Every finding on record at Surge Rehabilitation and Nursing LLC

Based on interviews and record review, the facility failed to ensure that all allegations of abuse, neglect, and mistreatment were thoroughly investigated; failed to put measures in place to prevent further potential abuse, neglect, exploitation or mistreatment; and failed to report results of the investigation to the New York State Department of Health within five (5) working days of the incident. This was identified for two (2) (Resident #96 and Resident #98) of three (3) residents reviewed for Abuse. Specifically, on 11/30/2025, Licensed Practical Nurse #1 received an allegation of physical abuse concerning Resident #96 from the resident's family member. The facility Administrator was not made aware of the incident until 12/01/2025. Resident #96 was discharged from the facility on 12/10/2025. [NAME] Resident #96 was discharged from the facility on 12/10/2025, their former roommate (Resident #98) reported to Registered Nurse #1 that they witnessed Resident #96 being slapped by an unidentified staff member. Registered Nurse #1 reported this allegation to License Practical Nurse #1 who was serving as the charge nurse. Licensed Practical Nurse #1 did not report this second allegation to the facility Administration. There was no documented evidence that an investigation was initiated for either allegation, as a result the facility did not take steps to protect residents from potential abuse. This resulted in no actual harm to Resident #96 with potential for serious injury, harm, impairment, or death for 131 residents residing in the facility that is Immediate Jeopardy.The finding is:The facility's policy titled Abuse Identification and Investigation; Prevention and Reporting last reviewed 09/02/2025, documented that all incidents should be investigated to rule out potential abuse. Allegations of abuse will be investigated; other injuries will be investigated to rule out abuse potential. The facility will conduct a thorough investigative procedure by interviewing the resident, staff, visitors where appropriate; assessing the resident; reviewing the medical record and including any pertinent diagnostic and any other relevant information. The result of the investigation will be completed within five (5) days and provided to the New York State Department of Health. The policy documented that any type of abuse can be perpetrated from staff to resident, where the resident is the victim, and a staff member is an aggressor. The physical abuse includes but is not limited to hitting, slapping, and punching. Even in cases where a staff member has a knee-jerk or responsive reaction to a resident, Staff to Resident abuse should be investigated. The facility will ensure the protection of the resident by responding immediately, assessing the alleged victim, increasing supervision as needed, changing room or staffing, and ensuring protection from retaliation.Resident #96 was admitted with diagnoses that included Parkinson's disease (a progressive brain disease), cognitive communication deficit, and bipolar disorder (causes extreme mood swings from high manic to depressive low). The admission Minimum Data Set (a resident assessment tool) dated 09/30/2025 documented a Brief Interview for Mental Status score of eight (8), which indicated the resident had moderately impaired cognition. Resident #96 had no behavioral or mood symptoms at the time of assessment.The Comprehensive Care Plan for potential for abuse dated 09/23/2025 documented interventions to encourage the resident to verbalize any concerns, fears or issue they may have. Monitor for any signs or symptoms of distress; report any suspected abuse via facility chain of command as per the policy and procedures. The care plan was not revised to reflect any actual allegation of abuse. The Trauma Informed Care/Trauma/Post Traumatic Stress Disorder (PTSD) Comprehensive Care Plan dated 09/24/2025 documented Resident #96 had post traumatic stress disorder as evidenced by past abuse. Interventions included to monitor for trauma and re-traumatized episode and report the episode to the interdisciplinary team; speak directly to the resident; maintain a calm and supportive environment. The care plan was not revised to reflect any allegation of abuse.Resident #98 was admitted with diagnoses that included dementia (condition causes loss of memory and brain function), chronic obstructive pulmonary disease (lung disease) and type 2 diabetes mellitus(condition where body cannot metabolize blood sugar properly due body's lack of insulin or inability to use insulin). The admission Minimum Data Set, dated [DATE] documented a Brief Interview for Mental Status score of seven (7), which indicated the resident had moderately impaired cognition. The resident had no behavioral or mood symptoms at the time of the assessment.The Abuse Comprehensive Care Plan dated 10/30/2025 documented Resident #98 had potential for abuse. Interventions included to encourage resident to verbalize any concerns, fears or issue they may have and to monitor for any signs or symptoms of distress. The care plan was not revised to reflect any actual allegations of abuse.During the initial screening interview on 12/15/2025 at 01:13 PM, Resident #98 stated that about two (2) weeks ago at approximately 5:30 AM, an aide had entered their room and hit their roommate (Resident #96) on the head. Resident #98 stated they saw the reflection of the aide hitting Resident #96 on their television screen which was turned off at the time. Resident #98 was unable to recall the exact date of the incident and was unable to identify the alleged perpetrator. Resident #98 stated they reported the incident to a staff member on the same day of the incident but did not know the name of the staff member. Resident #98 stated that Resident #96 has been discharged from the facility.A review of the facility's Grievance and Accident and Incident Reports from 11/15/2025 to 12/15/2025 lacked documented evidence that an investigation was completed related to the physical abuse allegation made by Resident #98.A review of Resident #96's medical record indicated the resident was discharged from the facility on 12/10/2025 and was unavailable for interview and observation.During an interview on 12/16/2025 at 2:39 PM, the Administrator and the Director of Nursing Services concurrently stated that they both were not aware of any allegations of abuse related to Resident #96 that was reported by Resident #98 to any staff member. The Administrator stated there were no Accident and Incident Reports or grievances filed related to allegation of physical abuse towards Resident #96.During an interview on 12/19/2025 at 8:06 AM, Licensed Practical Nurse #1, the unit manager, stated Resident #98 did not report any allegations of physical abuse related to Resident #96. Licensed Practical Nurse # 1 stated that they were not aware of any abuse allegation involving Resident #96.During an interview on 12/19/2025 at 8:12 AM, Registered Nurse # 1, the 7:00 AM-3:00 PM medication nurse, stated that Resident #98 reported (date not recalled) that their roommate, Resident #96, was hit by an aide; however, they could not recall which aide. Registered Nurse #1 stated they could not remember the date Resident #98 had reported the incident to them. Registered Nurse #1 stated after they were told about the physical abuse allegation, they immediately reported to the unit manager (Licensed Practical Nurse #1).During a re-interview on 12/19/2025 at 8:21 AM, Licensed Practical Nurse #1 stated Resident #96's family member informed them that Resident #96 told the family member that someone hit them on the head twice. Licensed Practical Nurse #1 stated they could not recall the date of the report or when the incident took place. Licensed Practical Nurse # 1 stated that they did not initiate an investigation and did not document the incident, they were only required to stop the abuse activities from continuing and report the incident to their supervisor. Licensed Practical Nurse #1 stated they do recall reporting the abuse allegation to the Director of Nursing Services after Resident #96's family member had reported the abuse allegation to them. Licensed Practical Nurse #1 stated they were not informed by Registered Nurse #1 regarding the physical abuse allegations toward Resident #96 as reported by Resident #98. During an interview on 12/19/2025 at 10:28 AM, Resident #96's family member stated during their visit on 11/30/2025, Resident #96 reported they were hit on the head twice and were treated unkindly by an aide. The family member stated that they had taken Resident #96 out on pass on 11/27/2025 for Thanksgiving and returned the resident to the facility the same night. The family member stated that the resident could not recall the day of the incident. The family member believed the incident would have occurred somewhere between 11/27/2025 to 11/30/2025. The family member stated that Resident #96 gave a description of the aide as a black female who spoke with an accent, short- medium build, and had dark hair. The family member stated that they reported the physical abuse allegation to Licensed Practical Nurse #1 right after the resident told them. The family member stated Licensed Practical Nurse # 1 informed them they would file a report. The family member stated that within two (2) days after they reported the incident, the Administrator informed them they had investigated the allegation and were unable to identify the perpetrator.A review of the facility's Grievance and Accident and Incident Reports from 11/15/2025 to 12/15/2025 is no documented evidence the facility completed an investigation related to the physical abuse allegation made by Resident #96's family member. During a re-interview on 12/19/2025 at 11:01AM, Registered Nurse #1 stated Resident #98 had reported the physical abuse allegation towards Resident #96, after Resident #96 was discharged from the facility [12/10/2025]. Registered Nurse #1 stated Resident #98 did not recall the date and time of the incident. Registered Nurse #1 stated they were unable to assess Resident #96 because the resident was no longer in the facility. Registered Nurse #1 stated they reported the abuse allegation to Licensed Practical Nurse #1. Registered Nurse #1 stated that they did not document the incident or initiate an investigation because they were not aware that they had to. During an interview on 12/19/2025 at 01:04 PM, the Administrator stated they were first made aware of the physical abuse allegation on 12/01/2025 by Licensed Practical Nurse #1 related to Resident #96. The Administrator stated they and the Director of Nursing Services immediately interviewed Resident #96. The resident provided a detailed physical description of the aide; however, they were unable to establish a definite timeline and the specific shift when the incident allegedly occurred. The Administrator stated they identified Certified Nursing Assistant # 2 as the alleged perpetrator based on the description provided by the resident and the amount of time Certified Nursing Assistant #2 had provided care to the resident. The Administrator stated Resident #96 was shown a picture of Certified Nursing Assistant #2 and Resident #96 denied that Certified Nursing Assistant # 2 was the perpetrator. Certified Nursing Assistant # 2 also denied hitting Resident #96. The Administrator stated that no staff member was removed from the unit or the resident's assignment pending any investigation. The Administrator stated they did not document their investigation findings and did not report the incident to the New York State Department of Health because the 12/01/2025 reported incident did not present to them as an abuse allegation. The Administrator stated that an Accident and Incident report should have been initiated and completed related to the allegation of physical abuse that was made by Resident #96's family member on 11/30/2025 to identify root cause of the incident. The Administrator stated they were not aware of an allegation of physical abuse by a staff member towards Resident #96 that was made by Resident #98 to Registered Nurse #1.During an interview on 12/19/2025 at 01:55 PM, the Director of Nursing Services stated on 12/01/2025 Licensed Practical Nurse #1 notified them of allegation of physical abuse related to Resident #96. The Director of Nursing Services stated they assessed Resident #96. There were no negative findings; however, they did not document the assessment and should have. The Director of Nursing Services stated Resident #96 provided a physical description and stated that the staff person was someone who had regularly cared for them. The Director of Nursing Services stated that resident told them that the incident had occurred after dinner and before night shift (11:00 PM); however, could not recall the date of the incident. The Director of Nursing Services stated that resident reported to them and the Administrator that when the aide was rolling them (Resident #96) over to clean during incontinence care, the aide hit them in the back of the head. Certified Nursing Assistant #2 was identified as the alleged perpetrator even though Certified Nursing Assistant #2 did not completely match the physical description. The Director of Nursing Services stated Resident #96 was also shown a picture of Certified Nursing Assistant # 2 and Resident #96 denied that Certified Nursing Assistant # 2 was the perpetrator. Certified Nursing Assistant # 2 was interviewed and denied hitting Resident #96. The Director of Nursing Services stated they concluded no abuse had occurred based on the re-enactment they conducted on their own with the resident and believed that the incident was most likely due to poor care technique. The Director of Nursing Services stated they did not conduct any re-enactment with any staff member including Certified Nursing Assistant #2 who had cared for Resident #96 between 11/27/2025 through 11/30/2025. The Director of Nursing Services stated they did not document their investigative findings and did not remove any staff member from the unit or the resident's assignment pending their investigation. During a re-interview on 12/19/2025 at 03:11 PM, Resident #96's family member stated that Resident #96 denied any physical pain or injury after being hit in the head but was upset that the staff hit them (Resident #96) twice during care. The family member stated that Resident #96 remained in the same room on the same unit until their discharge on [DATE].During an interview on 12/22/2025 at 8:21AM, Certified Nursing Assistant #2 stated that they had cared for Resident #96 during the evening and night shift on various occasions with no concerns. Certified Nursing Assistant #2 stated they did not ever hit the resident. Certified Nursing Assistant #2 stated Resident #96 was able to support themselves and they did not need support to position their head. Certified Nursing Assistant #2 stated the Director of Nursing Services had questioned them regarding an allegation of physical abuse towards Resident #96 and were not reassigned to another unit.10 NYCRR 415.4(b)(3)

