Every finding on record at Sutton Park Center for Nursing and Rehabilitation

Based on observation and interview conducted during the recertification survey and abbreviated surveys (686919, 2690393) from 01/20/2026 to 01/28/2026, the facility did not maintain a homelike environment for two of four (third and sixth floor) nursing units, and a tub room on the 4th floor. Specifically, 1) resident rooms # 302 a-b, 307 a-d, 315 a-d, 316 a-d were not personalized, lacked adequate visitor seating, 2) fifteen resident rooms (602, 603, 604, 605, 606, 607, 608, 609, 610, 611, 614, 616, 617, 619, and 620) were observed stark and bare without personalization; and 15 resident rooms (603, 604b, 605a, 606a-b, 609a, 610, 606 a-b, 607a-d, 609a, 610, 616a-d, 617a, 618b, 619a-b, and 620) did not contain a chair for resident/visitor use; and 3) the tub room on the 4th floor, had window insulation that was coming out and a cold draft was coming from the window. The findings included: A facility policy titled Resident Rights dated 08/2021 documented: Resident has the right to have a homelike environment, keep and use your personal belongings and property as long as they do not interfere with the rights, health, or safety of others. 1) During an observation on 01/22/2026 at 8:49 AM, room [ROOM NUMBER] (a four-resident room) was cluttered and the floor was dirty with debris. The walls were bare had no personalized items were present. No chairs were available for visitors or residents in the room. During observation on 01/23/2026 from 8:32 AM to 8:44 AM, room [ROOM NUMBER] did not have personalized photos of the residents or clocks; room [ROOM NUMBER] had bare walls and lacked chairs for the residents or visitors; room [ROOM NUMBER] (four-resident room) had no personalized items for 3 of the 4 residents; Rooms 316 (a four-resident room) had an activities calendar on the wall, but lacked any other personalization and no chairs were available. 2) During observations on 01/22/2026 at 3:31 PM and 01/23/2026 at 9:08 AM, the following resident rooms were stark and bare, without visible personalization such as photos, pictures on the wall or decorations: 602a-b, 603a, 604a-b, 605a, 606a-b, 607a-b, 608a-b, 609a-b, 610, 611, 614, 616c-d, 617a-b, 619a-b, and 620b; and the following resident rooms did not have a chair for residents or visitors: 603, 604b, 605a, 606a-b, 609a, 610, 606 a-b, 607a-d, 609a, 610, 616a-d, 617a, 618b, 619a-b, and 620a-b. During an interview on 01/27/2026 at 11:43 AM, Registered Nurse Supervisor #6 stated they were aware many of the resident rooms were not homelike or personalized. They stated residents who had visits from family members were more likely to have a personalized, homelike room than residents who did not have visitors. They stated many of the residents did not have family or friends who visited. They stated they were unaware there were no chairs in many resident rooms. During an interview on 01/27/2026 at 4:37 PM, Social Worker #2 stated resident family/friends frequently assisted with decorating or personalizing a resident's room. They stated the Social Work Department did not usually address creating a home-like environment and it would be a Recreation Department activity. During an interview on 01/27/2026 at 4:59 PM, the Administrator stated units were decorated by Recreation Department for the holidays, usually the day room, dining area, hallways, and nurse station and they were not sure if they also decorated resident rooms. They stated that resident rooms were frequently personalized by the resident families and that every resident room should have a chair for resident/visitor use. During an interview on 01/28/2026 at 11:02 AM, the Director of Recreation stated Recreation staff rounded resident rooms daily and when they observed rooms that were bare and not homelike, they would reach out to resident families. If a resident or family requested assistance in hanging pictures or printing out items such as photos, the Recreation Department would assist. They stated the Recreation Department decorated unit hallways, dayroom and dining room for the holidays and resident rooms were not decorated or personalized unless requested by the resident or staff. They stated they had not received requests from staff or residents to personalize resident rooms on the 6th floor unit and had not discussed personalizing and creating a homelike environment for resident rooms with managers or administration. 3) During an observation on 1/20/26 at 3:44 PM of the 4th floor tub room, two (2) windows in the bathroom had insulation that was coming out and there was a draft by the window. During an interview on 1/28/2026 at 1:14 PM the Director of Building Services stated the building was being renovated and the 4th floor was 95% renovated. They further stated they were not aware of any concerns with the window insulation in the 4th floor tub room and there had been no work orders for it. 10NYCRR 415.5(h)(1)

Based on observation, interview, and record review conducted during the recertification and abbreviated (2569922) surveys from 01/20/2026 to 01/28/2026, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for one (1) of seven (7) residents (Resident # 51) reviewed for Activities of Daily Living and one (1) of one (1) residents (Resident #158) reviewed for non-pressure skin conditions. Specifically, 1) Resident #158 did not have their daily wound dressing changed for 7 days and did not receive treatment according to the physician order. 2) Resident # 51 dislocated their hip and did not have an orthopedic follow-up as recommended in the hospital discharge summary. The findings are: 1) Resident # 158 had diagnoses of lumbosacral and pelvis fractures, Type II Diabetes Mellitus and skin graft right arm. The admission nursing note dated 1/10/2026 documented the resident was alert and oriented and had traumatic wounds from being dragged by a car. Wound sites included the right thigh donor site, bilateral knees, posterior back cluster wounds and a left scalp wound. The physician orders dated 1/17/2026 documented to clean left lower back with normal saline, pat dry, apply Santyl (an ointment used to remove dead tissue) and xeroform (a moist non adherent gauze) to wound bed, apply telfa (non-adhering dry gauze) and cover with absorbent non adherent dressing daily and as needed. The care plan for Actual Skin Impairment to the left lower back wound dated 01/17/2026, documented interventions included providing wound treatments as ordered, monitor for signs and symptoms of infection including redness, warmth, drainage and odor. During an observation and interview on 01/20/2026 at 10:28AM, Resident #158 stated they wanted to have their shirt changed more frequently because the dressing on their back was leaky and itchy. They pulled up their shirt and a dressing to left lower back was observed with date 1/15/26 and a small amount of drainage coming from the lower edge of dressing. During an observation on 01/21/2026 at 11:30AM, the same dressing to the lower left back was in place with dried brown drainage on the bandage dated 01/15/2026. The Treatment Administration Record documented nurses changed the left lower back dressing on 01/17/26, 01/18/26, 1/19/26, 1/20/26 ,1/21/26, 1/22/26 during the 7-3 shift. During an observation and interview on 01/23/2026 at 09:58 AM Resident#158 stated their dressing needed to be changed and had not been changed in a long time. They stated it was itchy and leaked on the bed sheets. The resident rolled over and same dressing dated 1/15/26 was observed still in place now with black dried blood and old drainage on dressing. During a wound dressing observation on 01/23/2026 at 10:12 AM Licensed Practical Nurse Unit Manager #2 prepared to perform the dressing change. They donned a gown and gloves, gathered supplies and explained the procedure to the resident. The resident was positioned; the old dressing was removed. Dirty gloves were removed, hand hygiene was performed, and clean gloves were donned. The wound was pink in color and cleansed with normal saline, gloves were removed, hand hygiene was performed, and clean gloves were donned. Licensed Practical Nurse Unit Manager #2 opened a package of Bacitracin ointment, squeezed it on to a piece of gauze and an island dressing (absorbent, nonstick pad surrounded by a breathable, adhesive border) was applied. During an interview on 01/23/2026 at 10:38 AM Licensed Practical Nurse #2 stated the dressing was dated 01/15/2026 which meant nurses were not changing the dressing daily as ordered. They stated it was important it be changed according to orders because nurses need to provide the care and to prevent infection. They stated nurses signed for it on the Treatment Administration Record but did not do it. During a second interview on 01/23/2026 at 01:10 PM, Licensed Practical Nurse Unit Manager#2 was made aware the treatment they provided was not as the physician ordered. They stated they did not check the orders prior to starting the dressing change but should have done that as the resident had a lot of wounds and all the wounds had different treatments. During an interview on 01/23/2026 at 1:56 PM, the Director of Nursing stated nurses needed to read the physician orders before doing the treatment. They stated they had educated nurses about following the orders. They stated they were not aware nurses were signing for treatments they did not do. 2) Resident #51 had diagnoses including right hip dislocation of prosthesis, dementia, and osteoarthritis. The quarterly Minimum Data Set (an assessment tool) dated 04/23/2025 documented that Resident #51 had severe cognitive impairment and was dependent on staff to complete daily activities of living, including transfers with the assistance of two people. An Occupational Therapy progress notes dated 01/28/2025 at 11:26 AM documented that the resident had been seen by the physician on 01/17/2025 for lethargy and tenderness of the right thigh. An X-ray of the right hip/pelvis had been conducted, which revealed a dislocation of the right femoral head prosthesis with inward rotation of the right hip and pain upon movement. The resident required a Hoyer lift with two staff for transfers and remained non-weight bearing on the right lower extremity with right hip precautions until cleared by Orthopedics. The nursing note dated 01/31/2026 at 11:02 AM, documented the resident went out to an orthopedic appointment accompanied by an aide and was sent to the hospital for further evaluation. The nursing note dated 02/01/2026 at 7:48 AM documented the resident returned from the hospital emergency department visit at 5:15 AM. The diagnosis was right hip dislocation, and the resident was weight bearing as tolerated for transfers only. The 02/01/2025 Hospital Discharge Summary documented the resident was seen in the emergency room on [DATE] and to follow-up with Orthopedic in one (1) week. A review of Resident #51's electronic medical records revealed no documented evidence the resident followed up with orthopedics or any attempts to schedule an orthopedic appointment. During an interview on 1/27/2026 at 1:20 PM, Physician #1 stated that after the resident's right hip was dislocated, the plan had been for the resident to follow up with orthopedics for possible hip replacement or other recommendations. They stated they were not informed by the staff if the Orthopedic appointments were made and did not get any feedback from the staff. During an interview on 1/28/2026 at 11:54 AM, the Director of Nursing stated the resident's orthopedic consultation was not done as the Orthopedic facility could not accommodate the resident in the Geri-chair. The Director of Nursing stated they were in the process of finding an orthopedic office that could accommodate the resident for their orthopedic appointments. 10 NYCRR 415.12

