-person assist with the use of a mechanical lift. The review of a Health Status note with an effective date of 11/01/2024 documented that Resident #1 received seven (7) stitches, was given morphine in the emergency room for pain, and all scans came back negative for fracture.During an interview on 01/22/2026 at 3:35 PM with the Infection Control Nurse, they stated that they were the Director of Nursing at the time of the 11/01/2024 incident with Resident #3. The Infection Control Nurse stated that when they interviewed Certified Nurse Assistant #2, they had stated they were not aware that Resident #1 was a two-person stand pivot. In their Incident/Accident interview, Certified Nurse Assistant #2 stated that they did not check the Kardex (guide used by staff to provide care). The Infection Control Nurse stated should the staff talk to each other? Yes, but at the end of the day you are supposed to check your Kardex and had Certified Nurse Assistant #2 checked the Kardex, which was accurate at the time, this would not have happened. The Infection Control Nurse stated that Certified Nurse Assistant #2 also said that they had seen other people transferring Resident #1 alone. The Infection Control Nurse stated that Certified Nurse Assistant #2 was re-educated on safe patient handling, but they did not recall if Certified Nurse Assistant #2 was reprimanded. The Infection Control Nurse stated that the Kardex is how you know what to do and that the certified nurse assistants all get the Kardex point of care training at orientation. They stated that they recall their interview with Certified Nurse Assistant #2, and they had stated to them, Why didn't you check the Kardex? How did you know something didn't change? They recalled asking Certified Nurse Assistant #2 if they knew how to check the Kardex and Certified Nurse Assistant #2 said that they did know. The Infection Control Nurse stated that after completing the training program, the certified nurse assistants should be able to verbalize their resident assignments and demonstrate where to obtain current information on care delivery tasks. The Infection Control Nurse stated that Resident #1's record indicated that they were a two-person transfer. Resident #2Resident #2 was originally admitted with diagnoses including, but not limited to, muscle weakness, insomnia, and glaucoma secondary to eye inflammation, bilateral. The 11/15/2025 Quarterly Review Minimum Data Set documented that Resident #2 was severely cognitively impaired. They had no need indicated for a mobility device, they required supervision or touching for most of their functional abilities like upper and lower body dressing, they were independent for rolling left and right, they required set up or clean-up for chair to bed transfer meaning they completed the activity on their own; the helper only assisted with set up prior to or following the activity.The Health Status note dated 12/22/2025 documented the resident returned from an eye doctor appointment with orders for urgent trab (trabeculectomy - a glaucoma surgery that creates a tiny drainage pathway to lower eye pressure) os (left eye) without mitomycin (the surgeon does not use the anti-scaring medication called mitomycin) surgery NPO (nothing by mouth) after midnight, and needs to be at the hospital by 3:00 PM for surgery. Daughter in agreement. Director of Nursing notified. The Transfer to Hospital Summary dated 12/23/2025 documented the diagnosis was eye surgery procedure, resident was discharged from nursing home facility on 12/23/2025, resident was admitted to hospital for an eye surgery procedure, was kept overnight for observation, and was anticipated to return once medical issues were resolved. The Health Status note dated 12/24/2025 documented the resident returned home (meaning the facility) via stretcher. Eye patch over left eye in place and remain in place until follow up appointment on 12/29/2025 at 9:45 AM. No complaints of pain or discomfort. Alarm placed on bed, Resident #2 is not to ambulate without assistance, they cannot bend, or lift, warm compresses four (4) times a day. Bruising noted right hand. The 12/25/2025 Accident and Incident report for the incident with Resident #2 is report number 1931 and provides the following description: Certified Nurse Assistant called nurse to room as bruise of light to dark purple in color, size of a 50-cent piece was found on right hip. Resident unable to give description. Immediate action taken includes x-ray order placed, provider aware, Director of Nursing aware, family aware, resident recently out for eye surgery alone. Resident sent to emergency department per family request. Resident taken to hospital. Note entered at end of incident report dated 12/29/2025 documented with very limited medical history, as per family resident declined to promote health and wellness for the majority of their life and has a long-standing history of tobacco product usage. Provider reviewed medical history and notes resident with osteoporosis. No evidence of abuse, neglect or mistreatment indicated. Resident was recently at the hospital alone without family support for eye surgery. There are no statements on this incident report. Review of the x-ray image results dated 12/28/2025 documented the findings as follows: A displaced acute fracture of the right femoral neck (upper part of thigh bone). No aggressive osseous lesion (an area of abnormal growth, damage, or tissue change within a bone, effectively replacing healthy bone with abnormal tissue) is present. No erosions (localized destruction or breakdown of bone tissue) were seen. Impression displaced acute traumatic fracture (occurs when a bone breaks into two or more pieces that shift out of normal alignment, often caused by severe trauma or falls) of the right femoral neck.During an interview with the Medical Director on 01/29/2026 at 3:42 PM, they stated in this case they would think there would be more of an investigation to see what happened, maybe everyone got into the holiday mood, maybe people were on vacation. They would expect a look back of staff that provided care. They had no idea what caused the incident. It is possible that Resident #2 could have fallen and then put themself back in bed. When reviewing the x-ray result, the Medical Director stated that Resident #2 had a fracture based on the resident's history and that this is a fracture of the hip, they would not assume it is trauma related. The Medical Director stated they think the person that read the x-ray made a mistake. The Medical Director stated that it was a Type 3 fracture which means partially displaced. The Medical Director stated that it may have been from trauma and maybe the resident did fall, but a resident could also have a fracture like this just because of osteoporosis.During an interview with Certified Nurse Assistant #1 on 02/03/2026 at 1:40 PM, they stated that they found a bruise on Resident #2's right hip, they had no idea what occurred, they had just come in that Friday and found it. Certified Nurse Assistant #1 stated that Resident #2 was fine before that time. Certified Nurse Assistant #1 stated Resident #2 could not stand and stated it hurt, and normally they could stand. Certified Nurse Assistant #1 stated that the resident walked out for their surgery that Tuesday the 23rd and on the 24th they were back at the facility with an eye patch on and could still get up and move. Certified Nurse Assistant #1 stated that they did not work on Christmas and did not know what occurred. Certified Nurse Assistant #1 stated that on Friday the 26th, they did not ask Resident #2 what happened, they just asked what was wrong. Certified Nurse Assistant #1 stated that Resident #2 was just telling them that it hurt and they could not get up and could not walk. Resident #3Resident #3 was originally admitted with diagnoses including, but not limited to, Alzheimer's disease, intermittent explosive disorder (a chronic mental health condition characterized by recurrent sudden episodes of impulsive, aggressive, or violent behavior disproportionate to the situation), and generalized anxiety disorder. The Quarterly Minimum Data Set, dated [DATE] documented that Resident #3 was severely cognitively impaired, they did not have any behaviors, they were incontinent of bowel and bladder, they had a wheelchair for mobility, unable to self-transfer and needed partial moderate assistance to roll left and right in bed meaning the helper lifts, holds or supports the trunk or limbs but provides less than half the effort.The Accident Incident report prepared by the Infection Control Nurse dated 12/15/2025 at 8:58 AM is numbered as 1912 and is titled As bruises documented that staff alerted registered nurse that Resident #3 had a large bruise to the left lower extremity. On inspection, the resident had a large purple bruise noted to their left lower leg. Resident #3 laughed when asked what occurred. Documented under the subtitle Immediate Action Taken Description: the resident shows mild discomfort when area palpated, left lower extremity is noted with mild swelling, no redness or warmth to the area. Resident seen by Nurse Practitioner with no further orders. After investigation, root cause analysis determined bruise to be the result of bumping the Hoyer during transfer. The pain level was assessed at two (2) facial grimacing. Under subheading Statements: there are no statements found. The Nurse Practitioner medical visit note written on 12/15/2025 at 3:39 PM documented that resident was seen to evaluate ecchymosis (bruise) on the left lower extremity. Resident #3 was seen sitting up in bed in no acute distress, and no signs or symptoms of pain. The plan for the contusion (bruise) was to monitor area, assess for signs or symptoms of pain.The Medical Director medical visit note dated 12/17/2025 at 11:52 AM documented Subjective: Patient is calm today, Patient noted with a large bruise to the left lower leg, no nausea, vomiting or diarrhea. Objective: vital signs all listed as stable. Assessment: lists all the diagnoses Order an x-ray to the lower left extremity at this time. Plan: continue present medications. The Health Status note written by the Infection Control Nurse dated 12/19/2025 at 11:22 AM documented x-ray unable to be completed today, resident has pain on palpitation [sic]. Resident to be sent to Emergency Department at this time. Sister made aware and in agreement.The Health Status note dated 12/19/2025 at 3:29 PM documented that a call was received from the Emergency Department stating that resident had a fracture of left tibia and fibula (bones of the leg) and would be transported back to the facility with a knee immobilizer, family made aware. During an interview on 01/21/2026 at 1:18 PM with Certified Nurse Assistant #3, they stated they found the bruise on 12/15/2025 and they told the infection control nurse and the overnight supervisor. They looked at it and they let the Nurse Practitioner know. Resident #3 finally got x-rays on Friday 12/19/2025. The x-ray people never came to the facility, so that Friday, the resident was sent out. Resident #3 had been complaining of pain from the moment staff found the bruise. Certified Nurse Assistant #3 stated that Resident #3 is not a very vocal person, but they said, Ow, ow, that hurts. Certified Nurse Assistant #3 stated they do not know how the bruise happened; Resident #3 gets up before they come in, and they are transferred using a Hoyer. They were last trained on a Hoyer way before Christmas time. Certified Nurse Assistant #3 counted out the number of residents that need a Hoyer for transfer and stated it was 15 to 16 residents on that unit. Certified Nurse Assistant #3 stated that no one knows how it happened. Certified Nurse Assistant #3 stated they were not sure how no one noticed, it was a huge bruise that wrapped around the leg, was swollen, and was green and purple. Certified Nurse Assistant #3 stated that it had been a while since Resident #3 had fallen. Certified Nurse Assistant #3 stated that Resident #3 has a history of sometimes resisting care, making noise and raising their hand up. During an interview with the Director of Nursing on 01/21/2026 at 12:00 PM, they stated they do not know how the Infection Control Nurse concluded that the bruise on Resident #3's leg was from a bump on the Hoyer as there are no statements in the Accident and Incident report. They further stated they do not know why they were not made aware earlier. The Director of Nursing stated that an injury of unknown origin was reported to the Infection Control Nurse on 12/15/2025 and a report was submitted by Director of Nursing to New York State Department of Health on 12/19/2025. 10 New York Codes, Rules and Regulations 415.12(h)(2)