Based on interviews and record review, the facility failed to ensure that all allegations of abuse, neglect, and mistreatment were reported immediately but not later than two (2) hours to the Administrator or the or the New York State Department of Health after the allegation was made, and failed to report results of the investigation to the New York State Department of Health within five (5) working days of the incident. This was identified for two (2) (Resident #96 and Resident #98) of three (3) residents reviewed for Abuse. Specifically, on 11/30/2025 Resident #96's family member reported an allegation of physical abuse towards Resident #96 to Licensed Practical Nurse #1. The facility Administrator was not made aware of the incident until 12/01/2025. A second allegation of physical abuse towards Resident #96 was reported by Resident #98 to Registered Nurse #1, who then reported the incident to Licensed Practical Nurse #1; however, neither Registered Nurse #1 nor Licensed Practical Nurse #1 reported the incident to the facility Administrator. Both incidents were not reported to the New York State Department of health within two (2) hours of the allegation of physical abuse. This resulted in no actual harm to Resident #96 with potential for serious injury, harm, impairment, or death for 131 residents residing in the facility that is Immediate Jeopardy.The finding is:The facility's policy titled Abuse Identification and Investigation; Prevention and Reporting last reviewed 09/02/2025, documented that any type of abuse can be perpetrated from staff to resident, where the resident is the victim, and a staff member is an aggressor. The physical abuse includes but is not limited to hitting, slapping, and punching. All allegations of abuse of a resident must be reported to the State Agency and one or more law enforcement entities within two hours, regardless of whether there is any injury. The facility will make its initial report to the New York State Department of Health within the reporting timeframes and requirements, and the results of the investigation will be submitted within five (5) working days of the incident. The facility will ensure the protection of the resident by responding immediately, assessing the alleged victim, increasing supervision as needed, changing room or staffing, and ensuring protection from retaliation. Resident #96 was admitted with diagnoses that included Parkinson's disease (a progressive brain disease), cognitive communication deficit, and bipolar disorder (causes extreme mood swings from high manic to depressive low). The admission Minimum Data Set (a resident assessment tool) dated 09/30/2025 documented a Brief Interview for Mental Status score of eight (8), which indicated the resident had moderately impaired cognition. The resident had no behavioral or mood symptoms at the time of assessment.The Comprehensive Care Plan for Abuse dated 09/23/2025 documented Resident #96 had potential for abuse. Interventions included to encourage the resident to verbalize any concerns, fears or issue they may have. Monitor for any signs or symptoms of distress; report any suspected abuse via facility chain of command as per the policy and procedures. The care plan was not revised to reflect any actual allegation of abuse. The Trauma Informed Care/Trauma/Post Traumatic Stress Disorder (PTSD) Comprehensive Care Plan, dated 09/24/2025, documented Resident #96 had post-traumatic stress disorder as evidence by past abuse. Interventions included to monitor for trauma and re-traumatized episodes and report the episode to the interdisciplinary team; speak directly to the resident; maintain a calm and supportive environment. The care plan was not revised to reflect any allegation of abuse.Resident #98 was admitted with diagnoses that included dementia (condition causes loss of memory and brain function), chronic obstructive pulmonary disease (lung disease) and type 2 diabetes mellitus (condition where body cannot metabolize blood sugar properly due body's lack of insulin or inability to use insulin). The admission Minimum Data Set, dated [DATE] documented a Brief Interview for Mental Status score of seven (7), which indicated the resident had moderately impaired cognition. The resident had no behavioral or mood symptoms at the time of the assessment.The Abuse Comprehensive Care Plan dated 10/30/2025 documented Resident #98 had potential for abuse. Interventions included to encourage resident to verbalize any concerns, fears or issue they may have and to monitor for any signs or symptoms of distress. The care plan was not revised to reflect any actual allegations of abuse.During the initial screening interview on 12/15/2025 at 01:13 PM, Resident #98 stated that about two (2) weeks ago at approximately 5:30 AM, an aide had entered their room and hit their roommate (Resident #96) on the head. Resident #98 stated they saw the reflection of the aide hitting Resident #96 on their television screen which was turned off at the time. Resident #98 was unable to recall the exact date of the incident and was unable to identify the alleged perpetrator. Resident #98 stated they reported the incident to a staff member on the same day of the incident but did not know the name of the staff member. Resident #98 stated that Resident #96 has been discharged from the facility.A review of the facility's Grievance and Accident and Incident Reports from 11/15/2025 to 12/15/2025 lacked documented evidence that an investigation was completed related to the physical abuse allegation made by Resident #98.A review of Resident #96's medical record indicated the resident was discharged from the facility on 12/10/2025 and was unavailable for interview and observation.During an interview on 12/16/2025 at 2:39 PM, the Administrator and the Director of Nursing Services concurrently stated that they both were not aware of any allegations of abuse related to Resident #96 that was reported by Resident #98 or any staff member. The Administrator stated there were no Accident and Incident Reports or grievances filed related to allegation of physical abuse towards Resident #96.During an interview on 12/19/2025 at 8:06 AM, Licensed Practical Nurse #1, the unit manager, stated Resident #98 did not report any allegations of physical abuse related to Resident #96. Licensed Practical Nurse # 1 stated that they were not aware of any abuse allegation towards Resident #96. During an interview on 12/19/2025 at 8:12 AM, Registered Nurse # 1, the 7:00 AM-3:00 PM medication nurse, stated that Resident #98 reported (date not recalled) that their roommate, Resident #96, was hit by an aide; however, they could not recall which aide. Registered Nurse #1 stated they could not remember the date Resident #98 had reported the incident to them. Registered Nurse #1 stated after they were told about the physical abuse allegation, they immediately reported to the unit manager (Licensed Practical Nurse #1).During a re-interview on 12/19/2025 at 8:21 AM, Licensed Practical Nurse # 1 stated Resident #96's family member informed them that Resident #96 told the family member someone hit Resident #96 on the head twice. Licensed Practical Nurse # 1 stated they could not recall the date of the report or when the incident took place. Licensed Practical Nurse #1 stated they do recall reporting the abuse allegation to the Director of Nursing Services after Resident #96's family member reported the abuse allegation to them. Licensed Practical Nurse # 1 stated they were not informed by Registered Nurse #1 regarding the physical abuse allegations towards Resident #96 as reported by Resident #98. During an interview on 12/19/2025 at 10:28 AM, Resident #96's family member stated during their visit on 11/30/2025, Resident #96 reported being hit on the head twice and being treated unkindly by an aide. The family member stated that the resident could not recall the day of the incident. The family member stated that they reported the physical abuse allegation to Licensed Practical Nurse # 1 right after the resident told them. The family member stated Licensed Practical Nurse # 1 informed them they would file a report. The family member stated that within two (2) days after they reported the incident, the Administrator informed them they had investigated the allegation and were unable to identify the perpetrator.During a re-interview on 12/19/2025 at 11:01AM, Registered Nurse #1 stated Resident #98 had reported the physical abuse allegation towards Resident #96, after Resident #96 was discharged from the facility [12/10/2025]. Registered Nurse #1 stated Resident #98 did not recall the date and time of the incident. Registered Nurse #1 stated they reported the abuse allegation to Licensed Practical Nurse #1.During an interview on 12/19/2025 at 01:04 PM, the Administrator stated they were first made aware of Resident #96's allegation of physical abuse on 12/01/2025 by Licensed Practical Nurse #1 based on the allegations made by Resident #96's family member on 11/30/2025. The Administrator stated they were not aware of Resident #98's allegation of physical abuse towards Resident #96. The Administrator stated any allegation of abuse must be reported to them and to the New York State Department of Health immediately. An investigation should have been initiated to rule out abuse neglect and mistreatment, and the results of the investigation should have been reported to the New York State Department of Health within five (5) working days. The Administrator stated they did not document their investigation findings and did not report the incident to the New York State Department of Health because the 12/01/2025 reported incident did not present to them as an abuse allegation.During an interview on 12/19/2025 at 01:55 PM, the Director of Nursing Services stated they were first made aware of Resident #96's allegation of physical abuse on 12/01/2025 by Licensed Practical Nurse #1. The Director of Nursing Services stated that they spoke with Resident #96 ruled out abuse within two (2) hours on 12/01/2025 after the allegation was reported to them by Licensed Practical Nurse #1 therefore, they did not report the abuse allegation to the New York State Department of Health. The Director of Nursing Services stated they did not document their communication with the resident or did not document the investigation findings. The Director of Nursing Services stated the facility must report to the New York State Department of Health any incident that clearly indicate abuse has occurred or when an abuse allegation cannot be ruled out within two (2) hours of after the allegation is made. 10 NYCRR 415.4(b)(2)