Based on observation, interview, and record review conducted during the recertification and abbreviated (2569922) surveys from 01/20/2026 to 01/28/2026, the facility did not ensure that all alleged injuries of unknown origin, were reported to the State Agency for one (1) of seven (7) residents. (Resident #51) reviewed for abuse. Specifically, Resident #51 had an x-ray that confirmed the dislocation of the right femoral head (top of long bone in the thigh) prosthesis (hip replacement). The 01/18/2025 Accident/Incident Report documented the date, location, and time of occurrence as unknown, and there was no documented evidence that the injury of unknown origin was reported to the State Agency. The findings include: The facility's Policy and Procedure titled Abuse Identification and Investigation; Prevention; and Reporting, revised 12/05/2025, documents that an injury should be classified as an injury of unknown source when the criteria are as follows: the injury was not observed by any person, the injury could not be explained by the resident, or the injury is suspicious because of the extent or location of the injury, especially if it is in an area not generally vulnerable to trauma. It is also the policy of the facility to investigate and report abuse and crimes per New York State Department of Health and the Centers for Medicare and Medicaid Services regulations. Resident # 51 had diagnoses including a right hip replacement, dementia, and osteoarthritis. The quarterly Minimum Data Set (an assessment tool) dated 04/23/2025 documented that Resident # 51 had severe cognitive impairment and was dependent on staff to complete their daily activities of living. A physician progress note dated 1/17/2025 at 10:46 PM documented the resident was seen for lethargy and tenderness in the right thigh. An X-ray report dated 01/17/2025 of the right femur documented acute posterior dislocation of the femoral head prosthesis with inward rotation of the femur. The accident and incident report dated 01/18/2025 documented that Resident #51 had tenderness in the right thigh. The resident had a dislocated right hip prosthesis according to an x-ray on 01/17/2025. The resident could not give an account of what had happened. Multiple statements were obtained on 01/18/2025 and 01/20/2025 from staff, with all staff documenting that they were not aware of or had not witnessed any incident involving the resident falling. The incident report documented the date, location, and time of occurrence as unknown. The facility investigative summary, dated 01/22/2025 documented that based on the investigation, there was reasonable cause to believe that abuse, mistreatment, or neglect had not occurred. Boxes for Y, N or N/A, (yes, no, or not applicable) for reporting the incident to the Department of Health was not checked. During a telephone interview with the resident's representative on 01/22/2026 at 1:33 PM, they stated they had spoken with the resident's physician, who told them the resident had a dislocated hip. They stated the facility did not provide any information on how the resident's right hip was dislocated. During an interview on 01/28/2026 at 8:58 AM, the Director of Nursing stated an x-ray on 1/17/2025 was done and showed the acetabular prosthesis was dislocated. They stated that the resident did not have a fracture, so it was not reported to the Department of Health (State Agency). They stated the facility followed proper protocols. They stated the resident was not cognitively intact to explain what happened. They stated that they did not know how it happened and based on their judgment and the facility's protocols, it was not a reportable incident. They stated they did not consider it an injury of unknown origin. 10 NYCRR 415.4(b)(2)

Based on observation, interview, and record review during the recertification and abbreviated (2569922) surveys from 01/20/2026 to 01/28/2026, the facility did not ensure a thorough and complete investigation was done to rule out abuse, neglect, or mistreatment for one (1) of seven (7) residents (Resident # 51), reviewed for abuse. Specifically, Resident # 51 had their right hip replacement dislocated, and the facility did not thoroughly investigate to determine if the care plan was followed when determining a root cause analysis for the dislocated hip. The findings include: The facility's Policy and Procedure titled Abuse Identification and Investigation; Prevention; and Reporting, revised 12/05/2025, documented that it was the policy of the facility to ensure all residents and families that the facility had taken the necessary steps within its control to prevent and prohibit abuse, neglect, and mistreatment. An injury should be classified as an injury of unknown source when the criteria were as follows: the injury was not observed by any person, the injury could not be explained by the resident, or the injury was suspicious because of the extent or location of the injury, especially if it was in an area not generally vulnerable to trauma. Resident # 51 had diagnoses including right hip replacement, dementia, and osteoarthritis. The quarterly Minimum Data Set (an assessment tool) dated 04/23/2025 documented that Resident # 51 had severe cognitive impairment and was dependent on staff to complete activities of daily living, including transfers with two-person assistance. A physician progress note dated 1/17/2025 at 10:46 PM documented the resident was seen for lethargy and tenderness in the right thigh.An X-ray report dated 01/17/2025 of the right femur documented acute posterior dislocation of the femoral head prosthesis with inward rotation of the femur. The accident and incident report dated 01/18/2025 documented Resident # 51 had tenderness in the right thigh. The resident had a dislocated right hip prosthesis, confirmed by an X-ray dated 01/17/2025. The report documented that the resident was unable to give an account of what happened. The report documented the date, location, and time of the occurrence as unknown. The resident's transfer status was documented as 2 person assist and ambulatory status was 1-person assist. The 01/18/2025, typed and signed statement by the Assistant Director of Nursing documented they called staff that were assigned to the 3rd floor and there was no report of any fall or other incidents. Certified Nurse Aides #15. #16, and #17's statements documented they did not see the resident fall or complain. The statements did not document the care the resident was provided. Licensed Practical Nurses #10, #13, and #14 statements documented they did not see or hear about the resident falling. There was no documentation as to the resident's activities.Fifteen (15) written statements by nursing staff, dated 1/20/2025, documented they were unaware of the resident having any falls or incidents. There was no documentation as to the care provided by staff.Three (3) written statements provided by the physical therapy department, dated 01/20/2025, documented the resident was provided physical therapy on 01/16/2025 and 01/17/2025. During treatment the resident denied pain and discomfort and was participative.The facility's investigative summary completed by the Assistant Director of Nursing, dated 01/22/2025, documented on 01/17/2025 the resident had tenderness to the right thigh, and an x-ray showed an acute posterior dislocation of the right femoral head prothesis. The resident required maximum assist of 1 staff for bed mobility and maximum assist of 2 staff for transfers and ambulation. The resident was unable to state how they sustained the dislocation. The investigation included statements from staff indicating there were no recent falls or incidents which may have contributed to the injury. The summary documented it was determined the resident most likely sustained the right femoral head prosthesis dislocation due to history of right hip arthroplasty and osteoarthritis to both hips and recent decline in ADLs. The report documented there was no deviation from the care plan and that abuse, mistreatment, or neglect had not occurred.Further review of the investigative summary dated 01/22/25 revealed no documented evidence as to who provided what care, when it was provided, and the number of staff performing care, including transferring the resident in and out of bed, to determine the care plan was followed.During a telephone interview with the resident's representative on 01/22/2026 at 1:33 PM, they stated they had spoken with the resident's physician, and told the resident had a dislocated hip. They stated they were not provided with any other information as to how the resident's right hip replacement was dislocated. During an interview on 01/28/2025 at 11:44 AM, the Assistant Director of Nursing stated they determined the care plan was followed through interviews with the certified nurse aides. They asked about the resident's activities of daily living and confirmed with the certified nurse aides that the care guide was followed including transfer status. They were unable to provide an explanation as to why it was not documented in the interviews or written statements they obtained from the staff. 10 NYCRR 415.4(b)(3)