Based on record review and staff interviews conducted during an abbreviated survey the facility failed to ensure that all alleged violations involving abuse, neglect, including injuries of unknown origin were reported immediately, but not later than 2 (two) hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the New York State Department of Health. This was evident for 2 (two) of 6 (six) residents reviewed for injury of unknown origin. (Resident #2 and Resident #3). Specifically, 1) On 12/26/2025, Resident #2 was provided with morning care, was unable to walk and had a significant bruise on their right hip. Resident #2 was sent out to the hospital for x-rays, and it was determined that they had a fractured right hip. There was no indication of how this occurred, no facility investigation, and no report to the New York State Department of Health. 2) On 12/15/2025, Resident #3 was noted to have a bruise on their left leg, was transferred to the emergency department on 12/19/2025 and diagnosed with a fracture of unknown origin to their left tibia and fibula. Each incident resulted in an injury of unknown origin to Resident #2 and #3 which the facility failed to report to the New York State Department of Health within the prescribed regulatory timeframe. The undated policy titled Accidents and Incidents - Investigating and Reporting documented under Policy interpretation and implementation part 2 (two) the following data, as applicable, shall be included on the report of incident/accident form: a. the date and time the accident or incident took place. b. The nature of the injury/illness. c. The circumstances surrounding the accident or incident. d. Where the accident or incident took place. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. It further documented that the Director of Nursing shall ensure that the Administrator receives a copy of the Report of Incident/Accident form for each occurrence. Resident #2Resident #2 was originally admitted with diagnoses including, but not limited to, muscle weakness, insomnia, and glaucoma secondary to eye inflammation, bilateral. A diagnosis of other specified disorders of bone density and structure unspecified is indicated with an onset date of 01/03/2026.The 11/15/2025 Quarterly Review Minimum Data Set documented that Resident #2 was severely cognitively impaired. They had no need indicated for a mobility device, they required supervision or touching for most of their functional abilities like upper and lower body dressing, they were independent for rolling left and right, they required set up or clean-up for chair to bed transfer meaning they completed the activity on their own; the helper only assisted with set up prior to or following the activity.The Health Status note dated 12/22/2025 documented the resident returned from an eye doctor appointment with orders for urgent trab (trabeculectomy - a glaucoma surgery that creates a tiny drainage pathway to lower eye pressure) os (left eye) without mitomycin (the surgeon does not use the anti-scaring medication called mitomycin) surgery (NPO (nothing by mouth) after midnight, and needs to be at the hospital by 3:00 PM for surgery. Daughter in agreement. Director of Nursing notified. The Transfer to Hospital Summary dated 12/23/2025 documented the diagnosis was eye surgery procedure, resident was discharged from nursing home facility on 12/23/2025, resident was admitted to hospital for an eye surgery procedure, was kept overnight for observation, and was anticipated to return once medical issues were resolved. The Health Status note dated 12/24/2025 documented resident returned home (meaning the facility) via stretcher. Eye patch over left eye in place and remain in place until follow up appointment on 12/29/2025 at 9:45 am. No complaints of pain or discomfort. Alarm placed on bed, Resident #2 is not to ambulate without assistance, they cannot bend, or lift, warm compresses four (4) times a day. Bruising noted right hand.The 12/25/2025 Accident and Incident report for the incident with Resident #2 is report number 1931 and provides the following description: Certified Nurse Assistant called nurse to room as bruise of light to dark purple in color, size of a 50-cent piece was found on right hip. Resident unable to give description. Immediate action taken includes x-ray order placed, provider aware, Director of Nursing aware, family aware, resident recently out for eye surgery alone. Resident sent to emergency department per family request. Resident taken to hospital. Note entered at end of incident report dated 12/29/2025 documented with very limited medical history, as per family resident declined to promote health and wellness for the majority of their life and has a long-standing history of tobacco product usage. Provider reviewed medical history and notes resident with osteoporosis. No evidence of abuse, neglect or mistreatment indicated. Resident was recently at the hospital alone without family support for eye surgery. There are no statements on this incident report. Review of the x-ray image results dated 12/28/2025 documented the findings as follows: A displaced acute fracture of the right femoral neck (upper part of thigh bone). No aggressive osseous lesion (an area of abnormal growth, damage, or tissue change within a bone, effectively replacing healthy bone with abnormal tissue) is present. No erosions (localized destruction or breakdown of bone tissue) were seen. Impression displaced acute traumatic fracture (occurs when a bone breaks into two or more pieces that shift out of normal alignment, often caused by severe trauma or falls) of the right femoral neck.During an interview with the Medical Director on 01/29/2026 at 3:42 PM, they stated in this case they would think there would be more of an investigation to see what happened, maybe everyone got into the holiday mood, maybe people were on vacation. They would expect a look back of staff that provided care. They had no idea what caused the incident. It is possible that Resident #2 could have fallen and then put themself back in bed. When reviewing the x-ray result, the Medical Director stated that Resident #2 had a fracture based on the resident's history and that this is a fracture of the hip, they would not assume it is trauma related. The Medical Director stated they think the person that read the x-ray made a mistake. The Medical Director stated that it was a Type 3 fracture which means partially displaced. The Medical Director stated that it may have been from trauma and maybe the resident did fall, but a resident could also have a fracture like this just because of osteoporosis.During an interview with Certified Nurse Assistant #1 on 02/03/2026 at 1:40 PM, they stated that they found a bruise on Resident #2's right hip, they had no idea what occurred, they had just come in that Friday and found it. Certified Nurse Assistant #1 stated that Resident #2 was fine before that time. Certified Nurse Assistant #1 stated Resident #2 could not stand and stated it hurt, and normally they could stand. Certified Nurse Assistant #1 stated that the resident walked out for their surgery that Tuesday the 23rd and on the 24th they were back at the facility with an eye patch on and could still get up and move. Certified Nurse Assistant #1 stated that they did not work on Christmas and did not know what occurred. Certified Nurse Assistant #1 stated that on Friday the 26th, they did not ask Resident #2 what happened, they just asked what was wrong. Certified Nurse Assistant #1 stated that Resident #2 was just telling them that it hurt and they could not get up and could not walk. Resident #3Resident #3 was originally admitted on [DATE] with the following diagnoses including but not limited to Alzheimer's disease, intermittent explosive disorder (a chronic mental health condition characterized by recurrent sudden episodes of impulsive, aggressive, or violent behavior disproportionate to the situation), and generalized anxiety disorder. The quarterly minimum data set, an assessment tool, dated 10/19/2025 documented that Resident #3 was severely cognitively impaired, they did not have any behaviors, they were incontinent of bowel and bladder, they had a wheelchair for mobility, unable to self-transfer and needed partial moderate assistance to roll left and right in bed meaning the helper lifts, holds or supports the trunk or limbs but provides less than half the effort.The accident incident report prepared by the Infection Control Nurse dated 12/15/2025 at 8:58 am is numbered #1912 titled bruises documented that staff alerted registered nurse that Resident #3 had a large bruise to the left lower extremity. On inspection, resident has a large purple bruise noted to left lower leg. Resident #3 laughed when asked what occurred. Documented under subtitle immediate action taken description: resident shows mild discomfort when area palpated, Left Lower extremity is noted with mild swelling, no redness or warmth to the area. Resident seen by Nurse Practitioner with no further orders. After investigation, root cause analysis determined to be bumping the Hoyer during transfer. The pain level was assessed at two (2) facial grimacing. Under subheading statements: there are no statements found. The Nurse Practitioner medical visit note written on 12/15/2025 at 3:39 pm documented that resident was seen to evaluate ecchymosis (bruise) on the left lower extremity. Resident #3 was seen sitting up in bed in no acute distress, and no signs or symptoms of pain. The plan for the contusion (bruise) was to monitor area, assess for signs or symptoms of pain.The Medical Director medical visit note dated 12/17/2025 at 11:52 am documented Subjective: Patient is calm today, Patient noted with a large bruise to the left lower leg, no Nausea, vomiting or diarrhea. Objective: vital signs all listed as stable. Assessment: lists all the diagnoses. Order an xray to the lower left extremity at this time. Plan: continue present medications. Health Status note written by the Infection Control Nurse dated 12/19/2025 at 11:22 am documented Xray unable to be completed today, resident has pain on palpitation. Resident to be sent to Emergency Department at this time. Sister made aware and in agreement.Health Status note dated 12/19/2025 at 3:29 pm documented that a call was received from the Emergency Department stating that resident had a fracture of left tibia and fibula and would be transported back to the facility with a knee immobilizer, family made aware. During an interview on 01/21/2026 at 1:18 PM with Certified Nurse Assistant #3, they stated they found the bruise on 12/15/2025 and they told the infection control nurse and the overnight supervisor. They looked at it and they let the Nurse Practitioner know. Resident #3 finally got x-rays on Friday 12/19/2025. The x-ray people never came to the facility, so that Friday, the resident was sent out. Resident #3 had been complaining of pain from the moment staff found the bruise. Certified Nurse Assistant #3 stated that Resident #3 is not a very vocal person, but they said, Ow, ow, that hurts. Certified Nurse Assistant #3 stated they do not know how the bruise happened; Resident #3 gets up before they come in, and they are transferred using a Hoyer. They were last trained on a Hoyer way before Christmas time. Certified Nurse Assistant #3 counted out the number of residents that need a Hoyer for transfer and stated it was 15 to 16 residents on that unit. Certified Nurse Assistant #3 stated that no one knows how it happened. Certified Nurse Assistant #3 stated they were not sure how no one noticed, it was a huge bruise that wrapped around the leg, was swollen, and was green and purple. Certified Nurse Assistant #3 stated that it had been a while since Resident #3 had fallen. Certified Nurse Assistant #3 stated that Resident #3 has a history of sometimes resisting care, making noise and raising their hand up. During an interview with the Director of Nursing on 01/21/2026 at 12:00 PM, they stated they do not know how the Infection Control Nurse concluded that the bruise on Resident #3's leg was from a bump on the Hoyer as there are no statements in the Accident and Incident report. They further stated they do not know why they were not made aware earlier. The Director of Nursing stated that an injury of unknown origin was reported to the Infection Control Nurse on 12/15/2025 and a report was submitted by Director of Nursing to New York State Department of Health on 12/19/2025.10 NYCRR 415.4 (b) (2)