Based on record review and interviews initiated on 12/15/2025 and completed on 12/22/2025, the facility did not ensure that an established system of records of receipt and disposition of controlled drugs in sufficient detail to enable an accurate reconciliation is maintained. This was identified for one (1) (Resident #12) of one (1) resident reviewed for Dialysis. Specifically, Resident #12 had a Physician's order for Fentanyl (opioid pain medication) 50 microgram/hour transdermal patch (a medicated adhesive patch to deliver medication through the skin layers into the blood stream) to be applied to the chest wall every three (3) days. There was no documented evidence that on multiple days a second nurse was utilized as a witness to appropriately dispose the used Fentanyl Patch. The finding is: The facility's Handling of Fentanyl Patches policy and procedure last reviewed on 10/25/2025 documented to ensure Fentanyl transdermal patches are handled and disposed in such a manner as to minimize potential for diversion or abuse and comply with the state as well as the local regulations and ordinances. The disposal will take place in the presence of another licensed nurse and the signature and countersignature of disposal shall be noted on the resident's Medication Administration Record. Resident #12 was admitted with diagnoses that included end stage renal disease, bladder cancer, and lung cancer. The admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, which indicated the resident had intact cognition. The resident's pain intensity over the last 5 days was five (5) on a zero to ten scale. A Comprehensive Care Plan for Pain dated 11/11/2025 documented interventions that included to evaluate pain characteristic, causes and consequences, and to monitor for signs and symptoms of pain; to medicate per the Physician's orders, and to offer as needed medications when signs and symptoms of pain are present. A Physician's order dated 11/11/2025 documented Fentanyl Patch 50 microgram/hour transdermal patch. Apply one (1) patch by transdermal route to the chest wall every three (3) days. The Medication Administration Record for November 2025 documented Fentanyl 50 microgram/hour transdermal patch. Apply one (1) patch to the chest wall every three (3) days. The signature section of the Medication Administration Record revealed on 11/18/2025, 11/21/2025, 11/24/2025, 11/27/2025 and 11/30/2025 the same nurses signed for the Fentanyl patch removal and disposal, and as the witness. A Review of the Medication Administration Record dated 12/2025 documented Fentanyl 50 microgram/hour transdermal patch. Apply one (1) patch to the chest wall every three (3) days. The signature section of the Medication Administration Record revealed on 12/03/2025, 12/12/2025, 12/15/2025 and 12/18/2025 the same nurses signed for the Fentanyl patch removal and disposal, and as the witness. On 12/06/2025 there was no documented evidence of a witness signature for the disposal of the Fentanyl patch. During an interview on 12/17/2025 at 10:45 AM, Licensed Practical Nurse #10, who was the 7:00 AM - 3:00 PM medication nurse on duty on 11/24/2025 and 12/03/2025, stated that two nurses are required to be present for the disposal of the Fentanyl patch. Licensed Practical Nurse #10 stated that they remove the patch and ask a second nurse to witness them discarding the patch in the hazard bin (sharps container) attached to the medication cart. Licensed Practical Nurse #10 stated when they discard the patch, they sign the medication administration record as the nurse that removes and discards the patch. Licensed Practical Nurse #10 stated that their signature is seen as the witness to the disposal because the second nurse signed the medication administration record under their (Licensed Practical Nurse #10) account. Licensed Practical Nurse #10 stated that the second nurse was supposed to sign into the electronic medical record under their account and sign the medication administration record as the second nurse. Licensed Practical Nurse #10 stated that they could not recall the nurse who witnessed the disposal of the Fentanyl patch on 11/24/2025 and 12/03/2025. During an interview on 12/19/2025 at 8:21 AM, Licensed Practical Nurse #5, who was the 7:00 AM-3:00 PM medication nurse on duty on 12/12/2025, 1/15/2025 and 12/18/2025, stated two nurses are required for the disposal of the Fentanyl patch. One nurse removes and disposes the patch, and the second nurse is used as a witness. Both the nurses should sign the Medication Administration Record to confirm appropriate disposal of the Fentanyl patch. Licensed Practical Nurse #5 stated they thought a second nurse must witness them disposing the Fentanyl patch; however, they (Licensed Practical Nurse #5) had to sign the Medication Administration Record. Licensed Practical Nurse could not recall the nurse that witnessed the disposal of the Fentanyl Patch on 12/12/2025, 1/15/2025 and 12/18/2025. During an interview on 12/19/2025 at 8:41 AM, Licensed Practical Nurse #6 (Unit Manager) stated when the Fentanyl patch is removed, the patch should be folded with the sticky side together and a second nurse should witness to confirm the disposal of the Fentanyl patch. Licensed Practical Nurse #6 stated that the nurse who removes and discards the patch and who witnesses the disposal of the patch, must sign Medication Administration Record.During an interview on 12/22/25 at 10:33 AM, Licensed Practical Nurse #7 who was on duty on 11/18/2025, they stated two nurses must be present when disposing the used Fentanyl patch. The nurse who witnesses the disposal must sign the Medication Administration Record to confirm the appropriate disposal of the patch. Licensed Practical Nurse #7 stated that it was a mistake on their part that they signed, as the nurse who was disposing the Fentanyl patch and as a witness, on the Medication Administration Record. Licensed Practical Nurse #7 could not recall the nurse that witnessed the disposal on 11/18/2025.During an interview on 12/22/2025 at 11:07 AM, Licensed Practical Nurse #8 who was the medication nurse on duty on 11/21/2025 and 11/27/2025, stated they signed as the nurse who removed and discarded the Fentanyl patch and as the witness on Resident #12's Medication Administration Record. Licensed Practical Nurse #8 stated there was a second nurse who witnessed the disposal of the Fentanyl patch on 11/21/2025 and 11/27/2025; however, they could not recall the name of the nurse.During an interview on 12/22/2025 at 3:22 PM, the Director of Nursing Services stated two nurses must be present for the disposal of the Fentanyl patch as per the facility policy and both nurses must sign the Medication Administration Record to indicate the patch was disposed of properly. 10 NYCRR 415.18(b)(1)(2)(3)

Based on observation, record review, and interviews during the Recertification Survey, initiated on 12/15/2025 and completed on 12/22/2025, the facility did not ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles. This was identified for one (Unit 3 North, Medication Cart A) of four (4) Medication Carts reviewed for the Medication Storage Task. Specifically, during observation on 12/17/2025, an open foil packet of Ipratropium Bromide-Albuterol Sulfate (used to prevent and treat wheezing and difficult breathing) nebulizer medication for Resident #79 was observed in the medication cart. The open foil packet or the medication box that stored the medication did not have a date indicating when the foil packet or the box was first opened. The finding is:The facility policy titled Medication Storage last revised 04/28/2025, documented medications are stored according to procedures established and in compliance with state and federal regulations, as well as manufacturers recommendations, to ensure the integrity of all medications. Resident #79 was admitted with diagnoses that included bacterial infection unspecified (bacteria in the body causing illness, but a specific germ or location is not identified), chronic obstructive pulmonary disorder (a progressive lung disease that blocks airflow, causing breathing difficulties), and Alzheimer's disease. The Quarterly Minimum Data Set assessment dated [DATE], documented Resident #79 had a Brief Interview for Mental Status score of 00, indicting the resident had severe cognitive impairment. A physician's order dated 12/15/2025, discontinued on 12/202/2025, documented Ipratropium-Albuterol, dispensed Ipratropium 0.5 milligrams/Albuterol 3 milligrams in 3 milliliters nebulization solution, inhale 3 milliliters by nebulization route every 6 hours, for Acute Bronchitis (an inflammation of the bronchi without evidence of pneumonia) unspecified.During an observation on 12/17/2025 at 04:35 AM, with Licensed Practical Nurse #3, Unit 3 Medication Cart A was observed with an open box of Ipratropium Bromide and Albuterol Sulfate in an open foil packet. The box or the foil package did not have an open date written. During an interview on 12/17/2025 at 04:35 AM, Licensed Practical Nurse #3 stated the box or fail package for Ipratropium Bromide-Albuterol Sulfate nebulizer should have been dated when it was first opened. The manufacture recommendations were to discard medication after two-week from the opening date of the foil packet.During an interview on 12/18/2025 at12:35 PM Registered Nurse Supervisor #2 stated the nurse who opened the foil packet should have dated the Ipratropium Bromide and Albuterol Sulfate nebulizer foil packet. The manufacture recommendations were to discard medication after two-week from the opening date of the foil packet.During an interview on 12/18/2025 at 1:42 PM, the Director of Nursing Services stated the nurse should date the foil packets for Albuterol, when they first open the foil package.10 NYCRR 415.18(e) (1-4)