Based on observation, record review and interview during the recertification survey from 01/20/2026 to 01/28/2026, the facility did not ensure residents received necessary treatment and services consistent with professional standards of practice, to prevent new pressure ulcers from developing and/or promote healing of pressure ulcers for two (2) of eight (8) Residents (Resident #125 and #94) reviewed for pressure ulcers. 1) Specifically, Resident #125 who had Stage 4 pressure ulcers to their right hip and sacrum and was at high risk for further development of pressure ulcers, was observed on multiple occasions without physician-ordered bilateral heel boots in place and/or their heels were not offloaded while in bed. Additionally, during a wound treatment observation for the two Stage 4 pressure ulcers, the resident was left with a saturated brief and bed liner contaminating the wound after it had been cleansed. 2) Resident #94 did not have their heels offloaded/floating while in bed and the comprehensive care plan was updated to include a physician order to offload Resident #94 heels while in bed. The findings included:A facility policy titled Pressure Injury-Prevention and Care dated 04/25/2025 documented: The facility commits to preserve the skin integrity of Residents by identifying all Residents at risk for skin breakdown upon admission, re-admission and during their stay the facility. Certified Nurse Aides will observe resident's skin every shift and report changes to the nurse. Prevention and treatment included pressure reducing surface as per protocol (special mattress, heels pads, overhanging heels on pillow).1) Resident #125 had diagnoses including Parkinson's disease, and Stage 4 pressure ulcers of sacral region and right hip. The annual Minimum Data Set (a resident assessment tool) dated 10/29/25 documented Resident #125 had severe cognitive impairment, was dependent on staff for all cares and mobility. They were always incontinent of bowel and bladder and at risk of pressure ulcers/Injuries. Resident #125 had two (2) Stage 4 pressure ulcers present on admission or reentry and had applications of ointments/medications other than to feet, and pressure reducing devices for chair and bed. A resident care plan titled Skin Integrity/ Risk for Skin Breakdown updated 03/25/2025 documented the resident had potential for new areas of skin breakdown and skin lesions. Interventions included daily skin inspection, floating heels while resting in bed, and heel booties when in chair as tolerated if not ambulating.The resident care plans, updated 03/25/2025, for the Stage 4 right hip ulcer and Stage 4 sacral ulcer had interventions including to apply local treatments as ordered by physician and monitor for signs and symptoms of infection (increased redness, warmth, drainage, foul odor, etc.), to assess for pain, effectiveness of pain medications per physician order, off-load wound, perform wound care rounds weekly, pressure reduction mattress, pressure reduction wheelchair cushion and refer for follow-up with the wound care team. Physician orders dated 11/14/2025 documented the treatments for both Stage 4 pressure ulcers, to the sacrum and right hip, included to cleanse the area with Dakins solution (wound cleanser), pat dry, apply calcium alginate and collagen particles (wound treatment) to wound bed, apply zinc paste (barrier cream) to peri-wound (surrounding skin), cover with silicone superabsorbent bordered dressing, daily and as needed.Physician orders dated 11/12/2025 documented heel booties while in chair as tolerated and to check skin integrity before placement and after removal; to float heels in bed; and enhanced barrier precautions. A physician order dated 12/05/2025 documented to off-load heels with pillows. During observations on 01/20/2026 at 11:31 AM, 01/20/26 at 3:32 PM, 01/21/2026 at 10:59 AM, and 01/21/2026 at 3:45 PM, Resident #125 was in their room seated in their Geri chair reclined at 45 degrees. They had socks on their feet, and their heels were observed resting on leg rests. The heel booties were not in place.During an observation on 01/23/2026 at 9:05 AM, Resident #125 was in bed, on their back, with their bare heels directly on the mattress.During an observation and interview on 01/23/2026 at 10:03 AM with Certified Nurse Aide #3, Resident #125 was in bed, lying on their back with bare heels resting on the mattress. Resident #125's mid left heel had a dime-sized white scab-like area of skin impairment and redness was observed on the right heel. Certified Nurse Aide #3 stated they did not know why Resident #125's heels were not offloaded. They stated they had not seen the skin impairments on Resident #125's heels and had not reported them to unit nursing staff. Certified Nurse Aide #3 stated they knew Resident #125's care included wearing heel booties when in the Geri chair. Certified Nurse Aide #3 located Resident #125's heel booties in closet. During a wound care observation and interview on 01/23/2026 at 11:01 AM with Wound Care Registered Nurse #4 and Registered Nurse Supervisor #7, wound care supplies were assembled by Wound Care Registered Nurse #4. During positioning, a saturated adult brief and wet disposable bed liner were observed, and when the brief was opened, Resident #125's right hip wound was exposed without a bandage/treatment in place. Registered Nurse Supervisor #7 and Wound Care Registered Nurse #4 stated they did not know why there was no bandage in place on the right hip. Registered Nurse Supervisor #7 pushed the wet adult brief and wet disposable bed liner under Resident #125's buttock and it remained there throughout the wound care treatment. Wound Care Registered Nurse #4 applied the treatment to Resident #125's right hip as ordered and proceeded to the sacral wound. During wound care for Resident 125's sacral wound, Nurse Supervisor #7 rested the lower edges of Resident 125's cleaned sacral wound area against the wet, soiled disposable bed liner while awaiting Wound Care Registered Nurse #4 to prepare calcium particles and calcium alginate. When interviewed at the time, Nurse Supervisor #7 stated they should not have allowed the cleaned wound to touch the soiled, wet disposable bed liner. Wound Care Registered Nurse #4 recleaned the wound and proceeded to complete sacral wound care as ordered. When interviewed at the end of the dressing change, Wound Care Registered Nurse #4 and Registered Nurse Supervisor #7 were unable to explain why the heavily saturated adult brief and soiled disposable bed liner remained in place throughout the care. Wound Care Registered Nurse #4 then observed Resident #125's heels and was interviewed at the time of observation. They stated there was a dime-sized white scab-like area of skin impairment on the left heel surrounded by some redness, and the right heel had redness. Wound Care Registered Nurse #4 stated they had not observed the skin impairments to the heels during recent wound rounds and that Resident #125 had a history of a left heel skin impairment which they stated was resolved. They stated they had not received a report of skin impairment on Resident #125's left or right foot from unit staff and that Resident #125's heels should have been offloaded/floated while in bed and they should have had bilateral heel booties in place while in Geri chair to prevent skin breakdown.During a follow-up interview on 01/27/2026 at 11:11 AM, Registered Nurse Supervisor #7 stated unit staff had not reported concerns with skin impairment on Resident #125's left or right heel prior to the wound observation on 01/23/2026. They stated certified nurse aides were expected to observe Resident #125's skin, including heels, during cares and when applying socks and heel booties. Registered Nurse Supervisor #7 stated they were not aware Resident #125 did not have bilateral heel booties in place while in the Geri chair or why their heels were not offloaded while in bed. They stated they were responsible for supervising certified nurse aide task completion on the unit and they did not perform rounds on 01/20/2026 through 01/23/2026 due to their workload of administering medications and treatments. They stated certified nurse aides should check the accountability binder to review tasks each shift. During an interview on 01/28/2026 at 1:00 PM, the Director of Nursing stated incontinence cares should have been completed prior to wound care treatments. During an interview on 01/28/2026 at 2:20 PM, Physician #1 stated medical orders should be followed and completed as ordered. They stated they were aware that Resident #125 had a history of heel pressure ulcers and that the order for heels booties while in Geri chair and floating heels while in bed was important in the prevention of further skin breakdown. They stated they were first made aware of concern with Resident #125's left heel by the Assistant Director of Nursing on 01/26/2026. Physician #1 stated they observed Resident #125's left heel and there was no redness observed, and a small-callused area of skin was observed. Physician #1 stated the callous could have been caused by friction with the resident's mattress or Geri chair. They stated floating the heels in bed and applying heel booties while in the Geri chair could have prevented an area of callousness/skin impairment on Resident #125's left heel. 2) Resident #94's diagnoses included Stage 4 pressure ulcer of the sacral region, muscle wasting and Alzheimer's disease.The Quarterly Minimum Data Set, dated [DATE] documented Resident #94 had severe cognitive impairment, was dependent on staff for all activities of daily living and mobility and was at risk for pressure ulcers. A physician order dated 12/05/2025 documented to float heels while in bed. A resident care plan titled Skin Integrity/Risk for Breakdown, dated 03/08/2024, documented the potential for skin breakdown and skin lesions due to limited mobility and needs assistance in toileting and bed mobility. Interventions included to avoid skin to surface sheering contact during care and transfer, daily staff skin inspection and monitor for skin breakdown/lesions, pressure relief air mattress in bed and turn and position of body in bed and in the wheelchair. The care plan did not include an intervention to offload/float heels while in bed, as ordered by the physician. During observations on 01/21/2026 at 11:00 AM and 01/23/2026 at 9:12 AM, Resident #94 heels were resting directly on the mattress and not offloaded/floated. During an observation and interview on 01/27/2026 at 10:41 AM, Registered Nurse Supervisor #7 stated Resident #94's heels were not offloaded while lying in bed. They stated the certified nurse aide who provided care for Resident #94 should have floated the heels on a wedge or pillows after completion of morning care. During an interview on 01/27/2026 at 10:47 AM, Certified Nurse Aide #3 stated they provided cares for Resident #94 about 7:30 AM. They stated they forgot to offload/float Resident #94's heels on wedge after care completed. During an interview and observation on 01/28/2026 at 9:59 AM, Registered Nurse Supervisor #11 stated there was a physician order dated 12/05/2025 to float Resident #94's heels while in bed. After review of Resident #94's care plans on the electronic medical record, Registered Nurse Supervisor #11 stated they were unable to locate a care plan intervention to float Resident #94's heels while in bed. They stated the unit manager registered nurse or any nurse on the unit would have been responsible for entering a care plan intervention after reviewing the physician order, preferably under the skin integrity care plan. 10 NYCRR 415.12(c)(1)

Based on observation, record review, and interviews during the recertification survey from 01/20/2026 to 01/28/2026, the facility did not ensure that needed services, care, and equipment were provided to ensure that a resident with limited range of motion and mobility maintained or improved function based on the resident's clinical condition for one (1) of three (3) residents (Resident #125) reviewed for position and mobility. Specifically, Resident #125 had a contracted left hand and was observed on multiple occasions without a physician ordered left-hand hand roll device in place.The findings included: Resident #125 diagnoses included Parkinson's disease, and Stage 4 pressure ulcers of sacral region and right hip.The annual Minimum Data Set (a resident assessment tool) dated 10/29/2025 documented Resident #125 had severe cognitive impairment, no rejection of cares and was dependent on staff for all cares and mobility. A resident care plan titled Activities of Daily Living updated 01/31/2025, documented interventions including a left-hand roll to be worn when out of bed as tolerated. Remove for hygiene, skin checks and as needed. Check skin prior to application and upon removal.A physician order dated 11/12/2025 documented a left-hand roll to be worn when out of bed as tolerated. Remove for hygiene, skin checks and as needed. Check skin prior to application and upon removal. The January 2026 Certified Nurse Aide accountability record documented a left handroll/left upper extremity. Perform skin check before/after application. Report to nurse any skin changes observed. During observations on 01/20/2026 at 11:31 AM, 01/20/2026 at 3:32 PM, and 01/21/2026 at 3:45 PM, Resident #125 was seated in a Geri chair in their room. A left-hand contracture was observed and there was not a device/hand roll in place.During an observation an interview on 01/27/2026 at 10:29 AM with Certified Nurse Aide #6, Resident #125 was observed in Geri chair in their room. Left hand contracture was observed with no device/hand roll in place. Certified Nurse Aide #6 stated Resident #125 should have had a left-hand roll device in place and did not know why the resident did not have one in place. During observation, the left-hand roll was observed under tray table on the floor at bottom of Resident #125's bed. Certified Nurse Aide #6 stated the hand roll should have been in Resident #125's left hand and not on the floor. During an interview on 01/27/2026 at 11:11 AM Registered Nurse Supervisor #7 stated Resident #125 should have had a left-hand roll device in place at least during the day hours. They stated they applied hand roll device to Resident #125 at about 8:00 AM while Resident #125 was in bed. They stated they did not know why it was not re-applied after cares were completed or why the hand roll device was not in place during observations 01/20/2026 to 01/27/2026. They stated certified nurse aides should be checking task accountability sheets to make sure they are aware of tasks for each resident assigned to them. They stated they were responsible for supervising certified nurse aide task completion on the unit and that they did not perform rounds 01/20/2025 through 01/23/2025 due to workload of administering medications and treatments to unit Residents.During an interview on 01/28/2026 at 1:00 PM, the Director of Nursing stated for residents with a physician order for hand roll devices or braces, the expectation was the resident would have device in place as ordered. 10NYCRR: 415.12(e)(2)