Based on record review and interviews conducted during an abbreviated survey the facility did not ensure accidents of unknown origin were thoroughly investigated for 2 (two) of 6 (six) residents reviewed for accidents (Resident #2 and Resident #3). Specifically, 1) On 12/26/2025, Resident #2 was provided with morning care, was unable to walk and had a significant bruise on their right hip. Resident #2 was sent out to the hospital for x-rays, and it was determined that they had a fractured right hip. There was no indication of how this occurred, no facility investigation, and no report to the New York State Department of Health. 2) On 12/15/2025, Resident #3 was noted to have a bruise on their left leg, was transferred to the emergency department on 12/19/2025 and diagnosed with a fracture of unknown origin to their left tibia and fibula. Each incident resulted in actual harm to Resident #2 and Resident #3 that is not immediate jeopardy.The undated policy titled Accidents and Incidents - Investigating and Reporting documented under Policy interpretation and implementation part 2 (two) the following data, as applicable, shall be included on the report of incident/accident form: a. the date and time the accident or incident took place. b. The nature of the injury/illness. c. The circumstances surrounding the accident or incident. d. Where the accident or incident took place. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. It further documented that the Director of Nursing shall ensure that the Administrator receives a copy of the Report of Incident/Accident form for each occurrence. Resident #2 was originally admitted with diagnoses including, but not limited to, muscle weakness, insomnia, and glaucoma secondary to eye inflammation, bilateral. The 11/15/2025 Quarterly Review Minimum Data Set documented that Resident #2 was severely cognitively impaired. They had no need indicated for a mobility device, they required supervision or touching for most of their functional abilities like upper and lower body dressing, they were independent for rolling left and right, they required set up or clean-up for chair to bed transfer meaning they completed the activity on their own the helper only assisted with set up prior to or following the activity. The Health Status note dated 12/22/2025 documented the resident returned from an eye doctor appointment with orders for urgent trab (trabeculectomy - a glaucoma surgery that creates a tiny drainage pathway to lower eye pressure) os (left eye) without mitomycin (the surgeon does not use the anti-scaring medication called mitomycin) surgery (NPO (nothing by mouth) after midnight, and needs to be at the hospital by 3:00 PM for surgery. Daughter in agreement. Director of Nursing notified. The Transfer to Hospital Summary dated 12/23/2025 documented the diagnosis was eye surgery procedure, resident was discharged from nursing home facility on 12/23/2025, resident was admitted to hospital for an eye surgery procedure, was kept overnight for observation, and was anticipated to return once medical issues were resolved. The Health Status note dated 12/24/2025 documented the resident returned home (meaning the facility) via stretcher. Eye patch over left eye in place and remain in place until follow up appointment on 12/29/2025 at 9:45 AM. No complaints of pain or discomfort. Alarm placed on bed, Resident #2 is not to ambulate without assistance, they cannot bend, or lift, warm compresses four (4) times a day. Bruising noted right hand.The 12/25/2025 Accident and Incident report for the incident with Resident #2 is report number 1931 and provides the following description: Certified Nurse Assistant called nurse to room as bruise of light to dark purple in color, size of a 50-cent piece was found on right hip. Resident unable to give description. Immediate action taken includes x-ray order placed, provider aware, Director of Nursing aware, family aware, resident recently out for eye surgery alone. Resident sent to emergency department per family request. Resident taken to hospital. Note entered at end of incident report dated 12/29/2025 documented with very limited medical history, as per family resident declined to promote health and wellness for the majority of their life and has a long-standing history of tobacco product usage. Provider reviewed medical history and notes resident with osteoporosis. No evidence of abuse, neglect or mistreatment indicated. Resident was recently at the hospital alone without family support for eye surgery. There are no statements on this incident report. Review of the x-ray image results dated 12/28/2025 documented the findings as follows: A displaced acute fracture of the right femoral neck (upper part of thigh bone). No aggressive osseous lesion (an area of abnormal growth, damage, or tissue change within a bone, effectively replacing healthy bone with abnormal tissue) is present. No erosions (localized destruction or breakdown of bone tissue) were seen. Impression displaced acute traumatic fracture (occurs when a bone breaks into two or more pieces that shift out of normal alignment, often caused by severe trauma or falls) of the right femoral neck.During an interview with the Medical Director on 01/29/2026 at 3:42 PM, they stated in this case they would think there would be more of an investigation to see what happened, maybe everyone got into the holiday mood, maybe people were on vacation. They would expect a look back of staff that provided care. They had no idea what caused the incident. It is possible that Resident #2 could have fallen and then put themself back in bed. When reviewing the x-ray result, the Medical Director stated that Resident #2 had a fracture based on the resident's history and that this is a fracture of the hip, they would not assume it is trauma related. The Medical Director stated they think the person that read the x-ray made a mistake. The Medical Director stated that it was a Type 3 fracture which means partially displaced. The Medical Director stated that it may have been from trauma and maybe the resident did fall, but a resident could also have a fracture like this just because of osteoporosis.During an interview with Certified Nurse Assistant #1 on 02/03/2026 at 1:40 PM, they stated that they found a bruise on Resident #2's right hip, they had no idea what occurred, they had just come in that Friday and found it. Certified Nurse Assistant #1 stated that Resident #2 was fine before that time. Certified Nurse Assistant #1 stated Resident #2 could not stand and stated it hurt, and normally they could stand. Certified Nurse Assistant #1 stated that the resident walked out for their surgery that Tuesday the 23rd and on the 24th they were back at the facility with an eye patch on and could still get up and move. Certified Nurse Assistant #1 stated that they did not work on Christmas and did not know what occurred. Certified Nurse Assistant #1 stated that on Friday the 26th, they did not ask Resident #2 what happened, they just asked what was wrong. Certified Nurse Assistant #1 stated that Resident #2 was just telling them that it hurt and they could not get up and could not walk. Resident #3Resident #3 was originally admitted with diagnoses including, but not limited to, Alzheimer's disease, intermittent explosive disorder (a chronic mental health condition characterized by recurrent sudden episodes of impulsive, aggressive, or violent behavior disproportionate to the situation), and generalized anxiety disorder. The Quarterly Minimum Data Set, dated [DATE] documented that Resident #3 was severely cognitively impaired, they did not have any behaviors, they were incontinent of bowel and bladder, they had a wheelchair for mobility, unable to self-transfer and needed partial moderate assistance to roll left and right in bed meaning the helper lifts, holds or supports the trunk or limbs but provides less than half the effort.The Accident Incident report prepared by the Infection Control Nurse dated 12/15/2025 at 8:58 AM is numbered as 1912 and is titled As bruises documented that staff alerted registered nurse that Resident #3 had a large bruise to the left lower extremity. On inspection, the resident had a large purple bruise noted to their left lower leg. Resident #3 laughed when asked what occurred. Documented under the subtitle Immediate Action Taken Description: the resident shows mild discomfort when area palpated, left lower extremity is noted with mild swelling, no redness or warmth to the area. Resident seen by Nurse Practitioner with no further orders. After investigation, root cause analysis determined bruise to be the result of bumping the Hoyer during transfer. The pain level was assessed at two (2) facial grimacing. Under subheading Statements: there are no statements found. The Nurse Practitioner medical visit note written on 12/15/2025 at 3:39 PM documented that resident was seen to evaluate ecchymosis (bruise) on the left lower extremity. Resident #3 was seen sitting up in bed in no acute distress, and no signs or symptoms of pain. The plan for the contusion (bruise) was to monitor area, assess for signs or symptoms of pain.The Medical Director medical visit note dated 12/17/2025 at 11:52 AM documented Subjective: Patient is calm today, Patient noted with a large bruise to the left lower leg, no nausea, vomiting or diarrhea. Objective: vital signs all listed as stable. Assessment: lists all the diagnoses Order an x-ray to the lower left extremity at this time. Plan: continue present medications. The Health Status note written by the Infection Control Nurse dated 12/19/2025 at 11:22 AM documented Xray unable to be completed today, resident has pain on palpitation. Resident to be sent to Emergency Department at this time. Sister made aware and in agreement.The Health Status note dated 12/19/2025 at 3:29 PM documented that a call was received from the Emergency Department stating that resident had a fracture of left tibia and fibula (bones of the leg) and would be transported back to the facility with a knee immobilizer, family made aware. During an interview on 01/21/2026 at 1:18 PM with Certified Nurse Assistant #3, they stated they found the bruise on 12/15/2025 and they told the infection control nurse and the overnight supervisor. They looked at it and they let the Nurse Practitioner know. Resident #3 finally got x-rays on Friday 12/19/2025. The x-ray people never came to the facility, so that Friday, the resident was sent out. Resident #3 had been complaining of pain from the moment staff found the bruise. Certified Nurse Assistant #3 stated that Resident #3 is not a very vocal person, but they said, Ow, ow, that hurts. Certified Nurse Assistant #3 stated they do not know how the bruise happened; Resident #3 gets up before they come in, and they are transferred using a Hoyer. They were last trained on a Hoyer way before Christmas time. Certified Nurse Assistant #3 counted out the number of residents that need a Hoyer for transfer and stated it was 15 to 16 residents on that unit. Certified Nurse Assistant #3 stated that no one knows how it happened. Certified Nurse Assistant #3 stated they were not sure how no one noticed, it was a huge bruise that wrapped around the leg, was swollen, and was green and purple. Certified Nurse Assistant #3 stated that it had been a while since Resident #3 had fallen. Certified Nurse Assistant #3 stated that Resident #3 has a history of sometimes resisting care, making noise and raising their hand up. During an interview with the Director of Nursing on 01/21/2026 at 12:00 PM, they stated they do not know how the Infection Control Nurse concluded that the bruise on Resident #3's leg was from a bump on the Hoyer as there are no statements in the Accident and Incident report. They further stated they do not know why they were not made aware earlier. The Director of Nursing stated that an injury of unknown origin was reported to the Infection Control Nurse on 12/15/2025 and a report was submitted by Director of Nursing to New York State Department of Health on 12/19/2025.10 NYCRR 415.4(b)(3)

Based on record review and interviews conducted during the abbreviated survey (544161), the facility did not ensure that adequate supervision and safety monitoring interventions were consistently implemented and documented to prevent accidents and recurrence of self-injurious behaviors for one (Resident #1) of one resident reviewed for accidents. Specifically, Resident #1 who was severely cognitively impaired and care planned as ha having behavior of chewing on nonfood items, was transferred to the hospital on [DATE] for evaluation after biting their left middle finger. Resident #1 had a portion of their left middle finger amputated and was diagnosed with self-inflicted traumatic amputation of the left finger. Resident #1 returned to the facility on [DATE] with an initial physician's order for hourly safety checks which was changed to 15 minute safety checks on 3/13/2024. Resident #1 returned to the hospital on 3/22/2024 for further amputation of the left middle finger. The facility was unable to provide documentation that the hourly or 15-minute safety checks were completed as ordered. The findings include: The facility policy titled Resident 15 Minute Safety Checks documented that the facility will implement 15-minute safety checks for any resident deemed at risk based on clinical assessment or physician order and that staff are responsible for documenting each observation promptly, accurately, and legibly. Resident #1 was admitted with diagnoses including but not limited to Alzheimer's Disease, anxiety disease, and osteoarthritis. The 01/26/2024 Quarterly Minimum Data Set (an assessment tool) documented that Resident #1 had severely impaired cognition. The 7/24/23 Behavior Care Plan documented that Resident #1 has a history of placing items in their mouth, picking at the arm rest of their wheelchair and placing foam padding in their mouth, and placing fingers in mouth and chewing, along with grinding their teeth. Interventions included to provide resident with mouth chewy daily. Monitor for items placed in mouth and remove as needed. Notify nurse The 03/09/2024 Incident Report documented that Resident #1 was visibly observed by staff biting their left middle finger. Upon assessment, the resident was noted to be bleeding from the left middle finger which had two open areas. Both areas were cleaned, and the resident was monitored. Resident #1 was then transferred to the emergency room for further evaluation. The 03/10/2024 emergency room after-visit summary documented that Resident #1 had a diagnosis of traumatic amputation of the left middle finger.The 03/10/2024 progress note documented Resident #1 returned to the facility with a diagnosis of self-inflicted amputation of the finger. Upon return, the resident was placed on 15-minute watch and visual checks.The 3/10/24 at 07:36 PM health status progress note documented that Resident #1 continues to gnaw on bandage, gown, clothes protector, and other nonfood items, several redirections needed and unsuccessful for lengthy time periods. The 03/11/2024 Physician's order documented that Resident #1 was to be placed on visual checks every hour; however, there was no documented evidence that the certified nurse aides completed or recorded the hourly visual checks as assigned. This order was discontinued on 03/13/2024 and was changed for Resident #1 to be placed on 15-minute safety checks.The 3/12/24 at 07:17 PM health Status note documented that Resident #1 was redirected several times to cease chewing on nonfood items (gown, clothing protector, and hand mitts. The 3/12/24 at 03:53 PM health status note documented that Resident #1 was observed chewing on blanket one time and was redirected. Review of the Certified Nurse Accountability form revealed no documented evidence that the certified nurse aides were completing the safety/visual checks as ordered. During an interview on 10/02/2025 at 1:57 PM, Licensed Practical Nurse #1 stated that when residents are placed on hourly or 15-minute checks, the certified nurse aides will document the checks on a paper form that is kept in a binder. Licensed Practical Nurse #1 stated that the certified nurse aides are aware of which residents are on 15-minute or hourly checks because this information is listed in their care guide, but the documentation itself is completed on paper. Review of Certified Nurse Aide Accountably records and Kardex during the onsite survey revealed no documented evidence that the certified nurse aides were documenting the checks as ordered. During an interview on 10/02/2025 at 2:00 PM, the Assistant Director of Nursing stated that when residents are placed on 15-minute checks or visual checks, the certified nurse aides are made aware during report and in their certified nurse aide care guides. The Assistant Director of Nursing stated that the certified nurse aides document the checks on paper forms, which are kept at the nurse's station. During an interview on 10/02/2025 at 2:35 PM, Certified Nurse Aide #1 stated that when a resident is placed on 15-minute or hourly visual monitoring checks, the certified nurse aides are informed during report, and the information is also listed in the certified nurse aide care guide. Certified Nurse Aide #1 further stated that the checks are documented on paper. During an interview on 10/01/2025 at 4:51 PM, the Director of Nursing stated that the facility uses a paper check-off form that is to be signed by all certified nurse aides but there were no visual check forms for Resident #1. The Director of Nursing stated that on 03/11/2024, an order was put in for the resident to be on hourly checks, and on 03/13/2024, that order was discontinued, and the resident was placed on 15-minute visual checks. The Director of Nursing stated that the facility was unable to provide documentation that either the hourly or 15-minute checks was completed. The Director of Nursing also stated that they had just recently started working at the facility and had looked all over for the visual check forms but were unable to find them and therefore were unable to provide evidence that the visual checks were completed.10NYCRR 415.12(h)(1)