Based on observations, record review, and interviews the facility did not ensure that residents requiring respiratory care were provided such care in accordance with professional standards of practice. This was identified for one (1) (Resident #9) of three (3) residents reviewed for Respiratory Care. Specifically, Resident #9 has a diagnosis of Chronic Obstructive Pulmonary Disease (lung disease characterized by persistent air flow limitation and chronic inflammation in the airways and lungs) and a physician's order for two (2) liters of supplemental oxygen to be administered as needed via a nasal cannula. On three (3) different observations, Resident #9 was observed receiving supplemental oxygen via nasal cannula at three (3) liters per minute.The finding is: The facility's Oxygen Therapy Administration policy dated 05/14/2025 documented that oxygen therapy must be ordered by a Physician. The procedure included to post the Oxygen in use sign and set the [oxygen] flow rate at the prescribed liter per minute. Resident #9 was admitted with diagnoses including chronic obstructive disease, atrial fibrillation, and dependence on supplemental oxygen. The quarterly Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview of Mental Status score of 14, which indicated the resident was cognitively intact. The assessment documented the resident received oxygen therapy and had no behaviors including rejection of care. The resident had an impairment to their upper and lower extremities and had functional limitations in range of motion. The physician's orders renewed on 11/29/2025 documented to check Oxygen Saturation every shift and as needed; administer oxygen therapy as needed at a flow rate of two (2) liters per minute for comfort and when the resident's pulse oxygen saturation is less than 90%. The care plan entitled Respiratory Disorder for Chronic Obstructive Pulmonary Disease initiated on 09/10/2019 documented the resident was at risk for respiratory distress due to the diagnosis of Chronic Obstructive Pulmonary Disease. The interventions included to assess the resident's level of anxiety, elevate head of bed to above 45 degrees due to shortness of breath while lying flat, and administer oxygen therapy as per the physician's order. During separate observations on 12/15/2025 at 10:32 AM, 12/16/2025 at 2:13 PM, and 12/17/2025 at 10:50 AM, Resident #9 was lying in their bed receiving oxygen therapy via nasal cannula. The oxygen flow rate was set to three (3) liters per minute on each observation. The Medication Administration Record for December 2025 documented the resident's oxygen saturation levels each shift. The oxygen saturation levels were measured to be above 90% (normal range 92% and above) except on 12/15/2025 during the 3:00 PM-11:00 PM shift where the levels were recorded to be 74%. During an interview on 12/17/2025 at 10:51 AM, Resident #9 stated they preferred to always have oxygen therapy because it makes them feel better due to their diagnosis of Chronic Obstructive Pulmonary Disease. Resident #9 stated they always need the oxygen on for their lungs. During an interview on 12/17/2025 at 8:05 AM, Certified Nursing Assistant #3 stated they were the regular dayshift aide for Resident #9 and the nurses were responsible of Oxygen administration. Certified Nursing Assistant #3 stated they did not see the resident adjusting the oxygen. Certified Nursing Assistant #3 stated the resident prefers to continuously receive the oxygen therapy. During an interview on 12/17/2025 at 10:53 AM, Licensed Practical Nurse #4 stated Resident #9 prefers to continuously receive supplemental oxygen. Licensed Practical Nurse #4 stated they did not know the oxygen flow rate was set to three (3) liters per minute. Licensed Practical Nurse#4 stated it was important to follow the physician's orders which currently prescribed oxygen therapy at two (2) liters per minute via nasal cannula. During an interview on 12/17/2025 at 11:04 AM, Registered Nurse Supervisor #3 stated that it was important for the resident to receive oxygen therapy as prescribed by the Physician because the resident has a diagnosis of chronic obstructive pulmonary disease. Registered Nurse Supervisor #3 stated increasing the oxygen flow rate can harm the resident. During an interview on 12/19/2025 at 8:52 AM, Physician #1 stated the nurses have to follow the physician's orders for oxygen therapy and if the nurses increase the oxygen flow rate, they have to let the Physician know and obtain a physician's order. Physician #1 stated they would need to examine the resident and determine if an increase of oxygen therapy is needed. During an interview on 12/19/2025 at 3:42 PM, the Director of Nursing Services stated the nurses should follow the physician's order for the oxygen therapy for safety and effectiveness of the treatment. The Director of Nursing Services stated if there is a need for increase in the oxygen flow rate, the nurses should have notified the Physician to evaluate the resident. 10 NYCRR 415.12(k)(6)

Based on record review and interviews, the facility did not ensure that a copy of the notice of transfer or discharge was sent to a representative of the Office of the State Long Term Care Ombudsman. This was identified for one (1) (Resident #118) of two (2) residents reviewed for Hospitalization. Specifically, Resident #118 was transferred to the hospital for evaluation status post fall. There was no documented evidence that a Notice of Transfer or Discharge was sent to the Office of the State Long Term Care Ombudsman.The finding is: The facility's policy titled Transfer and discharge: Notice Requirement dated 04/28/2025 documented before the facility transfers or discharges a resident, the Social Worker or designee will notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing in a language and manner they understand; and send a copy of the Notice to a representative of the Office of the State Long Term Care Ombudsman. Resident #118 was admitted with diagnoses that included left hip fracture and non-Alzheimer's dementia. A Significant Change Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score was three (3) which indicated the resident had severely impaired cognition. The resident has functional impairment to bilateral lower extremities and is dependent on staff for all areas of mobility and transfers. A nursing progress note dated 11/27/2025 documented Resident #118 sustained a fall and was found on the floor in the dining room near the wheelchair in a left lateral position. On assessment, the resident was grimacing with pain when touching the right shoulder and right hip. The physician was notified, and an x-ray was ordered for both arms and legs. A nursing progress note dated 11/27/2025 documented Resident #118 was sent to the hospital after their x-ray came back positive for a left hip fracture. At 9:00 PM, the resident was transferred via emergency medical technician per the physician's order. During an interview on 12/22/2025 at 1:52 PM, the Director of Social Services stated the ombudsman office was not notified when Resident #118 was transferred to the hospital. The Director of Social Services stated that during the ombudsman onsite visits, they offered to give the transfer and discharge notices to the Ombudsman, but the Ombudsman declined to take the notices. The Director of Social Services stated they received a notice recently from the ombudsman office notifying them that the transfer or discharge notices must be sent to the Office of the State Long Term Care Ombudsman. The Director of Social Services stated that the transfer or discharge notices were not being sent to the Ombudsman's office. The Director of Social Services stated that they could not recall the last time the transfer or discharge notices were sent to the Ombudsman office as required. The Director of Social Services stated that the transfer or discharge notices should have been sent to the Ombudsman office. During an interview on 12/22/2025 at 2:08 PM, the Administrator stated that Director of Social Services or social work team was responsible for sending the transfer discharge notices to the Ombudsman office. The Administrator stated that the discharge notice for Resident #118 should have been sent to the Ombudsman office as required. 10 NYCRR 415.3

Based on observation, record review, and interviews, the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections. This was identified for one (1) (Resident #112) of eight (8) residents during the medication administration task. Specifically, Resident #112 had a Percutaneous Endoscopic Gastrostomy tube (feeding tube) and a physician's order for enhanced barrier precautions. Licensed Practical Nurse #9 did not perform hand hygiene prior to going to Resident #112's room; did not utilize personal protective equipment while administering Resident #112's medications; and handled the resident's feeding tube without the use of gloves.The finding is: The facility's Enhanced Barrier Precautions Policy dated 04/28/2025 documented to adhere to the Center for Disease Control's enhanced barrier precautions (EBPs) guidelines to prevent the transmission of multidrug-resistant organism (MDROs) while promoting resident quality of life. Enhanced barrier precautions require the use of personal protective equipment including a gown and gloves. The hand washing policy dated 04/28/2025 documented the facility encourages frequent hand hygiene, both handwashing and the use of alcohol-based hand sanitizers, consistent with accepted standards of practice. Frequent hand hygiene with an alcohol-based hand sanitizer throughout the day is recommended under the following circumstances but not limited to: before beginning work and when leaving work, before and after touching a resident or the residents immediate environment. Resident #112 was admitted with diagnoses including cerebral infarction (sudden blockage of an artery supplying the brain), dysphagia (difficulty swallowing), and gastrostomy (tube feeding status). The Annual Minimum Data Set assessment dated [DATE] documented the resident could not complete the Brief Interview for Mental Status assessment because the resident was rarely or never understood. The resident was utilizing a feeding tube for nutrition. The Enhanced Barrier Precaution (EBP) Care plan dated 04/14/2025 documented the resident was at risk for infections due to an indwelling medical device as evidenced by a Percutaneous Endoscopic Gastrostomy (feeding) tube. Interventions included to maintain enhanced barrier precautions, monitor for signs and symptoms of infection, and use a gown and gloves during the high contact resident care activities. The care plan for Percutaneous Endoscopic Gastrostomy tube (feeding tube) dated 04/12/2025 documented interventions including to administer feeding formula with required amount of water as prescribed by the feeding; check feeding tube patency and position before each feeding; and check gastric residuals before each feeding and document the amount. The physician's orders dated 12/06/2025 documented give 30 milliliters of water via Percutaneous Endoscopic Gastrostomy tube (feeding tube) prior to medication administration; 10 milliliters of water via feeding tube after each medication; and Jevity 1.5 formula via bolus feeding (a syringe and gravity is used to feed directly into the stomach through a feeding tube) 237 milliliters five (5) times a day at 6:00 AM, 10:00AM, 2:00 PM, 6:00 PM and 10:00 PM; and 60 milliliters of water before and after each feeding . During an observation of Resident #112's medication administration on 12/17/2025 at 4:50 AM, an enhanced barrier precautions signage was posted on the room door, and personal protective equipment was available outside the room door. Licensed Practical Nurse #9 did not perform hand hygiene prior to going to Resident #112's room; did not utilize personal protective equipment while administering Resident #112's medications; and handled the resident's feeding tube without the use of gloves. During an interview on 12/17/2025 at 6:30 AM, Licensed Practical Nurse #9 stated they forgot to disinfect and wash their hands before starting the resident's medication administration. Licensed Practical Nurse #9 stated they should have used gloves when they handled the resident's feeding tube and did not because they forgot. Licensed Practical Nurse #9 stated they were supposed to follow the enhanced barrier precautions instructions including to wear a gown and use gloves while providing the direct care to prevent the spread of infections. During an interview on 12/17/2025 at 07:03 AM, Registered Nurse Supervisor #4 stated Licensed Practical Nurse #9 should have washed their hands before and after they provided care to Resident #112. Registered Nurse Supervisor #4 stated Licensed Practical Nurse #9 should have followed the infection control policy and utilized the personal protective equipment to prevent the spread of infections. During an interview on 12/17/2025 at 08:16 AM, the Infection Control Preventionist (Registered Nurse #1) stated all staff must follow the enhanced barrier precautions and use personal protective equipment while providing care. The Infection Control Preventionist stated staff members should perform hand hygiene before and after resident care and utilize gloves to handle the feeding tube to prevent infections. During an interview on 12/19/2025 at 3:42 PM, the Director of Nursing Services stated the nurses should follow the physician's order for enhanced barrier precautions and the infection control policy to prevent the spread of the infections. 10 NYCRR 415.19(a)(1-3)(b)(4)