Based on observations, interviews, and record review conducted during the Recertification Survey 01/20/2026-01/28/2026 it was determined for 1 of 2 residents (Resident #8) the facility did not ensure that residents who need respiratory care are provided such care, consistent with professional standards of practice, Specifically, Resident #8, who had a tracheostomy, (an surgical opening into the trachea to provide an airway for easier breathing) did not have an Ambu bag (and a self-inflating bag resuscitator) and an extra tracheostomy replacement provided in the resident room to be used in the event of accidental extubation.The findings are: Based on observations, interviews, and record review conducted during the Recertification Survey from 01/20/2026-01/28/2026 the facility did not ensure residents who needed respiratory care were provided with such care, consistent with professional standards of practice, for 1 of 2 residents (Resident #8) reviewed for respiratory care. Specifically, Resident #8 had a tracheostomy, (a surgical opening into the trachea to provide an airway for easier breathing) and did not have an Ambu bag (and a self-inflating bag resuscitator) and an extra tracheostomy replacement provided in the resident room to be used in the event of accidental extubation.The findings include:Resident #8 had diagnoses of acute hypoxic respiratory failure, bilateral above the knee amputations, and tracheostomy.The admission Minimum Data Set assessment tool dated 09/24/2025 documented the resident was cognitively intact and was dependent on staff for all activities of daily living and received oxygen through a tracheostomy.The current physician orders dated 12/5/25 documented cuffless tracheostomy set size 6.5, oxygen at three liters as needed, and tracheal suctioning every shift and as needed. During an observation and interview on 01/23/2026 at 11:07 AM Registered Nurse Unit Manager#1 was asked to locate emergency equipment in the resident's room in the event of accidental extubation namely, an Ambu bag and an extra tracheostomy set. Registered Nurse Unit Manager#1 opened all drawers in the resident's supply cart and closet and stated there were no supplies in the resident's room. They stated they thought there was a spare tracheostomy set at the nurse's station locked in a cabinet and there was an Ambu bag in the dining room on a cart. They left the resident's room and went to the nursing station and observed a tracheostomy set size 6.0 and were unable to locate a 6.5 size as ordered by the physician. They stated if the resident needed a quick replacement the supply on hand would not be the correct size or fit. They stated they should have the right size. They stated it was good practice to check supplies at the beginning of the shift, and they did not. They stated that the Ambu bag was essential equipment for tracheostomy residents and needed to be accessible in case of emergency. During an interview on 01/23/2026 at 1:45 PM the Director of Nursing stated all residents with tracheostomies should have emergency supplies including Ambu bags, replacement sets, suction and oxygen at the bedside. They stated managers and nurses were supposed to check every shift to ensure supplies were accessible. 10 NYCRR 415.12

Based on observations, interviews, and record review during the Recertification Survey from 11/7/23-11/14/23, the facility did not ensure residents were treated with dignity for 2 of 4 residents (#71 and #119 ) reviewed for dignity. Specifically, 1) staff were not seated when feeding Resident #71; and 2) staff were observed entering Resident #119's room without knocking on the door. The findings are: The facility policy for Feeding Assistance Program dated 3/2023 documented, staff will be seated when feeding a resident. 1) Resident# 71 was admitted with diagnoses of metabolic encephalopathy, Alzheimer's disease and abnormal weight loss. The Minimum Data Set (MDS) dated [DATE] documented Resident #71 required assistance with eating. During an observation on 11/08/23 at 12:41 PM, Licensed Practical Nurse (LPN) #5 was observed standing while assisting Resident # 71 with their meal. During an interview with LPN #5 on 11/08/23 at 12:55 PM, they stated they knew they should have been seated while feeding the resident, but they did not sit while assisting Resident #71. 2) Resident #119 was admitted with diagnoses of diabetes mellitus, cerebral vascular accident (CVA, stroke) and peripheral vascular disease. The MDS dated [DATE], documented Resident #119 was cognitively intact. During an interview on 11/8/23 at 10:16 AM, Resident #119 stated some staff knocked and some did not. Resident #119 stated it got uncomfortable at times and privacy was important to them. They worried someone might hear them while they were on the phone. During an observation on 11/8/23 at 11:11 AM, Activity Aide #1 entered Resident #119's room without knocking on the door and/or asking for permission to enter. An interview was conducted on 11/08/23 at 11:11 AM with Activity Aide #1 who stated they forgot to knock because it slipped their mind. 10NYCRR 415.3

Based on record review and interview during the recertification and abbreviated surveys (#NY 00315269), the facility did not immediately inform the physician or nurse practitioner of the resident's refusal to take prescribed medications. Specifically, Resident # 67 had multiple consecutive refused dosages of Latanoprost and artificial tear eye drops. Findings include: The 2/2016 facility policy titled Medication Administration stated any medication/treatment that is refused by the patient/resident must be documented in the appropriate section of the electronic medical administration record. The physician must be notified when the patient/resident refuses three consecutive administrations for further evaluation of medication usage. Resident #67 was admitted with diagnoses including [NAME] disease, muscle wasting and atrophy, and motor vehicle accident. The annual Minimum Data Set (MDS) dated [DATE] documented Resident # 67 was cognitively intact and had no issues with mood and behavior. The 2/16/2023 care plan titled noncompliance with care and treatment intervention included notify the physician for refusal of care and treatment. The current physicians' orders included Latanoprost 0.005% eye drop once daily at bedtime and artificial tears instill one drop in each eye 2 times per day The Medication Administration Records (MAR) revealed Resident #67 refused Artificial tears on - 9/11/2023 at 5 PM, 9/12/2023 at 9 AM and 530 PM, 9/22/2023 9 AM and 5 PM, and 9/23/2023 at 9 AM -10/5/2023 at 9 AM and 5 PM,10/6/2023 at 9 AM, 10/8/2023 at 9 AM and 5 PM,10/9/2023 at 9 AM, 10/11/2023 at 5 PM, 10/12/2023 at 9 AM and 5 PM, 10/14/2023 at 9 AM and 5 PM, 10/15/2023 at 9 AM, 10/24/2023 at 9 AM and 5 PM, 10/25/2023 at 9 AM, 10/30/2023 at 5 PM and 10/31/2023 at 9 AM and 5 PM -11/6/2023 at 9 AM and 5 PM, 11/7/2023 at 9 AM, 11/11/2023 at 9 AM and 5 PM, and 11/12 at 9 AM. The MAR revealed Resident #67 refused Latanoprost on: - 11/10/2023 at 9 PM, 11/11/2023 at 9 PM, 11/12/2023 at 9 PM and 11/13/2023 at 9 PM. There was no documented evidence in the progress notes dated 9/2023-11/2023 that the physician or nurse practitioner (NP) were made aware of the resident's refusal of Latanoprost and artificial tears eye drops. During interview on 11/14/23 at 12:10 PM, NP #1 stated if the nursing staff did not tell them the resident is/was refusing medication, they have no way of knowing but, if they were informed, they would talk with the resident and educate them; then discontinue the medication if possible or write an order for referral to the specialty involved. During an interview on 11/14/23 at 3: 50 PM the pharmacist, stated the Medical Administration Records (MARs) are spot-checked, especially with the electronic medical record (EMR). If they noticed any issues with unadministered/refusal of medication, they would contact the nursing supervisor or the Director of Nursing (DON). However, it was the nurse's responsibility to report refusal of medication to the NP or physician. 10NYCRR 415.3(e)(2)(ii)]

Based on record review and interview conducted during recertification and abbreviated survey (NY00308547), the facility did not ensure a thorough and complete investigation was conducted for 1 of 6 residents (Residents #95) reviewed for accidents. Specifically, the facility did not complete a timely and thorough investigation after Resident #95 reported a 5/8/2023 incident in which the shower chair broke while Resident # 95 was being transferred into it. Findings include: Resident #95 was admitted to the facility with diagnoses including chronic respiratory failure and other muscle spasm. The 7/24/2023 annual Minimum Data Set (MDS) an assessment tool documented Resident #95 was cognitively intact and required total dependence with an assist of 2 staff for bed mobility, transfer and toileting. During an interview on 11/10/2023 at 10:07 AM, Resident # 95 stated that on 5/8/2023 the shower chair broke when they were being transferred into it, resulting in them banging their feet against the ground. Resident #95 stated now every time they take a shower, they are afraid of being hurt. Resident #95 stated they told licensed practical nurse (LPN) # 6 (Unit Manager) on 5/8/2023 and they did not do anything about it. Review of the 3rd floor Maintenance Logbook documented a shower chair broke on 5/8/2023. Review of the resident's record and facility incident report revealed no documented evidence of an investigation for the 5/8/2023 incident involving Resident #95 being transferred into a shower chair that broke during the transfer. During an interview on 11/10/23 at 1:17 PM, LPN #6 stated they were working on 5/8/23 and were not told of an incident on 5/8/23 involving Resident #95 being transferred into a shower chair that broke or that the resident's feet were hurt. During an interview on 11/13/2023 at 11:42 AM, certified nurse aide (CNA) #4 stated on 5/8/23 Resident #95 was in the Hoyer lift and when they brought it down the weight of the resident's body snapped the wheel on the shower chair. CNA #4 stated they immediately brought the resident back up and transferred the resident back to bed. CNA #4 stated they told the nurse on duty, and they stated they were going to fix the shower chair. CNA #4 stated they asked if Resident #95 was okay and the resident stated they were fine. CNA #4 stated they were not sure if Resident #95 was assessed by the nursing staff. CNA #4 stated they were not aware of the resident's foot being injured. During an interview on 11/13/2023 at 12:30 PM, the Assistant Director of Nursing (ADON) stated the resident did not report the shower chair breaking when they were being transferred into it or that the incident resulted in them banging their feet. 10NYCRR 415.4(b)

Based on record review and interviews conducted during the Recertification Survey from 11/7/2023 through 11/14/2023 the facility did not ensure that resident and/or resident representative were notified in writing of the reason for the transfer/discharge to the hospital in a language that they understood, and the facility did not notify the Ombudsman for 1 of 5 residents (Residents # 109) reviewed for hospitalization . Specifically, the resident was transferred to the hospital and the facility could not provide evidence that a written notice of transfer/discharge was provided to the resident, or the resident representatives and that notification was sent to the State Ombudsman. The findings are: The policy and procedure titled Admission, transfer discharge revised 1/2022 documented the resident or representative will be informed of the resident transfer discharge. The state Ombudsman will be notified of all facilities-initiated discharge. Resident # 109 was admitted to the facility with diagnoses of schizoaffective disorder, major depressive disorder, and hypertensive heart disease. The Minimum Data Set (MDS-a resident assessment tool) annual assessment dated [DATE] documented Resident #109 had moderately impaired cognition. Review of the electronic medical record documented Resident #109 had three hospitalization s, 10/5/2023 through 10/6/2023, 10/7/2023 through 10/7/2023, and 10/26/2023 through 10/28/2023. The facility was unable to provide documented evidence that Resident #109 or their representative had been notified in writing of the resident's transfers/discharges from the facility and the reasons for the transfers/discharges or that notices were sent to the Ombudsman. During an interview on 11/14/2023 at 11:00 AM, Resident #109's representative stated they had not received written notification regarding hospital transfer and/or discharge. During an interview on 11/14/2023 at 11:10 AM, the Director of Nursing stated they did not know if Resident #109 was given transfer and/or discharge notification or if the Ombudsman was notified of the residents hospital transfer and/or discharge. During an interview on 11/14/2023 at 11:15 AM, the Director of Social Work stated they did not give Resident #109 or the family representative the transfer/discharge notices. The Director of Social Work further stated they did not notify the Ombudsman when Resident #109 was transferred and/or discharged to the hospital. 10NYCRR 415.3(I)(3)(i)(a)