Based on record reviews and interviews conducted during an abbreviated survey (2620167), the facility did not ensure the Medical Director fulfilled their responsibility for the implementation of resident care when the resident died. This was evident for 1 of 3 residents reviewed for death. Specifically, Resident # 1 died on [DATE] and the Medical Director signed the death certificate electronically on [DATE]. In accordance with State Public Health Law 4041, this was required within 72 hours of death.Resident #1's diagnoses include, but not limited to, Dementia, repeated falls, chronic kidney disease stage 3, and basal cell carcinoma of skin of nose. A significant change Minimum Data Set, dated [DATE] documented Resident #1 had a brief interview for mental status score of 09; indicating the resident has moderate cognitive impairment with no behaviors present. Resident had no impairments to upper and lower extremities and used a wheelchair for locomotion. A Nursing progress note dated [DATE] at 1:31am documented the called by unit licensed practical nurse # 1for assessment of Resident #1. Resident was absent of respirations, no apical pulse noted. Time of death 1:31am. Post-mortem care provided by Certified Nurse Aide. Family made aware. Funeral home called. Provider made aware. During a telephone interview on [DATE] at 8:45 am with Resident # 1's Representative they stated Resident #1 died at approximately 2 am on 8/15 and they were notified by the facility. After they were notified of Resident # 1's death they went to the funeral home to discuss everything. Resident # 1's Representative stated on [DATE] they made the decision to cremate the resident. Funeral home called the family and stated they could not proceed forward because the death certificate was not signed and then the death certificate was signed and received on [DATE]. They believe it is typically a business day. The delay in the death certificate put extra stress because services were delayed until [DATE] because the death certificate was not signed on time. During a telephone interview on [DATE] at 1:19 pm with the Funeral Director they stated they worked in the funeral home over 20 years. The Funeral Director stated the Care Center at Sunset Lake is typically good about signing the death certificates. The provider has 48 hours by law to sign the death certificate. This does not include weekends. They have two (2) business days to sign the death certificate. Once the provider has signed the death certificate it is sent to the township of Liberty and then a permit is issued. Surveyor requested for the director to review the death certificate of Resident #1. Funeral Director stated they should have signed it on the 18th, but it was signed on the 19th and the resident had the burial on [DATE]. During a telephone interview on [DATE] at 10:22 am with the Medical Director, they stated the process for signing a death certificate involves the nurse contacting the provider on call to make them aware. The Director of Nursing will start the death certificate in the Health Commerce System to start the process, or sometimes they will complete it their self. They have 72 hours to sign the death certificate, but they are not sure if the other providers are credentialed to sign them. A lot of times when the other providers are on call the nurses will make them aware, but they are not aware of this communication until later. Medical Provider stated they usually sign the death certificate within 24 hours because they do not want to wait because you can forget with everything going on. If they are not aware that the death certificate needs to be signed, then they cannot sign it. They go to the facility once a week, but they are available 24 hours. They signed the Resident #1's death certificate once they were made aware. The facility investigated and spoke with the nursing staff, but the facility had no documentation that anyone called them to sign. That is why they signed it late because they were not informed. The nurses are aware they need to call the provider otherwise how would they know to sign the certificate. Surveyor reviewed the expiration note with the provider, and the Medical Director stated they spoke with the nurse who put the expiration note in the system and the nurse acknowledged that they put the note in but never followed up with a phone call to inform me. This is rare and typically does not happen. 10NYCRR 415.15(a)

Based on record review and interviews the facility failed to initiate and complete a thorough investigation of an alleged violation of abuse to prevent further potential abuse. Specifically , On 3/2125 at 12:00pm Resident #1 was at the nurse's station and 3 staff witnessed (Certified Nurse Aide #1 and #2 and Domestic Aide #1)and reported to different Registered Nurses (Registered Nurse #1 and #2) and to the Director of Nursing that they witnessed an incident where Resident #1 was picked up from behind in a bear hug and dropped on the floor and then carried to their room by Domestic Aide #2. There was no evidence that the nursing staff reported the allegation of abuse to the facility Administrator or that they conducted an investigation into the allegations of abuse. Resident #1 had diagnoses including Unspecified Dementia, Mood Disturbance, and Non-Alzheimer Dementia. The 12/20/24 Minimum Data Set for Resident #1 documented had moderately impaired cognition. Review of the facility Abuse Policy last revision date 10/24 under the section Procedure documented that any report of suspected mistreatment, neglect, misappropriation, abuse or involuntary seclusion is documented, and investigation is started immediately. This is to immediately be reported to the Administrator/Director of Nursing or Administrator. In the event that the Administrator/Director of Nursing or Assistant Director of Nursing is not in the building at the time of the allegation or suspected abuse they are to be notified, via telephone call immediately. Any allegation of abuse will be reported in keeping with the New York State Department of Health and CMS regulations. An incident report will be completed. Statements will be obtained from all staff having knowledge of the events surrounding the event and the resident. During interviews conducted on 3/28/2025 and 3/31/2025 facility staff (Certified Nurse Aides #1, #2, and Domestic Aide #1) reported that on 3/21/2025 at approximately 12:15 PM they were all sitting at the nurse's station on Unit 3 when they observed Resident #1 standing and playing with the clothing protectors, the resident was yelling as per their usual behavior. They all stated that they observed Domestic Aide #2 come up behind the resident and bear hug them, and then dropped them on the floor. They stated that Domestic Aide #2 then picked the resident up under their arms and removed them from the nurse's station brought them back to their room. During an interview on 3/28/2025 at 10:43 AM Certified Nurse Aide #1 stated, after witnessing the incident they informed Registered Nurse #2. During an interview on 3/31/2025 at 12:39 PM Registered Nurse #1 stated, that on the day of the incident both Certified Nurse Aide #1 and Domestic Aide #1 came to them and told them what occurred. They called the Director of Nursing who stated they would take care of it. Registered Nurse #1 did not go to the unit at that time since she had informed the Director of Nursing, but they were there later when the police came to the facility. During an interview on 3/31/25 at 12:52 PM Registered Nurse #2 stated, that on 3/21/2025 at 12:58 PM they received a call from the Director of Nursing requesting they go to Unit 3 to see if they needed any assistance. During an interview on 3/31/2025 at 10:08 AM Domestic Aide #1 stated when Registered Nurse #2 arrived on the unit, Domestic Aide #1 reported that the Domestic Aide #2 grabbed the resident from behind and carried them to their room. \They stated that Registered Nurse #2 told them that they would take care of that later, that they needed to attend to the resident. Registered Nurse #2 took the resident into the lounge, stayed with them and called 911. During an interview with the Director of Nursing on 4/1/2025 at 11:00 AM they stated they do not know why they did not do an investigation of suspected abuse. On the day of the incident when they spoke to the two different registered nurses (Registered Nurse #1 and #2) that is not how it came across. The Director of Nursing stated that no one used the words manhandle or abuse when describing the incident. There was no further investigation because they took their information of the event from the 2 registered nurses, they did not have a suspicion that abuse occurred. 10NYCRR 415.4(b)(3)

Based on record reviews, and interviews conducted during a Complaint survey (NY00376081) the facility did not ensure that services provided met professional standards of quality. This was evident for 1 (Resident #1) of 3 residents reviewed for Medication Administration. Specifically, Resident #1 was administered an intramuscular injection of Lorazepam solution 1 MG that had been prescribed for another resident. The findings are: The facility policy titled Medication Administration created 1/87 and with a revision date of 4/24, documented that it is not acceptable to share medications between residents. The policy also documented that the right medication, is given to the right resident, at the right time, by the right route in the right dose. Resident #1 was admitted to the facility with diagnoses that included Unspecified Dementia, Mood Disturbance, and Non-Alzheimer's Dementia. The admission Minimum Data Set assessment dated [DATE] documented that Resident #1 had moderately impaired cognition. The Medication Administration Record dated 3/1/2025 to 3/31/2025 documented that Resident #1 was scheduled to receive Lorazepam Oral Tablet 0.5 MG 1 tablet by mouth two times a day for aggressive agitation anxiety. The Medication Administration Record dated 3/1/2025 to 3/31/2025 documented that Resident #1 received Lorazepam Solution 2 MG/ML inject 0.5 ml intramuscularly one time only for Bipolar Disorder on 03/19/2025 at 12:02 PM. There was no documented evidence that Lorazepam Solution had been dispensed by the pharmacy for administration to Resident #1. During an interview on 03/28/2025 at 3:47 PM, the Director of Nursing stated that Resident #1 was having escalating behavior and was evaluated by the Psychiatrist who ordered an immediate intramuscular injection of Lorazepam 1 MG which they administered. During an interview on 04/02/2025 at 3:57 PM, the Nurse Educator stated they do not administer medication, and they do not believe that Lorazepam Solution is stocked anywhere in the facility as an emergency medication. The Nurse Educator also stated that they went to Unit 2, retrieved the medication, did not look at the name on the bag or recall who it was prescribed for, but used it because it was needed at that moment. The Nurse Educator further stated that they prepared the medication and gave it to the Director of Nursing to administer to Resident #1. The Nurse Educator stated that it was only after the incident that they learned that the Lorazepam liquid used was not house stock medication. The Nurse Educator also stated that they would not use medications prescribed for another resident and thought that the Lorazepam liquid was a stock medication for use with all residents. In a subsequent interview on 04/03/2025 at 2:39 PM, the Director of Nursing stated that they knew what medications were in the building, and there was no liquid Lorazepam in stock, in either the emergency medication kits or in the medication refrigerators, as it was not a house stock medication. The Director of Nursing also stated that in the middle of the situation, they did not ask where the medication came from, as all they were thinking about was the safety of the resident and staff. 10 NYCRR 415.11(c)(3)(ii)

Based on record review and interviews conducted during an abbreviated and extended survey (NY00376081), the facility did not ensure that all nursing staff were competent and trained in providing care to residents with various psychiatric/mood disorders as listed in the current facility assessment. Specifically, 1 (Resident #1) of 4 residents with psychiatric diagnoses do not have staff in the facility that are trained to provide appropriate behavioral health care. The facility was unable to provide documented evidence that they provided nursing staff education on behavioral health training other than for dementia. Resident #1 Minimum Data Set, dated [DATE] with diagnoses unspecified dementia, moderate with mood disturbance. non traumatic brain dysfunction, non-Alzheimer's dementia. No behaviors are noted. Resident #1 was evaluated and was found to be moderately cognitively impaired with a brief interview of mental status of 11. On PHQ2-9 a depression screening tool Resident #1 scored a 13, indicating elevated depression. Review of the Facility assessment revealed it was last updated on 3/27/25. The Facility assessment listed the types of psychiatric/mood disorders and other diagnoses related to behavioral health specific to their resident population This list is used to identify the types of staff and material resources necessary to meet the needs of residents living with these diagnoses. The assessment lists the following disorders and conditions: psychosis, impaired cognition, mental disorder, depression, bipolar disorder, schizophrenia, post-traumatic stress disorder, anxiety disorder, intermittent explosive disorder, adjustment disorder. The Facility assessment documented that staff training is based upon the resident population and that training topics and competencies may/will change as resident needs are identified. Review of the General Orientation Packet revealed no date the 17th item on the list is titled Behavioral Health Training and Trauma Informed care. Further review of the packet indicated that on page 27 it is documented that Trauma Informed Care is defined as practices that promote a culture of safety, empowerment, and healing. It is a model for systems to address the impact of trauma and Post-Traumatic Stress Disorder (PTSD). There is another section in the full training packet on page 26 titled Behavioral Health training and it documented that it was for care of residents with dementia. There is nothing in the General Orientation Packet that addresses how to care for residents with any other mental health or behavioral health diagnosis or issue that is listed in the facility assessment. During an interview on 3/31/25 at 12:52pm with Registered Nurse #2 they stated there is no behavioral health training, no protocols when residents act out, no one knows what to do. If a resident tries to bite or hit, none of the staff have been trained on how to handle these situations. Registered Nurse #2 stated they can call for assistance but there isn't a behavior code to call they just page for assistance. During an interview on 4/2/25 at 11:23am with the Staff Education Nurse they stated there is no specific training to provide care for residents with schizophrenia or bipolar disorders. They stated that they recall staff saying they felt unsafe at times, and that they wanted behavioral health training. During an interview on 4/2/25 at 12:30pm with the Administrator they stated there is a difference between dementia care training and behavioral health training, the focus has been on training for dementia management and care. 10 NYCRR 415.26(c)(1)(iv)