Based on observation, record review, and interviews the facility did not ensure a resident who is fed with enteral means receives the appropriate treatment and services to prevent potential complications of enteral feeding including but not limited to dehydration. This was identified for one (1) (Resident # 112) of eight (8) residents observed during the medication administration task. Specifically, Resident #112 had physician's orders to flush the feeding tube before medication administration and in between each medication administration. Licensed Practical Nurse #9 was observed administering medications without flushing the feeding tube before and after the medication administration. The finding is: The facility's Enteral Tube Feeding policy dated 11/03/2025 documented to provide enteral nutrition and hydration when by mouth intake is not an adequate option. [Physician] Orders shall include the amount of water to flush the feeding tube before and after feeding, or otherwise. Flushing the feeding tube on a routine basis (before and after medication administration, before and after feeding) will be designated by the Registered Dietician and the Physician. Resident #112 was admitted with diagnoses including cerebral infarction (sudden blockage of an artery supplying the brain), dysphagia (difficulty swallowing), and gastrostomy (tube feeding status). The Annual Minimum Data Set assessment dated [DATE] documented the resident could not complete the Brief Interview for Mental Status assessment because the resident was rarely or never understood. The resident was utilizing a feeding tube for nutrition. The physician's orders dated 12/06/2025 documented give 30 milliliters of water via Percutaneous Endoscopic Gastrostomy tube (feeding tube) prior to medication administration; 10 milliliters of water via feeding tube after each medication; and Jevity 1.5 formula via bolus feeding (a syringe and gravity is used to feed directly into the stomach through a feeding tube) 237 milliliters five (5) times a day at 6:00 AM, 10:00AM, 2:00 PM, 6:00 PM and 10:00 PM; and 60 milliliters of water before and after each feeding . The physician order dated on 11/14/2025 documented Tylenol (pain medication) 325 milligrams tablet give two (2) tablets (650 mg) every eight (8) hours as needed. Crush and administer the medication via the feeding tube. The care plan for Percutaneous Endoscopic Gastrostomy tube (feeding tube) dated 04/12/2025 documented interventions including to administer feeding formula with required amount of water as prescribed by the Physician; check feeding tube patency and position before each feeding; and check gastric residuals before each feeding and document the amount. The care plan for dehydration/Fluid Maintenance dated 10/07/2024 documented the resident was at risk for dehydration due to potential for electrolyte imbalance, pressure ulcers/wounds, dementia, altered mental status, dependence on staff for fluids, and dysphagia. Interventions included to monitor for signs and symptoms of dehydration; monitor labs as ordered by the Physician; and provide tube feeds and water flushes per physician orders. During an observation of Resident #112's medication administration on 12/17/2025 at 4:50 AM, Licensed Practical Nurse #9 completed Resident #112's bolus feeding but did not administer 60 milliliters of water before and after the feeding as per the physician orders. Licensed Practical Nurse #9 also administered two tablets of Tylenol 325 milligrams but did not administer 30 milliliters of water before the medication administration and 10 milliliters of water after the medication was administered. During an interview on 12/17/2025 at 6:00 AM, Licensed Practical Nurse #9 stated they forgot to give the resident 60 milliliters of water before and after the bolus feeding, 30 milliliters of water before the medication administration, and 10 milliliters of water afterwards because they were nervous. Licensed Practical Nurse #9 stated it was important to flush the feeding tube for patency to prevent any blockage and maintain the resident's hydration. During an interview on 12/17/2025 at 07:03 AM, Registered Nurse Supervisor #4 stated the nurses must follow the physician's orders, the facility policy, and the resident's care plan to maintain the resident's tube feeding patency and hydration. During an interview on 12/19/2025 at 8:39 AM, Physician #1 stated it was important for nurses to maintain tube feeding patency and hydration and follow the physician's orders regarding flushing the feeding tube with water before and after the bolus feeding and medication administration. During an interview on 12/19/2025 at 3:42 PM, the Director of Nursing Services stated that all nurses must follow the physician's orders to flush the feeding tube before and after bolus feedings and medication administration to maintain patency and hydration. 10 NYCRR 415.12(g)(2)

Based on observation, record review, and interviews the facility did not ensure that services provided or arranged by the facility met the current professional standards of quality. This was identified for one (1) (Resident # 112) of eight (8) residents during the medication administration task. Specifically, Resident #112 had physician's orders to flush the feeding tube before medication administration and in between each medication administration. Licensed Practical Nurse #9 was observed administering medications without flushing the feeding tube before and after the medication administration. The finding is: The facility's Enteral (feeding) Tube Feeding policy dated 11/03/2025 documented it is the policy of the facility to provide enteral nutrition and hydration when by mouth intake is not an adequate option. [Physician] Orders shall include the amount of water to flush the feeding tube before and after feeding, or otherwise. Flushing the feeding tube on a routine basis (before and after medication administration, before and after feeding) will be designated by Registered Dietician and Medical Doctor. Resident #112 was admitted with diagnoses including cerebral infarction (sudden blockage of an artery supplying the brain), dysphagia (difficulty swallowing), and gastrostomy (tube feeding status). The Annual Minimum Data Set assessment dated [DATE] documented the resident could not complete the Brief Interview for Mental Status assessment because the resident was rarely or never understood. The resident was utilizing a feeding tube for nutrition. The physician's orders dated 12/06/2025 documented give 30 milliliters of water via Percutaneous Endoscopic Gastrostomy tube (feeding tube) prior to medication administration; 10 milliliters of water via feeding tube after each medication; and Jevity 1.5 formula via bolus feeding (a syringe and gravity is used to feed directly into the stomach through a feeding tube) 237 milliliters five (5) times a day at 6:00 AM, 10:00AM, 2:00 PM, 6:00 PM and 10:00 PM; and 60 milliliters of water before and after each feeding . The physician order dated on 11/14/2025 documented Tylenol (pain medication) 325 milligrams tablet give two (2) tablets (650 mg) every eight (8) hours as needed. Crush and administer the medication via the feeding tube. The care plan for Percutaneous Endoscopic Gastrostomy tube (feeding tube) dated 04/12/2025 documented the interventions including to administer feeding formula with required amount of water as prescribed by the feeding, check feeding tube patency and position before each feeding, check gastric residuals before each feeding and document the amount. The care plan for dehydration/Fluid Maintenance dated 10/07/2024 documented the resident was at risk for dehydration due to potential for electrolyte imbalance, pressure ulcers/wounds, dementia, altered mental status, dependence on staff for fluids, and dysphagia. Interventions included to monitor for signs and symptoms of dehydration; monitor labs as ordered by the Physician; and provide tube feeds and water flushes per physician orders. During an observation of Resident #112's medication administration on 12/17/2025 at 4:50 AM, Licensed Practical Nurse #9 completed Resident #112's bolus feeding but did not administer 60 milliliters of water before and after the feeding as per the physician orders. Licensed Practical Nurse #9 also administered two tablets of Tylenol 325 milligrams but did not administer 30 milliliters of water before the medication administration and 10 milliliters of water after the medication was administered. During an interview on 12/17/2025 at 6:00 AM, Licensed Practical Nurse #9 stated they forgot to give the resident 60 milliliters of water before and after the bolus feeding, 30 milliliters of water before the medication administration, and 10 milliliters of water afterwards because they were nervous. Licensed Practical Nurse #9 stated it was important to flush the feeding tube for patency to prevent any blockage and maintain the resident's hydration. During an interview on 12/17/2025 at 07:03 AM, Registered Nurse Supervisor #4 stated the nurses must follow the physician's orders, the facility policy and the resident's care to maintain the resident's tube feeding patency and hydration. During an interview on 12/19/2025 at 3:42 PM, the Director of Nursing Services stated that all nurses must follow the physician's orders to flush the feeding tube before and after bolus feedings and medication administration to maintain patency and hydration. 10 NYCRR 415.11(c)(3)(i)

Based on record review, and interviews during a Recertification Survey initiated on 12/15/2025 and completed on 12/22/2025, the facility did not ensure that a comprehensive person-centered care plan was developed for each resident that included measurable objectives and timeframes to meet each resident's medical and nursing needs. This was identified for one (1) (Resident #79) of five (5) residents reviewed for Unnecessary Mediations. Specifically, Resident #79 had a physician's order for Methenamine Hippurate (a urinary tract antiseptic for a history of Urinary Tract Infection. There was no documented evidence that a comprehensive person-centered care plan was developed to address the long-term use of a urinary tract antiseptic drug. The finding is:The facility policy titled Comprehensive Care Plans dated 09/2025, documented a comprehensive assessment of the resident's needs will be prepared and developed by the interdisciplinary team. Informatician obtained from the comprehensive assessment and staff interviews enable the facility staff to plan care that focuses on each resident's ability to achieve their highest practicable mode of function that includes but not limited to past medical history, and drug therapy. The comprehensive care plan will be revised or a new care plan developed quarterly, annually and as needed.Resident #79 was admitted with diagnoses that included bacterial infection unspecified (bacteria in the body causing illness, but a specific germ or location is not identified), chronic obstructive pulmonary disorder (a progressive lung disease that blocks airflow, causing breathing difficulties), and Alzheimer's disease. The Quarterly Minimum Data Set assessment dated [DATE], documented Resident #79 had a Brief Interview for Mental Status score of 00, indicting the resident had severe cognitive impairment. The Quarterly Minimum Data Set assessment documented Resident #79 was frequently incontinent. A physician order dated 07/19/022 last reviewed on 11/27/2025, documented Methenamine Hippurate (a urinary tract antiseptic)1 gram tablet twice a day for a personal history of Urinary Tract Infection.A review of the current Comprehensive Care Plans had no documentation for the current use of prophylactic antibiotics for reoccurring Urinary Tract Infections.During an interview on 02/19/2025 at 8:02 AM, Registered Nurse Supervisor #2 stated Resident #79 is currently on a prophylactic medication for Urinary Tract Infections and has been since 2022. The care plan for reoccurring Urinary Tract Infections was resolved inadvertently and should not have been resolved. Registered Nurse Supervisor #2 stated that there should have been a current comprehensive care plan to address the resident's history of Urinary Tract Infections and use of a long-term urinary antiseptic. During an interview on 12/19/2025 at 3:36 PM the Director of Nursing Services stated a care plan should be in place for the use of a long-term prophylactic medication. The nursing supervisors and registered nurses were responsible to initiate and update the care plans. The Licensed Practical Nurses could also update the care plan. 10 NYCRR 415.11(c)(1)