Based on observation, record review and interview during the recertification and abbreviated surveys (NY00325370) conducted from 11/6/2023 to 11/14/2023, the facility did not ensure the development and implementation of comprehensive person-centered care plans to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #120) reviewed for accidents, 1 of 3 residents (Resident #10) reviewed for hospitalization and 1 of 4 residents (Resident #46) reviewed for dignity. Specifically, 1) the facility did not ensure a person-centered care plan was developed for Resident #120 to be able to self-administer medications. 2) Staff did not implement interventions as per care plan for Resident #10 with a history of falls. 3) Staff did not develop a care plan to address Resident #46's refusal to wear clothes. The findings are: Review of the facility policy and procedure (P&P) titled Medication Administration-General dated 04/2018, documented medications are administered to resident/patients in a timely and accurate manner and to never leave medication at the bedside for a resident to self-administer. 1. Resident #120 was first admitted on [DATE] and last admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), anxiety disorder, and agoraphobia with panic disorder. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], documented Resident #120 was cognitively intact. Physician orders dated 10/31/2023 documented to administer albuterol sulfate HFA 90 mcg/actuation aerosol inhaler, one puff by inhalation route every six hours as needed for COPD. On 11/14/2023 at 4:32 PM, Resident #120 was observed with the prescribed albuterol sulfate inhaler in their room located in the nightstand. When interviewed on 11/14/2023 at 4:32 PM, licensed practical nurse (LPN) #1 stated the resident was in possession of the albuterol sulfate inhaler because they self-administered their medication. When interviewed on 11/14/2023 at 4:33 PM, Resident #120 stated they were given the albuterol inhaler by the nurses and kept it in their possession to be able to self-administer. Resident #12 stated when the inhaler runs out, the nurse replaces it. When interviewed on 11/14/2023 at 4:55 PM, the Assistant Director of Nursing (ADON) stated the resident should not be carrying their own medication due to safety concerns and regardless of cognitive status. The ADON stated it was the policy of the facility that nurses administered all medications to residents and not to leave medications at bedside for a resident to self-administer. 2. Resident #10 was admitted to the facility with diagnoses including Alzheimer's disease, bipolar disorder, and a history of falling. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], documented the resident had severely impaired cognition and required extensive assist of one for bed mobility, eating, toileting, and transfers. The falls care plan dated 6/1/2023 and updated on 6/2/2023, documented the resident was at risk for falls with potential for injury related to the Morse scale assessment with diagnoses of gait disturbance and abnormality. Interventions included keeping the call bell within reach, providing a clutter free environment, and providing adequate lighting while avoiding glare. On 11/09/2023 at 12:04 PM, Resident #10 was observed in their room sitting in wheelchair unsupervised with their door closed. The call bell was observed on the floor on the opposite side of the bed and the lights in the room were off. On 11/09/2023 at 12:07 PM, Resident #10 was observed sitting in their room, with the door closed and was heard from the hallway banging on the door. Certified Nurse Aide (CNA) #6 was observed walking past the room while the door was closed and did not open the door to check on the resident. On 11/09/2023 at 12:12 PM, Resident #10 was observed in their room with the door closed. Upon opening the door, the resident was observed sitting in their wheelchair. The call bell was not in reach, and lights were off in the room. When interviewed on 11/09/2023 at 12:21 PM, CNA #6 stated that Resident #10 was placed in their room because they were in the hallway running their wheelchair into other residents' wheelchairs and the other residents were complaining. CNA #6 stated that Resident #10 was at risk for falls and should not have been in the room alone with the door closed due to safety concerns. CNA #6 stated the call bell should always be within the residents reach. When interviewed on 11/14/2023 at 10:58 AM, Licensed Practical Nurse (LPN) #1 stated that Resident #10 should not be in the room with the door closed, and if the door was closed, staff should open door to check on the resident. 3. Resident #46 was admitted to facility on 10/10/2022 with diagnoses including fibroid neurofibromatosis, malnutrition, and low back pain. The annual Minimum Data Set (MDS, an assessment tool) dated 8/28/2023 documented Resident #46 was cognitively intact, there were no behaviors and Resident #46 required extensive assist of one person for bed mobility, transfer, eating and toileting. The behavior care plan initiated 10/13/2022 documented Resident #46 had alteration in mood and behavior pattern due to diagnosis of depressive disorder and history of insomnia. The interventions documented to use the resident's name and explain purpose upon approach during care, psychiatric or psychological consult and follow up as ordered, provide routine daily caregivers as much as possible, maintain safety measures during periods of behavior disruptions. The behavior care plan had no documented evidence of resident having behaviors regarding not wearing clothing and/or not wanting the curtain closed. There was no documented evidence in the electronic medical record (EMR) of any behaviors regarding not wanting to wear clothing. During observation on 11/07/2023 at 12:13 PM, 11/10/2023 at 1:16 PM and 11/14/2023 at 1:47 PM, Resident #46 was in their bed laying down, wearing an adult brief with no clothes on and visible from hallway During an interview with certified nurse aide (CNA) #14 on 11/14/2023 at 1:30 PM, CNA #14 stated the resident was supposed to be wearing clothes but was informed the resident always took their clothes off. During an interview on 11/14/2023 at 1:33 PM, CNA #4 stated Resident #46 did not like to wear clothes. CNA #4 stated they offered Resident #46 a gown, but they refused to wear the gown and refused to put a blanket on. CNA #4 stated they did not know if this behavior was discussed with the family or social worker. During an interview with licensed practical nurse (LPN) #6 on 11/14/2023 at 1:36 PM, LPN #6 stated Resident #46 refused to wear clothes and believed the resident had the right to refuse clothing. LPN #6 stated the resident did not want to have their bed side curtain drawn. LPN #6 stated they never thought to change the resident's bed position in the room as to make the resident not visible from the hallway. LPN #6 stated there were no care plan meetings held about Resident #46 not wearing clothes. 10NYCRR 415.11(c)(1) 48847

Based on observation, record review, and interviews during the Recertification Survey 11/7/2023-11/14/2023 the facility did not ensure medications were provided to meet the needs of each resident for 2 of 2 residents (#119 and #116) reviewed for insulin. Specifically, long-acting insulin was not administered consistently as per physician order for Residents #119 and #116. The findings are: The facility policy for Administration of Medication dated 1/2023, documented before starting medication pass, check the physician order book for changes in medication orders against the Medication Administration Record (MAR). 1. Resident #119 was admitted with diagnoses including diabetes mellitus type II, cerebral vascular accident (CVA, stroke) and peripheral vascular disease. The 9/15/2022 nursing care plan for diabetes documented to provide medications as ordered. The 10/12/2022 physician order documented insulin glargine (U-100) 100u/ml (3 cc), inject 12 units by subcutaneous route once daily at bedtime. The Minimum Data Set Assessment (MDS) dated [DATE] documented Resident #119 was cognitively intact. The September 2023 medication administration record (MAR) documented insulin glargine (U-100) 100u/ml (3 cc), inject 12 units by subcutaneous route once daily at bedtime, hold if blood sugar equals 126, if greater than 400 or below 60, call physician. The MAR documented: - on 09/16/2023 at 9:00 PM glargine insulin was not administered. The reason documented, blood sugar (143) was below normal parameters. - on 09/24/2023 at 9:00 PM glargine insulin was not administered. The reason documented, blood sugar (240) was below normal parameters. The October 2023 MAR documented: - on 10/21/2023 at 9:00 PM glargine insulin not administered. The reason documented the resident was sleeping. - on 10/30/2023 at 9:00 PM glargine insulin not administered. The reason documented the blood sugar was (144). Upon further review of physician orders and the MAR, there were no clear documented parameters as when to hold the insulin. During an interview with Resident #119 on 11/08/2023 at 10:05 AM, they stated they were not sure if they were getting their insulin on time. Resident #119 stated sometimes they get only pills and no insulin. 2. Resident #116 was admitted with diagnoses including of diabetes type II, hypertension and major depressive disorder. The 6/24/2022 nursing care plan for Diabetes documented to administer medications as ordered. The 9/12/2023 MDS documented Resident #116 was cognitively intact. The current physician order documented Levemir flex pen 100/ml (3 ml), inject 20 units daily in the morning and Levemir flex pen 100/ml (3 ml), inject 30 units daily at bedtime. The September 2023 MAR documented: - on 9/4/2023 at 9:00 PM Levimir 30 units not administered. The reason documented within normal range. The October 2023 MAR documented to administer Levemir flex pen 100/ml (3 ml), inject 20 units daily in the morning with protocol for blood sugar monitoring. The MAR documented: - on 10/10/2023 at 8:00 AM Levimir 20 units was not administered. The reason documented the blood sugar (118) was below normal parameters. - on 10/15/2023 at 8:00 AM Levimir 20 units was not administered. The reason documented the blood sugar (131) was below normal parameters. - on 10/19/2023 at 8:00 AM Levimir 20 units was not administered. The reason documented the blood sugar (96) was within normal parameters. - on 10/27/2023 at 8:00 AM Levimir 20 units was not administered. The reason documented the blood sugar (119) was within normal parameters. - on 10/31/2023 at 8:00 AM Levimir 20 units was not administered. The reason documented the blood sugar (99) was within normal parameters. Upon further review of physician orders and the MAR, there were no documented parameters as when to hold the insulin. During an interview on 11/10/2023 at 12:56 PM Charge Nurse #1 stated it did not make sense to not give the insulin because the sugars were within range or below normal parameters as documented on the MAR. Charge Nurse #1 further stated they did not do audits or even check MARS for completion. Charge Nurse #1 stated they follow up behind the physician to make sure medications were picked up correctly, but they were not sure what happened with the two residents (#119 and #116) not receiving their insulin. During an interview on 11/10/2023 at 1:12 PM the Pharmacy consultant stated their role was to review new admissions and existing residents' medications, review orders, review labs, and review notes. The Pharmacy consultant stated nursing should be involved to find out why the insulin was not being given because of a parameter. The Pharmacy consultant stated as far as parameters, there were no parameters for Levemir insulin because it was long acting and it was a standing order. The Pharmacy consultant stated the MD needed to be involved/called if medications were not being given. During an interview on 11/10/2023 the Director of Nursing (DON) stated if insulin was ordered as a standing order as in this case, it should have been given that way. The DON stated there were no parameters for long-acting insulins. The DON stated they did not know why blood sugar testing was performed. The DON stated the pharmacy consultant reviewed medications and would notify them if there was a concern. The DON stated medication errors were part of quality assurance, but it had not been addressed because the facility did not have medication errors. 10NYCRR 415.12