Based on observation, record review, and interview conducted during the Recertification and Abbreviated Surveys (NY00333577 and NY00320085) from [DATE] to [DATE], the facility did not ensure that the residents environment remained as free of accident hazards as possible for 2 (Residents #219 and #95) of 7 residents reviewed for accidents. Specifically, 1. Resident #219 who- was being transferred via Mechanical lift by two certified nurse aides, fell from the mechanical lift due to the battery dying and Certified Nurse Aides #20 and #23 unhooking the straps instead of using the emergency lower button, subsequently causing a hematoma (large pool of blood under the skin resulting from injury) to the back of Resident #219's head which resulted in them having to be transferred to the emergency room for further evaluation. 2. Resident #95 was provided with a snack upon request, which was not according to the resident's prescribed diet order. As a result, the Resident #95 sustained a choking occurrence, became unresponsive, with initiation of a full Code Blue, and was eventually transferred to the hospital. This resulted in actual harm to Residents #'s 219 & #95 that was not immediate jeopardy. The findings are: The facility policy titled Accident/Incident dated ,d+[DATE] and last revised on ,d+[DATE] documented to ensure resident health and safety. 1. Resident #219 was admitted with diagnoses including below the knee amputation to both legs, chronic pain syndrome, and dementia. The Admission Minimum Data Set, dated dated dated [DATE] documented Resident #219 had moderate intact cognition and was dependent with toileting and transfers. The [DATE] Falls Care Plan documented Resident #219 is at risk for Falls as evidenced by deconditioning, incontinence, high risk meds, and history of falls. Interventions included educating the resident/family/caregivers about safety reminders and what to do if a fall occurs. The [DATE] Accident and Incident form documented Resident #219's wheelchair tipped backwards, during a transfer from bed to chair via a mechanical lift when the battery died resulting in the resident falling on the floor. Resident #219 sustained a large hematoma to the posterior scalp (back of head) subsequently causing them to be transferred to the emergency room for evaluation. The [DATE] Investigative Summary documented Resident #219 was sent to the Emergency Department for evaluation after sustaining a fall during a mechanical lift transfer and hitting their head. Resident #219 sustained a minor injury to the back of their head after falling during the transfer. Resident #219 returned to the facility, and abuse, neglect and mistreatment was ruled out. There was immediate re-education at the point of care provided to the certified nurse aides involved. The education included both verbal and demonstration of proper mechanical lift use. Further education was then provided, facility wide. During the following week, audits were conducted to ensure proper mechanical lift use among staff and checking for charging of the battery, with competencies to be completed by staff. Resident #219 was placed on safety and neuro checks per facility policy after returning from the emergency department. The [DATE] Nursing Home Facility Incident Report submitted to the New York State Department of Health documented Resident #219 was being transferred from the bed to the wheelchair with 2 Certified Nurse Aides assistance via a mechanical lift, and per the Certified Nurse Aide statements, the mechanical lift malfunctioned, and upon further investigation and interviews, it was concluded there was also user error during the transfer. The [DATE] Nursing Progress note by Registered Nurse Supervisor #18 at 11:35 PM documented upon arrival to Resident #219's room, the resident was observed lying on their back in a wheelchair, with the lower portion of the mechanical lift pad still connected to the mechanical lift. The Certified Nurse Aides reported during transfer, the mechanical lift malfunctioned, resulting in the resident falling during transfer. Resident #219 was assessed and there was a large hematoma noted to their posterior scalp. Resident denied loss of consciousness, awake, alert answering questions appropriately, complaint of blurring/double vision and back pain but stated he had 3 herniated disks. The resident was transferred to the Emergency Department for evaluation. Review of the emergency room After visit summary dated [DATE] documented Resident #219 had a head injury with a diagnosis of falling from a height of greater than 3 feet. On [DATE] at 11:15 AM, during an observation of Unit 2 there were 4 operable mechanical lift batteries observed in the clean utility room. During an interview on [DATE] at 11:19 AM, Certified Nurse Aide #19 stated if the mechanical lift is dead, it will make a beeping noise and struggle to go up. Certified Nurse Aide #19 stated after the mechanical lift is finished being used, the battery should be placed on the charger. During an interview on [DATE] at 12:30 PM, Certified Nurse Aide #20 stated when they were lowering the resident to the chair, the battery died , and they unhooked the mechanical lift straps, resulting in Resident #219 tilting backwards in the wheelchair and falling, hitting the back of their head on the floor. Certified Nurse Aide #20 stated they did not know the battery was dead and should have checked before taking Resident #219 out of bed. Certified Nurse Aide #20 stated they should have checked the battery prior to transferring the resident and was aware the mechanical lift had an emergency button to lower the resident if the battery died . During an interview on [DATE] at 9:35 AM, the Director of Nursing stated although, the certified nurse aides should not have operated the mechanical lift with a dead battery, causing Resident #219 to fall and hit their head, there was no negligence deemed on the certified nurse aides part. During an interview on [DATE] at 9:45 AM, the Administrator stated safe patient handling listed on the competencies included knowledge of the mechanical lift and that Certified Nurse Aide #20 and Certified Nurse Aide #23 were trained in operation of a mechanical lift. During an interview on [DATE] at 10:52 AM, the Director of Nursing stated prior to Resident #219 falling out of the mechanical lift on [DATE], the certified nurse aides were aware of the emergency lower button on the mechanical lift. The Director of Nursing stated it was the responsibility of the night shift to charge the mechanical lift batteries. During an interview on [DATE] at 11:30 AM, the Director of Medical stated Resident #219's fall from the mechanical lift on [DATE] was considered significant and the resident was sent to the emergency department for further evaluation, and to rule out significant trauma. 10 NYCRR 415.12 (h)(1) 49255 2. The Policy and Procedure titled Certified Nurse Aide Shift Routine with purpose to ensure compliance with resident care and policies revised on ,d+[DATE] documented residents are fed according to care plan. The Policy and Procedure titled Food and Nutrition Services revised on ,d+[DATE], and edited on [DATE] documented the multidisciplinary staff, including nursing staff, the attending physician, and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. A resident-centered diet and nutrition plan will be based on this assessment. Resident #95 was admitted with diagnoses including but not limited to non-Alzheimer's dementia, adult failure to thrive, and psychotic disorder. The [DATE] care plan documented the resident required interventions which included, but were not limited to, partial/moderate assistance with eating. Speech Therapy note dated [DATE] documented swallow evaluation was completed. The resident tolerated thin liquids and puree, liquids upgraded, no straws. Review of physician orders on [DATE] documented regular diet puree texture, thin consistency, no straws. The [DATE] care plan documented the resident required interventions which included, but were not limited to, diet as ordered: regular diet, pureed texture, thin consistency. The [DATE] Admission Minimum Data Set Assessment (a resident assessment tool) documented Resident #95 had severe cognitive impairment, needed supervision with eating, and substantial assistance with self-care. Resident #95 had a swallowing disorder evidenced by loss of liquids/solids from mouth when eating or drinking, holding food in mouth/cheeks or residual food in mouth after meals, coughing or choking during meals or when swallowing medications, complaints of difficulty or pain with swallowing. With nutritional approaches: mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids). A facility Investigation Report signed by the Director of Nursing documented on [DATE] at approximately 8:00 PM Resident #95 requested a peanut butter and jelly sandwich from Certified Nurse Aide #7. The resident was given a sandwich upon request, the resident was at the nurse's station eating the sandwich when they began to cough. The resident was noted to be unresponsive, Code Blue called, Emergency Medical Services called, Heimlich maneuver (first aide, abdominal thrusts for someone choking) performed, the resident was suctioned, and oxygen was provided. The resident was transferred to the emergency room for an evaluation. Based on investigation, the resident's diet order was noted to be pureed. Based on interviews with staff and Certified Nurse Aide #7, who gave the resident the sandwich, Certified Nurse Aide #7 did not check the resident's diet prior to giving the resident the sandwich. Patient Review Instrument from the hospital documented the resident was admitted to the hospital on [DATE] with diagnosis including respiratory arrest associated with feeding. The Employee Statement signed by Certified Nurse Aide #7 on [DATE] documented the resident told them they were hungry and asked to have a peanut butter and jelly sandwich. Certified Nurse Aide #7 stated they got the sandwich, cut all around it and gave the resident a small piece from the middle. The resident ate it, got up, walked, and started choking. During the interview on [DATE] at 5:02 PM Certified Nursing Aide #12 stated every resident on the unit had a different diet, and they checked the tray ticket to make sure they received the right diet. If a resident had changes in their diet, the nurse would give an update or a report at the beginning or at the end of the shift. They said they also knew the electronic medical record had a fluid and nutrition section they could see the diet. If the resident asked them to have something to eat, they provided the resident with a snack depending on their diet. Certified Nursing Aide #12 said for the consistency of the food they check the list on the unit refrigerator at the nursing station, which was constantly updated. They said they received in-service education how to follow the diet upon hiring in [DATE]. During the interview on [DATE] at 5:10 PM Licensed Practical Nurse #13 stated for any residents who were on a pureed diet and requested snacks, they could provide chocolate pudding or yogurt. They said that Resident #95 had a puree diet, with thin liquids. Licensed Practical Nurse #13 said the resident did not have teeth and refused to get dentures and refused to have a dentist appointment. Licensed Practical Nurse #13 showed a list of the residents and the information with type of diets for them posted on the refrigerator at the nurse station. 10 NYCRR 415.12 (h)(1)

Based on observations and interviews conducted during the recertification survey from [DATE] to [DATE], the facility did not ensure that food was stored in accordance with professional standards for food safety practice, and essential equipment was not in safe operating condition. Specifically, 1. Food was stored in the walk-in freezers and refrigerators that was unlabeled, undated and without expiration dates. 2. Expired foods were stored in refrigerators and the dry storage room. 3. Freezers #6 and #7's insulation door seals were not attaching properly causing the formation of ice on the ceiling and walls inside the freezers. 4. Damaged tile flooring next to the dishwashing machine formed an uneven and wobbly surface. Finding include: The undated facility policy Food Receiving and Storage documented all foods stored in the refrigerator or freezer will be covered, labeled, and dated. During an initial tour of the kitchen on [DATE] at 4:40 PM conducted with Head [NAME] the following were observed in the walk-in freezer #7: 1. A bag of frozen chicken breast, without original box, with receiving date ,d+[DATE] on the label. The Head [NAME] could not find the expiration date on another chicken breast box. 2. Opened box of beef patties with no date of opening. 3. A bag of beef chuck stored on top of a bag of corn beef and a bag of opened mix frozen vegetables with no original boxes. 4. The formation of ice on the ceiling and walls inside the freezer. Observation of walk-in freezer #6 on [DATE] at 4:55 PM revealed a bag of hash brown patties on top of the bag of sausage for pizza without original box, and no expiration date. Observation of walk-in refrigerator #5 on [DATE] at 5:03 PM revealed an undated 5-pound bag of mozzarella cheese, an undated leftover of angel food cake, an opened on [DATE] mild cheddar cheese cubes. The head cook said opened cheese could be kept for 3 days after opening. Observation of walk-in refrigerator #4 on [DATE] at 5:11 PM revealed an undated metal tray of leftover baked ziti covered with plastic. The head cook said it was made yesterday. Observation of dry storage room on [DATE] at 5:22 PM revealed a box of yellow cake mix with expiration date [DATE]; a bag of cashews whole 320-count with an illegible date of opening and with an expiration date of [DATE]; bags of mini penne and mini enriched macaroni with open dates of [DATE] and without the original box and expiration date. Observation of the area around the dish washer machine on [DATE] at 5:48 PM revealed damaged tile flooring next to the dish washer machine, which formed uneven and wobbly surface. During an interview with the Food Services Director on [DATE] at 01:00 PM, they said the door seals for freezers #6 and #7 had not been closing properly for over a year. The insulation seals were not attaching properly to the doors leaving a gap between doors and door frames, causing formation of ice on the ceiling and walls inside of the freezers. They said they sent reports about the situation with broken floor and door seals to QAPI meeting every month, and the people who were responsible for fixing the doors were aware of this situation. 10 NYCRR 415.14 (h)