Based on observation, record review, and interviews, the facility did not ensure that each resident had secure and confidential medical records. This was identified for one (1) (Resident #112) of eight (8) residents reviewed for the Medication Administration Task. Specifically, Licensed Practical Nurse #9 left Resident #112's electronic medical record open in the hallway with the resident's personal and medical information visible to other staff, residents, and visitors.The finding is: The facility's Administration of Medication policy dated 04/28/2025 documented the medication nurse will protect [residents' medical record] privacy by lowering the laptop screen or locking the screen. Resident #112 was admitted with diagnoses including cerebral infarction (sudden blockage of an artery supplying the brain), dysphagia (difficulty swallowing), and gastrostomy (tube feeding status). The Annual Minimum Data Set assessment dated [DATE] documented the resident could not complete the Brief Interview for Mental Status assessment because the resident was rarely or never understood. The resident was utilizing a feeding tube for nutrition. During an observation of the medication administration on 12/17/2025 at 4:55 AM, Licensed Practical Nurse #9 entered Resident #112's room and left Resident #112's medical record on the laptop screen unattended and visible to staff and residents in the hallway. A pharmacy delivery vendor was present in the hallway. During an interview on 12/17/2025 at 6:00 AM, Licensed Practical Nurse #9 stated they were supposed to turn the computer screen off so that the resident's medical record would not be visible to other residents, staff, and visitors. Licensed Practical Nurse #9 stated they forgot to turn the screen off. During an interview on 12/17/2025 at 07:03 AM, Registered Nurse Supervisor #4 stated the computer screen should have been closed to maintain the resident's privacy. During an interview on 12/19/2025 at 3:42 PM, the Director of Nursing Services stated the nurse should have turned the screen off or close the laptop to maintain the privacy of the resident's personal information. 10 NYCRR 415.3(e)(1)

Complaint Investigation Survey, ACTS reference # (NY00366463) was conducted at Surge Rehabilitation and Nursing LLC from 07/25/2025 through 08/11/2025 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities. Deficiencies were cited as a result of this survey. 42 CFR 483.12 Freedom from Abuse, Neglect and ExploitationBased on observation, interview and record review during an abbreviated survey (#NY00366463) the facility did not ensure each resident was free from misappropriation of resident property and exploitation for 1 (Resident #1) of 5 residents reviewed. Specifically, a facility employee obtained 16 checks from Resident #1, who cashed the checks for the various dollar amounts. The findings are Resident #1 was admitted to the facility with diagnoses that included with diagnoses that included heart failure, circulatory problems and anxiety. The review of the Annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score- 12 indicating moderately impaired cognition skills for decision making for Resident.The review of the Admissions Packet, signed by Resident#1 dated 4/20/2023 documented the facility shall not request and/or accept any remuneration, tip or gratuity in any form from the Resident and this was signed by Resident#1.The Review of the facility policy, entitled Abuse Identification and Investigation: Prevention: Reporting dated 8/2024 documented for Misappropriation of Resident Property: New York State Definition as the theft, unauthorized use or removal, embezzlement or intentional destruction of personal property including but not limited to money.The review of the Comprehensive Care Plan (CCP) documented, Resident #1 has potential for abuse and at risk for victimization dated 11/14/2023 and the interventions documented report any suspected abuse via the facilities chain of command.The review of the Facility Investigation dated 01/03/2025 documented 12/28/2024 at 02:21PM, there is reasonable cause to believe that abuse, neglect or mistreatment occurred. The investigation further documented Resident #1, alert and orientated has been voluntarily giving money to the accused staff member/Certified Nurse's Aide#1. The Next of Kin contacted Administration to inform them about the situation as they were reviewing the patients' funds. They provided copies of checks, showing money going from Resident #1's account to the accused Certified Nurses Aide's bank account. Resident was interviewed with presence of Suffolk County Police Officer, Director of Nursing, and Social Worker and acknowledged willfully, and voluntarily giving money to the accused Staff Member to help them out. The accused staff member was removed from the schedule. The Investigation further documented copies of checks documented the name of Resident #1 printed on the front of the check, made out to Certified Nurse's Aide#1, signed with the name of Resident#1 the opposite side of the check documented that the name of Certified Nurse's Aide#1 was signed on the opposite side of the checks with their name of Certified Nurse's Aide#1. Copies of the front and back of the check documented the following: Check date: 10/20/2024 Amount : $2,500.00Check date: 10/22/2024 Amount : $2,000.00Check date: 10/23/2024 Amount :$3,500.00Check date: 10/28/2024 $Amount : 3,200.00Check date: 11/4/2025 Amount : $1,000.00Check date: 11/9/2025 Amount : $3,000.00Check date: 11/19/2024 Amount : $1,800.00Check date: 11/25/2025 Amount : $2,700.00Check date: 11/29/2024 Amount : $1,600.00Check date: 12/3/2024 Amount : $400.00Check date: 12/6/2024 Amount : $500.00Check date: 12/13/2024 Amount : $6,080.00Check date: 12/21/2024 Amount : $2,000.00Check date: 12/23/2024 Amount : $3,700.00Check date: 12/26/2024 Amount : $2,000.00Check date: 12/28/2024 Amount : $2,800.00The review of the Psychiatric Evaluation dated 1/3/2025 at 10:18AM documented Resident #1 denies any suicidal ideation. Further documented Resident #1 was evaluated on 12/30/24 at 10:18AM, Medical Evaluation, Mood/Anxiety, and vague suicidal ideation without intent or plan, Resident #1 wrote between $27,000-$40,000 to a Certified Nurse's Aide because they were in love with them , however became angry when staff learned of the occurrence.The review of the Resident Nursing instruction as of 07/25/2025 documented Resident #1 has clear speech, understands and is understood, negative statements two-person approach.During the telephone interview dated 7/25/2025 at 2:48PM, with Certified Nurse's Aide # 1 they stated they were trained at the facility not to exploit patients and stated they did not exploit Resident #1 whom they recall. During an interview on 5/23/2025 at 3:50PM with Director of Nursing, they stated when Resident#1's personal checks were discussed with the Certified Nurse's Aides#1, they admitted to receiving checks in their name. The Certified Nurse's Aide#1 stated they should not take money or checks from Resident#1 or any other residents. The Director of Nursing (DON) stated residents are not permitted to give employees any items of value such as money or jewelry and facility employees are trained not to accept these items. During an interview with the Administrator on 5/23/2025 at 4:10PM they stated on December 28, 2024, the next of kin reported to the facility that several personal checks were made out to Certified Nurse's Aide#1. The employee was terminated from employment and was a satisfactory employee prior to this incident. The Administrator stated the resident was writing and signing personal checks made out to Certified Nurses Aide #1 and Certified Nurse's Aide#1 should never have accepted the checks from the Resident. 483.12

Based on record review and interviews during the Recertification Survey initiated on 8/5/2024 and completed on 8/9/2024, the facility did not ensure a person-centered comprehensive care plan was developed and implemented to address each resident's medical needs. This was identified for one (Resident #81) of three residents reviewed for unnecessary medications. Specifically, Resident #81 was receiving anticoagulant medications as per the physician's orders; however, there was no comprehensive care plan developed for the use of an anticoagulant. The finding is: The undated facility's policy and procedure titled Comprehensive Care Plans (CCP) and Resident/Patient Meeting documented within 14 days of the resident's admission, a comprehensive assessment of the resident's needs will be prepared and developed by the interdisciplinary team, as required by the course of treatment specific to the resident. Information obtained from the comprehensive assessment enables the facility staff to plan care that focuses on the resident's ability to achieve the resident's highest practicable mode of functioning that includes but is not limited to the following: medical status measurement (functional physical and mental abilities including, but not limited to, information on the vital signs, laboratory values and/or diagnostic test), and drug therapy. Resident #81 was admitted with diagnoses of multiple fractures and Atrial Fibrillation. The admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 14, which indicated the resident had intact cognition. the resident received an anticoagulant medication. A Physician's order dated 7/2/2024 documented to administer Enoxaparin (an anticoagulant medication) 30 milligrams/0.3 milliliter, inject 0.3 milliliters by subcutaneous route every 12 hours for Fracture of one rib, right side. There was no documented evidence that a comprehensive care plan was developed for the use of the anticoagulant medication use. The Registered Nurse Supervisor #1 was interviewed on 8/07/2024 at 2:13 PM and stated any Registered Nurse can develop and initiate a care plan. The Registered Nurse Supervisor #1 stated that the admitting nurse was responsible for admissions assessment and initiating the care plans. The next day, a Registered Nurse should follow and initiate any other care plans that were required and were not initiated by the admission nurse. Registered Nurse Supervisor #1 stated that if a resident is on an anticoagulant, then there should be a care plan for the use of the anticoagulant medications. The Registered Nurse Supervisor #1 reviewed the resident's electronic medical record and stated no care plan was developed for the use of the anticoagulant medication. The Director of Nursing Services was interviewed on 0/07/2024 at 2:22 PM and stated if the resident is getting an anticoagulant medication, such as Enoxaparin, then there should be an anticoagulant care plan developed. The Director of Nursing Services reviewed the electronic medical record to identify a care plan for the anticoagulant medication use and there was no documented evidence that a care plan was developed. 10 NYCRR 415.11 (c)(1)