Based on record review and interview during the recertification survey from 11/6/2023 to 11/14/2023, the facility did not ensure certified nurse aide (CNA) performance reviews were completed at least once every 12 months or that they provided regular in-service based on outcomes of such reviews for 5 of 5 reviewed for staffing (CNA #8, 9, 10, 11,and 12). Specifically, there were no performance evaluations provided when requested. Findings include: There was no documented evidence that CNA #8, 9, 10, 11, and 12 had performance reviews completed at least once every 12 months. During an interview on 11/09/2023 at 2:03 PM, the Assistant Director of Nursing (ADON) stated that staff performance reviews had not been done and that the facility did not have a policy in place. During an interview on 11/09/2023 at 2:45 PM, CNA # 8 stated that had been employed at the facility for many years and had not had a performance review. During an interview on 11/13/23 at 9:58 AM, the Administrator stated the facility did not provide staff performance evaluations. 10NYCRR 415.26

Based on observation and interview conducted during the recertification survey from 11/8/23 to 11/16/23, the facility did not ensure that food was stored in accordance with acceptable standards for food safety practice. Specifically, perishable foods in kitchen freezer #1 and freezer #2 were not labeled and/or dated properly. The findings are: The 10/2023 facility food service policy titled Food Receiving/storage, procurement/Labeling documented foods will be labeled with a best-by date and use by that date or discarded; foods that do not have either a best-buy date or expiration date will be labeled with the date received and discarded within 6 months. 1. Observations during the initial tour of the kitchen on 11/7/2023 at 10:48 AM revealed the following unlabeled and/or undated foods were stored in walk-in freezers # 1 and freezer #2: -Freezer #1, had one (1) box of frozen manicotti, which was opened and unsealed without a use by date. -Freezer # 2, had one (1) box of frozen chicken wings, which was open and unsealed with a handwritten illegible use by date of either 10/18/2023 or 10/18/2025. During an interview on 11/7/2023 at 10:48 AM the Dietary Supervisor stated that the box of manicotti should have had a use by date. The Dietary Supervisor stated the use by date on the box of chicken wings was 10/18/2025. They added that the manufacturers were supposed to put a use by date and a received/prepared date on their products, and if there was no use by date, the director was supposed to call the manufacturer to obtain a use by date for the items. During the same initial tour on 11/7/2023 the Dietary Director was interviewed and stated if there was no manufacturer use by date, they would use the food within 3 months. The Dietary Director further stated that they should have called the manufacturer and also stated Dietary Aide #1, who received the food items from the delivery truck, was responsible for labeling the food items. During an 11/13/2023 at 10:30 AM follow up interview Dietary Aide # 1 (receiver) stated the frozen items should have a received/prepared date on the box and a use by date. If there was no use-by date on the box, they tell the supervisor or the director, and they should contact the manufacturer to obtain a use-by date to label the items. They added that all new frozen foods were supposed to be dated and rotated. 10NYCRR 415.14

Based on record review, and interview conducted during an abbreviated survey (NY00315794), the facility did not ensure that a resident assessment accurately reflected the resident's transfer and toileting status. The assessment in the medical record did not represent an accurate picture/assessment of the resident's status during the observational period. This was evident for 1 of 8 residents (Resident #1) reviewed. Specifically, the Admission Minimum Data Set (MDS, a resident assessment tool) dated 12/09/2022 section G documented resident required extensive 2-person physical assistance for transfer and toileting. The Quarterly MDS dated [DATE] documented resident was totally dependent 2-person physical assistance for transfer and toileting. A Physician order dated 04/21/2023 documented resident required extensive 1-person physical assistance for transfer out of bed (OOB) to wheelchair (W/C)/toileting. The Discharge MDS dated [DATE] documented resident required total dependence for transfer and toileting. The residents' Activities of Daily Living (ADL) Care Plan, the Resident's Care Profile (Certified Nursing Assistant - CNA Instructions), and the ADL Flow Sheet was not updated to reflect the Physician's order on 04/21/2023. The findings are: The Facility Comprehensive Care Plan (CCP) Policy dated 11/2016 documented that the facility utilizes the requirements within the body of this policy / procedure to meet the care plan needs of each resident. The purpose of the assessment is to accurately communicate the resident's capability to perform daily life functions and to identify significant impairment(s) in functional capacity and the plan suggested by the CCP team for improvement / maintenance for each of the resident's primary care issues. Information obtained from the comprehensive assessment and staff interviews enables the facility staff to plan care that focuses on the residents' ability to achieve their highest practicable mode of functioning that includes physical function status such as (ability to perform ADL's, determining the resident's need/possible need). Resident #1 was admitted from the hospital to the facility on [DATE] with diagnoses that included Unspecified Convulsions, Epilepsy, Alcohol Abuse with Intoxication, and Gastroesophageal Reflux Disease with Esophagitis. The Admission Minimum Data Set (MDS, an assessment tool) dated 12/09/2022 documented Resident #1 required extensive 2-person physical assistance for transfer and toileting. The ADL Care Plan initiated on 02/21/2023 documented that Resident #1 had self-care deficit due to right sided weakness. It also indicated that Resident #1 required extensive one-person physical assistance for transfer and toileting. The Resident Care Profile dated 03/02/2023 documented that Resident #1 required total dependence with 2-person physical assistance for transfers and toilet use. Resident #1's ADL status was changed on 03/07/2023 to total dependence 2-person physical assistance. The Quarterly MDS dated [DATE] documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 15/15, associated with intact cognition (00-7 severe impairment, 08-12 moderate impairment and 13-15 cognitively intact). It also documented Resident #1 was totally dependent 2-person physical assistance for transfer and toileting. The Resident Care Profile dated 04/14/2023 documented that Resident #1 required extensive 1-person physical assistance for transfers, and total dependence 2-person physical assistance for toilet use. The Physician Order dated 04/21/2023 documented that Resident #1 was OOB to W/C with extensive assist x 1. There was no documented evidence that the ADL Care Plan was updated to reflect the new order for transfer by the Physician on 04/21/2023. There was no documented evidence that the Resident Care Profile was updated with the new transfer order by the physician on 04/21/2023. There was no documented evidence that the ADL Flow Sheet was updated to reflect the new transfer status on 04/21/2023. The Discharge MDS dated [DATE] documented Resident #1 required total dependence for transfer and toileting. During an interview conducted with the MDS Coordinator (MDSC) on 05/05/2023 at 11:15 AM, the MDSC stated that their MDS assessments are derived from resident assessments/evaluations, residents care plans, the physician orders, Resident Care Profile, and the ADL Flow Sheet. The MDSC stated that when Resident #1's change in transfer status was ordered on 04/21/2023, the nurse on the unit should have updated the ADL care plan, the Resident Care Profile, and the ADL Flow Sheet to reflect the change. 415.11

Based on record review and interview conducted during an abbreviated survey (NY00315794), the facility did not ensure that the Comprehensive Care Plan (CCP) were reviewed and revised in a timely manner. This was evident for 1 of 8 residents (Resident #1) reviewed for care plans. Specifically, (1) Resident #1's Activities of Daily Living (ADL) Care Plan was not updated to include the new transfer and toileting order status from total dependence 2-person physical assistance to extensive 1-person physical assistance on 04/21/2023; (2) Resident #1's Fall Care Plan was not updated to include new goals and interventions post fall on 04/26/2023. The findings are: The Facility CCP Policy dated 11/2016 documented that the facility utilizes the requirements to meet the care plan needs of each resident. The purpose of the assessment is to accurately communicate the resident's capability to perform daily life functions and to identify significant impairment(s) in functional capacity. The plan suggested by the CCP team for improvement / maintenance for each of the resident's primary care issues. Information obtained from the comprehensive assessment and staff interviews enables the facility staff to plan care that focuses on the residents' ability to achieve his/her highest practicable mode of functioning that includes physical function status (ability to perform ADL's, determining the resident's need/possible need for staff assistance. The Facility policy did not include guidance specific to timeliness of reviewing and updating care plans. Resident #1 was admitted from hospital to the facility on [DATE] with diagnoses that included Unspecified Convulsions, Epilepsy, Right Sided Weakness, and Right Ankle Tendinitis (h/o inversion of right ankle joint). The Quarterly Minimum Data Set (MDS, an assessment tool) dated 03/11/2023 documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 15/15, associated with intact cognition (00-7 severe impairment, 08-12 moderate impairment and 13-15 cognitively intact). Resident #1 was totally dependent requiring 2-person assistance with transfer, and toilet use. Resident #1's ADL Care Plan initiated on 02/21/2023 documented that Resident #1 had self-care deficit due to weakness (right sided weakness), and that Resident #1 required extensive one-person physical assistance for transfer and toileting. On 03/07/2023, Residents #1's ADL status was documented as total dependence 2-person physical assistance for transfer and toileting. The Physician Order dated 04/21/2023 documented that Resident #1 was out of bed (OOB) to wheelchair (W/C) with extensive assist x 1 that included for transfer and toileting. There was no documented evidence that the care plan was updated in 04/21/2023 to reflect the Physician's transfer order for Resident #1. The Resident A/I Report dated 04/26/2023 documented that Resident #1 asked to be transferred to the toilet upon return from a medical appointment on 04/26/2023 at approximately 3:45 PM. Resident #1 fell off the toilet on 04/26/2023 at 4:20 PM. Resident was found on the floor by a certified nurse aide lying in a fetal position sweating and complained of chest pain. Nurse Practitioner was notified. Resident #1's Fall Risk Care Plan initiated on 02/21/2023 indicated high risk related to poor body function, antidepressant medication, needs wheelchair for locomotion, diagnosis of Seizure Disorder, Right Sided Weakness, Right Ankle Tendinitis (h/o inversion of right ankle joint). Interventions included provide assistance in ADL and care as required, fall risk assessment quarterly and as needed, ensure safe transfer with the assistance required as ordered. There was no documented evidence that the care plan was updated post fall on 04/26/2023 to include new goals and new interventions. During an interview conducted with Licensed Practical Nurse (LPN #1) on 05/03/2023 at 12:07 PM, LPN#1 stated that the LPNs in the facility can update care plans but not initiate a new care plan. LPN #1 also stated that LPNs can carry out physician orders and update the Resident Care Profile and ADL Flow Sheets. During an interview conducted with LPN #3 (who electronically picked up Resident#1's PT recommendation) on 05/05/2023 at 12:30 PM, LPN #3 stated the facility process is that when Physical Therapy (PT) makes a recommendation about resident's functional status, it shows up on the electronic dashboard, where they will sign, and it will populate as a Physician Order which needs to be carried out. The residents' ADL flowsheet and the Activities of Daily Living (ADLs) is updated by the LPN so the CNAs will know what to do. The LPN stated they updated the ADLs but not the care plan. The LPN stated that they do not do the care plan, it is usually done by the LPN Unit Manager who updates the care plan. During an interview conducted with the Assistant Director of Nursing (ADON) on 05/05/2023 at 1:41 PM, the ADON stated that recommendation from the PT and OT can be seen by the nurses on their dashboard. The nurse who clicks on recommendation completes it and it populates in the Physician Order. The nurse will then update the Resident Care Profile, the ADL Flow Sheet, and the Care Plan. The nurse who picked up the recommendation from PT for Resident #1 did not update the care plan. The facility has begun in-servicing the nurses. Only RNs can initiate a care plan. LPNs can update a care plan. When the resident fell on [DATE], the CNA should have been right next to the resident since the resident was one-person extensive assistance. The ADON stated they are now aware of the discrepancies in the ADL forms and that is why they are reeducating the nursing staff and disciplining the CNA involved. During an interview conducted with the DON on 05/05/2023 at 12:25 PM, the DON stated that the facility process was followed. The recommendation by the PT was signed and completed by LPN #3 and it showed up as a Physician Order. LPN #3 should have updated the care plan as well. LPNs cannot initiate care plans, but they can update them. 415.11(c)(2) (i-iii)