Based on record review and interviews conducted during the Recertification and Abbreviated surveys (NY 00351488 and NY 00335211) from 9/22/24 to 9/27/24, the facility did not ensure that there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, upon review of the staffing schedule for multiple days and on all three shifts of staffing for each floor, the facility did not provide adequate staffing to meet the needs of the residents. The findings are: The Facility assessment dated [DATE] documented Licensed Practical Nurses providing direct care and Nurses Aides were staffed based on the acuity of units or demands of unit as determined by the Clinical Administration on a fluid basis as the needs of the residents and census are ever changing. 1) The facility census on 9/22/2024 was 115 residents. On 9/27/2024, the Unit 1 census was 17 and Unit 2 census was 39. A review of actual Staffing Sheets from 9/1/2024 to 9/27/2024 documented 17 of 28 night shifts where 1 Certified Nursing Assistant was scheduled and staffed on Unit 1. There were 8 of 28 night shifts where 2 Certified Nursing Assistants were scheduled and worked on Unit 2 on the night shift. On 9/27/2024 at 7:26 AM, Unit 1 was observed with a strong smell of feces emanating from a room at the beginning of the unit and permeating throughout unit. Registered Nurse #17 was observed coming out of a room and calling to Certified Nursing Assistant #25 who was in the hallway at the soiled linen cart. Licensed Practical Nurse #26 was observed sitting at the nursing station. There were 2 of 17 total residents on the unit up and out of bed eating breakfast. There were 12 residents asleep with their breakfast trays at bedside. At 7:50 AM, Registered Nurse #17 left the unit and 2 staff members remained. The smell of feces was still apparent and observed from the Unit 1 hallway. On 9/27/2024 at 7:32 AM, Certified Nursing Assistant #25 was interviewed and stated they always worked the night shift from 12 AM to 8 AM and was usually assigned to the Unit 4. Certified Nursing Assistant #25 was asked to cover the shift on Unit 1 because the facility was short of staff. Registered Nurse #17 was the Nursing Supervisor and helped with providing residents with care because the Licensed Practical Nurse was responsible for medication pass and wound treatments. The night shift was hectic because Certified Nursing Assistant #25 was usually assigned to 20 residents and had to begin getting residents up at 5 AM for breakfast at 6:15 AM. Some residents complained about getting up early and were allowed to sleep in. Most of the residents agreed to eat breakfast. There were approximately 3 residents on Unit 1 that requested not to be assigned to a male aide and the charge nurse did assist in providing those residents' care. The same aide kept calling out or not showing up which created a staffing shortage. Domestic Aides were used by the facility on the day and evening shifts to escort residents to appointments, make beds, or restock the units. The Domestic Aides did not assist with or provide activity of daily living care to residents. There were no Domestic Aides assigned to the night shift. Certified Nursing Assistant #25 stated they found their assignment overwhelming at times when they had several residents that required more assistance. On 9/27/2024 at 7:48 AM, Registered Nurse #17 was interviewed and stated they worked as the Nursing Supervisor on the night shift for the facility for approximately 1 year. The staffing ratio was 1 Certified Nursing Assistant to 15 residents. There was a mistake on the schedule so 1 Certified Nursing Assistant was placed on Unit 1 and Registered Nurse #17 helped the aides. During the interview, Registered Nurse #17 referenced a printed email from the Director of Nursing dated 9/10/2024 that was hanging from a bulletin board in the nursing office and stated, the Nursing Supervisors were informed Unit 1 was overstaffed and should only be assigned 1 Certified Nursing Assistant for the night shift. The staffing par levels were 1 aide for Unit 1 and 3 aides each on Unit 2, Unit 3, and Unit 4. The night shift that just ended had 1 aide on Unit 1, 2 aides on Unit 2, and 3 aides each on Unit 3 and 4. Unit 1 was considered the subacute rehab unit for beds 100 to 110 and the rest of the unit was for residents on palliative care. Registered Nurse #17 stated their shift began at 8 PM and they were usually dealing with staffing issues. There was at least one callout daily and there was one staff member that consistently called out every time they were on schedule. There were also times the schedule had mistaken where someone was scheduled but did not know they were scheduled or were on vacation. Callouts were the biggest issue. Certified Nursing Assistant #27 was mistakenly scheduled to work Unit 1 on the 9/27/2024 night shift but was on a rotating weekend schedule and was supposed to be off so they should have never been placed on the schedule. There were also times the facility would schedule an agency aide for a double shift and after working 1 shift, the aide would cancel their second shift and leave the facility short of staff. Another Licensed Practical Nurse did not work a full shift on Unit 1 and left early leaving Licensed Practical Nurse #26 as the only nurse on Unit 1. Night shift staffing became a problem during breakfast time at 6 AM. There were less staff scheduled for the night shift and the staff were expected to have residents up and fed for the breakfast meal. Registered Nurse #17 pointed to the schedule and stated the empty slots on the page were slots for staff that should have been scheduled but had not been filled. The problem with staffing was on the night shift because of the breakfast meal. Registered Nurse #17 stated they were also responsible for fielding callouts and assisting with staffing for the upcoming day shift. On 9/27/2024 at 8:40 AM, Licensed Practical Nurse #8, was interviewed and stated they were concerned with agency staff that were assigned to cover their unit on their days off that were not properly trained in the charge nurse responsibilities. They had email communications with the Director of Nursing that started in January 2024 but stopped in March 2024 after the Director of Nursing told Licensed Practical Nurse #8 to stop complaining about staffing. There were times that aides disappeared for several hours without repercussion. Licensed Practical Nurse #8 stated they had issues with looking for supplies on other units and was unable to find staff. There was no oversight or supervision of staff on the night shift. Licensed Practical Nurse #8 had to assist with feeding breakfast to residents on their shift and there were times that they were still feeding residents until 7:45 AM. Staff burnout occurred because the assignments were not rotated, and some aides complained that their assignment was heavier. The facility Administration made room changes to accommodate staff complaints regarding their assignments instead of rotating staff. Recently, the get-up schedule of residents that the night shift were required to have out of bed for breakfast and before the day shift arrived, changed and residents were added to the list, placing more responsibility and work on the night shift. On 09/27/24 at 9:34 AM, Licensed Practical Nurse # 4 was interviewed and stated they worked overtime for the facility 1-2 two times per week. Licensed Practical Nurse # 4 stated they covered three 12-hour shifts and two 8-hour shifts per week. On 09/27/24 at 9:37 AM, Registered Nurse Unit Manager #5 was interviewed and stated, on average the direct care staff were short staffed usually 1-2 times per week. However, the facility was very short staffed and did not have enough staff to care for the residents. On 09/27/2024 at 11:16 AM, the Staffing Coordinator was interviewed and stated the staffing schedule was created on 2-week cycles and was a collaboration between the Administrator, the Staffing Coordinator, and the Director of Nursing. There was a meeting held every Thursday to discuss staffing schedule needs and changes. Staffing par levels changed according to unit census. If there were more than 15 residents on Unit 1, there should be 2 Certified Nursing Assistants. The Administrator and/or Director of Nursing dictated whether units were overstaffed. The evening 4 PM to 12 AM and night 12 AM to 8 AM shifts were very challenging to staff. The facility was unable to find staff that wanted to work those shifts. Callouts and other staffing issues were considered when making the schedule. The Staffing Coordinator stated they were continually working to cover the blank slots on the schedules. If the slots were not filled, staff were asked to work double shifts or stay over. The Staffing Coordinator worked with 3 separate staffing agencies but there were no-calls, no-shows. Agency staff were given 3 chances to show up and, if they did not show, the Staffing Coordinator took them off the schedule. Agency staff were booked for more than one shift before the facility confirmed they were reliable. There were limitations in asking certain regular staff to work double shifts because of their contract. The Director of Nursing determined 1 Certified Nursing Assistant was acceptable on Unit 1 because the facility had staffing issues. There were staffing issues identified on the previous recertification survey and the facility attempted to attract more staff with flexible hours, higher wages, hiring staffing agencies, and other incentives. Domestic Aides were used on the day and evening shifts to assist with filling water pitchers, making beds, and as escorts to outside clinic appointments. On 09/27/2024 at 03:27 PM, the Administrator was interviewed and stated the facility made efforts to improve staffing since the last recertification survey, conducted job fairs, and put a process in place to get in touch with job candidates faster. There were also pickup shift bonuses, sign on bonuses, additional staffing agencies brought on board, and flexible hours given to staff to obtain and retain staff. Hiring and new employee orientation have been improved with the new inservice coordinator. The facility par levels were in line with the New York State Department of Health staffing par levels of 3.5 nursing hours per resident per day. Unit 1 should have 2 aides if they have a census of 20 residents. Acuity level was part of the staffing discussion during the weekly staffing meetings. Unit 1 currently had a census of 17 residents and only required 1 aide to be scheduled on the night shift. Unit 2, the locked Dementia Unit, should be staffed with 2 to 3 Certified Nursing Assistants at night. The Administrator stated they were aware that a meal service was scheduled on the night shift and that there had been discussions regarding how this effects staff and residents. The Licensed Practical Nurse and Registered Nurse Supervisor helped with providing activity of daily living care to residents. It was more difficult to staff the night shift. The Administrator stated they were more concerned with staffing the evening shift and stated agency staff were used to pick up shifts on a regular basis. 10 NYCRR415.13(a)(1) (i-iii) 49364

Based on observation and interview conducted during the Recertification survey from 9/22/24 to 9/27/24, the facility did not provide food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, food was served out of temperature (chicken, pasta, vegetables, and milk). Findings include: The facility policy Food and Nutrition Services revised on 8/2023 and edited on 12/4/2023 documented, food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. During an interview on 9/22/24 at 5:42 PM, Resident #27 stated the food was cold by the time they got their tray in their room. Resident #27 stated it took the Certified Nurse Aide a half-hour to bring the tray to them, after they finished serving the residents in the dining room. During an interview on 09/23/24 at 11:36 AM, Resident #94 stated that the food was cold by the time they brought it to them. During a Resident Counsel Group meeting on 09/24/24 at 1:35 PM, some of the residents stated the food did not look appetizing at times, and on many occasions the food was cold when it got to them. On 9/25/24 at 12:09 PM, temperatures were checked on a test tray with the Food Service Director. The chicken was 130 degrees Fahrenheit, the cooked vegetables were 105 degrees Fahrenheit, the pasta was 106 degrees Fahrenheit, and a half pint box of reduced fat milk was 48 degrees Fahrenheit. During an interview on 9/25/24 at 12:11 PM, the Food Services Director stated that the food and milk were at acceptable temperatures when they left the kitchen. 10 NYCRR 415.14 (d)(1)(2) 49364

Based on record review and interview conducted during an abbreviated survey (NY00319128), the facility failed to initiate Cardiopulmonary Resuscitation (CPR) to an unresponsive resident who had a Full Code status with Advance Directives in place. This was evident for 1 of 3 residents (Resident #1) reviewed for CPR. Specifically, on [DATE] at 5:00 AM Resident #1 was found in their bed unresponsive with no pulse by a Training Nurse Assistant (TNA) #1. The Registered Nurse (RN ) #1 on duty was summoned to the resident's room and did not initiate CPR. The facility did not activate their Medical Emergency Services Protocol (Code Blue) and did not call 911(Emergency Medical Service). Subsequently, Resident #1 was pronounced dead by the RN #1 at 5:04 AM. This resulted in actual harm to Resident #1 and the likelihood for serious harm to the health and safety of 28 residents with Full Code directives, that was Immediate Jeopardy and Substandard Quality of Care. Findings include: A facility policy titled, CPR, last revised ,d+[DATE], documented CPR must be initiated by any CPR certified employee, in the event of cardiac and/or respiratory arrest of a resident unless a Do Not Resuscitate (DNR) order is in place or unless an RN has determined that irreversible signs of death are present. All nurses will be appropriately skilled and certified in the performance of and expected to perform, basic life support, including CPR, Heimlich maneuver and rescue breathing. In the event a resident is assessed as in distress or without a pulse and/or respiration, the CPR certified employee will check the resident's chart, pull call bell, and yell code blue and initiate CPR. Resident #1 was admitted to the facility with diagnoses including coronary artery disease, heart disease, and diabetes. The Minimum Data Set (MDS, a resident assessment tool) dated [DATE] documented Resident #1 was cognitively intact. Resident #1's Medical Order for Life Sustaining Treatment (MOLST: a form that documents someone's treatment preferences concerning life-sustaining medical treatment), signed [DATE], documented Resident #1 wished to have CPR performed in the event their heart stopped beating. Resident #1's Comprehensive Care Plan dated [DATE] documented the resident was a Full Code. A facility Care Profile (electronic medical record which provides information regarding resident care requirements) last reviewed [DATE] documented Resident #1's code status Full Cardiopulmonary Resuscitation (CPR), Consent on file MOLST. A Facility Accident/Incident report (A/I) dated [DATE], documented Resident #1 was found unresponsive around 5:00 AM on [DATE], and pronounced dead at 5:04 AM was signed by the RN Director of Nursing. An undated incident summary signed by the facility's Director of Nursing (DON), documented that on [DATE] at approximately 5:00 AM, Training Nurse Aide (TNA) #1 notified RN #1 that Resident #1 would not wake up. RN #1, who was CPR certified attempted to check Resident #1's vital signs and was unable to obtain any vital signs. RN #1 did not initiate CPR. A review of facility CPR certification records documented RN#1 was certified to perform CPR through the end of ,d+[DATE] . A Facility Health Status Note Text (Progress Note) dated [DATE] and signed by RN # 1 documented TNA #1 found Resident #1 having difficulty breathing and notified writer. Writer found resident gasping for breath, no pulse, no BP (Blood Pressure). RNS arrived. No breathing. No pulse, During an interview on [DATE] at 11:33 AM, TNA #1 stated they found Resident #1 unresponsive and then left Resident #1's room to find help. They found Certified Nurse Aide (CNA) #1, who stated they were busy and instructed TNA #1 to go find the unit nurse. TNA #1 stated they then found RN #1 at the nurses' station and TNA #1 and RN #1 walked back to Resident #1's room. RN#1 assessed the resident . During an interview on [DATE] at 12:18 PM, RNS #2 stated they were the nursing supervisor on [DATE] and were alerted by the front desk staff of Resident #1's code. RNS #2 stated they immediately responded to Resident #1's room, saw a crash cart (a cart filled with emergency medical equipment required for life saving measures), assumed CPR had already been performed by RN #1, and followed the direction of RN #1 who was a more experienced nurse. RNS #2 then stated once in the room, RN #1 stated they did not have a stethoscope, so RNS #2 left the room to find one, returned and listened for heart sounds for Resident #1. RNS #2 did not hear a heartbeat. RNS #2 was asked by RN #1 for the time, which was 5:04 AM. RN #1 then pronounced Resident #1's time of death at 5:04 AM on [DATE]. RNS #2 stated CPR should have been performed on Resident #1 and 911 should have been called. During an interview on [DATE] at 3:23 PM, the Director of Nursing (DON) stated anybody who was certified in CPR was expected to initiate CPR when they discover a resident whose heart has stopped beating. The DON stated RN #1 should have initiated CPR on Resident #1. RN #1 did not follow the facility policy. DON stated they have been unable to reach RN #1 since the incident. During an interview on [DATE] at 9:27 AM, RN #1 stated they were alerted by TNA #1 that Resident #1 was not breathing. RN #1 stated they attempted to obtain vital signs and were unable to find a pulse. RN #1 stated they did not initiate CPR, rather they went to call the RN Supervisor (RNS) #2 for additional assistance. RN #1 stated RNS #2 did not pick-up their phone, so they called the front desk. RN #1 stated they informed the front desk staff to call RNS #2 and alert them of Resident #1's medical emergency. RN #1 stated they were aware Resident #1 was a Full Code but did not initiate CPR because they were concerned that Resident #1's roommate may find the sounds associated with CPR traumatic. RN #1 stated they should have performed CPR on Resident #1. During an interview on [DATE] at 12:36 PM, the facility Administrator stated they expected staff to follow policy and Resident #1 should have been provided CPR when staff discovered them without a heartbeat. During an interview on [DATE] at 2:45 PM, the facility's Medical Director stated they were made aware of Resident #1's cardiac arrest on [DATE] by the DON. The Medical Director stated Resident #1's Full Code orders were clear and staff should have provided CPR. The Administrator was informed of the Immediate Jeopardy and provided the Immediate Jeopardy Template on [DATE] and signed it at 6:29 PM. Based on the following corrective actions, the facility corrected the non- compliance as of [DATE], (IJ past non-Compliance indicates the facility had an IJ, but the non-compliance was corrected prior to the survey staff entering the Nursing Home on [DATE]). A Statement of Deficiency will be issued but a Plan of Correction is not required given the facility had corrected the non-compliance). On [DATE] an adhoc QAPI meeting was held to review incident. On [DATE] the facility reviewed their policies on CPR, DNR and Code Response On [DATE] mandatory in-service on CPR and Code Response was initiated for all staff. As of [DATE] ,d+[DATE] staff were in-serviced. In-service is ongoing for per diem and staff on leave. All staff will be required to be in-serviced prior to shift. On [DATE] all residents with advance directives were audited. On [DATE] all staff CPR certifications were audited. On [DATE] the facility initiated mock drills for code response. On [DATE], RN#1 was suspended. 10 NYCRR 415.3 (e)(2)(iii)