Based on record review and staff interviews during the Recertification Survey initiated on 11/29/2022 and completed on 12/6/2022, the facility must designate one or more individual(s) as the Infection Preventionist(s) (IP)(s) who are responsible for the facility's Infection Prevention Control Program (IPCP). The IP must have completed specialized training in infection prevention and control. Specifically, the facility's designated IP did not have documented evidence of specialized training in infection prevention and control. The finding is: The facility's policy, titled Infection Preventionist, effective 10/25/2022, documented the facility will employ an infection prevention nurse with the mission of preventing the spread and managing the many infections/viruses that the facility may encounter; and the Infection Preventionist (IP) nurse will have specialized training in infection prevention and control and will hold a certification. The Director of Nursing Services (DNS) was interviewed on 12/1/2022 at 11:26 AM and stated the facility has hired a Registered Nurse (RN #1) who is training to be the infection preventionist but is not yet certified. The DNS stated RN #1 was hired in September 2022 and started the specialized infection control training in October 2022. The DNS further stated the facility has no interim infection preventionist at this time. RN #1 was interviewed on 12/1/2022 at 12:05 PM and stated they (RN #1) started working at the facility in September 2022 and began the specialized infection control training in October 2022. RN #1 stated they (RN #1) received infection control guidance from either the DNS or someone at corporate level for this facility. RN #1 stated they (RN #1) are working on modules 1-4 of the required infection control trainings, and none are completed. The DNS was re-interviewed n 12/5/2022 at 2:06 PM and stated they (DNS) have no current documentation for certification or training for infection prevention. The DNS stated the only training they (DNS) have is the infection control training that all nurses have to take when renewing their license. 10NYCRR 415.19

Based on record review, observation, and staff interviews during the Recertification Survey initiated on 11/29/2022 and completed on 12/6/2022, the facility did not implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical and nursing needs that are identified in the comprehensive assessment. This was identified for one (Resident #92) of one resident reviewed for Rehabilitation and Restorative Services. Specifically, Resident #92 had a Physician's order to utilize a right-foot Darco shoe (specialized shoe) to offload heel pressure when out of bed. Resident #92 was observed out of bed on two occasions without wearing the right-foot Darco shoe. The finding is: The facility Policy and Procedure titled, Assistive Devices, dated 4/2017 documented when a resident has an assistive device such as a [NAME] (Darco) shoe or a splint/brace/immobilizer applied to an injured extremity, proper care will be given to ensure healing of the injury without complications and the nursing staff is responsible to ensure the wearing schedule is followed. Resident #92 had diagnoses of Peripheral Vascular Disease, status post left Above Knee Amputation (AKA), Pressure Ulcer to the right heel and anterior foot, and Severe Protein Calorie Malnutrition. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderately impaired cognition. The MDS documented Resident #92 required limited assistance of one staff member for transfer and extensive assistance of one staff member for dressing. The resident utilized a wheelchair for mobility. The MDS indicated the resident was at risk for developing pressure ulcers. The MDS also documented the resident had one unstageable pressure ulcer injury that was present upon admission. The Comprehensive Care Plan (CCP) for Activities of Daily Living effective 7/5/2022 documented, under the focus section, the resident uses a right heel offloading Darco shoe when out of bed and to remove the Darco shoe every shift to check skin integrity. The CCP interventions section did not include use of the Darco shoe. The Physician order initiated on 7/7/2022 and last renewed on 11/12/2022 documented to apply Betadine and a dry protective dressing to the right heel unstageable pressure ulcer daily and as needed. The Physician's order initiated on 8/24/2022 and last renewed on 11/12/2022 documented to utilize a right heel offloading Darco boot (shoe) when out of bed and to remove every shift to check for skin integrity. Resident #92 was observed on 11/30/2022 at 9:30 AM in their room sitting in a wheelchair. Resident #92's right foot was resting on the floor, and there was no dressing observed on the right foot. At 11:38 AM the resident was observed with a white gauze wrapped around their foot. The resident was not wearing the right heel offloading Darco shoe on either occasion. The Licensed Practical Nurse Unit Nurse/ Nurse Manager (LPN) #4 came into the resident's room while the surveyor was present and located the Darco shoe in a bag on top of the resident's dresser. LPN #4 was interviewed on 11/30/2022 at 11:39 AM and stated that the resident was supposed to be wearing the Darco shoe when out of bed and the assigned Certified Nursing Assistant (CNA) #9 should have placed the Darco shoe on the resident's foot as soon as the resident was taken out of bed since the resident has vascular ulcers to their right foot. Resident #92 was interviewed on 11/30/2022 at 11:45 AM and stated that they (Resident #92) have been waiting for the Certified Nursing Assistant (CNA) #9 to put the Darco shoe on their foot. Resident #92 stated that CNA #9 told them (Resident #92) that they (CNA #9) would come back to put the Darco shoe on them (Resident #92); however, they (CNA #9) did not come back. Resident #92 stated they have wounds on their foot and wearing the Darco shoe makes them comfortable. CNA #9 was interviewed on 12/5/2022 at 2 PM and stated they (CNA #9) were assigned to care for Resident #92 on 11/30/2022 during the 7 AM to 3 PM nursing shift. CNA #9 stated they took Resident #92 out of bed in the morning before breakfast and did not put the Darco shoe on the resident's right foot. CNA #9 stated they (CNA #9) were aware that they (CNA #9) needed to put the Darco shoe on Resident #92's foot when the resident was out of bed. CNA #9 stated they (CNA #9) were going to go back to Resident #92 to put the Darco shoe on but forgot. The Director of Nursing Services (DNS) was interviewed on 12/06/2022 at 2:35 PM and stated that CNA #9 should have placed the Darco shoe on Resident #92 as the resident has wounds on their right heel. The DNS stated they (DNS) expected staff to follow each residents' plan of care and follow the Physician's orders. 10NYCRR 415.11(c)(1)

Based on observation, record review, and interviews during the Recertification Survey, the facility did not develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical and nursing needs that are identified in the comprehensive assessment. Specifically, one (Resident #159) of one resident reviewed for infections, who had a Midline Catheter line, had no care plan interventions developed for care and monitoring the Midline Catheter. The finding is: There was no policy and procedure developed to address care and monitoring of midline catheters. There was a policy and procedure developed for Peripherally Inserted Central Catheter (PICC) lines dated 4/18 and documented to do assessments before and after administration of intermittent intravenous medications. Assessments included to document the absence or presence of [DIAGNOSES REDACTED], drainage, swelling, induration and label the dressing with date and time. Resident # 159 admitted on [DATE] with [DIAGNOSES REDACTED]. The hospital Patient Review Instrument (PRI) dated 11/13/19 documented a Midline catheter was inserted on 11/12/19 and care per the facility policy. The physician's orders [REDACTED]. On 11/14/19 the physician ordered Intravenous (IV) antibiotic [MEDICATION NAME] 1 gram (GM) in 100 milliliter (ml) Normal Saline (NS), give 2 grams by intravenous route once daily for 10 days and to flush the Midline catheter with 5 ml NS before and after the medication. On 11/20/19, the physician ordered another Midline Insertion because the resident had dislodged the previous midline. The Comprehensive Care Plan (CCP) for IV Antibiotic, last reviewed/revised on 11/14/2019, documented the resident has a need for IV antibiotic therapy. There were no interventions to address how to care for and monitoring of the Midline catheter. A progress note dated 11/19/2019 at 2:37 PM documented the PICC line was dislodged. A replacement was ordered. The progress note referred to the midline catheter as a PICC line. The Registered Nurse (RN) Supervisor was interviewed on 11/21/19 at 11:44 AM and stated the CCP should have listed interventions on how to take care of the Midline catheter. She stated this was an oversight. She further stated the resident has a behavior that may have caused the Midline catheter to dislodge on 11/18/19 and this behavior should be included in the CCP to prevent the Midline catheter from dislodging again. An observation of the Midline catheter site was made on 11/22/19 at 11 AM. There was an undated dressing in place. No redness or signs and symptoms of infection were observed. The Director of Nursing Services (DNS) was interviewed on 11/22/19 at 1:45 PM and stated the CCP should have been resident-centered to address the resident's Midline catheter. The CCP should have included the care to the Midline catheter and how nurses were to monitor the Midline catheter. Additionally, she stated a CCP should have been developed after the first incident when the resident's Midline catheter was dislodged. 415.11(c)(1)

Based observation, record review, and interviews during the Recertification Survey, the facility did not report an alleged allegation of abuse immediately or not later than two hours to the State Agency after the allegation was first made. This was identified for one of one resident reviewed for Abuse. Specifically, Resident # 258 had made an allegation of being forced to take medication that the resident was refusing. There was no documented evidence that the facility had reported the alleged abuse within the two hour time frame to the State Agency. The finding is: Resident # 258 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was usually understood, can sometimes understand and had a Brief Interview for Mental Status (BIMS) Score of 6, indicating severely impaired cognition. The resident's Mood Score was 12, indicating moderate Depression. A Nursing Progress Note dated 11/19/19 at 12:36 AM documented that the resident's 11:00 AM-7:00 PM Certified Nursing Assistant (CNA) had reported to that nurse that the resident had been abused at 9:00 PM on 11/18/19 and that the Supervisor was notified. During the initial tour on 11/19/19 at 10:30 AM, the resident appeared to be anxious and reported to the surveyor that the night before (11/18/19) the resident had been held down and forced to take medication. The resident's Social Worker (SW) was notified by the surveyor immediately at 10:45 AM on 11/19/19 and stated that an investigation would be initiated. A Nursing progress note dated 11/19/19 at 2:58 PM documented that the nurse was made aware by the 11:00 AM-7:00 PM shift that the resident had made a statement regarding mistreatment by staff. The SW was made aware, as well as the Director of Nursing Services (DNS), the Physician and the Psychiatrist. The Accident/Incident Summary of the investigation dated 11/20/19 documented that the facility was unable to substantiate the resident's claims of abuse. The DNS was interviewed on 11/22/19 at 11:40 AM. The DNS stated that the alleged abuse incident had not been called into the State Agency because after the investigation the resident's allegation had been unsubstantiated. The Administrator was interviewed on 11/25/19 at 9:58 AM. The Administrator stated that the State Agency had not been called because the Department of Health was in the facility for survey and had brought the resident's concern to the Administrator's attention. 415.4(b)(1)(ii)