Based on interview, and record review conducted during an abbreviated survey (NY00315794), the facility did not develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of the resident to be an active partner and effectively transition the resident to post-discharge care, and the reduction of factors leading to preventable readmission. Specifically, no discharge planning process was developed and implemented since Resident's admission to the facility. This was evident for 1 (Resident #1) of 8 residents reviewed for discharge. The findings are: The facility Policy and procedure on Discharge Planning dated 11/2017 documented that Throughout the resident's stay, the social worker and/or team will regularly reevaluate resident to identify changes that require modification of the discharge plan. Resident #1 was admitted from hospital to the facility on [DATE] with diagnoses that included Unspecified Convulsions, Epilepsy, Alcohol Abuse with Intoxication, and Gastroesophageal Reflux Disease with Esophagitis. The Minimum Data Set (MDS, an assessment tool) dated 03/11/2023 documented that the resident had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 15/15, associated with intact cognition (00-7 severe impairment, 08-12 moderate impairment and 13-15 cognitively intact). The Facility Discharge Planning Care Plan effective 12/06/2022 documented under focus that Resident #1 was a short term/subacute rehabilitation and would require discharge planning. The Discharge Care Planning did not document Resident #1's discharge goal to return home. The Discharge Care Planning did not document Resident #1 being placed on custodial care. Social Service Progress Note dated 01/04/2023 documented Social Worker (SW) notified today that Resident #1 lost their Health Maintenance Organization (HMO) appeal decision. Resident #1 in agreement of custodial care at the facility, due to not enough support at home. SW will continue to remain as needed. Social Service Progress Note dated 02/08/2023 documented referral sent for home care hours coverage upon Resident #1 returning home. Social Service Progress Note dated 04/11/2023 documented SW met with Resident #1 regarding discharge planning. Resident #1 stated they would like to return home eventually to live with their young children. Resident #1 is on rehab program with no potential discharge date . Resident #1 is in agreement to remain in the facility until able to return home with appropriate home care services. Resident's chart was reviewed from admitted [DATE] to 04/27/2023, there was no documented evidence that discharge planning process has been discussed with the resident or resident's representative to effectively transition the resident to post-discharge care. There was no documented evidence that discharge the care plan was updated and implemented to focus on the resident's discharge goals to effectively transition the resident to post-discharge care. Interview on 05/05/2023 at 10:46 AM with Social Worker (SW) #2, SW #2 stated they were responsible for Resident #1 but ended up being out of work and SW #1 took on Resident #1. SW #2 stated they tried to set up several discharge meetings with Resident #1, but it was unsuccessful. SW #2 stated they did not document their efforts to schedule care plan meetings with Resident #1. SW #2 stated it is the responsibility of the SW to seek outside services to assist residents with discharge. SW #2 stated there was a home health referral sent for Resident #1, but they did not know the outcome of the referral that was sent out by SW #1. SW #2 stated SWs are responsible for updating discharge planning care plan as needed. SW #2 stated the care plan should have been updated to reflect that Resident #1 was switched from short term care to long term care after the resident was approved for custodial care. SW #2 stated that the discharge plan should also have been updated with Resident #1's wishes to return to the community with appropriate services. Interview on 05/05/2023 at 10:46 AM with SW #1, SW #1 stated they were responsible for updating discharge care plan and was working with Resident #1 regarding discharge home in January or February 2023. SW#1 stated they met with Resident #1 in February and Resident #1 stated they want to go home if they could get home care hours approved. SW#1 stated they sent a home care referral out for the resident SW#1 stated after sending the home health referral, Resident #1 stated they would like to stay in the facility until they had ankle surgery because they did not have enough support at home. Custodial care in the facility was approved. SW#1 stated they did not document their follow up with the home health referral or their conversation with Resident #1 regarding agreeing to stay in the facility. SW stated they did not update Resident #1's discharge care plan and that they were the person responsible for doing so. An Interview was conducted with Resident #1's daughter on 05/05/2023 at 2:45 PM, Resident #1's daughter stated they were contacted in December regarding a care plan for Resident #1 but denied being contacted regarding discharge planning. Resident #1's daughter stated Resident #1 told them that someone at the facility informed them they were a long-term resident but never notified them directly. Resident #1's daughter stated Resident #1 actively wanted to go home but was waiting for the facility to assist with initiating home health services. Resident #1's daughter stated every time Resident #1 would ask about going home they were told they would work on it the next month. 415.11(d)(3)

Based on record review and interview conducted during an abbreviated survey (NY00315794), the facility failed to ensure that a resident received treatment in accordance with professional standards of practice for 1 of 8 residents (Resident #1) reviewed for quality of care. Specifically, on [DATE], Resident #1 who required extensive 1-person physical assistance for toileting was found on the bathroom floor diaphoretic (sweating) with shortness of breath and complained of chest pain. Resident #1 stated they fainted and fell on the bathroom floor. There was no documented evidence that Resident #1 was placed on neurological checks for 24 hours as per facility policy. There was no documented evidence that a STAT (immediate) order for electrocardiogram (EKG) was carried out. There was no documented evidence of any additional clinical monitoring including bloodwork provided to Resident #1 post fall. There was no documented evidence of a physician order to send Resident #1 to the hospital post fall. There was no medical provider note of an assessment of Resident #1 until [DATE] at 4 PM, which was 8 days after the fall, 7 days after Resident #1 expired, and the same day that surveyors were on site. The findings are: The Facility Policy on Notification of Change in Condition dated [DATE] documented that it will be the policy of the facility to inform the resident; consult the physician; and if known, notify the residents legal representative or an interested family member when there has been a change in the resident's condition as defined in guidelines, which included (a) An accident involving the resident which results in injury and has the potential for requiring physician intervention. The family will be notified about all accidents and incidents. (b) A significant change in the resident's physical, mental, or psychosocial status. (c) A decision to transfer or discharge the resident from the facility. The Facility Policy on Accident/Incident (A/I) Reporting dated [DATE] documented that a resident's environment will remain free from as many hazards as possible. Under the heading Procedure, the policy documented that should an A/I occur, examine the resident, and provide emergency care as needed. Under the heading Documentation, the policy documented that if a resident hits their head, is unable to state whether or not they hit their head, neurological checks will be done for 24 hours, or as ordered by the physician. The Facility Policy on Progress Notes dated [DATE] documented that all entries into the clinical record will occur within the shift of the staff member implementing the documentation, as soon as possible. When needed, as appropriate or necessary, correction notes, or late entry notes may be added to the record only in order to make the record accurate and complete, or if erroneous information is noted and needs to be corrected. Resident #1 was admitted from hospital to the facility on [DATE] with diagnoses that included Unspecified Convulsions, Epilepsy, Right Sided Weakness, and Right Ankle Tendinitis (h/o inversion of right ankle joint). The Minimum Data Set (MDS, an assessment tool) dated [DATE] documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of ,d+[DATE], associated with intact cognition (,d+[DATE] severe impairment, ,d+[DATE] moderate impairment and ,d+[DATE] cognitively intact). Resident #1 was totally dependent with transfer, and toilet use. The Resident Accident and Incident (A/I) Report dated [DATE] documented that Resident #1 returned to the unit from a medical appointment on [DATE] at approximately 3:45 PM. Resident #1 asked to be transferred to the bathroom and fell off the toilet on [DATE] at 4:20 PM. Resident #1 was able to explain what happened stating they fainted and had chest pain. Resident #1 was found on the bathroom floor diaphoretic with shortness of breath and chest pain. The Nurse Practitioner (NP) was notified at 4:30 PM and a STAT EKG was ordered. One dose of Aspirin 325 mg and oxygen (02) 2 liter via nasal cannula was also ordered and administered to Resident #1. Resident #1's daughter was notified at 4:45 PM. Review of the Resident Clinical Monitoring Record and Progress Notes from [DATE] to [DATE] revealed Resident #1's vital signs (VS) were taken as follows: [DATE] Blood Pressure (BP) was ,d+[DATE] - VS taken at 5:38 PM [DATE] Temperature (T) 96.8 F, Pulse (P) 103, Respiration (R) 24, BP ,d+[DATE], Oxygen Saturation 97% - VS taken at 7:24 PM [DATE] BP ,d+[DATE], resident had no pain - VS taken at 10:32 AM [DATE] No Pain - VS taken at 11:02 AM [DATE] T 97.7, P 96, BP ,d+[DATE], Oxygen Saturation 99% - VS taken at 1:57 PM [DATE] BP ,d+[DATE], resident had no pain - VS taken 6:57 PM There was no documented evidence that neuro checks were completed There was no documentation on [DATE] of an assessment of Resident #1 post fall by the NP. The assessment post fall on [DATE] by the NP was not documented until [DATE] (a late entry), when surveyors were onsite. During an interview conducted with the NP on [DATE] at 2:02 PM, the NP stated they were notified by the Registered Nurse Supervisor (RNS), and they ordered EKG, O2, and Aspirin. The NP stated Resident #1 was informed more than once that the NP wanted to send them to the hospital, but they refused to go. The NP stated they saw Resident #1 on the morning of [DATE] but did not document due to lack of time. The NP stated they were called on [DATE] by the RNS and notified of Resident #1 being unresponsive and being sent out to the hospital. The NP stated they are the one that is in the facility, so the medical doctors respect their discretion and normally agree with them. During a follow up interview conducted with the NP on [DATE] at 3:00 PM, the NP stated the EKG that they read was abnormal (abnormal sinus rhythm) but there were no blocks or immediate concerns of any cardiac issues. During the the two interview of the NP, the NP did not provide any documentation regarding Resident #1's refusal to go to the hospital. After those interviews, at 4 PM on [DATE], the surveyors noted documentation by the NP in Resident #1's medical record . During a further follow up interview with the NP on [DATE] at 12 PM, the NP stated they saw Resident #1 on [DATE] at around 10 AM and shortly after that they called and spoke with Resident #1's Primary Care Physician (PCP) to inform them that Resident #1 fell on [DATE] and had chest pain but refused to go to the hospital. The NP stated that they also informed the PCP that Resident #1 was feeling better, was stable, and improving. During an interview conducted with Resident #1's PCP on [DATE] at 1:56 PM, the PCP stated that on [DATE] Resident #1 had a dental extraction and a fall. The PCP stated they were notified by the NP on [DATE]. The PCP stated that according to the NP they wanted to send Resident #1 to the hospital, but Resident #1 refused. The PCP stated that the NP added that Resident #1 had improved and was stable at that point. The PCP stated that if they had been called, they would have recommended to monitor with routine neuro checks every 2 hours and if the resident did not improve, they would have sent them to the hospital. The PCP stated it used to be routine for residents to be sent to the hospital for head and chest x-ray because the hospital is across from the facility. However, the facility has contracted with a new vendor who provides bedside radiology images. The PCP added that if Resident #1's blood pressure was within normal limit, they would have ordered nitroglycerine and would have had their legs elevated. The PCP stated they would have ordered oxygen and an EKG as well. During a telephone interview conducted with the Medical Director (MD) on [DATE] at 2:08 PM, the MD stated they were contacted by the Administrator on [DATE] regarding Resident #1 who was admitted in [DATE]. The MD stated they were told that on [DATE] Resident #1 reported they had fallen in the bathroom while on the toilet and had chest pain. The MD stated that the NP was notified by phone and the NP ordered chest x-ray, EKG, and vital sign checks. The MD stated they were informed that the x-ray results were received on [DATE] between 5 PM to 6 PM and that the x-ray was negative. The MD stated that later that evening they were informed that Resident #1 was found unresponsive, CPR was initiated, Resident #1 was transferred to the hospital, and expired at 9 PM. The MD stated he was informed that NP notes were entered late. The MD stated the NP can assess emergency situations. The MD stated they had no reason to believe Resident #1 was not seen by the NP but felt there should have been more documentation regarding Resident #1's refusal to go to the hospital. The MD stated that if they had also been contacted, they would have sent Resident #1 to the ER for further evaluation considering that the hospital is directly across the street, adding that Resident #1 could have always returned to the facility. The MD stated the conclusion that the facility provided was okay and they agreed with it. However, going forward the NP will need to discuss cases with them if a resident is refusing to go to the hospital. The MD stated that if a resident is alert and oriented and refuses care, they cannot make the resident go, but they could involve other departments like social services to try to talk to the resident. The MD stated that the EKG and x-ray being done on the second day was not a concern, particularly since the EKG results presented no immediate concerns. 415.12