Based on record review and interview the facility did not ensure there was evidence that all alleged violations were thoroughly investigated for one ( # 17) of four residents reviewed during the extended recertification survey. Specifically: there was no evidence of investigation when Resident #17 exhibited unsafe wandering and was found on a unit that was an active construction sight. This had the potential to affect all wandering residents.For Resident #17 this resulted in no actual harm with a potential for more than serious harm that is Immediate Jeopardy to resident health and safety and Substandard Quality of Care. Additionally, it was determined that the facility did not conduct the required Nurse Aide Registry Check on 1 of 3 new employees. Specifically, the facility hired 1 of 3 new employees without knowledge of the result of the required State nurse aid registry check. This resulted in no actual harm but had the potential for more than minimal harm. This is evidenced by the following : Resident # 17 There was no evidence of investigation of an incident when the resident was found on a unit that was under construction after having entered the unit unnoticed by staff. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) dated 4/24/13 assessed that the resident sometimes understands, rarely/never was understood, had long and short term memory problems and had severely impaired cognition for decision making. It further documented that the resident had the behavior of wandering daily and used a trunk restraint. During the initial tour interview on 5/20/13 at approximately 10:00 am the Registered Nurse (RN), acting charge nurse, stated that a resident had entered a unit undetected that was closed and under construction. The Accident/Incident Report (A/I),dated 4/27/13 (a Saturday) at 1:40 pm, was requested on 5/20/13 and was provided by the above noted RN. The A/I documented the location was the Unit 2 construction zone. It documented the resident was unable to explain the incident. The resident's family was notified on 4/29/13 at 3:40 pm and an investigation was not initiated. Under the heading " Describe exactly what happened" it documented: Resident was found on Unit 2 which is under construction by dietary staff, the resident was not injured and was found in the wheelchair and brought back to Unit 1. Under the heading " what was done to prevent an occurrence" was documented: a door alarm has been placed on the entrance doors to Unit 2 with a loud alarm so that he does not enter Unit 2 again while it is under construction. When residents go near the door alarm sounds loudly. Under the heading " staffing at time of the accident/incident" it documented: the names of 2 nurses and 3 CNAs ( certified nurse aides). The physician signed the A/I but did not date it. The date of the report was 4/29/13 and signed by the RN acting charge nurse. The Administrator and Director of Nurses (DON) did not sign the A/I. There was a statement attached to this A/I written by a staff member (was a laundry worker) that documented: " On Saturday the 27 th around 1:40 pm I was waiting for the elevator. So I took a look through the window for Unit 2 and saw the resident (name of resident) was all the way at the end of the hallway, near a pile of wood. So I went to report it to the nurse on Unit 1. Then I proceeded to go and get the resident. After the A/I was reviewed on 5/20/13 at approximately 2:30 pm, the Acting Director of Nurses was asked for the investigation of the incident. She came back and stated she had sent an e-mail to the DON, who was on vacation out of the country, and did not know if she would hear back. She stated she could not find any further investigation of the incident. During an interview on 5/21/13 at 8:14 am the RN acting charge nurse stated she worked the day the resident went to Unit 2 but did not find out about it until that next Monday. She stated the other nurse, also an RN, was the person told about the incident. The RN acting charge nurse stated the other RN did not put the incident on the 24 hour report and did not tell her of the incident. The RN acting charge nurse stated she asked the other RN why she did not put the incident on 24 hour report sheet. That RN told her that it was the charge RN who takes care of that and she thought she had told the charge RN. The RN acting charge nurse stated she found out about the incident on Monday. The DON came to her with the staff statement and asked her to find out what happened. She stated that she filled out the A/I form from the statement from the staff person. The RN acting charge nurse stated she did not know how long the resident was on Unit 2 and stated she did not do an investigation of the incident, just filled out the A/I report. The RN acting charge nurse stated she got the A/I from the doctor's bin in the exam room. She stated that on that Monday (4/29/13) the doctor saw the resident and signed the A/I form and then it got put in the bin. She stated the DON gets the A/Is from the bin. She did not know why the A/I was still in the bin from the end of April. She stated she did not know if the Administrator saw it. During an interview on 5/21/13 at 8:36 am the Administrative Secretary stated that the RN on the unit would fill out the A/I then it would go to the DON who would do further investigation if needed. The DON would get more statements if needed. She stated the DON and Administrator usually sign off on the A/Is. She stated there were no investigations for the incident in the Administrators files but did not know if the DON had something. They did not have a key to the DONs files. During interview on 5/21/13 at 3:47 pm the laundry worker, who found the resident, stated she wrote the statement because her supervisor had told her to. She gave the statement to the Supervisor. She stated no one came to talk with her about the incident. She also stated that on that day she delivered laundry to the resident after lunch and he was not in his room at that time. During an interview on 5/21/13 at 4:02 pm the Supervisor of Laundry Workers stated that on Saturday (4/27/13) in the afternoon, she was called by the laundry worker who explained the incident with the resident being found on Unit 2 by her. The laundry worker had told her that the nurse had taken care of it. When the Supervisor came in on Monday she talked with the DON and asked if anyone had reported it. The DON told her she did not know anything about the incident. The DON asked the Supervisor to have the laundry worker write a statement about what happened. The Supervisor had the laundry worker write one and gave it to the DON. She never heard anything more about it after that. Finding # 1 Within the past 4 months, the facility hired 1 of 3 new employees without knowledge of the result of a required State nurse aid registry check. The personnel files for the Administrator, hired on 05/20/2013, were reviewed on 05/21/2013. This record review revealed that the facility conducted a State nurse aide registry check for this individual on 05/20/2013, the first day of employment. The Administrative Secretary stated in an interview conducted on 05/22/2013 at 10:30 am that State nurse aide registry checks are normally conducted prior to an employee starting work and that she was not notified of the Administrator's first day of work thereby causing the check to be late. The facility policy titled Employee-Pre-employment Screening stated that "Prospective employee names will be checked on the state nurse aid registry by the Administrative Assistant. " 10 NYCRR 415.4(b) (1)(ii)