Based on observations, record reviews, staff interviews during the recertification survey, the facility did not ensure that a resident's comprehensive person-centered care plan was implemented. This was evident for 1 of 6 residents reviewed for medication pass observation. Specifically, Resident #42 had a Physician's Laboratory Order to obtain a Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) on 6/29/18. The laboratory order was not implemented as of 7/27/18. The finding is: Resident #42 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 9 indicating the resident was moderately impaired in cognition. The physician's orders [REDACTED]. The Nurse's Progress Note dated 6/29/18 documented a CBC and BMP were ordered. Review of the medical record on 7/27/18 revealed that there was no CBC and BMP laboratory results on file. An interview with the Director of Nursing Services (DNS) was conducted on 7/27/18 at 12:17 PM. The DNS stated that she could not locate the CBC and BMP laboratory report as ordered on [DATE]. An interview with the Laboratory Provider was conducted on 7/27/18 at 1:10 PM. The Provider stated that the laboratory facility never received the order and that the CBC and BMP were not done. An interview with the Attending Physician was conducted on 7/27/18 at 1:17 PM. The Physician stated that he was not aware that the CBC and BMP that he ordered on [DATE] were not completed and that he had not followed-up on the laboratory order. Review of the resident's medical record from 6/29/18 to 7/27/18 revealed no documented evidence the nursing staff or the Physician had contacted the laboratory to follow-up on the CBC and BMP results. 415.11(c)(1)

Based on observation, record review, and staff interviews during the recertification survey, the facility did not ensure that the physician was notified that the resident refused her medications. This was evident in 1 of 6 residents reviewed for medication pass observation. Specifically, Resident #42 refused all her 6 medications on 7/24/18 medication pass observation. Review of the resident's Medication Administration Record [REDACTED]. There was documented evidence that the Physician was notified. The finding is: The facility's policy and procedure dated 4/2018 titled Medication: Administration-General documented . 8) Any medication(s) /treatment(s) that are refused by the Patient/Resident must be documented on the appropriate section of the Electronic Medication Administration record. The physician must be notified when patient/resident refuses three (3) consecutive administrations for further evaluation of medication usage . Resident #42 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 9 indicating the resident was moderately impaired in cognition. The (MONTH) (YEAR) MAR indicated [REDACTED] -Juven Powder 1 packet every (q) day (d) -[MEDICATION NAME] Diskus Powder q 12 hours -Aspirin (ASA) 81 milligram (mg) q d -[MEDICATION NAME] 20 mg capsule q d -[MEDICATION NAME] 20 mg q d -Potassium Chloride (KCL) 10 milliequivalence (mEq) qd The Comprehensive Care Plan (CCP) developed for Behavioral Symptoms dated 7/6/18 documented occasional refusal of medication and care. The CCP included an intervention to notify the Physician immediately for changes in behavior. On 7/24/18 at 8:40 AM, a medication pass was conducted with the Licensed Practical Nurse (LPN) #1 for Resident #42. The resident refused all medications that included Juven, [MEDICATION NAME], ASA, [MEDICATION NAME], and KCL. The LPN did not document in the Nurse's progress note that she notified the physician of the resident's refusal. An interview with the Medical Director was conducted on 7/26/18 at 9:30 AM. The Medical Director stated that the medication nurse should have notified the Attending Physician if and when the resident refused her medications for any alternative action. The Registered Nurse (RN) Unit Charge Nurse was interviewed on 07/26/18 at 10:49 AM. The RN stated that LPN #1 forgot to document Resident # 42's medication refusal and that she would ask LPN #1 to document it on the progress note. LPN #1 was interviewed on 07/26/18 at 12:06 PM. LPN #1 stated that she had informed the Physician via phone but the Physician had not returned her call. LPN #1 also stated that she forgot to document that the resident refused all her 9:00 AM medications on 7/24/18 in the progress note. The Attending Physician was interviewed on 7/26/18 at 12:45 PM. The Physician stated that he was on the unit at that time on 7/24/18. The Physician stated that he was not made aware that Resident #42 had refused her all medications. The Physician also stated that he was aware of the previous times the resident had refused medications. The Physician further stated that he expects the nurse to try to offer the medications again and also expects the nurse to notify him that the resident refused the medications. The (MONTH) (YEAR) MAR indicated [REDACTED] -[MEDICATION NAME] 5,000 Units (1 milliliter) injection solution by subcutaneous route q 8 hours -[MEDICATION NAME] aerosol inhaler to inhale 2 puffs q 12 hours. Review of the Medication Administration Record [REDACTED]. On 7/27/18 at 11:56 AM, an interview LPN #2 was conducted regarding Resident #42's [MEDICATION NAME] and [MEDICATION NAME] aerosol inhaler refusal. LPN #2 stated that he did not document the resident's refusal in the progress note. LPN #2 also stated that he did not notify the Attending Physician until after the next day (unspecified date). The Attending Physician was interviewed on 7/27/18 at 12:00 PM. The Physician stated that he was not notified of the resident's [MEDICATION NAME] and [MEDICATION NAME] refusals. The Physician stated that he expected to be notified of the medication refusals. Review of the medical record from 7/21/18 to 7/24/18 revealed there was no documented evidence in the medical record that the Physician was notified concerning the resident's [MEDICATION NAME] and [MEDICATION NAME] refusals. 415.3(e)(2)(ii)(c)

Based on observations, record review and staff interviews during a Recertification survey the facility did not ensure that each resident receives adequate supervision to prevent accidents. This was noted for one of one resident (Resident #106) reviewed for dental concerns. Specifically, for Resident #106, the facility did not consistently follow the Dentist's recommendations for safe use of a denture. The finding is: Resident #106 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Nurse's note dated 5/29/18 documented the resident has natural teeth and has an upper denture. A Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental status (BIMS) score as 8, indicating moderately impaired cognition. The MDS also documented the resident required extensive assist of 2 persons for bed mobility, transfer and toilet use and extensive assist of 1 person for locomotion, dressing, eating and personal hygiene. The resident was observed on 7/19/18 at 11:00 AM talking to a Certified Nursing Assistant (CNA) in the hallway. As the resident spoke the upper denture appeared loose and moved with her lip and tongue movement. A Comprehensive Care Plan (CCP) dated 5/31/18 documented Behavioral Symptoms related to Dementia, including poor safety awareness, physical aggression, calling out, combative, restless and resists care. A CCP dated 5/31/18 for Dental care included to place dentures in the resident's mouth before breakfast and to provide dentures that are clean and fit properly. A CCP dated 6/6/18 for Communication documented impaired ability to make self understood and understand due to Dementia and that the resident's needs will be anticipated. A Resident nursing instruction sheet for CNAs from (MONTH) (YEAR) to (MONTH) (YEAR) documented CNA care notes including anticipate needs, dentures to be collected and placed in protective container every (q)hour of sleep (HS) and placed back in mouth every morning for breakfast. Use Fixodent when placing dentures. The Treatment Administration Records (TAR) for (MONTH) and (MONTH) (YEAR) documented that the Nurses could not collect the denture from the resident and place the denture in a protective container on 6/20/18, 6/21/18, 6/22/18, 6/23/18, 6/27/18, 6/29/18, 6/30/18 and on 7/1/18, 7/13/18, 7/14/18, 7/18/18, 7/23/18 and 7/24/18 due to the resident's refusal. A Dental consult dated 6/5/18 documented the resident was with loose teeth and crown, and bridge work was present. The consult also documented the resident has a horse shoe shaped full upper denture (not full plate coverage) causing poor retention. The consult stated further that patient refuses to use adhesive to increase retention. Remove full upper denture over night and put on when laying down (aspiration risk). Soak in denture cup. Patient has no discomfort. Continue good oral hygiene AM and PM. The Resident's 7:00 AM-3:00 PM Licensed Practical Nurse (LPN) was interviewed on 7/21/18 at 11:05 AM and stated that the dentures are supposed to come out at night and replaced in the morning but the resident is very difficult and will sometimes not let any staff help remove the denture leaving them in through the night. The LPN also stated that she has never noticed the resident's denture being loose or moving during her shift and there have been no CNA reports about the resident's denture being loose. The CNA who was assigned to the resident for the 3:00 PM- 11:00 PM shift on 7/2/18, 7/4/18, 7/5/18, 7/7/18, 7/8/18, 7/9/18, 7/11/18, 7/16/18, 7/18/18, 7/19/18, 7/21/18 , 7/22/18, and 7/23/18 was interviewed on 7/24/18 at 11:30 AM and stated that the resident often refuses to take her denture out and that the Nurses are aware of it. The 7:00 AM-3:00 PM CNA was interviewed on 7/23/18 and stated that she is frequently assigned to care for the resident. The CNA stated that sometimes the resident has the denture in from the previous night and refuses to use adhesive for dentures. The Dentist was interviewed on 07/26/18 at 12:08 PM and stated that removing the denture at night is a standard precaution for every one with dentures. The Dentist also stated that the resident's denture is smaller that conventional and that some people cannot tolerate the small denture and may gag on it. She added that it's a much smaller denture, more like a partial denture, could possibly be an aspiration risk, although remote, but it is a possibility. 415.12(h)(2)