Based on record review and interview conducted during an abbreviated survey (NY00315794), the facility failed to provide adequate supervision to ensure that the appropriate interventions and means of mitigating the risk of an accident/fall were in place, were understood by and were followed by the facility staff for 1 of 8 residents (Resident # 1) reviewed for quality of care. Specifically, Resident #1 who had diagnoses that included Unspecified Convulsions and Epilepsy and required extensive one-person physical assistance for toileting was left in the bathroom by themselves on [DATE]. Consequently, Resident #1 was observed lying on the bathroom floor on their left side, diaphoretic (sweating), and with shortness of breath. Resident #1 stated that they were having chest pain, fainted and fell . Resident #1 was transferred to the hospital on [DATE] and expired. The findings are: The Facility Policy on Accident/Incident (A/I) Reporting dated [DATE] documented that a resident's environment will remain free from as many hazards as possible. When an accident or incident occurs to a resident, it will be documented in an A/I Report, and an internal investigation is conducted to determine the root cause of the A/I, and in many cases, an intervention may be added to prevent reoccurrence. Resident #1 was admitted from hospital to the facility on [DATE] with diagnoses that included Unspecified Convulsions, Epilepsy, Right Sided Weakness, and Right Ankle Tendinitis (h/o inversion of right ankle joint). The Quarterly Minimum Data Set (MDS, an assessment tool) dated [DATE] documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of ,d+[DATE], associated with intact cognition (,d+[DATE] severe impairment, ,d+[DATE] moderate impairment and ,d+[DATE] cognitively intact). Resident #1 was totally dependent requiring 2-person assistance with transfer, and toilet use. The Discharge MDS dated [DATE] documented that Resident #1 required total dependence. The Physician Order dated [DATE] documented that Resident #1 was out of bed (OOB) to wheelchair (W/C) with extensive assist x 1. The Certified Nursing Assistant (CNA) Accountability Record for the month of [DATE] documented that Resident #1 required extensive 1-person physical assistance for transfer and toileting. The Resident Care Profile (CNA Instructions) dated [DATE] documented that Resident #1 required extensive 1-person physical assistance for transfers, and total dependence 2-person physical assistance for toilet use. The Activities of Daily Living (ADL) ADL Flow Sheet documented that Resident #1 was totally dependent with 2-person physical assistance for transfers and toileting from [DATE] to [DATE] (Resident #1 expired on [DATE]). Resident #1's ADL Care Plan documented that Resident #1 had self-care deficit due to weakness (right sided weakness) initiated on [DATE], and that Resident #1 required extensive one-person physical assistance for transfer and toileting. On [DATE], Residents #1's ADL status was changed to total dependence 2-person physical assistance for transfer and toileting. There was no documented evidence that the care plan was updated in [DATE] to indicate that Resident #1 was extensive 1-person assistance for transfer and toileting. Resident #1 had a Care Plan on Falls Risk / Precautions related to poor body function, antidepressant medication, needs wheelchair for locomotion, Dx Seizure Disorder, Right Sided Weakness, Right Ankle Tendinitis (h/o inversion of right ankle joint) initiated on [DATE]. Interventions included provide assistance in ADL and care as required, fall risk assessment quarterly and as needed, ensure safe transfer with the assistance required as ordered. There was no documented evidence that the care plan was updated post fall incident on [DATE]. There was no incident camera footage review, the fall occurred inside the shower room bathroom. Observations on the unit revealed that there are cameras installed at the unit hallways. However, review of the Resident Accident and Incident (A/I) Report and Facility Investigative Summary revealed no incident camera footage review on [DATE] and [DATE] that would confirm and/or verify staff statements (thoroughness of investigation). The Resident A/I Report dated [DATE] documented that Resident #1 asked to be transferred to the toilet upon return from a medical appointment on [DATE] at approximately 3:45 PM. Resident #1 fell off the toilet on [DATE] at 4:20 PM. Resident #1 was able to explain what happened stating they fainted and had chest pain. Resident #1 was found diaphoretic with shortness of breath and chest pain. Nurse Practitioner (NP) was notified. STAT (immediately) Electrocardiogram (EKG) was ordered. Resident #1 was ordered and received 1 dose of Aspirin 325 mg and oxygen 2L via nasal cannula. The facility notified Resident #1's physician at 4:30 PM, Resident #1's daughter at 4:45 PM. The facility did not identify that staff did not follow Resident #1's plan of care in their summary of investigation. The facility did not update the ADL Care Plan to reflect that Resident #1 required extensive 1-person physical assistance for transfer and toileting. The facility did not update the care plan post fall incident. During a telephone interview conducted on [DATE] at 1:26 PM with CNA #1, CNA #1 stated they could not recall what happen because they only heard about it. CNA #1 stated they did not remember who told them, but they did not ask any questions about the incident. During a telephone interview conducted on [DATE] at 1:28 PM with CNA #2, CNA #2 stated Resident #1 had just came back from an outside appointment and they rang the bell stating they needed to go to the restroom. CNA #2 stated they assisted Resident #1 to the toilet with CNA #1's assistance (CNA #1 did not corroborate this claim). CNA #2 stated Resident #1 was left with the call bell and instructions to use the call bell when done. CNA #2 stated that while they were walking down the hallway Resident #1 rang their call bell. CNA #2 stated that when they went back into the bathroom Resident #1 was on the floor. CNA #2 stated they notified the supervisor, and the supervisor came to assess Resident #1. During an interview conducted on [DATE] at 1:08 PM with CNA #5, CNA #5 stated that whether a resident is 2-person or 1-person assistance for toileting, they do not leave them unattended in the bathroom, even when the resident requests for privacy they cannot leave the resident alone. During an interview conducted on [DATE] at 1:15 PM with CNA #6, CNA #6 stated that they do not leave the resident in the bathroom when they require assistance, even when they request for privacy, they remain by the door. CNA #6 stated if the resident is in the shower room bathroom, then they do not step out, they remain inside the bathroom. During an interview conducted on [DATE] at 10:13 AM with Occupational Therapy Assistant (OTA), the OTA stated that when Resident #1 was admitted they initially required 2- people total dependence for transfers and toileting. The OTA stated that Resident #1 became able to do a lot more for themselves and so it changed to extensive with 1- person assistance. The OTA stated that Resident #1 still needed somebody with them in the bathroom when being toileted. The OTA stated that Resident #1 cannot be left on their own when they are still requiring assistance even when they ask for privacy. The OTA stated that the CNAs are aware of these resident care measures. During an interview conducted on [DATE] at 1:41 PM with the Assistant Director of Nursing (ADON), the ADON stated that when Resident #1 fell on [DATE], the CNA should have been right next to Resident #1 since they required 1-person extensive assistance. The ADON stated they are now aware of the discrepancies in the ADL forms and that is why they are reeducating the nursing staff and disciplining the CNAs. 415.12 (h) (2)