Based on observation, record review and interview the facility failed to ensure that the resident environment remained as free of accident hazards as is possible; and each resident received adequate supervision to prevent accidents for one ( # 17) of four residents reviewed during the extended recertification survey. Specifically: there was a lack of an adequate plan in place to supervise and prevent access to a potentially hazardous area by residents as determined when a resident was able to enter a construction site located within the facility on Saturday 4/27/13. The facility placed a sensor alarm immediately after the incident but did not educate staff or test the alarm for its effectiveness. Survey observations on 5/21/13 determined that the alarm was not audible by staff in close proximity to the door to the construction site. There was no investigation subsequent to the incident to determine the root cause. Observation of the construction site revealed a delayed egress door with an alarm that could not be heard in areas attended by staff. The door lead to a non alarmed exit with direct access to the driveway, a non-fenced in lake and an adjacent public road. This resulted in no actual harm with a potential for serious harm that was Immediate Jeopardy to the health and safety and Substandard Quality of Care for Resident # 17. This had the potential to effect 13 residents with wandering behaviors. This is evidenced by: Resident # 17 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ( MDS) of 4/24/13 assessed that the resident sometimes understands, rarely/never was understood, had long and short term memory problems and had severely impaired cognition for decision making. It documented that the resident had the behavior of wandering daily and used a trunk restraint. It further documented the resident did not walk and needed limited assist of one staff for locomotion. The Comprehensive Care Plan (CCP) dated 8/26/11(in effect at the time of the incident 4/27/13) for wandering: documented that on 1/6/11 the resident wandered into the room next to his and fell and dislocated his shoulder and needed to go to the hospital. The resident continues to wander around the first floor of the facility. The goal was that the resident remain safe and not wander out of the facility. The approaches included: wander guard will be checked for placement daily on every shift; monitor resident's whereabouts to ensure safety. During the tour interview on 5/20/13 at approximately 10:00 am the Registered Nurse (RN), acting charge nurse, stated that a resident had entered a unit that was under construction. She stated the resident use to go over to Unit 2 and make a lap or two around the unit prior to the construction. The Accident/Incident Report (A/I) for the incident was requested after lunch on 5/20/13 and a copy was provided by the above noted RN. The A/I was dated 4/27/13 (a Saturday) at 1:40 pm. The location was the Unit 2 construction zone. It documented the resident was unable to explain the incident. The resident's family was notified on 4/29/13 at 3:40 pm and an investigation was not initiated with a date of 4/30/13 next to that. Under the heading " Describe exactly what happened it documented: Resident was found on Unit 2 which is under construction by dietary staff, the resident was not injured and was found in the wheelchair and brought back to Unit 1". Under the heading " what was done to prevent an occurrence" was documented: a door alarm has been placed on the entrance doors to unit with a loud alarm so that he does not enter unit 2 again while it is under construction. When residents go near the site the door alarm sounds loudly. Under the heading " staffing at time of the accident/incident" it documented: the names of 2 nurses and 3 CNAs ( certified nurse aides). The physician signed the A/I but did not date it. The date of the report was 4/29/13 and was signed by the RN acting charge nurse. The Administrator and Director of Nurses (DON) did not sign the A/I. There was a statement attached to this A/I written by a staff member ( a laundry worker) that documented: " on Saturday 27 th around 1:40 pm I was waiting for the elevator. So I took a look through the window for Unit 2 and saw that the resident (name of resident) was all the way at the end of the hallway, near a pile of wood. So I went to report it to the nurse on Unit 1. Then I proceeded to go and get the resident. During an interview on 5/20/13 at 2:25 pm the Acting Director of Nurses (ADON) stated there were no alarms on the Unit 2 entry doors prior to the resident getting onto the unit on 4/27/13. She stated the receptionist was the security guard and was there 24 hours a day 7 days a week. During an interview on 5/20/13 at 2:30 pm the Security Guard (SG) stated she could not see the Unit 2 doors from her desk. She stated that when she goes on break someone relieves her. She stated she has a list of wandering residents and showed this surveyor the resident's name on the list. The SG stated she has to stay with the smokers when they are smoking. She stated the smoking times are: 7:00 am, 10:00 am, 12:30 pm, 2:30 pm, 5:30 pm, 7:30 pm, and 9:30 pm. She stated there is no smoking after 9:30 pm. The SG stated she was working when the incident occurred. She did not see the resident go onto Unit 2 and was not aware of it. She stated now there is an alarm on the door and if it goes off she goes to check on it. She stated she was never interviewed about the incident but was told about it. On 5/20/13 at 3:28 pm the doors to Unit 2 were observed. There were 4 signs on the door. The first stated " Caution Laser Area", the second stated " Danger- Hard Hat Area", the other two stated " Caution- construction area, restricted access, Please Keep Doors Closed." The surveyor accidentally set off the alarm ( a motion sensor alarm that could be purchased anywhere). It took the SG 30 seconds to come check on it. The door was able to be opened. During an interview on 5/20/13 at 3:30 pm the General Construction Supervisor (GCS) and the Housekeeping Supervisor (HS) showed this surveyor the construction area. The GCS stated that construction began on March 18 th. He stated the end of April they would have been framing, drywalling and painting. He stated there would not have been any workers around on Saturday and that the tools would have been locked up in a room. He showed this surveyor the locked room with the tools in it. He stated there would have been ladders chained together and placed against the wall and there might have been wood piled up against the wall. He stated there were no alarms or locks on the Unit 2 entry doors. He stated the area had to be maintained as an exit for the building. The surveyor did see several ladders chained together and pushed near the far wall. The hallways were clear. The GCS stated they did not do anything to protect residents from getting into the area. During an interview on 5/20/13 at approximately 3:40 pm the HS stated there was no plan in place prior to the incident to keep residents from entering into the construction area. He stated there was no discussion in meetings about keeping the residents from getting into the construction area. He stated they did talk in meetings about keeping the doors shut and keeping the paths of egress clear. He stated that egress was their biggest concern. The HS stated he did not know about the incident until the alarm was put on the door. At 3:50 pm on 5/20/13 the surveyor and the HS walked through the Unit 2 doors and set the alarm off. No one came to check on the sounding alarm. The surveyor went to the reception desk and asked if the SG heard the alarm. The SG stated no. There was music playing at the time and the SG was looking down. The SG stated she was not told she had to check on the Unit 2 door alarm when it was placed on the door. She stated that if the phone was ringing she could not hear it and that she cannot always hear it , it is not loud enough. The delayed egress door on Unit 2 was inspected on 05/20/2013 at 4:00 pm. When tested the door alarmed and released after 15 seconds and opened into a stairwell. The exit door in the stairwell was not alarmed and opened onto a level area which leads to the facility driveway. The driveway is approximately 250 feet from the stairwell door to Sunset Lake Road, a public way. Access to Sunset Lake is approximately 500 feet from the stairwell door exit. The Acting Director of Nurses stated in an interview conducted on 05/20/2013 at 4:21 pm that the delayed egress doors in the facility alarm and are heard locally when activated and do not annunciate in a continually monitored location. During interview on 5/21/13 at 8:45 am the Building Maintenance staff stated he was not involved in any discussions of keeping residents from getting onto the Unit 2 construction area. He stated there was nothing done to keep residents from getting into the construction area. He stated the construction contractor put signs on the door. He stated he was not aware of the resident getting into the construction area and was not aware of the alarm being put on the door. He stated that when he is in the facility he checks the Unit 2 exit door and makes sure it is locked. He stated he did that on Friday 4/26/13. During interview on 5/21/13 at 10:00 am the activity aide stated that there are activities daily, 7 days a week in the dining room ( adjacent to the unit 2 entry doors) from 8:30 am to 11:00 am and 1:30 pm to 3:15 pm. She stated the activity staff have to stay in the dining room because residents cannot be left alone. She stated they could hear the Unit 2 door alarm but would not be able to see a resident go through the doors. She stated sometimes the residents might be alone in the dining room but not for long. She stated anyone who hears an alarm should answer it. During an interview on 5/21/13 at 9:50 am 4 construction workers ( all on the unit at the time) stated they had never seen a resident come onto the unit when they were there. The GCS who was one of the 4 stated they eat lunch on unit 2. The GCS eats in a room near the doors and the others eat in another room near the doors. He stated he did not think a resident could enter without them seeing him during lunch. The GCS also stated that their construction equipment is not locked up during lunch. As the surveyor left Unit 2 the alarm sounded for 17 seconds then stopped. As this surveyor rounded the corner to unit 1 which was approximately 65 feet the surveyor could no longer hear the alarm. During interview on 5/21/13 at 11:01 am the AADON stated the DON left on 5/7/13 for vacation. The AADON stated that when she heard of the 4/27/13 incident her expectation was that the SG would be responsible to answer the Unit 2 alarm if she heard it ringing. The AADON stated the SG could hear it because her office was near the elevators and she could hear it. She stated the signs on the door were the only plan in place to keep residents out of the construction area. She stated the resident had lived on Unit 1 but that he visited Unit 2 frequently, he thought his room was on Unit 2 and that the facility was aware of that. She stated she was not in-serviced about changes to the evacuation plan, being extra vigilant, etc to ensure resident safety during the construction. She stated she was not involved in doing any in-servicing. She stated the In-service Coordinator had been gone for a while and the DON was covering. During interview on 5/21/13 at 11:13 am the Administrator stated she had been Administrator since Monday 5/20/13. She stated the former Administrator had left on Friday and that she had spent a few hours with her. The current Administrator stated the former Administrator showed her the alarm on the Unit 2 door as the mechanism to keep residents safe. The current Administrator did not remember if she was told about a resident getting onto the construction site. The administrator did not know if the SG was supposed to answer the alarms and stated the AADON would be the person who would probably know that. She stated that her expectations of what happened when an alarm sounded was that there needed to be a fast response to whatever the situation was. She stated she had not been on the units to check on alarm response yet. She stated she did not know of any Quality Assurance being done on response time to alarms. During an interview on 5/21/13 at 12:08 pm CNA #1, from Unit 1, stated she cannot hear the door alarm near the nurses station, it is way too far to hear. She did not know if anyone was designated to listen for that alarm but presumed the SG would be the person. She stated the SG could hear the alarm because the SG answers the elevator alarms. During observation on 5/21/13 at 2:00 pm the chime feature of the Unit 2 door alarm did not work. The device was placed back to alarm and it did not work when tried. The surveyor went to the SG and had the alarm set off. It could be heard faintly at the reception desk. The SG was asked if it was her job to answer that door alarm and she stated no, it is up to any worker who hears an alarm to check on it. She stated that if she hears it she will answer it. She stated when smokers are outside she is with then. She stated at night the SG goes with the smokers also. The SG stated sometimes she is very busy so everyone should check on the alarm. She stated she cannot distinguish that alarm from other alarms. During interview on 5/21/13 at 3:47 pm the laundry worker who found the resident on 4/27/13 stated the same as her written statement. She stated there were signs on the door but it was not locked or alarmed. She stated that after the nurse brought the resident back to the unit she went downstairs and let her supervisor know what had happened. She stated that after she wrote her statement no one ever came to talk with her about the incident. She also stated that they ( she and co-worker) were delivering clothes after lunch and were coming back from delivering clothes which is why they were at the elevator when she saw the resident. She stated the resident was not in his room when they delivered his laundry. During interview on 5/21/13 at 5:12 pm a Unit 1 evening CNA#2 stated that she could not hear the Unit 2 alarm on the unit. She stated the SG would check on the alarm and there was always someone there at the reception desk. She stated that prior to the construction they received an update on the emergency fire plan, the emergency phone was moved from Unit 2 to Unit 4. She received no other in-servicing about the construction or keeping residents safe. During interview on 5/22/13 at 6:50 am the night SG stated she did not know about the alarm being put on the Unit 2 doors until she heard it going off. She stated she would be responsible to answer it if she heard it but sometimes that could be a problem. If there are residents with wander guards in the lobby she cannot leave them or they could go out the front doors.She stated she did not receive any in-servicing prior to the construction about keeping the residents from getting onto that unit or keeping them safe. During an interview on 5/22/13 at 6:57 am Licensed Practical Nurse # 1, from the night shift stated she couldn't hear the Unit 2 door alarm at the nurses station. She stated she did not receive any in-servicing prior to the construction about keeping the residents from getting onto that unit or keeping them safe. During interview on 5/22/13 at 6:59 am a night CNA # 3 did not know the resident went into the construction site on the Unit 2. She stated she could not hear the Unit 2 alarm on the unit then stated if it was very quiet on the unit she could. She stated the SG would answer the alarm. She stated she did not receive any in-servicing prior to the construction about keeping the residents from getting onto that unit or keeping them safe. During interview on 5/22/13 at 7:01 am a night CNA # 4 from the resident's unit stated he could hear the Unit 2 door alarm when it was very quiet. He stated he had not had any in-servicing prior to the construction about keeping the residents safe during construction. During interview on 5/22/13 at 8:19 am the Administrative Secretary stated she was not inserviced on the construction and keeping residents safe. She stated the Administrator would talk about the construction during managers meetings but she was not aware of any in-servicing. During interview on 5/22/13 at 10:13 am LPN # 2 stated she had not had any in-servicing prior to the construction about keeping residents safe during the construction. During an interview on 5/22/13 at 10:14 am the RN unit manager of Unit 4 stated she was not in-serviced prior to the construction about any changes or keeping the residents safe. She stated the resident used to live on Unit 2. He moved to Unit 1 on 6/9/09 but continued to think he lived on Unit 2. She stated that ever since the move the resident would go over to Unit 2 regularly right up to the start of the construction. During an interview on 5/22/13 at 10:15 am day CNA # 5 stated she had not had any in-servicing about keeping the residents safe during construction. She stated the HS did tell staff not to go into construction area because of the use of the laser. 10 NYCRR415.12(h)(1)(2)

Based on medical record review and staff interviews the Quality Assurance (QA) program failed to have a program that readily identified issues that had the potential to cause serious harm to residents during the extended recertification survey. Specifically, the QA program failed to investigate a root cause of a resident wandering into an unsecured construction area and failed to ensure adequate supervision was provided to protect other residents from wandering into the construction area. This resulted in no actual harm but has the potential for serious harm that is Immediate Jeopardy for the health and safety of residents. Refer to Resident Behavior and Facility Practices F 225 -scope and severity- K Refer to Quality of Care F 323- scope and severity - K A Safety Plan Considerations memo (no date) documented the former administrator attended a meeting on 3/15/2013 to address privacy and dignity with the contractors, at which time the contractors were informed they could not smoke on facility grounds and must wear visible identification. The memo also documented that during the meeting the need to secure the work area to prevent residents from entering the site was discussed . Barricades will be placed as well as temporary doors where needed. The memo did not address potential unsafe wandering by residents and securing doors on the evening and night nursing shifts and on weekends. A letter dated 3/18/13 from the former administrator to the sanitarian in the New Rochelle area office documented that the Safety Considerations memo had been sent as an attachment to the letter but did not address unsafe wandering by residents into the construction area. During an interview on 5/23/13 at 9:00 am the Administrator stated she was the coordinator of the Quality Assurance (QA) committee. The Administrator stated she was just hired by the facility as of 5/20/13. She stated the QA committee meets quarterly (every three months) and the membership includes herself, Director of Nursing, Rehabilitation disciplines, Corporate Compliance person and Infection Control/In-service Nurse. The Administrator stated that the Medical Director and Director of Maintenance are not members of the QA committee but will be from now on. The Administrator stated meetings will be held monthly. The Administrator stated she did not know if QA had been completed which would have recognized resident entry into the construction area as a hazard. The Administrator stated there was no evidence available that QA looked into the potential problem of residents entering into the construction area. During an interview on 5/23/13 at 9:00 am the Director of Maintenance stated that a meeting took place on 03/15/2013 to discuss safety considerations in the construction area but the meeting did not have enough involvement with the former Administrator, and the Director of Nursing did not attend. During an interview on 5/23/13 at 9:00 am the In-service Coordinator stated she was not aware of staff education to prevent residents from wandering into the construction area and did not complete staff education after the meeting on 3/15/13. 10NYCRR 415.27(a-c)